All supplies and equipment are
to be provided by the client.
Individualized Service Plan
Name of Care Recipient: DOB: Sex: Phone Number of CR:
Physicians Name and Phone Number: Start of Care Date:
Address of CR: CR Soc. Sec. #:
Driving Directions to CR Home:
Name of Responsible Party: Phone Number of RP:
Initial Health Assessment: RP Email
Pertinent Medical History:
Mon Tue Wed Thur Fri Sat Sun
_______ _______ _______ _______ _______ _______ ______
Services Provided: Skills Requested:
_____ Laundry _____ Transferring _________________
_____ Make Bed _____ Personal Hygiene _________________
_____ Personal Care _____ Meal Preparation _________________
_____ Cleaning _____ Errands _________________
_____ Bathing _____ Shopping _________________
Coordination of Care (Name and phone number(s) of agencies that apply):
Frequency of Supervision:
Monthly Quarterly Semi – Annually Annually
Referred By: Rate: $
Client or Responsible Party Signature: Agency Representative Signature: Date:
CLIENT SERVICES AGREEMENT
AGREEMENT made on the ___ day of ________, 200___ between
(the “Care Recipient”), located at _________________ (the ''Service Address'') and
VISITING ANGELS LIVING ASSISTANCE SERVICES (''Visiting Angels'').
The Care Recipient desires to engage the services of Visiting Angels, as an
independent contractor and not as an employee, to assist in the provision of non-medical
"companion" home care services on the terms and conditions provided in this Agreement.
Visiting Angels is properly licensed to provide non-medical "companion" home care
services in the State of Texas. Visiting Angels desires to render such services for the Care
Recipient on the terms and conditions provided in this Agreement.
THEREFORE, the Care Recipient engages the services of Visiting Angels. In
consideration of the mutual promises contained in this Agreement, the parties agree as
This Agreement is effective as of above date. It will continue in effect until the Care
Recipient no longer needs Visiting Angels services, or until it has been terminated as
provided in Section 6 of this Agreement.
(A) The services to be rendered by Visiting Angels to the Care Recipient consist of
the referral of a non-medical home caregiver, who is an employee of Visiting Angels (the
“Caregiver Employee”), to the Care Recipient for provision of non-medical "companion"
home care on a schedule of days and hours which will be predetermined by Agreement
between the Care Recipient and Visiting Angels in advance of each week of service. In
the event that the Care Recipient does not contact Visiting Angels to change the
predetermined weekly schedule in advance of any week, Visiting Angels will assume that
the predetermined weekly schedule is the same as it was for the most recent preceding
week of service. Visiting Angels will exert every reasonable effort to adhere to the
predetermined weekly schedule. Visiting Angels will make reasonable effort to provide a
“back up” Caregiver Employee (as defined herein) if the scheduled caregiver does not
arrive. Additionally, Visiting Angels can be available to the Care Recipient “after hours”
or on an “on call” basis during their scheduled hours. Furthermore, Visiting Angels
administrative staff may be contacted for emergency care/scheduling issues outside of
normal, 8am-5pm, business hours at: Temple 254-899-9400 or Waco 254-772-8660.
(B) As part of the companion home care, the Caregiver Employee shall provide light
housekeeping services to the Care Recipient, defined as: (i) tidying up of rooms in which
the Care Recipient spends his/her time (bedroom, living room, and kitchen), (ii) washing
dishes after meals, (iii) wiping spills on sink or floor, (iv) mopping, (v) sweeping kitchen
floor when needed, (vi) passing the vacuum in rooms used by Care Recipient, (vii)
tidying bathrooms after use by Care Recipient, and (viii) rinsing tub or shower after use.
The Caregiver Employee is not required to perform the following tasks, which are
considered heavy housekeeping duties and are outside the scope of the services to be
provided under this Agreement: (i) scrubbing floors in kitchen and bathrooms, (ii)
window or mirror washing, (iii) dusting behind & under furniture, (iv) drape cleaning and
(v) heavy laundry. Should the Care Recipient desire that such services be performed,
then it will be necessary to arrange for that separately.
