Healthcare Long Term Care Agreement

HEALTHCARE LONG TERM CARE AGREEMENT

Parties and Admission

This Long Term Care Agreement is entered into by and between the facility and the resident named below. Facility Name: and Resident Name: .

Accommodation and Services

Facility agrees to provide care and services to Resident at the location identified above in accordance with this Agreement. Room Type: Monthly Rate: $ Security Deposit: $

Personal care assistance    Skilled nursing    Medication management

Meals and dietary supervision    Physical/occupational therapy    Transportation for medical appointments

Payment, Insurance and Billing

Resident or Responsible Party shall be liable for all charges for services ordered by authorized clinical staff or permitted under this Agreement. Billing Cycle: Payments due within days of billing.

If insurance, Medicare, Medicaid, or other third-party payor does not pay, Resident or Responsible Party remains obligated for payment. Late payment may incur a finance charge and collection costs as set forth in facility policy.

Medical History and Care

Resident authorizes Facility and its medical staff to provide or arrange for medical care, nursing, medication administration and emergency treatment as clinically indicated during residency. Facility will attempt to notify the Responsible Party promptly of material changes in condition and of significant medical events.

I authorize Facility to administer prescribed medications.    Resident will self-administer medications when capable.

Advance Directives and Decision-Making

Resident has provided the following advance directive documentation and decision-making designations. Advance Directive Present: Yes No

Privacy and HIPAA Acknowledgment

Resident acknowledges receipt of Facility’s Notice of Privacy Practices and understands that Protected Health Information will be used and disclosed for treatment, payment and health care operations as permitted by law. Resident acknowledges: I acknowledge receipt of privacy notice.

Termination, Discharge and Transfer

Facility may discharge or transfer Resident for reasons including but not limited to nonpayment, change in care level beyond facility capability, or behavior posing risk of harm. Resident may terminate this Agreement upon written notice in accordance with facility policy. Upon discharge or termination, Resident remains responsible for charges incurred through the effective date of discharge.

Liability, Indemnity and Limitation of Remedies

Facility will exercise reasonable care in providing services. Except as otherwise required by law, Facility is not liable for loss or damage to Resident property except for loss caused by Facility’s gross negligence or willful misconduct. Resident and Responsible Party agree to indemnify and hold Facility harmless from third-party claims arising from Resident’s acts or omissions.

Any dispute arising under this Agreement shall be resolved first by good-faith negotiation. If unresolved, the dispute shall be submitted to binding arbitration unless prohibited by applicable law. By initialing below, parties acknowledge agreement to arbitration:

Personal Belongings and Property

Resident acknowledges responsibility for disposition and security of personal property. Facility may require valuables to be stored off-site or in facility safe; Facility shall maintain an inventory of valuables when requested by Resident or Responsible Party.

Notices

Acknowledgment and Certification

By signing below, Resident or Responsible Party certifies that the information provided in this Agreement is accurate to the best of their knowledge, that they have read and understand the terms and conditions of this Agreement, and that they consent to the services and policies described herein.

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