HOME INSTEAD SENIOR CARE SERVICE AGREEMENT
Please note: this is an online agreement and so please do not print this out, please just fill it out online (you can type using the keyboard) and then click Submit at the end. If you have any questions, call us at 212-614-8057.
Christian M Steiner
The Undersigned (as herein defined below) wishes to enter into this Service Agreement (the “Agreement”) with Home Care Associates, Inc., (d/b/a an independently owned and operated Home Instead Senior Care franchise) (“Provider” or "Agency" used interchangeably) to provide Client (as herein defined below) with non-medical homecare service. Each Home Instead Senior Care(R) franchised business is independently owned and operated.
The Undersigned (as herein defined below) wishes to enter into this Service Agreement (the “Agreement”) with Home Care Associates, Inc., (d/b/a an independently owned and operated Home Instead Senior Care franchise) (“Provider”) to provide Client (as herein defined below) with non-medical homecare services. Each Home Instead Senior Care(R) franchised business is independently owned and operated.
Date this agreement is being signed
Name of person to receive home care services from Provider ("Client" and/or "Senior", used interchangeably)
Name of Person filling this out (the "Undersigned")
Email of the Undersigned
Relationship of the Undersigned to Client
Self (I am the Client)
Health Care Proxy (I am the legally appointed Health Care Proxy for the Client)
Family Member (I am a family member and as such, I can sign and bind this agreement)
Authorized Third Party (I am legally authorized to sign this agreement and it's provisions)
COVID-19 (Coronavirus) Intake Screening - please note that we are not taking any cases whereby the Patient is positive (or suspected to be positive) for COVID
Please check off any and all that apply
(*) Senior (nor anyone living with Senior) does not (did not have) a diagnosis of COVID-19 (or suspected COVID-19)
(*) Senior (nor anyone living with Senior) did not recently travel to any of the following countries: China, Iran, South Korea, Italy, Spain or Japan
(*) Senior (nor anyone living with Senior) has not had contact with anyone with confirmed COVID-19 (or suspected COVID-19) in the last 14 days
(*) Senior (nor anyone living with Senior) does not have Fever greater than 100
(*) Senior (nor anyone living with Senior) does not have Difficulty breathing
(*) Senior (nor anyone living with Senior) does not have Cough
***************COVID-19 PATIENT INFORMATION GUIDE ***************
By typing in the field below, I acknowledge receiving access to written education and information concerning the Coronavirus and how to keep myself and my home as safe as possible (click this link)
***************COVID-19 LIABILITY WAIVER AGREEMENT ***************
SIGNATURE: By typing in the field below, I the Undersigned, do the following:In recognition of the relative risks and benefits of services provided by the Agency, Client assumes all risks other than gross negligence by the Agency in connection with risks associated with the COVID-19 pandemic. Client agrees to the fullest extent of the law that Agency and its owners, officers, directors, members, employees, independent contractors, successors, and assigns shall not be liable if Client contracts COVID-19 and/or suffers any complications from contracting COVID-19, including death. Client also agrees to hold harmless Agency and its owners, officers, directors, members, employees, independent contractors, successors, and assigns from and against any and all causes of action, obligations, losses, liabilities, penalties, claims, damages, actions, suits, proceedings, settlements, judgments, and costs and expenses (including reasonable attorneys’ fees) arising out of, or in connection with, Client being diagnosed with COVID-19 and any subsequent complications from the disease, including death, except for gross negligence or as otherwise prohibited by law.
***************SECTION: CONSENT, AUTHORIZATIONS FOR INTAKE, ASSESSMENTS, VISITS, COMMUNICATION, HOME CARE SERVICES ***************
SIGNATURE: By typing in the field below, I the Undersigned, do the following:
• Authorize Provider to conduct a nursing assessment, a home safety assessment and conduct periodic nursing visits (some of which are announced, others of which will be unannounced (to assure staff is doing their job well)) and consent for services
• Give consent and authorization for release of Client medical information to Provider
• Authorize Provider to take photographs and/or video for purposes of documentation (never for marketing or any purposes that will entail publication to anyone not involved in the underlying services) or to have caregivers do same in the home for similar purposes
• Authorize Provider and caregivers to use power and wifi for purposes of using technology such as tablets or smart phones or computers to submit reports and pull up information related to the underlying services
• Authorize Provider to release copies of Client's medical records, reports or summaries as may be relevant for services
• Unless I detail specific members (in the Notes section at the bottom of this Agreement) to whom not to communicate, I hereby consent to have Home Instead communicate with (i) me (ii) members of my family where appropriate or (iii) other physicians, nurse practitioners and pharmacists via (a) telephone (b) e-mail (c) fax or (d) other method of communication regarding my condition, my medications and my home care and other things related to my home care. I understand that e-mail is not a confidential method of communication.
