Client Information

Emergency Contact Information

This agreement is between Friendly Companions LLC DBA Visiting Angels, hereby known as Visiting Angels, and the Client and/or parties listed above.

Nature of Visiting Angel Services:  The duties of Visiting Angels caregivers may include but are not limited to the following: reminding Client to take medications, assisting with basic personal care and ambulation, providing companionship, and performing care-related light housekeeping tasks, e.g. tidying rooms in which Client spends time, tidying bathrooms after Client’s use, and washing Client’s dishes or laundry. Care-related light housekeeping tasks do not include cleaning services for the general household, such as scrubbing floors, vacuuming, washing windows, dusting behind and under furniture, cleaning drapes or blinds, and washing laundry for members of the household other than Client. Visiting Angels and its caregivers do not practice medicine or nursing, and make no recommendations concerning diagnosis, prognosis, treatment, medication, dosage, prescriptions, or other medical or health related services.

We will refer to you a caregiver who is employed by us who will provide non-medical "companion" home care on a schedule of days and hours that will be predetermined by all parties involved in advance of each week of service.  In the event that you do not contact us to change the predetermined weekly schedule in advance of any week, we will assume that the predetermined weekly schedule is the same as it was for the most recent preceding week of service. Our assurance to you is that we will, at all times, exert every reasonable effort to have you attended to, during this predetermined weekly schedule.

Emergency Procedures:  Visiting Angels is not an emergency care service.  In emergencies, the caregiver will call 911 and then will contact Visiting Angels.  Visiting Angels will then contact the Contact stated at the beginning of this Agreement or, in the absence of a Contact other than Client, Client’s next of kin. Caregivers are not CPR Certified.

Services to be Provided; Payment.  Client authorizes Visiting Angels to provide the services stated on the attached Schedule of Services and Fees.  Client shall pay for such services in accordance with the Schedule of Services and Fees and this Agreement. 

Client Must Submit for Third Party Payment.  If Client is eligible for benefits from any third party payor, such as insurance, Client must pay Visiting Angels as stated in this Agreement and then seek reimbursement from the third party payor. Visiting Angels will not submit claims to third party payors on Client’s behalf.  However, upon request, Visiting Angels will provide copies of time sheets and daily logs to Client to assist Client in Client’s submission of claims to a third party payor.  Client acknowledges that Visiting Angels has not given any assurance that any third party payor will pay for the services it provides to Client.

Changing Services or Schedule.  In the event Client wishes to alter the time or date of services during a single week, Client must notify Visiting Angels of the requested change at least twenty-four (24) hours prior to the time the service is regularly scheduled to begin.  Notice given to a caregiver and not to Visiting Angels is not considered notice to Visiting Angels.  If Client does not provide the required 24-hour notice, Client must pay for the full scheduled hours. In the event that a referred caregiver fails to arrive at your home and/or the home of the care recipient or alters the predetermined weekly schedule in some way, we will adjust the amount that you are billed accordingly.  All hourly visits will be rounded to the nearest quarter hour.

To change the weekly schedule during more than a single week, Client must notify Visiting Angels at least seven (7) calendar days prior to the week Client wants the new schedule to begin.  Notice given to a caregiver and not to Visiting Angels is not considered notice to Visiting Angels. 

In the event that Visiting Angels agrees to the proposed change to the schedule of services, Visiting Angels shall document the new schedule and the documentation will become a part of this Client Services Agreement upon Client’s acceptance of the requested services. 

Changing Rates.  The rates stated in the Schedule of Services and Fees may be changed from time to time by Visiting Angels by Visiting Angels giving Client at least fourteen (14) calendar days prior written notice of the change.

Billing; Payment; Collection; Interest.  Invoices will be sent to Client biweekly.  Client shall make the best effort to pay the amount of an invoice within ten (10) calendar days after the date of the invoice.  Any unpaid balance not paid within thirty (30) calendar days shall accrue interest at the rate of 1.5% per month.  Client shall reimburse Visiting Angels for any fee charged by a bank due to insufficiency of check submitted to Visiting Angels for payment.  In the event Visiting Angels is required to take action to collect any amounts due under this Agreement, Client shall pay Visiting Angels’ reasonable attorney fees and costs incurred in collecting those amounts.

Deposits.  Visiting Angels may require a deposit for service.  This amount will be determined prior to service.  An additional deposit amount may be required if Client later requests an increase in the services provided.  This money will be held by Visiting Angels and applied to any outstanding balance on the final invoice after termination of services.  Any balance remaining after all outstanding invoices have been paid in full will be refunded.

