Rate Agreement (Required) I agree to the rates for care as listed below.
Personal Care Services are provided by a caregiver. These services can include but are not limited to: medication reminders, companionship, light meal preparation, light house cleaning, hygiene care, dressing, bathing, assist with transfers/ambulation. Non-Skilled Nursing Assessment and Follow Ups $150 * Nursing Assessments are required by the state at least every 90 days.
- Hourly Care $35+/hour
- Live-In Care $350+/day
- Skilled Nursing Services are provided by a Registered Nurse or Licensed Practical Nurse. These services can include but are not limited to: medication management, wound care, central line care, OB/maternity needs, hospice/palliative care. Skilled Nursing Admission and Follow Ups $195*. *Nursing assessments are required by the state at least every 90 days.
-Skilled Nursing Hourly Care $75/hour
- Skilled Visits $195/Visit
Clients who are transported in a caregiver's vehicle or ask caregiver to do errands in the caregivers vehicle will be charged 75 cents per mile. Private Duty Personal Care Nurse Assessments (Required) I agree and understand this state mandated policy.
As a licensed home care organization, all clients receiving personal care services must be supervised by a Registered nurse. Nurse assessments are done at the initial assessment and every 30, 60 or 90 days. The fee for the non-skilled (personal care) nurse assessment is $150. The fee for the skilled (nursing care) nurse assessment is $195.
Is The Client In Need Of Any Home Modifications? ( Grab Bars, Kitchen & Bath Renovations, Stairlifts, Custom Ramps, etc.) (Required) Yes No
We have a construction engineer on our team who provides home modification management for clients who need these services. He works with contractors that provide excellent and complete services to our clients.
Client's Full Name (Required)
Client's Home Address
(Required) Email Address Of Client (Required) Is The Information (Name, Address, E-mail) Of The Client The Same As The Person Providing Payment For Services? (Required) Yes No Card Holder's Full Name (Required)
Card Holder's Home Address
(Required) Email Address Of Card Holder (Required) Card Holder's Relationship To Client (Required) Self Spouse Sibling Child Parent Friend Power Of Attorney (Not Family) Do You Have An Active Long Term Care Policy That You Would Like To Utilize To Pay For Services? (Required) No Yes
Medicare and commercial insurances do not pay or reimburse for hourly personal care services. Examples of Long Term Care Companies: Banker's Life, John Hancock, CNA etc. We will submit invoices and notes to the long term care insurance and to you. An administrative fee will be charged for additional claim submissions and documentation requests if you are not currently an active client.
What Method Of Payment Would You Like To Use? (Required) Click the link provided on the invoice I must enter my checking or savings routing and account numbers on the payment site. I acknowledge the site is secure and that I-CARE will not have access to my banking information. (ACH charges a flat $10 fee) Credit/Debit Card(5% convenience fee added)
To Begin Services, We Hold A Retainer/Deposit Equal to 2 Weeks Of Services. This Shall Be Charged Prior To The Start Of Service And Will Be Applied To The Final Invoice. If You Would Like To Use the ACH Option, We Still Require Credit Card Information To Charge The Retainer/Deposit & To Pay Any Unpaid Balances.
What Is The Type Of Credit Card You Would Like To Use? (Required) Visa Mastercard Discover Amex Holiday, Overtime & Cancelled Shift Policy (Required) I Agree And Understand I-CARE's Holiday, Overtime & Cancelled Shift Policy
Christmas Eve, Christmas Day, New Year’s Eve, New Year’s Day, Easter, Memorial Day, July 4th, Labor Day, & Thanksgiving Day. Time and a half shall be charged for all hours worked over 40 hours in a given Mon-Sun work week per caregiver. All hourly shifts that are cancelled/reduced within 48 hours of the scheduled shift are subject to a cancellation fee equal to the amount of the cancelled shift/hours. Shifts that are added within 48 hours of the shift will be charged at the overtime rate. A one week written cancellation notice is required to cancel service or the scheduled visits will be charged.
Consent (Required) I Consent To Personal Care Services And/Or Nursing Services From I-CARE, Inc. For The Client I Have Listed Above.
I agree to the rates listed above and hereby authorize I-CARE to charge my debit/check card a deposit equal to two weeks of service. The deposit shall be charged prior to the start of service and will be applied to the final invoice. Invoices are generated weekly. I-CARE will be reimbursed all credit card fees incurred due to the client's use of their credit card. The charges are approximately 3.5%. A late fee will be charged for invoices not paid within 48 hours after invoice has been provided. I agree not to solicit or hire any I-CARE employee for a period of 1 year post I-CARE identifying employee. I understand and agree to pay $25,000 damages to I-CARE, if I breach this agreement.
Electronic Signature (Required)
I am (Required) The patient receiving care The spouse of the patient receiving care. I have the legal power of attorney for the patient. The child of the patient receiving care. I have the legal power of attorney for the patient The power of attorney of the patient receiving care Electronic Signature (Required) I Accept
I agree my electronic signature is the legal equivalent of my manual signature on this Agreement.