Please note: this is an online agreement and so please do not print this out. Please complete it online (you can type using the keyboard and sign using the mouse/pad) and then click Submit at the end. If you have any questions, call us at 212-614-8057.
Thank you!
Christian M Steiner
E / P / PDF

    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 franchise) (“Provider” or "Agency" used interchangeably) to provide Client (as herein defined below) with non-medical homecare service. Each Home Instead(R) franchised business is independently owned and operated.
  • / /
  • Please specify the relationship of this person to the Senior
  • 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
  • Questions? call us at 212-614-8057
  • * We reserve the right to freeze up to one week's worth of services.
  • Please list valuables here.
  • Please add
    1. Insurance Carrier Name
    2. Phone and fax # of the Insurance carrier
    3. Policy and Claims #s

Home Instead
400 East 56th Street
Professional Wing, Suite #2
New York, NY 10022
P: 212-614-8057
F: 212-614-8056 




 Manhattan's Trusted Source of Homecare to the Elderly