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I hereby authorize BEST QUALITY Home Care AGENCY to render appropriate home care services to the patient/client named

I understand an appropriate level of home care personnel will provide such care. I recognize and agree that I have the right to refuse treatment or terminate services at any time by notifying the Best quality home care agency  office. In addition, Best quality home care agency may terminate service by notifying me of termination and the reason.I acknowledge the considerable expense incurred by Best quality  Home Care agency in advertising, recruiting, evaluating and retaining employees. Accordingly, I agree that during the term of this Agreement and for one (1) year after termination of this Agreement, I will not (without prior written consent of Be) solicit, employ, or seek to employ any individual who is currently employed by or has been an employee of BEST QUALITY Home Care within the last year. Nor will I induce any such person to leave his or her employment with BEST QUALITY HOME CARE . If I violate the foregoing provisions, I agree to pay BEST QUALITY HOME CARE AGENCY  a finder’s fee of Five Thousand Dollars ($5,000) for each such employee.


I agree not to pay the employees directly. Employees are not authorized to accept, have custody or the use of cash, credit cards or other valuables of a client. If cash or other items are advanced to employee, I waive any right to offset this amount from the invoice. Best quality Home Care will not be responsible for claims against its Fidelity Bond unless such claims are reported in writing to Best quality home care agency  and to the local police within ten (10) days after notice of loss


I understand that live-in employees residing on my premises are scheduled for hours of duty of “on call” time per day, and their pay is based on this schedule. If client needs to change shifts or working hours to keep an employee on duty for more than eight (8) hours per day, authorization from Best quality  Home Care must first be obtained and wage and billing adjustments will be made.


Service Interruption

I agree to pay Best quality Home Care a minimum of four (4) hours of service charges on behalf of any employee who reports for duty should I decide to terminate this Agreement without proper notice.


 I understand Best quality Home Care uses its best efforts to provide uninterrupted services; however, sometimes interruptions are unavoidable. During any interruption of service, I understand that I may be responsible for and agree to provide or arrange for backup care.However,Best Quality Home Care will make all reasonable attempts to provide service through their caregivers or another agency


Termination

 I understand that I may terminate this Agreement by giving at least four (4) hours notice to Best Quality Home Care. I understand that Best quality  Home Care may terminate this Agreement by providing at least three (3) days notice or other minimum notice required under applicable state law. I recognize that notification may be furnished verbally in person or by telephone and that written confirmation will follow by mail. In those circumstances in which the life, safety, or well-being of agency personnel is or may be jeopardized, Best quality Home Care may terminate this Agreement without prior notice. Freedom of Choice . I understand that I have the right to choose any provider of personal care services.I voluntarily select Best Quality Home Care as my provider of services


RELEASE OF INFORMATION: I do hereby authorize Best Quality Home Care Agency LLC to release information contained in my medical record and any other medical information about me in their possession in the following instances:

1)To service/care providers who with my consent are involved in my care and in the transfer of my care and or in the co-ordination of my care


2)To my insurance company/third party payer for the purpose of obtaining payment for service provide (if applies) [ initial]

3)To peer review, utilization review or other organizations responsible for monitoring the quality or appropriateness of patient care


4) This authorization does not permit the disclosure of release of information that may arise out of communications with a psychotherapist, social worker or sexual assault counselor, HTLV-III (HIV or AIDS) test results, records from an alcohol or drug abuse treatment facility or records pertaining to sexually transmitted diseases. Release of any such information shall require an additional specific consent for disclosure. I understand that this authorization shall pertain to and remain in effect for the time I receive care from the Agency. I also understand that no further consent for release of information shall be required in the above circumstances, unless I notify the Agency otherwise in writing.


CONSENT TO TREAT: I hereby authorize this Agency and its agents full consent for the provision of care and services under the Service Plan and to abide by the Agency’s specific policies and procedures relating to home care which have been reviewed with me and which include provisions for termination of home care services at my request and/or the Agency’s request. I acknowledge that no guarantees have been made with respect to the outcome of this service or of any treatments or procedures.


PHOTO CONSENT: I hereby give the agency and its staff, consent to photograph me in relation to my care/services while under the care of the agency.


ELECTRONIC RECORDS/SIGNATURES CONSENT: if our agency utilizes an electronic medical record system, I give my consent to the use of electronic medical records & e-signature use.


 

I acknowledge that the Agency does not routinely perform drug testing on employees but may do so at their discretion.


I consent to the proposed Service Plan and authorize care be provided by the Agency under supervision of agency staff. I understand that I have the right to refuse treatment or terminate care at any time by providing the agency notification [ initial]



Best Quality Home Care Agency LLC

6325 York Road, Suite 201, Parma Heights OH 44130



(440) 373-7192

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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