Client Service Plan Form (Non-Medical)

Levels of Cases
 
CASE 1
This is for clients who usually live independently but need some basic assistance in daily living activities, such as assistance with eating, bathing, bathroom care, walking, medication reminders, personal hygiene, companionship, light housekeeping, meal planning & preparation, shopping, and transportation to doctors’ appointments. For live- in cases, the caregiver will be available to assist the client during 24 hours period. However, the caregiver must be provided with a private area in which he or she has at least 7 hours of interrupted sleep per night.

CASE 2
This includes all of the duties listed in CASE 1 in addition to partial lifting of wheelchair bound recipients, use of specific adaptive equipment, and bladder/bowel care. For live-in cases, the caregiver will be available to assist the client during 24 hours period. However, the caregiver must be provided with a private area in which he or she has at least 7 hours of interrupted sleep per night.

CASE 3
This includes all of the duties listed in CASE 1 and CASE 2 in addition to specialized care for patients with Dementia, Alzheimer’s, Parkinson’s disease, Cancer, Multiple Sclerosis, and chronic or other critical illnesses. Those recovering from surgery will also be considered under this case. For CASE 3, one caregiver will not be allowed to work for a 24-hour period. Multiple caregivers (2 or 3) will be assigned, depending on the needs of the client.

CASE 4
This includes all of the duties listed under CASES 1, 2, and 3 in addition to total bed care for clients who are completely immobile. For case 4, one caregiver will not be allowed to work for a 24-hour period. Multiple caregivers (2 or 3) will be assigned, depending on the needs of the client..
 
PAYMENT OF SERVICES POLICY
 
Payment of services. Affordable Home Care Services, Inc. will bill its clients every two weeks. It is expected that payment is received in a timely manner. Payment for services may be arranged as follows:
 
Direct Payment: AHCS, will collect two weeks in the advance of the projected charges of the services. Payments will be automatically deducted from specified checking or savings account through Direct Payment Plan Collection. Proof of payment will appear on your statement that you receive from AHCS. If amount of charges changes we will credit the balance to your account during the next billing period or if the services is cancel we will refund your payment within seven days after the termination of services. Return or decline collection will assessed a late fee charged of $35.00. All rates will be subject to a 2% annual increase in order to supplement for increases in the cost of items including, but not limited to, employees salaries, transportation, and equipment costs.

Note: Depending on the insurance that you carry, it is possible that your health insurance or long term insurance may pay for some or all of the services you receive. It is your responsibility to contact your insurance company to determine if they will provide payment for these services. In this case, you will be responsible for pay Affordable Home Care Services, Inc. directly, and your insurance would have to reimburse you for the payment.

img-stop
PLEASE READ BEFORE YOU COMPLETE THE FORM ATTACHED.

 
Personal Needs and Activities:
In order for us to provide you with the best possible services, it is very important for us know about your personal needs, activities, and your expectations for the services you will be receiving. When completing the attached form, please be as detailed as possible. We will use this form to help you determine how many hours per week of care are needed, but it is up to you to identify your personal needs and expectations. Also consider the following issues:

1. When and how often do you need a caregiver? Is it likely to change soon? If so, will it be a problem? Provide us this information under the Special Instructions space.

2. What duties and responsibilities would you like the caregiver to perform and how often? List out the duties and frequency (e.g., light housekeeping weekly, driving to doctor’s appointment as needed, aiding with bathing every morning, etc.). The client Service Plan Form should be filled out completely and must be as detailed as possible. The information you provide in the Care Plan will be the basis for the care you or your loved one will receive from the caregiver.

3. Do you need any specialized care, such as for Alzheimer’s, dementia, chronic illness, cancer, hospice care, or special care such as AIDS or HIV? These must be specified in detail. Please provide this information under Current Condition being treated for and provide us detailed instructions of care under the Special Instructions space in the Client Service Plan Form.

Religion, Cultural Awareness, and Sensitivity:
If comfortable doing so, please provide us with information about any cultural habits or traditions, religious practices, preferred clothing etiquette, food preferences, or any other sensitive areas. This will help us to better serve your needs by ensuring that the caregiver understands and is aware of your expectations. It will also help us find the best possible caregiver to provide your services.

Pet Care and Smoking:
Please inform us if you have pets that are in need of care. Also, we need to know if you or anyone else living in the home smokes inside the home. This is important because we need to be sure that the caregiver is not allergic to pets and is not sensitive to cigarette smoke.

Likes and Traits:
We want our clients to feel comfortable with and get along well with the caregiver. Are there any personality traits or special concerns that would be beneficial or detrimental for a caregiver to have in this relationship? Please make your concerns known to us.

Valid XHTML 1.0 Transitional
Valid CSS!