Informed Consent Agreement for Home Care Services

1. Consent for Services — The undersigned, being the Client/Patient/Parent or POA of the Client/Patient hereby contracts with Golden Grace Health Care LLC to furnish the services listed above to the Client/Patient. State law shall govern this Agreement/Informed Consent for Services.

2. Nature of Services — I understand that Golden Grace Health Care LLC provides non‑medical home care services only. Caregivers do not provide medical diagnosis, medical treatment, or skilled nursing services unless specifically authorized under applicable regulations.

3. HIPAA, Medical Consent, and Information Authorization — Client agrees that Provider and its employees and agents shall not be liable for any act or omission which results from following the instructions of the client’s physician. Client authorizes any hospital or physician to furnish to Provider or its agents, all records pertaining to Client’s medical history, services rendered or medical information to any applicable insurance carrier, or government entity as required by the level of service provided. Client authorizes the sending of all medical information, medical records and any other information pertinent to the client’s care by fax, mail, electronic relay, oral relay, or relay by courier as may be necessary in the provision of agreed to services. Client also agrees that his or her records may be used for purposes of payment to third parties.

4. Supervision of Care — The client is monitored by our administrative staff trained to assess progress and the quality of the care you receive. Records are reviewed quarterly by our supervisory staff. We also audit our client records for quality assurance. Periodically you may receive a satisfaction survey via telephone that will enable us to provide enhanced service. A client may receive a supervisory visit depending on the complexity of the case. All employees are bonded and insured in case of theft, breakage of property, or injury to client.

5. Acknowledgement of Risk — Client fully acknowledges that he/she has not hired Provider to provide personnel to be by the Client’s side at all times during the assigned shifts. Client understands that the duties of a caregiver entails many activities that require them to leave the Client’s immediate vicinity (e.g. to cook meals, clean within the client’s home) or to leave the Client’s home (e.g. to shop outside the Client’s home) or to be sleeping at night (in the case of a Live-In assignment). Similarly, if Client refuses care or disallows any Caregiver from doing his or her job, including, assisting with ambulation, or assisting in ways that are necessary to prevent injury, the Caregiver cannot use physical force to assist and must respect the Client’s right to refuse care. Accordingly, the Caregiver and Provider are not responsible for any resulting harm, injury or death that may result from being away from the client or Client’s refusal of care or assistance. Also, the Client fully acknowledges that there are risks that are not possible to eliminate, such as the risk of falling, and it is not the responsibility of the Provider to eliminate these risks.

6. Cancellation of Scheduled Shift(s) — Provider must be notified no less than 48 hours in advance if Client wishes to cancel a scheduled shift for a Caregiver. If the Client fails to give 48-hour notice for cancellation, the Client will be liable for payment of all scheduled shifts within that 48-hour period. Emergency cancellations, such as hospitalization, will not result in cancellation charges.

7. Termination of Services — Either the Client or Provider may terminate this Agreement with 1-week written notice. If either party terminates this Agreement, then all fees and other charges incurred through the effective date of the termination will be due and payable immediately by Client. Provider will return any prepaid but unearned fees within 45 to 60 days. If the Client Relationship Agreement or Private Pay Agreement are breached, services may be immediately terminated by either party. If caregivers feel threatened by you or your representatives, we will immediately terminate services.

I certify that I have received a copy of this agreement and understand the terms set out herein upon which Golden Grace Health Care LLC will provide services.