2022-03-07_gscott_CCA Template 1-13-22_Gary Edits.docx

CLIENT CONSENT AGREEMENT

This Client Consent Agreement (the “Agreement”) is entered into on [insert date] (“Effective Date”) between Home Care Assistance of [insert state and/or applicable entity], LLC (“Company”) and Client and/or Responsible Party as listed below (together referred to as “Client”).

TERMS AND CONDITIONS

PLACEMENT FEE: Client understands Company spends a significant amount of time, money and resources in the process of recruiting, screening, hiring and training its employees, including its Caregivers, Care Managers and Skilled Care Employees (collectively, “Care Providers”), and therefore acknowledges each Care Provider is a valuable asset to Company. Client further understands that each Care Provider working for Company is prohibited from accepting private employment from Client directly (or through another organization/agency) while the Care Provider is employed by Company as well as for a period of three (3) years following Care Provider’s termination of employment from Company. If Client wishes to employ any Care Provider within a three (3) year period of Care Provider’s termination of employment from Company, Client agrees to pay Company a one-time placement fee of THIRTY THOUSAND DOLLARS ($30,000.00) per Care Provider hired, which amount shall be due within 10 business days after Client hires the applicable Care Provider.  Payment of the placement fee by Client does not affect any liability or contractual obligations Care Provider may have toward Company.

ACH AND DEBIT/CREDIT CARD AUTHORIZATION FORM: Client is required to provide Company with an automatic payment method (ACH, debit, or credit). Client shall execute an “ACH and Debit/Credit Card Payment Authorization” form (“Payment Authorization form”) and all terms contained in the Payment Authorization form are incorporated into this Agreement.

BILLING RATE CHANGES: The rates listed above (“Billing Rates”) are subject to change upon any change to Client’s schedule, Client’s circumstances, regulatory updates, or Company-wide policy. Billing Rates are also subject to an automatic increase every six (6) months, rounded to the nearest twenty-five cents ($0.25), measured from the Effective Date (the “Automatic Rate Adjustments”). Automatic Rate Adjustments will be implemented every six months without further notice to Client. Company also retains the right to implement an additional increase to its Billing Rates prior to the end of each calendar year, including the calendar year in which Company begins providing services to Client. For changes to Billing Rates other than Automatic Rate Adjustments, Client acknowledges that receipt of at least three (3) weeks written notice or completion of a new Client Consent Agreement is sufficient notice for modifications to Billing Rates. Client may request an updated Client Consent Agreement in the event of any Billing Rate change and Company will not withhold one unreasonably.

BILLING ISSUES: Non-Payment by Client in excess of ten (1) days will be considered late and may be subject to interest charges of 1.5% per month on unpaid amounts and collection/attorney fees at Company’s discretion. Any payments made by Client will be applied first to any accrued interest owing, and then to the principal unpaid balance. Client is responsible for the full cost of Services rendered regardless of whether the cost is reimbursable or reimbursed by Client’s insurance, if any, or any governmental or other benefit. Client agrees not to pay a Care Provider directly for any Services. All charges are non-refundable, earned in full, and due and payable according to the terms of this Agreement. All fees, costs and interest relating to any collection activity will be added to Client’s balance and Client agrees to pay all such charges. To the extent authorized by law, Client agrees to pay Company any charge Company incurs if Client’s debit card, credit card, ACH or other payment is returned or refused.

ADDITIONAL SERVICE CHARGES: Client is advised to communicate any scheduling matters with their client/relationship manager. Client may not alter, eliminate, or add schedules directly with a Care Provider. Failure to observe these scheduling requirements may result in additional charges, including overtime (one and one-half times the Billing Rate), which will be added to Client’s regular invoice. Client shall pay additional charges for non-scheduled hours of Services received, including working outside the scheduled shift, missed or interrupted break periods, etc.

RECORDKEEPING: Client must provide Care Provider with sufficient time to report time and tasks on a daily basis, including on Client’s home phone.

CANCELLATIONS: Cancellations of scheduled shifts must be made during normal business hours for Client’s designated Company office and more than twenty-four (24) hours prior to the start of the shift. Cancellations during non-business hours are recorded as of the next business day. Cancellations for weekend Services must be made by no later than close of business the previous Friday. Cancellations not received within the timeframes provided herein will be subject to a cancellation fee equivalent to the Billing Rate for the entire scheduled shift.

CLIENT CONCERNS: Client agrees to promptly notify Company of any concerns or complaints Client has regarding Company’s Services. If Client does not promptly raise any concerns or complaints as required under this Agreement, Client agrees the Services were performed in a satisfactory manner.

HOME CARE LIVE-IN SHIFTS: For Clients receiving Live-In Services, Client may be required to execute a Live-In Addendum related to mandatory breaks for Care Providers as required by law.  All terms of the Live-In Addendum are incorporated into this Agreement.

CLIENT INFORMATION AND UPDATES: Client agrees to provide Company with all relevant information necessary for Client’s care, including any change in Client circumstances, insurance information (if applicable), billing/payment information, etc.

CARE PROVIDER RISK OF PHYSICAL HARM: If there is an imminent risk of physical harm to a Care Provider in the course of Services, Care Provider is entitled to vacate Client’s premises without exposing themselves and/or Company to liability. If Client creates the imminent risk of physical harm then Client remains liable for the full payment of charges.

VEHICLE USAGE: If Client allows Care Provider to drive Client’s vehicle to render Services, Client agrees to (i) notify and obtain authorization from Company; (ii) properly maintain the vehicle; (iii) maintain a current and valid registration for the vehicle; (iv) carry all legally required insurance; and (v) provide proof of maintenance, registration and insurance to Company upon Company’s request. Client shall also obtain Company’s authorization for Care Provider to drive Care Provider’s vehicle on Client’s behalf.

WEAPONS AND SURVEILLANCE CAMERAS: Company must be notified of any firearms in Client’s home and any firearms must be secured. Company must also be notified of any surveillance cameras in Client’s home and at least one (1) restroom must remain free of surveillance for employee use.

VALUABLES: Client agrees to secure and not entrust to Care Providers any Client valuables, including cash, jewelry, and confidential financial and personal information. Client agrees not to give any gifts, loans, bonuses, tips, payments, or advance any money to Care Provider without authorization from Company.

EQUAL OPPORTUNITY EMPLOYER: Company is an equal opportunity employer and does not discriminate and gives equal opportunities to employees and applicants, including with regard to staffing, without regard to race, color, religion, sex, age, national origin, disability, and/or any other characteristic protected by federal, state or local law.

INDEMNIFICATION, DISCLAIMERS, LIMITATION OF LIABILITY: In recognition of the relative risks and benefits of Services provided by Company, Client agrees to the fullest extent permitted by law to indemnify, defend and hold harmless Company and its officers, directors, members, employees, affiliated entities, successors and assigns (“Company Releasees”) from and against any and all causes of action, losses, liabilities, claims, damages, actions, suits, proceedings, settlements, judgments, costs and expenses (including reasonable attorneys’ fees) arising out of, or in connection with, any and all liability or cause of action, however alleged, related to or arising under Client’s acts, omissions, or breaches of this Agreement. Should Client fail to maintain automobile liability insurance, and/or fail to maintain sufficient coverage, or if the insurance coverage is denied for whatever reason, Client further agrees to release Company Releasees and hold them harmless and indemnify them from any claim, liability, or cause of action for any injury to Client or property damage resulting from the use of Client’s automobile if operated by Company, whether or not prior authorization from a Company office has been obtained. Company warrants and represents that the Services will be provided in a good and workmanlike manner in accordance with prevailing industry standards and applicable law. THE SERVICES ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS WITHOUT ADDITIONAL WARRANTIES. COMPANY MAKES NO REPRESENTATION, WARRANTY, OR GUARANTEE THAT THE SERVICES WILL MEET CLIENT’S REQUIREMENTS OR WILL BE AVAILABLE ON AN UNINTERRUPTED OR ERROR-FREE BASIS. COMPANY SHALL NOT BE LIABLE FOR INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, PUNITIVE, OR CONSEQUENTIAL DAMAGES IN CONNECTION WITH OR RESULTING FROM CLIENT’S USE OF OR INABILITY TO USE THE SERVICES. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY. COMPANY’S AGGREGATE LIABILITY FOR DAMAGES, WHETHER IN CONTRACT, TORT (INCLUDING NEGLIGENCE) OR ANY OTHER BASIS SHALL NOT EXCEED THE AMOUNT PAID BY CLIENT DURING THE PRECEDING THREE MONTHS PRIOR TO THE EVENT GIVING RISE TO THE CLAIM.

