Admission Agreement - PACE Subsidized
Resident’s First and Last Name:
Resident Social Security #
Resident date of birth
Resident’s Agent Full Legal Name:
The parties to this Admission Agreement (“Agreement) are ASPEN CARE, whose address is 3225 GEORGIA St., NE, Albuquerque, New Mexico 87110 (“Facility”), hereinafter referred to as “Operator”, and (“Resident”). The Facility is licensed as an Aging and Long Term Care Facility by the New Mexico Department of Health to provide residency, care, and services, as needed, to qualified persons.
This agreement sets out the terms and conditions of residency; the duties and responsibilities of the Operator, the Resident, and the Authorized Representative (Placing Agent), and the means by which this agreement may be terminated. This agreement shall not be altered, changed or amended except by a written instrument executed by the Operator and the Resident/Resident’s Agent.
This Agreement is effective from date of signature until its revision or termination. The Agreement supersedes all previous Agreements.
Total Monthly Patient Responsibility PLUS any fee not covered by PACE
For InnovAge/PACE participants:
2 DUTIES AND RESPONSIBILITIES OF OPERATORS
3 DUTIES AND RESPONSIBILITIES OF RESIDENT
4 DUTIES AND RESPONSIBILITIES OF RESIDENT’S AGENT
5 ADDITIONAL CHARGES
5.1The Operator is willing to assist in taking the Resident to medical appointments when prior arrangements are made with the Operator to do so. An additional charge of $50.00 per appointment will be added to the Resident’s bill to cover the cost of transporting the Resident to any such appointments. An additional $10.00 per hour will be added for appointments that exceed two hours.
5.2 A one time intake and assessment fee of $300.00 is due upon admission.
5.3 A late fee of $100.00 shall be assessed if monthly fees are not received by the due date.
5.4 The Resident/Resident’s Agent agrees to be responsible for any damage caused by any acts of the Resident that are not covered by the Operator’s insurance. A letter of coverage denial shall be sufficient to establish non-coverage.
5.5 The Resident/Resident’s Agent is responsible for individual telephone and/or newspaper services while under this Agreement.
5.6 The Facility is not responsible for furnishing or paying for healthcare or hygiene items or services not expressly included in the Agreement, including, but not limited to, incontinence products, toothpaste, Kleenex for room, over-the-counter medications, physician’s services, nursing services, medical treatment or equipment. If a case arises where out of necessity the Operator does purchase supplies for the Resident, the cost of supplies shall be added to the Resident’s bill with an additional five percent (5%) fee.
6.1 If Resident/Resident’s Agent fails to pay for all fees due under the agreement, the Operator will give Resident/Resident’s Agent a Seven Day Notice in writing to pay fees plus late charges, if any due, or to vacate the facility. If such charges are not paid within 7 days of the Resident/Resident’s Agent receiving such notice, this agreement will terminate automatically and the Resident will be subject to removal from the facility. Under such condition, Resident’s Agent shall assume full responsibility for locating a new facility for the Resident, and for transporting the Resident to such new facility.
6.2 The Facility, may upon at least 15 days written notice to the Resident and/or Resident’s Agent, discharge the Resident for one or more of the following reasons:
6.3 The Operator shall have the right to remove or to request the removal of any resident, if the resident’s conduct or physical condition is life-endangering to the Resident, to other residents, or to the staff, or if the resident is causing a severe disturbance to the normal routine of the facility or other residents. Under such circumstances, the Operator shall give 1 day notice to the
Resident/Resident’s Agent that the Resident must be removed. The Operator will fully assist the Resident/Resident’s family in locating an appropriate placement and help make the transition as smooth as possible. In this instance, prepaid fees will be refunded at a prorated per day rate as soon as the resident’s room is completely vacated.
6.4 In the event that a Resident’s condition presents an immediate and serious risk to the health, safety or welfare of the Resident, staff, or others and emergency termination of this Admission Agreement is necessary, a 15-day notification of the planned discharge does not apply. Additionally, emergency termination of this Admission Agreement may occur under the following situations:
6.5 There will be a prorated refund of prepaid rates in the event of death of the Resident. As soon as the Resident’s room is completely vacated the refund will be returned within 5 days.
ASSISTED LIVING FACILITIES CONTRACT – LIMIT ON CHARGES AFTER RESIDENT DEATH.
6.6 The Resident/Resident’s Agent agrees to give the Facility at least thirty 30 days written notice of an intent to move from the Facility. Facility Management may grant exceptions if the Resident’s condition prevents advanced notice from being given (see 6.4.a).
7 MISCELLANEOUS PROVISIONS
In case of emergency, Operator shall notify the following:
This agreement shall be binding upon the parties, their successors, assigns and personal representatives. Time is of the essence on all undertakings. My signature below as “Resident” or “Resident’s Agent” indicates that I have read the provisions of this agreement. I sign this Agreement voluntarily.
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Document Name: Admission Agreement - PACE Subsidized
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