ADMISSION, CONSENT FOR SERVICE, AND RELEASE OF INFORMATION AGREEMENT: Couples

 Please indicate service frequency and times requested.

Always Good Company has a 3-hour minimum for each requested shift.

Service Charges / Fees are as follows:

Less than 6 hours/ week: $45/hour; $50/hour for overnights & weekends; additional $20 monthly administrative fee

6+ hours/week: $45/hour; $50/hour for overnights & weekends (no monthly administrative fee)

This service agreement verifies that the client and/or responsible party listed above has requested services, consents to services, and authorizes Always Good Company Home Care, Inc. to release information to specified persons involved in the client’s care. The client and/or responsible party must initial each section and provide a signature acknowledging that a representative of Always Good Company Home Care, Inc. has reviewed and explained the policies below. Always Good Company Home Care, Inc. is not responsible for the accuracy of information collected from the client and believes all information collected from the client and/or responsible party during the initial evaluation is true and accurate.

SCOPE OF SERVICES: Always Good Company Home Care, Inc. is approved and licensed by the NC Department of Health and Human Services to provide Home Care services to individuals in a place of temporary or permanent residence used as an individual’s home. Services include companion care, sitter, respite care, and in-home aide services. The client and/or responsible party agree to notify Always Good Company Home Care, Inc. of any changes in the client’s health status that would require a change in the client’s level of care.

 
CANCELLATION OR CHANGES TO SERVICES: Always Good Company Home Care, Inc. will respond promptly to service changes requested by the client and/or responsible party. Requests for service changes must be authorized by Always Good Company. The client and/or responsible party agree to provide at least 24 hours’ notice to make changes to or discontinue services. A cancellation is not accepted if a caregiver has arrived or is in route to the assignment. In the event that services are changed or cancelled without 24-hour notice, the client will be billed for and the caregiver will be paid for the scheduled hours. Client will be billed for the hours agreed to and scheduled, even if client sends the caregiver home before the end of a shift.

 
BILLING: There is no charge for the initial evaluation. The client and/or responsible party will be billed bi-weekly for services provided. Always Good Company has a 3-hour minimum. Schedule shifts of less than 6 hours per week will incur a monthly service fee of $20. Payments may be made securely by bank draft or credit card using your payment portal. Client agrees to companion care services at a rate of ______/hour, and at a rate of ______/hour for weekend and/or overnight care. A weekend is defined as Friday beginning at 5 pm through Monday morning at 8 am. An overnight is defined as companion care services from 8 pm through 8 am the following day.

 
INTERRUPTION IN SERVICE: The client understands that Always Good Company uses its best efforts to provide uninterrupted services; however, occasional interruptions may be unavoidable. During interruption of essential services, the client agrees to provide or arrange for back-up care, as needed.

HOLIDAY SERVICE: If service is provided on one of our seven recognized holidays, the rates are charged at time and one-half. Holidays include: New Year’s Day, Easter Sunday, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day.

 
EMERGENCY CARE: Always Good Company Home Care, Inc. is licensed to provide non-medical companion care, sitter, respite care, and in-home aide services. In the event of a medical emergency the caregiver will call 911 for emergency medical assistance.

 
PERMISSION TO PHOTOGRAPH: The client understands and authorizes photographs to be taken and used occasionally on the website and on social media. Client will always be asked permission before a photograph is taken.


COMPLAINT POLICY: All clients serviced by Always Good Company Home Care, Inc. have the right to participate in decisions regarding their care and/or services, to voice grievances/complaints and to recommend changes in policies, care and services without coercion, discrimination, reprisal and/or unreasonable interruption in services. If you are not satisfied with your care or services at any time we request that you call us so that we may attempt to resolve the problem. Administrators must respond to your concerns within 3 business days from receipt of the request. Please call 910-538-5207.

 
PROHIBITION TO EMPLOY AGC PERSONNEL: The client understands that they may not independently employ or contract any personnel sent to the client by Always Good Company while still receiving services from Always Good Company, or within one (1) year from client’s date of discharge or completion of services from Always Good Company. In the event that such employment or contracting was to occur, client agrees to pay a Finder’s Fee to Always Good Company in the amount of five thousand ($5,000.00) dollars, payable upon demand.

 
INDEMNITY AND ACKNOWLEDGEMENT: Always Good Company Home Care, Inc. is not responsible for claims made under its bond unless such claims are reported in writing by the client and/or responsible party within 14 days of occurrence.

 

PLEASE READ & INITIAL:
The client and/or responsible party request admission to Always Good Company Home Care, Inc., and consent to receive companion care described in the Scope of Services and above policies, which is authorized by me and/or my representative.

 

A representative of Always Good Company Home Care, Inc. has provided a copy of the Client Bill of Rights and the client and/or responsible party has had the opportunity to review it and to ask questions.

 

Always Good Company Home Care, Inc. is authorized to release information regarding my care and services to the following person(s):

 

The undersigned certifies that he/she has read the above policies and is the Client, or is duly authorized by the Client’s general agent to execute the above and accept its terms. The client and/ or responsible party acknowledge that all the information on this form is correct and my signature represents that I have read and understand this form in its entirety.