AHS Client

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AHS Client Folder

1. Emergency Contact Information

2. Client’s Bill of Rights

3. Authorization Agreement for Direct Payment (ACH Debits)

4. Authorization Agreement for Direct Credit Card Payment

5. Client’s Live-In Obligation

6. Medication Reminder Schedule

7. Long Term Care Insurance Verification Sheet

8. Weekly Time Sheet Record (Bonus Form)

9. Incident Report (Bonus Form)

10. Supervisory Note (Bonus Form)

11. Client Weekly Schedule (Bonus Form)

12. Client Service Agreement

13. Time Card/Activity

14. Notebook to chart daily (It is important to buy a notebook for you and your caregiver to chart about the care provided to your clients)

15. Automobile Waiver

16. Client Information Summary

17. Care Plan

18. Emergency Plan

19. Transportation Waiver

20. Supervisory Visit Record

Disclaimer: I am not a lawyer; therefore, any legal forms are to be revised by your attorney.

EMERGENCY CONTACT INFORMATION

Primary Contact Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Secondary Contact Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Additional Contact Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Address Detail

Name:

Date of Birth:

Address:

Telephone:

City:

State:

Zip:

Allergies:

Health Insurance Provider:

Policy Number:

DNR? Yes/No

Yes

DNR Paperwork Location:

For a fire or life-threatening emergency, please call 9-1-1.

CLIENT’S BILL OF RIGHTS

The right to be treated courteously.
The right to privacy while receiving care.
The right to participate in the development of the Care Plan.
The right to safe and competent care.
The right to have their property treated with respect.
The right to know costs of services prior to receiving services.
The right to be informed of caregivers that will be delivering services.
The right to be notified in writing of changes in service, termination, and/or discharge of services.
The right to refuse home care.
The right to express dissatisfaction without fear of recrimination.
The right to a grievance procedure should the client feel his or her rights have been violated.

STATEMENT OF CONFIDENTIALITY

One-Step Ahead Home Care LLC keeps all clients’ information confidential.

We promise you that we will not release your information without your consent unless it is required by law and in the instances cited below:

Revelation that one has intent to harm oneself or someone else.
Reason to suspect that one will harm oneself or someone else.

Any decision or action on the part of the client or family members, which may cause harm to themselves or others, must, by law, be reported to the local Adult Protective Services.

I HAVE READ THE ABOVE, ASKED ALL THE QUESTIONS I DESIRED, AND UNDERSTAND AND AGREE.

Client Signature:

Date

MM slash DD slash YYYY

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

I (We) hereby authorize One-Step Ahead Home Care LLC, hereinafter called COMPANY, to initiate debit entries to my (our) account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account.

I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. Law.

Checking Account

Savings Account

I authorize the below account to be electronically credited and debited by One-Step Ahead Home Care LLC on a recurring weekly basis:

as settlement for our actual receivables or reclamation on returned transactions

Depository Name:

Branch:

City:

State:

Zip Code:

This authorization is to remain in full force and effect until COMPANY has received verbal or written notification from me (or either of us) of its termination in such time and in such a manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Name:

Email:

Signature:

Date:

MM slash DD slash YYYY

AUTHORIZATION AGREEMENT FOR DIRECT CREDIT CARD PAYMENT

Client’s Name:

I (We) hereby authorize One-Step Ahead Home Care LLC to charge my credit card on a weekly basis for payments for services rendered to the above-named client for the most recent weekly invoice.

I accept acknowledgement/statements from my financial institution as a receipt for my payment. I understand and accept the following conditions:

One-Step Ahead Home Care LLC will charge my credit card weekly for payment for services rendered.
Weekly charges will recur for as long as services are rendered.
In the event where services are no longer needed, I will give One-Step Ahead Home Care LLC written notice to discontinue automatic credit card billing.
In the event that my financial institution rejects charges to my credit card by One-Step Ahead Home Care LLC for any reason, I will pay the charges due immediately and no later than three (3) days after rejection.
I will notify One-Step Ahead Home Care LLC immediately if there are any changes to my credit card (number, expiration date, etc.).
I agree to address any disputed charges directly to the One-Step Ahead Home Care LLC office BEFORE disputing the charges with my financial institution.

Credit Card Number:

Untitled

Visa

AMX

Credit Card Expiration Date :

Security Code:

Credit Card Billing Address:

Street Name:

City:

State:

Zip Code:

Card’s Holder Relationship to Client:

Name:

Email:

Signature:

Date:

MM slash DD slash YYYY

CLIENT’S LIVE-IN OBLIGATION

Client’s Name:

I understand that One-Step Ahead Home Care LLC caregiver(s) will be living in my residence or another facility identified by myself for the provision of companionship services several days per week as written in our Client Consent Agreement.

As part of this live-in arrangement, I agree to provide the following for our live-in caregiver(s).

MEALS

All meals and snacks, within reason. I am not required to follow any specific dietary restrictions that the caregiver may have.

