NR Client ID # ___________
CONTRACT FOR CAREGIVER SERVICES AND WEEKLY WORK LOG
This Agreement between Patient/Client _____________________________ and Caregiver ___________________________
represents the actual caregiver services requested by Patient/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 the Caregiver’s billing and collection agent. I understand that if services
were not performed as requested, I should not sign and should call
immediately to adjust the schedule.
* Work logs submitted without the checking of Activities of Daily Living actually performed (below) 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 Patient/Client: ______________________________ Signed by Caregiver: ______________________________
Week Ending Date: _____________________________
Role: RN___ LPN___ CNA___ HHA___ Companion___
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 patient/client report any change(s) in services immediately to American In-Home Care as the licensed Nurse Registry.
American In-Home Care Florida State Licenses #: NR30211518, NR30211295, NR30211586, NR30211651
*USE ORIGINAL FORM ONLY*
As per the direction of Patient/Client, Caregiver
did / did not perform the following services:
RANGE OF MOTION ASSISTANCE
CHANGE BED LINEN
REMIND PATIENT OF MEDICATIONS
ASSIST PATIENT. WITH MEDICATION
OBSERVE PHYSICAL & MENTAL CHANGES
ACCOMPANY TO APPOINTMENTS
ASSIST WITH OSTOMY CARE
RECORD VITAL SIGNS
INTAKE / OUTPUT
CHANGE IN ORIGINAL
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.