Fill and Sign the Personal Care Agreement Form

Agreement for Home Health Care by a Nursing Service This agreement is being made between ___________________________________ of ________________________________ (street address, city, county, state, zip) ( A Nursing Service @ ), and __________________________________ (client) residing at ____________________________________________ (street address, city, county, state, zip), ("Client"). 1. The Nursing Service agrees to furnish the services of ___________________________________ (a certified nursing assistant, registered nurse, nurse assistant, etc.) hereinafter called A Caregiver @ at the rate of $____________ per hour. 2. Nurse agrees that Caregiver shall perform work for the Client on the terms and conditions specified in this Agreement, to include the following: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______ 3. Nursing Service will bill the Client on a weekly basis and Client agrees that the work week will extend from _______________________ (day of week) to _____________________ (day of week) from _____________ (hour of day) to _______________ (hour of day). 4. Client agrees to pay _______% interest per month on all amounts not paid within ____days of statement. Client agrees to pay all reasonable attorney fees and court costs in cases of collection. Client understands that regardless of Client's insurance or lack thereof, Client is responsible for any and all payments to Nursing Service. Client acknowledges that filing of insurance claims is the sole duty of Client, and that Nursing Service assumes no duty to file insurance claims for Client. 5. Nursing Service is able to provide services only by a substantial investment in advertisement, recruitment, testing and training of employees. Therefore, Client agrees that if they privately employ the worker or workers assigned to their care within a period of ____weeks from the last day the worker or workers provided services to them, Client will pay Nursing Service a placement fee of $____________for each employee so employed. 6. Client understands and agrees that Nursing Service is an equal opportunity employer, and the placement of workers will be according to level of skills and needs of the Client without regard to race, religion, color, sex, or national origin. 7. Nursing Service will make all reasonable efforts to staff the shifts which are requested by the Client. Client agrees to hold Nursing Service harmless if unforeseen circumstances do not allow for coverage of a shift as requested. Client understands and agrees that if prescheduled shifts must be canceled, Nursing Service makes no guarantee or assurance that the canceled shift can be later filled if Client later elects to have shift covered. Client further agrees to hold Nursing Service harmless if it is then later unable to staff the canceled shift. Client understands and agrees that if the shift has begun and the Client wishes to cancel, the Client may do so, however the Client will be charged _____% of the remaining time at the hourly rate of $____________. 8. In the event of any breach of this Agreement, the party responsible for the breach agrees to pay reasonable attorneys' fees and costs incurred by the other party in the enforcement of this Agreement or suit for recovery of damages. The prevailing party in any suit instituted arising out of this Agreement will be entitled to receive reasonable attorneys' fees and costs incurred in such suit. 9. Client hereby releases and holds Nursing Service harmless for any acts of simple negligence of on the part of the personnel provided by Nursing Service. 10. Client understands and agrees that this agreement will be governed by the laws of the state of ______________________. 11. Client agrees to sign and include Client's permission to release any information pertaining to Client's health care from any other health care provider to Nursing Service. 12. Bills will be sent to: Name: _______________________________________________ Address: _____________________________________________________________ Phone Number:_____________________________ Witness our signatures as of the day and year first above stated. ____________________________________ ______________________________ Nursing Service Client