CLIENT SERVICES AGREEMENT

Care Recipient Name: ___________________________________Phone: ______________

Responsible Party/Client Name: ________________________ Phone: ______________

Social Security #: ___________________ Referral date: _________________________

Initial Service Date: _____________________________

Description of Services Requested (as described by the client): ______________________

________________________________________________________________________

Services to be provided include: Companion Care Personal Care Medically Frail

__Medication Reminders __Hygiene Assistance Bathing, toileting etc. __ Meal preparation/Diet monitoring __feeding assistance

__Light housekeeping __Errands and Shopping and Appointments __Companionship, Entertainment __ Live in or 24 hr care

__Respite for Family Caregivers __Transportation.

Visiting Angels will provide assistance with activities of daily living as requested and Transportation as needed
accordance with the nurses plan of care.

Hearth and Home Enterprises, LLC, a franchisee of Living Assistance Services, Inc, dba Visiting Angels,
(hereinafter

Visiting Angels), as provider and _____________________________ and his or her agent or Estate (hereinafter

Care Recipient) and _________________________________ (hereinafter Responsible Party) enter in this Client

Services Agreement as follows:

Visiting Angels will provide the services of a non-medical home caregiver (beginning date)
on ____________________________ until services are no longer needed. Care will be provided on:

Day M Tu W Th F S Su
Start Time
End Time
Total Hours

The services rendered shall be performed at the charge of $______ /hour on weekdays, $______ on
weekends. This rate requires a 4 hour minimum per visit. Services provided in blocks of less than 4 hours
will be provided at a rate of $30.00/hour. Services will be provided at the following
location:_____________________________________________________________________________

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OUR ROLE: We will refer to you a caregiver who is employed by us who will provide non-medical "companion" home
care on a schedule of days and hours that will be predetermined by agreement by you and us in advance of each
week of service. In the event that you do not contact us to change the predetermined weekly schedule in advance of
any week, we will assume that the predetermined weekly schedule is the same as it was for the most recent
preceding week of service. Our assurance to you is that we will, at all times, exert every reasonable effort to have you
attended to, during this predetermined weekly schedule.

INVOICES AND BILLING: Invoices will be issued weekly and payable in full upon receipt (typically mailed on
Wednesday). Payment may be made in cash, personal check or money order payable to HEARTH AND HOME
ENTERPRISES, LLC. Should your account balance not be paid within 7 days of the invoice date, the agency will charge
a 10% late fee to your account. In the event that you wish to reduce the number of hours and/or days to be worked
by the referred caregiver employee on the predetermined schedule for a given week, you must contact us at least 24
hours in advance of any day for which you wish to reduce the schedule. In the event that you reduce the schedule
without contacting us at least 24 hours in advance, you will be billed for the full amount of the predetermined
weekly schedule. In the event that a referred caregiver fails to arrive at your home and/or the home of the care
recipient or alters the predetermined weekly schedule in some way, we will adjust the amount that you are billed
accordingly. Changes, in the level of service, require a signed Change Order.

LIGHT HOUSEKEEPING DEFINED: The caregiver employee is not required to provide a general housekeeping
service. Typical "light" housekeeping tasks to be provided by the caregiver employee would include: tidying up of
rooms in which the care recipient spends his/her time (bedroom, living room, kitchen), washing dishes after meals
(wiping spills on sink or floor, "spot cleaning"), sweeping kitchen floor when needed, passing the vacuum in rooms
used by care recipient, tidying bathrooms after use by care recipient (rinsing tub or shower after use, wiping spills on
sink or floor). It is recommended that you hire an independent cleaning service for tasks such as: scrubbing floors in
kitchen and bathrooms, window mirror washing, dusting behind & under furniture, drape cleaning and heavy laundry.
Housekeeping duties may not exceed 20% of the visit.

