Private Pay Client Agreement

A deposit will be required before commencing service and held until the final week of service. The deposit will be applied to your final invoice. If the final balance is less than the deposit, the Client and/or FRP will receive a refund. If client’s service routinely exceeds 80 hours per week, Client and/or FRP will be required to submit weekly payments via credit card or ACH transfer only and an additional deposit may be required.

Payment is due upon receipt. Outstanding invoices past due 30 days from the invoice date may be turned over to a collection agency at Client’s and/or FRP’s expense. In the event Client and/or FRP has an outstanding past due balance of 30 days, or any payment is denied for insufficient funds, Provider has the right to suspend services and Client and/or FRP agrees to pay all collection costs including attorney fees, court costs, sheriff fees, collection company fees, and applicable late payment fees. All accounts are subject to a late payment fee of 2% per month for invoices more than 30 days past due.

Some or all services provided to Client by Provider may be covered by long term care insurance. Client and/or FRP authorizes any insurance company to furnish Provider, or its agents, all information pertaining to Client’s insurance benefits and the status of claims submitted by Provider. While Provider will use best effort to cooperate with third-party insurance companies, the individual signing this agreement is financially and legally responsible for payment.

Client and/or FRP agree for Provider to service the account or to collect any past due amount, Provider or its Assignees may contact you by telephone at any telephone number associated with the account, including wireless telephone numbers which could result in charges to you. Provider or its Assignees may also contact you by sending text messages or e-mails, using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Client and/or FRP acknowledges that Provider is a provider of private duty services and is not an employment agency or a placement service. Client, Client’s family and/or FRP agree not to solicit for employment, employ or engage in any way employees introduced through this Agreement. Any caregiver introduced to Client by Provider must not be employed privately or through another agency providing services to Client in any way for a period of 180 days after termination of this agreement. Client and/or FRP agrees to pay Provider $15,000 per employee for violations of this section. Client may request a buy-out of an employee by calling the agency office, however Provider may refuse any such request.

I acknowledge that I am financially responsible for, and I agree to pay Provider for, all invoiced services provided to Client.