Client Service Agreement
This Agreement is made effective immediately between N.A.T.I.V.E. Placements ("Agency") and the Client (individual, family, and/or entity requesting placement services) upon acknowledgment of this Disclosure.
Introduction
N.A.T.I.V.E. Placements provides personalized services to clients, their family members, or legal representatives seeking retirement living resources and elder care options. The relationship is at-will, and the client may terminate the relationship with written notice at any time.
Services Provided:
__Care Management- ___Organizational Payee (Representative Payee)
- __Retirement Living Placement
Referral Services Include:
- Independent Living Communities
- Assisted Living
- Memory Care
- Board and Care Homes
- Independent Living Facilities
- Single Room Occupancy
- In-Home Care Agencies
- Cal-AIM Programs
- Community-Based Organizations
Referrals are based on the intake assessment, which includes health history, personal preferences, care needs, and financial abilities. All client information is handled confidentially and in compliance with applicable laws.
Client Responsibilities:
Clients agree to comply with all provisions related to placement, referrals, and care coordination services. Clients and authorized representatives agree to use the information provided in compliance with all state and federal laws.
Confidentiality and Information Security:
N.A.T.I.V.E. Placements and the Client will make every reasonable effort to safeguard and secure all client information. All client data will be held in strict confidence, except as permitted by law, and only used for necessary business purposes related to placement and care services.
Medical Release of Information:
This document acts as a medical release and allows information sharing with providers related to admission and care services.
Liability & Indemnification:
N.A.T.I.V.E. Placements is not liable for the actions or omissions of any referred provider, community, or care facility. The Client agrees to indemnify and hold harmless N.A.T.I.V.E. Placements from any claims, damages, or liabilities related to services provided by third-party organizations.
Referral Fees:
N.A.T.I.V.E. Placements represents both the client and the retirement living or elder care provider. Providers pay a referral fee after the client assumes financial responsibility. Referral fees cannot be passed onto the client and are governed by provider contracts.
Agency Agreement:
By signing this agreement, the Client appoints N.A.T.I.V.E. Placements to assist in the search for long-term care and housing. This agreement supersedes any verbal, written, or internet-based agreements.
- Term: The agreement expires one year from the service start date.
- Warranties: N.A.T.I.V.E. Placements makes no warranties regarding the suitability of any referral and advises the client to conduct necessary investigations.
- Fees: Placement and referral services are free. Additional consulting services are available at $200/hr.
- Medicaid Clients: Referral fees cannot be collected for Medicaid clients, except for private-pay portions of care.
Complaints:
For concerns regarding elder abuse or neglect, contact Adult Protective Services at 1-833-401-0832 and enter your zip code for assistance.
Authorization:
Authorization: I certify that this request has been made freely, voluntarily and without coercion and that the information provided to N.A.T.I.V.E. Placements partners is accurate and complete to the best of my knowledge. I understand that I can revoke my authorization at any time in writing. I hereby accept the Disclosure of Services and I Agree with all terms above, and I acknowledge receiving the N.A.T.I.V.E. Placements Disclosure of Services and Agency Agreement.
By signing below, the Client acknowledges understanding and agreement to the terms outlined above.
Client's Name: ________________________________
Client's Signature: ____________________________ Date: _______________
Client Representative Name: ______________________
Client Representative Signature: ________________ Date: _______________
REPRESENTATIVE PAYEE AGREEMENT
This Representative Payee Agreement ("Agreement") is made effective as of Date: _________, by and between N.A.T.I.V.E. Placements, a nonprofit 501(c)(3) organization ("Payee"), and Client Name: ________________________________ ("Client" or "Beneficiary").
Purpose:
N.A.T.I.V.E. Placements will serve as the Organizational Representative Payee for the Client’s Social Security or Supplemental Security Income (SSI) benefits to ensure funds are used in the Client’s best interests.
Client Responsibilities:
- Maintain sobriety when conducting business with N.A.T.I.V.E. Placements.
- Treat staff with courtesy and respect.
- Conduct business by appointment only.
- Receive personal spending funds through designated disbursement methods.
- Allow N.A.T.I.V.E. Placements to deposit checks on behalf of the Client into a trust account.
- Request statements as needed.
Failure to comply may result in a request to SSA for reassignment of the Representative Payee role.
By signing below, the Client acknowledges and agrees to the terms of this Representative Payee Agreement.
- Client's Name: ________________________________
Client's Signature: ____________________________ Date: _______________
N.A.T.I.V.E. Placements Representative: ____________________________
Signature: ___________________________________ Date: _______________
Client Service Agreement (1) (pdf)
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N.A.T.I.V.E. PLACEMENTS
8929 Complex Drive Suite 7-A, San Diego, California 92123, United States
Hours
Today | Closed |
Saturdays are by appointment only
Closed Sundays and all major holidays
New clients please fill out the Intake and Client Service Form and our Care Coordinator will follow up with you.
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