(C) From time to time, other services appropriate to the role of non-medical home
caregiver may be added by agreement between Visiting Angels and the Care Recipient.
A Care Recipient’s vehicle is not to be driven by the Caregiver Employee without
prior written authorization from Visiting Angels. Visiting Angel’s insurance does not
cover loss or damage caused by employees operating the Care Recipient's owned or
leased vehicle. The Care Recipient accepts full responsibility for any and all claims. If
the Caregiver Employee drives his/her own vehicle in order to perform services to Care
Recipient, the Care Recipient will be billed at $0.75 per mile. Other expenses incurred in
rendering services to the Care Recipient shall be added to the regular service bill,
provided that no expense greater than $20 shall be incurred without authorization from
the Care Recipient or the Responsible Party, as appropriate.
All services to be performed under this Agreement shall be performed at the Service
Address, unless otherwise agreed upon by the Care Recipient and Visiting Angels. Any
equipment required for the provision of such services will be provided by the Care
5. Fee and Accurate Billing Policy
(A) For services to be rendered under this Agreement, Visiting Angels will be
entitled to be paid at a rate of $ _________________. In addition, Visiting Angels is
entitled to reimbursement for expenses incurred under the terms of Section 3 of this
Agreement. Those expenses are payable on presentation of a statement of their amount to
the Care Recipient. If the Care Recipient requires additional services not included in this
Agreement, the fee for the services must be negotiated and paid separately. If the Care
Recipient desires services to be rendered on any of the following days: New Year’s Day,
Easter Sunday, Memorial Day, The Fourth of July, Labor Day, Thanksgiving, Christmas
Eve, and Christmas Day (collectively a “Holiday”), then the rate charged shall be as set
forth above multiplied by a factor of 1.5.
(B) Visiting Angels will provide accurate (monthly/weekly) billing of all services
rendered. Each invoice will be due and payable in full upon receipt. In the event that the
Care Recipient wishes to reduce the number of hours and/or days to be worked by the
Caregiver Employee on the predetermined schedule for a given week, the Care Recipient
must contact Visiting Angels at least 24 hours in advance of any day for which the Care
Recipient wishes to reduce the schedule. In the event that the Care Recipient reduces the
schedule without contacting Visiting Angels at least 24 hours in advance, the Care
Recipient will be billed for the full amount of the predetermined weekly schedule. In the
event that a referred caregiver fails to arrive at the Care Recipient’s home and/or the
home of the care recipient or alters the predetermined weekly schedule in some way,
Visiting Angels will adjust the amount that the Care Recipient is billed accordingly.
(C) If a party other than the Care Recipient is arranging for the provision of services
hereunder, then such person (the “Responsible Party”) agrees to pay for all charges
incurred under this Agreement including services which may not be reimbursed by
insurance, furthermore, the Responsible Party shall be a party to the Agreement and shall
have read, understood, and agreed to the terms of this Agreement.
The first week of service will be a trial week, and the Care Recipient may terminate
Visiting Angels services for any reason with no requirement of advance notice on the
Care Recipient’s part. Visiting Angels may also terminate its services to the Care
Recipient at any time upon notice to the Care Recipient. Subsequent to the first week,
this Agreement would remain in effect for the term set forth in Section 1, above, or until
Visiting Angels gives the Care Recipient seven (7) days written notice of termination or
until the Care Recipient provides twenty-four (24) hours written notice of termination to
7. Insurance, Release and Non-Solicitation Agreement
The Care Recipient hereby releases Visiting Angels from responsibility for any
events that may be harmful to the Care Recipient in the course of receiving services from
the referred Caregiver Employee, other than harm resulting from the negligence of such
Caregiver Employee. The Care Recipient agrees to maintain homeowner’s insurance,
medical insurance and/or other coverage as may be necessary to provide protection for
the Care Recipient. The overriding business relationship would be strictly between the
Care Recipient and Visiting Angels and, by agreeing to this proposal, the Care Recipient
is confirming to Visiting Angels that the Care Recipient will abstain from making or
accepting any offers whereby any of the caregivers/employees Visiting Angels has
referred to the Care Recipient would provide services other than as set forth herein
or as sanctioned by Visiting Angels, whether the Care Recipient still has an ongoing
relationship with Visiting Angels or not. If the Care Recipient chooses to hire one of
the Visiting Angels employees privately, the Care Recipient agrees that this action will
cause harm to Visiting Angels and that reasonable compensation for that harm shall be a
$5,000 non-refundable referral fee.
