February 25, 2024


This XXXX Beneficiary Agreement (“Agreement”) is made between [Beneficiary’s Name], the recipient of Medicaid services (“Beneficiary”), and [Your Company’s Name], the provider of Medicaid services (“Provider”).


Services Provided

Provider shall provide Medicaid services to the Beneficiary as specified in the Medicaid plan approved by the State of XXXX The Beneficiary understands that the services provided are subject to the terms and conditions of the Medicaid plan, including but not limited to the number of hours and days of service.


Computer-generated Schedule

The Beneficiary and Provider may modify the computer-generated schedule to best fit the Beneficiary’s needs within the approved hours and days of service. Provider will work with the Beneficiary to ensure that the schedule reflects their actual needs.


Evaluation by State

The Beneficiary understands that the state will conduct an evaluation every six months to determine if the services provided by Provider are satisfactory and if the Beneficiary continues to qualify for Medicaid services.


Changes to Services

Provider reserves the right to make changes to the services provided, subject to the terms and conditions of the Medicaid plan and the Beneficiary’s agreement.


Beneficiary’s Responsibilities

The Beneficiary agrees to cooperate with Provider in the provision of services and to notify Provider of any changes in their needs or circumstances that may affect the services provided.


Termination of Services

The Beneficiary has the right to terminate services at any time if they feel that they are not receiving quality care. Provider will work with the Beneficiary to address any concerns or issues before termination of services.


Provider will protect the Beneficiary’s personal and health information in accordance with applicable laws and regulations.


Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of Michigan, without giving effect to its conflict of law provisions.


Entire Agreement

This Agreement constitutes the entire agreement between the Beneficiary and Provider and supersedes all prior agreements and understandings, whether written or oral.



By signing below, the Beneficiary acknowledges that they have read, understood, and agree to the terms and conditions of this Agreement.



[Insert Your Name],

[Name of Company]





[Name of Beneficiary]

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