FALL RISK: Client understands that individuals with dementia, Alzheimer’s or any condition that causes physical instability or mental confusion are at high risk for experiencing falls. Client understands that even with the provision of twenty-four-hour Services, Client may potentially experience a fall. Company will make reasonable efforts to minimize fall risks; however, Client understands that the risk cannot be eliminated.

COMPANY COMMUNICATIONS: Client agrees Company may contact Client via email, phone or text for any purpose, including communications related to quality assurance, marketing, Service offerings, etc.

ELECTRONIC SIGNATURE: Client agrees any electronic signature is the legal equivalent of a manual signature on any applicable Client documents.

TERMINATION: Either Client/Responsible Party or Company may terminate the Agreement by providing twenty-four (24) hours written notice. Upon notice of termination, Client is obligated to pay all outstanding amounts owed under the Agreement.

ENTIRE AGREEMENT: This Agreement constitutes the entire agreement between Client/Responsible Party and Company

with respect to the subject matter hereof and supersedes all other prior agreements and understandings between them. This Agreement shall be governed and construed in accordance with the laws of the state where the Client received Services.

CLIENT & RESPONSIBLE PARTY INFORMATION | CLIENT & RESPONSIBLE PARTY INFORMATION | CLIENT & RESPONSIBLE PARTY INFORMATION | CLIENT & RESPONSIBLE PARTY INFORMATION | CLIENT & RESPONSIBLE PARTY INFORMATION | CLIENT & RESPONSIBLE PARTY INFORMATION

CLIENT: | CLIENT: | CLIENT: | CLIENT: | CLIENT: | CLIENT:

Name: _____________________________________________________________________________________________________ | Name: _____________________________________________________________________________________________________ | Name: _____________________________________________________________________________________________________ | Name: _____________________________________________________________________________________________________ | Name: _____________________________________________________________________________________________________ | Name: _____________________________________________________________________________________________________

Address: _____________________________________________ | Address: _____________________________________________ | Address: _____________________________________________ | City/State: _________________________ | City/State: _________________________ | Zip: ____________

Ph (H): ________________ | Ph (W): ________________ | Ph (C): ________________ | Ph (C): ________________ | Email: __________________________ | Email: __________________________

RESPONSIBLE PARTY (if other than the Client): | RESPONSIBLE PARTY (if other than the Client): | RESPONSIBLE PARTY (if other than the Client): | RESPONSIBLE PARTY (if other than the Client): | RESPONSIBLE PARTY (if other than the Client): | RESPONSIBLE PARTY (if other than the Client):

Name: _______________________________________________ | Name: _______________________________________________ | Name: _______________________________________________ | Relationship to Client: __________________________________ | Relationship to Client: __________________________________ | Relationship to Client: __________________________________

Address: _____________________________________________ | Address: _____________________________________________ | Address: _____________________________________________ | City/State: _________________________ | City/State: _________________________ | Zip: ____________

Ph (H): ________________ | Ph (W): ________________ | Ph (C): ________________ | Ph (C): ________________ | Email: __________________________ | Email: __________________________

SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING | SERVICES AND PRICING

a

SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate. | SERVICES
Company shall provide the following Services to Client as authorized and in accordance with applicable law:

Home Care   Skilled Care   Care Management 

RATES
Hourly Rate for Home Care Services: ____________/hour    
Rate for Home Care Live-In Shifts: ____________/day
Hourly Rate for Skilled Care Services: ____________/hour
Hourly Rate for Care Management Services: ____________/hour

HOLIDAY RATES
Company will charge one and one-half times the rates listed above for Services provided on holidays. Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Presidents’ Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Eve, Christmas, and New Year’s Eve.

