2023-03-20_skoyanagi_Montreal Client Consent Agreement English - Clean.docx

Client Consent Agreement

CLIENT NAME: ______________________________________________________________________________

This Client Consent Agreement (“Agreement”) is entered into on _________________________ (the “Effective Date”) by and between the  aforementioned Client(s) and/or the undersigned Client’s Authorized Agent (together referred to as “Client”) and Home Care Assistance of  Montreal, Inc. (“HCA” or “Company”). The “Parties” are HCA, Client, and Client’s Authorized Agent, if applicable, and, in the singular, refers  to any of them, as the context makes apparent.

CONSENT TO RECEIVE SERVICES

Company is hereby authorized to assign caregivers (“Caregivers”) to Client’s residence or other location identified by Client for the provision of personal attendant and/or companionship services, which may include assistance with activities of daily living such as companionship,  bathing, personal hygiene and grooming, ambulating, transferring, meal preparation, medication reminders, light housekeeping, personal  transportation, and other services, treatments and procedures as outlined in the plan of care (the “Services”). Client understands that no  guarantees will be made with respect to the outcome of these Services or of any treatments and procedures and Client waives any issues  of medical liability on Company’s part. A general description of services to be performed for Client is outlined as a part of the initial  assessment and updated as modifications become necessary.

CAREGIVER AGREEMENT

Client understands that Company spends a significant amount of time, money, and resources in the process of recruiting, screening, hiring  and training its Caregivers and therefore, each Caregiver is a valuable asset to Company. Client further understands that each Caregiver  working for Company is prohibited from accepting private employment from Client directly (or through another organization/agency) while  said Caregiver is employed by Company, as well as for a period of six (6) months following the conclusion of services rendered to the Client by the Caregiver through the Company. Accordingly, should Client desire to employ any of Company’s Caregivers, such employment will be deemed in violation of these restrictions. In the case that Client wishes to employ any such Caregiver within this six (6) months period, Client agrees to pay Company a one-time placement fee of THIRTY THOUSAND DOLLARS ($30,000.00), which  amount shall be due within ten (10) business days of employment of such Caregiver. Payment of such amount does not affect any liability or contractual obligations that the Caregiver may have toward Company. __________ (INITIALS)

RATES AND HOURLY MINIMUMS

Until notice is given by Company to the contrary, the rates for care are as follows:

Company will charge one- and one-half times the normal rate for services rendered on holidays, although Client can decline holiday service  by notifying Company at least seventy-two (72) hours in advance. Observed holidays are: New Year’s Day, Easter Monday, Victoria Day,  Saint-Jean-Baptiste Day, Canada Day, Labour Day, Thanksgiving Day, and Christmas Day.

Client hereby acknowledges responsibility to pay additional service fees for any additional hours the caregiver is requested or required to  work including, but not limited to, extra time spent on the shift at the client’s request or need, missed break periods at the client’s request  or need, and specialized training or meeting times at the client’s request or need. This additional time may be billed at overtime (one and

one-half times the billing rate) if the client is requesting the caregiver to work beyond the normal schedule and directly causing Company  to incur overtime payroll. Overtime can be avoided by confirming schedules in advance with HCA and accepting alternate coverage  strategies proposed, including back-up Caregivers.

Client also acknowledges that HCA may periodically modify the billing rates due to client circumstances, regulatory changes, or company wide policies, including our automatic annual increases. Client acknowledges the receipt of notice from HCA with at least three (3) weeks’  written notice or completion of a new Client Consent Agreement as sufficient for modifications to the billing rates. HCA acknowledges that  the client may request an updated Client Consent Agreement in the event of any rate change and will not withhold one unreasonably.

DEPOSIT

Client agrees to make a prepayment of $_________ for ________ minimum hours of care. Company will immediately apply the prepayment  toward services rendered. When the prepayment is exhausted, Client agrees to pay future invoices for services upon receipt,  consistent with this Agreement. EXCEPT AS SET FORTH BELOW, THE DEPOSIT IS NON-REFUNDABLE FOR THE MINIMUM HOURS OF CARE  REQUIRED BY THIS AGREEMENT. CLIENT ACKNOWLEDGES THAT THEY REMAIN RESPONSIBLE FOR THE PAYMENT OF THE DEPOSIT  IRRESPECTIVE OF WHETHER CLIENT USES THE SERVICES FOR THE MINIMUM HOURS. In its sole discretion, Company may issue a pro-rata  refund of the deposit to the Client. Examples of refund requests include the Company terminating its service without servicing the Client  for the minimum hours due to Client mortality, or in the case of Company’s failure to deliver services to Client. For any such incidents,  Client may request a refund of the deposit by submitting a written request to Company.

MEAL AND REST PERIODS

Caregivers are entitled to a thirty (30) minute break for every five (5) hours worked.

Live-In care is defined as a twenty-four (24) hour shift. Live-In Caregivers are entitled to receive four (4) hours of break time spread  throughout the day for meals and personal time. All meals within reason are to be provided for the caregiver by the client. Client  understands that if a Caregiver has any special dietary restrictions or preferences that are not reasonable for Client to adhere to, Client is  not obligated to do so. In general, however, Client and Caregiver share the same meals. Live-In Caregivers are also entitled to one six (6)  to eight (8)-hour block of uninterrupted sleep period every evening. During this period, the caregiver is not to be disturbed and is  considered off-duty and must be provided with decent, private, and sanitary accommodations.

