E-Laboratory Network (ELN) – Home Supportive Caregiver Program - 2015
Home Supportive Services
Home Care
Care delivered in the home to support people with the active activities of daily living.
Seniors Personal Caregiver provides in-home supportive care. This allows your loved one to remain in their home while still getting the attention they need and is typically more affordable than the other types of long-term care, depending on the schedule. To learn more, just call us at 678-834-7472
Does your parent need in-home care?
Client Name: ______
Phone: ______
Address: ______
1.Is he/she affected by Alzheimer’s or dementia?
2.Have you noticed changes in his/her ability to get around?
3.Is your loved one affected by a medical condition?
4.Have you noticed changes in your parent's eating habits?
5.Have you seen changes in his/her personal hygiene?
6.Is your parent's home safe?
7.Have you seen changes in his/her social habits?
8.Are you or other caregivers experiencing burnout?
9.What are your care options?
10.What are the types of long-term care?
11.What are funding options for long-term care?
12.What are your payment options?
Client Name: ______
Address: ______City______State______Zip______
Phone Number: ______Email: ______
Contact Person: ______Phone: ______
Today’s Date: ______
Fax form to 770-376-6557
Fee Chart$97 Registration Fee
Hourly RATESPromotional Rate buy1hr - get1hr free
Wellness Watch - Rate $31.47/hr
Peace of Mind Services - Rate $33.59/hr
Nurse Visit - Rate $47.16/hr
Personal Care - Rate $43.79/hr
Surgery Assistance & Sitter Services - Rate $39.27/hr
SERVICES REQUEST –NEW BUSINESS
Type of Support Care
Personal Care/ Wellness Watch
/ Nurse Visits
/ Peace of Mind Service
/ Surgery Assistance & Sitter Services
Whether you need SeniorsPersonal' caregiver 24/7 or just a two hours a day, our Palmetto office is here to help. Our service options are flexible and customizable according to your specific situation, and your personalized seniorcaregiver plan can be a combination of any of our service
Full Service:
1.COMPANION CARE
2.ALZHEIMER'S & DEMENTIA CARE
3.HOUSEKEEPING
4.PERSONAL CARE / If your elderly loved one doesn't need daily home care visits but you still want to ensure that they are safe, our Wellness Watch service offers daily and weekly check-in phone calls and bi-weekly wellness visits by our caregiver team. The semi-monthly visits include Companion Care Services customized to the needs of your parent or loved one. In addition, the family receives a monthly report and access to quick-start home care. (Caring companionship and conversation Help with hobbies, Transportation and appointments). / Our on-staff Registered Nurses (RNs)are personally and actively involved in your loved one’s care. First, one of our RNs will conduct a full nursing assessment and design a customized personal care plan.They will then supervise the caregiver, conduct periodic nursing assessments, and monitoryour loved one’s care to make sure it stays in line with his or her changing needs.
One of our RNs will also visit your loved one on a regular basis to assess any possible "red flags" you need to be aware of or new care options you may want to consider.
. / Peace of Mind Service offers you the reassurance you need and the care your senior family member deserves. If your aged loved one is just starting to show a sign of needing additional assistance this is a great way to ease into the change of outside help and gets to know SeniorsPersonal Caregiver home care experts. These short 2-hour visits give your loved one the extra help they need and you peace of mind that they are being cared for. (Companionship and conversation, Meal preparation, Medication reminders, Light housekeeping needs). / You want to be there with your elderly family member every minute of the day, but you simply can't. You’ll want somebody there who cares. Rests assure with confidence knowing a warm caring personal caregiver will be there.
(We can monitor your elderly loved one while they are in the hospital so that you can get some respite. Our professional, locally-based caregivers are available 24 hours a day to give you the peace of mind that your loved one is not alone. Services can typically be provided in the following facilities).
Full Service ListingService Options
Our service options are flexible and customizable according to your specific situation, and your personalized senior care plan can be a combination of any of our service offerings.