***************WRITTEN INFORMATION/ WELCOME PACKAGE***************
By typing in the field below, I acknowledge having being provided oral and written information in the Welcome Package concerning: Home Instead services, NYS Proxy Law/ Advanced Directives, Homecare Bill of Rights, Privacy Policies (HIPAA)(click this link to download an additional copy of the written version that was provided in the Welcome Package)
***************SCOPE OF PRACTICE OF HOME HEALTH AIDES/ PERSONAL CARE AIDES***************
Click here, this link has a list of all the things Home Instead caregiver ("Caregivers") CAN do
By typing in the field below, I acknowledge a Caregiver as defined above is a non-medical paraprofessional whose scope of practice does NOT include the following: CPR, detecting strokes, tube feeding, wound care, medication administration, assuring that medications are taken by Client as prescribed, finger sticks, oxygen management, nebulizing medications, bookkeeping for petty cash spending, medical observations, monitoring vitals, proper communication of observations and other things possibly associated with a medical or nursing professional. I acknowledge that I have chosen to not hire an LPN or RN or other licensed professional who would be able to provide these such services
Mental/ cognitive status (Choose 1)
1. Senior has FULL capacity, will direct all decisions (no need to involve anyone else)
2. Senior has IMPAIRED capacity, will direct all decisions but please just inform the designated person below
3. Senior has IMPAIRED capacity, will direct all decisions but please get approval from designated person below (designated person below is authorized to disapprove of any decisions made by Senior)
4. Senior LACKS capacity, decisions need to be made by designated person below
Name of Person who will assist with care management related decisions
Please specify the relationship of this person to the Senior
Client takes medications (Choose 1)
Directly from the pill bottles (Client has capacity to do this)
Directly from the pill organizers (labeled Sun, Mon, Tues, Wed, Thurs, Fri and Sat)
If you choose that medications will be pre-poured in pill organizers (labeled Sun, Mon, Tues, Wed, Thurs, Fri and Sat), please let us know who will be pre-pouring
I did not choose that option, the Senior will be taking the medications directly from the bottle
I am requesting medication pre-pouring services at the charge of $250 per visit which should be able to cover 3-4 weeks of medications, performed by an LPN or RN (I acknowledge that a Home Health Aide cannot do this, only reminders).
The name of the person designated for this task is (please add name)
A Home Health Aide cannot pre-pour medications, they can only remind them to take them from the pill organizers. Please call us if this is not clear at 212-614-8057
Client needs the following assistance from Home Instead Senior Care Caregiver
No assistance needed with medications
Simple Medication reminders from a Home Health Aide (which does not entail Provider assuring medication will be taken as prescribed)
Questions? call us at 212-614-8057
***************RISK OF FALL***************
Duties of Provider entail many activities that require Provider to leave the Client unattended (e.g. including but not limited to preparing a bedside bath, meals, organize/clean home, preparing clothing) and/or leave the Client’s home (e.g. to shopping, errands) or to be resting (when the Provider's caregiver is allowed for rest time).
By typing in the field below, I am stating that I understand that Provider's service does not include assuring falls do not take place
If Client explicitly or implicitly refuses care (as is Client’s right under the NYS Patient Bill of Rights), Provider's caregivers must respect the Client’s right. This may result in Client falling as well as Client not taking medications or other things otherwise beneficial to the Client.
By typing in the field below, I am stating that I understand this
***************BILL OF RIGHTS***************
By typing in the field below, I acknowledge receipt and understanding of Client's rights
1. Be informed of your rights both verbally & in writing at time of admission & prior to initiation of care.
2. Receive competent, individualized care and service from Provider staff regardless of age, race, color, national origin, religion, sex, disease, disability or any other category protected by law or decisions regarding
3. Be treated with dignity, courtesy, consideration, respect and have your property treated with respect.
4. Be informed verbally and in writing of the services available and related charges and to be informed of any changes no later than thirty (30) calendar days after Home Instead Senior Care, becomes aware of the change.
5. Be informed both orally and in writing, in advance of the Plan of Care, of any changes in the Plan of Care, and to be included in the planning of care before treatment begins; be informed of all treatment prescribed.
6. Participate in the planning of your care and be advised in advance of any changes to the plan of care.
7. Refuse care and treatment after being fully informed of and understanding the consequences of such actions and to initiate an Advance Directive, “Living Will”, durable power of attorney and other directives about
your care consistent with applicable law and regulations. Refuse to participate in research or experimental treatment.
