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SILVERTHORNE ADULT DAY CARE CENTER

           

                                                SERVICES AGREEMENT

 

The Silverthorne Adult Day Care Center and____________________________________ hereby agree to the following terms and agreements.

           

Each participant and/or his/her agent, as evidenced by this signed acknowledgment, has received a copy of the Participant’s Rights and Responsibilities.

Each participant and/or agent agrees to their responsibility of fees for services being paid in full by the 15th of the month. If participant/agent is awaiting coverage by a third party payor, once payment is received by this third party, monies paid by participant/agent will be reimbursed to participant/agent.

 

The Silverthorne Adult Day Care Center staff will in turn recognize the participant’s rights and will provide regular communication with the participant and/or his/her agent regarding the participant’s Treatment Plan and any changes in the participant’s condition as well as any changes in the program’s policies or Rate Schedule.

 

All participants of the Silverthorne Adult Day Care Center enjoy equal rights while at the Day Care Center.

 

The participant will attend the program____ days per week,  M T W TH F and will be  at the center for ____brkst (9:00am)____lunch __(12 pm) snack_____(2:30)

You are responsible for payment of scheduled sessions.

 

Signatures: __________________________________________Participant

                 __________________________________________Agent

                 __________________________________________ADCC Director

 

            As noted in your Bill of Rights, you have the right to be treated with respect and dignity.  If you feel you or your rights are being abused, you can speak directly to the Administrator. You also have the right to report complaints to:

                        Office of Program Support

                        Health Facilities Administration

                        129 Pleasant St.

                        Concord, NH 03301

            1-800-852-3345 (ext 4592 or 1-601-271-4592TDD access 1-8000-735-2964

 

Participant_______________________________________________________________

 

Agent___________________________________________________________________

 

Date____________________________________________________________________

(copy of this form with above numbers received________________)please initial

 

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