If there is a complaint that the Care Recipient has about the service of Visiting Angels
the Care Recipient may call and file a complaint. This complaint will be documented in
Visiting Angels complaint log, and an investigation will be conducted within 10 calendar
days of the filing, and resolved within 30 calendar days. Otherwise, the Care Recipient
can file a complaint with the Texas Department of Human Services at P.O. Box 149030,
Austin, TX 78714-9030 or call them at (800) 458-9858. Visiting Angels will report all
instances of abuse, neglect, or exploitation, to The Texas Department of Human Services.
9. HIPAA Release
Effective immediately, the Care Recipient authorizes Visiting Angels to release any
of the Care Recipient’s individually identifiable health information and other medical
records as may be in Visiting Angels possession to any doctor, physician, medical specialist,
psychiatrist, chiropractor, health-care professional, dentist, optician, health plan, hospital,
hospice, clinic, laboratory, pharmacy, pathologist, or other provider of medical or mental
health care as necessary. This Release authority applies to any information governed by the
Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 USC 1320d
and 45 CFR 160-164.
10. Entire Agreement
This Agreement constitutes the sole and only Agreement of the parties and supersedes
any prior understandings or written or oral Agreements between the parties respecting
this subject matter. The ancillary documents attached to this Agreement as Exhibits “A”.
“B”, and “C” are deemed to be a part of this Agreement and are incorporated herein by
Neither this Agreement nor any duties or obligations may be assigned by Visiting
Angels without the prior written consent of the Care Recipient. In the event of an
assignment by Visiting Angels to which the Care Recipient has consented, the assignee or
the assignee’s legal representative must agree in writing with the Care Recipient to
personally assume, perform, and be bound by all the provisions of this Agreement.
12. Successors and Assigns
Subject to the provisions regarding assignment, this Agreement is binding on and
inures to the benefit of the parties to it and their respective heirs, executors,
administrators, legal representatives, successors, and assigns.
13. Attorney's Fees
If any action at law or in equity is brought to enforce or interpret the provisions of
this Agreement, the prevailing party is entitled to reasonable attorney's fees in addition to
any other relief to which they may be entitled.
14. Governing Law
This Agreement, and the rights and duties of the parties under it, are governed by the
laws of the State of Texas.
This Agreement may be amended by the mutual Agreement of the parties to it, in a
writing to be attached to and incorporated in this Agreement.
16. Legal Construction
In the event that any one or more of the provisions contained in this Agreement is for
any reason be held to be invalid, illegal, or unenforceable in any respect, that invalidity,
illegality, or unenforceability will not affect any other provisions, and the Agreement will
be construed as if the invalid, illegal, or unenforceable provision had never been
contained in it.
Executed at _________________, Texas, on the date first written above.
Signature of Care Recipient Date
Signature of Responsible Party for Payment Date
Other than Care Recipient
Visiting Angels Representative and Title Date
Our Non-Medical Home Care Division is designed to supplement the services of the
primary care giver(s) with respect to companionship and help for the elderly, or for
anyone else who is afflicted with one or more faculty impairments. We provide assistance
to you and the extended family in your routine daily needs or those of your loved one(s).
We are not a medical organization. We do not administer medication or provide any
service defined as medical by our state. The medical or professional qualifications of any
of our representatives or referred caregivers who will provide you with assistance are
strictly incidental to their activities as our referees and/or representatives. We make no
recommendations or instructions concerning diagnosis, prognosis, treatment, medication,
dosage, or prescriptions or other medical or health related services. At your direction, we
may remind the person left in our care to take his or her medication prescribed by others,
and per schedules left for that person by you. We desire to provide the best companion
and home management services. That is where our expertise ends.
Further, we are not licensed dietitians or chefs. At your directions, we shall cook meals
on site or do whatever preparatory work you feel is necessary in our capacity as a
homemaker, companion or helper. Again, it is up to you and the extended family to
provide primary instructions concerning this service.