RESTRICTIVE COVENANTS AND GOOD FAITH AGREEMENT: You hereby release us from responsibility for any
events that may be harmful to the care recipient in the course of receiving services from the referred caregiver
employee. You agree to maintain homeowner’s insurance, medical insurance and/or other coverage as may be
necessary to provide protection for the care recipient. The overriding business relationship would be strictly between
you and Visiting Angels and, by agreeing to this proposal, you are confirming to us that you will, abstain from making
or accepting any offers whereby any of the caregivers/employees we have referred to you would provide services
other than as sanctioned by Visiting Angels whether you still have an ongoing relationship with Visiting Angels or not
(for a period of 2 years after the date of the final fee that you pay to us).

In good faith, you, individually, on behalf of the family and the care recipient, release Visiting Angels from
responsibility for money or any articles that may be found missing from the home of the care recipient.

In agreeing to utilize Visiting Angels homecare services, the client agrees not to compete with the agency by hiring
any caregiver (referred by the Visiting Angels agency to client) directly, thus taking the caregiver away from the
Visiting Angels agency responsible for that caregiver’s service. Since the damages for hiring away of the Visiting
Angels employee are difficult to measure, in the event of such an occurrence, the client agrees to pay liquidated
damages in the amount of $14,000 to the Visiting Angels agency providing the caregiver’s service which is the best
estimate by both parties for the likely damages Visiting Angels is likely incur.

NOTICE OF TERMINATION: As a client of Visiting Angels, we request that you give us one week’s notice to
terminate services. We understand, however, that this is not possible in all cases. Anything less than 24 hour notice
will require a $20 Cancellation Fee. We may also terminate our services to you upon notice by letter or telephone to
you, with one week of notice.

VEHICLE POLICY: A vehicle is not to be driven by the caregiver employee without prior written authorization from
the client to agency. Agency's insurance does not cover loss or damage caused by employees operating the client's
owned or leased vehicle. The client accepts full responsibility for any and all claims. If the agency employee drives
his/her own vehicle in order to perform services for client, the client will be billed at $ 0.65 per mile.

Do you wish to have the caregiver / employee use your car? Please initial Yes ______
No_______

OTHER RATES SHOULD YOU REQUEST A CHANGE IN SERVICE HOURS: Minimum hours may apply.
INDIVIDUAL RATES COUPLE RATES
Week Day Rates: $17.50/hr $ 30.00/hr
Weekend Rates: $18.50/hr $ 35.00/hr
Live-in Care $ 9.00/hr (48 hour block minimum) $ 10.00/hr (48 hour block
minimum)
Angel Care $ 35.00/hr (Care provided in less than 4 hr blocks) $ 35.00/hr

Weekend rates are in effect from 12:00 AM Friday to 12:00 AM Monday.

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Holidays are billed at time and one half rates.
Overtime actual work hours (>40) for one caregiver would need to be managed by the Visiting Angels office and
would need pre-approval.

SUPERVISORY VISITS: The client’s home care will be closely monitored and supervised. Within seven days of
beginning services, at no cost to the client, a nurse will conduct an assessment of the client’s general condition. A
Care Plan will be completed to document vital signs, progress and problems and observations about the levels of care
being offered i.e. (Any functional limitations, special instructions for care, goals and objectives for maintaining some
level of independence, equipment needs, diet and nutrition needs, and list of medications and any reminders
needed). Care will be evaluated every 92 or 122 days depending on what level of care the client is receiving. The
Care Plan will be updated following each evaluation.

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CONTACT INFORMATION: Visiting Angels has procedures and policies in place to ensure every step possible is
taken to provide the best care. Visiting Angel’s requests if there are problems or concerns, you use the contact
information below. Visiting Angels will work to resolve your concerns as soon as possible.

Visiting Angels
110 Habersham Drive
Fayetteville, Ga. 30215
dmciver@visitingangels.com
Phone: 678.817.4200

Georgia State Licensing requires we provide you with contact information either to verify a license or to file a license
violation. The contact information is:

Georgia Department of Human Resources

Office of Regulatory Services
Health Care Section
2 Peachtree Street
Suite 33-250
Atlanta, GA 30303
Main Phone: 404.657.5550
Complaints: 404.657.5728 or 1.800.878.6442

Georgia State Licensing Authority

404.657.1509

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ACKNOWLEGEMENT OF RECEIPT OF INFORMATION (Client Initials or “NA” with
initials)
 Client Rights and Responsibilities, including HIPAA documents. ____
 Transportation Waiver. ____
 Access to Funds. ____
 Contact Information for Problem Resolution. ____
 Unannounced monitoring visits by Visiting Angels (p.3). ____
 Personal Home Care supervisory visits by nurses (p.3). ____
 Release form for Media Recording. ____

The parties responsible for direct payment is/are_________________________________,

and agree to pay for said patient care including services that may not be reimbursed by
insurance.

