Client Services Agreement

Client Information

Client Name
Address

Contact Information

If Different than Client.
Name
Address

Nature of Home Care of W.V. Services:

The duties of Home Care of W.V. caregivers may include [but are not limited to] the following: reminding Client to take medications, assisting with basic personal care and ambulation, providing companionship, and performing [care-related] light housekeeping tasks, e.g. tidying rooms in which Client spends time, tidying bathrooms after Client's use, and washing Clients dishes or laundry. Care-related light housekeeping tasks do not include general household cleaning services, such as scrubbing floors, vacuuming, washing windows, dusting behind and under furniture, cleaning drapes or blinds, and washing laundry for non-client members of the household. Home Care of W.V. and its caregivers do not practice medicine or nursing, and make no recommendations concerning diagnosis, prognosis, treatment, medication, dosage, prescriptions, or other medical or health related services.

Emergency Procedures:

Home Care of WV is not an emergency care service. In emergencies, the caregiver will call 911 and then will contact Home Care of WV. Home Care of WV will then call the Contact listed at the beginning of this Agreement and/or the Power of Attorney. In the instance that Home Care of WV is unable to reach the designated contact and/or P.O.A., Client's next of kin and/or contacts listed by client as "emergency contact(s)" will be called.

Services to be Provided and Payment.

Client authorizes Home Care of WV to provide the services stated on the attached Schedule of Services and Fees. Client shall pay for such services in accordance with the Schedule of Services and Fees and this Agreement. Clients shall be invoiced weekly and pay weekly. Any client with special payment arrangements will be charged a premium and be subject to interest penalties.

Client Must Submit for Third Party Payment.

If Client is eligible for benefits from any third party payer, [such as but not limited to Long-Term Care insurance], Client must pay Home Care of WV as stated in this Agreement and then seek reimbursement from the third party payer. Home Care of WV will not submit claims to third party payers on CLient's behalf. However, upon request, Home Care of WV will provide copies of timesheets and daily logs to Client to assist Client in Client's submission of claims to a third party payer. Client is expected to give Home Care of WV a reasonable amount of time to provide said documentation. An administrative fee will be assessed at an hourly rate of no less than $75/hour for administrative management personnel to process the data and compile the necessary reports. Client acknowledges that Home Care of WV has not given any assurance that any third party payer will pay for the services it provides to Client.

Changing Services or Schedule.

In the event the Client wishes to alter the time or date of services during a single week, Client must notify Home Care of WV of the requested change at least twenty-four (24) hours prior to the time the service is regularly scheduled to begin. Notice given to a caregiver and not to Home Care of WV is not considered notice to Home Care of WV. If Client does not provide the required 24-hour notice, Client must pay for the full scheduled hours.
To change the weekly schedule during more than a single week, Client must notify Home Care of WV at least seven (7) calendar days prior to the week Client wants the new schedule to begin. Notice given to a caregiver and not to Home Care of WV is not considered notice to Home Care of WV.
In the event that Home Care of WV agrees to the proposed change to the schedule of services, Home Care of WV shall document the new schedule and the documentation will be come a part of this Client Services Agreement upon Client's acceptance of the requested services. Client understands that any change in services requested and performed may result in increased fees. Client shall pay for the increased fees in the same manner as for the other payments due under this Client Services Agreement.

Changing Rates.

The rates stated in the Schedule of Services and Fees may be changed from time to time by Home Care of WV by Home Care of WV giving Client at least fourteen (14) calendar days prior written notice of the change.

Billing; Payment; Collection; Interest.

Invoices will be sent to clients weekly. Client shall pay the amount of an invoice within ten (1o) calendar days after the date of the invoice. Any unpaid balance not paid within that ten (10) calendar day period shall accrue interest at the rate of 2% per month. a $75 fee will be charged for a check that is returned by a bank due to insufficiency of funds on a check submitted to Home Care of WV for payment. In the event Home Care of WV is required to take action to collect any amounts due under this Agreement, Client shall pay Home Care of WV reasonable attorney fees and costs incurred in collecting those amounts.

Deposits.

Home Care of WV requires an initial deposit equal to the cost of one (1) week of service. This money will be held by Home Care of WV. An additional deposit amount may be required if Client later requests an increase in the services provided. A refund check will be issued after termination of services has been established and all invoices are paid in full. Deposits are refunded on the 30th of every month. Upon termination of services and all invoices are paid in full, a refund check for the initial deposit will be issued on the next 30th day of the month.

Hiring Home Care of WV Employees.

