Negotiated Service Agreement
Resident Name: _____________________________ Apartment # ______
Date of this Agreement: _______________________
The following Negotiated Service Agreement is entered into by and between
Kenneth Caldwell Assisted Living Manor and _______________________ for services
provided to ________________________.
The purpose of this Agreement is to outline the care and/or services necessary for
Resident, which services addresses Resident’s cognitive issues and are developed with
consideration for Resident’s preferences as to how services are to be delivered. When a
service is provided by an outside resource, this Agreement will indicate the outside
resource and source of payment.
Services Provided by Kenneth Caldwell Assisted Living Manor:
1. Nutrition Services:
___ 3 meals daily ___Room Tray ___Reminders
Needs/Preferences:
__________________________________________________________________
__________________________________________________________________
2. Nursing Services:
Licensed Nurse responsible for nursing plan: ____________________________
___Diabetic Management ___Treatment Management
___Medication Management ___Behavior Management ___Education/Teaching
Needs/Preferences: ________________________________________________
__________________________________________________________________
3. Personal Care: ___Ambulation/Transfer ___AM Dressing Assist ___Fall Prevention
___Toileting Assist ___PM Dressing Assist ___Personal Hygiene
___Bathing ___Neck Alarm
Needs/Preferences: _________________________________________________
__________________________________________________________________
4. Housekeeping/Laundry Services: ___Linens Weekly ___Personal Laundry
___Weekly Cleaning ___Daily Bed making
Needs/Preferences: __________________________________________________
5. Transportation: __Medical/Dental Appointments ___Social Transportation
Needs/Preferences: __________________________________________________
6. Activity/Socialization:
Needs/Preferences___________________________________________________
__________________________________________________________________
7. Personal Shopping:
___Resident ___Family ___Facility ___Other
Needs/Preferences:
__________________________________________________________________
8. Money Management: ___Resident ___Family ___Legal Representative ___Other
Needs/Preferences:
__________________________________________________________________
9. Refusal of Services:________________________________________________
10. Consequences of refusal:____________________________________________
11. HCBS Services____________________________________________________
Services Provided by Outside Agency:
Service: Podiatry Service: Lab
Provider: Christopher Surtman Provider: AMS
Billed to: _________________ Billed to: ___________
Service: Therapy____________ Service: Home Health/Hospice
Provider: Select Rehab_______ Provider: _________________
Billed to: ___________________ Billed to: _________________
Service: Oxygen Service: Pacemaker check
Provider: __________________ Provider: ______________
Billed to: __________________ Billed to: ______________
Service: ___________________ Service: Social Serv/Psych Consult
Provider: __________________ Provider: _____________________
Billed to: ___________________ Billed to: _____________________
_____________________________________ _________________________________
Resident’s Signature Date Legal Representative Date
_____________________________________ _________________________________
Licensed Nurse Date Family Member Date
Mailed for signature: Date sent__________ Date returned__________
