ࡱ> Z\Y 'bjbjdd 4Jcc( ( mmmmm8T <.Ip" S.U.U.U.U.U.U.$03y.my.mm.vmmS.S.r)T*g7d/*?..0.=*44*4m*d",y.y.h.4( 3: 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/CAREGIVERS 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.  FORMCHECKBOX  Transportation and errands: ___ Driving ELDER/ADULT WITH DISABILITIES to medical, dental, adult day care and other appointments and activities; ___ Shopping for groceries and other items needed by ELDER/ADULT WITH DISABILITIES, and filling/refilling prescriptions; ___ Running other errands for ELDER/ADULT WITH DISABILITIES. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Meals: Preparing ______ meals per day and daily snacks for ELDER/ADULT WITH DISABILITIES. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Housework: ___ Cleaning ELDER s/ADULT WITH DISABILITIES living area. ___ Laundry and changing linens __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Financial: Paying ELDERs/ADULT WITH DISABILITIES bills, balancing Elders/Adult with Disabilities checkbook, making deposits, dealing with health insurance, other paperwork. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Administration of medication. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  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. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Monitoring the ELDER/ADULT WITH DISABILITIES for safety, including responding to alarm system to control wandering/ fall risk. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  Monitoring the ELDER/ADULT WITH DISABILITIES health, and bringing health problems to attention of health care providers. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  FORMCHECKBOX  OTHER: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Schedule CAREGIVER will provide services on the following schedule: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Compensation ELDER shall pay CAREGIVER $______ per HOUR/ DAY/ MONTH. Circle One TO BE USED IF ELDER LIVES IN CAREGIVERS 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). ELDER/ADULT WITH DISABILITIES shall reimburse CAREGIVER for all out of pocket expenses borne by CAREGIVER in connection with CAREGIVERS work. Such expenses shall include mileage at the rate of $_____ cents per mile. ON BEHALF OF ELDER/ADULT WITH DISABILITIES: __________________________________ Date [To be signed by Elder/Adult with Disabilities or by a legal representative for Elder/Adult with Disabilities such as agent under POA, guardian or conservator] CAREGIVER: _________________________________ Date     PAGE   PAGE \* MERGEFORMAT 1 December 16, 2011 Department of Health and Human Services Office for Family Independence  (2345>[qrt    & ( . / 2 3 C D E ѽѽѽѽь|qmhZYh#Wh,CJaJh#WCJaJh%hgQm5h#Wh%h%CJaJh%5CJaJh%h%5CJaJhxG5CJaJhcpeh%h-h=NhQUhgQmhxGhnrhdPhU5;>*hHx5;>*hdPh=5;>*hL5;>*(345st  ( 3 D E F X Y s gdD ^`gdxGgdW/^gd%gdxGgdgQm$a$gd=E F X Y y D M S Y Z _ v w  p q s u 沨≍}yuyqqmhDhrhhkhcpeh*0h\>hHxh68h6"h-hZY h5h!h5>*h!hZY5>* h%G5>* hh*0 hhW/h#WhxGCJaJhxGCJaJhxGhO hy(hW/ hW/5hLVEhW/5>* hxG5>**s v w  { | s t  & Fgd},gd},^gd}, & Fgd & FgdD & Fgdrh & Fgd!gd!gd}$a$gd68gd68gdgQmu v w  6 B G H _ ` i k t z | } ¾ƾ~zvvzrnrzh*0hE{hO9hh68hrhCJaJh68h-CJaJh68h68CJaJh68hy(CJaJh CJaJh68CJaJh9Qh68hy(hrhhcpeh- h5h!h5>*h!hS5>*h!hZY5>* h%G5>*hZY(   : > G a r s t u NSkqy¯««£«hh},hhhrhh9Qh68hy(hkh9 hD%jh},CJOJQJU^Jh},CJOJQJ^Jjh},CJOJQJU^J h},h}, h6hh6 h},6hh63,-.0AGZ`kp ".04OPŽŖŽŦw%j\h},CJOJQJU^JhE{hh9Qhrhh},h},5h!hO %jh},CJOJQJU^Jh},hy(hh*0h}jh},CJOJQJU^J%jth},CJOJQJU^Jh},CJOJQJ^J.0Pb#-.h`hgdgdrh & FgdE{8^8gdrh 8h^8`hgd & Fgd^gdE{^gd^gd}, & FgdO  & FgdDh^hgd}a+./=>?A 8X7нЪЦЋht%jh},CJOJQJU^Jhkh9Qh-%jDh},CJOJQJU^J%jh},CJOJQJU^Jh},CJOJQJ^Jjh},CJOJQJU^JhE{hhhy(hrh0X7zT]^xgdX:^gdO 8^8gd}, & FgdrCgdrC^gdrC 8h^8`hgdrC 8h^8`hgd & FgdE{gdrh^gd8^8gd-]^_mnoqvwx"""ЩХ{vrnfa h%G5hX:h0[5h.hzw hI5hzwhI5>** h%G5>* h>hO h},hhy(%jh},CJOJQJU^JhE{hrChhth-h},CJOJQJ^Jjh},CJOJQJU^J%j,h},CJOJQJU^J""""""#&$'$%%%2%3%w%&& ^`gdFz^gdgd. & Fgd-^gd & FgdTQh^hgd]igdX:gd#8 h^h`gdS"""""""""""""""###7#@#J#W#\#t#{############$$#$&$'$,$D$E$K$L$U$^$|$}$~$ѭٵŵŋՓյ͇Ńhth'4h.hHjh.@h*0hh CJaJhhCJaJhCJaJh hhy(>*hh-hkhDh(h9Qhy( hX:5hzwhX:5>*Se25>*]i5>*2~$$$$$$$$$$$$$$$%%%%%%%%0%1%2%3%L%O%m%v%w%|%}%%%%%&&&& &!&'&0&1&þ詤zh3hX:5 h-5h3hQnhLVE hU>*hhDhK h9Q>* hFz>*hht5hhX:5 hHj5 hy(5hFzhFzhFz5hh.hfZhm~ hy(hth`lhX:h-h'4hL.& &!&2&3&t&&&&&&&&&&&&&&&&&&&&'$a$gd*0$a$ &`#$gd!h^hgd]i1&2&3&A&K&P&t&y&|&~&&&&&&&&&&&&&&&&&&&&&&&&&&'''''''''h\2-h\2-CJaJh\2-CJaJhI^mHnHujh\2-Uh} h}0Jjh}0JUh2h\2-h: jh: Uh(h9QhKh=NhD hU>* hFz>* h9Q>*hth3ht5+''''''''h^hgd]i21h:p68/ =!"#$% tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1 v002&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@666_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH DA`D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4 @4  p0Footer  !.)@.  p Page Number@@@ b List Paragraph ^>">  Footnote TextCJaJD1D Footnote Text CharOJQJ@&A@ Footnote ReferenceH*4@R4 *00Header  H$>a> *00 Header CharCJOJQJaJHrH *0 Balloon TextCJOJQJ^JaJNN *0Balloon Text CharCJOJQJ^JaJ>> *00 Footer CharCJOJQJaJ6U6 *0 Hyperlink >*B*phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] J E u "~$1&' !#s &''"$t- .>^nG$G$G$G$G$G$G$G$G$35!!8@0(  B S  ?Check1  `8`88*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace z %t 0 b .X7'459:pt&.2F]^vw:;=>ABMNkl0TGF&s!s#r5  ggO$T:808^8`05o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. 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