Please note that the individual(s) you may ask us to refer caregivers for may have their
mobility or other faculties severely impaired. We rely on you to instruct us to all
limitations in this regard. We urge you, if you have not already consulted competent
medical personnel, to do so before instructing us to act. We shall take all necessary
precautions to operate within the guidelines you establish for us.
Our relationship is based on mutual good faith. You are representing to us that you have
the requisite knowledge and authority to instruct us as to the needs of the care recipient.
We shall make our continuing best efforts to meet those needs.
Most of our care recipients are elderly and increasingly susceptible to illness and injury.
We cannot prevent these things and can only put forth our best efforts to provide the
assistance and companionship that can make life more comfortable and fulfilling for the
care recipient, as well as for you and the extended family.
In good faith, you, individually, on behalf of the family and the care recipient, release
Visiting Angels from responsibility for any and all injuries and illnesses, whether or not
due to errors or omissions of Visiting Angels or its representatives that may regrettably
come to the care recipient. You agree to maintain homeowner’s insurance, medical
insurance and/or other coverage as many as necessary to provide protection for the care
We also strongly recommend and you hereby agree to keep any/all cash, jewelry and
other valuables in a secure locked place such as a safe. In addition you agree to maintain
insurance coverage for any such items under a homeowner's insurance policy.
It is against Visiting Angels policy for any employee of Visiting Angels to use controlled
substances. Therefore, Visiting Angels reserves the rights to ramdomly test its
employees for these substances at any time.
In the case that Visiting Angels is no longer able to maintain its day-to-day operations
and care for clients, the management of Visiting Angels will follow the following
Management will notify the DHS, caregivers, and clients 60 days in advance of ceasing
its operations. Visiting Angels will notify each client and caregiver of no less than three
other organization they could use to receive the type of care they are currently receiving.
Visiting Angels will also inform the organizations whose names are given to the clients
and caregivers that Visiting Angels will be ceasing its operations, and that their names
have been given to our employees and clients.
Finally, Visiting Angels will work with the clients to select a new organization, and
coordinate the transfer of client files to the selected organization.
In case of a natural disaster or fire at a client’s home all Visiting Angels employees are
instructed to remove the client(s) from harm immediately. Visiting Angel’s caregivers
are not to leave the client(s) until a member of the Visiting Angels office staff or a family
member of the client has come to relieve the caregiver. All Visiting Angel’s caregivers
also have directions to immediately call 911, family members of the client, and Visiting
Angel’s office in case of a natural disaster or fire in a client’s home.
In the event of a natural disaster Management will conduct a phone census of all clients.
Clients that are unaccounted for or may be in danger will be immediately reported to the
police department and or EMS as appropriate. Visiting Angels will also make every
reasonable effort to contact the family members of each of these clients.
Visiting Angels also has a systematic method of color coordination for all clients that
organizes clients by severity of disability. Each color has a specific action that should be
performed in case of a disaster.
Finally, we are not an emergency care service. In emergencies, the only thing our
referred caregivers can do is call 911 or Hospice; following which, make every
reasonable effort to contact you or the designated person in charge or next of kin.
This disclosure is incorporated by reference into other agreements Visiting Angels may
have with the care recipient(s) or their families or next of kin or guardian, when such
agreements are in effect. When we do not enter into an agreement, or when an agreement
is awaiting the outcome of a preliminary trial period, this disclosure, filled and signed by
you, in and of itself stipulates that you have been carefully and methodically informed as
to our limitations. Please make sure that it is a well informed decision that you make
when requesting our homecare services.
Client Conduct and Responsibility and Client Rights
The client has the right to be informed in advance about the care to be furnished, the plan of care,
expected outcomes, barriers to treatment, and any changes in the care to be furnished. The client has
the right to participate in the planning of the care or treatment and in planning changes in the
care or treatment.
The client has the right to refuse care and services.
The client has the right to be informed, before care is initiated, of the extent to which payment may be
expected from the client, third-party payers, and any other source of funding known to the agency.
