Client Admission Packet

Where Caring for Your Family is an Excellence

Price List

Personal Care

4 Hours Minimum Per Shift / 8 Hours Minimum Per Week
Bathing, Dressing, Grooming, Mobility Assistance, Incontenence Care, Transfers.


4 Hours Minimum Per Shift / 8 Hours Minimum Per Week
Meals, Light Housekeeping, Transportation, Medication Reminders, Alzheimer's, Dementia.
Rates will be determined at the time of care consultation and are evaluated through our Supevisory Visits and feedback from our caregivers. Services may fluctuate in these evaluations from one classification  to another, depending on the need of the client, Severity of Alzheimer's / Dimentia may affect level of care required.

Cancellations, Billing and Payment

Cancellation Fee
This fee is applied for cancellation services wthout a minimum of 24- hour notice. $56.00
Service Deposit
A service deposit equivalent to 7 days of service will be required before the start of services. It will be refunded at completion of service once the final balance is paid in full.
Invoices are sent weekly and terms are net due within 5 days of the end of the invoice period.
Payments made via check, cash, or automatic withdrawal through your financial institution.


Theres nothing more important than a convenient and reliable care solution that works for everyone in your family, whenever your loved ones need home health services. Contact us to begin a care plan to fit your family needs.

Companionship Services

Offer Companionship / Conversation
Simple Respite Care
Monitor diet and eating
Check Food Expiration
Participate in crafts
Play games / Cards
Stimulate mental awareness
Assist with entertaining
Answer the door
Photo Memory
Assist with reading
Write letters and correspondence
Prepare grocery lists
Clip Coupons
Monitor TV usage
Assist with clothing selection
Assist with walking
Visit Friends / Family

Home Making Services

Provide Light Housekeeping
Escort to appointments
Prepare future meals
Accompany to lunch / dinner
Assist with laundry / ironing
Pick up prescriptions
Change bed linen
Help with airport tasks
Attend club meetings and events
Take out garbage
Make bed
Escort to church

Personal Care Services

Cognitive impairment


Hires caregiver who are screened, trained, bonded, and insured.
Responsible for firing, scheduling, handling performance issues and paying state and federal payroll taxes.
Handles all other employment obligations such as workers' compensation, liability coverage, and addressing performance issues.
Supplies added support between the family, caregiver and client.
Independent contractor with a Registry
A caregiver is recruited, screened and referred to the customer.
You become the employer and handle hiring, scheduling, handling performance issues, and paying federal and state taxes.
You assume the isk as the employer since the independent contractor will be covered by workers compensation liability and bond insurance.
While the contractor may have had a criminal background check and reference check, it is likely they are not receiving support, training and education nor is a replacement caregiver available should they be sick.
Independent Caregivers

Otherwise referred to as "the gray market", the independent caregiver handles marketing themselves and finding new clients.
They may have criminal Background and reference checks at the expense and effort of you.
You become the employer and handle scheduling, handling performance issues and paying federal and state payroll taxes.
You assume the risk as the employer since the independent caregiver will not be covered by workers compensation, liability and bond insurance.
The independent caregiver does not receive support, training and continuing education, nor is a replacement caregiver available should they be sick.

Questions to Ask a 
non-medical homecare service provider

Is the individual and agency employee (recommended arrangement), and independent contractor with a Registry (make sure you understand the implications), or are they working on their own/independent (be wary)?

