CCA Client Intake

Electronic Transaction: I authorize Colorado CareAssist to initiate an electronic debit against the following account when payment is due. This authority remains in effect until I notify CCA in writing to cancel. I agree to a 3% transaction fee.

Receipts sent to payer via:

Name of Agency: Colorado CareAssist
Agency Type: Personal Care or Non-Medical

Each home care agency is required to provide the consumer information as to the responsibilities of the agency, the home care worker, and the consumer regarding the employment and duties of each.

Agency is the employer of record for all staff providing direct care services and is responsible for all items listed below.

Consumer	Worker	Agency	Responsibility
		✓	Employer of the home care worker
		✓	Supervision of the home care worker
		✓	Scheduling of the home care worker
		✓	Assignment of duties
		✓	Hiring, firing and discipline
✓			Provision of supplies/materials for services
		✓	Training and qualifications
		✓	Liability for worker in consumer's home

Consumer	Worker	Agency	Payment of:
		✓	Wages to the home care worker
		✓	Employment taxes
		✓	Social Security taxes
		✓	Unemployment insurance
		✓	General liability insurance
		✓	Worker's Compensation
		✓	Bond Insurance (if provided)

As a consumer of home care and services you are entitled to receive notification of the following rights both orally and in writing. You have the right to exercise the following rights without retribution or retaliation from agency staff:

1. Receive written information concerning the agency's policies on advance directives, including a description of applicable state law;
2. Receive information about the care and services to be furnished, the disciplines that will furnish care, the frequency of proposed visits in advance and receive information about any changes;
3. Receive care and services without discrimination based upon personal, cultural or ethnic preference, disabilities or whether you have formulated an advance directive;
4. Authorize a representative to exercise your rights as a consumer of home care;
5. Be informed of the full name, licensure status, staff position and employer of all persons supplying, staffing or supervising the care and services you receive;
6. Be informed and participate in planning care and services and receive care from staff who are properly trained and competent;
7. Refuse treatment within the confines of the law and be informed of the consequences;
8. Participate in experimental research only upon your voluntary written consent;
9. Have you and your property treated with respect and be free from neglect, financial exploitation, verbal, physical and psychological abuse;
10. Be free from involuntary confinement and from physical or chemical restraints;
11. Be ensured of the confidentiality of all records, communications, and personal information;
12. Express complaints verbally or in writing about services or care that is or is not furnished.

If you believe your rights have been violated you may contact the agency directly:
Colorado CareAssist, 1911 11th Street, Floor 2, Boulder CO 80302

You may also file a complaint with:
Health Facilities and Emergency Medical Services Division, CDPHE
4300 Cherry Creek Drive South, Denver, CO 80246
303-692-2910 or 1-800-842-8826

I understand that all Personal Care Workers employed by Colorado CareAssist Inc. who are assigned transporting duties are required to have valid drivers' licenses and carry relevant vehicle insurance including Personal Injury Protection.

I understand that CCA checks employees' driving records to ensure they are free from infractions.

I understand that CCA reviews the currency of employees' driver licenses and motor vehicle insurance coverage but does not perform safety inspections or monitor maintenance on employee-provided or employee-owned vehicles.

I understand that CCA does not provide vehicle insurance for employee-owned vehicles.

I acknowledge that driving is risky and can result in serious injury or death.

I assume the risk of riding in motor vehicles of CCA or its employees and I forever discharge and release the Agency and its employees from any and all claims, including their own negligence, which may arise out of the operation of motor vehicles in which I am riding.

I acknowledge that I am responsible for my own vehicle insurance during all times that a CCA employee uses my vehicle or any vehicle that I supply.

I have read and voluntarily agree to sign this Transportation Liability Waiver.