8. To appropriate assessment of pain and management of his/her pain.
9. Receive information regarding community resources and to be informed of any financial relationships between Home Instead Senior Care and other providers to which you may be referred to by the agency.
10. Be informed of the procedures for submitting patient complaints, voice complaints and recommend changes in the policies and services to Director of Patient Services by calling the following telephone number: 212-614-8057. The expression of such complaints by the patient shall be free from interference, coercion, discrimination or reprisal.
11. If dissatisfied with the outcome, you may also submit the complaint to the NYS Department of Health or any outside representative of the patient’s choice.NYS Department of Health. Metropolitan Regional Office. 90 Church St New York, New York 10017. 212-417-5888. The expression of such complaints by the client or client designee shall be free from interference, coercion, discrimination or reprisal
12. Express complaints about the care and services provided or not provided and complaints concerning lack of respect for property by personnel furnishing services on behalf of Home Instead Senior Care, and to expect the agency to investigate such complaints within 15 days of receipt of complaint. Also, if dissatisfied with the
outcome, may submit an appeal to the agency’s governing authority which will be reviewed within 30 days of receipt of appeal request.
13. Receive timely notice of impending discharge or transfer to another agency or to a different level of care and to be advised of the consequences and alternatives to such transfers.
14. Privacy, including confidential treatment of records and access to your records on request. Information will not be released without your written consent except for those instances required by law, regulation or third
15. In the situation when the patient lacks capacity to exercise these rights, the rights shall be exercised by an individual, guardian or entity legally authorized to represent the patient.
By typing in the field below, I acknowledge my responsibility (as 100% guarantor) to make the following payments (irrespective of (i) any capacity or arrangement as power of attorney for the Client or (ii) any insurance arrangement with Home Instead outside of an executed Assignment of Benefit agreement) for services rendered
- Hourly Rate (PCAs/HHAs) for one senior: $35 per hour (see overtime and couples section below)
- Live-in Rate (PCAs/HHAs): $560 per live-in day (as detailed in live-in section / Miscellaneous)
- Initial Nurse Assessment/Care Consult: $125. This fee is waived for those clients who choose to pay for services through ACH (direct debit) method.
- Sick Visits (RN): $125 per visit (if Client requests or needs)
- Periodic RN Visits (RN): $150 (if Client requests)
- Medication Prepour (RN): $250 per visit (if Client requests)
- Specialized RN Visits (RN): $250 per visit (if Client requests)
- Care Coordination/ Management: $250 per hour (if Client requests or needs)
I. HOLIDAYS: Rates for Services are computed at time and one half for the following 8 holidays: (1) New Year's Day (2) President’s Day (3) Easter Sunday (4) Memorial Day (5) Independence Day (6) Labor Day (7) Thanksgiving Day (8) Christmas Day.
II. Minimum hours: Shifts can be every day or as little as once a month but we require that any weekday shift be at least 5 hours and weekend shifts be at least 8 hours.
III. One person vs. Couple: this rate is for one person. If the caregiver is caring for another person there will be an additional charge depending upon how much the caregiver is doing for the second person (up to 50% increase). Please make a note if this is the case.
By typing in the field below, I acknowledge I read and understood and agree to this entire section.
I understand that choosing to pay overtime allows me to maintain continuity after the 40th hour by keeping the same caregiver (assuming that caregiver is available).
I acknowledge that Overtime will be charged at 1.5 times the hourly rate for hours worked in excess of 40 hours per week (Sunday thru Saturday) by any single caregiver.
Choosing to not pay overtime will result in a new caregiver after the 40th hour.
I authorize the following with respect to overtime:
I want to maintain continuity and have the same caregiver after the 40th hour and I am willing to pay overtime. (Note: this is the most recommended option; 90% of our clients prefer continuity of personnel, over the savings.)
I do not want ANY overtime and understand that any caregiver I like will not work more than 40 hrs per week. (Note: this choice may entail the introduction of additional caregivers; this is the less optimal option if you prefer less aides.)
************Financial Guarantee/ Method of Payment ************
I acknowledge that Home Instead is relying upon my unconditional commitment to guarantee payment for homecare services rendered to Client (irrespective of the Client’s ability to pay for the services).
I authorize payment every 14 days for services rendered as established under the pricing detailed through the following method:
Choice #1) ACH Direct Debiting (we debit directly from your account, most popular (Initial Care Consult/Assessment fee is waived for you if you choose this method))
Choice #2) Payment by Credit Card (plus 2.5% service charge)
Choice #3) Payment by check with a Credit Card on file (with 6% yearly interest charge after 30 days of no payment in addition to 2.5% service charge)
Choice #4) Direct billing to LTC Insurance (subject to Assignment of Benefit form filled out by Client & accepted by Home Instead and LTC). Credit Card or ACH is required, given that any amount not paid by insurer is responsibility of the undersigned
Please enter the information for one of these payment/guarantee options * (also required for payment by check): this is a 100% secured site
1) ACH Info (a) Name of Bank (b) Routing Number (c) Account #
2) Credit Card Info (a) Credit Card # (b) Exp Date (c) Security Code (d) Name on Card
* We reserve the right to freeze up to one week's worth of services.
