HOME CARE SERVICES AGREEMENT
This Home Care Services Agreement (“Agreement”) is entered on _
(“Effective Date”) by and between ______ (“Agency”) of
_______________________ (“Address”) AND ______
(“Client”) of __________________ (“Address”). The Agreement sets
forth the terms and conditions that will be adhered by both parties and By Client’s or
Client’s Representative at the bottom of this agreement and/or receipt of services,
whichever is first, Client agrees to the terms and conditions in this Agreement.
- Term of the Agreement
The term of this Agreement will start on the first day that the Client receives and
Services from Agency, “Effective Date” and will continue for a period of 12 months
unless terminated earlier by either party. - Services
Agency will provide to Client the services and care outline in Client’s Plan of Care
(“Services). The Services to be provided to the Client will be one or more of the
following, as identified by the Client in a separate addendum to this Agreement:
I. Housekeeping
II. Personal laundry
III. Cooking
IV. Shopping
V. Assistance in getting to and from appointments
VI. Maintenance of household records
VII. Daily living support - Service Plan
Services will be provided for the Client’s hours and days, following the terms of this
Agreement. The client will schedule the Caregiver’s hours of care as needed. The
Agency will be notified of the work hours, for purposes of invoice processing, by the
Caregiver. - Changing Services
Changes to Services may be initiate by Client and/or his/her representative through a
phone call or written communication to Caregiver or Agency. Advance notice of
__ days will be provided for any change contemplated herein. Services and
billing amounts shall be stated in writing and provided to Client. Depending on the
Client’s selected communication method, Agency may provide written notice concerning
billing and Services through email for Client or text. Acceptance by Client of new or
additional Services will be deemed acceptance by Client of new or different Services
rates and agreement to pay for such new or different services.
- Fees for Services
Agency will charge the following rates for Services
Hourly Rate for Weekend Services _____
Hourly Rate for Weekday Services _________
Live-In Services Rate ______ per day
Travel Charges ____________
In case the Client delays in payment of fee by three or more days, he/she will be
required to pay a late fee of $ 10 every day. In case payment is not made, Agency has
the right to garnish wages until payment is made. - Paying for Services
Client assumes full responsibility for the payment of any and all sums that become due
for Services. Agency recommends direct debit via EFT from Client’s bank account or for
a fee using Visa, MasterCard, Discover and America Express or pays by check. The
Client will be required to pay a deposit fee before receiving the services of a Caregiver.
The deposit fee of $ __ is non-refundable. - Client Income Information
Gross income ____
Net income _____
Expenses _______ - Direct-hire
In the event the Client desires to hire a Caregiver of the Agency directly, the direct hire
fee will be % of the placed individual’s first year annualized compensation.
An officer of the Agency shall approve or deny the request to hire within 10 days, and in
the event of an approval, payment of % will be due within 14 days from the
Client to the Agency. - Insurance
Client agrees to maintain homeowner’s insurance and/or other coverage as may be
necessary to provide for negligent acts of Caregiver. All Caregivers referred to the
Client are independent contractors and are required to carry general liability insurance.
Caregivers are required to pay their taxes. Agency carries Crime Liability, Errors and
Omissions, Workman’s Compensation, and other insurances to protect the Agency and
some aspects of services to the clients.
- Background Checks
To the extent permitted by federal, state and local laws, Agency will conduct a full
background check on all Caregivers retained to provide Services under this Agreement.
Client acknowledges and agrees that this Agreement by Agency to conduct background
check may serve as a defense to any negligent hiring or negligent retention lawsuit
brought by or on behalf of the Client. - Supplies and Equipment
Client is responsible for providing all supplies, i.e. cleaning, personal care supplies,
including safety latex gloves, needed for safe execution of any personal care) and
equipment which may be necessary for the provision of Services. If the Agency makes a
payment on behalf of the Client to purchase supplies or equipment for Client, the
amount of such payment will be added to the Invoice. - Cancellation or Suspension of Services
The client may cancel a scheduled shift, but, to the extent, a Caregiver arrives for the
work on the scheduled day. No work is available for the Caregiver. The Client agrees to
pay the Caregiver for at least 4 hours pay when the cancellation occurred.