□ COMPANION CARE
- Caring companionship and conversation
- Help with hobbies
- scrapbooking & games
- gardening
- sports & news
- General shopping and errands
- Transportation and appointments
□ ALZHEIMER’S & DEMENTIA CARE
- Customized care plans
- Cueing programs to stimulate memory
- Constant patient monitoring
- Supervise medication and daily activities
- Fostering of supportive communication
- Promoting a positive environment
- Providing meaningful activities
□ HOUSEKEEPING
- Laundry & ironing
- Vacuuming & dusting
- Meal preparation & washing dishes
- Caring for pets and plants
□ PERSONAL CARE *
- Personal hygiene assistance
- Medication reminders
- Diet monitoring and meal planning
- Walking assistance
In-Home Visit Need Assessment
□ Wellness Watch - If your elderly loved one doesn't need daily home care visits but you still want to ensure that they are safe, our Wellness Watch service offers weekly check-in phone calls and semi-monthly wellness visits by our care team.
□ Sitter Services - A watchful companion for your loved one - We can monitor your elderly loved one while they are in the hospital so that you can get some respite. Our professional, locally-based caregivers are available 24 hours a day to give you the peace of mind that your loved one is not alone. Services can typically be provided in the following facilities:Hospitals• Nursing Homes, Continuing Care Retirement Communities (CCRC), Assisted Living CentersELNSeniorsPersonal Caregiver can help your loved one while they are in facilities, and then provide care when they transition back to home.
□ Care Management - help with medication - When provided with a schedule, our caregivers can remind clients to take medication at the appropriate times, but they cannot assist or administer the medication.
□ Light Housekeeping - It's those everyday chores our caregivers offer to help keep the home tidy, including doing the dishes and laundry, ironing, changing the linens and vacuuming.
□ Nurse Visit - our RNs will conduct a full nursing assessment and design a customized personal care plan. She will then supervise the caregiver, conduct periodic nursing assessments, and monitor your loved one’s care to make sure it stays in line with his or her changing needs.
As experts in Alzheimer's and dementia care, you can trust us to make your loved one's life, and yours, much easier and more enjoyable. If your elderly loved one is suffering from Alzheimer's or other forms of dementia, it can also take a tremendous toll on your own physical and emotional well-being. But with assistance from ELNSeniorsPersonal Caregiver, you don't have to go it alone.
CLIENT INFORMATION SHEETDate ______
Client Name______Account # PAL-0577-______
Address______City ______State ____ Zip ______
Phone______
Service Type______Service start date: ______201___
Person responsible for payments: ______Contact # ______
Method of payment: □ Check□ Debit□ Credit Card□ Cash□ M/O
Day(s) for service: □ Mon □Tue □Wed □Thu □Fri □Sat □Sun
Hours requested□2hrs□4hrs□6hrs□8hrs□12hrs
How many visit per week□ ONE□ TWO□ THREE□ FOUR □ FIVE □ SIX □ SEVEN
Start Time ______End Time______
ELN Official use only
Personal Caregiver Manager (PCM) ______
Employee No.______
PCM Phone number ______
PCM afterhours contact number______
Physical Location of Service
Full legal name (client) (name as it appears on driver’s license) ______
Social Security Number______- ______- ______
Home AddressCityStateZipPhone Number
______
Is thisphone number listed □Yes□No
Personal Contact Information:
Primary contact full nameRelationship to clientDirect Telephone Number
______
Secondary Contact Name Relationship to clientDirect Telephone Number
______
Billing Information
Full name of person responsible for payment: ______
Social Security Number ______Phone number ______
Billing AddressCityStateZip
______
Email address ______
Method of Payment□Cash□M/O□Check□Credit Card□Debit
NameAddress
______
CityStateZipPhone Number
______
Custom Care Plan
Client’s Name______
