M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY v.2022.0121

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M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY
PATIENT NAME PATIENT NAME First Last
DATE OF AGREEMENT DATE OF AGREEMENT / MM / DD YYYY

Enter Date of Agreement
DATE OF BIRTH DATE OF BIRTH / MM / DD YYYY
PATIENT'S PHONE PATIENT'S PHONE - ### - ### ####
PATIENT EMAIL
PATIENT ADDRESS PATIENT ADDRESS
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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.
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.
I CONSENT TO RECEIVE SERVICES FROM M & M HOME CARE
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.
I AGREE TO THE AUTHORIZATION FOR EMERGENCY MEDICAL SERVICES.
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.
I AGREE TO THE RELEASE OF MEDICAL RECORDS.
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.
I AGREE TO THE ASSISTANCE WITH MEDICATIONS.
NOT APPLICABLE
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.
I HAVE ADVANCE DIRECTIVES I DO NOT HAVE ANY ADVANCED DIRECTIVES
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.
I AGREE TO THE NON-SOLICITATION
SERVICE RATES, FEES & DEPOSITS
The undersigned (herein referred to as “”Client” or “Guarantor”) wish to enter into this Financial Responsibility Agreement (the “Agreement”) with M & M Home Care (“Provider”) to provide the Client with home care services.

The minimum shift length is 4 hours unless we can accommodate fewer than 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.

If multiple service types or hours are requested, or if the service request changes, the rates may change accordingly.

Rates for services are subject to review from time to time, but increases will be subject to at least a four-week advance notice.

We are required by law to pay our employees time-and-a-half if they work more than 40 hours per week. To accommodate the rates you have been quoted, we will manage your care in such a way that the employee does not work more than 40 hours in any Sunday through Saturday time period. If you would like a given Home Health Aide to be assigned to work when it means they will be accruing overtime pay (and they are willing to work the overtime), you will be charged time-and-a half.
HOURLY CARE
(4 OR MORE HOURS)
T1022 - Personal care services, per hour. - $39.00 per hour

T1030 - Nursing care, in the home, by registered nurse, per hour - $105.00 per hour

T1031 - Nursing care, in the home, by registered nurse, per hour - $75.00 per hour

VISIT RATES
(LESS THAN 4 HOURS)
SKILLED NURSING HOME CARE VISIT - $225.00 - 265.00 PER VISIT

NON SKILLED NURSING VISIT - $45 PER 15 MINUTES

HOME HEALTH AIDE VISIT - $85.00 - $95.00 PER VISIT

THERAPY SERVICES

OCCUPATIONAL / PHYSICAL THERAPY - $85 PER UNIT

THERAPEUTIC MASSAGE THERAPY - $75 PER UNIT
TRAVEL CHARGE APPLICABLE?

TRAVEL CHARGE APPLICABLE? YES NO
CLIENT WILL BE RESPONSIBLE FOR A PER VISIT FEE LISTED BELOW FOR TRAVEL $ Dollars . Cents
I AGREE WITH THE RATES SHOWN ABOVE.
BILLING
Our billing period begins on Sunday and ends on Saturday. You will receive an invoice from M & M Home Care by your preferred method bi-weekly. All balances are due within 7 days. Credit card authorizations will be processed at the time your invoice is created.
YOUR PREFERENCES FOR RECEIVING INVOICES

YOUR PREFERENCES FOR RECEIVING INVOICES Mail to Patient's Home Mail to Other Address Email
OTHER ADDRESS FOR BILLING OTHER ADDRESS FOR BILLING
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
BILLING EMAIL
SOURCE OF PAYMENT

SOURCE OF PAYMENT Check Credit/Debit Card Automatic Payment (Fill Out Credit Authorization Form Below) Credit/Debit Card Self Payment (Receive an electronic invoice and make payment yourself)
CLICK HERE TO COMPLETE CREDIT CARD AUTHORIZATION FORM
DEPOSITS
A deposit equivalent to two week’s service charge will be expected upon execution of this contract before the start of services.

The deposit will be held by M & M Home Care without interest for the duration of services. Any unused portion of that amount will be promptly refunded to the patient upon termination of services.

If you request an increase in services, the deposit will be increased proportionately.
THE AGREED UPON TOTAL DEPOSIT: $ Dollars . Cents
I AGREE WITH THE DEPOSIT SHOWN ABOVE. NOT APPLICABLE
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.
I AGREE WITH THE TRANSPORTATION POLICY AND CHARGES. NOT APPLICABLE
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.
I AGREE TO THE PATIENT VEHICLE RELEASE POLICY NOT APPLICABLE
CANCELLATIONS
Cancellations may be made up to 24 hours in advance of a scheduled visit without charge. We reserve the right to charge for a scheduled visit if insufficient notice is given.

In the event that a referred caregiver fails to arrive at the care recipient’s home, we will make every effort to find a replacement as quickly as possible. If a replacement is not found or if the caregiver alters the predetermined weekly schedule in some way, we will adjust the amount that you are billed accordingly.
I AGREE WITH THE CANCELLATION POLICY.
LIGHT HOUSEKEEPING DEFINED

The Home Health Aide is not required to provide a general housekeeping service. Typical “”light” housekeeping tasks to be provided by the Home Health Aide employee would include:

a. tidying up of rooms in which the care recipient spends his/her time (bedroom, living room, kitchen)
b. washing dishes after meals (wiping spills on sink or floor, “spot cleaning”)
c. sweeping kitchen floor when needed, passing the vacuum in rooms used by care recipient
d. tidying bathrooms after use by care recipient (rinsing tub or shower after use, wiping spills on sink or floor).

It is recommended that you hire an independent cleaning service for tasks such as scrubbing floors in kitchen and bathrooms, window or mirror washing, dusting behind and under furniture, drape cleaning and heavy laundry.
I AGREE WITH THE LIGHT HOUSEKEEPING POLICY.
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
I HAVE ACKNOWLEDGE THE PRIVACY POLICY.
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
I UNDERSTAND THE PATIENT RIGHTS AND RESPONSIBILITIES.
SEVERE / BAD WEATHER
In severe weather, we may determine it is not safe for our Home Care Workers 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.
I AGREE TO THE BAD WEATHER POLICY.
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.
I AGREE TO THE CANCELLATION POLICY.
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.
I AGREE WITH THE ACKNOWLEDGEMENT OF RISKS
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.
I UNDERSTAND MY FINANCIAL RESPONSIBILITY.
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M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY v.2022.0121

M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY

M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY

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.

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.

HOURLY CARE

VISIT RATES

THERAPY SERVICES

BILLING
Our billing period begins on Sunday and ends on Saturday. You will receive an invoice from M & M Home Care by your preferred method bi-weekly. All balances are due within 7 days. Credit card authorizations will be processed at the time your invoice is created.

CLICK HERE TO COMPLETE CREDIT CARD AUTHORIZATION FORM

M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY v.2022.0121

M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY

M & M HOME CARE CONSENT & SERVICE AGREEMENT - PRIVATE PAY

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.

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.

HOURLY CARE

VISIT RATES

THERAPY SERVICES

BILLING Our billing period begins on Sunday and ends on Saturday. You will receive an invoice from M & M Home Care by your preferred method bi-weekly. All balances are due within 7 days. Credit card authorizations will be processed at the time your invoice is created.

CLICK HERE TO COMPLETE CREDIT CARD AUTHORIZATION FORM

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.

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.

BILLING
Our billing period begins on Sunday and ends on Saturday. You will receive an invoice from M & M Home Care by your preferred method bi-weekly. All balances are due within 7 days. Credit card authorizations will be processed at the time your invoice is created.