This Payment Agreement ("Agreement") is entered into between [Your Company Name] located at [Your Company Address] ("Nursing Home") and the resident or responsible party identified below ("Resident"):

1. Services Provided: The Nursing Home agrees to provide the following services to the Resident:

• Room and board

• Nursing care

• Personal care services

• Medication management

• Meals and dietary services

• Recreational activities

• Other services as deemed necessary by the Nursing Home

2. Payment Terms:

• Monthly Rate: The Resident agrees to pay a monthly fee of [$0] for the services provided by the Nursing Home.

• Payment Due Date: Payment is due on the [0] of each month.

• Late Payment: A late fee of [$0] will be assessed if payment is not received within [0] days of the due date.

• Billing: The Nursing Home will provide an itemized statement of charges on a monthly basis.

3. Payment Method: The Resident agrees to make payments via check or electronic funds transfer..

4. Changes in Rate: The Nursing Home reserves the right to adjust the monthly rate upon [0] days' notice to the Resident. Any changes in rates will be communicated in writing.

5. Deposit Requirement: A deposit of [$0] is required upon admission to the Nursing Home. This deposit will be applied towards the Resident's final bill upon discharge.

6. Additional Charges: The Resident may incur additional charges for services not covered under the monthly rate, including but not limited to pharmacy services, medical supplies, and transportation.

7. Insurance Coverage: The Resident is responsible for providing the Nursing Home with information regarding any insurance coverage or benefits that may apply to the services provided.

8. Termination of Agreement: This Agreement may be terminated by either party upon [0] days' written notice to the other party.

9. Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the State of [Your State].

10. Entire Agreement: This Agreement constitutes the entire understanding between the parties concerning the subject matter hereof and supersedes all prior agreements and understandings, whether oral or written.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date set forth above.

[Your Company Name]

By:

[Administrator]

[Month, Day, Year]

Resident:

By:

[Month, Day, Year]

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