Common Contracts
2 similar Home Care Agreement contracts
ContractHome Care Agreement • April 16th, 2004
AGREEMENT TO PROVIDE HOME CARE FOR PATIENT 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF PATIENT 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. NAME OF PATIENT’S PHYSICIAN 8. NAME OF SOCIAL WORKER 9. AGREE TO CARE FOR THE PATIENT AT THE MONTHLY RATE OF 10. DATE WILL ACCEPT THE PATIENT INTO MY HOME AGREEMENT: I, the undersigned, agree to accept the above worker at the hospital, name and telephone number listed above, named patient into my home on the date indicated in Item No. at once if there is any change for the worse in the patient's10 at the monthly rate shown in Item No. 9. I will provide the condition, either physical or mental, or if the patient absent patient with room, board, laundry service, and look after his himself from my home for any period of time without my personal welfare. knowledge or consent.I understand that the patient will be on trail visit status I further agree to notify a social worker or physician at during his stay in my home and will be visited at
ContractHome Care Agreement • April 16th, 2004
AGREEMENT TO PROVIDE HOME CARE FOR PATIENT 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF PATIENT 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. NAME OF PATIENT’S PHYSICIAN 8. NAME OF SOCIAL WORKER 9. AGREE TO CARE FOR THE PATIENT AT THE MONTHLY RATE OF 10. DATE WILL ACCEPT THE PATIENT INTO MY HOME AGREEMENT: I, the undersigned, agree to accept the above worker at the hospital, name and telephone number listed above, named patient into my home on the date indicated in Item No. at once if there is any change for the worse in the patient's10 at the monthly rate shown in Item No. 9. I will provide the condition, either physical or mental, or if the patient absent patient with room, board, laundry service, and look after his himself from my home for any period of time without my personal welfare. knowledge or consent.I understand that the patient will be on trail visit status I further agree to notify a social worker or physician at during his stay in my home and will be visited at
