Please select the service required. (You can select more than one.)

Authorization for Automated Withdrawals (Debit)

Company Information: Home to Stay LLC

Company ID: 46-1635620

I authorize Home to Stay to initiate entries to my checking/savings account at the financial institution listed above (BANK INFORMATION), and if necessary, initiate adjustments for any transactions credited/debited in error. 

This authority will remain in effect until Home to Stay is notified by me in writing to cancel it in such time to afford Home to Stay and the financial institution listed above a reasonable opportunity to act on it.

I request that payment of authorized benefits from insurance, or other responsible payer sources be made in my behalf to the above-named Home Care Agency. I understand that I am responsible for all amounts not paid by my insurance. If I am a private pay client, I agree to pay for all services rendered by the agency. 

We honor all rights of client privacy and HIPAA Guidelines. I hereby restrict Home to Stay to provide my health care information to the following person(s):

I understand my care is based on a treatment per agency policy. I have participated in the development of, and am in agreement with, the treatment plan outlined. My treatment plan may change as my care needs change and I will be informed. 

I understand that I have the right to refuse care or treatment at any time.

Hourly rates require a (4) hour minimum. 

Holidays will be billed at one and one half times the hourly, daily, or visit bill rate (whichever is applicable). Holidays include: New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, Christmas Day, and New Year's Eve (5:00 p.m. to 8:00 a.m.).

The rates quoted include all payroll, social security, and unemployment taxes, general and professional liability, workers compensation insurance, and all employee recruitment, screening and training expenses. 

Mileage is billed to the client when the H2S caregiver transport the Client or completes errands on behalf of the Client using the employee's vehicle at the federal mileage reimbursement rate.

Billing statements are mailed weekly and payment is due upon receipt. Billing is based on actual time worked, (or tasks performed during "visit"), by H2S employees as evidenced by their time card or electronic tracking.

Client and/or Guarantor understand that Home to Stay uses a telephony system to track time and attendance for our employees. Client and/or Guarantor guarantees payment for services rendered and then tracked/verified through this system. 

Credit card payments can be set up as a method of payment. H2S will adjust the rate by 3% to account for additional expenses incurred in processing, recording and reporting such transactions (i.e. expenses unrelated to the fee payable by H2S to the credit card issuer).

Payment for all services is the responsibility of the client receiving services unless stated otherwise. H2S may attempt to bill insurance or third party payer for services provided. You agree to pay H2S as soon as you receive an invoice from H2S, regardless of whether you believe an invoice should have been paid by your insurance or third party payer.

Cancellation Notice. Show-Up Pay will apply if client fails to notify H2S regarding cancellation of services for the scheduled shifts. The client will be responsible for a two-hour show-up fee, which will be billed to the client, for caregivers who show up for these scheduled shifts.

The client agrees to safeguard all cash, confidential information (e.g. social security or financial information), credit cards, valuables, or similar property; H2S will not reimburse the client for the loss of such information or property.

I agree not to employ any employee of H2S privately for a period of 12 months following the completion of services. In the event I violate this agreement, I shall be liable to pay the sum of $10,000.00 as liquidated damages. An employee is any individual who is working for or has worked for H2S within the last 12 months.

Although we expect to never have to use a collection process, the Client and/or Guarantor will receive statements after each week of completed services, 30 days, and 60 days (final notice). If the account remains unpaid, further collection efforts are pursued, which may include turning the account over to collections. The Client and/or Guarantor agrees that if H2S incurs any legal fees and related expenses in collection efforts, then the Client and/or Guarantor shall be responsible for paying H2S the legal fees and related expenses incurred.

If H2S has not received full payment for services within 30 days of the billing date, an interest charge of 1.5% is added to the bill each month the bill remains unpaid. H2S reserves the right to discontinue services at any time.

If services are cancelled before 30 hours of service are completed, a nominal fee of $75 will be charged for the nursing assessment. 

In the event the Client requests an agent or an employee of Home to Stay to transport and such is honored by the Home to Stay employee or agent and said agent's, employee's, or Client's personal vehicle is utilized, Client as part of the consideration for the services provided by Home to Stay, shall release, hold harmless, and indemnify Home to Stay agent or employee from any and all claims for physical or other injury or damages to Client and all liability and expenses that may result from said transport. 

