Client Agreement (Company Logo)

Client Information / Date
Last Name / First Name / Middle
Initial
Address
City / State / Zip
Telephone / Alternate
Phone
Contact or Personal Representation
Last Name / First Name / Middle
Initial
Address
City / State / Zip
Telephone / Alternate
Phone
Do you have Power of Attorney?  Yes  No
Authorization for Service
I authorize the employees of (Company) to render services as outlined in the Service Plan, a copy of which is attached. I understand that the Service Plan may be changed at my request. Initial:_____
Term and Termination
This agreement shall commence upon______. This agreement shall continue for one year and shall renew automatically each year. This agreement may be terminated by either party upon written notice. This agreement shall automatically terminate upon my death. Initial:_____
Services to be Provided -
______at $ ______per hour
______at $ ______per hour
______at $ ______per hour
______at $ ______per hour
______at $ ______per hour ______at $ ______per hour
Additional charges may include:
______at $ ______per hour
______at $ ______per hour ______at $ ______per hour
Initial:_____
Verification of Service
I agree to provide my signature on a service record(s) or time document(s) necessary to verify that the employee(s) of (Company) has/have provided planned services on a given date. I agree to not withhold my signature on the time/service record unless I disagree with the documentation or representation made therein. I understand that signing documentation indicating I have received services when I have not received them is fraud and could result in penalties against me. Initial:_____
Financial Responsibility
I agree to be responsible for payment of services, including those not paid by my insurer, if applicable. (Company) ( will  will not) bill insurer directly.Invoices will be sent on______. I agree to pay within ______days receipt of invoice. If my account is not paid within _____days, I agree to pay late fees of an additional $______and interest of _____% after _____. In the event (Company) is required to take action to collect any amounts, I agree to pay(Company’s) reasonable attorney fees and costs incurred in collecting these amounts. Upon my death, my estate or heirs will pay any unpaid amounts due to (Company).
Initial:_____
Deposit for Services
A deposit equivalent to _____ weeks of anticipated services will be paid at signature of this Client Agreement. Deposit will be applied to any outstanding amounts stated on the invoice after termination of this agreement.
Initial:_____
Assignment of Benefits
If (Company) bills my insurance company and Insurer pays, I hereby assign benefits to (Company) and authorize insurer to pay (Company) directly. Initial:_____
Medicaid Waiver/CHOICE Services
NOA # ______Case Manager ______
IHCP #______Case Manager ID # ______
Term of NOA: From Date ______To Date ______
Service Authorizations: (Number of Hours per Month)
ATTC ______HMK ______RATTC ______RHMK ______
I understand the services and number of hours is authorized by the Area Agency on Aging in the NOA. I agree to pay (Company) for any hours and/or services agreed to in the service plan that I/we have requested that are above and beyond those that have been authorized by the Area Agency on Aging. Initial:_____
Release of Information
I authorize (Company) to release information about client to healthcare providers, third party payers, government surveyors, accrediting bodies, auditors or other organizations that may assist me to meet or improve my activities of daily living or independence. Initial:_____
Hiring Employees
I agree not to employ the employee(s) (Company) assigns to Client for a period of ______following the last day the employee(s) rendered services to Client. In the event that I violate this condition, I agree to pay $______as a finder’s fee and any reasonable attorneys fees and costs associated with collecting those liquidated damages. This amount reflects the costs of recruiting, screening, and training the employees.
Initial:_____
Jurisdiction and Venue
If it is necessary to litigate a dispute arising out of or relating to this agreement, I agree to Jurisdiction in the State of Indiana and the Venue in the Court of ______County, Indiana. Initial:_____

______

Client or Authorized SignaturePrint NameDate

______

(Company) Representative SignaturePrint NameDate

Financially Responsible Party/Guarantor
By signing below I, ______, agree to be personally responsible for any and all charges for services to the Client.

______

Financially Responsible Party SignatureDate

Method of Payment
Credit CardCheckCash EFT (use separate form)
I authorize (Company) to make regular charges to my credit card ending in ______for services rendered until notice to discontinue.
Cardholder Signature ______

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This section to be removed and destroyed upon entry into PCI compliant system.

Credit Card Information
Name on Card______
Card Number______
Type of Card ______Exp. Date______Security Code______

IC 16-27-4-127/2012

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