MILEAGE REIMBURSEMENT
Client agrees to reimburse Company for automobile traveling expenses incurred by Care Providers in the performance of their duties for Client. Company will invoice Client for these expenses at the prevailing U.S. General Services Administration privately-owned vehicle mileage reimbursement rate.

INVOICE & DEPOSIT INFORMATION | INVOICE & DEPOSIT INFORMATION | INVOICE & DEPOSIT INFORMATION | INVOICE & DEPOSIT INFORMATION

INVOICES
Invoices are sent weekly for Services provided to Client and are due upon receipt. If Client requests invoices be mailed or electronically mailed to a different address or payor, please provide delivery information below: 
Name: 			________________________________________
Relationship to Client:	________________________________________ 
Street Address: 		________________________________________
City, State, Zip: 		________________________________________
E-Mail (if applicable): 	________________________________________

DEPOSIT 
Client agrees to pay Company a deposit of $__________ at the time of signing this Agreement. This deposit will be subtracted from the final invoice at the conclusion of Services between Company and Client. Client remains obligated for amounts due to the Company in excess of the deposit. Any unused portion of the deposit will be returned to Client. | INVOICES
Invoices are sent weekly for Services provided to Client and are due upon receipt. If Client requests invoices be mailed or electronically mailed to a different address or payor, please provide delivery information below: 
Name: 			________________________________________
Relationship to Client:	________________________________________ 
Street Address: 		________________________________________
City, State, Zip: 		________________________________________
E-Mail (if applicable): 	________________________________________

DEPOSIT 
Client agrees to pay Company a deposit of $__________ at the time of signing this Agreement. This deposit will be subtracted from the final invoice at the conclusion of Services between Company and Client. Client remains obligated for amounts due to the Company in excess of the deposit. Any unused portion of the deposit will be returned to Client. | INVOICES
Invoices are sent weekly for Services provided to Client and are due upon receipt. If Client requests invoices be mailed or electronically mailed to a different address or payor, please provide delivery information below: 
Name: 			________________________________________
Relationship to Client:	________________________________________ 
Street Address: 		________________________________________
City, State, Zip: 		________________________________________
E-Mail (if applicable): 	________________________________________

DEPOSIT 
Client agrees to pay Company a deposit of $__________ at the time of signing this Agreement. This deposit will be subtracted from the final invoice at the conclusion of Services between Company and Client. Client remains obligated for amounts due to the Company in excess of the deposit. Any unused portion of the deposit will be returned to Client.

CLIENT/RESPONSIBLE PARTY SIGNATURE | CLIENT/RESPONSIBLE PARTY SIGNATURE | CLIENT/RESPONSIBLE PARTY SIGNATURE | CLIENT/RESPONSIBLE PARTY SIGNATURE

By signing below, Client and/or Responsible Party acknowledge they have read the entire Agreement, including the terms and conditions below, and agree to be bound and comply with all terms and conditions contained in this Agreement. | By signing below, Client and/or Responsible Party acknowledge they have read the entire Agreement, including the terms and conditions below, and agree to be bound and comply with all terms and conditions contained in this Agreement. | By signing below, Client and/or Responsible Party acknowledge they have read the entire Agreement, including the terms and conditions below, and agree to be bound and comply with all terms and conditions contained in this Agreement. | By signing below, Client and/or Responsible Party acknowledge they have read the entire Agreement, including the terms and conditions below, and agree to be bound and comply with all terms and conditions contained in this Agreement.

Client:  _______________________________________________________________ | Date: ____________________________ | Date: ____________________________

Responsible Party: _____________________________________________________ | Date: ____________________________ | Date: ____________________________