CLIENT INTAKE FORM

AmeriTouch Home Health Services Inc
Client Intake Form

CLIENT INFORMATION

Address

EMERGENCY CONTACT (Outside the Home)

Address

DIAGNOSIS AND CODES

Services/Freq./Duration

FUNDING SOURCE INFORMATION

Elig
Address
Address

IF WORKER'S COMP

Address
Address
CLIENT CONSENT

Definition: Service Period is one (1) calendar month.

  • Client will be responsible for a Service Period payment upon renewal of this Agreement within 5 days prior to start of each month.
  • Agency reserves the right to re-evaluate Client and reassess the fee prior to a new Service Period, based on Client need.
  • Client or any person responsible for client agrees to pay ONE AND A HALF times the agreed upon live-in or hourly rate for the following holidays: New Year’s Day, Easter Sunday, Memorial Day, Labor Day, Independence Day, Thanksgiving Day and Christmas Day.
  • Client shall provide adequate, proper and reasonable accommodations for caregivers sleepingconditions, food and nutritional support. Client will ensure Caregiver obtains seven and one-half (71/2) hours of sleep in a twenty-four (24) hour period, including an uninterrupted and continuous period of at least four and one-half (41/2) hours.
  • Client will reimburse Caregiver’s expense incurred on behalf of a Client within seven (7) days of receipt of proof of expense. Expense may include but are not limited to groceries, parking, bus fare, transportation utilizing caregiver’s automobile, etc.
  • Client will reimburse Caregiver for transportation provided utilizing Caregiver’s automobile at the current reimbursement rate per mile.
  • Term is indefinite and shall be renewed by timely receipt of next Service Period Payment (see Obligation of Client section).
  • Except as otherwise provided herein, this agreement may be terminated by either party with 5 days prior written notice.
  • In the event of Client’s hospitalization, Agency will suspend Caregiver services until return from hospital. Credit will be given in next billing cycle for the days Agency services were not rendered. Agreement will not be terminated by temporary interruption or suspension of service.
  • Services may be terminated without 5 days’ notice if one of the following occurs:
    1. Client/family member is abusive or endangers the health or safety of the caregiver.
    2. Client requires services or care that Agency cannot provide.
    3. Client needs full time care by a licensed healthcare professional or needs institutionalization.
    4. Client no longer lives in the geographic area serviced by Agency.