• Service Agreement

  • I, the “Undersigned” wish to enter into this Agreement with Emerald Grace Homecare, LLC (“Provider”), to provide non-medical homecare services for the "Client" at the "Client's Address".

    SERVICE RATES: Rates are subject to change upon client’s service needs, client condition, and periodic rate revisions. Clients requesting a particular caregiver that requires the caregiver to work more than 40 hours a week will be billed at an alternative (Pass-Through) overtime rate per wage & labor laws. Each visit to provide services requires a minimum of four (4) hours. The following holidays are billed at time and ½ including New Year's Eve, New Year’s Day, Easter Sunday, Independence Day, Memorial Day, Labor Day, Thanksgiving Day, Christmas Eve and Christmas Day.

    DEPOSIT: A two-week service deposit is waived if payment method is authorized electronic bank withdrawal. Payment by check requires a deposit, equivalent to 2 weeks of service is due at the time of signing this Agreement. The deposit will be refunded following payment of the final invoice provided your account is current. Provider may require the deposit to be increased if service hours are expanded.

    Administrative Fee: A One-Time $75.00 administrative fee will be added to your first invoice to cover a portion of administrative costs associated with staffing your assignment.

    PAYMENT TERMS: Invoices are emailed whenever possible. Billing is twice a month. Payment is due and is processed 7-10 days after close of billing cycle by authorized electronic bank withdrawal or by check. If such charge cannot be successfully made, the Client will be charged a $25.00 late billing fee and an 18%
    per annum charge on overdue amount. Client checks rejected by the bank for non-sufficient funds will result in a $25.00 fee to the client. If collection action is necessary, the Client agrees to pay all collection expenses, including attorneys’ fees and costs. The Client is obligated to pay for all services and associated charges regardless whether or not the Client is reimbursed by a third party, such as a long-term care insurance company, and is not relieved of such obligation even if an assignment to Provider of insurance or other benefits was made by Client.

    TEMPORARY ASSIGNMENT: Clients requiring a limited duration of service (less than 30 days) are required to pay in advance (as determined according to the care plan) in full, to start services, by authorized electronic bank withdrawal or check for service during such period.

    INCIDENTAL TRANSPORTATION: If employee uses his or her own vehicle to serve the client, the client will be charged the mileage per mile driven. The mileage rate is currently $ .70 per mile. There will be no charge if client’s vehicle is used. Client must provide proof of automobile insurance coverage and vehicle
    registration and inspection.

    MISCELLANEOUS EXPENSES: Clients are responsible to provide safety gloves and any other supplies required for the safety, care and comfort of the client and safety of our caregivers. If not supplied, your bill will reflect the cost of the purchase of these supplies. Any client expenses incurred by the caregiver
    on the client’s behalf during the performance of their duties (e.g., lunch, outings, etc.) will be billed to the client’s account with explanation.

    NON-SOLICITATION/SUBSTITUTION: The client agrees not to hire or employ any provider employee(s), whether current or former and whether specifically assigned under this agreement or subsequently provided by provider, while this agreement is in effect and for a period of one (1) year after termination of
    this agreement, whether for personal reasons or otherwise, unless provider has given express written consent and collected a referral fee in the amount of $10,000 or an amount equal to the highest billing of any consecutive two month period during the term of this agreement, whichever is greater. This employment restriction does not alter the agreement between Client/Undersigned and Provider. The employment restriction includes the hiring of Provider employees by Client, Client's authorized representative and/or Client's relatives whether they are signatory to this agreement or not.

    CANCELLATION/TERMINATION: If Client/Undersigned wishes to interrupt or terminate the Services provided under this Agreement for any reason, Client/Undersigned agrees to provide Provider with as much notice as possible. If a notice of termination by Client/Undersigned is received less than twenty-four (24) hours before the schedule start of Services, the minimum hours per visit as noted above will be billed to Client. Provider may terminate the Services for any reason upon twenty-four (24) hour notice to Client/Undersigned.

