Client Agreement
Multiple Clients
Your Phone/Email is associated with multiple clients. Please select the Client Agreement to review:
The Senior Company Terms & Agreement
- THIS IS A DAY TO DAY SERVICE AGREEMENT. NO LONG-TERM COMMITMENT.
- NO EXCESS FEES. The Senior Company will not assess any initial startup fees, Registered Nursing fees, reassessment fees, administrative fees or deposits.
- Client may terminate services at any time. 24-hour notice is required. If less than 24-hour notice is provided, client is responsible for the entire shift.
- If Client or anyone residing in client's environment has tested positive or is symptomatic for COVID-19 or if they have been treated in a facility where COVID-19 is or has been present, a hazard rate of 1.3 times the base rate will apply until the client has been medically cleared or has been asymptomatic for 14 days (whichever comes first). Additional PPE will be provided for use by the caregiver during this period.
- _______________________________ agrees to pay for services in full accordance with the terms below and authorize The Senior Company to review my medical records and/or insurance information as they relate to my care.
- Any services that I request will be billed to me and will be my sole financial responsibility regardless of my private insurance coverage. Any amounts not satisfied by insurance in a timely manner are still my responsibility.
- Services will be determined by checklists or timesheets that are signed by both the client and the CHHA/RN/LPN.
- The Senior Company understands that in some circumstances a pet may also need support in a client's home while the client is receiving care. It is highly recommended that pet care is also coordinated as the Senior Company does not provide care or support for animals nor can it be held responsible for the health and welfare of any animals in the home while care is being provided.
- All services that exceed forty (40) hours per week for a specific caregiver will be charged at the standard overtime rate of 1.5 times the base rate.
- All overtime will be billed at a rate of 1.5 times the base rate.
- The following Holidays will be billed at 1.5 times the hourly or live in rate: Easter, Memorial Day, July 4th, Labor Day, Thanksgiving, Christmas Day, New Year's Day. Christmas Eve & New Years Eve are WAIVED as a courtesy.
- Client will be billed for any CHHA/RN/LPN services that extend beyond the schedule initially agreed upon by client and The Senior Company at the specified hourly or live in rate.
- All emergency visits, changes in patient condition, or patient's family requests for evaluation are billable visits dictated by the medical/nursing standards of care at a standard rate of $125 per hour.
- The Senior Company invoices our clients every Monday.
- For example - The Senior Company begins services on Wednesday the 1st and provides those services every day from Wednesday-Sunday the 5th. Our client would receive an invoice on Monday the 6th for the previous week's services.
- The Senior Company's system will automatically generate an invoice and email the invoice to ________________________
- Clients are responsible for payments weekly after services are rendered.18. The client is responsible to check all mail folders, junk mail folders etc. If you are having trouble finding the email in your inbox, type in "Clearcare" into your search bar. If you do not receive an invoice by Tuesday morning, please call our office.
- The Senior Company offers several payment methods. We highly recommend utilizing our automatic payment methods. ACH - Direct debit from our clients checking account is the most secure and cost-effective way to make payment.
- If our clients prefer to pay by check, The Senior Company does accept a personal check as a payment method, however, for security reasons and payment consistency, The Senior Company strongly advises against this payment method and recommends an automatic secure form of payment.
- Payment must be made within 5 business days after the previous week's services have been rendered.
- In the event _________________________________________ fails to submit payment when due, a representative from The Senior Company will call to notify the client by the end of the week. The Senior Company will automatically charge the legal maximum allowable late fee . In the event payment is not received and services are discontinued, the client will be responsible for all late fees, reasonable attorney fees, and other collection costs.
- Rates are subject to change depending on several factors, including but not limited to; if Client requires a higher level of care or reduces the level of care needed, hours per day and days per week increased or decreased, location and national and/or state wage increases. Client will be notified prior to any rate increase taking effect.
- TSC may terminate services without notice if the safety or well-being of the agency's staff is or may be in immediate jeopardy. TSC may terminate services for non-payment of services with seventy-two (72) hours' notice to the client or party that is responsible for weekly payment.
- The client acknowledges and agrees that the Caregiver/RN/LPN assigned to provide services under this agreement is an employee of TSC and is prohibited by law from providing personal care services privately to the client. As such, the client agrees that the responsible party and/or the client will not solicit or encourage TSC's employees to leave their employment with TSC and will not engage or employ TSC's employees to provide services to client directly or through another company while this agreement is in effect AND continuing for a period of one (1) year after the termination of this agreement. The responsible party/client agrees to pay TSC a lost opportunity charge of $25,000.00 should the responsible party and/or the client violate this provision of the agreement.
- In the event TSC's employee uses his or her own vehicle for the services, the client will be charged mileage at the rate of $.75 cents per mile , which shall be in addition to the regular service charges. TSC employee may use the client's vehicle for errands and incidental transportation with permission from the client in connection with the services at no charge. Client agrees to and will maintain effective automobile insurance coverage for this vehicle for at least the minimum state statutory amounts as required by the laws of the state of New Jersey. During the term of this agreement, the client will be responsible for maintaining coverage for authorized third-party drivers, including, without limitation, TSC and TSC's employees. Client/responsible party agree to indemnify and hold TSC harmless from and against all claims, liability, or causes of action for any injury to person or property related to TSC's employee use of client'svehicle.
- Client acknowledges that emergency situations or crises may impact TSC's ability to provide service to its clients, due to the increased risk and difficulty of providing service during such times. These situations or crises include, but are not limited to, extraordinary weather conditions, natural disasters and acts of terrorism and/or war. In the event TSC has the need to provide a car service for your CHHA/RN/LPN during any such situation or crises, client agrees to pay for the cost of transportation.
HIPPA Agreement
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION
- I may inspect or copy the protected health information to be used or disclosed.
- I may revoke this authorization in writing by contacting your office, attention: Administrator
- Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA.
- I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections/questions, please discuss with your The Senior Company Representative.
I give permission to the representatives of the Commission on Accreditation for Home Care (CAHC) to review my records and speak with The Senior Company staff, family members and other professionals listed below about the services provided.
I give permission for The Senior Company to discuss my medical condition with my medical insurance companies, my physicians, visiting nurse/hospice services, physical/occupational Therapy, Speech Therapy, laboratory and/or hospital, to coordinate and collaborate for my care, and to facilitate payment of my medical expenses. I also give permission for the contacts I listed provided to receive information regarding my medical care/conditions.
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