Admision Packet

Health Plan Information

  • We offer a personalized, 8-hour Alzheimer's training class for Caregivers developed by leading experts in their field, this class will help enhance the lives of he seniors we serve.
  • We have our own training facility where our Caregivers are trained by our licensed RN staff in all.
  • Our unique computer tracking system supplies our office the exact time caregivers arrive and leave clients home.
  • Our caregivers have special training in safety and precaution. We also supply level 2 background and reference check, and random drug testing.
  • We handle all payroll taxes, insurance, worker compensation, and third-party bonding.
  • We supply free in-home consultation at the request of the family. Same day consultations are available.
  • We also monitor Quality Services by contacting client or family members monthly.
  • We provide 24 hours 7 days a week contact with trained staff members for any questions or concerns you may have.
  • We make any adjustments for clients such as time of services or Caregivers replacement. (We work for you; you do not work for us.)
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Patients Right/Emergency Plan/Complaint Procedure: I have been informed of my rights and received a copy of the Clients Bill of Rights prior to the start of care procedure. Advanced Directives Emergency Plan, Out-of-Hospital, Do-Not-Resuscitate. Patient's Conduct & Responsibilities, Abuse/Neglect/Exploitation: I have been allowed to participate in planning my care and have received a copy of the states Toll Free Home Health Agency Hotline Number for Florida, 1888-419-3456 which receives complaints or grievances 24 hours a day, seven days a week.

CONFIDENTIALITY: It is our policy to protect all clinical records against loss, defacement, tampering, and use by unauthorized person or persons. All identifiable information in the clinical record, including OASIS data remains confidential and is not released to the public. OASIS data will be electronically transmitted to the state. The patient's written consent shall be required for the release of medical information to person not otherwise authorized by law (federal and state) to receive the information. Authorized persons who may review the clinical record include surveyors, physicians, Centers for Medicare, and Medicaid Services(CMS), and external and internal auditing personnel.

RELEASE OF RECORDS: I understand the agency policy with regards to confidentiality and release of records prohibits access to my providers in my treatment care. The patient has received written information regarding their rights to make healthcare decisions.

Patient / Authorize Agent Signature
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Agency Representative Signature
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Authorization, Agreement, and Acknowledgements

I GRANT permission to the employees of Heart of Carrie LLC, herein referred to as "The Agency" to render nursing care and other ancillary skilled professional home health services such as required and ordered by my physician and as outlined in the plan of care.

I ACKNOWLEDGE that the agency has informed and explained to me the PATIENT BILL OF RIGHTS. I have received information on Advance Directives, Directives Physicians, Durable Power of Attorney for Home Health Care and Out of the Hospital DNR orders, the services to be provided, the supervision of the services, and charges for services rendered will be the responsibility of the patient/family to pay.

I Authorize the Agency to release any medical information requested by representative of local, state, or federal agencies, accrediting bodies, insurance companies, or other organizations or entities as may be required by said for representatives for payment of claims out of this home health care which are due. The agency has notified me of the policies and procedures regarding disclosure of any records.

I realize that agency staff may not be always present in my home and my caregiver or legal guardian will assume responsibility for my care when agency staff / contractors are not present. I understand that the agency does not routinely perform drug testing on staff/contractors but may do so at our discretion using urine samples.

I understand the agency will notify me in writing and orally, no later that 30 calendar days from the date they become aware of the changes not covered by Medicare or other sources.

I understand that in the event of an emergency during which the Agency cannot meet my needs, the Agency can transfer me to another Agency that can provide the care I require.

I understand that the Heart of Carrie LLC Employees may not be employed by me without first compensating the Heart of Carrie LLC $2500.00 or employees annual wages, which is even or greater.

I have been informed of the Agencies policies for resuscitation, medical emergencies and accessing 911 services (EMS).

I am aware that a Registered Nurse (RN) will be monitoring my care and if I have complaints regarding services rendered, I am to contact the RN in charge of my care.

I have been informed of my rights and that I may file complaints about the Agency with Florida Home Health Hotline at 1-888-419-3456 during regular business hours, after hours holidays calls will be answered by machine and responded to the next business day.

Client Name
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Client Signature

Plan of Care Report

The following information has been provided to and / or discussed with the Client:

Check All That Apply

Documentation and Information: I acknowledge that the information and documentation as noted above, has been discussed with me and I will be provided with a copy.

Client Consent: I consent to have the Non-Medical Home Service as requested and recorded in this service plan.

I understand that my service request/needs will be reviewed by the Supervisor at least every 6 months, or as required, and that the service(s) may be changed according to my needs, wants or wishes.

