Senior & Elder Care
Elder Care Services Agreement
Agreement for elder care and home health aide services covering care plan, schedule, duties, and emergency procedures. Two signers (caregiver and family_member).
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# Elder Care Services Agreement **Effective Date:** ___________ This Elder Care Services Agreement ("Agreement") is entered into by and between: **Caregiver/Care Provider:** ___________ ("Caregiver") **Family Representative:** ___________ ("Family Member") acting on behalf of the care recipient: **Care Recipient:** ___________ ("Recipient") ## 1. Care Recipient Information **Date of Birth:** ___________ **Address:** ___________ **Primary Physician:** ___________ **Physician Phone:** ___________ **Known Medical Conditions:** ___________ **Allergies:** ___________ **Current Medications:** ___________ **Mobility Status:** ___________ **Cognitive Status:** ___________ ## 2. Scope of Services The Caregiver agrees to provide the following services: **Care Level:** ___________
Fields (41)
effective date
date · required
caregiver name
text · required
family member name
text · required
care recipient name
text · required
recipient dob
date · required
recipient address
textarea · required
primary physician
text · required
physician phone
text · required
medical conditions
textarea · required
allergies
textarea
medications
textarea · required
mobility status
select · required
cognitive status
select · required
care level
select · required
services
textarea · required
excluded services
textarea
care schedule
select · required
specific hours
textarea · required
overnight
select · required
term
select · required
compensation
text · required
compensation basis
select · required
overtime
select · required
holiday pay
select · required
payment frequency
select · required
payment method
select · required
emergency contact 1
text · required
emergency phone 1
text · required
emergency contact 2
text
emergency phone 2
text
medical consent
select · required
medication management
select · required
transportation
select · required
mileage rate
text
background check
select · required
certifications
select · required
termination notice
select · required
governing state
select · required
caregiver signer name
text · required
family member signer name
text · required
relationship
text · required
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