Billing Address:

__________________________________________________________________________
__

__________________________________________________________________________
__

Drivers License Number State _______, Number ______________________

Social Security Number __________________

Date of Birth __________________

I understand a consumer report and a credit check may be requested. I authorize Hearth and
home Enterprises, LLC to conduct the above listed reports, in accordance with Company
Policy.

_________________________________________
___________________
Signature of Client Date

Hearth and Home Enterprises, LLC

_________________________________________
___________________
Agency Representative Date

***Personal Guarantee: I, _________________________, agree that if the above named

Care Recipient is unable to or refuse to pay any fee or invoice in regard to Visiting
Angels that I, the Responsible Party, will personally guarantee the payment.

Hearth and Home Enterprises LLC Page 5

_________________________________________
___________________
Signature of Responsible Party for Payment Date

Clients Rights and Responsibilities

• You have the right to be informed about and/or participate in the plan of service being
provided.

• You have the right to be promptly and fully informed of any changes in the service plan.
Any change in time of service, availability or staff changes shall be reported to you prior
to the time of service.

• You have the right to accept or refuse services at any time.

• You have the right to be fully informed of the charges for services.

• You have the right to be informed of the agency’s name, business telephone number
and the business address of the person supervising the services.

• You have the right to be informed of the Agencies Complaint Procedures and the right
to submit complaints, without fear of discrimination or retaliation and to have the
agency conducts a complete investigation within a reasonable period of time.

• You have the right of Confidentiality of Clients records.

• You have the right to have all property and residence treated with respect.

• You have the right to receive a written notice of the address and telephone number of
the state licensing authority. (This information has been provided in the Client Service
Agreement).

• You have the right to obtain a copy of Visiting Angels recent report of licensure
inspection upon written request.

• You have the responsibility, in conjunction with the Caregiver, to advise Visiting Angels
of any changes in your condition or any specific events that may affect the Clients Care
Plan, which may include but not limited to medical changes, medication, functional
limitations, and admission to a hospital, etc.

____________________________________ ________________________
Client Signature Date

_________________________________ ______________________
Agency Signature Date
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 1.1 Access of Funds Authorization

This is an authorization from the client, or responsible party, for access to the client’s
personal funds when home management services are to be provided and when those
services include assistance with bill paying or any activities, such as shopping, that
involves access to or use of such funds.

When and for what purpose funds are to be accessed:

________________________________________________________________

How funds should be accessed:

________________________________________________________________

________________________ __________________________
Signature of Client Date
or Responsible Party

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 CLIENT AUTOMOBILE RELEASE OF LIABILITY

At my discretion and with my permission I will provide my automobile for the caregiver to drive
to take me to various appointments, shopping errands etc. as part of the services that I will
receive from the caregiver.

I agree that I have the primary responsibility for my automobile insurance and that the caregiver
is covered under my insurance as an authorized driver. I agree to indemnify, hold harmless, and
release the Visiting Angels agency from responsibility for any action in which there is damage to
my automobile and/or property and/or injury to third parties or their property.

I agree to notify Visiting Angels immediately should any change related to my current and in
force insurance be made.

Insurance Company:
____________________________________________________________________

Telephone:
____________________________________________________________________

Policy #: _____________________________ Exp. Date: ______________________

Coverage Verified: _______________________________

Client Signature: ______________________________________

Date: __________________

Visiting Angels
110 Habersham Drive
Fayetteville, Ga. 30214
678.817.4200

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 DISCLOSURE AGREEMENT OF VISITING ANGELS

Our Non-Medical Home Care Division is designed to supplement the services of the primary
care giver(s) with respect to companionship and help for the elderly, or for anyone else who is
afflicted with one or more faculty impairments. We provide assistance to you and the extended
family in your routine daily needs or those of your loved one(s).