Agency may suspend Services immediately if Fees are in arrears by two (2) weeks
unless suspending the Services would create a threat of immediate harm or danger to
the Client. Agency will determine in its reasonable discretion whether there is a threat of
immediate harm or danger. If suspending Services would create an immediate threat of
harm or danger to Client, Agency may suspend Services upon five (5) days calendar
notice to the Client. - Termination of Agreement
Either Client or Agency may terminate this Agreement upon seven days written notice to
the other party for any reason.
Should the Agency terminate the Agreement, the Client is solely responsible for
arranging replacement services upon notice of termination of this Agreement. Client
assumes all the risks of such replacement services.
Upon termination of this Agreement, a discharge plan and summary will be provided to
the Client. The discharge plan will include: (a) documentation of discharge planning
preparation; (b) notification to the Client’s authorized practitioner of the discharge; (c)
reasons for discharge and date of discharge; (d) summary of care provided pursuant to
this Agreement; (e) recommendations and referral for anything for any follow-up care if
needed. - Representations and Warranties
The Agency represents that it has a clear policy on records procedures and it retains
records for a minimum of two years beyond the last date of services provided. The
agency may utilize hard copies or an electronic format.
The Agency represents that it has adhered to the Health Care Worker Act and the
Background Check Act.
The Agency represents and warrants that it has adhered and will continue to adhere to
applicable agency requirements and personal requirements, including requirements for
initial health evaluations, employee health policies, and criminal background checks if
applicable. - Contact information
All written notices required to be provided by either party to this Agreement may be
provided via text messages, email or written notice or by hand-delivery or regular mail.
For purposes of this Agreement, notice shall be deemed provided when it is sent (in
case of text messages or email) or when it is received (in the cases of written notice that
is provided by hand-delivery or regular mail or fax).
Agency contact information;
Telephone number _____
Email ____________
Fax ___________
Address ____________
Client Contact Information
Telephone number __
Email ___________—
Fax _____
Address _______
Emergency Contact Information
Name ____
Relationship _______
Phone number ___
Email _________–
Address ________ - Reporting Abuse
In case of any instance of abuse, please contact: - Dispute Resolution
In the event of a dispute, claim or controversy arising out of or under the terms or
provisions of this Agreement, including the determination of the scope or applicability of
this agreement to arbitrate, Agency or Client hereby agrees to submit to binding
arbitration conducted in accordance with the Consumer Arbitration Rules of the
American Arbitration Association (“AAA”). A neutral arbitrator will be appointed from the
AAA’s National Roster of Arbitrators and fees, and compensation of the arbitrator will be
following the AAA’s Rules.
Judgment on an Award by the neutral arbitrator may be entered in any court having
competent jurisdiction. The clause shall not preclude the parties from seeking
provisional remedies in aid of arbitration from a court of competent jurisdiction. - Complaint Handling Procedure
Agency will be responsible for the coordination of client complaint investigations. As
determined by Agency, Agency will investigate complaints at no charge and supply
Client with a written report summarizing the cause for the Client and any corrective
actions required within 14 days of receipt of the complaint from Client. - Governing Law
The State of Illinois laws shall govern the terms and c0nditions of the Agreement,
without regard to choice of law principles. - Assignment
The Agreement may not be assigned under any circumstances by the Client. - Severability
In case of any term, phrase, clause, section, restriction, covenant, or agreement
contained in this Agreement shall be held to be invalid or unenforceable and incapable
of being reformed, the term and condition will be severable from the rest of the
Agreement and shall not defeat or impair the remaining provisions of the Agreement. - Modification
This Agreement shall not be changed, modified, terminated, or discharged in whole or in
part, except by an instrument in writing signed by both parties hereto, their
representatives, successors or assignees. - Entire Agreement
This Agreement, including any Addendum or Schedule attached hereto, constitutes the
entire agreement between the Parties concerning the subject matter of this Agreement
and supersedes and replaces all prior oral or written representations or agreements.
By signing this Agreement, Client hereby consents to receive the Services in
accordance with the terms and conditions in this Agreement.
Client’s or Client’s Representative Signature Date
Print Client Representative’s name (if applicable)
(Client Representative’s Relationship to Client (if applicable)
Agency Representative Signature Date
Agent Representative Title
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