Healthcare Residency Document

HEALTHCARE RESIDENCY AGREEMENT

Facility Name:    Admission Date:

Resident Information

Date of Birth:    Gender: Female Male Other

Insurance and Billing

Medical & Clinical Information

Mobility Status: Ambulates independently Requires assistance Wheelchair required Bedbound

Services, Fees, and Payment Terms

Monthly Residency Fee: $    Security Deposit: $

Billing Responsibility:

Late Payment Charge: per billing cycle. Fees for additional services will be billed as incurred and are due upon receipt.

Refunds and Termination: Resident or facility may terminate this agreement with thirty (30) days written notice, subject to facility policies regarding refunds of prepaid fees and deposit deductions for outstanding charges or damage.

Consent for Treatment & Health Information

Consent to Routine and Emergency Care: The undersigned authorizes the facility and its staff to provide routine care and to obtain or arrange emergency medical treatment for the resident when, in the judgment of the facility, such treatment is necessary to preserve life or prevent harm. This includes transportation to emergency facilities and consent to necessary emergency procedures.

Advance Directives: The facility will respect any valid advance directive or health care power of attorney presented and placed in the resident's record. Please indicate if an advance directive is on file: Yes    No

HIPAA Acknowledgment and Authorization: I acknowledge receipt of the facility's Notice of Privacy Practices. I authorize the facility to use and disclose protected health information for treatment, payment, and health care operations in accordance with the facility's policies. I further authorize the facility to disclose health information to the persons listed below.

Authorization Expiration Date: . If left blank, this authorization expires upon discharge from the facility.

Resident Rights, Responsibilities, and Liability

Resident Rights: The resident retains rights to privacy, dignity, and to receive reasonable notice of changes in services or fees. The facility will make reasonable efforts to accommodate the resident's personal preferences and needs.

Responsibilities: The resident or responsible party must provide current and accurate health information, comply with facility policies, and pay fees in accordance with this agreement. The resident is responsible for personal property and valuables; the facility is not liable for loss except in cases of proven negligence.

Limitation of Liability: Except where prohibited by law, the facility's liability for any claim related to residency is limited to direct compensatory damages. The facility is not liable for indirect, incidental, or consequential damages.

Dispute Resolution: Any disputes arising under this agreement shall be resolved by good faith negotiation between the parties. If unresolved, disputes may be submitted to non-binding mediation prior to pursuing other remedies.

Certification

By signing below, I certify that the information provided in this document is true and complete to the best of my knowledge. I acknowledge that I have read and understand the terms of residency, the facility's policies described herein, and that I have had the opportunity to ask questions. I authorize the facility to provide care consistent with this agreement.

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