My refrigerator, cabinet space, and equivalent are available for storage and preparation of this food for the caregiver.

SLEEP AND STORAGE

A place to obtain 8 hours of sleep (including 5 hours of uninterrupted sleep). The sleeping space has to be in a room separate from the client’s bedroom.

The sleeping space can be a sofa bed, a cot, or a regular bed.

I will do my best to provide storage space for the caregiver’s personal belongings such as clothes, books, and toiletries.

Caregivers will not store personal belongings on my property while he/she is not at work.

REST AND PRIVACY

The caregiver is to have 2 separate 30-minute breaks.

The caregiver will stay on my premises during his/her shift.

The caregiver’s rest and privacy time are immediately interruptible for my needs.

TELEPHONE USE

The caregiver will not use my telephone for personal purposes.

The caregiver may answer my phone and take messages on my behalf with my permission.

The caregiver may make and receive calls to and from One-Step Ahead Home Care LLC and my family members to discuss my case.

Client Signature:

Home Care Rep Signature:

Date

MM slash DD slash YYYY

MEDICATION REMINDER SCHEDULE

Medication / Dosage

BREAKFAST (7-9am)/# of pills to be taken

LUNCH (11-1pm)/# of pills to be taken

SUPPER (4-6pm)/# of pills to be taken

BEDTIME (7-9pm)/# of pills to be taken

AUTOMOBILE WAIVER

Client’s Name:

Client’s Legal Representative (if applicable):

I, __________________________________ (Client or Representative), request One-Step Ahead Home Care LLC permit its employee(s) to transport CLIENT as a passenger in Client’s automobile described as below:

License Tag Number/State:

Type / Make / Color:

Owner / Title Holder:

Owner Address:

Insurance Company:

Policy Number:

Insurance Agent:

Insurance Company Address:

Agent Phone Number:

The owner of the automobile described above agrees that the automobile is properly licensed, registered, inspected, and in safe and operational condition.

I further agree to release One-Step Ahead Home Care LLC and its employees from any and all liability in case of an accident or injury while transporting CLIENT in the above listed automobile.

It is the client’s or client’s legal representative’s responsibility to notify One-Step Ahead Home Care LLC if a substitute vehicle is being used for client transportation and that the provisions contained herein shall apply to all substituted vehicles.

Client Signature:

Date

MM slash DD slash YYYY

CLIENT CONSENT AND SERVICE AGREEMENT

Client’s Name:

Client ID Number:

CONSENT TO RECEIVE SERVICES

I hereby authorize One-Step Ahead Home Care LLC to render appropriate home care services to the client named above.

I understand such care will be provided by a trained caregiver.

I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying the One-Step Ahead Home Care LLC office.

In addition, One-Step Ahead Home Care LLC may terminate services by notifying clients of termination and the reason.

Company will dispatch caregivers (“Caregiver(s)”) to the residence or other facility identified by Client for the provision of home care services.

Client understands that the Company is a non-medical agency that does not provide medical services or treatments.

Client waives any issues of medical liability on Company’s part for the provision of these non-medical services.

A general description of services to be performed is outlined as a part of the initial assessment and updated as modifications become necessary.

CAREGIVER AGREEMENT

Client understands that the Company spends a significant amount of time, money, and resources in the process of recruiting, screening, hiring, and training its Caregivers.

Client further understands that each Caregiver working for Company is prohibited from accepting private employment from Client directly (or through another organization/agency) while said Caregiver is employed by Company, as well as for a period of __________________ (_) year(s) following the Caregiver’s termination of employment with the Company.

Should Client desire to employ any of the Company's Caregivers, such employment will be deemed in violation of these restrictions.

In the case that Client wishes to employ any such Caregiver within a __________________________ (_) year period of Caregiver’s termination of employment with Company, Client agrees to pay Company a one-time replacement fee of ________________ ($___________), which is due to One-Step Ahead Home Care LLC immediately upon your employment of such Caregiver.

AUTHORIZATION FOR EMERGENCY MEDICAL SERVICES

At any time while under care, and in the event of any medical emergency, I authorize One-Step Ahead Home Care LLC or its employees to obtain such medical treatment as they deem advisable under the circumstances (calling 911).

I agree to assume sole responsibility for all charges for such treatment.

RATES

The rate for hourly care is $____________ per hour, with a minimum of _____________ hours per Caregiver visit, and the rate for live-in care is $_______________ per day.

Payment is accepted by ACH / direct deposit / Credit Card.

I understand that this fee schedule represents the current published rates for services and is subject to change.

Time-and-a-half rates apply for all hours worked on the following holidays: New Year’s Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Day, plus overtime if applicable.

If the client wants care during the holidays, clients should notify the agency at least seventy-two (72) hours in advance.

Rates may be increased with an advance 30-day written notice from One-Step Ahead Home Care LLC.

BILLING

Weekly billing is every _____________________________________ and payment is expected to be received by ________________________________________________ during the same week.

