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EMERGCARE 0966: HOME BASE CARE

This form is for individual and households not a medical aid plan seeking affordable, pre-paid emergency and transfer coverage

SECTION 1. PERSON RECEIVING CARE & RESPONSIBLE PARTY DETAILS

CLIENT (PERSON RECEIVING CARE)

Full Names

SECTION 1. PERSON RECEIVING CARE & RESPONSIBLE PARTY DETAILS

RESPONSIBLE PARTY (PAYER/CONTACT)

Full Names

SECTION 2. HEALTH AND CARE NEEDS ASSESSMENT

Please check all that apply to the client’s current status:

Mobility
Mobility Independent Cane Walker Wheel chair-dependent Bedridden
ADLs (Activities of Daily Living) - Assistance Required With:
Assistance required with: Bathing Dressing Toileting Feeding Transfers
Chronic Conditions
Medication Management
Special Procedures

SELECT CARE NEED CATEGORY

Benefit Options and Selection

EmerGcare0966 would typically offer tiered packages. You must contact them for current pricing and exact service lists

Option Name Service Level Typical Inclusions
1. The Connect (Entry Level) Monitoring & Companionship 1 scheduled visits per week. Includes vital signs monitoring, medication reminders, companionship.
2. The Guardian (Mid-Level) Assisted Living 3 scheduled visits per week. Includes Wellness Check Plan, mobility assistance with bathing/dressing/toileting.
3. The Premium (High-Level) Intensive Nursing/Long Hours Multiple visits daily or dedicated 24/7 care. Includes all Supported Living benefits, wound care, dedicated Registered Nurse oversight, and complex medical care as needed.
Selection (Rate/Week)
OPTIONAL ADD-ON SERVICES (Per occurrence or hourly rate)

TERMS and CONDITIONS

1. Scope of Agreement and Fees

  • 1.1. Engagement: This agreement covers only the services selected and agreed upon in the attached Care Plan and is provided at the Client's registered home address.
  • 1.2. Fees and Payment: Fees are payable in advance by the Responsible Party on or before the $1^{st}$ day of each month. Failure to make payment within 3 days of the due date may result in the immediate suspension or termination of services.
  • 1.3. Adjustments: Any increase or change in the scope of services must be agreed upon in writing by both parties. EmerGcare reserves the right to review and adjust rates annually with 30 days written notice.

2. Client and Home Environment

  • 2.1. Safety: The Client and Responsible Party must provide a safe, clean, and hazard-free environment for the care staff. EmerGcare staff have the right to withdraw immediately if they feel their personal safety is at risk.
  • 2.2. Cooperation: The Client/Responsible Party must fully disclose all relevant medical information and cooperate with the agreed-upon Care Plan.

3. Provision of Service and Staffing

  • 3.1. Staff Qualifications: EmerGcare confirms that all caregivers are appropriately trained and qualified for the services they provide.
  • 3.2. Replacement Staff: EmerGcare reserves the right to substitute caregivers due to illness, shift change, or other operational necessity to ensure continuity of care.
  • 3.3. Emergency Protocol (0966): In the event of a medical emergency, the caregiver will immediately initiate the 0966 EmerGcare Emergency Toll-Free Line protocol and notify the primary contact.

4. Limitation of Liability and Indemnity

  • 4.1. Liability: EmerGcare and its staff shall not be liable for any loss, damage, or injury arising from causes beyond their reasonable control, the natural progression of the Client's illness, or the failure of the Client/Responsible Party to comply with the Care Plan.
  • 4.2. Indemnity: The Responsible Party agrees to indemnify EmerGcare against all claims, costs, or losses arising from any act or omission by the Client or any other third party on the premises.

5. Confidentiality and Data Protection

  • 5.1. All personal and medical information collected is confidential and will be managed in accordance with Eswatini's applicable privacy laws. It will only be shared with medical professionals as required for the provision of care.

6. Termination of Agreement

  • 6.1. By Client: The Client/Responsible Party may terminate this agreement with 30 days written notice.
  • 6.2. By EmerGcare: EmerGcare may terminate this agreement with immediate effect if there is non-payment, a serious breach of the terms, or if the home environment is deemed unsafe for staff.
Agreement and Consent