Contract For Caregiver Services And Weekly Work Log
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1CONTRACT FOR CAREGIVER SERVICES AND WEEKLY WORK LOG
This Agreement between Client _____________________ (Client #_________) and Caregiver _____________________
represents the actual caregiver services requested by Client and provided by Caregiver for the dates listed below.
By signing below I (Patient/Client) contracted with above Caregiver for whom I certify performed all services noted below
satisfactorily and I agree to pay PayFirst Services, Inc as Caregiver’s billing and collection agent. I understand that if services
were not performed as requested, I should not sign and should call 561-279-0808 immediately to adjust the schedule. **Work logs
submitted without the checking of Activities of Daily Living actually performed, and required by the insurance company, may
result in the patient/client being billed directly by PayFirst Services, Inc.
**Caregiver has reviewed Confirmation of Services Requested by Patient/Client and agrees to same**
Signed by Client: ______________________________
Signed by Caregiver: ______________________________
Week Ending Date: _____________________________
Role:
RN____ LPN____ CNA____ HHA____
Pursuant to Regulations by the Agency for Health Care Administration, it is mandatory that Caregiver document any changes in caregiver services.
Consequently, it is imperative that patients/clients report any change(s) in services immediately to Whitsyms as the licensed Nurse Registry.
Whitsyms Nursing Service FL State Licenses: NR30210978, NR30211226, NR30211293, NR30211316, NR30211382, NR30211390
*USE ORIGINAL FORM ONLY*
As per the direction of Patient, Caregiver did / did
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
not perform the following services:
BATHING
DRESSING
AMBULATING
TRANSFERRING
TOILETING
RE-POSITIONING
FEEDING
APPLY LOTION
ORAL HYGIENE
SHAVE, HAIR CARE
ADL & IADL SUPERVISION
RANGE OF MOTION ASSISTANCE
CHANGE BED LINEN
GROCERY SHOPPING
LAUNDRY
LIGHT HOUSE-KEEPING
REMIND PATIENT OF MEDICATIONS
ASSIST PATIENT WITH MEDICATION
OBSERVE PHYSICAL & MENTAL CHANGES
ACCOMPANY TO APPOINTMENTS
PREPARE MEALS
ASSIST WITH OSTOMY CARE
RECORD VITAL SIGNS
RECORD INTAKE / OUTPUT
WEIGHT
INCONTINENCE CARE
DAY
DATE
TIME STARTED DATE
TIME FINISHED TOTAL
CHANGE IN ORIGINAL
PATIENT/CLIENT’S SIGNATURE
HOURS
SCHEDULED HOURS
SUN
MON
TUE
WED
THUR
FRI
SAT
FAX ONLY TO: 561-819-6611
WHITSYMS NURSING SERVICE
2605 West Atlantic Avenue, Delray Beach, FL 33445
Telephone: 561-279-0808
Worklog must be signed daily by patient/client, signed weekly by Caregiver, and submitted to the office by 9 AM every Monday immediately
following the end of each work week.
*** Failure to timely submit will result in delay of caregiver payment until next pay period ***
*** Complete with black ink pen ONLY ***
Inform the office immediately whenever case ends or whenever patient/client is hospitalized or if there are patient gross behavioral changes.
Revised 3-10-2015
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