Account Number PAL-0577-______
Address______
City______City ______State___ Zip code______
Phone______
Long Term Care Plan Type
□ Personal Care / □ Wellness Watch / □ Nurse Visits / □Peace of Mind Service / □Surgery Assistance & Sitter ServicesSupportive Service
□Companionship and conversation
□Assistance with activities of daily living
□Meal preparation
□Medication reminders
□Light housekeeping needs
□Light Laundry
□Prescription drop off and pick up
□Dry Cleaners drop off and pick up
□Grocery shopping
□Walks
□Doctor Visit
□Play cards
□Read books
□Discuss current affairs
□Share family stories
□Assist with hobbies and other interests
Length of Service:2 hours minimum a dayMonday through Friday
□Day□2 hrs□4hrs□6hrs□8hrs
□Weekly□2 hrs□4hrs□6hrs□8hrs
□Bi-weekly□2 hrs□4hrs□6hrs□8hrs
□Monthly□2hrs□4hrs□6hrs□8hrs
What day of the week you request service? ______
Weekend Service:
[ ] Saturday□2 hrs□4hrs□6hrs□8hrs
[ ] Sunday□2 hrs□4hrs□6hrs□8hrs
Custom Plan - Specific Needs
Detailed Recommendations
Modification
Need Assessment - Detailed Notes:
Client Name: Client Acct#PAL – 0577-
Hobbies:
Interests:
Basic Needs Assessment:
PAYMENT METHOD
Credit Card Payment Processing
Card Type Name on Card
Address
City, State, Zip
Credit Card Number
Exp. Date CVS Digit Code
Bank Account Payment Processing
Name on Account:
Address:
City, State, Zip
Name of Banking Intuition:
Routing Number:
Bank Account Number:
ELN General Term’s
This Agreement effective upon mutual execution of the parties is by and between Seniors Personal Care (a division of E-Laboratory Network (ELN) Supportive Services, Inc., a Georgia corporation) a LLC organized under the laws of the state of Georgia. It sets forth the general terms and conditions under which ELN will provide services to Client, including the Seniors Personal Care Program services requested from ELN that are as defined on the ELN website, hereinafter "Services".
ELN is a consumer reporting agency ("CRA") as such term is defined in the federal Fair Credit Reporting Act, 15 U.S.C. §1681 et. Seq., as amended ("FCRA") that provides employment related background screening and verification services using public and non-public records sources.
Client is an employer or individual in need of the Services provided by ELN and wishes to enter this Agreement to have ELN provide them.
Therefore, in consideration of the terms and conditions set forth herein, the parties agree as follows:
1. Service
ELN will provide Client with Consumer Reports, Investigative Consumer Reports, and/or Consumer Credit Reports, as those terms are defined in the FCRA and various state statutes, hereinafter ("Report(s)"). Client hereby subscribes to Services and agrees to pay to ELN the applicable rates and charges set forth on the Pricing Exhibit attached to and incorporated by reference into the Agreement.
2. Performance
ELN will use its best efforts to provide timely reporting of available information in a manner consistent with generally accepted standards of business practices in its industry - typically within 1 to 3 business days. However, ELN will not be responsible for delays or failures in performance resulting from acts beyond its control. Such acts shall include, but shall not be limited to, Acts of God, strikes, lock-outs, and riots, governmental regulations including those superimposed after the fact, fire, system failures, and disruption in communications, earthquakes, or other disasters. Client hereby acknowledges that from time to time, Reports may be delayed due to a jurisdictional delay, slow information source or other unusual circumstances beyond the control of ELN.
3. Term
This Agreement operates under a month to month term, and extends automatically for additional like terms unless either party submits written notice of termination thirty (30) day's prior to the intended date of termination. If notice of termination by ELN is given due to the nonpayment by Client for Services rendered, Client will have fifteen (15) days to cure the nonpayment.
