New Client Service Agreement

BrightStar Care

44004 Woodward Avenue, Suite 100, Bloomfield Hills, MI 48302 248-952-9944
SERVICE AGREEMENT
44004 Woodward Avenue, Suite 100, Bloomfield Hills, MI 48302
Client Receiving Services:*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Date of Birth*

MonthDayYear
Date
Age*
Payor Name*
Address*

Address

Street Address Line 2

CityState / Province

Zip
Phone number*
Email*
example@example.com
Payment Method*

Option 1: ACH withdrawl from bank account: I authorize BrightStar Care to make weekly deductions:Option 2: Credit Card I authorize Brightstar Care to charge my credit card weekly (An additional $0.50 per hour will be charged to my rate for credit cards)
Name of Bank:
Name on Account

First NameLast Name
Credit Card Type

VisaMasterCardAmerican Express
Name on Card

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Caregiver/home health aide hourly rate: blanks (based on required level of care). Skilled Nurse visits, (2 hours or less): Flate Rate $180 (up to two hours).
(Skilled visits such as medication set-up, wound care, infusions, etc.) are not included in BrightStar Caregiver hourly rate.
Signature of Responsible Party*

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Date

MonthDayYear
Date
BrightStar Staff Signature

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Date

MonthDayYear
Date

1.0 Emergency Medical Treatment: In the event of a medical emergency, I authorize BrightStar to perform CPR and seek emergency medical treatment, which, if delayed, may endanger client’s life, cause disfigurement or significant discomfort. If there is a valid signed DNR in the home at the time of the emergency, the DNR will be honored. Initial* .
Advance Directives*

I have prepared an Advance Directive regarding my health care.I have not prepared an Advance Directvie regarding my healht care.I do not wish to make an Advance Drirective at this time.
blanksis my Power of Attorney for health care. I give persmission for Brightstar to speak to all but previously identified members of my patient care team.
2.0 Service Payments: Payment is due weekly thereafter or service may be terminated. If at any time the balance on the account exceeds $5,000 or 30 days, service will be discontinued until payment is received. Payment for BrightStar services should only be made payable to BrightStar and never be made payable to a BrightStar employee. BrightStar will assess interest of 1.5% per month on all balances over 30 days. I agree to pay all collection costs, including attorneys and court fees, if I fail to pay. I understand that no 3rd party payor, insurance, Medicare or Medicaid will be billed or liable for services provided by BrightStar. Initial* .
2.1 The caregiver rate will increase annually by 5% to cover additional costs related to employee wage increases and an increase in the cost-of-living allowance. Initial* .
3.0 Additional or estimated charges: I understand that authorized out-of-pocket expenses such as groceries or household incidentals will be included in my bill. The estimated charges are based on the services originally requested. Billing will be based on actual time worked by caregivers. The amounts billed may differ from the estimated charges as the client's desires and needs changes. Initial* .
4.0 Holiday Rate: The 24-hour period constituting the following holidays will be billed at 1-1/2 times the regular hourly caregiver rate: New Year’s Day, Easter Sunday, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, Christmas Eve, Christmas Day, New Year’s Eve. Initial* .
5.0 Short Shift Rate: Any shift of 2 hours or less will be considered a visit and will be billed at a flat rate of $100.00. 3 hours or less will be billed at a flat rate of $130.
Initial* .
6.0 Credit Card Rate: An additional $0.50 per hour will be charged for credit cards.
Initial* .

7.0 Hiring Process: If I choose to hire a BrightStar employee (defined as a BrightStar employee or former employee who has rendered services for me in the past six months) directly before I have used BrightStar services for a period of 12 months, a fee of 30% of full time (2,080) hours at the employee’s bill rate will apply. After 12 months, the fee is 15%. After 18 months, 12% and after 24 months, 10%.

8.0 Hourly Clients: Should I desire to change or cancel the hours scheduled for service, I will notify BrightStar Care 24 hours in advance in order to prevent service and billing errors. Charges for the scheduled shift will apply for failure to notify the office.

9.0 Insurance / Liability Limits: I agree to carry standard homeowner’s insurance policy or similar tenant’s policy on the client residence. I understand that BrightStar limits its liability for property loss or damage to claims filed within 30 days of occurrence and will file any claims within the period. I agree to hold BrightStar harmless from liability for any damage of any nature caused by the use of any automobile while performing services for clients.

10.0 Scheduling / Substitution and Supervision of Employees: BrightStar reserves the right to substitute employees at its discretion and to make supervisory visits. Every effort will be made to provide a caregiver; however, BrightStar cannot guarantee scheduling. BrightStar strives for continuity of care but suggests that a family member or friend be designated as a backup caregiver for those rare instances when BrightStar may be unable to provide caregivers. BrightStar conducts a criminal background check on all employees. I understand this process
will be conducted during the first 30 days of employment.

11.0 Scheduling Communication: I agree to communicate all scheduling changes with the BrightStar office and not directly with the caregiver.

12.0 Nurse Visits: A BrightStar nurse will make regular reassessment and supervisory visits as part of BrightStar Care’s service. Additional skilled-nursing visits may be subject to additional charges.

13.0 Property Damages: In consideration for the health treatment being provided to me by BrightStar, I hereby release BrightStar, its subsidiaries and affiliates from any and all claims, demand, and causes of action involving any and all damages to my property except that caused solely by the negligence of BrightStar agents or employees acting within the scope of their employment.

14.0 Consent for Care Services: I consent to services from BrightStar of Birmingham and Rochester Hills, Michigan consistent with an established plan of care. I confirm that I have been informed and have participated in planning the care and procedure(s) to be carried out by BrightStar and sign this consent willingly and voluntarily.

15.0 I understand that this consent is valid from the date of the initial visit by BrightStar personnel and that I may withdraw my consent at any time by notice to BrightStar Care, and if I do so, the services will not thereafter be provided. I understand that admission to and continuation of services are subject to BrightStar policies and procedures.

16.0 I understand that BrightStar will make every effort to provide for my care and comfort during the hours of service. BrightStar cannot guarantee that the client will not be involved in an unforeseen accident and incur injuries. Accidents can happen to clients even under the care of our staff and BrightStar cannot be held liable in such event.

17.0 Every person signing this service agreement is jointly and individually responsible to pay the amounts due to BrightStar for the services provided. If client terminates or changes the services of BrightStar and subsequently decides to again retain or continue the company’s services, the same terms and conditions as set forth in this service agreement will apply unless superseded by a new service agreement. I understand rates are subject to change. I hereby acknowledge that I have carefully read this entire agreement.

18.0 Patient Rights and Responsibilities: BrightStar has given me a set of my rights and responsibilities as a BrightStar client.
Signature of Responsible Party*

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Date*

MonthDayYear
Date
Comments
Marketer Email
example@example.com
Name

First NameLast Name
Should be Empty:

BrightStar Care

SERVICE AGREEMENT