This SERVICE AGREEMENT (‘’this Agreement’’) is entered into between [NAME OF
AGENCY] of address [ADDRESS] (“Service Provider/ Agency”) and [NAME] of address
NOW, THEREFORE, in consideration of the premises, and of the mutual promises and
undertakings herein contained, the parties, intending to be legally bound, do agree as follows:

  1. Term of Agreement.
    1.1 The term of this Agreement will start on the first day that Client receives any Service
    from Agency (the “Effective Date”) and will continue on an as-needed basis until the
    Agreement is terminated by either party, as provided in this Agreement.
    1.2 This agreement shall be a two year agreement and is eligible for renewal unless
    otherwise. Early termination may be penalized on a case by case basis as the agency
    deems fit.
    1.3 In the event where the client terminates this agreement earlier, the client shall pay an
    amount equivalent to that of a three months service.
  2. Services Provided.
    Agency will provide to Client the services and care outlined 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.
  • o Companion
  • o Nursing
  • o Home Health Aide
  • o Personal Care Aide
  • o RN Supervision
  • o Other _______
    Services will be provided by independent contractors (Caregivers) that are referred to the Client
    for interviewing and hire, such as companions home health aide, certified nurse assistant, private
    duty nurse or other worker (each individually a “Contractor” and, collectively, “Contractors”).
    Services will be provided at the Client’s home, or where negotiated by the Client and the
    Contractor(s) (“Location”).
  1. Scheduling.
    Services will be provided for the hours and days requested by Client, and in accordance
    with the terms of this Agreement. Client will schedule the Contractor’s hours of care, as
    needed. The Agency will be notified of the work hours, for purposes of invoice
    processing, by the Caregiver.
  2. Changing Services.
    Changes to Services may be initiated by Client and/or his/her representative through a
    phone call or written communication to the caregiver or the Agency. Advance notice of
    two (2) calendar days will be provided for any change contemplated by this Section 4.
    Adjustments to rates and billing may be made as a result of changes to Services. Any
    such changes to Services and billing amounts shall be stated in writing and provided to
    Client. Depending on Client’s selected method of communication, Agency may provide
    written notice concerning billing and Services through email on file 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

  1. Paying for Services.
    5.1 The Client shall pay to the agency $150 per day which will be payable on 5 th and 20 th
    of each month.
    5.2 Client assumes full responsibility for the payment of any and all sums that become
    due for Services. Agency recommends [payment method]. Agency will charge
    Client’s credit card or bank account on the invoice date. Agency will send written
    invoices by email to Client for Services each week (“Invoices”).

By signing this Agreement, Client authorizes Agency to automatically charge, on a bi-monthly
basis, [Client’s credit/debit card or bank account] for Service Fees.
Credit Card or Debit Card Type: ______________________
Name (as it appears on the card): ________________________
Card Number: _______________________________________
Security Code: _________
Expiration Date: ______
Billing Zip Code: ______
Electronic Funds Transfer (EFT) Information
Bank Name: _______________________________________
Name on the Bank Account: ___________________________

Routing Number: _____________________________________
Bank Account Number:
Back-Up Payment Credit Card Type: ___________________
Name (as it appears on the card): ________________________
Card Number: _______________________________________
Security Code: _________
Expiration Date: ______
Billing Zip Code: ______
5.3 Contractors/ Caregivers are not permitted to accept payment on behalf of Agency.
5.4 Client will contact Agency to change Client’s method of payment.

  1. Contractor’s/ Caregiver’s Responsibilities.
    Contractor shall perform the Services, as they may be arranged for by the Contractor and
    the Client. The Contractor is an independent contractor and, thus, the Client is required to
    identify the work that needs to be performed for him/her by the Contractor.
  2. Client’s Responsibilities.
    7.1 Client will not give a Contractor a check, credit card or bank card (ATM, LINK,
    debit, etc.) for withdrawals, activation, or shopping. Likewise, Client will not provide
    confidential financial information to Caregiver. Any exception to these prohibitions
    must be provided by Agency in writing. Client will remove all valuables and securely
    store them in a safe and locked location. Client releases Agency from any liability or

obligation arising from the unauthorized provision of cash or other items paid or
given to Caregiver. Client will not be released from Client’s obligation to pay Fees for
Services as a result of any unauthorized provision of cash or other items paid or given
to Caregiver.
7.2 Client agrees not to directly employ Caregiver at any time during the two-year period
starting from the effective date.
7.3 Client guarantees the care giver 5 working days every week.

