I, the “Undersigned,” wish to enter into this Agreement with Emerald Grace HomeCare (“Provider”) for the provision of private home care services to the “Client” at the “Client’s Address.” Services may include nursing services, personal care tasks, companion or sitter services, and other private home care services within the scope of Emerald Grace HomeCare’s license, as identified in the Client’s Service Agreement and Individualized Service Plan.

Nursing services shall be provided by appropriately licensed nursing personnel within their authorized scope of practice and in accordance with the Client’s Individualized Service Plan and applicable Georgia laws and regulations.

SERVICE RATES
Rates are subject to change based upon the Client’s service needs, condition, level of care, services provided, and periodic rate revisions. Any change in services, frequency, duration, or charges will be discussed with and agreed upon by the Client or Responsible Party, as applicable, before the change takes effect.

Clients requesting a particular employee whose assignment would result in more than forty (40) hours of work during a workweek may be billed at an applicable overtime or pass-through rate in accordance with applicable wage and hour laws.

Unless otherwise authorized by Emerald Grace HomeCare based on the Client’s Individualized Service Plan, assessed needs, payer requirements, or type of service provided, each scheduled visit requires a minimum of four (4) hours. Visits of less than four (4) hours may be provided with prior Agency approval.

Holiday rates are billed at one and one-half (1½) times the applicable regular billing rate. Holidays include New Year’s Eve, New Year’s Day, Easter Sunday, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, and Christmas Day.

DEPOSIT AND PREPAID SERVICES
For private-pay services, a deposit equivalent to two (2) weeks of estimated services may be required at the time this Agreement is executed. The deposit requirement may be waived when the Client authorizes an approved electronic bank withdrawal or other approved automatic payment method.

Any required deposit will be applied to the Client’s final account balance. Any remaining refundable balance will be returned after the final account has been reconciled, provided the account is current. Emerald Grace HomeCare may require an adjustment to the deposit when the Client’s authorized services or scheduled hours materially increase.

For Medicaid, Veterans Affairs, insurance, or other third-party payer services, deposits, advance-payment requirements, rates, billing, and Client financial responsibility will be governed by applicable payer requirements, authorizations, program rules, and any Client cost-share or patient-liability obligations.

ADMINISTRATIVE FEE
For private-pay clients, a one-time administrative fee of $75.00 may be added to the first invoice to offset administrative costs associated with admission, coordination, and staffing.

The administrative fee will not be assessed when prohibited by an applicable Medicaid program, government payer, insurance contract, or other third-party payer requirement.

PAYMENT TERMS
Emerald Grace HomeCare bills twice monthly unless otherwise required by the Client’s payer or agreed upon in writing. Invoices will be provided electronically whenever possible and will identify applicable services, service dates, rates, authorized charges, and the amount due.

For private-pay services, payment is due according to the billing schedule established by Emerald Grace HomeCare and may be processed through an authorized electronic bank withdrawal, check, credit/debit card, or other approved payment method.

Payments made by credit or debit card may be subject to an applicable payment-processing fee when permitted by law. Clients may avoid this fee by using an available fee-free payment method accepted by Emerald Grace HomeCare.

If payment cannot be successfully processed or is not received when due, a $35.00 late fee may be assessed. Overdue balances may accrue interest at a rate not exceeding eighteen percent (18%) per annum or the maximum rate permitted by applicable law, whichever is less. Returned checks or payments may result in a $35.00 returned-payment fee.

If collection action becomes necessary, the Client/Responsible Party agrees to pay reasonable collection expenses, including attorney’s fees and costs, to the extent permitted by law.

For services covered by Medicaid, Veterans Affairs, long-term care insurance, or another third-party payer, billing and Client financial responsibility shall be determined in accordance with the applicable authorization, payer agreement, program requirements, and any established cost share, patient liability, copayment, deductible, or non-covered service obligation.

The Client will not be held financially responsible for amounts that Emerald Grace HomeCare is prohibited from billing to the Client under applicable Medicaid or other payer/program requirements.

TEMPORARY ASSIGNMENT / SHORT-TERM SERVICES
For private-pay services expected to last fewer than thirty (30) days, Emerald Grace HomeCare may require payment in advance based upon the anticipated services identified in the Client’s Individualized Service Plan.

