Service Agreement Form for Home Care

Service Agreement for Home Care Services

Document ID: TR-HCS-001 Effective Date: [//2026]

---

Instructions for Use

• This form is to be completed by the Provider's authorized representative and the Client or their authorized legal representative prior to the commencement of services.
• Retain the original signed agreement in the Client's file for a minimum of seven (7) years following the termination of services. A copy must be provided to the Client.
• Mandatory attachments include: Care Plan, Client Bill of Rights, Emergency Contact Information Form, and any applicable financial disclosures or rate sheets.

---

Section 1: Parties to the Agreement

This Service Agreement ("Agreement") is made and entered into by and between:

A. Client Information:

• Client Name: [__________]
• Client Address: [__________]
• City, State, Zip: [__________]
• Phone Number: [__________]
• Email Address: [__________]
• Date of Birth: [____/____/____]
• Primary Language: [__________]

B. Client Representative (if applicable):

• Representative Name: [__________]
• Relationship to Client: [__________]
• Phone Number: [__________]
• Email Address: [__________]
• Legal Authority (e.g., POA): [__________] (Attach copy of legal document)

C. Home Care Provider Information:

• Provider Name: [__________]
• Provider Address: [__________]
• City, State, Zip: [__________]
• Phone Number: [__________]
• Email Address: [__________]
• License/Certification No. (if applicable): [__________]

---

Section 2: Scope of Services

The Provider agrees to furnish non-medical home care services to the Client as detailed in the attached "Individualized Care Plan" (referred to as the "Care Plan"), which is incorporated into this Agreement by reference. The Care Plan outlines the specific services, frequency, and duration tailored to the Client's needs.

A. Service Start Date: [____/____/2026] B. Estimated Service End Date (if applicable): [____/____/20____] C. General Service Categories (as per Care Plan):

• [ ] Personal Care (e.g., bathing, dressing, grooming)
• [ ] Companionship
• [ ] Light Housekeeping
• [ ] Meal Preparation and Nutrition
• [ ] Medication Reminders (not administration)
• [ ] Errands & Transportation (specify: [__________])
• [ ] Respite Care
• [ ] Other (specify): [__________]

D. Modifications to Services: Any changes to the services provided must be agreed upon in writing by both parties and documented in an updated Care Plan or an amendment to this Agreement.

---

Section 3: Service Schedule and Location

A. Primary Service Location: Services will be primarily rendered at the Client's residence located at: [__________]

B. Agreed Schedule (detailed in Care Plan):

• Typical Days of Service: [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun
• Typical Hours of Service: From [____:____] to [____:____]
• Total Weekly Hours (approx.): [__________] hours

C. Emergency Contact Information: The Client's emergency contact information is provided in the attached "Emergency Contact Information Form." The Provider will use this information in case of an emergency involving the Client or the caregiver.

---

Section 4: Fees and Payment Terms

A. Service Rates: The following rates apply for services rendered:

• Minimum Shift Duration: [__________] hours
• Travel Surcharge (if applicable): [__________] per [ ] hour / [ ] mile

B. Billing Cycle: Invoices will be issued [ ] Weekly / [ ] Bi-Weekly / [ ] Monthly on [__________] (day of week/date).

C. Payment Due Date: Payment for services rendered is due within [__________] days from the invoice date.

D. Accepted Payment Methods: [ ] Check / [ ] Credit Card / [ ] Bank Transfer / [ ] Other: [__________]

E. Late Payment Policy: A late fee of [__________]% per month (or [__________] whichever is less) may be applied to overdue balances. Services may be suspended or terminated if payment is not received within [__________] days of the due date, following written notice to the Client.

F. Cancellation Policy:

• To avoid charges, the Client must notify the Provider of a cancellation at least [__________] hours in advance of the scheduled service time.
• Cancellations made with less than [__________] hours notice may be charged for a minimum of [__________] hours of service.

---

Section 5: Term and Termination

A. Agreement Term: This Agreement commences on the Effective Date stated above and shall continue until [____/____/20____] unless terminated earlier in accordance with this Section. This Agreement will automatically renew for successive [__________] periods unless either party provides written notice of non-renewal at least [__________] days prior to the end of the then-current term.

B. Termination by Either Party: Either the Client or the Provider may terminate this Agreement for any reason by providing [__________] days' written notice to the other party.

