Advocate 4 Elderly

Elder Care Advocacy

Advocate 4 Elderly

Client Intake

Registration Form

Client & HIPAA Forms

This form must be completed in its entirety prior to the client being cared for by Advocate 4 Elderly.

Client Information

Please provide complete and accurate information about the client.

First Name*

Middle Initial

Last Name*

Date of Birth*

How the client prefers to be addressed*

Name of Residential Care Home*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Insurance Plan Name

Policy Number

Contact Information

Contact Name (Client or Assisted Living)*

Contact Phone Number*

Family Member or POA Responsible

Title*

First Name*

Middle Initial

Last Name*

Your Phone*

Your Email*

Emergency Backup Contacts

Emergency Contact 1 Name*

Emergency Contact 1 Phone*

Emergency Contact 2 Name

Emergency Contact 2 Phone

Billing Information

Billing address and payment information for the responsible party.

Billing Address

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Credit Card on File

Your card information is stored securely and used only for approved charges per the billing policies below.

Name on Credit Card

Credit Card Number

Terms & Conditions

Please read all sections carefully before signing.

Communication & Coordination

Accurate and timely communication is essential to providing effective advocacy and support services.
Clients and/or responsible parties must provide a reliable phone number where they can be reached during services in the event of an emergency, scheduling issue, or important care-related communication.
If transportation services are being provided, clients or facilities must notify Advocate 4 Elderly as soon as possible regarding delays, cancellations, or schedule changes.
If transportation delays caused solely by Advocate 4 Elderly result in a missed appointment, the fee for the rescheduled appointment will be waived.
If an advocate accompanies a client into a medical appointment, Advocate 4 Elderly may provide appointment notes or summaries to the client and/or authorized parties within approximately 24 hours.

HIPAA & Medical Information Authorization

By requesting, scheduling, or utilizing services through Advocate 4 Elderly, the client and/or authorized responsible party acknowledges and authorizes Advocate 4 Elderly to communicate with physicians, hospitals, medical offices, rehabilitation facilities, care facilities, insurance representatives, pharmacies, and healthcare staff as reasonably necessary to coordinate advocacy and support services.

This authorization may include discussion and review of relevant medical information, care plans, appointment information, discharge planning, insurance matters, medications, and related healthcare records as permitted under applicable HIPAA regulations and any additional written authorizations provided by the client or legal representative.

Clients understand that certain providers or facilities may require separate HIPAA release forms or written authorizations before releasing specific records or information.

Billing & Payment Policies

Payment for services is due within ten (10) calendar days of invoice delivery ("Net 10") unless otherwise agreed to in writing.
Invoices are typically emailed within 24 hours of services rendered. For accounts enrolled in automatic payment, the authorized card on file will be processed within 48 hours of invoice delivery unless a billing concern is raised before processing.
A 2.99% processing fee applies to all credit or debit card transactions.
Accepted payment methods: credit or debit card, Zelle, or check mailed to the Advocate 4 Elderly office.
No out-of-pocket purchases, supplies, transportation expenses, or third-party costs will be advanced by Advocate 4 Elderly without an approved payment method on file unless otherwise agreed in writing. Reasonable spending caps or pre-approval arrangements may be established upon request.
Past-due invoices may incur a $50 late fee per billing cycle, suspension of future services, mandatory enrollment in automatic payment, or immediate payment requirements before additional services are scheduled.
Returned checks, declined payment methods, chargebacks, or disputed charges determined to be valid may result in additional administrative fees and immediate suspension of services until the balance is resolved.
In the event collection activity or legal proceedings become necessary to recover unpaid balances, the client agrees to be responsible for reasonable collection costs, court costs, filing fees, attorney's fees where permitted by law, and other related recovery expenses.

Autopay & Recurring Payment Authorization

Clients enrolled in automatic payment may receive a 0.5% courtesy discount.
By enrolling in autopay or providing a payment method on file, the client authorizes Advocate 4 Elderly to process approved charges related to services rendered and authorized expenses.
Receipts may be emailed following processing.

Independent Contractor & Non-Solicitation Policy

All services must be coordinated directly through Advocate 4 Elderly.
Clients, family members, facilities, or representatives agree not to directly hire, solicit, contract with, or otherwise engage Advocate 4 Elderly employees, contractors, or representatives outside the company relationship during active services and for twelve (12) months following the last date of service.

Limitation of Liability

Advocate 4 Elderly provides advocacy, coordination, communication, and support services but does not provide medical, legal, or emergency healthcare services.
Clients understand that healthcare outcomes cannot be guaranteed.
To the fullest extent permitted by law, Advocate 4 Elderly shall not be liable for injuries, damages, delays, medical outcomes, or losses except in cases involving gross negligence, willful misconduct, or failure to exercise reasonable care.

Acceptance of Terms: By using this website, requesting services, scheduling appointments, submitting payments, or continuing engagement with Advocate 4 Elderly, clients acknowledge that they have read, understood, and agreed to these Terms & Conditions.

I have read, understood, and agree to all Terms & Conditions above, including the Communication & Coordination, HIPAA Authorization, Billing & Payment, Autopay, Non-Solicitation, and Limitation of Liability policies.

Signature & Agreement

By signing below, you confirm you have read and agree to all policies above.

Client / POA Printed Name*

Date*

Client / POA Signature*

You must sign below before this form can be submitted. Type your name above, then click the signature field.

Enter your name above, then click here to sign

By clicking above, you are providing a legally binding electronic signature.

Advocate 4 Elderly

520-990-2119