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Client Name
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Client/Client Representative's Signature
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Client Plans of Care is Privileged and Confidential Information: This is intended only for the sole purpose of providing care and does not provide health or medical information. Any use of this Document without the written consent of Heart of Carrie LLC is prohibited. If you have been given this document by error, please contact (386) 585-4406.

Plan of Care Report

Client Name
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Client is cognizant and functionally able to determine preference for type of bath
Caregiver Accommodations
Client Condition
Condition of Home
Coordination Organizations
Functional Limitations
Medication Reminders
Nutritional Services
Personal Interests
Place of Service
Service Level
Skin Precautions

Client Plans of Care is Privileged and Confidential Information: This is intended only for the sole purpose of providing care and does not provide health or medical information. Any use of this Document without the written consent of Heart of Carrie LLC is prohibited. If you have been given this document by error, please contact (386) 585-4406.

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Client Name
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Client/Client's Representative Signature
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Patient Rights and Responsibilities

Statement of Purpose

It is anticipated that observance of these rights and responsibilities will contribute to more effective care and greater satisfaction for the patient as well as the staff. The rights will be respected by all personnel and integrated into all Home Care programs. A copy of these rights will be given to patients and their families or designated representative. If the patient or his/her designated representative does not speak English, a copy of these rights will be provided in a different language that is understood. The patient or his/her designated representative has the rights to exercise these rights. In the case of a patient adjudged incompetent, the rights of the patient are exercised by the person appointed by law to act on the patients behalf. In the case of a patient who has not ben adjudged incompetent, any legal representative may exercise that patient's rights to the extent permitted by Law.

The Patient has the right:
  1. To be fully informed in advance about care/service to be provided, including the disciplines that furnish care and frequency of visits, as well as any modifications to the plan of care.
  2. To choose a healthcare provided.
  3. To access necessary professional services 24 hours a day 7 days a week. This care will be appropriate and professional care relating to physician orders.
  4. To be informed, both orally and handwritten in advance of care being provided, and of the charges including payment for care service expected from the third parties including Medicare, Medicaid, or any other federally funded or aided program known to the organization, charges for service that will be covered by Medicare and any changes for which the patient will be responsible.
  5. Receive information about care/services covered under the Medicare Home Health Benefits.
  6. Receive information about the scope of service that the HHA will provide and specific limitation of those services.
  7. Participate in the development a periodic revision of the plan of care
  8. Refuse care or treatment after the consequences of refusing care or treatment are fully presented.
  9. To be advised the agency complies with subpart I of 41 CFR 489 and receive a copy of the organization's written policies and procedures regarding advance directives.
  10. Be informed of patient rights under state law to formulate an Advance Directive.

Patient Rights and Responsibilities

The Patient had the Responsibility:

  1. To Provide, to the best of his/her knowledge, accurate and complete information about:
    1. Past and present medical histories.
    2. Unexpected changes in his/her condition.
    3. Whether he/she understands a course of action selected.
  2. To follow the treatment recommended by the Plan of Care.
  3. For his/her actions if he/she refuse treatment or does not follow physicians orders.
  4. For meeting those financial obligations of his/her health care plan and paying their invoices.
  5. To respect the rights of all staff providing the service.
  6. To notify the agency promptly in advance of an appointment or visit you must cancel.
  7. To become independent in care to the extent possible, utilizing self, family, and other sources.
  8. To pay for care or services not covered by third party payers.
  9. To comply with the rules and regulations established by the agency and any changes after the rules.
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  • Living Will or Out of Hospital Do Not Resuscitate (DNR)
  • Statutory Power of Attorney for Health Care decisions
  • Advance Directives In Florida - A Health Care Directive
  • HIPPA/Home Care Privacy Rights

I understand it is my responsibility o ask questions about the information provided by the Agency. They have offered to provide a copy of the state's Illustrative forms under state law if I request. I have also been advised to consult with my physician, lawyer, family, clergy, social worker, or other qualified personnel for additional information or contact with a lawyer should I need assistance in changing the forms to reflect my treatment wishes or in executing a Living Will or Statutory Power of Attorney for healthcare decisions.

