"Long Term Care Personal Support Services Agreement Form" - Maine

This "Long Term Care Personal Support Services Agreement Form" is a document issued by the Maine Department of Health and Human Services specifically for Maine residents with its latest version released on December 16, 2011.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Maine Department of Health and Human Services.

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Download "Long Term Care Personal Support Services Agreement Form" - Maine

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LONG TERM CARE PERSONAL SUPPORT SERVICES AGREEMENT
This Agreement is made by and between the following parties:
______________________________________and _______________________________ on
ELDER/ADULT WITH DISABILITIES
CAREGIVER
______________________.
DATE
Term of Agreement
This Agreement shall commence on______________________, and may be
Date
terminated by either party on reasonable notice to the other party.
Purpose
The purpose of this Agreement is to set forth the terms and conditions under
which CAREGIVER will assist ELDER/ADULT WITH DISABILITES with
instrumental activities of daily living and/or activities of daily living in order for
ELDER/ADULT WITH DISABILITIES to continue to live at home and prevent
the ELDER/ADULT WITH DISABILITIES from moving to a residential or
nursing care facility.
Services to be Performed
CAREGIVER will provide care to ELDER/ADULT WITH DISABILITIES in
_____________________________________________________________________________
Specify location, i.e. Home of the ELDER/ADULT WITH DISABILITIES/CAREGIVER’S own home/OTHER
Services to be provided by CAREGIVER will include, but shall not necessarily
be limited to:
Check all that apply and provide detailed information about the services to be
performed to meet the specific needs of the Elder/Adult with Disabilities.
1.
Transportation and errands:
a.
Driving ELDER/ADULT WITH DISABILITIES to medical,
___
dental, adult day care and other appointments and activities;
1
December 16, 2011
Department of Health and Human Services
Office for Family Independence
LONG TERM CARE PERSONAL SUPPORT SERVICES AGREEMENT
This Agreement is made by and between the following parties:
______________________________________and _______________________________ on
ELDER/ADULT WITH DISABILITIES
CAREGIVER
______________________.
DATE
Term of Agreement
This Agreement shall commence on______________________, and may be
Date
terminated by either party on reasonable notice to the other party.
Purpose
The purpose of this Agreement is to set forth the terms and conditions under
which CAREGIVER will assist ELDER/ADULT WITH DISABILITES with
instrumental activities of daily living and/or activities of daily living in order for
ELDER/ADULT WITH DISABILITIES to continue to live at home and prevent
the ELDER/ADULT WITH DISABILITIES from moving to a residential or
nursing care facility.
Services to be Performed
CAREGIVER will provide care to ELDER/ADULT WITH DISABILITIES in
_____________________________________________________________________________
Specify location, i.e. Home of the ELDER/ADULT WITH DISABILITIES/CAREGIVER’S own home/OTHER
Services to be provided by CAREGIVER will include, but shall not necessarily
be limited to:
Check all that apply and provide detailed information about the services to be
performed to meet the specific needs of the Elder/Adult with Disabilities.
1.
Transportation and errands:
a.
Driving ELDER/ADULT WITH DISABILITIES to medical,
___
dental, adult day care and other appointments and activities;
1
December 16, 2011
Department of Health and Human Services
Office for Family Independence
b.
Shopping for groceries and other items needed by
___
ELDER/ADULT WITH DISABILITIES, and filling/refilling
prescriptions;
c.
Running other errands for ELDER/ADULT WITH
___
DISABILITIES.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2.
Meals: Preparing ______ meals per day and daily snacks for
ELDER/ADULT WITH DISABILITIES.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3.
Housework:
a. ___ Cleaning ELDER ’s/ADULT WITH DISABILITIES’ living area.
b. ___ Laundry and changing linens
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4.
Financial: Paying ELDER’s/ADULT WITH DISABILITIES’ bills,
balancing Elder’s/Adult with Disabilities’ checkbook, making
deposits, dealing with health insurance, other paperwork.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5.
Administration of medication.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2
December 16, 2011
Department of Health and Human Services
Office for Family Independence
6.
Assistance with the following activities of daily living: transferring
from bed, chair and toilet; ambulation; bathing, hygiene/ grooming;
toileting; eating.
OR
Cueing ELDER/ADULT WITH DISABILITIES as to when to dress, eat,
get up, go to bed and attend scheduled appointments.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7.
Monitoring the ELDER/ADULT WITH DISABILITIES for safety,
including responding to alarm system to control wandering/ fall risk.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8.
Monitoring the ELDER/ADULT WITH DISABILITIES health, and
bringing health problems to attention of health care providers.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
9.
OTHER:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________
Schedule
CAREGIVER will provide services on the following schedule:
______________________________________________________________________________
______________________________________________________________________________
3
December 16, 2011
Department of Health and Human Services
Office for Family Independence
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Compensation
1. ELDER shall pay CAREGIVER $______ per HOUR/ DAY/ MONTH.
Circle One
2. TO BE USED IF ELDER LIVES IN CAREGIVER’S HOME: In addition,
ELDER/ADULT WITH DISABILITIES shall pay CAREGIVER $______ per
month for room and board (which consists of a proportional share of
mortgage, taxes, insurance, heat, electricity, water, sewer and groceries).
3. ELDER/ADULT WITH DISABILITIES shall reimburse CAREGIVER for all
out of pocket expenses borne by CAREGIVER in connection with
CAREGIVER’S work. Such expenses shall include mileage at the rate of
$_____ cents per mile.
ON BEHALF OF ELDER/ADULT WITH
DISABILITIES:
__________________________________
Date
[To be signed by Elder/Adult with
Disabilities or by a legal representative for
Elder/Adult with Disabilities such as
agent under POA, guardian or
conservator]
CAREGIVER:
_________________________________
Date
4
December 16, 2011
Department of Health and Human Services
Office for Family Independence
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