  1. Background Checks.
    Agency will conduct a full background check, to the extent permitted by Federal, state
    and local laws, on all Contractors/Caregivers retained to provide Services under this
    Agreement. Client acknowledges and agrees that this Agreement by Agency to conduct
    background checks may serve as a defense to any negligent hiring or negligent retention
    lawsuit brought by or on behalf of Client.
  2. Supplies and Equipment.
    Client is responsible for providing all supplies (i.e. cleaning, personal care supplies,
    including latex gloves, needed for the safe execution of any kind of personal care) and
    equipment which may be necessary for provision of Services. If Agency makes a
    payment on behalf of Client to purchase supplies or equipment for Client, the amount of
    such payment will be added to the Fees on the Invoice. Contractors/ Caregivers are also
    responsible for supplying any and all equipment needed for the work.
  3. Cancellation or Suspension of Services.

Client may cancel a scheduled shift but, to the extent a Contractor arrives for the work on
the scheduled day and no work is available for the Contractor, the Client agrees to pay
the Contractor for at least 4 hours of pay at the time the cancellation occurred. Agency
may suspend Services immediately if Fees are in arrears by __ weeks/months,
unless suspending the Services would create a threat of immediate of 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) calendar days’
prior notice to the client.

    11.1 The undersigned indemnify, jointly, and severally hereby forever release,
    discharge, acquit, and forgive any and all claims, actions, suits, demands, liabilities,
    judgment, and proceedings both at law and in equity, arising from the beginning of
    time to the date of termination of this agreement with the Agency Provider, such are
    caused directly by acts or omissions by the above items and “Services” and the
    “agency caregivers” and which result in bodily injury or property damage. This
    release shall be binding upon insured to benefit the parties, their successors, assigns
    and personal representatives.
    11.2 However, negligent acts from either party shall give rise to claims.
  2. Termination of this Agreement.
    Either Client or Agency may terminate this Agreement upon seven days prior written
    notice to the other party for any reason. Should the Agency terminate the Agreement,

Client is solely responsible for arranging replacement services upon notice of termination
of this Agreement; Client assumes all the risks of such replacement services or the
inability to secure replacement services. Upon the 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 and progress of the
Client, if any; (e) Client’s status/condition upon discharge, including a description of any
remaining needs for client care and supportive services; (f) Client or family ability to
self-manage in relation to any remaining problems; and (g) recommendations and referral
for any follow-up care, if needed.

  1. Governing Law.
    The laws of the State of California shall govern the terms and conditions of the
    Agreement, without regard to choice of law principles.
  2. Dispute Resolution
    Any dispute that may arise shall be resolved by the parties to that dispute. If an amicable
    solution is not reached, the parties shall opt for external mediation.
  3. Severability.
    In case of any term, phrase, clause, section, restriction, covenant, or agreement contained
    in this Agreement shall be held to be invalid, unreasonable 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.
  4. Notices.
    All written notices required to be provided by either party to this Agreement may be
    provided via text messages, email, written notice by hand-delivery or regular mail, or fax.
    For purposes of this Agreement, notice will be deemed provided when it is sent (in the
    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). Notices that are not required to be in
    writing may be provided in writing or by telephone. A notice provided by telephone will
    be deemed received when Agency relays the message to Client or his/her designated
    representative. Agency will document internally when notice by telephone is provided to
  5. Waiver.
    The waiver by Agency of a breach of any provision of this Agreement by Client shall not
    operate or be construed as a waiver of any subsequent or continuing breach of this
    Agreement by Client.
  6. 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

Agency Representative Title

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