Advance-payment requirements do not apply where prohibited or otherwise governed by Medicaid, Veterans Affairs, insurance, or another third-party payer.

INCIDENTAL TRANSPORTATION
When transportation or escort services are included in the Client’s authorized services, transportation may be provided in accordance with the Client’s Individualized Service Plan, applicable payer/program requirements, and Emerald Grace HomeCare’s transportation policies.

When an Emerald Grace HomeCare employee uses their personal vehicle for authorized Client transportation, mileage will be billed at the current IRS standard mileage rate in effect on the date transportation is provided, unless otherwise established or prohibited by the applicable payer or program.

When the Client’s vehicle is used, the Client/Responsible Party must maintain current automobile insurance, vehicle registration, and any other documentation required by law and must provide written authorization for Emerald Grace HomeCare personnel to operate the vehicle.

Emerald Grace HomeCare personnel providing transportation will meet applicable driver, licensing, insurance, screening, and Agency requirements.

Any required transportation authorization, consent, or waiver will be maintained in the Client’s record.

MISCELLANEOUS EXPENSES AND SUPPLIES
The Client/Responsible Party is responsible for providing ordinary personal supplies and other items reasonably necessary for the Client’s care unless such items are supplied or covered by an applicable payer.

Emerald Grace HomeCare will provide supplies or equipment that the Agency is legally required to furnish to its employees for workplace safety and infection-control purposes.

Client-specific expenses incurred on the Client’s behalf during authorized services, including parking, tolls, admission fees, meals, outings, or purchases requested by or for the Client, may be billed to the Client when permitted by the applicable payer and this Agreement. Receipts or other documentation will be maintained as appropriate.

NON-SOLICITATION OF EMPLOYEES
The Client/Responsible Party agrees not to directly hire or privately employ an Emerald Grace HomeCare employee assigned to the Client during the term of this Agreement or for one (1) year following termination of services without the prior written consent of Emerald Grace HomeCare.

Any applicable placement or referral fee must be separately disclosed and agreed upon in writing and shall be subject to applicable law.

CANCELLATION, INTERRUPTION, OR TERMINATION OF SERVICES
The Client/Responsible Party may cancel this Service Agreement or request cancellation or interruption of scheduled services at any time by notifying Emerald Grace HomeCare.

The Client/Responsible Party will be responsible for services actually rendered prior to the time Emerald Grace HomeCare receives notice of cancellation or termination.

For scheduled private-pay services, the Client/Responsible Party is requested to provide at least twenty-four (24) hours’ notice of a cancellation whenever reasonably possible. If notice is not provided in sufficient time to cancel the scheduled service before the assigned employee arrives at the Client’s residence, Emerald Grace HomeCare may assess a reasonable charge for staff time and/or travel actually incurred, to the extent permitted by applicable law and payer/program requirements.

No cancellation charge will be imposed when prohibited by Medicaid, Veterans Affairs, insurance, or another applicable payer or program.

Emerald Grace HomeCare may suspend, modify, or terminate services when the Agency can no longer safely or reasonably meet the Client’s needs; conditions in the home create an unsafe environment for the Client or Agency personnel; the Client fails to pay amounts for which the Client is legally responsible; or for other reasons permitted by applicable law, regulation, payer/program requirements, and Agency policy.

When required or otherwise appropriate, Emerald Grace HomeCare will provide reasonable notice and assist with coordination of alternative services consistent with the Client’s needs and applicable requirements.

CLIENT RECORDS
Emerald Grace HomeCare will establish and maintain a confidential client record for each individual receiving services. Each client will be assigned a unique Client Record Number for identification and recordkeeping purposes. Records will be maintained in accordance with applicable federal and Georgia laws, including HIPAA, Agency policies, and applicable payer requirements.

SCOPE OF SERVICES AND ADDITIONAL TERMS
Emerald Grace HomeCare is a Georgia-licensed Private Home Care Provider. Depending upon the Client’s assessed needs, authorized services, and Individualized Service Plan, services may include nursing services, personal care tasks, companion or sitter services, and other services permitted within the scope of the Agency’s license.

