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������������ ������ ������������ ������ ������������ ���������� ���� ���� ���� ���� ���� �� How often is my care evaluated by your agency? ���� ���� ���� ���� ���� �� Is my care reviewed regularly with me and family members? ���� ���� ���� ���� ���� �� Is my caregiver able to take me to my doctor/medical appointments? ���� ���� ���� ���� ���� �� Is there an additional cost for transportation? ���� ���� ���� ���� ���� �� Is my caregiver insured by your agency to provide transportation? ABOUT THE CONTRACTS & COSTS ���� ���� ���� ���� ���� �� Is there a written document that shows your agency’s fees for services and products? ���� ���� ���� ���� ���� �� Is there a written agreement on the care I am going to receive? ���� ���� ���� ���� ���� �� Can my agreement be cancelled? ���� ���� ���� ���� ���� �� Does the agency require a service deposit? ���� ���� ���� ���� ���� �� Does the agency provide a payment plan for private pay? ���� ���� ���� ���� ���� �� Do I pay the agency for my care services? ���� ���� ���� ���� ���� �� Do I receive an itemized bill for services and products? ���� ���� ���� ���� ���� �� Is the agency Medicare/Medicaid certified? ���� ���� ���� ���� ���� �� Are all of my care needs covered by Medicare? ____ ____ ____ If Yes, for how long? ���� ���� ���� ���� ���� �� If No, will I be notified prior to receiving my care? ���� ���� ���� ���� ���� �� Does the agency bill Medicare or my insurance directly? ���� ���� ���� ���� ���� �� Are all of my care needs covered by my private insurance? ____ ____ ____ If Yes, for how long? ���� ���� ���� ���� ���� �� If No, will I be notified prior to receiving my care? • Personal Care • Light Housekeeping • Errands • Meal Prep • Medication Reminders • Dementia Care • Caregiver Support • Companionship Call Today (863) 680-1223 AssuranceHomeCare.com om REGISTRY #30211294 Celebrating Our 10th Anniversary


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