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M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY
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Enter Date of Agreement
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YOUR PREFERENCES FOR RECEIVING STATEMENTS *
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Please review this agreement carefully, as it sets forth the understanding between you (“Patient”) and M & M Home Care regarding the services you have requested and we will provide for you. If you have any questions, concerns or issues about the content of this Agreement please contact us for clarification before signing it.
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CONSENT TO RECEIVE SERVICES
I hereby authorize M & M Home Care to render appropriate home care services to the patient named above. I understand an appropriate level of home care personnel will provide such care. I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying the M & M Home Care office. In addition, M & M Home Care may terminate service by notifying me of termination and the reason.
I authorize M & M Home Care to conduct a nursing assessment, a home safety assessment and provide medical and non-medical services.
The services provided which M & M Home Care will provide have been explained to me and I understand that the undersigned and/or Client may refuse treatment within the confines of the law after being informed of the consequences of such actions.
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AUTHORIZATION FOR EMERGENCY MEDICAL SERVICES
At any time while receiving services from M & M Home Care, and in the event of any medical emergency, I authorize M & M Home Care or its employees/contractors to provide or obtain such medical treatment as they deem advisable under the circumstances, and I agree to assume sole responsibility for all charges for such treatment.
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RELEASE OF MEDICAL RECORDS
I give consent and authorization for release of medical information to M & M Home Care by physicians and other health care providers, facilities and similarly I authorize M & M Home Care to release copies of my medical records, reports or summaries as may be relevant to other health care providers for the purpose of continuing and coordinating my home care plan and for quality assurance purposes.
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ASSISTANCE WITH MEDICATIONS
I have been informed by M & M Home Care, Inc. that I may be receiving assistance with self administration of medication from an unlicensed person.
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ADVANCE DIRECTIVES / DNR (DO NOT RESUSCITATE) ORDERS
I understand that it is my responsibility to provide M & M Home Care with a copy of any Do Not Resuscitate order signed by my physician and any advance directive I may have.
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NON-SOLICITATION
I agree that neither I nor any one on my behalf, including paying another agency, person, or entity may employ any M & M Home Care staff for a period of one (1) year following completion of services rendered.
In the event I violate the above condition, I shall pay M & M Home Care the sum of $5,000.00 as liquidated damages.
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SERVICE RATES & FEES
(EFFECTIVE 6/30/2025)
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The undersigned (herein referred to as “Patient” or “Guarantor”) wish to enter into this Financial Responsibility Agreement (the “Agreement”) with M & M Home Care (“Provider”) to provide the Patient with home care services.
The minimum shift length is 4 hours. Holidays are billed at 50% greater than the above or “time-and-a-half”. Designated holidays are New Year’s Day, Memorial Day, July Fourth, Labor Day, Thanksgiving and Christmas Day.
S9123: NURSING CARE, IN THE HOME; BY REGISTERED NURSE, $92.50 PER HOUR
S9124: NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, $72.85 PER HOUR
S9122: STANDARD CARE - HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PROVIDING CARE IN THE HOME; $45.35 PER HOUR
T1001: NURSING ASSESSMENT/EVALUATION - $92.52
T1022: HOME HEALTH AGENCY SERVICES, ALL SERVICES PROVIDED UNDER CONTRACT, $555.12 PER DAY
97140: MANUAL THERAPY TECHNIQUES, 1 OR MORE REGIONS, EACH 15 MINUTES (MOBILIZATION / MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION) - $90.85/UNIT
97124: THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE, AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) - $90.85/UNIT
OCCUPATIONAL THERAPY / SPEECH THERAPY / PHYSICAL THERAPY: FEES WILL VARY PER SERVICE. PLEASE REQUEST OUR FEE SCHEDULE FOR SPECIFIC CHARGES.
M & M Home Care rates are subject to change without notice. For the most up-to-date information on current rates, please contact the M & M Home Care office directly to obtain a current rate sheet.
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FEE FOR SERVICE
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TRAVEL
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TRAVEL CHARGE APPLICABLE?
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CLIENT WILL BE RESPONSIBLE FOR A PER VISIT FEE LISTED BELOW FOR TRAVEL
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PREPAYMENT REQUIREMENT FOR PRIVATE PAY SERVICES
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Prepayment Policy. All services provided by M & M Home Care on a private pay basis must be paid in advance. The Client and/or Responsible Party agrees that payment for scheduled services must be received by M & M Home Care no later than seven (7) calendar days prior to the first scheduled service date for the applicable service period.
Condition of Service. Prepayment is a condition precedent to the provision of services. M & M Home Care reserves the right to delay, suspend, or cancel scheduled services if the required prepayment has not been received by the due date.
Service Period. Prepayment shall apply to the anticipated schedule of services for the upcoming week, based on the care plan or mutually agreed service schedule. Any additional services requested beyond the prepaid schedule may require additional advance payment prior to being rendered.
Application of Payments. Payments received will be applied to the next scheduled service period unless otherwise specified in writing by M & M Home Care.
Non-Payment. If payment is not received within the required timeframe, M & M Home Care shall have the right, at its sole discretion, to suspend services until the account is brought current, without liability for any resulting interruption of services.
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CREDIT CARD AUTHORIZATION FORM
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Click here to be directed to the M & M Home Care Credit Card Authorization Form
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TRANSPORTATION POLICY & CHARGES
M & M Home Care does not permit the transportation of any patient in the staff member's personal vehicle or company vehicle UNLESS the M & M Home Care "Private Transportation Release" is signed.
If a M & M Home Care staff member is required to drive the patient’s vehicle, that vehicle shall be insured without limitations on the Personal injury Protection (PIP)and the patient hereby releases M & M Home Care and/or that employee from all liability should an injury or accident occur.
