Home Care Services Signup Form – Pest Control Website Template

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Please select your community liaisonLISACINDYSTEPHANIERACHELROBINBRAINMASHADENISE

Client in Need of Services ("Client")

First Name

Last Name

Date of Birth

Height

Weight

GenderMaleFemalePrefer Not To Answer

Service Address & Client Contact Information

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Client Home Phone

Client Mobile Phone

Preferred Phone *HOMEMOBILE

Who is Filling Out & Signing this Form ("Filler")

Your relationship to ClientFatherMotherFathert-in-LawMother-in-LawSpouseBrotherSisterSonSon-in-lawDaughterDaughter-in-LawGrandsonGranddaughterDoctoreSocial WorkerDischargeplannerGeriatric Care Manager (GCM)NurseFriendNeighborInsurance CompanyOther

Email Address

Client's Medical Power of Attorney Information ("MPOA")

Are you client's medical power of attorney?*YesNo Someone EsleClient does not have medical power of attorney

Field Group

First Name

Last Name

Street Address

City

State/Province

ZIP / Postal Code

Phone

Email Address

Service Requests: Variable and Flexible

Please specify the times and days of the week that you would like Cambridge Caregiver services. Be sure to enter "am" or "pm" as appropriate.

Monday Service Times(s)

Tuesday Service Times(s)

Wednesday Service Times(s)

Thursday Service Times(s)

Friday Service Times(s)

Saturday Service Times(s)

Sunday Service Times(s)

Preferred Start Date

Requesting a male or female caregiverMaleFemaleNo Preferance

Service Request Notes

Please share any additional details or notes about your service request, so we can better understand your needs and provide the most appropriate assistance.

Enter detailed notes below:

Health Status & Continuity of Care

Hospice Status

Is the client currently in Hospice?YesNo

What is the Hospice company name?

Hospice primary contact phone

Hospice primary contact name

Home Health StatusYesNo

What is the Home Health company name?

Home Health primary contact name

Home Health primary contact phone

Primary Care Physician Information

Primary care physician first name

Primary care physician last name

Primary care physician phone

Authorized Contacts

First Contact

Emergency Contact?YesNo

First Name

Last Name

Email Address

Primary phone

Secondary phone

Your relationship to ClientFatherMotherFathert-in-LawMother-in-LawSpouseBrotherSisterSonSon-in-lawDaughterDaughter-in-LawGrandsonGranddaughterDoctoreSocial WorkerDischargeplannerGeriatric Care Manager (GCM)NurseFriendNeighborInsurance CompanyOther

Add Second Authorized Contact?YesNo

First Name

Last Name

Email Address

Primary phone

Secondary phone

Your relationship to ClientFatherMotherFathert-in-LawMother-in-LawSpouseBrotherSisterSonSon-in-lawDaughterDaughter-in-LawGrandsonGranddaughterDoctoreSocial WorkerDischargeplannerGeriatric Care Manager (GCM)NurseFriendNeighborInsurance CompanyOther

Add Third Authorized Contact?YesNo

First Name

Last Name

Email Address

Primary phone

Secondary phone

Your relationship to ClientFatherMotherFathert-in-LawMother-in-LawSpouseBrotherSisterSonSon-in-lawDaughterDaughter-in-LawGrandsonGranddaughterDoctoreSocial WorkerDischargeplannerGeriatric Care Manager (GCM)NurseFriendNeighborInsurance CompanyOther

Individualized Service Plan: Variable & Flexible

Client hereby engages Cambridge to, and Cambridge shall provide personalized companion services for the fees and according to the terms provided below.

Please select all that applyAmbulation & TransferBathingContinence CareDressing & GroomingEatingToiletingHouseworkMedication RemindersMeal PreparationDrivingCompanionshipOther

Individual Service Plan: Client Assessment

Client Medical Diagnosis (if any) and Care Needs

Fall Risk - Standby While MovingYesNo

ContinentYesNo

VisionGoodPoorBlind

Is oral hygiene assistance required?YesNo

Uses walker or caneYesNo

DentalGoodPoorDentures

HearingGoodPoorHearing Aids

Uses Wheel ChairYesNo

Is showering assistance required?YesNo

SpeechGoodPoorOther

Wheel Chair BoundYesNo

What level of showering assistance is required?StandbyAssist in and outTotal

Please specify other

Any supplies or or additional comments?

Individualized Service Plan: Behavior & Cognition

ConfusionYesNo

AgitationYesNo

Description of behavior

SuspiciousYesNo

Up at NightYesNo

Description of behavior

WithdrawnYesNo

WandersYesNo

Description of behavior

CombativeYesNo

Description of behavior

Individualized Service Plan: Additional Information

Does the client have pets?YesNo

Does the client have allergies?YesNo

Pet type?Large DogSmall DogCatOther

Please note allergies

Are firearms present at the service address?YesNo

Is there a smoker at the service address?YesNo

Are the firearms stored securely?YesNo

Does the client need to be driven?YesNo

Will the caregiver be using their personal vehicle or the client's vehicle for transportation needs?Client VehicleCaregiver VehicleBoth

Individualized Service Plan Signature

Please sign below stating that you agree to the required items above.

