Bcal 3266 Form – Fill Out and Use This PDF

AFC – RESIDENT CARE AGREEMENT

Michigan Department of Human Services

Division of Adult Foster Care Licensing and Home for the Aged Licensing

This agreement to provide adult foster care for (resident’s name)				is made
between (licensee name)			and (resident/resident’s designated representative)
.

This agreement is required to be completed at the time of a resident’s admission, reviewed annually, and updated as needed to reflect changes.

This agreement is to be completed by the licensee in cooperation with the resident or his/her designated representative and the responsible agency, if applicable, Designated representative means that person or agency which has been granted written authority, by a resident, to act on behalf of the resident or which is the legal guardian of a resident. Acceptable written authority includes orders of guardianship or conservatorship, powers of attorney, durable powers of attorney, or other documents executed by the resident that specify the relevant scope of authority. If a resident’s designated representative signs this agreement, a copy of the signer’s written authority is to be maintained in the resident’s file at the AFC home.

A resident shall be provided care and services as stated in this resident care agreement and the resident’s assessment plan.

This agreement constitutes the fee policy statement required by Family Home Rule 400.1407(11), if applicable.

RESIDENT OR DESIGNATED REPRESENTATIVE CHECK ALL BOXES BELOW THAT APPLY:

I have received a copy of the house rules (if applicable) and agree to follow them.

I agree to provide all required resident information to the licensee, including a current health care appraisal, at the time of admission, annually and as the resident’s condition changes.

I agree to participate in all required fire and emergency drills, as determined by BCAL and the licensee. I have signed and received a copy of the home’s refund agreement. (GROUP HOMES ONLY)

I have received a copy of the home’s discharge policy and agree to follow those procedures. (GROUP HOMES ONLY)

I agree to have the licensee manage funds and account for financial transactions on my behalf. Expenditures of my personal funds over

the amount of $

require my prior written approval.

I agree to pay the licensee the agreed upon fees for the services designated.

I agree to pay the basic fee of $

on a

basis.

daily, week or monthly

The basic fee includes the following basic services:

and are further described in the resident’s assessment plan, and attachment

, if applicable.

The basic fees do not include any transportation services.

The basic fees include the following transportation services.

Transportation fees are charged as follows:

and are further explained in attachment

, if applicable.

BCAL-3266 (Rev. 10-13) Previous editions obsolete. MS Word

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I agree to additional services according to the fee schedule contained in attachment			. Such additional
services may include but are not limited to:

If applicable. I have read the attachments relating to fees and agree with the terms and conditions established therein, I further
acknowledge that additional services are available for additional fees as described in attachment	.

BY MY SIGNATURE BELOW, I AFFIRM THAT:

This home is licensed by the Department of Human Services to provide foster care to adults.

I have provided the resident with a copy of the AFC Resident Rights and agree to respect and safeguard these rights.

I have provided the resident with a copy of the home’s discharge policy and procedures and agree to follow them. (AFC Group Homes only.)

I have provided the resident with a signed copy of the home’s refund agreement. (AFC Group Homes only.)

I agree to provide personal care, supervision, and protection, in addition to room and board, and to assure the availability of transportation services as indicated in this agreement, the resident’s written assessment plan, and the resident’s health care appraisal, as defined in the act.

A copy of this resident care agreement is required to be provided to the resident’s guardian or resident’s designated representative and also be maintained in the resident’s file at the AFC home.

Attachments to this Resident Care Agreement and any other agreements or contracts with this licensee may not have been reviewed and/or approved by the department. If any contractual provision contained in an attachment conflicts with the Adult Foster Care Facility Licensing Act and/or administrative rules, the act and rules would prevail and the specific provision is not binding.

SIGNATURES

Resident	Date
Resident’s Designated Representative (if applicable)	Date
Licensee/Licensee Designee	Date
Responsible Agency (if applicable)	Date

Compliments, comments and/or complaints about this licensed facility can be made by calling the licensing consultant, or at www.michigan.gov/afchfa. Additional information regarding adult foster care is also available at this website.

Complaints (only) can also be made by calling toll-free: 1-866-856-0126.

BCAL-3266 (Rev. 10-13) Previous editions obsolete. MS Word

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