4. Pricing and Billing
for each response to a request for a chargeable service, Client agrees to pay to ELN the applicable charge then prevailing for Services rendered to Client, ("Current Price(s)"). Current Prices do not include third party access or processing fees that may be incurred by ELN. These fees include but are not limited to, laundry fees, prescriptions fees, fuel fees, parking fees entertainment fee, dinning fee, third party services and collection fees ("Third Party Fees"). Such fees are set by third parties, and are subject to modification by the source without prior notice to ELN. ELN will make available a list of all then current Third Party Fees upon Client request. Third Party Fees are passed through to Client without markup on its Invoice. ELN reserves the right to bill bi-weekly, or as it deems necessary. Client agrees to pay all bills upon receipt and no later than five (5) days from the date of the invoice. Fees are incurred at the inception of the order and as a result the profile may not be fully completed when billed. ELN will charge "late fees" for overdue invoices at the rate of 2.5% of the unpaid balance due bi-weekly or the maximum allowed by law. Clients with invoices 10 days past due are subject to having their accounts suspended until all past due and current invoices including fees are paid. With just cause, such as delinquency or violation of the terms of the agreement or a legal requirement, ELN may, at its sole discretion, discontinue serving the client and cancel the Agreement without notice. In the event client believes an adjustment needs to be made to any invoice, it needs to be brought to the attention of ELN for its review. Any resulting credits will appear on the next Invoice. All invoices are deemed final and complete if no adjustments are requested within 5 days of receipt.
5. Client Credit and Banking Information
by executing this Agreement, Client acknowledges and agrees that ELN may request its credit report. Subsequent credit reports may be requested solely in connection with any renewal or extension of credit to Client. Client also acknowledges and agrees that ELN may confirm that it holds an active business banking account a required part of its credentialing procedures. Client hereby authorizes ELN to communicate with its bank, verbally, in writing or by e-mail to obtain confirmation of its business banking account. Client agrees to indemnify the Bank against any liability related to the release of any information necessary to confirm that the Account is active and is held in Client's name to anyone calling, writing or e-mailing and properly identifying themselves as someone authorized to receive information on behalf of ELN.
6. Negation of Liability and Disclaimer of Warranty
Client recognizes that information is obtained from and managed by fallible sources and that where ELN in neither the maker nor the keeper of the information provided it cannot guarantee or ensure the accuracy or the completeness of the content, nor ensure the suitability, fitness or identity of any Consumer. Senior Personal Care is primarily a service provide that will make best efforts to provide the maximum level of accuracy possible under the circumstances. Although reasonable effort is made to ensure accuracy, ELN does not act as the final guarantor of the information's accuracy or completeness. ELN does not guarantee, represent or warrant that its services will prevent any loss, that its service may not be circumvented or that its services will in all cases provide the protection or information for which the services were intended. Furthermore, Client releases ELN and its affiliates, officers, agents, employees, contractors, information providers and credit agencies from any liability and claims including negligence, losses, injury or any damage whatsoever arising out of any report or service, or arising from any inaccuracy and/or incompleteness of the information reported, or related in any way to any Consumer or hiring decision stemming from Client's use of Reports. In no event shall either party be liable to the other party for any special, incidental, consequential or punitive damages arising out of this agreement, services rendered hereunder or its termination whether liability is asserted in contract, tort (including negligence) or otherwise and irrespective of whether such party has been advised of the possibility of any such harm, injury, loss or damages.
7. Representations
Each party to this Agreement represents and warrants that: (I) it has full power and authority to enter into and perform this Agreement and the person(s) signing this contract on behalf of each has been properly authorized and empowered to do so; (ii) it has read this Agreement, understands it, and agrees to be bound by it; (iii) it has direct knowledge of all facts certified herein; (iv) it is free to enter into the Agreement and that it is not subject to any restrictions, which might prohibit it from fulfilling its responsibilities and duties; and (v) it will comply with all applicable laws, rules and regulations in performing its obligations hereunder.