Facebook-f Linkedin-in Google Instagram Yelp
Quick Inquiry
Schedule Appointment
This field is for validation purposes and should be left unchanged.

1. PARTIES INVOLVED

CARE PROVIDER / AGENCY

2. SCOPE OF SERVICES & SCHEDULE

CHECK ALL AUTHORIZED NON-MEDICAL CARE SERVICES:
AUTHORIZED DAYS:

3. PRIVATE PAY RATES & FINANCIAL TERMS

Services are provided strictly on a private-pay (out-of-pocket) basis. Services are not billed to Medicare/Medicaid.

BILLING FREQUENCY
ACCEPTED PAYMENT METHOD

4. TERMS & CONDITIONS

  1. Payment Responsibility: The undersigned Client/Guarantor assumes full financial responsibility for all services rendered. Invoices are due upon receipt or according to the agreed billing schedule.
  2. Cancellation Policy: A minimum of 24 hours' notice is required to cancel or modify a scheduled care shift. Shifts canceled with less than 24 hours' notice will be billed at the standard rate for up to 4 hours.
  3. Late Payment & Interest: Accounts remaining unpaid after 15 days from the invoice date are subject to a late fee of $25 or 1.5% interest per month, whichever is greater.
  4. Long-Term Care Insurance (LTCI): If applicable, the provider will provide itemized invoices for LTCI reimbursement claims; however, direct payment to the provider remains the responsibility of the client.
  5. Termination of Service: Either party may terminate this agreement at any time by providing at least 7 days' advance written notice.
Clear Signature
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

Quick Inquiry

This field is for validation purposes and should be left unchanged.

Schedule Appointment

This field is for validation purposes and should be left unchanged.