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Client & Agency Service Agreement

Please review this agreement carefully, as it sets forth the understanding between (“Client”) and Compassionate Homecare of South Florida, LLC (“Agency”) regarding the services you have requested, and we will provide for you. If you have any questions, concerns or issues about the content of this Agreement please contact us for clarification before signing it.

THIS AGREEMENT made this day of (“Effective Date”) by and between Compassionate Homecare of South Florida, LLC and Name of Client and/ or Responsible Person

Street Address
City
State
Zip Code
Home Phone
Cell
Other
Emergency Contact Name
Relationship
Phone No

(“Client”) on the terms and conditions set out below:

Term of Agreement. The term of this agreement will start on the Effective Date, and will continue on an as-needed basis until the Agreement is terminated by either party, as provided hereunder.
Services Requested. We will provide the services (“Services”) requested and agreed upon as set out in the Service Plan enclosed. The preferred day, time and duration of services will be mutually agreed upon by you and/or your representative and the agency.
Cancellations may be made up to 4 hours in advance of a scheduled visit without charge. We reserve the right to charge for a 2 hour visit if insufficient notice is not given.
Either “Client” or “Agency” may terminate this agreement at any time, with a minimum of 14 days written notice to the other party. If either party terminates this Agreement, all fees due at time of termination will be due and payable by you immediately. We will immediately refund any prepaid fees. This item excludes emergency dismissal of services (theft, insufficient service delivery, Abuse).
Should either the Agency or Client wish to amend the Agreement:
Either an Agency Representative or the Client may initiate a meeting to determine the scope of the amendment and determine the sections of the Agreement that need to be modified, added or deleted.
When both parties consent to the amendments, the changes shall be recorded in writing.
If the Agreement requires extensive changes, an entirely new agreement shall be drawn up. Otherwise, small changes can be handled via a letter or a notation.
All parties who signed the original agreement shall sign the Amendment.
The Amendment shall be dated with a copy being given to the Client and a copy being filed in the Client’s records at the Agency’s office.
Relevant staff and other persons shall be advised about any change in the Agreement terms immediately.
Governing Law. The laws of the state of Florida and applicable federal and municipal regulations shall govern this Agreement, including, but not limited to:
Chapter 400. Part III, Florida Statutes and,
those specified in the Agency’s Policy and Procedure Manual, including:
Compliance & Accompanying Forms
Pre-employment Background Checks & Accompanying Form

Standards of Conduct & Work Ethics and Accompanying Form

Agency’s Responsibilities. Compassionate Homecare of South Florida, LLC’s responsibilities are outlined on the enclosed “Client and Agency Rights and Responsibilities” form
Client’s Responsibilities. Your responsibilities are outlined on the enclosed “Rights and Responsibilities” You will be required to sign it.
Transportation. If an employee of the Agency transports a client in their own, company vehicle or the client’s vehicle both client and employee must have liability insurance. The client will sign a transportation Waiver in which the client will release the Agency and/or that employee from all liability should an injury or accident occur.
Private/Direct Hiring. You may not privately/directly hire an Agency employee for a period of

90 days_ following the date that employee last provided services for you. In the event you break this condition, a replacement fee of _$500 or lose the start of service refund, whichever is highest is due to the Agency immediately upon your employment of that individual.

Background Checks

The Agency requires that all employees undergo a level 2 FBI criminal and other background checks as a condition of employment, in accordance with Agency’s Pre-employment Background Check Policy, Federal Department of Labor Regulations and State Laws.

Severe/Bad Weather. In severe weather, we may determine it is not safe for our Home Care Workers to travel and provide services to your home that day and may have to cancel that day’s

service. When this occurs we will notify you and reschedule. We appreciate your understanding regarding this matter.

Supplies and Equipment. You are responsible for supplying all supplies (i.e. cleaning, personal care etc.) and equipment which may be necessary in the provision of services. Extra charges will apply if the Agency provides the supplies and/or equipment.
General Information. You will be provided with a list of contact names and numbers in the event you have any questions or concerns or should an emergency arise.

Payment for Services. The accepted payments by CHSFL are a) private pay with debit/credit care b) direct deposit c) Longterm Care Insurance (401K, Annuities, etc which must be attached to a cash account with a credit or debit card available for payment of weekly invoices), or d) Workmen Compensation Insurance. An encrypted invoice link will be sent by email on Monday by 3:00 pm and the corresponding payment is due upon receipt of invoice no later than Wednesday noon for payroll on Friday. Click on the link for payment. Payments are received via Paypal. Major cards accepted. Immediate confirmation receipt of payment will be sent to email for your records. Rates may increase with 30 day written notice from Agency.

Payment and Overdue Accounts. Fees for services rendered are payable upon receipt of invoice. An account is considered overdue if not paid within 5 days of the billing date. Interest will be charged on account balances which remain unpaid for 6 days or more after the same becomes due at the rate of 5% per month (10% per annum), until paid. We reserve the right to discontinue providing services until the account is paid in full, including any additional charges and accrued interest. Client is responsible for all collection, court and attorney’s cost relating to the collection of this debt.

Your signature and/or your representative’s signature below indicate that you and/or your representative:

have been given sufficient, relative information to be able to give your informed consent to the terms and conditions of this agreement; and,
understand, and are in agreement with, the terms and conditions of this Agreement.

I CONSENT TO and ACCEPT the terms of this Service Agreement:

I DO NOT CONSENT to the terms of this Service Agreement for the following reason(s):

The consequences of not consenting to the Service Agreement have been explained to me.

Yes

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December 11, 2023 9:20 pm GMT

Client & Agency Service Agreement Uploaded by John Smith - smitch@chsfl.co IP 202.47.33.79