📄 Agreement for Services & Consent for Home Care

Please read each section carefully, complete all fields, and sign below.

I request and consent to services from Martinez Heart & Home Care according to my current service agreement and plan of care, in accordance with Washington State DSHS regulations.

📋 Section 1 — Client Information

Client Full Name *

Date of Agreement *

Phone *

Home Address *

🏠 Section 2 — Services Authorized

💜 Companion / Supervision Care 🧴 Assistance with Activities of Daily Living (ADLs) 🍲 Meal Setup / Preparation 🏠 Light Homemaking Related to Client Care 💊 Medication Assistance / Administration (when authorized) 🛡️ Safety Monitoring ❤️ Respite / Family Support

📅 Section 3 — Schedule & Rates

Service Start Date *

Usual Schedule / Frequency *

Hourly Rate

Assigned Caregiver

Special Conditions / Limitations

📜 Section 4 — Agreement Terms

I understand I may participate in developing and revising my plan of care. I may refuse a specific service; refusals may be documented per agency policy. I will notify the agency of important changes in my condition, medications, schedule, or care needs. Services are limited to the agency's authorized scope, staff qualifications, and agreed plan of care. I acknowledge receipt of the HIPAA Notice of Privacy Practices. I acknowledge receipt of the Client Rights & Responsibilities document.

✍️ Section 5 — Signatures

By signing below, all parties agree to the terms of this Service Agreement.

Client / Legal Representative Signature *

✍️ Sign here

Printed Name *

Relationship (if not client)

Date *

Agency Representative Signature

✍️ Agency signature

Agency Rep Printed Name

Date

All fields marked * are required. DSHS Form MHH-04.

📄 Agreement for Services & Consent for Home Care

✅ Agreement Submitted!