Assurance Home & Convalescent Care, Inc.
3004 Taylorsville Rd
Louisville, KY 40205
Phone (502) 479-1906
Fax (502) 479- 2956
assurancecare@assurancecare.com
EMERGENCY INFORMATION
CLIENT INFORMATION
ACTIVITIES of DAILY LIVING (ADLS)
Please indicate and briefly describe the client’s level of function for each ADL.
I=Independent A=Assistance needed from caregiver D=Dependent upon caregiver
TYPES and SCHEDULE of SERVICES to be PROVIDED TO CLIENT
CLIENT’S PERSONAL INTERESTS, FAMILY LIFE AND DAILY ROUTINE
METHOD OF PAYMENT
Bill to Information:
Long Term Care Company Information:
POWER OF ATTORNEY INFORMATION
OFFICE USE
RATE SCHEDULE:
Hourly Rate for One Person:
Hourly Rate for Two People:
Bath Visit
Mileage Fee
Deposit Fee
Assurance Home & Convalescent Car, Inc. has a 24 hour cancellation policy. Client will be billed the rate due for the entire shift if client fails to give Assurance’s office staff the required 24 hour notice of cancellation of shift.
The client will be billed at time and one half of the regular rate on holidays. Please refer to the Assurance Home & Convalescent Care, Inc. Service Agreement for a list of holidays.
The client will be billed at time and one half of the regular rate if caregiver works over 40 hours in a week for said client.
Or