Client shall not employ or receive services from the employee(s) assigned to CLient by Home Care of WV except as contemplated by this Agreement for a period of two (2) years following the last day the employee(s) rendered services to CLient on behalf of Home Care of WV pursuant to this Agreement. This prohibition includes but is not limited to:
  1. Paying the caregiver directly for services during the caregiver's employment with Home Care of WV;
  2. Paying the caregiver directly for services after the caregiver's employment with Home Care of WV is terminated;
  3. Paying another agency, person, or entity for services provided by the caregiver after the caregiver's employment with Home Care of WV is terminated; and,
  4. Accepting services from the caregiver while the caregiver is employed by another agency or entity.
In the event that Client violates this condition, Client shall pay $20,000.00 for each such employee to Home Care of WV as liquidated damages and any reasonable attorney's fees and costs associated with collecting those liquidated damages. This amount reflects the costs of recruiting, screening, and training the employee(s). In addition to this remedy, Home Care of WV shall be entitled to obtain injunctive relief against any violation of this Agreement, without notice to Client, without the necessity of proving actual damages and without posting a bond. These remedies shall be cumulative and not mutually exclusive. Home Care of WV reserves the right to pursue any other or further remedies at law or in equity to enforce its rights under this agreement.

Transportation.

No caregiver shall operate a vehicle to provide transportation for Client without prior written authorization from Home Care of WV regardless who owns the vehicle. Client shall pay the mileage fee stated in the attached Schedule of Services and Rates for transportation provided by Home Care of WV caregivers. Client acknowledges that Home Care of WV insurance covers loss or damage caused by caregivers' operation of any vehicle only after Client's insurance coverage is exhausted, and Client shall be primarily responsible for any and all claims, including negligence, related to caregivers' operation of a vehicle to transport Client.

Securing Property.

Client shall secure all cash and valuables in a secure place (such as a safe) or remove them from Client's premises. Home Care of WV caregivers shall be bonded and Client shall file a police report in the event that any cash or valuable is found to be missing from Client's premises. In addition, Client shall maintain insurance coverage for the theft or loss of cash or valuables.

Jurisdiction & Venue.

If it is necessary to litigate a dispute arising out of or relating to this agreement, Client agrees to jurisdiction in the State of West Virginia and venue in the County of Raleigh.

Entire Agreement & Severability.

This agreement contains the entire understanding of the parties regarding the subject matter of this agreement, and supersedes all prior and contemporaneous negotiations and agreements, whether written or oral, between the parties with respect to the subject matter of this agreement. If a provision of this agreement is determined to be unenforceable in any respect, the enforceability of the provision in any other respect and of the remaining provisions of this agreement will not be impaired.

Release of Liability:

Client hereby releases Home Care of WV from liability for any act or omission of a Visiting Angel caregiver that may be harmful to Client and that arises from the provision of services to Client pursuant to this Agreement, including those acts or omissions that arise from a caregiver's negligence. Client shall maintain homeowner's insurance, medical insurance and/or other coverage as may be necessary to provide protection for Client.
Max. file size: 256 MB.

Financially Responsible Party

Name
Address

Schedule of Services and Fees

Services will be provided for:
Care recipient Name:
At Address:(Required)
Possible Beginning Date of Service:
Home Care of WV will provide the following services the days and times stated below:(Required)
Day
Times
 
To add an additional day, click the + icon at the end of the row.

Rates

The rates for services are:
  • Hourly Weekday $24/hr (weekly schedule required.)
  • Hourly Weekend $25/hr (weekly schedule required.)
  • PPN Service $23-24/hr
  • Mileage charged at current federal rate.
  • Cleaning Service $40/hr
  • Holiday Rate A: 1 1/2 x the current hourly rate. (Easter, Memorial, 4th July, Labor Day, Thanksgiving, Christmas Eve Day.)
  • Holiday Rate B: 2 x the current hourly rate. (New Years Eve, New Years Day, Christmas Day.)

    Minimum Charge:

    A minimum charge of 4-8 hours per visit will be charged.

    Weekend Rate:

    The weekend rate begins on Friday at 10:00 p.m. and ends on Sunday at 11:59 p.m. Any service that begins during that period will be charged at the weekend rate.

    Overtime Rate:

    The overtime rate is one-and-one half the weekday or weekend rate and is charged for any hours worked over 40 hours in a workweek, (Monday thru Sunday) by a caregiver. Home Care of WV will not schedule any caregiver for more than forty (40) hours in a workweek without prior consent of the Client or Client's representative. Requesting a caregiver in overtime will result in your rate being the 1 1/2 times your current applicable rate.

    Communication, Cancellations, Refusal of Service:

    All communication regarding hours of service, change of service or cancellation in service must be communicated by telephone to the Home Care of WV office at (304) 252-5060. Clients will be charged for time scheduled unless the client gives Home Care of WV a minimum of 24 hour cancellation notice. Any cancellation in service must be communicated by telephone to the Home Care of WV office at (304) 252-5060.

    Do not send schedule changes through the caregivers and do not contact the caregivers on their personal phones ALL COMMUNICATION MUST GO THROUGH THE OFFICE.

    Change of Rates:

    As stated in the Client Services Agreement, Home Care of WV may change any or al of the rates stated in this Schedule by giving Client not less than fourteen (14) calendar days prior written notice of the change.