Form BCAL-3266 at a glance
What it is: BCAL-3266 is the AFC Resident Care Agreement, the agreement to provide adult foster care for a resident.
Who signs: The Resident, Resident's Designated Representative (if applicable), Licensee/Licensee Designee and Responsible Agency (if applicable) each sign with a Date.
A filled-in Form BCAL-3266 example: a licensee completes a monthly fee agreement
How to fill out Form BCAL-3266, box by box
Resident Name, Name of Home and License Number
Enter the Resident Name, the Name of Home and the License Number.
Who the agreement is made between
In "This agreement to provide adult foster care for (resident's name) is made between (licensee name) and (resident/resident's designated representative)", enter the resident's name and the licensee name.
Resident or designated representative: check all boxes that apply
The resident or designated representative checks all boxes that apply.
Check "I have received a copy of the house rules (if applicable) and agree to follow them." when it applies.
Check "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." when it applies.
Check "I agree to participate in all required fire and emergency drills, as determined by BCHS and the licensee." when it applies.
Check "I have signed and received a copy of the home's refund agreement." when it applies (GROUP HOMES ONLY).
Check "I have received a copy of the home's discharge policy and agree to follow those procedures." when it applies (GROUP HOMES ONLY).
Assistance by a staff member of the opposite sex
Mark I agree or I do not agree to receive assistance in bathing, dressing, or personal hygiene by a staff member of the opposite sex, if a member of the same sex is not available.
Safekeeping of funds and valuables
Mark I agree or I do not agree to entrust Funds or Valuables (specify) to the license for safekeeping, if this option is available.
Managing funds and the amount of expenditures
Check "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 $ you enter require my prior written approval.
Basic fee and basic services
Check "I agree to pay the licensee the agreed upon fees for the services designated." Enter the basic fee in $ and its basis, daily, week or monthly.
List the basic services in "The basic fee includes the following basic services:"; they are further described in the resident's assessment plan, and attachment, if applicable.
Transportation services and fees
Check "The basic fees do not include any transportation services." or "The basic fees include the following transportation services."
Check "Transportation fees are charged as follows:" and write them; they are further explained in attachment, if applicable.
Additional services and attachments
Check "I agree to additional services according to the fee schedule contained in attachment" and write the attachment; such additional services may include but are not limited to those you write.
If applicable, check "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
By my signature, I affirm that this home is licensed by the Department of Licensing and Regulatory Affairs 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
The Resident, Resident's Designated Representative (if applicable), Licensee/Licensee Designee and Responsible Agency (if applicable) each sign with a Date.
More rules for Form BCAL-3266
The licensee completes this agreement 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.
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.
Common questions about Form BCAL-3266
Is there a deadline?
This agreement is required to be completed at the time of a resident's admission, reviewed annually, and updated as needed to reflect changes.
Is there a penalty?
PENALTY: Violation of Adult Foster Care Administrative Rule.
Sources
[1] Form BCAL-3266 (Rev. 1-16), AFC Resident Care Agreement, Michigan Department of Licensing and Regulatory Affairs (the Official source link on this page).