Nursing services will be provided by a Georgia-licensed Registered Professional Nurse (RN) or Licensed Practical Nurse (LPN), as appropriate, within the individual’s authorized scope of practice, under required supervision, and in accordance with the Client’s Individualized Service Plan.

Emerald Grace HomeCare will provide only those services that the Agency can reasonably and safely provide in accordance with applicable laws, regulations, professional standards, payer/program requirements, and the Client’s Individualized Service Plan.

Emerald Grace HomeCare may replace or remove assigned personnel when necessary and may arrange for appropriately qualified substitute personnel to maintain continuity of authorized services.

All requests for schedule changes, changes in services, or changes in the Client’s needs shall be communicated directly to Emerald Grace HomeCare.

The Client/Responsible Party agrees to provide and maintain a reasonably safe environment for Agency personnel and to promptly notify Emerald Grace HomeCare of hazards, significant changes in the Client’s condition or needs, hospitalization, emergency events, medication or treatment changes, or other circumstances that may affect the safe provision of services.

Emerald Grace HomeCare may conduct supervisory visits, nursing assessments, reassessments, and other reviews as required by the Client’s services, applicable regulations, payer/program requirements, and Agency policy.

Changes in the Client’s services, frequency, duration, or charges will be documented and communicated to the Client/Responsible Party as required.

The Client/Responsible Party agrees not to provide Agency personnel with loans or substantial cash gifts or gratuities in violation of Emerald Grace HomeCare policy.

Type/Description of Services Required:

The Client requires home care services as determined by the Agency's assessment and as identified in the Individualized Service Plan, including, but not limited to, nursing services, personal care, companion/sitter services, homemaker services, transportation, respite care, supervision, and other authorized services necessary to meet the Client's assessed needs and support the Client's health, safety, independence, and well-being. Services shall be provided in accordance with the Individualized Service Plan and, when applicable, the requirements of the Client's payer or program authorization.

Please select one rate option (as agreed upon by Emerald Grace Homecare Office Staff)

CLIENT TRANSPORTATION / MOTOR VEHICLE AUTHORIZATION

When transportation or escort services are included in the Client’s authorized services, transportation may be provided in accordance with the Client’s Service Plan, applicable payer/program requirements, and Emerald Grace HomeCare’s transportation policies.

Mileage: When an Emerald Grace HomeCare employee uses their personal vehicle for authorized Client transportation, mileage may be billed at the current IRS standard mileage rate in effect on the date transportation is provided, unless otherwise established or prohibited by the applicable payer/program requirements.

When the Client’s vehicle is used, the Client/Responsible Party is responsible for maintaining current automobile insurance, vehicle registration, and other documentation required by law.

CLIENT FUNDS & BANKING

When home management services include assistance with bill paying, shopping, or other authorized activities requiring access to or use of the Client’s personal funds, Emerald Grace HomeCare staff may access or use Client funds only when authorized by the Client/Responsible Party and only as necessary to perform the authorized service.

Any staff member receiving or using Client funds will document the amount received, maintain receipts or other appropriate documentation for purchases or expenditures, document the amount returned, and return any remaining funds to the Client/Responsible Party.

QUESTIONS, CONCERNS, COMPLAINTS, & GRIEVANCES

Clients and Responsible Parties have the right to submit questions, concerns, complaints, or grievances regarding services provided by Emerald Grace HomeCare without fear of discrimination, interference, coercion, or retaliation.

Complaints may be made verbally or in writing. Emerald Grace HomeCare will investigate complaints within a reasonable period of time and take appropriate action when indicated.

Emerald Grace HomeCare Complaint Contact

Tiffany Carignan, Director
Emerald Grace HomeCare
347 Bow Dr.
Lavonia, GA 30553
Telephone: (706) 250-1347
Cell: (706) 805-0782
Email: info@emeraldgrace.org

If a complaint concerning a possible violation of licensing requirements is not satisfactorily resolved by Emerald Grace HomeCare, or if the Client or Responsible Party has questions regarding the licensing of private home care providers, the state licensing authority may be contacted at:

Georgia Department of Community Health
Healthcare Facility Regulation Division
Private Home Care Provider Unit
2 Martin Luther King Jr. Drive SE, 17th Floor, East Tower
Atlanta, GA 30334
Telephone: (800) 878-6442

The Georgia Department of Community Health, Healthcare Facility Regulation Division is responsible for licensing private home care providers and investigating Client complaints that appear to involve violations of applicable licensing requirements.