The Client understands that the Home to Stay caregiver holds no liability for accidents that may occur while the Client is being transported to the caregiver's personal vehicle. The Client agrees to abide by the accident coverage held by the caregiver on his/her personal insurance. 

In the event that an employee of Home to Stay is permitted to drive the client in either the employee's or Client's own vehicle, Home to Stay shall verify either the employee or they Client's vehicle insurance depending on which vehicle is being driven in advance and prior to the transportation of the Client. 

As a home care provider, we have an obligation to protect the rights of our clients and explain these rights to you before treatment begins. Your family or your designee may exercise these rights for you in the event that you are not competent or able to exercise them for yourself. As a client of Home to Stay, you should be aware of the following rights and obligations you have in working with us:

1. To expect you and your property to be treated with courtesy and respect by all of our staff.

2. Be free from verbal, physical, and psychological abuse or harassment of any form.

3. To receive service regardless of race, creed, nationality, disability, age, marital status, gender or sexual orientation.

4. To work toward mutually agreed-upon goals.

5. Choose care providers, to communicate with this providers and to provide reasonable continuity of care.

6. To receive information on the qualifications and supervision of our caregivers.

7. To request a change of caregiver.

8. To know that our caregivers all work under regular supervision, and if medically related personal care is needed, the supervision will be performed by a registered nurse.

9. To privacy and the expectation that all records pertaining to your service are confidential. Except when required by law. Or for professional purposes within the agency, records can only be released with your permission, and in accordance with applicable legal requirements. It is mandatory that we report cases where neglect/abuse is involved, or a threat of harm to self or others is perceived.

10. To know that our organization maintains liability insurance

11. Review your case record, to request corrections or to submit rebuttal data, according to established procedures.

12. To discuss grievances regarding your service, or terminate service at any time.

13. To comment on agency services and make suggestions about how they could be improved.

14. To be responsible for prompt payment of all fees for services rendered.

15. To ask questions of the staff about anything they do not understand concerning the services provided.

16. To provide complete and accurate information concerning your present health, medication, allergies, etc.

17. To inform staff of your health history, including past hospitalization, illness and injury. 

18. To involve yourself and/or your caregiver, as needed and as able, in developing, carrying out and modifying their service plan. 

19. To review the agency's information on maintaining a safe and accessible home environment in your residence.

20. To respect the rights of all organization personnel and cooperate with them, regardless of race, color, religion, age, gender, sexual orientation, or national origin.

21. To request additional assistance or information on any phase of their service plan they do not fully understand.

22. To inform the staff when a health condition or medication change has occurred.

23.To inform the staff of any changes made to Advance Directives.

24. To notify the agency when they will not be home for a scheduled visit. There is a cancellation fee if agency is not gen 24 hours notice, except in the case of an emergency.

25. To notify the agency prior to changing your place of residence or telephone number.

26. Be informed of your state's home health aide agency in order to obtain information about home care agencies, to lodge complaints or to report abuse, neglect or exploitation, as applicable:

State of New Jersey

Department of Law and Public Safety

Division of Consumer Affairs

New Jersey Board of Nursing

124 Halsey St., 6th Floor, P.O. Box 45010

Newark, NJ 07101

I hereby grant permission for Home to Stay to use my loved one's images/videos for display on our website, educational, instructional, promotional videos or advertisements, or printed materials developed and distributed by Home to Stay.

I agree that my electronic signature is the legal equivalent of my manual signature on this Agreement. I am legally bound by this Agreement's terms and conditions. I further agree that my use of a key pad, mouse, or other device to select an item, button, icon, or similar act/action, or to otherwise provide Home to Stay or in accessing or making any transaction regarding any agreement, acknowledgement, consent forms, disclosures or conditions constitutes my signature (also known as "E-Signature"), acceptance and agreement as if actually signed by me in writing. I also agree that no certification authority or other third party verification is necessary to validate my E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of my E-Signature or any resulting contract between Home to Stay and I.