I understand this agency will honor the advance directives and is willing and able to provide any procedure specified on the advance directives.

I understand the fact that I have or have not signed a living will or Statutory Power of Attorney for Home Care decisions do not affect the medical treatment and home care to be provided by the agency. I understand that it is the agency written policy to fully comply through its healthcare providers with the terms of a patient's Living Will or Statutory Power of Attorney for Healthcare decision to the fullest extent permitted by state Statutory Power of Attorney.

I have been given and explanation and acknowledge receipt of the HIPPA/PRIVACY RIGHTS. I understand that I may contact the Agency at any time for questions and concerns.



Patients have the rights to give adequate notice according to the use/disclosure of their Personal Health Information (PHI) on the first date of service delivery, or as soon as possible after an emergency.

The Privacy Rule grants patients new rights over their PHI including the following:

  1. Receive a Privacy Notice at the time of the first delivery date of service.
  2. Restrict use and disclosure, although the covered entity is not required to agree.
  3. Have PHI communicated to them by alternate means and an alternate location to protect confidentiality.
  4. Inspect, correct, and amend PHI and obtain copies, with some exceptions.
  5. Request a history of non-routine disclosures for six years prior.
  6. Contac designated persons regarding any concerns or breach of privacy within the facility or at HHS.
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Emergency Contact Address
In an event of evacuation
Is this patient in need of a special shelter?
Does patient have DNR?
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* Emergency Contact will be notified if the client returns home via telephone call and /or text message.


Emergencies include natural and manufactured disasters. This may include hurricanes, tornadoes, earthquakes, severe weather or other natural disasters or it may include manufactured disaster such as bioterrorism, terrorism, radiation, chemical spills, nuclear accidents and hazardous materials. Wherever you decide to seek refuge during an evacuation or other emergency, at a friend or a relative's home, a motel/hotel, an emergency public shelter, you must take provision with you.
  • Food that does not need cooking
  • Drinking Water in a non-breakable container (1 gallon per person per day)
  • Special dietary food if required
  • Identification, valuable papers, photos
  • Personal hygiene items such as: Soap, deodorant, shampoo, toothbrush, toothpaste, Aspirin, antacid, incontinent supplies, washcloth, towel, etc.
  • Utensils, such as: Manual can opener, disposable plates, cups, forks, knives, spoons, napkins
  • Prescription medicines, written prescription for refills & list of medications
  • Specific medical information in writing
  • Carrying container for items
  • Books magazines, cards, toys, and games for adults and children
  • Infant care items such as formula food, disposable diapers, and toys
  • Battery operated radio, extra batteries and earphones
  • Flashlight lantern
  • First Aid Kit including: betadine solution, bandages, adhesive tape, band-aids, safety scissors, non-prescription medicines
  • Spare batteries for radio and flashlights
  • personal aids such as: eyeglasses, hearing aids & prosthetic devices
  • Change of clothing and underwear
  • Sleeping bag or blanket



Section 1:

Client's Payor Source / Health Plan is

All clients will be financially responsible for service received. One-week advance payment is required before starting service.

Method of payment

Checks are payable to Heart of Carrie LLC.

Note: Private pay obligations and rates below do not apply to clients on Medicare or Medicaid and other Health Insurance Planes with existing contract with Heart of Carrie LLC.

Section 2:

Service to be provided:

Section 3:

Charges to be billed
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A: Authorization for Credit Card Use

I ( Type Name in field provided below ) willingly gave Hart of Carrie LLC. Staff my Credit/Food Stamp Card/Cash and will provide me with receipts after each purchase has been made.

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I ( Type Name in field provided below ) willingly gave Hart of Carrie LLC. Staff my House Key/Garage Key, to enter my home and provide service. I am disabled and unable to get up and open my door for staff all of the time. For this reason, I have given staff my house and or/ garage key. I request that my house keys be returned to me upon termination of service/contract with Heart of Carrie LLC..

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© 2024 Heart Of Carrie LLC. All Rights Reserved.
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