Notice of Termination; Trial Period.  Prior to the start of service or within the first week of service, this Agreement may be terminated by the Client or Visiting Angels for any reason with no requirement of advance notice. Subsequent to the first week, this Agreement shall remain in effect until either party gives the other not less than seven (7) calendar days prior notice of termination.  Such prior written is required under all circumstances, excluding hospitalization and/or death of the care recipient.  Notice must be given to office staff and not to the caregiver.  Visiting Angels may terminate services without such prior written notice if Client fails to pay for services as required by this Agreement and his/her account is more than fourteen (14) calendar days in arrears or if the health and safety of a Visiting Angels employee is at risk.

Hiring Visiting Angels’ Employees. Client shall not employ or receive services from the employee(s) assigned to Client by Visiting Angels except as contemplated by this Agreement for a period of two (2) years following the last day the employee(s) rendered services to Client on behalf of Visiting Angels pursuant to this Agreement.  This prohibition includes but is not limited to:

Paying the caregiver directly for services during the caregiver’s employment with Visiting Angels;
Paying the caregiver directly for services after the caregiver’s employment with Visiting Angels is terminated;
Paying another agency, person, or entity for services provided by the caregiver after the caregiver’s employment with Visiting Angels is terminated; and,
Accepting services from the caregiver while the caregiver is employed by another agency or entity.

In the event that Client violates this condition, Client shall pay $10,000.00 for each such employee to Visiting Angels as liquidated damages and any reasonable attorney’s fees and costs associated with collecting those liquidated damages. This amount reflects the costs of recruiting, screening, and training the employee(s).  In addition to this remedy, Visiting Angels shall be entitled to obtain injunctive relief against any violation of this Agreement, without notice to Client, without the necessity of proving actual damages and without posting a bond.  These remedies shall be cumulative and not mutually exclusive.  Visiting Angels reserves the right to pursue any other or further remedies at law or in equity to enforce its rights under this agreement.

Transportation. A vehicle is not to be driven by the caregiver employee without prior written authorization from the client to agency. Agency's insurance does not cover loss or damage caused by employees operating the client's owned or leased vehicle. Client shall be primarily responsible for any and all claims, including negligence, related to caregivers’ operation of a vehicle to transport Client. If the agency employee drives his/her own vehicle in order to perform services to client, the client will be billed at $.80 per mile.

Securing Property.  Client shall secure all cash and valuables in a secure place (such as a safe) or remove them from Client’s premises. Visiting Angels caregivers shall be bonded and Client shall file a police report in the event that any cash or valuable is found to be missing from Client’s premises.  In addition, Client shall maintain insurance coverage for the theft or loss of cash or valuables. 

Jurisdiction & Venue.  If it is necessary to litigate a dispute arising out of or relating to this agreement, Client agrees to jurisdiction in the State of New Jersey and venue in the County of Passaic.

Entire Agreement & Severability.  This agreement contains the entire understanding of the parties regarding the subject matter of this agreement, and supersedes all prior and contemporaneous negotiations and   agreements, whether written or oral, between the parties with respect to the subject matter of this agreement.  If a provision of this agreement is determined to be unenforceable in any respect, the enforceability of the provision in any other respect and of the remaining provisions of this agreement will not be impaired.

Release of Liability:  Client hereby releases FRIENDLY COMPANIONS LLC DBA VISITING ANGELS from responsibility for any events that may be harmful to the care recipient in the course of receiving services from the referred caregiver employee, including those acts or omissions that arise from a caregiver’s negligence. You agree to maintain homeowners insurance, medical insurance and/or other coverage as may be necessary to provide protection for the care recipient.  In good faith, you, individually, on behalf of the family and the care recipient, release FRIENDLY COMPANIONS LLC DBA VISITING ANGELS from responsibility for money or any articles that may be found missing from the home of the care recipient.

AGREED AND ACCEPTED

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

 Note: If you sign this Client Services Agreement on behalf of the Client, a copy of the Power of Attorney or court order appointing you as the Client’s legal guardian must be attached to this Agreement.

By signing below, I, the above identified Financially Responsible Party, agrees to pay for any and all charges for services Visiting Angels provides to the Client pursuant to this Client Services Agreement and the attached Schedule of Services and Rates, as both may be amended from time to time.  There is up to a 3.5% surcharge for invoices paid via credit or debit card.

SCHEDULE OF SERVICES AND FEES

 

This Schedule of Services and Fees is part of the Client Services Agreement

between Client and Visiting Angels dated the same date as this Schedule.