Emerald Grace HomeCare is committed to providing services in a manner that respects each Client’s dignity, privacy, independence, preferences, and individual needs. Each Client and/or Responsible Party will be informed of the Client’s rights and responsibilities and the procedures for submitting questions, concerns, complaints, or grievances.

CLIENT RIGHTS
As a Client of Emerald Grace HomeCare, you have the right to:

• Be treated with consideration, respect, and dignity and have your property and residence treated with respect.

• Receive services without discrimination based on race, color, national origin, religion, sex, age, disability, or any other status protected by applicable law.

• Be informed about the services available through Emerald Grace HomeCare and the Agency’s capabilities and limitations in providing services.

• Participate in the development and planning of your services and be informed about your current Service Plan.

• Participate in decisions regarding your care and services, including expressing preferences regarding schedules, routines, activities, caregivers, and services, when reasonably possible and consistent with your needs, Service Plan, and applicable payer/program requirements.

• Be promptly and fully informed of changes in your Service Plan or services.

• Accept or refuse services and be informed of the potential consequences of refusing services, when applicable.

• Be informed of the charges for services for which you may be responsible and receive notice of changes in charges in accordance with the Service Agreement and applicable payer/program requirements.

• Receive services in accordance with your current Service Plan, applicable orders or authorizations, and applicable payer/program requirements.

• Receive services from personnel who meet applicable licensing, qualification, competency, training, screening, and supervision requirements for the services they provide.

• Be informed of the name, business telephone number, business address, and means of contacting the person supervising your services.

• Have your personal information and Client records maintained confidentially in accordance with applicable federal and state laws and regulations.

• Review or obtain access to your Client records as permitted by applicable law.

• Have your personal property, finances, and belongings treated with respect and protected from misuse.

• Be free from abuse, neglect, exploitation, discrimination, mistreatment, coercion, and retaliation.

• Exercise freedom of choice regarding available service providers and other community resources, subject to applicable payer or program requirements.

• Voice questions, concerns, complaints, or grievances regarding services without fear of discrimination, interference, coercion, retaliation, or unreasonable interruption of services.

• Have complaints investigated by Emerald Grace HomeCare within a reasonable period of time and be informed of the Agency’s complaint procedure.

• Be informed of the name and telephone number of the person designated by Emerald Grace HomeCare to receive complaints and questions.

• Contact the appropriate state licensing authority regarding questions about licensing or complaints concerning possible violations of licensing requirements.

• Terminate services in accordance with the terms of the Service Agreement and applicable payer/program requirements.

• Receive a copy of the Client Service Agreement and Client Rights and Responsibilities.

• Obtain, upon written request, a copy of Emerald Grace HomeCare’s most recent completed report of licensure inspection. The report is not required to be released until Emerald Grace HomeCare has had an opportunity to submit a written plan of correction for any violations identified. Reasonable photocopying charges may apply.

CLIENT RESPONSIBILITIES
As a Client and/or Responsible Party of Emerald Grace HomeCare, you are responsible for:

• Providing accurate and complete information reasonably necessary for Emerald Grace HomeCare to assess, plan, coordinate, and provide appropriate services.

• Participating in the development and updating of the Service Plan, as applicable.

• Informing Emerald Grace HomeCare promptly of significant changes in the Client’s condition, needs, medications, treatments, physician or practitioner orders, hospitalization, residence, contact information, payer status, or other circumstances that may affect the provision of services.

• Informing Emerald Grace HomeCare of concerns, problems, or changes related to the services being provided.

• Treating Emerald Grace HomeCare employees, contractors, and representatives with consideration and respect.

• Providing and maintaining a reasonably safe environment in which services can be provided.

• Following the agreed-upon Service Plan and communicating questions or concerns regarding the plan to Emerald Grace HomeCare.

• Following applicable scheduling and cancellation procedures and providing as much advance notice as reasonably possible when services must be changed or cancelled.

