You are on page 1of 5

ON CALL ELDER CARE SERVICE AGREEMENT

The On Call Elder Care service is a caregiver service provided by only one caregiver, Albert L., pictured above with Anna M., Client (and Mother) on an 85th birthday outing. Mr. Ls interest in providing a caregiver service, qualifications and experience stem initially from the in-home care of both his wifes parents, his father (with Alzheimers) and mother. Companionship, a sensitive but practical approach to need fulfillment, problems solution, affairs management and service with loving kindness were the natural substance and effect of these relationships and experience and, now, the mission and hallmark of Mr. Ls caregiver service for elderly clients: men, women and couples.

THIS AGREEMENT is a legal contract between Caregiver known as ___________________________, of __________________________________________________________________________ (address), whose telephone number is _________________________________________________________; and (circle one) Client or Guardian/Attorney-In-Fact known as ___________________________________. Clients name(s) ______________________________________________________________________. Clients address ______________________________________________________________________. Clients phone _______________________________________________________________________. The address of Guardian, Attorney-in-Fact, or legal entity acting on behalf of Client is: ____________________________________________________________________________________, whose telephone number is ____________________________________________________________. THIS AGREEMENT is made and entered into as of the _______ day of _________________, _______, the effective date, and shall terminate at midnight twelve months after, subject to a written notice of termination given by one party to the other and delivered by mail or eMail. Upon the absence of such notice, this Agreement shall be deemed automatically renewed for successive additional twelve month periods, year to year, until such notice is given. Either party may terminate this Agreement as of any specified date upon three days written notice of such election to the other party. Upon termination compensation due is to be paid to the Caregiver through the completion of authorized work in process up to the effective date of termination.
1 of 5

PRICE INCLUDED COMPANIONSHIP SERVICES (1) Guardian rest and relief. Caregiver services for Guardian respite and/or personal time of any kind: days off, vacation time, night out, Holidays, family time, shopping, personal time, etc. (2) Companionship and conversation (3) Driving, errands and shopping (4) The monitoring of diet and assistance with and/or preparation of meals and assistance with eating (5) Check food expirations (6) Assist with evening bedtime preparation and tuck-in (7) Aid with morning wake-up and rising (8) Arrange appointments (9) Provide medication reminders (10) Position, lift and assist with mobility and ambulation when needed (11) Assist in the use of bedpans, urinals or chair commode when needed (12) Assist in activities of daily living such as oral and personal hygiene including brushing of teeth, bathing, and/or assisting in showering, skin care, nail care, etc. (13) Assist with clothing selection and dressing (14) Write letters and correspondence (15) Organize mail (16) Stimulate mental awareness (17) Assist with entertainment (18) Answer the door (19) Care for pets and houseplants (20) Pickup prescriptions and medical supplies (21) Accompany the Client to Doctors appointments and other appointments that require the assistance of a companion and/or caregiver (22) Change and wash soiled linen to maintain a clean and orderly environment (23) Perform light housekeeping tasks such as laundry, ironing, dishes for Clients use only, the making of beds, the organization of closets, trash removal, etc. (24) Assist with reading and/or read books, magazines, the newspaper, etc. and discuss current events (25) Participate in crafts (26) Play games and cards (27) Supervise home maintenance (28) Oversee home deliveries (29) Prepare grocery lists and/or shop for groceries and supplies as needed (30) Monitor TV usage (31) Mail bills and letters (32) Buy magazines, papers and books (33) Rent and play movies (34) Plan visits, outings and trips (35) Visit neighbors and friends (36) Escort to religious services, read religious materials, watch religious shows (37) Attend club meetings and sporting events (38) Aid with airport tasks (39) Accompany to lunch or dinner (40) Pick up prescriptions, drop off and pickup dry cleaning (41) Maintain calendar (42) Perform a variety of non-complex care treatments (43) Report of changes in Clients condition to a family member or Doctor (44) Keep records as requested by Client or Guardian. NON CAREGIVER SERVICES / Caregiver will not (1) Administer insulin shots, morphine or any other injections to the Client (2) Perform any major cleaning task such as mopping floors, cleaning refrigerators, etc. (3) Do any plumbing, gardening, painting, electrical repair or trouble shooting, install electrical or electronic equipment or do jobs of a similar nature (4) Do any heavy lifting such as the moving of furniture and other actions that require heavy lifting (5) Perform any financial transaction on behalf of the Client such as paying bills or bank transactions such as withdrawals and deposits or other similar transactions (6) Handle Clients cash on hand other than petty cash for groceries and supplies provided Caregiver by Client or Guardian. CAREGIVER IS NOT A LICENSED NURSE / The law does not allow caregivers to administer any medications, including oral medications. All medications must be pre-measured and/or pre-poured by the Client, a Licensed Nurse or Family Member. The caregivers duty is simply to monitor and remind the Client of the time for each medication and assist the Client to take his or her medication as ordered by a Physician. CAREGIVER ADHERES TO THE NATIONAL ASSOCIATION OF PROFESSIONAL GERIATRIC CARE MANAGERS CODE OF ETHICS Provision of Service / I will provide ongoing service to you only after I have assessed your needs and you, or a person designated to act for you, understand and agree to a plan of service, the results that may be expected from it, and the cost of service.
2 of 5

