Healthcare Residency Agreement

HEALTHCARE RESIDENCY AGREEMENT

This Healthcare Residency Agreement (the Agreement) is entered into between the Facility and the Resident for the provision of residential care, accommodations, and related services. The parties set forth their agreement below concerning the terms of residency, services, payment obligations, and rights and responsibilities.

PARTIES AND IDENTIFICATION

Facility Name:

Facility Address:

Resident Name:

Date of Birth:    Gender:

ADMISSION AND TERM

Admission Date:    Room/Unit Assigned:

Term: Residency shall commence on the Admission Date and continue on a month-to-month basis until terminated in accordance with the Termination provisions of this Agreement. The Facility may require completion of a personalized service plan prior to full initiation of certain services.

SERVICES PROVIDED

The Facility shall provide the following services as part of residency (as applicable): room and board, basic daily living assistance, medication administration per written orders, routine housekeeping and laundry, coordinated access to medical services, and emergency response. Additional services and their costs are set forth below.

FEES, PAYMENT, AND INSURANCE

Monthly Room & Board Fee: $    Payment Due On:

Additional Service Fees (e.g., therapy, transportation, advanced medical care) will be billed as incurred and are payable in accordance with Facility billing practices. The Facility reserves the right to change fees upon 30 days' written notice to the Resident or authorized representative.

HEALTH INFORMATION AND MEDICAL AUTHORIZATIONS

Authorization for Treatment: The Resident authorizes the Facility and its staff to provide routine and emergency medical care, to administer medications prescribed by licensed practitioners, and to coordinate referrals. The Resident understands that Facility staff will follow written medical orders and will contact the Resident's authorized representative as required.

Medication Administration Consent: The Resident consents to the Facility administering prescription and over-the-counter medications as ordered. The Resident acknowledges responsibility to provide accurate medication information and to notify the Facility promptly of changes.

RESIDENT RESPONSIBILITIES

The Resident agrees to: timely payment of fees; comply with Facility rules and policies; provide accurate medical and financial information; respect the rights of other residents and staff; accept reasonable care and supervision. The Resident shall not engage in activities that endanger self or others and shall comply with safety directives.

TERMINATION, DISCHARGE, AND NOTICE

Termination by Resident: The Resident may terminate this Agreement by providing at least 30 days' written notice unless otherwise agreed. Termination by Facility: The Facility may terminate residency for nonpayment, failure to follow essential policies, a material change in the Resident's care needs that the Facility cannot meet, or for safety concerns, with at least 30 days' written notice where feasible or immediate notice when immediate action is required.

Discharge Planning: In the event of discharge for medical reasons, the Facility will make reasonable efforts to coordinate an appropriate discharge plan and notify the Resident's authorized representative.

LIMITATION OF LIABILITY, INDEMNIFICATION, AND INSURANCE

The Facility shall exercise reasonable care in providing services. Except as provided by applicable law, the Facility's liability for claims arising from the provision of services is limited to direct damages and does not include consequential or punitive damages. The Resident agrees to indemnify the Facility for claims arising from intentional acts or gross negligence by the Resident or the Resident's visitors. The Resident is encouraged to maintain personal health and liability insurance.

PRIVACY AND AUTHORIZATIONS

The Resident acknowledges receipt of the Facility's Notice of Privacy Practices and authorizes the Facility to use and disclose protected health information for treatment, payment, and healthcare operations consistent with applicable privacy laws. The Resident may revoke written authorizations except where action has already been taken in reliance upon the authorization.

HIPAA Acknowledgment: I acknowledge receipt of the Facility's Notice of Privacy Practices and consent to the use and disclosure of my health information as described above.

DISPUTE RESOLUTION AND GOVERNING LAW

The parties agree that disputes arising under this Agreement shall first be submitted to good faith negotiation. If unresolved, disputes may be submitted to mediation or binding arbitration in accordance with rules selected by the parties. This Agreement shall be governed by the laws of the state in which the Facility is located.

MISCELLANEOUS

Amendments to this Agreement must be in writing and signed by the Resident or authorized representative and an authorized Facility representative. If any provision is found unenforceable, the remaining provisions shall remain in full force. Notices required under this Agreement shall be in writing to the addresses listed above.

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