• Meeting applicable financial responsibilities in accordance with the Service Agreement and applicable payer/program requirements.

• Refraining from requesting Emerald Grace HomeCare personnel to perform services or tasks that are outside the Client’s Service Plan, outside the employee’s authorized scope of practice or assigned duties, or prohibited by applicable law, regulation, payer, or program requirements.

• Respecting the rights, safety, and professional boundaries of Emerald Grace HomeCare personnel.

COMPLAINTS AND GRIEVANCES

Clients and Responsible Parties have the right to submit questions, concerns, complaints, or grievances regarding services without fear of discrimination, interference, coercion, retaliation, or unreasonable interruption of services.

Complaints may be made verbally or in writing to Emerald Grace HomeCare. Emerald Grace HomeCare will review and investigate complaints within a reasonable period of time and take appropriate action when indicated.

Emerald Grace HomeCare Complaint Contact

Tiffany Carignan, Director
Emerald Grace HomeCare
347 Bow Dr.
Lavonia, GA 30553
Telephone: (706) 250-1347
Cell: (706) 805-0782
Email: info@emeraldgrace.org

LICENSING INFORMATION AND COMPLAINTS

Clients and Responsible Parties may contact the state licensing authority for information or questions regarding the licensing of private home care providers or to report complaints concerning possible violations of licensing requirements.

Georgia Department of Community Health
Healthcare Facility Regulation Division
Private Home Care Provider Unit
2 Martin Luther King Jr. Drive SE, 17th Floor, East Tower
Atlanta, GA 30334
Telephone: (800) 878-6442

The Georgia Department of Community Health, Healthcare Facility Regulation Division is responsible for licensing private home care providers and investigating client complaints that may involve violations of applicable licensing requirements.

ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have received a copy of the Emerald Grace HomeCare Client Rights and Responsibilities. I have been informed of my rights and responsibilities and the procedures for submitting questions, concerns, complaints, or grievances. I have been given an opportunity to ask questions and understand whom to contact regarding my services or concerns.

Emerald Grace HomeCare maintains the confidentiality and security of each Client’s personal, health, medical, financial, and service information in accordance with applicable federal and state laws and regulations.

Client information may be used or disclosed as permitted or required by law for purposes related to the provision, coordination, and management of the Client’s care and services; payment for services; healthcare operations; quality assurance and improvement; regulatory compliance; and administration of services.

Client information may be used or disclosed, as applicable:

• To Emerald Grace HomeCare personnel who require the information to provide, coordinate, supervise, document, evaluate, or manage the Client’s care and services.

• To the Client, the Client’s legally authorized representative or Responsible Party, physician, practitioner, nurse, or other healthcare provider involved in the Client’s care, as permitted by applicable law.

• To Medicaid, Veterans Affairs, insurance companies, other governmental programs, third-party payers, case managers, care coordinators, or other authorized entities as necessary for eligibility, authorization, coordination, billing, payment, or administration of services.

• As necessary to coordinate nursing services, personal care services, companion/sitter services, transportation, home management, or other authorized services provided to the Client.

• For quality assurance and improvement, supervision, auditing, compliance, licensing, and other lawful Agency operations.

• When necessary in an emergency to assist in the provision or coordination of appropriate care or services, as permitted by law.

• When disclosure is required or permitted by law, including reporting suspected abuse, neglect, exploitation, or other circumstances subject to mandatory reporting requirements.

• To the Georgia Department of Community Health, Healthcare Facility Regulation Division, or other governmental, regulatory, or oversight authorities when authorized or required by law.

• Pursuant to a valid subpoena, court order, or other lawful process, as applicable.

• To other individuals or entities when the Client or legally authorized representative has provided appropriate written authorization or when disclosure is otherwise permitted or required by law.

Emerald Grace HomeCare will limit the use and disclosure of Client information to information reasonably necessary and permitted by applicable law. Client records will be maintained confidentially and safeguarded against unauthorized access, use, alteration, loss, or disclosure.

Certain disclosures of Client information to family members, friends, or other designated individuals require the Client's written authorization unless otherwise permitted or required by law. The accompanying Authorization for Release/Disclosure of Information allows the Client to designate those individuals or entities and specify the information that may be disclosed.

