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Service Agreement - Matrix Home Health Care

Service Agreement We hereby order and authorize Matrix Home Care to furnish the following services to: Patient/Client Name: ...

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Text of Service Agreement - Matrix Home Health Care

Service AgreementWe hereby order and authorize Matrix Home Care to furnish the following services to:Patient/Client Name:___________________________________ ________________________________________ _________________________Source of Payment: Private Insurance Worker s Compensation Other_____________Type of Service(circle)RateNURSE / AIDE / PT / OT / ST $/Visit $Co-pay/Visit N/CNURSE / AIDE / PT / OT / ST $/Visit $Co-pay/Visit N/CNURSE / AIDE / PT / OT / ST $/Visit $Co-pay/Visit N/CRN / LPN / AIDE $/Hour wd $ /Hour we N/CRN / LPN / AIDE $/Hour wd $ /Hour we N/CRN / LPN / AIDE $/Hour wd $ /Hour we N/COTHER ____________________ $ ________________________________________ _____ N/CWithout releasing the above-named patient from liability for the charges for such services, each of us herebyguarantees and agrees to pay all Matrix Home Care charges for the services and rates described above, plusovertime where applicable, including any increase or decrease in such rates after ten (10) days notice to the Clientof such changes. Holidays and authorized overtime will be charged at time and one-half. Client and Guarantor agreeto pay all invoices, UPON RECEIPT, and understand the unpaid accounts will be considered in default after thirty(30) days, after which a default charge will be imposed at 1-1/2% per month on unpaid balances (ANNUALPERCENTAGE RATE OF 18%) or the maximum legal interest rate, whichever is lower. Client and Guarantor agreeto pay the default charge including reasonable attorney s fees and all costs of the event any portion of the charges for service is to be submitted as an insurance claim, Client and Guarantorassume full responsibility of charges for services rendered by Matrix Home Home Care acts solely as an agent for the Client in filing for insurance or other benefits assigned to , Matrix Home Care assume no responsibility for assuring that benefits so assigned will be paid. Client saccount will be credited only when Matrix Home Care actually receives TO OBTAIN CONSUMER CREDIT INFORMATIONIn connection with service provided by Matrix Home Care, we agree to pay for services, and hereby give ourconsent to Matrix Home Care to obtain public record information from any consumer-reporting agency. Thisinformation may be obtained prior to, during, or after the provision of services and will be used to determine ourability to pay for services provided. We understand that we are not applying for credit nor will Matrix Home Caredeny us the opportunity to purchase services as a sign on the lines provided for Client and Guarantor, respectively, date and return to Matrix Home Care. Aself- addressed, stamped envelope is enclosed for your : a four(4) hour notice of cancellation is required to avoid a minimum charge (minimum charge is equivalent tofour (4) times the above hourly rate or one (1) times the visit :_______________________________________ ________________________________________ Client or Authorized Representative (please sign)Date:______________________________ ________________________________________ _________Guarantor (please sign)Witness: ______________________________________08 0309White - Clinical File Yellow - Patient CopyMatrix Service Agreement 1 8/27/09 3:36 PM Page 1

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