We are not a medical organization. We do not administer medication or provide any service
defined as medical by our State. The medical or professional qualifications of any of our
representatives or referred caregivers who will provide you with assistance are strictly incidental
to their activities as our referees and/or representatives. We make no recommendations or
instructions concerning diagnosis, prognosis, treatment, medication, dosage, or prescriptions or
other medical or health related services. At your direction, we may remind the person left in our
care to take his or her medication prescribed by others, and per schedules left for that person by
you. We desire to provide the best companion and home management services. That is where
our expertise ends.

Further, we are not licensed dietitians or chefs. At your directions, we shall cook meals on site
or do whatever preparatory work you feel is necessary in our capacity as a homemaker,
companion or helper. Again, it is up to you and the extended family to provide primary
instructions concerning this service.

Please note that the individual(s) you may ask us to refer caregivers for may have their mobility
or other faculties severely impaired. We rely on you to instruct us to all limitations in this
regard. We urge you, if you have not already consulted competent medical personnel, to do so
before instructing us to act. We shall take all necessary precautions to operate within the
guidelines you establish for us.

Our relationship is based on mutual good faith. You are representing to us that you have the
requisite knowledge and authority to instruct us as to the needs of the care recipient. We shall
make our continuing best efforts to meet those needs.

Most of our care recipients are elderly and increasingly susceptible to illness and injury. We
cannot prevent these things and can only put forth our best efforts to provide the assistance and
companionship that can make life more comfortable and fulfilling for the care recipient, as well
as for you and the extended family.
Initials______

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 Disclosure Agreement
page 2

In good faith, you, individually, on behalf of the family and the care recipient, release
VISITING ANGELS from responsibility for any and all injuries and illnesses, whether or not
due to errors or omissions of VISITING ANGELS or its representatives that may regrettably
come to the care recipient. You agree to maintain homeowners insurance, medical insurance
and/or other insurance as many be necessary to provide protection for the care recipient.

We strongly recommend and you hereby agree to keep any/all cash, jewelry and other valuables
in a secure locked place such as a safe. In good faith, you, individually, on behalf of the family
and the care recipient, release VISITING ANGELS from responsibility for money or any
articles that may be found missing from the home of the care recipient. If such a claim arises
and the facts are indisputable that the caregiver is responsible, we will exercise our best efforts
to obtain restitution from the caregiver on your behalf. However, we will make no such effort to
influence the caregiver to restitution in instances in which the item(s) were not kept in a secure,
locked setting. In addition you agree to maintain insurance coverage for any such items under a
homeowner's insurance policy.

Finally, we are not an emergency care service. In emergencies, the only thing our referred
caregivers can do is call 911; we then will make every reasonable effort to contact you or the
designated person in charge or next of kin.

This disclosure is incorporated by reference into other agreements VISITING ANGELS may
have with the care recipient(s) or their families or next of kin or guardian, when such agreements
are in effect. When we do not enter into an agreement, or when an agreement is awaiting the
outcome of a preliminary trial period, this disclosure, filled and signed by you, stipulates that
you have been carefully and methodically informed as to our limitations.
Acknowledgment of Disclosure:

Please Print Your Name:

First Middle Last

Name of Care Recipient (s):

First Middle Last

Your relationship to the Care Recipient(s)

