CareSource: Sample Agreement

SAMPLE CONTRACT FOR SERVICES

THIS AGREEMENT, made as of {date}, by and between {Purchaser}, and CareSource, Inc. (hereinafter CS) for services for {Client.}

CS and {Purchaser} agree to the following terms:

• CS will provide care management services for {Client}. An overview of services is included in Exhibit A as marked.

• {Purchaser} agrees to pay CS for care management services for {Client} as follows:

• {Purchaser} agrees that the fee is $______ per hour. The hourly fee begins when the care manager leaves the office and continues until he/she arrives back at the office. All charges will be billed in six-minute increments.

• {Purchaser} will be billed for any postage, photocopies and long distance charges incurred on behalf of {Client}. Because of the lag time for receiving phone company charges, charges may be reflected on the following month's bill. Charges for goods bought will be included in the monthly bill but will be listed separately with receipts attached.

• {Purchaser} agrees to pay a retainer of $1,000.00 to be held in a non-interest bearing account and applied to fees incurred in the last month of service or refunded if not used.

• CS will bill {Purchaser} on a monthly basis. The amount billed is due and payable upon receipt by {Purchaser}. {Purchaser} agrees to pay a late charge of one and one-half percent (1.5%) per month on any amount past due for more than twenty (20) days.

• {Purchaser} may terminate care management services by giving CS written notice fifteen (15) days prior to termination of services. {Purchaser} will discuss with CS termination of services for {Client} so that proper closure can be brought to the service contract and referral to another resource can be given. All services performed throughout the final termination date are the obligation of {Purchaser}.

• CS, by the inherent nature of care management, may, from time to time, arrange for services for {Client} with other providers of service, i.e. home health agencies, pharmacies, cleaning services, etc. While CS strives to refer only providers of high quality services, we cannot warrant and do not assume liability for the actions of third party vendors. Charges for any services from third party vendors will be a separate responsibility of {Purchaser}.

• In the event either party shall incur legal expenses to enforce or interpret any provision of this Agreement, the prevailing party shall be entitled to recover such reasonable legal expenses, including without limitation, attorneys fees, costs and necessary disbursements at both the trial and appellate levels.

The undersigned fully understands the nature of the services provided by CareSource, Inc. and gives consent for such services and agrees to be responsible for payment of fees.

__________________________________________________	_____________________
{Purchaser}	Date

__________________________________________________	_____________________
CareSource, Inc.	Date

Please complete the following if you would like to pay with a credit card:

Print name (as it appears on credit card): __________________________________________

Billing Address (for credit card statement):_________________________________________

Type of card (circle one)

Account Number: ________________________________________ Expiration Date: ______

______________________________________________________ ___________________ Signature of cardholder Date

Overview of Services

Financial Services