C. Immediate Termination by Provider: The Provider may terminate this Agreement immediately upon written notice to the Client under the following circumstances:

• Non-payment of fees after due notice.
• Creation of an unsafe working environment for caregivers.
• Client's significant breach of this Agreement or non-compliance with the Care Plan.
• Caregiver safety concerns or threats.
• Unresolved infectious disease risk.

D. Immediate Termination by Client: The Client may terminate this Agreement immediately upon written notice to the Provider under the following circumstances:

• Provider's significant breach of this Agreement.
• Failure to provide agreed-upon services or adequate care.
• Any act of negligence or abuse by Provider staff.

---

Section 6: Client Responsibilities

The Client or their Representative agrees to:

• Provide a safe, clean, and accessible environment for the provision of services.
• Communicate any changes in the Client's health, schedule, or care needs promptly to the Provider.
• Make timely payments for services rendered as per Section 4.
• Cooperate with the Care Plan and the directives of the caregivers.
• Provide all necessary supplies and equipment for care (e.g., toiletries, mobility aids) unless otherwise agreed in writing.
• Treat caregivers with respect and dignity.

---

Section 7: Provider Responsibilities

The Provider agrees to:

• Employ qualified and competent personnel to deliver services.
• Ensure caregivers adhere to the Care Plan.
• Maintain the confidentiality of Client information in accordance with Section 8.
• Implement emergency procedures as outlined in Section 9.
• Supervise caregivers and address performance issues.
• Provide a Client Bill of Rights, outlining the Client's rights and responsibilities.

---

Section 8: Confidentiality and HIPAA Compliance

The Provider acknowledges its obligation to maintain the confidentiality of all Client information, including Protected Health Information (PHI), in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and all other applicable federal and state privacy laws. Client information will not be disclosed to any third party without the Client's or Representative's written consent, except as required by law or for payment and healthcare operations purposes.

---

Section 9: Emergency Procedures

In the event of an emergency involving the Client, the Provider's caregiver will:

1. Assess the situation and ensure the Client's immediate safety.
2. Provide appropriate first aid or immediate care within their scope of practice.
3. Contact emergency services (e.g., 911) if necessary.
4. Immediately notify the Client's designated emergency contacts and the Provider's supervisory staff as per the attached "Emergency Contact Information Form."

A detailed "Emergency Preparedness Plan" is integrated into the Care Plan.

---

Section 10: Insurance and Liability

A. Provider's Insurance: The Provider maintains professional liability and general liability insurance coverage for its operations and employees. Upon request, evidence of coverage can be provided.

B. Client's Property: The Provider is not responsible for loss or damage to Client's property unless such loss or damage is caused by the negligence or willful misconduct of the Provider or its employees while on duty.

C. Limitation of Liability: The Provider shall not be liable for any indirect, incidental, special, or consequential damages arising from the provision of services hereunder, except in cases of gross negligence or willful misconduct.

---

Section 11: Complaint Resolution

Any complaints or grievances regarding services or caregivers should be directed to [__________] at [__________] (phone) or [__________] (email). The Provider commits to investigating and addressing all complaints promptly and fairly, in accordance with its internal complaint resolution policy.

---

Section 12: Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of [__________], without regard to its conflict of laws principles.

---

Section 13: Amendments

Any modification, amendment, or waiver of any provision of this Agreement must be in writing and signed by both the Client (or Representative) and an authorized representative of the Provider.

---

Section 14: Entire Agreement

This Agreement, together with the attached Care Plan, Client Bill of Rights, and Emergency Contact Information Form, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior agreements, understandings, negotiations, and discussions, whether oral or written, between the parties.

---

Section 15: Client Rights and Responsibilities

The Client acknowledges receipt and understanding of the "Client Bill of Rights," which outlines their rights and responsibilities as a recipient of home care services. This document is attached hereto and incorporated by reference.

---

Execution and Signature Block

By signing below, the Client (or their authorized representative) and the Provider acknowledge that they have read, understood, and agree to the terms and conditions set forth in this Service Agreement.

FOR THE CLIENT / CLIENT REPRESENTATIVE:

_______________________________________ Authorized Signature

[__________] Printed Name

[__________] Title (e.g., Client, Power of Attorney)

Date: [//2026]

---

FOR THE HOME CARE PROVIDER:

_______________________________________ Authorized Signature

[__________] Printed Name

[__________] Title

Date: [//2026]

---

Disclaimer: This document is provided as a standardized framework. Consult qualified legal counsel for jurisdiction-specific statutory compliance.