Money orders & Checks
Checks & Money Orders are to be made payable to Unity Care Home LLC
a) Term of Agreement:
The term of this agreement will continue until it is terminated by either party.
b) Service Requested:
Unity Care Home LLC will provide the services requested and agreed upon as set out in the Service Plan enclosed.
c) Terms of Payment (Self Pay):
5 SERVICE DAYS PRE-PAYMENT REQUIRED TO START SERVICES.
Invoices are payable upon receipt. I understand that by making this request, I become fully financially responsible for any and all changes incurred in the course of the services rendered. I understand that employee time sheets must be initialed on a daily basis and signed at the end of the work week in order to confirm the hours/days of services rendered. I further understand that fees are due and payable as set forth herein. Invoices are prepared on a weekly basis. We will charge your credit card or debit with your bank account pursuant to the Electronic Funds Transfer (EFT) Authorization on the date the invoice is rendered. I understand that any invoices(s) that become past due in excess of 10 days will be assessed a late fee of $25. Unity Care Home LLC reserves the right to discontinue providing services until the account is paid in full, including any additional charges and accrued fees. Should any balance be referred for collection, you further agree to pay all reasonable costs of collection, including attorney’s fees, disbursements, court costs and interest. A $25 fee will also be charged for every returned Check.
Holidays/Overtime:
All overtime will be billed at a rate of 1.5 times the hourly rate in effect at the time. Federal and state law requires employers to pay employees overtime for hours worked in excess of 40 hours per week. In the event that a caregiver is specifically requested by the client to work longer than 40 hours per week, the overtime rate will be charged at a rate of 1.5 times the hourly rate. When we provide services on New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day or Christmas Day, you will be charged the 1.5 rate during the twenty-four hour holiday period.
Fees:
The payment terms and rates set forth above are based upon our current fees for the type of services required based upon the Plan of Care prepared for you.
d) Private/Direct Hiring
I agree not to privately/direct hire Unity Care Home LLC’s caregiver/employee for a period of 1 year following the date that employee last provided services for you. In the event you break this condition, a replacement fee of $5,000 is due to Unity Care Home LLC immediately upon me employing that individual or soliciting for another agency with the intent of the other agency hiring the aide on your behalf.
e) Valuables
- Our Caregivers are not authorized to accept gifts, have custody of or have the use of cash, credit or debit cards, bank cards, checks or other valuables belonging to you, without written approval in advance. If services requested include tasks such as assistance in bill pay, grocery shopping or any other tasks that involve caregivers and clients exchanging cash, debit or credit card information or any of the sort, written approval in advance is required.
Please circle and initial one: - YES – I allow agency aides to handle my funds to provide tasks/services I need ____________.
- NO – I do not consent to agency aides using or having access to my funds ____________.
f) Termination of Agreement by Client
You have the right to change or terminate service at any time. If you change or suspend service with less than twenty-four hours’ notice, you may be subject to incurring charges for the service scheduled during that twenty four (24) hour period. Except in cases of emergency, all notices of change or notices terminating this agreement should be in writing. In the event of cancellation, clients will receive a full refund of all monies owed by the agency within 14 days.
g) Termination of Agreement by Ally Home Care LLC
We reserve the right to terminate this agreement for any cause upon three (3) days written notice (except in cases of emergency). Termination may, but will not necessarily be based upon one or more of the following conditions in our sole determination:
- You no longer require our services based upon your health or social needs.
- Your home is no longer adequate for safe and effective care.
- Our fees for services rendered have not been paid as required herein.
- You no longer live in the geographic area serviced by us.
- Our personnel and resources are no longer adequate, available and/or suitable to accommodate your needs.
- You and/or your family, representatives or caregivers fail to cooperate with us in any manner deemed necessary or prudent.
h) Governing Law
This agreement shall be governed by, and constructed in accordance with the laws of the State of Georgia, and will be litigated in that State or in the Federal Courts located within that State.
The department that regulates this agency is: Department of Community Health/Healthcare Facility regulation/Home Care Unit.
Main Office tele: (404)-657-5850 / (404)-657-5700
Address: 2 M.L. KING Jr Dr SE, 17th floor – East Tower – Atlanta, GA 30334
i) Transportation
Unity Care Home LLC’s insurance does not cover loss or damage caused by employees operating the client’s own or leased vehicle. The client accepts full responsibility for any and all claims. If an employee of the Agency transports a client in their own vehicle, or the client’s vehicle, the client will release the Agency and/or that employee from all liability should an injury or accident occur. Unless otherwise agreed upon in writing regarding transportation needs, caregivers do not transport clients in their vehicles. Driver’s license is not a pre-requirement for employment.
DO NOT allow caregivers to drive your vehicle without consent from Agency in writing. Medicaid clients have access to free transportation provided by Medicaid transportation brokers and caregivers can accompany clients to their appointments within their shift hours. If client is still in need of transportation using their own vehicle, written permission allowing the caregiver to drive the client’s vehicle along with proof of insurance is required prior to any transportation services.
j) Expenses
I agree to that, in addition to the Home Care rates, any necessary and reasonable out-of-pocket expenses incurred by Unity Care Home LLC or its employees will be reimbursed by me. For any transportation (such as errands, driving you to a physician’s appointment, etc.), provided on my behalf by a Unity Care Home LLC employee, I will pay an additional per mile charge of seventy-five cents $.75.
k) Supplies and Equipment
I am responsible for providing all necessary supplies needed for the execution of any kind of personal care and equipment which may be necessary in the provision of services. Unity Care Home LLC does not provide medical equipment or medical/cleaning/safety supplies.
l) Emergency
I understand that Unity Care Home LLC provides only non-medical assistance and that in the event of a medical emergency; the caregiver will call 911 for emergency medical assistance. I also acknowledge and understand that Unity Care Home caregivers are not allowed to administer medication unless licensed to do so in the state of Georgia. I absolve Unity Care Home LLC of any liability in the event of accidents or death.
INDEMNIFYING CLAUSE
The undersigned fully understands that the provider (a) is a non-medical provider, (b) is not licensed to perform medical services, and (c) the undersigned, indemnify, jointly, and severally hereby forever release, discharge, acquit, and forgive any and all claims, actions, suits, demands, liabilities, judgment, and proceedings both at law and in equity, arising from the beginning of time to the date of termination of this agreement with the Agency Provider, such are caused directly by the negligent acts or omissions by the above items and “Services” and the “agency caregivers” and which result in bodily injury or property damage. This release shall be binding upon and inure to benefit the parties, their successors, assigns and personal representatives.
m) Statement of your Rights and Responsibilities
I hereby acknowledge receipt of a Statement of my Rights and Responsibilities as a Home Care Client.How We Use Your Information
