Healthcare Residential Services Contract

HEALTHCARE RESIDENTIAL SERVICES CONTRACT

This Healthcare Residential Services Contract (Contract) is entered into between Provider Name: and Resident/Client Name: on Effective Date: . Provider agrees to provide, and Resident agrees to receive, residential healthcare services subject to the terms and conditions set forth below.

1. FACILITY AND CONTACT INFORMATION

2. RESIDENT INFORMATION

3. INSURANCE AND PAYMENT

Fees: Resident agrees to pay Monthly Fee: $ for room, board and basic services. Additional charges for specialized therapies, transportation, or one-time assessments will be billed separately. Payment is due by the day of each month. Insurance assignments and third-party payments will be accepted where applicable; Resident remains responsible for unpaid balances.

4. SERVICES PROVIDED

Provider shall furnish residential healthcare services as appropriate to Resident's assessed needs. Services may include (check all that apply):

5. MEDICAL HISTORY AND CARE INSTRUCTIONS

Resident authorizes Provider to follow the medical care plan prepared by Resident's licensed practitioners and to seek emergency medical care if necessary. Provider will make reasonable efforts to notify the Emergency Contact prior to or promptly after emergency treatment.

6. PRIVACY, AUTHORIZATIONS AND HIPAA

Resident acknowledges receipt of Provider's privacy practices and authorizes Provider to use and disclose protected health information as necessary to provide services, process claims, and coordinate care consistent with applicable law. Resident also authorizes Provider to obtain medical records from prior providers and to release records to third parties involved in payment or care coordination.

7. TERM, TERMINATION, AND DISCHARGE

Admission Date: This Contract continues on a month-to-month basis until terminated by either party upon thirty (30) days' written notice, or sooner where immediate discharge is required for medical, safety, or regulatory reasons. Provider may terminate services for nonpayment, material breach, or when care needs exceed the facility's capabilities, subject to applicable notice requirements.

8. LIABILITY, INDEMNIFICATION AND INSURANCE

Provider will exercise reasonable care in the performance of services. Provider is not liable for outcomes resulting from Resident's refusal of recommended care, pre-existing conditions, or events outside Provider's control. Resident shall indemnify and hold harmless Provider from claims arising from Resident's negligence or failure to disclose material health information. Resident is encouraged to maintain personal liability and health insurance.

9. GRIEVANCE, DISPUTE RESOLUTION, AND GOVERNING LAW

Complaints or grievances should be submitted in writing to the Facility's administrator. Parties agree to attempt good faith resolution of disputes. This Contract shall be governed by the laws of the state where the Facility is located. If not otherwise resolved, disputes may be resolved by mediation or arbitration in accordance with applicable law.

10. ADDITIONAL TERMS

Modification: Any modification of this Contract must be in writing and signed by both parties. Severability: If any provision is found invalid, remaining provisions shall remain in force. Entire Agreement: This Contract, together with any care plans and consents signed by Resident, constitutes the entire agreement between the parties.

11. REPRESENTATIONS AND CERTIFICATIONS

By signing below, Resident and Provider each represent that they have authority to enter into this Contract, have read and understand its terms, and acknowledge receipt of a copy of this Contract. Resident certifies that the information provided in this Contract is true and complete to the best of Resident's knowledge.

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