If the employee of M & M Home Care drives her/his own vehicle in order to perform service(s) (without the patient as an occupant), the patient will be billed at $0.60 per mile.
It is the responsibility of the patient to pay for directly any expenses incurred in the course of providing services, such as tolls and parking.
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PATIENT VEHICLE RELEASE
Should I permit a M & M Home Care employees/contractors to operate my automobile, I understand and agree that it is my responsibility to maintain automobile liability insurance at the minimum level established by the state covering my automobile and authorized drivers, including M & M Home Care employees/contractors.
Furthermore, I understand and agree that M & M Home Care does not provide insurance coverage under any circumstances for any damages to my automobile, bodily injury or damage to property resulting from the use of my automobile by M & M Home Care employees/contractors.
I hereby release M & M Home Care and its employees/contractors assigned to me, and hold M & M Home Care and such employees/contractors harmless and indemnify them from any claim, liability, or cause of action for any injury to my person (including death), bodily injury to a third party, or property damage resulting from the use of an automobile (whether or not owned by me) if operated by a M & M Home Care employee/contractor, whether or not prior authorization from the M & M Home Care office has been obtained.
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CANCELLATION and SCHEDULE CHANGE POLICY
Notice Requirement. Because M & M Home Care schedules clinical staff and caregivers in advance, the Client and/or Responsible Party agrees to provide no less than twenty-four (24) hours’ notice for any cancellation, reduction, or rescheduling of a scheduled service visit.
Late Cancellations. Cancellations made with less than twenty-four (24) hours’ notice may be treated as a late cancellation. In such cases, M & M Home Care reserves the right to bill the Client for the full cost of the scheduled service visit, as staffing and scheduling commitments have already been made.
No-Show Appointments. If a caregiver or clinician arrives at the scheduled service location and the Client is not present or refuses services, the visit will be considered a “no-show.” No-show visits may be billed at the full scheduled rate.
Application to Prepaid Services. For private pay clients who prepay for services, visits cancelled with proper notice may be credited toward future services within the same service period, subject to scheduling availability. Visits cancelled with insufficient notice or considered a no-show may not be eligible for credit or refund.
Agency Cancellations. In the rare event that M & M Home Care must cancel a scheduled visit due to staff illness, emergency, or circumstances beyond the agency’s control, the agency will make reasonable efforts to provide a replacement provider or reschedule the visit, or apply the appropriate credit toward future services.
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NOTICE OF PRIVACY PRACTICES
I consent to let M & M Home Care use and disclose health information about me as described in the Notice of Privacy Practices. In doing so I am consenting to the use and disclosure of health information about substance abuse, psychiatric care, or HIV, if applicable.
I consent to the release of health information about me to my insurer, other third party payers, and any agents or consultants that help M & M Home Care get paid or assist in my treatment or its health care operations. I can revoke my consent in writing at any time except to the extent that M & M Home Care has already relied on my consent.
The complete M & M Home Care Notice of Privacy Practices can be found at our website.
CLICK HERE TO VIEW THE COMPLETE NOTICE
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PATIENT RIGHTS AND RESPONSIBILITIES
Home care patients and their staff have a right to not be discriminated against based on race, color, religion, national origin, age, sex, or handicap. Furthermore, patients and caregiver's have a right to mutual respect and dignity, including respect for property.
Caregivers are prohibited from accepting personal gifts or borrowing from patients.
The complete Patient Rights and Responsibilities can be found at our website.
CLICK HERE TO VIEW THE COMPLETE PATIENT RIGHTS AND RESPONSIBILITIES
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SEVERE / BAD WEATHER
In severe weather, we may determine it is not safe for our staff to travel and provide services to your home that day and may have to cancel that day’s service. When this occurs we will notify you and reschedule. We appreciate your understanding regarding this matter.
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TERMINATION OF SERVICES
I have the right to reasonable, advance notice of changes in services, including at least a 30 day advance notice of the termination of a service by M & M Home Care, except in cases where:
- an abusive or unsafe work environment for the individual providing home care services exists; or
- an emergency for the caregiver or a significant change in the patient’s condition has resulted in service needs that exceed the current agreement and cannot safely be met by M & M Home Care.
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ACKNOWLEDGEMENT OF RISKS
I fully acknowledge that I have not hired M & M Home Care to provide personnel to be by the patient’s side during every minute of the shifts I am requesting. As such, I understand that the duties of M & M Home Care personnel entail many activities that require such personnel to leave the patient’s side (eg. including but not limited to preparing a bath, preparing clothing) and often times to leave the patient's immediate vicinity (eg. to cook or clean within the home) and/or leave the patient’s home (eg. to shop outside the home).
Similarly, if patient refuses care or disallows any M & M Home Care employee from doing their job, included but not limited to, assisting with ambulation or assisting in ways that are necessary to prevent injury, the M & M Home Care employee cannot use physical force to assist and must respect the patient’s right to refuse care under the Patient Bill of Rights.
M & M Home Care employees and M & M Home Care are not responsible for any resulting harm, injury or death that may result thereto. Accordingly, I fully acknowledge that there are risks that are not possible to eliminate and therefore it is not the responsibility of M & M Home Care to eliminate such risks. Such risks may include but are not limited to the risk of falling, wandering, over-medication and choking, all of which may lead to serious injury or even death.
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FINANCIAL RESPONSIBILITY
I understand that I am financially responsible for all charges and agree to pay for services. My failure to provide the necessary information to M & M Home Care, Inc. will make me personally responsible for all charges related to the care provided.
The undersigned, hereby authorizes payment directly to M & M Home Care, Inc., for all services provided and for medical expenses that I may incurred.
This is irrevocable unless terminated by mutual agreement of the Patient and M & M Home Care.
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A special link to resume the form will be sent to your email address.
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