Minimum Charge: A minimum charge of 2 hours per visit will be charged.

Weekend Rate: The weekend rate begins on Friday at 10PM and ends on Sunday at 10 PM.  Any service that begins during that period will be charged at the weekend rate.

Holiday Rate: The holiday rate is one-and-one half times the weekday rate and will be charged for the Visiting Angels holidays listed below.  The holiday rate begins at 12:00AM on the date of the holiday and ends at 11:59PM.  Any service rendered during that period will be charged at the holiday rate.  Visiting Angels' holidays are:

• New Years Day
• Easter
• Memorial Day
• July 4th
• Labor Day
• Thanksgiving
• Christmas

Overtime Rate: The overtime rate is one-and-one half of the weekday rate and is charged for any hours worked over 40 hours in a workweek (Sunday thorugh Saturday) by a caregiver if the caregiver is not legally exempt from overtime pay.  Visiting Angels will not schedule any caregiver for more than forty (40) hours in a workweek without prior consent of the Client or Client's representative.

Cancellations; Refusal of Service:  A two (2) hour minimum charge at the applicable rate will be charged if a cancellation is recieved less than 24 hours prior to the time scheduled for the caregiver to arrive at the Client's residence.  Any canncellation in service myst be communicated by telephone to the Visiting Angels office at (973) 839-3761.  A two (2) hour minimum also will be charged if Client refuses service or is not at his/her residence when the caregiver arrives to provide service.

 

Rev 8/24/2024

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

WE ARE REQUIRED BY LAW TO MAINTAIN THE PRIVACY OF PROTECTED HEALTH INFORMATION, TO PROVIDE INDIVIDUALS WITH NOTICE OF OUR LEGAL DUTIES AND PRIVACY PRACTICES WITH RESPECT TO PROTECTED HEALTH INFORMATION AND TO NOTIFY AFFECTED INDIVIDUALS FOLLOWING BREACH OF UNSECURED PROTECTED HEALTH INFORMATION.

1. Below is a description, including at least one (1) example, of the types of uses and disclosures that the above organization is permitted to make for each of the following purposes: treatment, payment and health care operations.

Disclosures to other health care providers, including, for example, to patients' attending physicians. Submission of claims and supporting documentation including, for example, to organizations responsible to pay for services provided by the organization. Disclosures to conduct the operations of the organization, including, for example, sharing information to supervisors of staff members who provide care to patients.

2. Below is a description of each of the other purposes for which the organization is permitted or required to use or disclose protected health information without an individual's written consent or authorization.

To patients, incident to another permitted use or disclosure, by agreement, to the Secretary of the U.S. Department of Health and Human Services, as required by law, for public health activities, information about victims of abuse, neglect or domestic violence, health oversight activities, for judicial and administrative proceedings, for law enforcement proceedings, about decedents, for cadaveric organ, eye or tissue donation, for research purposes, to avert a serious threat to health or safety, for specific government functions, to business associates of the organization, to personal representatives, de-identified information, to workforce members who are victims of crimes, to workers' compensation programs, for involvement in the individual's care and for notification purposes, with the individual present, for limited uses and disclosures when the individual is not present, and for disaster relief purposes.

3. Other uses and disclosures, such as disclosure of psychotherapy notes, use of protected health information for marketing activities and the sale of protected health information, will be made only with the individual's written authorization and the individual may revoke such authorization.

4. The organization may contact the individual to schedule visits and for other coordination of care activities.
revised July 2013

5. The individual has the right to request further restrictions on certain uses and disclosures of protected health information, but the organization is not required to agree to any requested restriction(s), except disclosures must be restricted to health plans if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the protected health information pertains solely to a health care item or service for which the individual or person other than the health plan on behalf of the individual has paid the organization in full.

6. The individual has the right to receive confidential communications of protected health information, the right to inspect and copy protected health information, the right to amend protected health information, the right to receive an accounting of disclosures of protected health information and the right to obtain a paper copy of this Notice from the organization upon request.

7. The organization is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information and to notify affected individuals following a breach of unsecured protected health information.

8. The organization is required to abide by the terms of this Notice currently in effect.

9. The organization reserves the right to change the terms of its Notice and to make the new notice provisions effective for all protected health information that it maintains. Individuals may obtain a revised copy of this Notice upon request.

10. Individuals may complain to the organization and to the Secretary of the U.S. Department of Health and Human Services if they believe their privacy rights have been violated. Complaints should be directed to Jasmeet Malik at the organization at the following telephone number (973) 839-3761. Individuals will not be retaliated against for filing a complaint.

