I, accept full responsibility for payment of services rendered by Assurance Home & Convalescent Care, Inc. (AHCC). 

I understand that my rate is established at 

per hour and requires a 

I understand that I will be billed 

per mile for any errands/transportation provided by the caregiver in the

I understand that I will be given 30 days written notice of any rate changes not specified in this document. 

I understand that the services I receive are provided by Assurance Home & Convalescent Care, Inc. (AHCC). All aides that provide home care services to clients are employees of AHCC. All aides have undergone criminal background checks, nurse aide abuse registry checks, substance abuse testing and TB testing. All aides have been trained by AHCC and evaluated for performance competency. Aides are covered by AHCC for payroll taxes and worker’s compensation. Assurance Home & Convalescent Care, Inc. is bonded and insured.

HOURS OF OPERATION 

Business hours are Monday through Friday 8:00 am until 5:00 pm.

Business phone # is 502-479-1906.

After hours emergency phone calls accepted by AHCC at 502-479-1906 or 502-386-4682.

Michelle Deneen is the Director of Client Care Services and Agency Manager for Assurance Home & Convalescent Care, Inc. She can be reached at 502-479-1906.

Anne Cooper Day is the Owner/Director of Assurance Home & Convalescent Care, Inc. She can be reached at either 502-479-1906 or 502-386-4682.

PAYMENT

I understand that invoices will be issued on a weekly basis and that payment of invoices is due upon receipt. If I fail to pay, or an insurer fails to pay, any amounts due after fifteen (15) days from invoice due date, AHCC has the right to discontinue services and/or will charge interest on the remaining balance at 1.5% per month until payment is made in full, starting with the date of service.  

ASSIGNMENT OF INSURANCE BENEFITS 

AHCC will accept assignment of benefits from 

(name of long term care

OVERTIME 

I understand that AHCC will bill the client or responsible party at time and one-half of the regular hourly rate when any aide works over 40 (forty) hours in a week for said client. 

Holidays 

I understand that I will be billed at time and one-half of my regular hourly rate on the following holidays: ​New Year’s Eve from 6:00 pm on, New Year’s Day, Derby Eve from 6:00 pm on, Martin Luther King,  Derby Day, Easter Sunday, Mother’s Day, Father’s Day,  Memorial Day, Fourth of July, Labor Day, Thanksgiving, Christmas Eve from 6:00 pm on, and Christmas Day. ​I understand and acknowledge full responsibility for payment to AHCC for services rendered on all applicable holidays at time and one-half the regular hourly rate. I understand that if I do not want services provided to me on any of the above mentioned holidays, it is my responsibility to notify AHCC at least 24 hours in advance of the cancellation. (See Cancellation Policy) If I fail to give AHCC the required 24 hour cancellation notice, I understand that I will be billed for the entire shift scheduled at time and one-half rate of the regular hourly rate. 

CANCELLATION POLICY 

I understand that AHCC has a 24 hour cancellation policy. I agree to pay the hourly rate for the entire shift should I fail to give the AHCC office 24 hours notice of the cancellation of a shift. 

To cancel service during regular business hours: 

1. Call AHCC at 502-479-1906

2. Report cancellation

SCHEDULE CHANGES 

I understand that schedule changes should be made as far in advance as possible and should be done during regular business hours, unless it is an emergency. 

To make a change in your schedule during regular business hours: 

1. Call AHCC at 502-479-1906

2. Request your change

To make emergency changes during non-business hours (after 5:00 pm M-F and all day Sat. and Sun.): 

1. Call AHCC at 502-479-1906

2. Leave a message identifying your name. Request your change.

3. Someone from AHCC will return your call to confirm your change and reschedule service.

AHCC staff will notify you, or your designee, in advance, by phone, when a change needs to be made to your schedule. 

TERMINATION OF SERVICES 

I understand that I must notify AHCC by phone (502-479-1906) or in writing to terminate my service plan. I understand that termination of service must be made 24 hours in advance of the next scheduled service date.

In the event of termination of services, the client and responsible party agree that for a period of twelve (12) months after termination of the services of AHCC, the client and responsible party will not: 

1. Engage or employ any person who was or is an employee of AHCC for home care services or any matter related hereto.

2. Advise past or present employees of AHCC to curtail or cease their business association with AHCC.

3. Disclose to any other person or company the names of past or present employees of AHCC.

4. Influence any other person or company to terminate their care and/or agreement with AHCC.

VIOLATION OF THE AGREEMENT 

Should a client or responsible party violate this agreement, AHCC shall be entitled to recover damages of $500.00 per day for each violation, it being stipulated herein that the actual loss is difficult to calculate with precision and the sum of  $500.00 per day for each violation is a reasonable estimate of damages and not a penalty.  In the event client or responsible party ends the contract with AHCC due to hiring an employee of AHCC the minimum penalty will be  $15,000. 

LIABILITY 

Assurance Home & Convalescent Care, Inc. is bonded and insured. In the event an employee of AHCC is convicted of theft from a client, AHCC’s liability shall be limited to the reasonable fair market value of the item(s) stolen. AHCC shall not be liable for any theft or missing property unless the client or responsible party prosecutes the employee/aide to the fullest extent of the law and unless the employee/aide is convicted in a court of law for such violation.

GRIEVANCE PROCEDURE 

I understand that I may file a grievance by calling the AHCC office at 502-479-1906. AHCC will investigate a grievance made by a client or a client’s designated representative alleging: 

1. An issue with a service that is furnished

2. Failure to furnish a service listed in the Service Plan

3. Failure to provide thirty (30) days advance notice of an increase in the amount AHCC charges for its services

4. Inappropriate conduct of an employee while the individual is providing services to the client

5. A violation of the client’s rights (see below)

 I understand I will be informed of the outcome of the investigation and any action AHCC plans to take as a result. 

CLIENT’S RIGHTS 

I understand that as a client of Assurance Home & Convalescent Care, Inc. I have a right to: 

1. Have my property treated with respect

2. Request a change in my Service Plan, including temporary suspension, permanent termination, temporary addition, or permanent addition of service.

3. File a grievance regarding services, employee conduct, or the lack of respect for property and not be subject to discrimination or reprisal for filing the grievance.

4. Be free from verbal, physical, and psychological abuse and to be treated with dignity.

SEVERABILITY/AMENDMENT/LAW 

In the event any portion of this agreement is declared invalid by a court of law, the court is empowered to limit the contract to the maximum enforceable at law. Any modification of this agreement must be in writing and signed by the parties hereto. This agreement is to be construed under the laws of the Commonwealth of Kentucky and all litigation arising there from shall be in the Jefferson Circuit or District Court, otherwise having jurisdiction.