You can open the Negotiated Risk Agreement Assisted Living Template in multiple formats, including PDF, Word, and Google Docs.
Negotiated Risk Agreement Assisted Living Template Printable | Editable FormSample
[Name of the Provider]
[Provider’s ID]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
[Name of the Resident]
[Resident’s ID]
[Resident’s Address]
This document outlines the terms and conditions of the Negotiated Risk Agreement for assisted living services, effective as of [Contract Start Date], to provide a safe and supportive living environment tailored to the Resident’s needs.
The Provider agrees to offer the following services: [Specify services, e.g., personal care, medication management, emergency response].
The Resident acknowledges understanding the potential risks associated with assisted living, including but not limited to [Specify risks, e.g., mobility challenges, health conditions].
The Provider commits to providing adequate supervision and support, including [Specify responsibilities, e.g., regular health assessments, wellness checks].
The Resident agrees to participate in care planning and communicate any concerns regarding their health or well-being to the Provider promptly.
This agreement may be terminated under the following conditions: [Specify conditions, e.g., non-compliance with care plan, change in health status].
Both parties agree to uphold the confidentiality of personal and medical information shared during the term of this agreement.
This agreement will be governed by the laws of [Jurisdiction].
[Signature of the Provider]
[Name of the Provider]
[Signature of the Resident]
[Name of the Resident]
[Name of the Provider]
[Provider’s ID]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
[Name of the Resident]
[Resident’s ID]
[Resident’s Address]
This agreement establishes the terms regarding the negotiated risks associated with assisted living services starting on [Contract Start Date].
The Provider will deliver the following services to the Resident: [List specific services, e.g., assistance with daily living activities, health monitoring].
The Resident has been informed of the risks involved with the agreed-upon services and acknowledges the potential need for alternative arrangements should their condition change.
In case of an emergency, both parties agree to the following procedures: [Specify procedures, e.g., contacting healthcare providers, emergency contacts].
The Resident agrees to assume financial responsibility for services rendered, including any co-payments or additional costs incurred due to negotiated risks.
This agreement will be reviewed periodically to ensure it meets the Resident’s current needs and conditions. Amendments may be requested by either party.
In the event of any disputes arising from this agreement, both parties agree to follow the outlined dispute resolution process: [Specify process].
[Signature of the Provider]
[Name of the Provider]
[Signature of the Resident]
[Name of the Resident]
Form
Please complete the form below to create the Negotiated Risk Agreement Assisted Living Template. All fields must be filled out to ensure a clear and complete agreement. We provide examples to guide you through each step. Negotiated Risk Agreement Assisted Living Template 1. Resident Information 2. Facility Information 3. Agreement Details 4. Risk Overview 5. Identified Risks 6. Strategies to Mitigate Risks 7. Resident and Family Involvement 8. Acknowledgment of Risks 9. Signatures and Acceptance 10. Declaration and Signatures
PDF
WORD
Negotiated Risk Agreement Assisted Living Template Printable | Editable FormPrintable
