Client Agreement

12-03-2024
Date: ___________________

Client Information
Last Name Nelson First Name Donald Middle Initial n/

Address 3440 N HARDING ST , Indianapolis , IN - 46208

City Indianapolis State IN Zip 46208

Telephone 3176921357 Alternate Phone

Contact or Personal Representation

Last Name Patterson First Name Tiffany Middle Initial D

Address 3440 N HARDING ST , Indianapolis, Indianapolis - 46208

City Indianapolis State IN Zip 46208

Telephone +13174573470 Alternate Phone

Do you have a power of Attorney? Yes No

Emergency Contact
Last Name Patterson First Name Harold Middle Initial n/

Address 571 West Napier Avenue

City Benton Harbor State Michigan Zip 49022

Telephone 269-925-3747 Alternate Phone

Authorization of Services
I authorize the employees of Abby Care to render services as outlined in the Service Plan, a copy of which is
attached. I understand that the Service Plan may be changed upon my request.

Initial: ___________________

IC 16-27-4-12 Page 1

Document Ref: C74DA-MZKWE-H2RPZ-PCTAH Page 1 of 4

 Term and Termination
12-04-2024
This agreement shall commence upon _________________________. This agreement shall continue for one year
and shall renew automatically each year. This agreement may be terminated by either party upon written
notice. This agreement shall automatically terminate upon my death.

Initial: ___________________

Services to be Provided
Attendant Care At $15 per hour

Structured Family Caregiving At $ Daily per hour

At $ Rate per hour

At $ per hour

At $ per hour

At $ per hour

At $ per hour

At $ per hour

At $ per hour

At $ per hour

Verification of Service
I agree to provide my signature on a service record(s) or time document(s) necessary to verify that the
employee(s) of Abby Care has/have provided planned services on a given date. I agree to not withhold my
signature on the time/service record unless I disagree with the documentation or representation made therein.
I understand that signing documentation indicating I have received services when I have not received them is
fraud and could result in penalties against me.

Initial: ___________________

IC 16-27-4-12 Page 2

Document Ref: C74DA-MZKWE-H2RPZ-PCTAH Page 2 of 4

 Financial Responsibility
I agree to be responsible for payment of services, including those not paid by my insurer, if applicable. Abby
Care will bill the insurer directly. Invoices will be sent bi-weekly. I agree to pay within 10 days of receipt of the
invoice. If my account is not paid within 10 days, I agree to pay Abby Care reasonable attorney fees and costs
incurred in collecting these amounts. Upon my death, my estate to heirs will pay any unpaid amounts due to
Abby Care.

Initial: ___________________

Assignment of Benefits
If Abby Care bills my insurance company and Insurer pays, I hereby assign benefits to Abby Care and authorize
the insurer to pay Abby Care directly.

Initial: ___________________

Medicaid Waiver Services

Notice of Action # Case Manager

IHCP # Case Manager ID #

Term of NOA from date: 11-28-2024 To date: 12-01-2025

Service Authorizations: Number of Hours per Month

ATTC: 21 HMK: RATTC: RHMK:

I understand the services and number of hours is authorized by the Area Agency on Aging in the Notice of
Action. I agree to pay Abby Care for any hours and/or services agreed to in the service plan that I/we have
requested that are above and beyond those that have been authorized by the Area Agency on Aging.

Initial: ___________________

Release of Information
I authorize Abby Care to release information about clients to healthcare providers, third party payers,
government surveyors, accrediting bodies, auditors or other organizations that may assist me to meet or
improve my activities of daily living or independence.

Initial: ___________________

IC 16-27-4-12 Page 3

Document Ref: C74DA-MZKWE-H2RPZ-PCTAH Page 3 of 4

 Hiring Employees
I agree not to employ the employee(s) Abby Care assigned to the client for a period of one year following the
last day of the employee(s) rendered services to the client. In the event that I violate this condition, I agree to
pay $1,000 as a finder’s fee and any reasonable attorney fees and costs associated with collecting those
liquidated damages. This amount reflects the costs of recruiting, screening, and training the employees.

Initial: ___________________

Jurisdiction and Venue

If it is necessary to litigate a dispute arising out of or relating to this agreement, I agree to Jurisdiction in the
State of Indiana and the venue in the Court of Marion County, Indiana.

Initial: ___________________

Client Agreement

Client Donald Nelson

Client Name: _________________________________________________________________________________

Client Signature (if applicable): _______________________________________________________________

12-03-2024
Date: ________________________________

Client’s Personal Representative

Tiffany D
Client’s Personal Representative Name (if applicable): _________________________________________
Patterson
Client’s Personal Representative Signature (if applicable): _____________________________________

Date: ________________________________

Abby Care Representative

Joel Richardson
Abby Care Representative Name: _____________________________________________________________

Case Manager
Abby Care Representative Title: _______________________________________________________________

Abby Care Representative Signature: __________________________________________________________

12-03-2024
Date: ________________________________

IC 16-27-4-12 Page 4

Document Ref: C74DA-MZKWE-H2RPZ-PCTAH Page 4 of 4

Signature Certificate
Reference number: C74DA-MZKWE-H2RPZ-PCTAH

Signer Timestamp Signature

Joel Richardson
Email: joel@[Link]
Shared via link

Sent: 03 Dec 2024 [Link] UTC

Viewed: 03 Dec 2024 [Link] UTC
Signed: 03 Dec 2024 [Link] UTC IP address: [Link]

Donald Nelson
Email: dn3664@[Link]
Shared via link

Sent: 03 Dec 2024 [Link] UTC

Viewed: 03 Dec 2024 [Link] UTC
Signed: 03 Dec 2024 [Link] UTC IP address: [Link]

Document completed by all parties on:

03 Dec 2024 [Link] UTC

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