Self-Determination / I will base my plan of service on goals you, or a person designated to act for you, have defined, and which enhance the decisions you have made concerning your life. Loyalty / My first duty is loyalty to you. I will always provide services based on your best interest, even if this conflicts with my interests or the interests of others. Termination of Service / I will end service to you only after reasonable notice. I will recommend a plan for you to continue to receive the services as needed. Substitute Judgment / I will not substitute my judgment for yours unless I am acting in the role of your guardian, appointed by a Court of Law, or with your approval, or the approval of someone designated to act for you. Confidentiality / I will hold in trust any confidence you give me, disclosing information to others only with your permission, or if I am compelled to do so by a belief that you will be seriously harmed by my silence, or if the laws of this State require me to do so. Referrals/Disclosure / I will refer you only to services and organizations I believe to be appropriate and of good quality. I will fully explain to you any business relationship I have with any service I propose, and give you information on alternatives, if at all possible, so that you, or a person designated to act for you, can make an informed decision to accept or reject the services I recommend to you. Cooperation / I will strive to ensure cooperation between all of the individuals involved in providing service and care to you. Qualification / I am fully qualified in my profession to provide the services I undertake. I continue to improve my skills and knowledge by participating in professional development programs and maintaining certification and licensing in my profession. Discrimination / I will not promote or sanction any form of discrimination. COMPENSATION / Compensation shall be paid to Caregiver as follows: Live-Out Care / The Client agrees to pay Caregiver at the rate of $25 per hour, minimum three hour shifts, plus one hour drive time at the same rate for each shift. Shifts exceeding three hours to be paid at the same rate for every portion of an hour exceeding the initial three hour shift up to eight hours. Exception / Twelve hour shifts scheduled in advance are billed at the flat rate of $250.00. Live-In Care / The Client agrees to pay Caregiver for live-in companion care at the rate of $300 per day. Caregiver will be on duty 24 hours, but should be expected to have at least eight hours of sleep time - interruptible - during any 24 hour shift as well as some personal time during each shift for grooming, rest and meals. The Client agrees that this is a modified Room and Board arrangement, that Client is to provide a clean, private room for Caregiver respite as well as proper stocks of food for meals for both Caregiver and Client on a comprehensive basis. Petty cash may be provided Caregiver to fulfill these and other needs. Couples / Couples or Co-Client care may be subject to a twenty-five to fifty-percent surcharge based on the needs of each of the Co-Clients determined and agreed upon in advance of service. Holiday Pay / Holiday pay for each of the following New Years Eve, New Years Day, Presidents Day, Easter Sunday, Memorial Day, The Fourth of July, Labor Day, Thanksgiving, Christmas Eve, Christmas Day are charged at time and a half. Mileage / Mileage for transporting the Client or for Client errands is billed at the standard mileage rate for business established by the IRS: adjusted down to $0.50 (50 cents) per mile. Terms of Payment / Cash or other payment method determined in advance and deemed acceptable by Caregiver at the end of each shift.
3 of 5

AUTOMOBILE INSURANCE / Should Caregiver provide transportation for Client in Caregivers vehicle, Caregiver shall maintain at Caregivers expense liability and uninsured motorist insurance with policy limits of at least $100,000 for bodily injury, $300,000 per incident maximum, and $50,000 property damage. Caregiver agrees to maintain such insurance at all times during the term of this agreement. Should Caregiver provide transportation for Client in Clients vehicle to appointments, errands, shopping and/or for social purposes, Client is responsible for maintaining appropriate liability and uninsured motorist insurance with policy limits of at least $100,000 for bodily injury, $300,000 per incident maximum, and $50,000 property damage. Client agrees to maintain such insurance at all times during the term of this agreement. CAREGIVER IN-HOME LIABILITY INSURANCE / Many insurance companies have specific Homeowners or Renters insurance policy riders that can be added to cover in-home caregiver service for a nominal cost. It is recommended that Client, a Family Member, or Guardian establish such a Homeowners or Renters insurance policy (or rider) for in-home caregiver services and provide Caregiver with a copy of said policy or rider. INDEMNITY / Caregiver agrees to indemnify and hold harmless Client of and from any and all claims, demands, losses, causes of action, damage, lawsuits, judgments, including attorneys' fees and costs, but only to the extent caused by, arising out of, or relating to the work of Caregiver. In no event shall the maximum liability hereunder exceed the amount actually paid to Caregiver under this Agreement. INDEPENDENT CONTRACTOR RELATIONSHIP (1) Client and Caregiver intend that, to the maximum extent permissible by law, this agreement does not constitute a hiring or employment agreement by either party (2) Client and Caregiver are independent contracting parties with respect to all obligations and services rendered under this agreement (3) Caregiver retains sole and absolute discretion and judgment in the methods, techniques, and procedures to be used in carrying out Caregivers activities, except as required by law or required of proper Client care as instructed by Client and/or Guardian (4) Caregiver shall not be treated as an employee with respect to services performed for state and federal tax purposes. EMERGENCY CONTACT INFORMATION Primary Contact /

Attorney-In-Fact/Guardian /

Physicians /

Local Emergency/Paramedic Services /

4 of 5

OTHER PROVISIONS / INSTRUCTIONS

GENERAL TERMS / This Agreement shall be interpreted, governed and enforced in accordance with the laws of the State of California and any dispute hereunder shall be subject to the jurisdiction of _____________________________________ County, California. This Agreement sets forth the entire agreement and understanding of the parties hereto and supersedes all other arrangements and understandings. In the event of a dispute, the prevailing party shall be awarded all attorneys fees and costs, including expert fees, at trial and on appeal. No waiver of any breach of any provision of this Agreement shall constitute a waiver of any subsequent breach of the same or any other provision. If any particular part of this Agreement should be determined by any court of competent jurisdiction to be invalid, unenforceable or otherwise illegal, such part shall be deemed severed from this Agreement and the remaining clauses and parts hereof shall remain in ful force and effect. CLIENTS CONTRACTING PARTY X
Printed Name

CAREGIVER X
Printed Name

Address

Address

Phones, eMail, etc.

Phones, eMail, etc.

5 of 5