SIGNATURE___________________________________DATE________________________________________

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 Release Form for Media Recording
I, the undersigned, do hereby grant or deny permission to Visiting Angels® to use the image of
myself,_________________________________, as marked by my selection(s) below. Such use
includes the display, distribution, publication, transmission, or otherwise use of photographs,
images, and/or video taken of myself for use in materials that include, but may not be limited to,
printed materials such as brochures and newsletters, videos, and digital images such as those on
the Visiting Angels® Web site.
 Deny permission to use my image at all.
 Grant permission to use my image in the following ways (mark all that apply):
 Limited usage: I want my image used within the Visiting Angels® setting only (not in
the larger community).
 Limited usage: I want my image used for marketing materials only (not internet). This
could be either within Visiting Angels® or in the larger community. One example of this
could be newspaper and magazines.
 Limited usage: I want my image used on printed materials only (no digital or video
use).
 Unrestricted usage: I give unrestricted permission for my image to be used in print,
video, and digital media. I agree that these images may be used by Visiting Angels® for a
variety of purposes and that these images may be used without further notifying me. I do
understand that my name will not be used in conjunction with any video or digital or
print images.

Signature_______________________________________________ Date__________________

Please make a copy of this form for your own records and mail or fax the original to:
David McIver
Director
Hearth and Home Enterprises, LLC
393 Rising Star Road
Fayetteville, Ga. 30215
Fax: (678) 817-5717
If you have questions, contact Visiting Angels at (678) 817-4200.

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 VISITING ANGELS
Privacy Notice
This notice is effective as of ______/______/_______

I have read the Privacy Notice brochure and understand my rights contained in the notice.

By way of my signature, I provide Visiting Angels with my authorization and consent to use and
disclose my protected health care information for the purposes of treatment, payment as
described in the Privacy Notice

________________________________________________
Patient’s Name (print)
________________________________________________ ______________
Patient’s Signature Date
________________________________________________ ______________
Authorized Facility Signature Date

Authorization to Use or Disclose Protected Health Information

VISITING ANGELS

Patient Name:_____________________________________________________

Address: _________________________________________________________

Date of Birth: _______________________ Date of Request:________________

As required by the Privacy Regulations, Visiting Angels may not use or disclose your
protected health information except as provided in our Notice of Privacy Practices
without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health
Information to the following person(s), entity(s), or business associates of this office:

__________________________________________________________________________
__

For the specific purpose of (describe in detail)

_____________________________________________________________________

I understand that the information disclosed above may be re-disclosed to additional

parties and no longer protected for reasons beyond our control.
______________________________________________________________
Signature or Patient or Patient’s Authorized Representative Date

____________________________________________________________________________________
Authorized Signature Date

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 Live-In Service

Live-in Service is provided for the client who will benefit from the services of a twenty-four (24) hour
protected environment. Because of the unique benefits of having competent personnel on a live-in basis,
comfortable activities become joint activities for the client and live-in companion, which further
normalize and enhance the benefits of home health care service.

Services are arranged to meet the needs of the client with the level of employee needed to safely staff the
case. Services are determined and staffed with a Nursing Assistant or Homemaker Companion.

SERVICES PROVIDED:

Assistance with activities of daily living:

• Plan and prepare meals
• Shopping for groceries and household items
• Cleaning and laundry
• Transporting or accompanying client by special arrangements
• Care Plan prepared and maintained in the home
• Service Coordinator “on-call” twenty-four (24) hours to conduct staffing problems

CLIENT PROVIDES:

• Meals (no special foods are required)

• Sleeping facilities (bed; linens; minimum privacy)
• Sleep, meals and personal time outside of the 10 hours of service
• Relief by family/responsible party on occasion when patient/client cannot be left alone at all

CUSTOMARY PRACTICES:

1. Live-In Companion provides 10 hours of service per 24 hour period. The employee is entitled to
the remainder of the time as personal time including sleeping time and breaks. The employee
must be allowed to sleep through the night.

2. Live-In will provide services according to a plan of care developed by the Nursing Supervisor, in
cooperation with the client and family.

3. Live-In is responsible for his/her personal needs, such as laundry, toiletries, etc.

4. Live-In may not use the client’s phone for personal use, except in an emergency situation. The
Live-In will reimburse the client for all other expenses incurred.

Visiting Angels will make its best efforts to provide the requested services. Because of circumstances
beyond control of Visiting Angels, services may be interrupted for a limited period. During that time it
will be necessary for the family/responsible party to assume responsibility for the client until services can
be resumed or services will be provided at an hourly rate.

Signature of Client or Client Representative Date

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