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Inclusive Home Care

Inclusive Home Care Client Registration

Inclusive Home Care Client Registration
Name*
First name Middle name Last name
Preferred name
Primary language*
Date of birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Social Security Number*
Primary telephone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Type*
- Home
- Work
- Cell
Second telephone
Type*
- Home
- Work
- Cell
Parent Email*
Agreement to Provide Home Care Services
The Agreement is entered into between the Client listed above and Inclusive Home Care, LLC, (“IHC”), a corporation organized and existing under the laws of the state of New Jersey, with its office located at 3444 Quakerbridge Road, Suite 11B, Hamilton, NJ 08619. IHC and Client herby agree as follows: 1. Term IHC shall provide home care services as specified in Section 2 of this Agreement for Client for 12 consecutive months following the service initiation date. This Agreement will automatically renew each year on the anniversary of the service initiation date for the following 12 consecutive months, unless it is terminated by either party in accordance with Section 4 of this Agreement. The following holidays are excluded from the terms of this contract: New Year’s Day, Easter, Memorial Day, Fourth of July, Labor Day, Thanksgiving and Christmas. Should IHC agree to provide services on these holidays, the Client shall pay to IHC an additional hourly fee specified in the rate schedule provided to the client.
Services*
Select the services you want IHC to provide services by a Licensed Caregiver.
- Companionship
- Dementia care
- Home health aid
- Light housekeeping
- Meal preparation
- Medication reminders
- Mobility assistance
- Personal hygiene & grooming
- Physical therapy
- Post stroke, surgery or injury care Rehabilitation Respite care
- Skilled nursing care
Enter the arrival and departure times for each day IHC will provide services by a Licensed Caregiver.

