Home Care Admission Packet

4. Review and Agree to Our Terms

Please review the following agreements. You must agree to each section to continue.

Consent for Private Duty Services

This section confirms your voluntary consent to receive customized home care services and authorizes our caregivers to perform tasks outlined in your non-medical Service Plan.

1. Consent for Services: I, the undersigned, voluntarily consent to receive private duty home care services from Kolofon Health. I understand these services are customized to my specific needs and preferences and may include, but are not limited to: Companion Care, Personal Care, and (if applicable) Skilled Nursing.

2. Service Plan: I understand that a personalized Service Plan will be created by Kolofon Health based on my stated needs and goals. I acknowledge that this is a non-medical plan (unless Skilled Nursing is explicitly included) and is not ordered by a physician. I reserve the right to request changes to this plan at any time.

3. Authorization & Direction: I authorize Kolofon Health caregivers to perform the tasks outlined in my Service Plan. I understand I have the right to direct my care, refuse any specific service, and provide feedback on caregiver performance.

4. Emergency Situations: In the event of a medical emergency, I authorize Kolofon Health staff to contact emergency medical services (911) and my designated emergency contacts.

Client Rights and Responsibilities

Here we outline your rights as a client—such as the right to direct your care and be treated with respect—and your responsibilities, including providing accurate information and a safe environment.

As a Client, you have the right to: Direct and be actively involved in your care; Choose your caregiver and request a change; Be treated with compassion and respect; Privacy and confidentiality; Voice concerns without fear of retaliation; Be informed of rates and policies.

As a Client, you have the responsibility to: Provide accurate information; Communicate changes in your condition or needs; Provide a safe and clean environment; Treat caregivers with respect; Fulfill your financial obligations.

Notice of Privacy Practices (HIPAA)

This acknowledges that you have been provided with our “Notice of Privacy Practices,” which explains how your personal and health information is protected under law.

Even in a private duty setting, protecting your privacy is paramount. Our “Notice of Privacy Practices” explains how your personal health and identifying information is protected, used, and disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws. You have the right to review our full “Notice of Privacy Practices” before signing. By checking the box, I acknowledge that I have been provided a copy of Kolofon Health’s “Notice of Privacy Practices” and have had the opportunity to ask questions about it.

Private Pay Financial Agreement

This agreement details the financial terms, including service rates, our bi-weekly advance billing policy, and your personal responsibility for payment for all services rendered.

1. Service Rates: I agree to the service rates as outlined in the Kolofon Health Service Rate Sheet. I understand these rates are for private pay services and are not billed to insurance.

2. Billing and Payment: I understand that Kolofon Health bills for services on a bi-weekly, advance basis. Invoices will be sent prior to the start of a service period. Payment is due upon receipt of the invoice to secure staffing. I agree to pay all invoices by the specified due date.

3. Financial Responsibility: I acknowledge that I am fully and personally responsible for the payment of all services rendered. This agreement is not contingent on reimbursement from any third-party source.

4. Cancellations and Refunds: I understand the agency’s policy regarding service cancellations. Any pre-paid services that are properly cancelled in accordance with the agency’s policy will be credited to my account or refunded.

Private Duty Service Agreement

This is the formal agreement covering the scope and schedule of services, cancellation policies (24-hour notice), and terms for terminating the agreement (14-day notice).

1. Scope & Schedule: The Agency agrees to provide non-medical services as detailed in the personalized Service Plan, according to a schedule agreed upon by the Client and Agency. The Agency requires 24 hours’ notice for schedule changes.

2. Agency & Caregiver Responsibilities: The Agency is responsible for screening, training, and supervising all caregivers. Caregivers are bonded, insured, and prohibited from accepting personal gifts or handling client finances.

3. Cancellation & Termination: The Client must provide 24 hours’ notice to cancel a visit to avoid being billed. The agreement may be terminated by either party with fourteen (14) days’ written notice. The Agency may terminate immediately for safety concerns or non-payment.

4. Governing Law: This Agreement shall be governed by the laws of the State of Iowa. This document constitutes the entire agreement between the parties.

Final Confirmation & Signature

By signing below, you certify that you have read, understood, and agreed to all the forms presented. This digital signature is legally binding.