    ADDITIONAL TERMS & CONDITIONS: Client/Undersigned fully acknowledges and agrees that Provider: (a) is a provider of non-medical services; (b) is not licensed or insured to perform medical services; and (c) shall be liable for any damages or liabilities except such damages as are caused directly by the negligent
    acts or omissions by Provider or Provider's employee and which result in bodily injury or property damage to Client.

    ClientUndersigned understands that Provider may, at its discretion, replace or remove any of Provider's employees from an assigned Client for any reason. Provider may arrange for a suitable substitute in order to provide Services.

    Client/Undersigned agrees to communicate all schedule changes through Provider's business office.


    Client/Undersigned agrees to provide a safe work environment for Provider's employees at all times, free from hazards and conditions that may cause injury or illness to any of Provider's employees.

    Client/Undersigned understands that Provider may conduct periodic and regular visits to Client so as to verify the quality of Services as well as evaluate appropriate level of service. Changes to the level of Services can be made at discretion of Provider with twenty-four (24) hours notice.

    Client/Undersigned agrees not to give Provider's employees gratuities, cash gifts or loans without prior permission from Provider.

  • Client Date of Birth*
     - -
  • Please select one rate option (as agreed upon by Emerald Grace Homecare Office Staff)

  • Holidays: Holiday rates are one and a half times the normal billing rate.

    Holidays include:
    New Year's Eve
    New Years Day
    Easter Sunday
    Memorial Day
    Independence Day
    Labor Day
    Thanksgiving Day
    Christmas Eve
    Christmas Day

    Cancelled visits, other than an emergency, will be billed at the regular hourly rate if cancelled with less than a 24 hour notice.

    Mileage is billed at: $ .70 per mile when the caregiver uses his or her own vehicle

  • Individual Care Plan

  • Today's Date*
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  • Date of Initial Contact*
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  • Start of Services*
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  • Rows
  • Rows
  • Rows
  • Client/ Caregiver Motor Vehicle Services

    The charge for employee use of his/her motor vehicle on behalf of the client will be billed and paid at a mileage rate of 0.76 cents per mile. If the client allows caregiver to use his/her motor vehicle the client will be responsible for his/her own mileage fees.

  • Access to Funds, Banking Records

    Client or responsible party, authorizes access to client’s funds and banking records if home management services are provided and when those services include assistance with bill paying or any activities, such as shopping, that require access to or use of such funds.

    I further understand that the staff member receiving the money will document the amount of money received, present me with a receipt of money spent, and document the amount of money returned to me. I agree to sign this statement of receipt of money or notify the provider agency if I am not satisfied with the transaction or have any questions about the transaction.

  • Licensing Information and Complaints

    Below is the telephone number of the state licensing authority to call for information or questions about licensing of the providers and to report complaints concerning violations of licensing requirements that are not satisfactorily resolved. Healthcare Facility Regulation Division, Private Home Care Provider Unit at (800) 878-6442; 2 Martin Luther King Jr Drive SE, 17th floor East Tower, Atlanta, GA 30334.

  • Rows
  • At a minimum, your invoice will include the following information:
    Payment received $      on   Pick a Date for services from   Pick a Date    to   Pick a Date    . An initial deposit in the amount of $      is required upon signing this agreement. Your deposit will be held and applied to your last month's invoice. and any additional deposit not used will be refunded to you.
    Please do not pay by cash or pay the service provider staff member.
     

  • Emergency Contact Information

  • Client Bill of Rights

  • An Emerald Grace Home Care Services client has the right to:

    • Be treated with dignity and respect
    • Access non-medical services regardless of disability, color, race, ancestry, religion, sex or national origin
    • Identify service needs and participate in planning the service schedule
    • Verbalize preferences regarding activities and day-to-day schedule
    • Be fully informed in advance-of the costs of non-medical services and receive proper notices of changes or increases in the fees
    • Know the company's-capabilities and limits in providing non-medical service
    • Review the Client Service Agreement with a Emerald Grace HomeCare Services Representative
    • Obtain a signed copy of the Client Service Agreement
    • Receive services from caregivers who are screened, trained, bonded and insured through Emerald Grace Home Care Services
    • A compatible relationship with the caregiver providing service
    • Personal privacy, the respect for their property, and confidentiality of all Emerald Grace HomeCare Services records
    • Review personal history and notes from client log
    • Exercise freedom of choice regarding the availability of services from other agencies and private companies in the community
    • Know the address and telephone number(s) of the Emerald Grace HomeCare Services office that is providing service
    • Terminate Emerald Grace HomeCare services with proper notices as indicated in the Emerald Grace HomeCare services Service Agreement
    • File grievances without the fear of discrimination or retaliation
    • Obtain a copy of the Emerald Grace HomeCare services state licensure, if residing in a state that requires non-medical home care companies to be licensed
  • Client Confidentiality Agreement

  • Emerald Grace HomeCare services maintains a practice of confidentiality and protection of personal and medical information of our clients. To provide the highest quality of care, there may be instances in which Emerald Grace HomeCare services discloses information about you.

    Use and disclosure may occur when:

    1. A referral is made on your behalf, or to coordinate other appropriate in-home services. These may include consultation with doctors, nurses, healthcare personnel, facilities, and providers who specialize in health-related products.
    2. For the purpose of billing of services, Emerald Grace HomeCare services may
      be required to release medical information to an insurance company or third party payer.
    3. To maintain quality assurance for your service, Emerald Grace HomeCare services may discuss your service needs with office staff and caregivers who provide service to you.
    4. In the event of a medical emergency when the release of confidential information will benefit professionals providing service or care.
    5. Situations of abuse, neglect, and domestic violence are identified or required by law.


    Information may be released to the following involved in the coordination of services: Designated Agent, Power of Attorney, Conservator, Guardian, Family Members, Relatives, and/or Friends who have your wellbeing in their interest and also have the need for relevant service information.

  • Electronic Signature Consent Agreement

  • By signing this document, you are giving Emerald Grace Homecare, LLC your consent to use your signature consent electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third-party verification is necessary to validate your E-Signature and that the lack of such certification or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Emerald Grace Homecare Services, LLC. You are also confirming that you are authorized to enter into this Agreement. You further agree that each use of your Emerald Grace Homecare documents equates to your E-Signature and constitutes your agreement to be bound by the terms and conditions of these Disclosures and Agreement as they exist on the date of your E-Signature on this form.

  • Signature Page

  • Client/Undersigned acknowledges that he or she has read and fully understands this entire Agreement and that by signing below, agrees with and accepts all the terms and conditions contained herein.

    If any provision of this Agreement is deemed to be invalid or unenforceable to any extent, the remainder of this Agreement shall not be affected thereby and shall be enforced to the greatest extent permitted by law.

    JOINT AND SEVERAL OBLIGATION: In the event that a party other than the Client executes this Agreement, the additional party shall be jointly and severally liable for all obligations of the Client under this Agreement.

    Sections above provided and accepted are as follows:

    1. Services Agreement
    2. Rate Sheet
    3. Individual Service Plan
    4. Emergency Contact Information
    5. Client Confidentiality Agreement
    6. Client Bill of Rights
    7. Electronic Signature Consent Agreement

     

     

  • Date*
     - -
  • All services to a client shall be based on a written service agreement, entered up with the client or the client’s responsible party, if applicable, and the Administrator or designer of Emerald Grace HomeCare, LLC. Services will not be offered to any client that our private home care cannot reasonably expect to deliver in accordance with the rules for private home care of the:

     

    Department of Community Health, Health Care Facility Regulation Division
    2 Martin Luther King Jr Drive SE, 17th floor East Tower, Atlanta, GA 30334

     

    EMERALD GRACE HOMECARE, LLC
    347 Bow Dr., Lavonia, GA 30553
    PHONE: 706.805.0782

     

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