Services will not be provided on holidays listed in Section 1 of this Agreement.
Monday
Arrive Depart
Tuesday
Arrive Depart
Wednesday
Arrive Depart
Thursday
Arrive Depart
Friday
Arrive Depart
The Client will contact IHC regarding any additional service requests. IHC may agree to or deny the request at IHC’s sole discretion. Should the Client’s in home care needs change, necessitating a modification of the agreed upon Individualized Care Plan, and/or the services specified in the Services section of this form, IHC reserves the right to adjust scheduling, services provided, fees charged and any other changes IHC deems necessary. 3. Fees IHC shall provide an in-home Caregiver for the hours and days as specified in Section 2 of this Agreement at a weekly rate specified in the rate schedule provided to the client. Additional hours of caregiving, outside of those specified in Section 2 of this Agreement, provided to Client by IHC will be billed at an additional hourly rate specified in the rate schedule provided to the client. Client shall make all payments payable to: Inclusive Home Care, LLC Client shall pay for the total amount of all invoiced charges within 10 calendar days of receipt of invoice. Client shall reimburse IHC, at a per mile rate specified in the rate schedule provided to the client., for the cost of any travel that exceeds 5 miles per trip. Should any fees be referred to a third-party company for collection, Client agrees to pay all reasonable costs of collecting the debt, including attorney’s fees, disbursements, court costs and interest. 4. Termination of Service Either Client or IHC may discontinue services for any reason with a minimum 2 weeks’ notice to the other party. A termination fee, as specified in the rate schedule provided to the client, shall be paid to IHC by Client if Client terminates this agreement with less than 2 weeks’ notice. IHC can choose to terminate this service agreement immediately, without notice, upon the occurrence of any of the following events, as determined by IHC in its sole and absolute discretion: Client presents a threat to him or herself Client presents a threat to an IHC Caregiver Client requires mental or physical healthcare beyond the capability of IHC’s Caregivers, as determined in IHC’s sole discretion Client fails to pay all invoices in full within 10 days of invoice date Client fails to provide a safe working environment for IHC Caregiver 5. Licensing IHC warrants that IHC is licensed in the state of New Jersey to provide the services listed in the Section 2 of this Agreement. Furthermore, any employee or representative of IHC, performing services under this agreement, is also is approved by the state of New Jersey and is current on all required training and certification. 6. Confidentiality IHC affirms that any and all private information obtained about the Client and the Client’s family during the course of this Agreement, including but not limited to personal, medical and financial information, is considered strictly confidential and may not be disclosed by IHC or its employees to any third party for any reason, except in cases of abuse or as required by law. The confidentiality protected by this clause remains in place in perpetuity. 7. Release of Liability Client hereby releases IHC, its owner, staff and agents from all claims, liability and damages that the Client may have for personal injuries or property damage occurring during or related to care provided by IHC. Client agrees that IHC will not be held liable for any medical or legal expenses and that Client will not take any legal action against IHC except in cases of gross negligence, willful injury or fraud. This release includes, but is not limited to, personal injury due to falls occurring during care or property damages caused by IHC, its owner, staff and agents; however, the release does not apply to liability for gross negligence, willful injury or fraud, and is not intended to release IHC insurers, if any, or non-agent third parties of any responsibility for any claims that may otherwise be asserted. 8. Amendments This Agreement may be modified or amended in writing, upon written agreement of the obligated parties. 9. Applicable Law This Agreement shall be governed by and interpreted in accordance with the laws of the State of New Jersey. In the event that any matter arising hereunder shall be in dispute, the parties agree that the exclusive forum for resolving any such dispute shall be a state or federal court of competent jurisdiction situated in the State of New Jersey.
Client lives with
Name*
First Name Last Name
Relationship to client*
Telephone*
Emergency contacts
Emergency contact name*
Relationship to client*
Telephone*
Telephone
Emergency contact name*
Relationship to client*
Telephone*
Telephone
Emergency medical contacts
Physician name*
Physician telephone*
Physician address*
Specialist name
Specialist telephone
Specialist address
Hospital name
Hospital telephone
Hospital address
Health care proxy
Health care agent
Relationship to client
Telephone
Insurance
Payment*
- Private pay
- Insurance
Insurance carrier
Customer service telephone
Subscriber
Plan name
Policy number
Customer service telephone
Subscriber
Plan name
Policy number
Insurance carrier
Customer service telephone
Subscriber
Plan name
Policy number
Authorization for use and disclosure of health information
Consent*
I voluntarily consent to authorize my previous health care provider to disclose my health information to Inclusive Home Care, LLC, for the purpose of providing me with home health care. I understand that this authorization will remain in effect while I am a client of Inclusive Home Care, LLC.
Previous care provider*
Care provider telephone*
Care provider address*
Information to be disclosed*
- All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.
- Only the following records or types of health information:
Only the following records or types of health information:*
Client consent
Release of information: I do hereby authorize Inclusive Home Care, LLC to release information contained in my medical record and any other medical information about me in their possession in the following instances: ● To health care providers who with my consent are involved in my care and in the transfer of my care and or in the co-ordination of my care. ● To my insurance company or third-party payer for the purpose of obtaining payment for care provide. ● To peer review, utilization review or other organizations responsible for monitoring the quality or appropriateness of patient care. This authorization does not permit the disclosure of release of information that may arise out of communications with a psychotherapist, social worker or sexual assault counselor, HTL V -Ill (HIV or AIDS) test results, records from an alcohol or drug abuse treatment facility or records pertaining to sexually transmitted diseases. Release of any such information shall require an additional specific consent for disclosure. I understand that this authorization shall pertain to and remain in effect for the time I receive care from the HCSF. I also understand that no further consent for release of information shall be required in the above circumstances, unless I notify the HCSF otherwise in writing. Consent to treat: I hereby authorize this HCSF and its agents full consent for the provision of care and treatment under the plan of care of the primary physician and to abide by the HCSF's specific policies and procedures relating to home health care which have been reviewed with me and which include provisions for termination of home health care services at my request, my physician's request and/or the HCSF's request. I acknowledge that no guarantees have been made with respect to the outcome of this service or of any treatments or procedures. Photo consent: I hereby give the HCSF and its staff, consent to photograph me and any parts of my body, in relation to my care/services while under the care of the HCSF. Electronic records and signatures consent: if our agency utilizes an electronic medical record system, I give my consent to the use of electronic medical records & e-signature use. Drug testing: I acknowledge that the HCSF does not routinely perform drug testing on employees but may do so at their discretion. Care plan: I consent to the proposed Care Plan and authorize care be provided by the HCSF in accord with my physician's orders, under supervision of HCSF staff. I understand that I have the right to refuse treatment or terminate care at any time by providing the HCSF 2 weeks notification. NJ Guide To Homemaker-Home Health Aides booklet: I am aware that the HCSF is required to provide me a copy of the NJ Guide to Homemaker-Home Health Aides 24 hours before the start of care. I waive the right to receive this booklet 24 hours before the start of care and will receive the booklet at start of care visit, before the provision of services.
Client information folder
Inclusive Home Care, LLC is pleased to have the opportunity to care for you. As part of your plan of care, click here to download a client information folder that includes important information about our services. Please review the contents of the folder with your clinician. We recommend that you keep your Patient Information Folder close by and refer to the materials if you have questions about your care. We recognize your rights as a patient and asks that you assume certain responsibilities to keep you as healthy as possible. I have received my Patient Information Folder which will be reviewed with me and includes: ● Welcome Letter ● Home Safety Guidelines ● Advance Directive Information ● Pain Management Information ● Privacy Notice ● Community Resources ● HIPAA Notice of Privacy Rights ● Abuse & State Hotlines ● Patient Consent Form (NCR) ● Insurance Information Form ● Patient Authorization Form (NCR) ● Med Work Sheet/Lock Box ● HCSF Complaint/Grievance Process ● Non-Discrimination/LEP Statement ● Disaster Planning/Emergency Plan Information ● Patient Rights & Responsibilities
Check the box beside the statement:*
I have read and understand all of the written information as outlined above, as well as the verbal review offered by my clinician. I agree to the terms presented in this material. I also agree to contact Inclusive Home Care, LLC if I have questions about my care.
Emergency evacuation plan*
- With family
- To a shelter
- Stay in home
- Other
Other
Evacuation assistance*
- Yes
- No
Client or agent signature
Emergency medical authorization:*
I authorize the Inclusive Home Care to obtain medical care for me in the event of a medical emergency. This authorization includes transportation for medical care and any medical care determined appropriate by medical personnel.
Emergency medical authorization:*
I certify that the information I have provided is accurate to the best of my knowledge.
Form completed by*
- Client
- Client's agent
Signature*
Date*
Date Format: MM slash DD slash YYYY

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