PAYMENT AND OVERDUE ACCOUNTS

Fees for services rendered are payable upon receipt of invoice.

An account is considered overdue if not paid by the due date.

CANCELLATIONS

Cancellations may be made up to 24 hours in advance of a scheduled visit without charge.

We reserve the right to charge for scheduled visits if insufficient notice is not given.

If any cancellations occur less than 24 hours before a scheduled visit, a fee of $50.00 will be billed for the insufficient notice.

However, all cancellations will be reviewed by the administration.

LIVE-IN CAREGIVER SCHEDULE

Live-In Caregivers have a standard schedule of fifteen hours per workday.

They are to receive two thirty-minute break periods.

Live-In Caregivers are to receive one eight-hour block of uninterrupted private time every evening.

During this period, the caregiver is not to be disturbed and is considered off-duty and must be provided with decent, private, and sanitary accommodations.

If the Client requests or requires the Live-In Caregiver to provide services during an off-duty period, the Client will be responsible for additional charges at our standard hourly rate based on the length of the interruption.

If the Caregiver is unable to achieve a minimum of five uninterrupted rest hours in the evening, the Client will be billed at our standard hourly rate for the entire eight-hour private time block.

Any additional service charges will be reflected on the client’s regular invoice.

SCHEDULING

All schedules for home care services are arranged between the Client and One-Step Ahead Home Care LLC.

Clients acknowledge that they should not alter, eliminate, or add schedules directly with the Caregivers.

Failure to observe our scheduling requirements may result in overtime rates.

Additional charges incurred will be reflected on the client’s regular invoice.

SECURITY OF CAREGIVER

Client understands and acknowledges that if a Caregiver is made to feel threatened and/or in physical danger while performing home care services, the Caregiver is entitled to leave Client’s premises without exposing the Caregiver and/or Company to any liability, and the Client remains liable for the full payment of fees.

In such circumstances, the caregiver(s) will notify.

COMPLAINTS and GRIEVANCE

If for any reason you are not satisfied with your services, please call our office.

To report a complaint regarding the services you receive or to report suspected Medicaid fraud, please call toll-free 1-866-966-7226.

To report abuse, neglect, or exploitation, please call toll-free 1-800-962-2873.

LIMITATION OF LIABILITY

In recognition of the relative risks and benefits of services provided by Company, Client agrees to the fullest extent of the law to limit the liability of Company for any and all claims, losses, costs, damages of any nature whatsoever, or expense from any cause or causes, including attorneys’ fees and costs, and costs of expert witness fees and costs, so that the total aggregate liability of Company to the Client shall not exceed the total fees payable to Company for services rendered.

It is intended that this limitation apply to any and all liability or cause of action however alleged or arising, unless otherwise prohibited by law.

Further, Client releases Company from any claims for liability which the Client may acquire by reason of damage, loss, injury, and/or suffering which arises from the operation and/or use of a vehicle by a Caregiver, whether that may be owned by the Client or a vehicle provided by the Caregiver or Company.

Client also agrees not to hold Company liable for any intentional acts of Caregivers acting beyond the course and scope of their duties to provide companionship services.

CLIENT’S RIGHTS AND RESPONSIBILITIES, ADVANCE DIRECTIVES, AND PRIVACY PRACTICES.

I understand it is my responsibility to report to One-Step Ahead Home Care LLC any problems or issues related to my services.

Place an X next to the days of the week you want service:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Estimated number of days per week

Estimated total hours per week

I acknowledge that I have received information about client’s rights and responsibilities and advance directives and have had any questions answered to my satisfaction.

I acknowledge that I have received a copy of the Notice of Privacy Practices, Client’s Bill of Rights, and have had any questions answered to my satisfaction.

Client or Authorized Agent Signature:

Date

MM slash DD slash YYYY

CARE PLAN

Client’s Name:

Client ID Number:

Address:

Client info:

Gender:

Male

Female

Date

MM slash DD slash YYYY

Pet:

Yes

Somker:

Yes

Diet:

Regular

Cardiac

Low Salt

Renal

Vegetarian

Ambulation:

Independent

Walker

Cane

Wheelchair

Devices:

Glasses

Dentures

Hearing Aids

Contact

Companionship

Medication Reminders:

Prepare Meals:

Encourage Fluids

Play Games/Cards:

Answer Telephone:

Assist with waking up:

Grocery Shopping:

Mail Organization:

Escort to Doctor’s Visit:

Incidental Transportation:

Other:

Homemaker

Light Housekeeping:

Linen Change

Bathroom Cleaning:

Kitchen Maintenance:

Laundry:

Ironing:

Bed Making:

Closet Organization:

Garbage Taken Out:

Personal Care

Assisted with Toileting:

Bathing:

Hair Care:

Assist with Exercise:

Assist with Walking:

Transfer from Bed to Chair:

Client’s Signature:

Date:

MM slash DD slash YYYY