Name of signer

Emergency Planning

1. Texas Administrative Code TITLE 26. PART 1. RULE §558.256 requires an agency, such as Cambridge Caregivers to categorize clients for emergency preparedness and response purposes. We ask that you select the appropriate urgency level based on the examples below. If you have any questions, don't hesitate to contact your community liaison. 2. The State of Texas offers Texans the option to register with the STEAR program, or the State of Texas Emergency Assistance Registry. This free registry provides local emergency planners and responders with additional information on the needs in their community. To find out more about STEAR or register yourself, dial 2-1-1.

Client Emergency Priority LevelHigh: e.g., Client is bedbound, has no other caretakers such as relatives nearby, or requires 24/7 careMedium: e.g., Client is a fall risk, lives with a child, or has care five (5) days a week.Low: e.g., Client is in companionship care only or lives in a retirement community.

Does the Client want to register for STEAR (State of Texas Emergency Assistance Registry)?YesNo

You can access STEAR by calling 2-1-1.

Payment Details

This Engagement Agreement, by and between Cambridge Caregivers LLC, a Texas limited liability company, located at 12770 Coit Rd, Suite 1020 Dallas, Texas 75251 ("Cambridge"), and Client, is dated as of (the "Effective Date"). For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Cambridge and Client hereby agree to the following terms:

Bill Rate

Please enter the rate as determined by your community liaison. Cambridge Caregivers charges a premium rate for all engagements under eight hours per day. If you have any questions as to this rate, please get in touch with your community liaison.

Enter Base Rate (Per Hour)

Category of CareCaregiverCaregiver Short-ShiftCouple CareLVN/LPNRNEMT-P

How would you like to provide payment?Bank (ACH/EFT)Credit CardCheck

Field Group

Client/Responsible Party Bank (ACH/EFT) Information

Bank Name

Account Holder Name

Routing Number

Account Number

Field Group

Client/Responsible Party Credit Card Information

Card Holder Full Name

Card Number

Routing Number

Account Number

Expiration

CVV

Zip

Client acknowledges that they will pay a 3% recurring fee for using a credit card. *Option 1

Billing Information Preferences

How should bills be sent?EmailUS Mail

To whom should bills be sent?ClientFilerMPOA

Billing Recipient Name

Billing Recipient Phone *

Billing Recipient Email *

Street Address

City

State/Province

ZIP / Postal Code

Long-term Care Insurance

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Although service may be covered by long-term care insurance, the Client is responsible for obtaining payments from their own insurance provider. The client is fully financially responsible for paying Cambridge Caregivers upon receipt of the invoice from Cambridge, regardless of when the Client receives reimbursement from their long-term care provider

Does the client have Long-term Care Insurance?YesNo

Does the Client want Cambridge Caregivers to submit information for reimbursement? *YesNo

Insurance Carrier

Policy Number

Claim Number

Documentation

The following documents will be provided to Cambridge (Select all that apply).Medical Power of Attorney (MPOA)Fiduciary Power of AttorneyDo Not Resuscitate Order (DNR)

Terms, Conditions, & Privacy Consent

Non-Solicitation

Client acknowledges, understands, and respects the relationship between Cambridge Caregivers and its employees. Client, and those acting on Client's behalf or on behalf of others, shall not solicit, hire, or attempt to solicit or hire any person or entity employed by or contracted with Cambridge Caregivers, and shall not engage in any activity which is directed toward such an objective or result which would circumvent the Company's relationship with its employee. If Client solicits or hires, or attempts to solicit or hire, a Cambridge Caregivers employee (or chooses to hire another firm representing the same employee) to work for Client, in any capacity, the Client shall pay to Cambridge Caregivers the amount of $15,000 per solicited and/ or hired employee as liquidated damages, and not as a penalty, and in addition to such other remedies that may be available to Cambridge Caregivers, including without limitation recovery of reasonable attorney's and/ or collection fees.

I agree to the Non-Solicitation termsYesNo

Limitation of Liability

Client, for itself, its Representative agents, and any other person or enterprise claiming hereunder, hereby acknowledges, understands, accepts, and agrees that Cambridge Caregivers shall not be liable or responsible for, and Client shall and does hereby waive, release and agree to indemnify and hold Cambridge, its liability, cost, damage, claims, suits, and/ or personal injury to Client or others arising in connection with the services provided by Cambridge Caregivers hereunder. The Client acknowledges and understands the natural consequences of aging, including but not limited to falls, wandering (elopements,) accidents or Client's refusal or non-compliance with physician's orders or the instructions, acts, or omissions of Cambridge Caregivers, including but not limited to medications, diet, physical activity, services or any other ordered therapy or treatment.