11. For further information, individuals should contact Jasmeet Malik at the organization at the following telephone number: (973) 839-3761.

12. My signature below is an ackknowledgement that I have received a copy of this notice.

I understand that protected health information may be used and disclosed to carry out treatment, payment or health care operations.

For a more complete description of such uses and disclosures I understand that
I should refer to the attached Notice of Privacy Rights. I further understand that I have the right to review this Notice prior to signing this authorization.

I understand that the organization reserves the right to change its privacy practices described in the attached Notice of Privacy Rights and that I can obtain a revised Notice upon request.

I understand that I have the right to request that the organization further restrict how protected health information is used or disclosed to carry out treatment, payment, or health care operations.

I also understand that the organization is not required to agree to any restrictions that I may request. If, however, the organization agrees to restrictions I request, I further understand that the restrictions are binding on the organization unless they are terminated.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by applicable statutes and regulations.

I understand that I have the right to revoke this authorization in writing, except to the extent that the organization has taken action in reliance upon my authorization.

I understand that I have the right to inspect or copy the protected health information to be used or disclosed.

I understand that use or disclosure of requested information will not result in direct or indirect remuneration to the above organization.

I also understand that I have the right to refuse to sign this authorization.
My signature below serves as acknowledgement that I have received a copy of this Authorization.

1. Each client shall have the right to choose care providers and the right to communicate with those providers.

2. Each client shall have the right to participate in planning of the client's care and the right to appropriate instruction and education regarding the plan

3. Each client shall have the right to refuse home health care and to be informed of possible consequences of this action.

4. Each client shall have the right to care that is given without discrimination as to race, color, creed, sex, or national origin.

5. Each client shall be admitted for service only if the agency has the ability to provide safe, professional care at the level of intensity needed.

6. Each client shall have the right to reasonable continuity of care.

7. Each client shall have the right to be advised in advance of any change in the plan of care before the change is made.

8. Each client shall have the right to confidentiality of all records, communications, and personal information.

9. Each client denied service for any reason shall have the right to be referred elsewhere.

10. Each client shall have the right to voice grievances and suggest changes in services or staff without fear of reprisal or discrimination.

11. Each client shall have the right to be fully informed of agency policies and charges for services, including eligibility for, and the extent of payment from third-party reimbursement sources, prior to receiving care. Each client shall be informed of the extent to which payment may be required from the client.

12. Each client shall have the right to be free from verbal, physical, and psychological abuse and to be treated with dignity.

13. Each client shall have the right to have his or her property treated with respect.

14. Each client shall have the right to contact Visiting Angels to discuss any questions or concerns, or to lodge a complaint. Please call Jasmeet Malik at 973-839-3761.

15. Each client shall have the right to contact the following agencies to lodge a complaint or get more information:

Visiting Angels (800) 365-4189

Commission on Accreditation for Home Care (201) 880-9135

N.J. Division of Consumer Affairs (973) 504-6200 or (800) 242-5846

Division of Disability Services for PCS (609) 292-7800

 

Each client has the right to receive a copy of The Consumer’s Guide for Homemaker-Home Health Aides, published by the NJ Board of Nursing within 24 hours prior to start of services. A client may waive his or her right to obtain the Consumer’s Guide for Homemaker-Home Health Aides within this time frame. If the client waives their right to receive a copy, Visiting Angels will document on the Waiver form and obtain the signature of the client/responsible party. A copy of the Waiver form will be maintained for at least 2 years in the clients record. A client may request a copy of the guide at a later date.

The client/family/responsible party is responsible for:

 a. Providing accurate and complete information about present complaints and other matters relating to the client’s overall status and mobility

 b. Reporting unexpected changes in the client’s status

 c. Providing feedback regarding services, needs and expectations

 d. Asking questions regarding care or services

 e. Following the organizations policies and procedures concerning client care and conduct

 f. Showing respect and consideration for the organizations personnel and property

 g. Meeting financial commitments by promptly meeting financial obligations agreed to with the organization

I have received a paper or electronic copy of The Consumer’s Guide for Homemaker-Home Health Aides.

*I have received a copy of the above information and these topics have been explained to me in a way that I fully understand. I agree to follow these guidelines and regulations:

I do hereby freely give my consent for the services discussed in the Client Service Agreement and/or supporting documentation.

I understand that my records may be reviewed by the State of New Jersey or Accrediting body for the purpose of inspection and/or Accreditation.