Access the Service Agreement Template tailored for Medicaid waiver or healthcare agencies. This template covers essential terms and can be customized based on your specific agency needs.
Service Agreement
This Service Agreement ("Agreement") is entered into on [Date] by and between [Agency Name] ("Provider") and [Client Name] ("Client") to outline the terms and conditions for the provision of services.
1. Scope of Services
Provider agrees to deliver the following services:
- [Description of Service 1]
- [Description of Service 2]
- Additional services as outlined in Attachment A (if applicable).
2. Duration of Agreement
This Agreement shall commence on [Start Date] and shall continue until [End Date or specify terms, e.g., "until terminated by either party in accordance with this Agreement"].
3. Service Schedule
Services will be provided on the following schedule:
- Days: [Specify days of the week, e.g., Monday, Wednesday, Friday]
- Time: [Specify times, e.g., 9:00 a.m. to 5:00 p.m.]
4. Location of Services
Services will be delivered at:
- Client's Residence: [Specify Address]
- Other Location: [Specify Address if applicable]
5. Fees and Payment Terms
- Service Fees: Client agrees to pay [Specify Fee Amount, e.g., $25/hour] for services rendered.
- Billing Cycle: Payments are due on a [weekly, bi-weekly, monthly] basis, payable upon receipt of invoice.
- Late Fees: A late fee of [Specify Late Fee, e.g., 5%] will be applied to payments not received within [Specify Number of Days, e.g., 15 days] of the due date.
6. Rights and Responsibilities of the Provider
Provider agrees to:
- Provide services in a safe, professional, and respectful manner.
- Maintain compliance with all state and federal regulations.
- Protect the confidentiality of Client information in accordance with HIPAA regulations.
7. Rights and Responsibilities of the Client
Client agrees to:
- Provide a safe working environment for the Provider's staff.
- Notify the Provider in advance of any schedule changes or cancellations.
- Fulfill financial obligations as outlined in this Agreement.
8. Termination of Agreement
This Agreement may be terminated by either party with [Specify Number of Days, e.g., 30 days] written notice to the other party. Provider reserves the right to terminate services immediately in cases of non-payment, unsafe working conditions, or violations of this Agreement.
9. Indemnification
Client agrees to hold harmless and indemnify Provider, its agents, and employees from any claims or damages arising from the services provided under this Agreement, except in cases of gross negligence or willful misconduct.
10. Confidentiality
Provider and Client acknowledge that they may have access to confidential information about each other. Both parties agree to keep such information confidential and not disclose it to any third parties except as required by law.
11. Entire Agreement
This Agreement constitutes the entire understanding between the Provider and the Client, superseding all prior agreements, whether oral or written. Any modifications to this Agreement must be made in writing and signed by both parties.
12. Governing Law
This Agreement shall be governed by the laws of the State of [Specify State].
Signatures
Client Signature: ___________________________________________ Date: ___________________
Provider Representative Signature: ____________________________ Date: ___________________
You may reach out to us for a more customized form based on your state-specific regulation. Call 302.888.9172 or email licensing@waivergroup.com for assistance.