I agree to the Limitation of Liability termsYesNo

Arbitration

All disputes regarding any aspect of this Engagement Agreement shall be subject to binding arbitration under the rules of the American Arbitration Association and conducted in Dallas, Texas, in accordance with Texas law, except for its conflicts of laws principles.

I agree to the Arbitration termsYesNo

Client or active MPOA or other Representative hereby give Cambridge Caregivers consent to use or disclose any protected health information to carry out Client's treatment, to obtain payment from insurance companies and for health care operations such as but not limited to quality reviews. Client or Representative further consent that protected health information may be received or released by Cambridge Caregivers by various means including but not limited to personal conversation, telephone, mail, email, or facsimile. Client or representative understands that they have the right to request a restriction of their protected health information used. However, they also understand that Cambridge Caregivers is not required to agree to this request. If Cambridge Caregivers agrees to the restriction the Company must abide by it. I, Client, or Representative have not requested a restriction of how my protected health information is used. Client or active MPOA understands that they may revoke this consent at any time by means of a request in writing, except for information already in use or disclosed.

I agree to the Consent termsYesNo

Billing Policies

I agree to the Billing Policies termsYesNo

Base Charge

The Client shall pay a per-hour rate for Cambridge Caregiver's services provided in accordance with this Engagement Agreement, which shall be due and payable within 10 days of the invoice date. Late payments are subject to a late fee equal to 5% of the past due amount calculated monthly. The Client agrees to pay Cambridge via Automated Clearing House (ACH,) credit card, or via check. Cambridge will not draft the Client's checking account without prior notice and authorization unless the invoice remains outstanding for more than 14 days after the invoice date or upon the passing of the Client. In either of these events, the Client and or Responsible Part hereby authorizes and agrees to allow Cambridge to charge the payment against the Client's and or Responsible Party's banking account. Banking information is as follows (which shall be kept current at all times applicable to this Engagement Agreement.)

I agree to the Base Charge termsYesNo

Cancellation Fees

Cambridge Caregivers understands that plans can change, and we strive to accommodate our clients accordingly. Nonetheless, if a client cancels within 24 hours of a particular shift's start time, they will be charged for the entirety of that shift. Furthermore, if caregivers or other staff members are sent home early, the Client or Responsible Party will be charged for the entire shift.

I agree to the Cancellation Fees termsYesNo

Holidays and Overtime

By law, Cambridge Caregivers is mandated to pay overtime to employees who work more than 40 hours per week on an engagement. Clients will be charged 1 1/2 times the agreed-upon hourly rate for any hours worked in excess of 40 hours during a one-week period. Further, employees will also receive holiday pay (1 ½ times the normal hourly rate) for six Federal Holidays throughout the year, including New Year's Day, the 4th of July, Memorial Day, Labor Day. Thanksgiving Day, and Christmas Day.

I agree to the Holidays and Overtime termsYesNo

Mileage Reimbursement

If the caregiver or other Cambridge Caregivers employee transports the Client in the caregiver or other Cambridge Caregiver employee vehicle, the caregiver or other Cambridge Caregivers employee will receive milage reimbursement. The Client or Representative will be billed the current IRS rate. Additionally, in the event that the caregiver or other Cambridge Caregivers employee purchases items on behalf of the Client, the Client or Representative will be billed accordingly.

I agree to the Mileage Reimbursement termsYesNo

Late Charges

Consistent with the paragraph above, payments are considered late if they are not paid 14 days from the invoice date (see amounts of late charges as described in the paragraph above.) Interest will be charged at the maximum interest charge allowable by law. Engagements 28 days in arrears are subject to immediate termination of this Agreement at the sole discretion of Cambridge Caregivers and may result in the collection and legal proceedings, none of which shall be deemed an election of remedies. The Client or Representative agrees to pay all costs of collection, including reasonable legal fees, associated with the collection of any and all amounts due.

I agree to the Late Charges termsYesNo

Insurance, Medicare, VA Benefits

Although services may be covered by long-term care insurance, the Client or Responsible party is accountable for obtaining payments from their own insurance provider. The Client or Responsible party is fully financially responsible for paying Cambridge Caregivers upon receipt of the invoice from Cambridge, regardless of when the Client or Responsible party receives reimbursement from their long-term care provider.

I agree to the Insurance, Medicare, VA Benefits termsYesNo

Privacy Consent

Consent

I agree with the storage and handling of my data by this website found at https://cambridgecaregivers.com/privacy-policy/.

I agree to the Privacy Consent termsYesNo

The undersigned has read and understands the foregoing and agrees to the terms and conditions of this agreement.

Name of signer