Unless otherwise agreed upon, or in the case of an emergency, the Caregiver will not leave Client premises during a scheduled shift. Client  understands that circumstances beyond Company’s control (e.g., Client or Caregiver short-term illness, change in Client sleep patterns,  etc.) may require additional hours to be provided at the hourly rate specified above. Any additional service charges will be reflected on the  client’s regular invoice.

CANCELLATIONS

Cancellations received less than forty-eight (48) hours before a scheduled shift will result in that shift being charged in full. All schedule  changes should be coordinated with Company to ensure accurate staffing and billing.

A Client who sends a Caregiver home before the end of their scheduled shift will be billed for the entire shift. INVOICING AND PAYMENT

Invoices are sent weekly and are due upon receipt. Company accepts payment by pre-authorized bank debit or e-transfer only. A credit  card may be requested as backup. Non-Payment in excess of thirty (30) 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. If Client requests that invoices be mailed or electronically  mailed to an address or payor other than Client’s home, please provide delivery information below.

Name: ________________________________________

Relationship to Client: ________________________________________

Street Address: ________________________________________

Province, Postal Code: ________________________________________

E-Mail (if applicable): ________________________________________

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CAREGIVER PROTECTIONS

Caregivers are instructed not to put themselves at risk of bodily harm or injury in the provision of companionship services. Thus, Client  understands and acknowledges that if there is an imminent risk of physical harm to Caregiver while performing companionship services,  the Caregiver is entitled to leave Client’s premises without exposing the Caregiver and/or Company to any liability and the Client remains  liable for the full payment of fees.

If Client uses surveillance cameras onsite, Company must be notified prior to starting services and at least one (1) restroom must remain  free of surveillance for Caregiver use.

Client will not give or leave cash, credit or debit cards, financial account information, disclose pass codes, jewelry, or other valuables unattended or in the presence of a Caregiver, or entrust the same to Company Caregivers. Client further agrees not to advance money or  give any gifts to Company Caregivers, employees, or representatives without first obtaining Company’s written consent.

Home Care Assistance is an equal opportunity employer. We do not discriminate and give equal opportunities to employees and applicants  without regard to race, color, religion, sex, age, national origin, disability, and/or any other characteristic protected by law.

LIMITATION OF LIABILITY

In recognition of the relative risks and benefits of services provided by Company, Client agrees to indemnify and hold Company, its affiliates,  partners, members, managers, officers, directors, agents, and employees (collectively, the “Indemnified Parties”) harmless from and  against any and all actions, damages, claims, liabilities, costs, expenses, or losses (including, without limitation, reasonable legal fees and  expenses) brought against, incurred by, or paid by any of the Indemnified Parties, for injuries arising out of, or in connection with, any and  all liability or cause of action, however alleged, related to or arising out of this Agreement, but expressly excluding claims resulting from an  Indemnified Party’s gross negligence, intentional misconduct, or breach of any material obligation in this Agreement.

The foregoing limitations of liability and indemnity cover and include, among other things, loss of or damage to cash, jewelry or furnishings;  or loss or damage resulting from the Services or Company (whether or not within the express scope of the services contracted under “Services” above); the operation and/or use of a vehicle by a Caregiver, whether that vehicle may be owned by the Client or provided by  the Caregiver or Company, a Client’s fall, handling of emergencies affecting Client, food preparation, or events occurring while a Caregiver  is on an authorized break.

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. Client further understands that Company will make reasonable efforts to minimize fall risks; however, Client understands  that the risk cannot be eliminated.

ELECTRONIC SIGNATURE

❏ By checking this box, client agrees and acknowledges that his or her electronic signature provided to Home Care Assistance (also  referred to as E-Signature), is the legal equivalent of a manual signature. Client expressly authorizes Home Care Assistance to use Client’s E-Signature to indicate Client’s validation of care notes and daily timesheets, which may be used to verify services for third-party insurance companies, provincial regulations, or other governing bodies.

CERTIFICATION OF AUTHORITY

If someone other than Client(s) (hereafter referred to as an “Authorized Agent”) signs this Agreement on behalf of Client(s), said Authorized  Agent hereby certifies that he/she has the authority to enter into this Agreement on behalf of said Client(s) and bind Client(s) to the terms  hereof. Client and Authorized Agent accept full responsibility for payment of all fees incurred for services rendered to Client(s) pursuant to  this Agreement.

TERMINATION

Company reserves the right to terminate this Agreement and/or deny services for good cause, which includes failure to provide a safe  environment to our employees, delinquencies in paying invoices, requests for services that Company cannot legally provide and/or a breach  of a material term of this Agreement. Upon notice of termination, Client is obligated to pay all outstanding amounts owed under the  Agreement.

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ENTIRE AGREEMENT

This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all other  prior agreements and understandings, both written and oral, between the Parties. This Agreement shall be governed and construed in  accordance with the laws of the province of Québec.

Client and/or Authorized Agent have read and fully understand the contents of this Agreement and agree to the terms.  Client or Authorized Agent Date Capacity of Authorized Agent in Relation to Client

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Service Type | Rate | Period

Hourly Care: 16 or more hours per week*  
($32-$36 per hour)  
Minimum commitment of _________ total hours of service. | per hour

Live-In Care: Individual | per day

Live-In Care: Couple | per day

Mileage (if Caregiver’s vehicle is used) | $0.75 | per KM

Parking | Varies | When services are rendered at a  hospital, client may incur a  caregiver parking charge

CTM Interventionist | $51 | per hour

Non-Scheduled Care Manager Visit | $60 | per visit