I acknowledge that I have received Emerald Grace HomeCare's Notice of Privacy Practices, which explains how my Protected Health Information (PHI) may be used and disclosed, my privacy rights under HIPAA, and Emerald Grace HomeCare's legal responsibilities regarding my Protected Health Information.

By signing this Agreement electronically, I consent to the use of electronic records and electronic signatures in connection with documents, forms, agreements, acknowledgments, authorizations, service records, and other records provided by or submitted to Emerald Grace HomeCare.

I understand and agree that my electronic signature is intended to have the same legal effect as my handwritten signature. When I electronically sign, initial, select “I Accept,” or otherwise apply an electronic signature to a document, I am indicating my intent to sign that specific document and agree to be bound by its terms to the same extent as if I had signed it by hand.

I understand that I am not required to conduct transactions with Emerald Grace HomeCare electronically and may request documents in paper form. I may withdraw my consent to receive and sign records electronically at any time by notifying Emerald Grace HomeCare. Withdrawal of electronic consent will apply to future electronic records and signatures and will not affect the validity or enforceability of electronic records or signatures completed before the withdrawal.

I understand that I may request a paper copy of any document that I receive or sign electronically.

I understand that I must have access to a device capable of displaying the electronic documents provided to me and the ability to access, retain, or save those documents. By providing my consent electronically, I confirm that I am able to access the electronic records presented to me.

I understand that I am responsible for providing Emerald Grace HomeCare with current contact information used for electronic communications and for notifying Emerald Grace HomeCare of any changes to that information.

I understand that electronic signatures and records may be used to the extent permitted by applicable federal and state law and that no certification authority or independent third-party verification is required solely to establish the validity of my electronic signature unless otherwise required by law.

By signing below, I confirm that I have read and understand this Electronic Signature and Electronic Records Consent Agreement, voluntarily consent to the use of electronic records and electronic signatures as described above, and am authorized to sign for myself or, if applicable, on behalf of the Client.

The Client and/or Responsible Party acknowledges that they have read, understand, and agree to the terms and conditions contained in this Service Agreement and have been given an opportunity to ask questions regarding the services to be provided, applicable charges, billing and payment arrangements, and the terms of this Agreement.

If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the greatest extent permitted by applicable law.

JOINT AND SEVERAL OBLIGATION

If a Responsible Party or other financially responsible person signs this Agreement and agrees to assume financial responsibility for services provided to the Client, that individual shall be jointly and severally responsible for the applicable financial obligations under this Agreement to the extent permitted by law and applicable payer/program requirements.

DOCUMENTS AND SECTIONS ACKNOWLEDGED

The Client and/or Responsible Party acknowledges receipt, review, completion, or authorization, as applicable, of the following documents and sections:

• Service Agreement
• Rate and Billing Information
• Client Confidentiality Agreement

• Client Rights and Responsibilities
• Authorization for Access to Client Funds, if applicable
• Client Transportation/Motor Vehicle Authorization, if applicable
• Electronic Signature and Electronic Records Consent Agreement, if applicable

Any Authorization for Release/Disclosure of Information is voluntary and will be completed and signed separately when the Client or legally authorized representative wishes to authorize Emerald Grace HomeCare to disclose information to designated individuals or entities.

The Client’s Service Plan is maintained as a separate document and will identify the Client’s assessed needs, specific services and tasks, frequency and duration of services, functional limitations, goals and objectives, and other applicable care or nursing instructions.

SIGNATURES

By signing below, the Client and/or Responsible Party acknowledges receipt of a copy of this Service Agreement and agrees to the applicable terms and conditions contained herein.

All services provided to a Client by Emerald Grace HomeCare shall be based on a written Service Agreement entered into with the Client or the Client’s Responsible Party, if applicable. Emerald Grace HomeCare will provide only those private home care services that the Agency can reasonably expect to deliver safely and in accordance with applicable Georgia laws and the Rules and Regulations for Private Home Care Providers of the Georgia Department of Community Health, Healthcare Facility Regulation Division. 

EMERALD GRACE HOMECARE
PHONE: 706.250.1347