Policy Manual sample

MDT Home Health Care Agency, Inc. CONTRACT With a Non-Licensed Provider This Contract is made in good faith between services herein called the first party and: (Please insert name of non-licensed provider of services), herein called the second party. In this contract, both parties agree as follows: (i) The services agreed upon on this contract are: (Please state clearly the services requested, example, the transportation of a patient to a designated place of treatment) (ii) The contract shall be in effect from the date both parties sign the contract and the date of discharge of the patient by our agency. (iii) This contract is subject to periodic review as may be necessary based on charges made by the patient's physician as are reflected in the patient's plan of treatment. (iv) Our Agency, MDT Home Health Care Agency, Inc. shall make a monthly supervisory visit to the second party to ensure compliance with the patient's Plan of Treatment. (v) Any and all home health services provided to the patient by the second party shall be in accordance with our Plan of Treatment established by the patient's physician in conjunction with our professional staff and, when appropriate, others involved in the patient's care. All information will be maintained CONFIDENTIAL. (vi) All services provided by the second party shall be within the scope and limitations set forth in the plan of treatment and shall not be altered in type, scope or duration by the secondary party. (vii) This contract is for a service that meets the requirements as those specified for our Agency's personnel, including personnel qualifications, functions, supervision, orientation, and in-service training. (viii) Our Agency has full responsibility over all contracted services. (ix) Our Agency has full responsibility to retain and maintain all clinical records of patients served by this Contract, and maintained CONFIDENTIAL. (x) The second party must submit evidence of liability and insurance coverage. Signed MDT Home Health Care Agency, Inc. For Non-Licensed Provider (First Party) of Services: (Second Party) Name: Name: Title: Title: Date: Date: Home Health Agency Agreements G-7