A client has the right to have assistance in understanding and exercising his or her rights.
The client has the right to have his or her person and property treated with consideration, respect, and
full recognition of his or her individuality and personal needs.
The client has the right to confidential treatment of his or her personal and medical records.
The client has the right to voice grievances regarding treatment or care that is or fails to be furnished,
or regarding the lack of respect for property by anyone who is furnishing services on behalf of the
agency and must not be subjected to discrimination or reprisal for doing so.
Reporting of Abuse, Neglect, and Exploitation
All suspected cases of adult abuse, neglect, or exploitation must be documented and reported as
required by state law. Reports, reviews, and investigations of suspected abuse, neglect, or exploitation
are held in the strictest confidence. Client rights and confidentiality will be maintained. Visiting
Angel’s caregivers will cooperate fully with those assigned to investigate reports of abuse, neglect, or
Each client or responsible party shall be provided a written copy of Visiting Angels’ policy on
reporting abuse, neglect, and exploitation. The client or representative shall acknowledge receipt of
this policy by signature. The signature acknowledging receipt of this policy shall be filed in the
client’s file. A copy of this policy will be left with the client.
Individuals are mandated to report suspected abuse, neglect, or exploitation if there is:
1. Any knowledge of client abuse, neglect or exploitation or client self-abuse or neglect.
2. Reasonable causes to suspect client abuse, neglect, or exploitation of self-abuse or neglect.
3. Client injury not reasonably explained by client’s history of injuries.
The Visiting Angels employee/caregivers reporting suspected abuse, neglect or exploitation must bring the
concern of suspected abuse, neglect, or exploitation to the Visiting Angels office Director/Manager.
The Director/Administrative Assistant will review the report of abuse, neglect and notify both Texas
Department of Human Services and the Department of Family and Protective Services of the suspected
abuse, neglect or exploitation.
Department of Family and Protective Services Department of Human Services
(800) 252-5400 (800) 458-9858
Client Information Advance Directives – DNR Policy
To our clients: In accordance with the Licensing Standards for Home and Community
Support Services Agencies regulation (97.283), we are providing you with our agency’s
policy for Advance Directives-DNR.
Visiting Angels will comply with the Health & Safety Chapter 166- Advance Directives
Statute thus constituting the following policy honoring all Out-of-Hospital DNR orders.
The following shall constitute the protocol that will be taken:
OOH DNR Form Copy: An OOH DNR Form Copy must be given to a Visiting Angels
representative at the time of assessment or at the time the agreement is signed.
DNR Bracelet/Necklace: Visiting Angels will acknowledge an approved DNR ID
necklace or bracelet for identification for the Visiting Angels caregiver. Visiting Angels
will require that a copy of the OOH DNR Form copy be given to Visiting Angels for the
Visiting Angels will not use CPR and other life-sustaining techniques. However, Visiting
Angels will always call 911 or Hospice, asking them to respond-notifying them that the
client has an OOH DNR in place. When 911 or Hospice arrives at the home of the client,
the Visiting Angels caregiver will present the copy of the OOH DNR or identify to them
that the client is wearing an approved DNR ID necklace or bracelet.
The desire of a competent person, including a competent minor, will supersede the effect
of an out-of-hospital DNR order executed or issued by or on behalf of the person when
the desire is communicated to Visiting Angels staff as provided in 166.086
CLIENT AUTOMOBILE RELEASE OF LIABILITY
At my own discretion I will provide my automobile for the caregiver to drive to take me
to various appointments, shopping errands etc. as part of the services that I will receive
from the caregiver.
I agree that I have the primary responsibility for my automobile insurance. I agree to
release the Visiting Angels agency from responsibility for any accident in which there is
damage to my automobile or injury to its occupants.
Insurance Company Telephone
Policy # Expiration Date
Client Signature Coverage Verified Date
Acknowledgment of receipt of Disclosure, Client Service
Agreement Including Reportable Conduct (abuse, neglect, and
exploitation), Client Conduct and Responsibility and Client
Rights, Rights of the Elderly, and Advance Directives
Please print the name of the Responsible party:
Name of Care Recipient(s):
Your relationship to the Care Recipient(s):