Additional Same-Day 
Services

The services to be provided to me by the agency have been explained to me. I understand that by signing this agreement, I authorize provision of procedures and/or services to me by Caregiver USA. I understand that my cares are under the direction of my physician and that the agency is not liable for any act or omission when following the instructions of said physician. I also understand a new contract will be negotiated if there is a change in insurance or other 3rd party payer, or a change in the plan for services.

Promotional pricing ends at 11:59AM on December 31, 2020 or 12 months after your initial contract for services begin.

I hereby authorize any holder of medical information (hospital, nursing home, physician's office or other health facility) about me to release to the agency any records pertinent to my medical history, services rendered, or treatment.

I consent to the release of my agency records to be reviewed by authorized representatives of Medicare, Medicaid, insurance, and/or any 3rd party payer for use in determining my home health benefits. I understand that I have the legal right to refuse the release of my personal and medical records now held by the agency and that I am waiving this legal right by signing this consent. This consent shall be valid for whatever period of time is reasonably necessary for the individual/agency requesting to review my clinical records to fulfill the above described purpose(s), or until I revoke this consent in writing. Such a revocation of this consent will have a prospective effect only. I further authorize the agency, Ohio Department of Health and other licensing bodies to periodically examine my records for the purpose of checking compliance to regulations and requirements. The HIPAA Notice of Privacy Practices has been given and explained to me. Contact information related to reporting privacy concerns has been given and explained to me.

I authorize direct payment to the agency of any Medicare, Medicaid or other 3rd party benefits otherwise payable to me, for agency-provided products or services. I also authorize any 3rd party payer to furnish to an agent of CaregiverUSA agency any and all information pertaining to any benefits and status of claims submitted by our agency for services rendered. I further authorize the agency to release any and all information pertaining to me for benefit determination.

I have read the service agreement outlining my financial responsibilities. I understand and agree to abide by this agreement. I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit. In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided. If I am uninsured, I agree to pay for the all services rendered to me upon invoicing due date.

I understand that supplies dispensed to me may not be returned to the agency for credit.

I have had the opportunity to participate in the plan of care/service. I understand that the plan of care may change and that such changes will be discussed with me. Instructions for care will be explained to me and will become my responsibility in the absence of a home care staff member in my home.

I understand that a 24 hour notice for any appointment change or cancellation must be provided to CaregiverUSA, if not I will incur a service charge that is equal to 100% of the reserved service duration and amount for that missed, changed or cancelled appointment.

I understand that I shall be subject to late penalty fees of 10% per month from the due date until the amount is paid.