E-Invoices - please list names and emails of those who you would like for us to email copies of invoices as they are generated
Quality Assurance (Telephone Calls) - please note we do periodic quality assurance calls. Please let us know all people who should be called for this. Please also note that unless you tell us otherwise, we will reach out to the senior for such calls.
Staffing Changes (Telephone Calls) - please note that when there is a last minute change in staffing, we want to know who to call (besides the senior). Please let us know who else to call or email.
************Long Term Care Insurance/ Major Medical Insurance and other Insurances ************
I hereby request that Home Instead Senior Care submit paperwork for LTC insurance so that Client gets reimbursed. In doing so, I acknowledge that Home Instead will assist in making claims and procuring benefits eligibility under Long Term Care Insurance or other type of insurance. However, I understand that they are making no representation as to whether or not payment(s) will actually be made or that I am even eligible for benefits. That is 100% my responsibility to do that
1. Insurance Carrier Name
2. Phone and fax # of the Insurance carrier
3. Policy and Claims #s
1. Cancellation: I acknowledge that either party may cancel services at any time and for any reason with 48 hours written or verbal notice. Unless Client gives such notice to Agency, Client will be charged for shifts scheduled within 48 hours of cancellation.
2. Non-Solicitation. I (or any affiliate of mine or the Client) agree not to engage, hire, employ or socially visit with any of Home Instead‘s employees nor will I (or any affiliate of mine or the Client) indirectly solicit, induce, recruit or encourage any of Home Instead's employees to leave their employment with Home Instead (or work privately through any arrangement outside of working with Home Instead) while this Agreement is in effect and continuing for a period of one (1) year after the termination of this Agreement, unless I receive Home Instead’s approval and pay Home Instead a referral fee in an amount equal to the greater of 3 months of service or $25,000 per employee, plus additional monetary damages as allowed by law and/or injunctive relief. I agree that any breach of this agreement will cause Home Instead substantial and irrevocable damage.
3. Live-In Caregivers (if applicable): I acknowledge that I am being offered a discounted rate based on the following 3 conditions (i) that I am providing sleeping accommodations including a bed and a closed off place where the caregiver can sleep and maintain his/her personal belongings (ii) 3 meals a day are being provided to the caregiver (meals are to be reasonable and that what the Senior is eating unless the Senior is on a restricted diet) and (iii) the live-in caregiver must be given the opportunity to get 8 hours of uninterrupted sleep at nighttime. If these conditions are not met, we will not be able to provide a live in caregiver at the discounted rate and alternative arrangements (such as two 12 hour shifts at the hourly rate) will need to be provided. I acknowledge that if meals are not provided, an additional $15 per day meal fee will be added to my invoice.
4. Services provided in an adult care home or hospital. I fully acknowledge that any services provided by Provider at any facility (any hospital, nursing home, assisted living facility, independent living facility) are subject to certain legal restrictions. In these instances, I have hired Provider to exclusively provide custodial non-medical support for the Client. Personal care, ambulation, doctor’s appointments and general or specific health issues is 100% responsibility of the adult care home or hospital in which Client resides. Whenever Home Instead is not responsible for providing personal care the services will be referred to as Companionship Services.
5. In the event of non-payment, I will be charged interest at a rate of 6% per year on any balance left unpaid after 30 days. I further agree to pay all collection costs including attorney’s fees incurred in collection if my balance is not paid within 90 days.
6. Dispute Resolution: This Agreement shall be governed by, and constructed in accordance with the laws of the State of New York and will be litigated in New York. This guaranty will bind my heirs, executor, administrator,
successors and assigns.
By typing below, I agree to the aforementioned provisions entirely
************NOTES (optional) to detail any questions or concerns or exceptions to the aforementioned provisions***************
By signing my name in this field I am stating that I have read, understand and agree to the terms set forth within this contract.
Any questions? Call 212-614-8057 or email
Billing questions? Please email
Bal - Any insurance questions, please email
Rosa - Any insurance questions, please email
Questions for the owner? Please email
Home Instead Senior Care
400 East 56th Street
Professional Wing, Suite #2
New York, NY 10022
Manhattan's Trusted Source of Homecare to the Elderly