ADS_Referral_-_Home_Health_Contract_sample.pdf

This document is an Attendant Care Confirmation form used by San Mateo County Aging and Disability Services to authorize home health and in-home support services for clients requiring assistance. The form serves as a telephone order confirmation mechanism for on-going or emergency services, allowing case managers to document client information, services requested, and authorization details. Services available through this contract include personal care and homemaker services, respite care, transportation, adult day center escort services, shopping assistance, communication and lifeline services, durable medical equipment pickup, medicine delivery, and household chores. The form captures essential elements such as client demographics, service dates and hours, weekly budget allocations, and special instructions, with authorization requiring signatures from the case manager, supervisor, and manager before payment authorization is issued.

The contracted rates detailed in this authorization form establish tiered pricing for various service categories: caregiver services at $38.00 per hour for individual clients (2-hour minimum) or $43.00 per hour for couples (4-hour minimum); professional care assistance at $38.00 per hour; in-home respite and protective supervision at $38.00 per hour; 24-hour live-in care ranging from $650.00 to $750.00 daily depending on care level (basic, medical, or heavy care); transportation at $50.00 per visit for trips of 2 hours or less or $30.00 per hour for longer trips; and in-home care with sleep overnight at $450.00 per 12-hour visit. All services must be authorized in writing by appropriate supervisory personnel, with case managers serving as the primary contact for questions regarding service delivery and authorization.