Patient Financial Agreement Please fill in the form below Please enable JavaScript in your browser to complete this form.Patient Financial AgreementPatient's Name *FirstMiddleLastYou have been referred and evaluated for acceptance to ACS Home Care LLC services. The charges for the services provided will be billed to the following: *Managed Long Term Care (MLTC)County Department of Social ServicesPrivate PayPrivate Long Term Care InsuranceWhich Managed Long Term Care (MLTC) Do You Use? *HomeFirstHEALTHFirstAgeWell NYArchCarePrivate PayHourly Rate: $30 per hour Live-in Rate: $390 per day (13 billable hours) Note: Aide MUST have at least 5 hours of uninterrupted sleep each day, 8 hours of sleep total. 1 hour break for Breakfast, 1 hour break for Lunch (between hours of 11am-2pm), and 1 hour for dinner every day. If aide is unable to take all 11 hours sleep/break, then that time is billable at the $30 hourly rate listed above. ACS Home Care ServicesSERVICE (Requested/Authorized number of Days Per Week & Hours Per Day. Duration for each service below is long term with no specific end date.) Skilled Nursing Visits: Initial evaluation and visits every 3-6 months or as necessary Home Health Aide (HHA) / Patient Care Assistant (PCA): Days and Hours will be your choice if you are paying privately or using your private Long-Term Care Insurance. You can change the days and hours as your needs dictate. If you are receiving these service(s) through a MLTC or County Dept of Social Service, they will determine and approve the days and hours you are entitled to. These days and hours can change according to your needs but must be approved through them. The undersigned agrees to pay for all services provided by ACS Home Care LLC via the billing selection above. The undersigned hereby understands that if their insurance does not pay that the undersigned becomes financially liable and will be billed for all services. The undersigned will be notified if there are any changes to the fee schedule in the Patient handbook. The undersigned certifies that the financial and insurance information supplied is correct. In the event that the undersigned gets paid directly from the insurance company, the undersigned will be fully responsible for reimbursing ACS Home Care LLC. Bills are due upon receipt. The undersigned may be required to pay for supplies not covered by insurance, as well as, be responsible for co-payment portion of the supplies. Two week security deposit is required if paying by check. Security deposit is 100% refundable at the end of service and after all invoices have been paid in full. Should the undersigned choose to pay privately or request additional hours other than what there insurance authorizes, the undersigned will be billed one and one half time (1 1/2) regular rate for all Overtime if such requested by client/undersigned. Overtime is considered to be any time over forty (40.0) hours of work in one seven day work week that is rendered by the same individual. The work week starts on Sunday and ends on Saturday. Holidays are billed at one and one-half (1 1/2) times the regular rate. Holiday bill rates begin at midnight on the day of the holiday through midnight the following day. Holidays are: • New Years Day • Memorial Day • Independence Day • Labor Day • Thanksgiving Day • Christmas Day Client/Client Representative Signature *Clear SignatureBy signing, I agree that I have complete understanding of the contents listed above. Refusal to sign this form gives ACS Home Care LLC the option to discontinue services immediately.Patient/Patient Representative's Name *FirstMiddleLastDate *Patient Representative's Relationship to Patient *If patient is acting on their own behalf, please enter Self.Reason Patient Unable To Sign: *Above, please enter the reason the patient is unable to sign. If patient is acting on their own behalf, and is able to sign, please enter "N/A' (Not Applicable) A copy of this document will be emailed to the responsible party upon Submission.Submit