Client Choice & Transfer Statement

I, the undersigned, client/guardian understand that it is my right to select the home care provider of my choice. I have selected Golden Grace Health Care LLC (further referred to as Agency) free of any undue pressure or solicitation by any officer, director, employee, agent or contractor of the Agency. I have been advised by the Agency that I may request information concerning its scope of practice, services available and telephone numbers. I was encouraged to ask specific questions concerning my individual needs to assess whether the Agency is a good fit for me. I have been able to ask questions and express concerns, which have been satisfactorily responded to by the Agency's staff. I further declare that my receipt of home care services from the Agency is by choice. I have been advised by the admitting staff that if for any reason I wish to change services to another home care agency, it is my right to do so.