Flexible Personal Care Services in
New Port Richey, FL

Levels of Assistance:
O=Independent - Completes the task independently
3-Minimum Assistance -Occasional assistance or supervision may be necessary
6=Moderate Assistance - Assistance or supervision is always necessary
9=Maximum Assistance - Totally dependent on others
1. For each activity check the box indicating the assistance needed.
2. If assistance is needed, indicate the source of help (be specific: spouse, family, friend,paid help,volunteer, professional)
3. In the comments indicate the type of assistance provided and how often it's provided. Indicate if client needs further help.

Typical Current Meals

If client has NOT fallen in the past year, skip questions4 & 5 below.

CONSENT TO RECEIVE HОME CARE SERVICES
I, the undersigned client or legal representative, hereby consent to receive home care services provided by Helping Hands Superior Care LLC. I understand and agree to the following:

This Service Agreement (“Agreement") is entered into by and between:

AND
Helping Hands Superior Care LLC ("Agency"), a licensed nurse registry in the State of Florida.

1. Scope of Services

The Agency agrees to coordinate and refer qualified caregivers to provide the following non-medical and/or skilled care services:

Care services will be rendered on the following schedule (subject to change with notice):

Invoices are issued (Friday) and payment is processed the same day All payments are securely collected through the ACH or credit card information we have on file.

The client agrees to:

• Provide a safe and accessible environment
• Notify the agency 24 hours in advance for any cancellations
• Refrain from offering caregivers cash or personal gifts in exchange for extra services outside of agency agreements
• Report concerns or dissatisfaction to the agency directly

The Agency agrees to:

• Conduct background checks and verify qualifications of all referred caregivers
• Maintain ongoing communication and conduct supervisory visits
• Provide replacements in case of call-outs (subject to availability)
• Comply with all state and federal regulations

6. Termination Clause

Either party may terminate this agreement with 30 day written notice. Immediate termination may apply in the case of abuse, unsafe conditions, or non-payment.

By signing below, the Client or their Legal Representative acknowledges:

• Receipt and understanding of this agreement
• That services are being rendered through a nurse registry model (independent contractors)
• That client agrees to hold harmless the Agency from any claims not resulting from gross negligence

I hereby authorize Helping Hands Superior Care LLC to release and/or receive confidential information about me as described below:

Client Rights & Acknowledgments:

• I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken.
• I understand that signing this form is voluntary and will not affect my eligibility for care or services.
• This consent is valid for one (1) year from the date signed unless revoked earlier in writing.

This Financial Responsibility Agreement ("Agreement") is entered into between the undersigned client or responsible party ("Client") and Helping Hands Superior Care LLC ("Agency").

1. PAYMENT POLICY

• The Client agrees to pay for allservices rendered by Helping Hands Superior Care LLC.
• All payments will be securely processed via ACH or Credit Card on file.
• Services will be billed at the agreed-upon rate of $________per hour/day/week (circle one).
• Invoices are generated weekly.

2. AUTHORIZED PAYMENT METHOD

• I authorize Helping Hands Superior Care LLC to automatically charge the payment method provided for services rendered.
• A receipt will be provided for each transaction.

3. INSURANCE / THIRD-PARTY PAYERS

• If applicable, the Client agrees to provide complete and accurate insurance or third-party payer information.
• The Client is responsible for any portion not covered by insurance, including cоpays, deductibles, or non-covered services.
• In the event that insurance or third-party payers deny payment, the Client is fully responsible for all charges.

4. LATE PAYMENTS / RETURNED PAYMENTS

• A late fee of $25 will be charged on any unpaid balance each day past due.
• Returned ACH or credit card payments will incur a $35 fee.

5. CANCELLATION / NO-SHOW POLICY

• To avoid charges, cancellations must be made at least 24 hours in advance.
• Services canceled with less than 24 hours' notice may be billed at 50% of the scheduled rate unless Due to an valid emergency.

6. TERMINATION OF SERVICES

• Services will be suspended or terminated if payment is not received in a timely manner.
• Any balance remaining upon termination will be immediately due.

7. ACKNOWLEDGMENT AND CONSENT
By signing below, I acknowledge and agree to the financial terms outlined in this agreement. I understand I am financially responsible for all services provided by Helping Hands Superior Care LLC. I authorize the use of my payment method for all associated charges.

Emergency Contacts and Resources

Local Emergency Services: 911

Client Acknowledgment
I acknowledge that I have reviewed and understand the emergency management plan.

IF APPLICABLE, PLEASE PROVIDE COPIES OF THE FOLLOWING DOCUMENTS:

• Do Not Resuscitate (DNR) Order
• Power of Attorney (POA) Documents
• Guardianship Papers

These documents will be securely stored in the client's confidential file to ensure appropriate care and compliance with legal and medical directives.

ACKNOWLEDGMENT:
I understand that it is my responsibility, or that of my legal representative, to provide Helping Hands Superior Care LLC with accurate and up-to-date copies of any applicable DNR, POA, or guardianship documentation. I acknowledge that without such documentation, emergency medical services will proceed with full resuscitation efforts as per standard protocols.

POLICY OVERVIEW:

At Helping Hands Superior Care LLC, we take all complaints and grievances seriously. We believe that every client and their family has the right to voice concerns without fear of retaliation or compromised services. This form is provided so that any individual whether a client, family member, caregiver, or community partner can formally report a concern regarding services, staff, care quality, safety, or any other issue. All complaints will be investigated in a timely, fair, and confidential manner. We aim to resolve all concerns within 7-10 business days. Follow-up communication will be made to the individual who submitted the complaint if contact information is provided.

COMPLAINTS/GRIEVANCES FORM

We are committed to providing high-quality, compassionate care. If you have experienced any issues or concerns, please complete this form so we can address and resolve the matter promptly.

Our Notice of Privacy Practices explains how we may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

You have the right to review our Notice before signing this Consent. If our Notice changes, you may request an updated copy at any time.

The Patient Understands and Acknowledges the Following:

• PHI may be used or disclosed for treatment, payment, and healthcare operations.
• I have the right to request restrictions on how my PHI is used or disclosed. However, the practice is not required to agree to those restrictions.
• I may revoke this Consent in writing at any time. This will not affect disclosures already made based on prior consent.
• The practice has provided access to its Notice of Privacy Practices.
• The practice may change its Notice of Privacy Practices and I may request a current version at any time.
• The practice may condition treatment upon execution of this Consent.

By signing this document, I acknowledge and agree:

• I have received a copy (or had access to review) the agency's Notice of Privacy Practices.
• I understand how my health information may be used or disclosed.
• I understand my rights regarding my PHI, including the right to request restrictions or revoke this consent in writing.
• I understand this consent is valid until revoked in writing.

This Waiver of Liability and Hold Harmless Agreement is made and entered into by and between Helping Hands Superior Care LLC ("Agency") and the undersigned individual or authorized representative of the individual receiving services ("Client") on the date written below.

Purpose:
Client acknowledges and understands that transportation services may be provided by Agency staff using their personal vehicles. This agreement outlines the responsibilities, risks, and reimbursement guidelines associated with such transportation.

1. Voluntary Participation
Client agrees that the use of transportation in a staff member's personal vehicle is voluntary and provided as a convenience.

2. Assumption of Risk
Client acknowledges that being transported in a personal vehicle carries inherent risks, including the possibility of injury or property damage. Client accepts and assumes full responsibility for any risks arising out of, or in connection with, transportation services.

3. Waiver and Release
To the fullest extent permitted by law, Client hereby waives, releases, and discharges Helping Hands Superior Care LLC, its owners, employees, contractors, and affiliates from any and all liability, claims, demands, causes of action, or damages arising out of transportation services provided by Agency staff in their personal vehicles.

4. Hold Harmless
Client agrees to indemnify and hold harmless Helping Hands Superior Care LLC and its staff from any claims, costs, or liabilities, including attorney fees, arising out of or related to transportation in a staff member's personal vehicle.

5. Mileage Reimbursement (For Internal Staff Use Only)
Staff who provide client transportation in their personal vehicles will be reimbursed for mileage at the standard rate for 2025, currently $0.67 per mile, or the rate in effect at the time of service. Mileage must be properly documented and submitted for approval per company reimbursement policy.

6. Insurance & Licensing
All staff providing transportation must maintain valid driver's licenses and insurance coverage as required by law. The Agency does not assume responsibility for any uninsured incidents or citations issued during transport.

7. Acknowledgment
By signing below, Client acknowledges that they have read, understood, and voluntarily agree to the terms and conditions of this Waiver of Liability and Hold Harmless Agreement.

I, ______________________ (RN or LPN), have completed a thorough review of the medications that assistance will be provided with, ensuring that the CNA/Aide has the proper training and that assistance aligns with the medication prescription.

I, ______________________ (Client/Client Representative), or my surrogate, guardian, or power of attorney, acknowledge that I may receive assistance with the selfadministration of medications from an individual who is not licensed to practice nursing, but who is under contract with the nurse registry and has received training to assist with medication selfadministration in accordance with agency policy ("unlicensed person").

Note: Clients who are able to self-administer their own medications independently will be encouraged to do so.

Unlicensed persons may assist with medication in accordance with a dispensed prescription's label or the directions on over-the-counter medications, provided the client is medically stable and the medications are part of a routine, regular schedule intended for self-administration.

Permissible assistance includes:

• (a) Retrieving the medication from its previously dispensed, properly labeled container, and delivering it to the client.
• (b) Reading the label, opening the container, removing the prescribed dosage in the presence of the client, and returning the medication to its container.
• (c) Placing the dosage in the client's hand or assisting by lifting the container to the client's mouth.
• (d) Applying topical medications.
• (e) Returning the medication to its proper storage location.
• (f) Documenting each time the client receives medication assistance.

At Helping Hands Superior Care LLC, we are committed to ensuring the highest standards of care and professionalism in the services we provide. All caregivers we assign to clients have been thoroughly vetted through the following process:

Caregivers are required to use a GPS-monitored system to clock in and out at the beginning and end of their scheduled shifts. This helps us ensure services are delivered accurately and safely.

1. No Private Contact:
Caregivers and clients are strictly prohibited from exchanging personal phone numbers or engaging in private communication. All communication should go through the Helping Hands Superior Care office.

2. Scheduled Hours Only:
Clients must not allow caregivers into their home outside of scheduled hours or visits not coordinated through the agency. We are not responsible for any actions, behaviors, or incidents that occur outside of the agency's scheduled visits.

3. No Private Hiring:
Clients are not permitted to hire Helping Hands caregivers privately. If a client chooses to do so, they agree to pay Helping Hands Superior Care a $5,000 liquidated damage fee, payable immediately upon demand.

4. No Direct Payments or Loans to Staff:
Clients may not provide caregivers with any direct payments, personal loans, gifts, gift cards, or cash advances. If you would like to gift something to your caregiver, please contact the office so we can distribute it appropriately and document it for your protection and ours.

5. Valuables Policy:
Clients agree to keep all cash, checks, jewelry, and other valuables in a secure and locked place during care visits. This helps protect both the client and the caregiver from misunderstandings.

6. Reporting Issues:
If there is any suspected theft, missing property, or misconduct, clients must immediately report the issue to the police and Helping Hands Superior Care LLC so we can fully investigate and document the concern.

By signing below, I acknowledge that I have read, understand, and agree to follow the policies outlined above. I understand that these policies are in place to protect both my household and the caregiver and to maintain the integrity of services provided by Helping Hands Superior Care LLC.

Our Commitment to You:
As our client, you have the right to receive compassionate, respectful, and high-quality care in the comfort of your home. We are committed to protecting your dignity, privacy, and personal preferences while delivering professional services.

CLIENT RIGHTS

• To be treated with respect and courtesy at all times.
• To receive care free of discrimination, abuse, neglect, or exploitation.
• To have your information kept confidential.
• To participate in planning your care.
• To report any concerns without fear of retaliation.

CLIENT RESPONSIBILITIES

• To treat staff with respect and dignity.
• To maintain a safe environment for caregivers.
• To notify the agency of any changes in your care needs.
• To secure all firearms and weapons safely out of reach.
• To communicate any dissatisfaction or concerns with services promptly.

AGENCY POLICIES & HOUSEHOLD BOUNDARIES

Please review and acknowledge the following expectations for all clients:

• No sexual, suggestive, or inappropriate behavior toward staff is tolerated under any circumstance.
• Staff are only permitted to provide light housekeeping directly related to the client's care (e.g., tidying up after meals, laundry for the client).
• Staff are not responsible for caring for other family members, pets, or performing unrelated tasks.
• Staff are not allowed to bring their own children, pets, friends, or family members into your home while on duty.
• Please refrain from personal conversations that may lead to staff becoming personally attached or discussing personal matters.
• Avoid discussions involving politics or religion, which can create an uncomfortable environment.
• Immediately report to the agency if a caregiver is disrespectful, behaves inappropriately, or makes you feel uncomfortable in any way.

We ask that you supportaprofessional and safe working environment by honoring these policies. Your cooperation ensures the well-being and professionalism of everyone involved.

CLIENT ACKNOWLEDGEMENT

I have read, understand, and agree to follow the client responsibilities and agency policies outlined above.

At Helping Hands Superior Care, your health and safety as well as that of our staff is our top priority. In light of ongoing concerns regarding COVID-19 and flu viruses, we've implemented the following safety policy:

SERVICE PAUSE POLICY

If you (the client) report any symptoms of COVID-19 or the flu, such as:

• Fever or chills
• Cough
• Shortness of breath
• Sore throat
• Body aches or fatigue
• Loss of taste or smell
• Vomiting or diarrhea

We may need to temporarily pause in-home services until your symptoms have cleared or you've been medically cleared.

Likewise, if your assigned caregiver informs us that they are experiencing symptoms of the flu or COVID-19, we will pause their services immediately and reassign once they are cleared.

RETURN TO SERVICE PRECAUTIONS

Once services resume, we may recommend but not require that both clients and staff wear gloves and masks for a few days following a return from illness. This extra step is just a precaution to keep everyone safe and healthy.

We appreciate your understanding and cooperation as we continue to protect our community.

Client Acknowledgment:
I acknowledge that I have read, understand, and agree to the policy outlined above regarding flu and COVID-19 precautions.