Duluth Care



    Date service agreement completed: This service agreement is between this(agency) and (“Client”)

    WHEREAS “Client” seeks this agency provides home care services, with qualified dependable personnel whom remain under consistent direct supervision of the Administration of this agency.

    Client Basic Information:

    Name: Phone #:

    Client Address: Client DOB:

    Client Emergency Contact Name and Number:

    Client emergency contact Address:

    Client Responsible Party Name and Contact Number:

    Client ResponsibleParty Address:

    Date of Referral: Date of Initial Contact: Source of Referral:

    Service Options:

    Personal Care: Companion Sitter: Nursing:

    Description of Service Requested (in Clients Own exact words):

    Written Description of services to be provided:

    Client Name:


    Frequency ofrequested services: Duration of services:

    Release of Information/Reimbursement Consent

    I hereby authorize Private Insurance/Other: to pay any or all-applicable benefits directly to this agency. I authorize the agency to release any of my medical records necessary to secure payment of documented charge. I understand that I am financially responsible for charges not covered by my insurance as specified;


    Hour’s client request per day Days per week client wants services: (SELECT ONE) . The service listed above will be provided at an hourly rate of $ per hour.

    The Service listed above will be provided at a rate of $ per day

    The service listed above will be provided at arate of $ per week

    Select one

    Method of Payment: by whom

    Agency will bill the client in the following ways: (1. weekly every Friday) (2. Semi-weekly on Friday) (Monthly) Friday) or (3. monthly last day of each month)

    Financial payee of the agency services Name & address:


    Check: Cash: Private Insurance:

    Billing Date: How Often:

    Client Name:


    I acknowledge receiving a copy of client's rights and responsibilities as outlined at rule (111-8-65-.12 Client Rights,
    Responsibilities) Client Initials here:( ).

    I acknowledge receiving a copy of client's rights and responsibilities as outlined at rule (111-8-65-.12 Client Rights, Responsibilities) Client Initials here: 866-235-2448(

    (Agency Contact Name:) EMMANUEL UGBAJA

    Statement of Authorization:

    Agency employees are: (SELECT ONE)

    If there is any use of client funds by staff for clients, including credit cards, or of the client’s cars. If so, there must be special written authorization for such use or access in the client’s record and all agency staff must be bonded and ensured when handling client funds. Agency Director will refer to L0943 regarding the requirement for bonding for any provider whose employees have access to client’s funds or a vehicle.

    Clientrequests Assistance with Bill paying, personal funds& handling of financial transactions; YES /NO(Client Initials: ) Client requests Assistance with providing transportation in their own personal vehicle; YES/NO (Client Initials:

    ** Transport and escort services for healthy individuals/families are not considered PHCP services. Prior to the establishment of this agency should attempt to determine if the client has a Responsible Party and has executed any written document designating a Responsible Party or has had a legal guardian appointed by the court. If unable to determine if client has a responsible party or guardian, efforts made to determine the status should be documented. It should be documented in the client’s record whether the client represents himself or whether another designated responsible party represents the client for the purposed of authorizations.

    Client’s Independent Status: Complete Independent Adjudicated Incompetent

    I authorize this agency to provide services described in this Service Agreement. I understand that I have the right to cancel this agreement at any time

    Client Name:


    I have had input into my Service Agreement, I understand my Service Agreement, and further understand who to contact and how if I have any question, concern, and/or desires to make changes in my Service Agreement. The Agency Administrator will be responsible for updated any changes to Service Agreement within 48-72 hrs.

    I understand that any changes or amendments will be updated correctly, and I will receive a revised copy of the new service agreement within 48-72 hours after it’s been changed by the Agency Adm.

    For Department of Community Health Private Home Care Program licensing questions, you may call 404-657-5700.

    State Licensing Program for this Agency is located @ 2 M.L.K. Jr Dr SE, Atlanta, GA 30334. 404-657-5700.

    If the matter is not resolved, or you cannot solve your problems with the agency staff, the Health Care Facility Regulation Division/Department of Community Health hotline to lodge complaints about provider services is: Complaint Line is: 404-657-5728 or toll free 1-800-878 6442

    Cancellation of services:

    If the client cancels services with the agency, they can do so at any time and shall only be charged for services rendered prior to the time that the provider is notified of the cancellation.

    Any outstanding balance that is owed to the agency for services previously rendered up until the day of cancellation will be required to be paid by client with 5 days after cancellation and final payment will be required to be paid in cashier’s check, postal money order or cash only to the agency. A final receipt will be given to the client once payment is made.

    Contacts for all Clients/client payees to be aware of:

    Healthcare Facility Regulation

    2 M.L.K. Jr Dr SE, Atlanta, GA 30334

    Main Licensing number 404-657-5700
    Local Complaint Number 404-657-5728
    Toll Free Complaint Number 800-878-6442

    I have been helped in understanding and how to exercise my rights as a client.

    Client’s Signature:


    Representative Signature:


    Agency Administrator: