I hereby consent to receive services from Bluelake Homecare. I understand that services will be provided according to the plan of care developed in collaboration with me, my family (as appropriate), my physician (if applicable), and Bluelake Homecare staff.
Agency Information
Agency Legal Name: Bluelake Homecare Phone: (313) 546-0363 | Website: bluelakehomecare.comAgency Administrator: Asher Klugman, DirectorDirect Contact for Questions/Concerns: (313) 546-0363 | Email: asher@bluelakehhc.com
Acknowledgement of Services and Fees:
I have been notified that the services to be provided are as follows:
Service
| Frequency
| Hourly Fee
| Expected Insurance Coverage
| Client's Financial Responsibility
|
|
|
|
|
|
Duration of Contract
Services are ongoing until terminated in accordance with the termination provisions set forth herein.
Modification and Termination
The terms under which this agreement may be modified, amended, or terminated are outlined in the Admission Packet provided to each client and incorporated herein by reference.
Complaint Process
Clients have the right to file complaints without fear of reprisal. Complaints about non-medical, private-pay services should first be directed to Bluelake Homecare using the contact information above. Complaints may also be filed with the Michigan Department of Attorney General, Consumer Protection Division (877-765-8388, michigan.gov/ag). Concerns involving abuse, neglect, or exploitation may be reported to Michigan Adult Protective Services (855-444-3911, available 24 hours a day, 7 days a week).
Employer ResponsibilityBluelake Homecare is the employer of all in-home workers. The agency, not the client, is fully responsible for the workers it assigns. This includes liability for the worker, payment of wages, employment taxes, unemployment insurance, workers’ compensation, and Social Security contributions. Bluelake Homecare also maintains responsibility for day-to-day assignment of duties, as well as hiring, training, disciplining, and, when necessary, terminating staff.
Authorization of Release of Information
I hereby authorize and consent to release and receive information for the purpose of treatments, payment, and daily operations. I consent to the release of all information and/or disclosure to BLUELAKE HOMECARE of: (1) all or any parts of my medical records by my physician, hospital, or other facility of which I have been a patient/patient; (2) review of my clinical records and other information related to services by government or licensing surveyors, third party auditors, financial and clinical auditors retained by BLUELAKE HOMECARE or other accrediting body surveyors, and (3) information about me in the possession of individuals acting in official capacities as my advocate, as representatives of governmental or third-party payers, or other health care providers involved in my care.
Authorization for Payment:
I understand that this is a private pay agreement, and I am responsible for all charges billed by Bluelake Homecare. If I maintain Long-Term Care (LTC) insurance and request the Agency’s assistance with documentation or claims, I authorize Bluelake Homecare to furnish information as necessary to my insurance company(ies) for benefit determination. I further authorize direct payment of any benefits otherwise payable to me, to be made directly to Bluelake Homecare. I remain financially responsible for all charges not covered or reimbursed by my insurance company.
Financial Responsibility:
PAYMENT TERMS (PRIVATE PAY): Invoices are rendered weekly and payable upon receipt. Acceptable forms of payment include credit card, debit card, ACH/bank draft, or check. Balances not paid within 30 days will accrue interest at 1.5% per month. If account balances exceed $2,000 or remain unpaid beyond 21 days, services may be suspended until payment is received. Client is responsible for all collection costs, including attorney fees.
HOLIDAY CHARGES: Services rendered on the following holidays will be billed at one and one-half times (1.5x) the regular hourly rate: New Year’s Day, Easter, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, Christmas Day, and New Year’s Eve.
SCHEDULE CHANGES & CANCELLATIONS: Client must notify the Agency at least 24 hours in advance for any cancellation or change in schedule. If notice is not provided and the caregiver arrives at the client’s home, a minimum of 2 hours (up to 4 hours, depending on the scheduled shift) will be billed.
CLIENT RESPONSIBILITIES: Client is responsible for providing necessary personal care and cleaning supplies. Client agrees not to pay caregivers directly, not to provide confidential financial information, and not to employ caregivers directly. If a client hires or contracts directly with any Agency caregiver during or within 12 months following services, Client agrees to pay a recruitment/training fee of $5,000 to the Agency.
INSURANCE / THIRD PARTY PAYERS: Agency will not seek reimbursement or payment for private pay services from Medicare, Medicaid, or any third-party payor. Clients seeking reimbursement from Long Term Care (LTC) insurance may request supporting documentation; however, the Client remains fully financially responsible for all charges billed by the Agency.
I understand and agree, that I am solely responsible for informing BLUELAKE HOMECARE of all health/medical insurance coverage and benefits for which I have paid or for which I am eligible, and providing BLUELAKE HOMECARE with all information that it may require to secure payment of its charges for services, including without limitation, any change in my coverage benefits or provider; all amounts charged by BLUELAKE HOMECARE, for the services requested above, that are not paid for by any of my insurance providers, including without limitation any deductible, co-payment, surplus, late charge, or costs of collection.
Emergency Preparedness Plan and/or Service Interruption:
I understand that BLUELAKE HOMECARE uses its best efforts to provide uninterrupted services; however, sometimes interruptions are unavoidable.
During any interruption of service, I understand that it would be prudent and in my best interests to establish a Home Emergency Plan in the event of an emergency such as a fire, hurricane, severe snowstorm, or other natural disaster. I agree to provide or arrange for back-up care, or BLUELAKE HOMECARE will assist in arranging for transfer to an appropriate emergency facility.
Service Modification:
Either the client (or authorized representative) or the Agency may end services at any time with written notice. The Agency will make reasonable efforts to provide referrals or assist with continuity of care if services are ended. Services may be discontinued immediately if the client’s needs exceed the scope of the Agency’s license or if staff safety is at risk.
If the client is unable to sign:
