Alliance Care, Inc



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CLIENT CONTACT INFORMATION

Client’s Name: Social Security Number: ______

Client Address: City: State: GA

Zip Code: Phone Number: Marital Status: Date of Birth:

Age: Height: Weight:

Representative/Guardian (if applicable): Medically Frail:

Insurance Company: Policy #:

Intake Person: Contact Date: Referral Source:

Referral Date: Private Pay or Insurance (circle one)

Type of Service: Nursing Personal Care Companion/Sitter (circle one)

Initial Service Date:

Pets in home: Dog Cat Other: ________ (circle all that apply)

I. EMERGENCY INFORMATION:

Contact Name: Relationship: Home Phone #:

Work #: Cell Phone #: Physician:

Physicians Phone #: Preferred Hospital:

Client’s Allergies: Power of Attorney: Phone #:

III. SERVICES REQUESTED/ORDERED: _____________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

IV. SERVICES PROVIDED: Circle Those That Apply: Bathing Bathroom Activities

Oral Care Grooming Dressing Light Housekeeping in Living Area Meal

Prep Ambulation Transferring Eating Medication Reminders

Taking for Walk or Other Activity Range of Motion Exercise

Observe & Report Status Trips Outside Home

OTHER: _______________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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SERVICE FREQUENCY: M T W TH F S SN

TIMES (note under each day):

Duration of Services (# of hours):

V. CHARGES FOR SERVICES: $ Per Hour

$ Per 5 Hour Visit

$ Per Live-In Day

VI. BILL PAYMENT CHOICE: To be billed weekly - CHECK or CASH

VII. ACKNOWLEDGEMENT OF RIGHTS:

VIII. AUTHORIZATION TO ACCESS FUNDS: NA

IX. TRANSPORT AUTHORIZATION: Circle One YES NO

I ________________________________ accept full responsibility for payment of service rendered by employees of Alliance Care of Atlanta Inc.

I understand that invoices will be issued weekly. Payments of invoices are due upon receipt. If I fail to Pay any amounts due after fifteen (15) days from invoice due date, Alliance Care Inc. has the right to discontinue services and/or charge interest of remaining balance at 1.5% per month until payment is made in full. I understand as a courtesy, Alliance, Inc. will accept the assignment of insurance benefits from____________________________, the patient’s insurance company. I also understand that Alliance Care, Inc. cannot guarantee full payment of services from your insurance plan, and that I will be liable for any remaining possible balance for services rendered by Alliance Care, Inc. to _____________________ (patient’s name) and not paid for by ____________________________ insurance company.

Furthermore, I agree to pay all costs (including legal fees) incurred by Alliance Care Inc. in collecting monies due under this agreement. The following holidays are recognized at 1 1/2 rate at Alliance Care Inc.: New Year’s Eve 6:00 p.m., New Years' Day, Easter Sunday, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Christmas Eve 6:00 p.m., Christmas Day. I understand and acknowledge full responsibility of payment for all holidays.

Cancellation Policy:

The client has a right to cancel service at any time and be charged for services rendered if the provider is notified at 678-417-1600 by speaking to the office staff. The provider may assess a fee of $120 if services are not cancelled 6 hours prior to a staff member arriving at the client’s home for an ordered shift.

In consideration of Services of Alliance Care, the client and Alliance Care agree:

That for present and a period of 12 months after the effective termination date of this service to you, the client, will not:

a. Engage in the practice of hiring home-care or private duty work with any past or present employees of Alliance Care either directly or though another individual, corporation, or agency.

b. Solicit or accept any care from any present or past employees of Alliance Care either directly, though another individual or corporation.

c. Receive any care from any friend or relative of a present or past employee of Alliance Care either directly or through another individual, corporation or agency.

d. Advise past or present employees to curtail their business association with Alliance Care.

e. Disclose to any other person or company the names or past or present employees.

f. Influence any employee or Independent agents to terminate their care and/or agreement either directly or through another individual, corporation or agency.

g. Should a client violate this agreement between Alliance Care Inc, Alliance Care has the right to sue for the amount of lost business plus $5,000 for each violation plus legal expense.

h. Alliance Care, although bonded and insured, only considers liability for lost/stolen items upon conviction in court of its carefully screened employee. Valued items are to be stored to prevent damage.

In consideration of the services to be provided by Alliance Care of Atlanta, Inc., the Customer agrees as follows:

1. Non-circumvention:

a. During the period of time that the Company is performing services for Customer, Customer shall not, either directly or indirectly, solicit, divert or hire or attempt to solicit, divert or hire, any person employed by Company for a determined period, or at will, for the purpose of having such person perform duties of any nature for another person or entity; and

b. For the one (1) year period following the last date that the Company provides services for Customer, Customer shall not, either directly or indirectly, on Customer’s own behalf or in the service of or on behalf of others, solicit, divert or entice, or attempt to solicit, divert or entice any person employed by the Company (“Solicited Person”) with whom Customer had direct and substantial contacts during the one (1) year period immediately preceding the last date that the Company provided services for Customer to perform duties or provide services for Customer which are substantially similar to those duties performed or services provided by or on behalf of such Solicited Person to Customer, whether or not such Solicited Person is a full-time employee or a temporary employee of Company, and whether or not the engagement of the Solicited Person by Company is pursuant to written agreement or whether or not such engagement is for a determined period of time or is at will. This provision shall only apply to those Solicited Persons that are employed by Company at the time of solicitation or attempted solicitation.

2. Definitions:

a. Customer – the individual or entity authorizing the services of Alliance Care as well as the individual or entity for whom Alliance Care is contracting to perform services.

b. Company – Alliance Care of Atlanta, Inc.

Remedies. The parties hereto acknowledge and agree that it would be difficult to ascertain damages in the event of a breach of the non-circumvention covenant set forth herein, and accordingly, Customer agrees that any violation by Customer of the non-circumvention covenant would cause irreparable harm to the Company. Customer further agrees that, upon proof of the existence of a violation of the non-circumvention covenant, Company will be entitled to recover compensatory damages, costs and reasonable attorney’s fees incurred by Company in bringing such action.

I acknowledge and understand this agreement between Alliance Care and me, the client or responsible party, and hereby bind myself to this agreement between Alliance Care and myself.

Dated this ______ day of ________________ 20________ Date of Birth: ________________

Client Signature: ________________________________________ S. S.: _______________________

P.O.A.:________________________________________________

Signature for Alliance Care: _____________________________ _ Title: ______________________

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Alliance Care, Inc.

Service Agreement

Confirmation of Service/Payment Agreement

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