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Experience Compassion and Quality with I-CARE Home Health Services Since 1993

At I-CARE, we bring over 30 years of expertise in health care to provide top-notch, family-focused nursing and personal care in the comfort of your home. Our team of over 60 dedicated caregivers understands the importance of supporting you through health challenges with sensitivity and respect. We are committed to not just offering care, but hope and guidance on your path to recovery and well-being. Each client receives a tailor-made In-Home Care Plan, meticulously overseen by our skilled nurses (RNs) from the initial assessment to ongoing follow-ups. Our promise is to nurture relationships with professionalism and consistent quality care. Choose I-CARE for a trusted partner in your home, where we treat every age and every story with the utmost care and attention it deserves

Consent For Care

Patient/ Client Name(Required)

First Last

Name Of Person Completing Form (If not patient)

First Last

Consent To Receive Services(Required)

I hereby authorize I-CARE, Inc. ® to render appropriate homecare services to the patient/client named above. I understand an appropriate level of homecare personnel will provide such care. I recognize and agree that I have the right to refuse treatment at anytime. I also recognize and agree that I can terminate services by notifying I-CARE via email to info@icareinc.com with 14 days notice.

Authorization Of Emergency Services(Required)

At any time while receiving services from I-CARE, Inc. and in the event of any medical emergency, I authorize I-CARE, Inc. or its employees/contractors to provide or obtain such medical treatment as they deem advisable under the circumstances, and I agree to assume sole responsibility for all charges for such treatment.

Statement of Patient Right & Responsibilities & Notice of Privacy Practices & Privacy Right(Required)

I certify that I have read, received a copy and understand the Statement of Patient Rights and Responsibilities that has been explained to me orally by a representative of I-CARE, Inc. I acknowledge that I have received a copy of the I-CARE, Inc. Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by I-CARE, Inc. and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. I hereby consent and request that copies, if necessary, of my prior medical records be delivered to I-CARE, Inc. to establish or continue my home care plan.

Statement of Patient Right & Responsibilities & Notice of Privacy Practices & Privacy Right(Required)

Patient Rights On Advance Directive

I certify that I/the client(Required)

Consent(Required)

I authorize I-CARE, Inc. to receive a copy of any of the above documents. The documents can be sent via email to info@icareinc.com. I certify that I have been instructed about, received a copy of, and understand the patient Rights on Advance Directives which was explained to me orally by a representative of I-CARE, Inc.

Service Options

Choose the type of services you would like to utilize:(Required)

Personal Care Assistance (4-24hrs/day 5-7 days per week)

Home Modification Management (To enhance safety of home -Grab bars, ramps, stair lift, bathroom renovation etc.)

Home Care Advocacy (Help navigate hospital-home, assisted living, to transition care and services

Health Care Coaching (Guidance & instruction in meal selection, Choice and Preparation etc.)

Patient/Client Signature

This form must be signed by the I-CARE, Inc. patient/client unless the patient/client is a minor, incompetent, or physically incapable of signing. I have read and fully understand the content of this Consent Form and hereby agree to and authorize the foregoing provisions. As used in this document, the terms “I’, “me” and “my” refer to and include, in addition to the undersigned, the patient/client named above and others for whom the undersigned is responsible or for whom the undersigned has assumed responsibility in engaging I-CARE, Inc. to provide services to the patient/client.

Date(Required)

Patient/ Client Electronic Signature or Signature Of Authorized Representative(Required)

First Last

Electronic signatures are legally valid and hold the same weight as handwritten signatures

Relationship of Authorized Representative To Patient