STATE OF [Your State]

COUNTY OF [Your County]

I, [Your Name], of legal age, residing at [Your Address], being duly sworn, depose and say:

1. Identity and Relationship:

I am the [Your Job Title], duly appointed and currently serving at [Your Company Name], which is legally established and operating at [Your Company Address]. My contact information is [Your Company Number] and [Your Company Email]. I am authorized to execute legal documents and represent [Your Company Name] in matters pertaining to resident admissions and care.

2. Consent for Admission:

I affirm that [Your Client Name] ("the Resident"), born on [Date], with a current residential address at [Your Client Address], has, through clear verbal communication or via legally binding documentation (such as a Power of Attorney or a court-appointed guardianship), given informed consent to be admitted to our care facility. This consent includes understanding and agreeing to comply with the rules and regulations of the facility, which have been duly explained to them or their authorized representative.

3. Understanding of Services:

The Resident, or their authorized legal representative, has received a comprehensive explanation of the healthcare and support services provided by [Your Nursing Home Name]. These services are designed to meet the full spectrum of the Resident's needs and include:

• 24-Hour Nursing Care: Continuous access to qualified nursing staff to monitor health, administer medications, and provide immediate medical attention.

• Medication Management: Rigorous protocols to ensure accurate dosing, timing, and monitoring of medication in accordance with physician orders.

• Physical and Occupational Therapy: Personalized therapy plans aimed at improving mobility, strength, and daily living skills, tailored to the Resident’s specific health conditions and recovery goals.

• Social Activities: A curated schedule of activities designed to enhance social interaction and mental stimulation, catering to a range of interests and abilities.

• Personal Hygiene Assistance: Assistance with daily living activities such as bathing, dressing, grooming, and toileting, provided with dignity and respect for personal preferences.

• Nutritional Meal Planning and Provision: Dietician-approved meals prepared on-site, designed to meet the nutritional needs and preferences of each resident, including special diets as medically required.

The Resident has actively participated in the development of their personalized care plan. This plan is subject to ongoing review and adjustment by healthcare professionals to reflect any changes in the Resident’s health status or preferences.

4. Financial Agreement:

The Resident, or their designated representative, confirms understanding and acceptance of the financial terms associated with residing at [Your Nursing Home Name]. This includes:

• Monthly Accommodation Fees: Costs associated with room and board, utilities, and access to facility amenities.

• Service Fees: Charges for additional services such as specialized medical care, personal care, and optional activities not included in the basic fee structure.

• Incidental Charges: Potential costs arising from special requests or needs outside the standard service package.

A detailed billing structure has been provided, outlining each cost component. The Resident agrees to adhere to the payment schedule as outlined in the financial agreement. Discussion on billing procedures, the timing of payments, and the consequences of late or non-payment has been conducted to ensure clear understanding and agreement.

5. Voluntary Participation:

Consent for admission and ongoing residency at [Your Nursing Home Name] has been given voluntarily by the Resident or their authorized representative. This consent has been granted following a full disclosure of what the residency entails, without any coercion or undue influence. The Resident has had ample opportunity to ask questions and seek clarification on any aspect of their care or living conditions, and all inquiries have been addressed to their satisfaction.

6. Privacy and Confidentiality:

The Resident agrees to the collection, processing, and sharing of their personal and health-related information, under strict adherence to state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA). The following provisions have been made:

• Data Use: Personal and health information will be used solely for the purpose of providing and managing the Resident’s care.

• Data Protection: All personal data is safeguarded through secure systems and protocols to prevent unauthorized access.

• Data Disclosure: Information will only be disclosed to authorized personnel involved in the Resident’s care, or where legally required.

The Resident has been reassured that their information is treated with the utmost confidentiality, and any access to their records is strictly controlled.

7. Right to Withdraw Consent:

It is understood that the Resident retains the right to withdraw their consent at any time. Such withdrawal must be executed in writing and will be effective upon receipt by the administration of [Your Nursing Home Name]. Withdrawal of consent may result in the termination of services, and this has been clearly communicated and understood by the Resident or their representative.

8. Execution:

This affidavit is executed to establish a clear, lawful, and mutual understanding of the consent given by the Resident for their care and treatment at [Your Nursing Home Name]. It is intended to serve as a legal document that confirms the Resident's agreement and understanding of all terms related to their care.

SWORN TO AND SUBSCRIBED before me this [Month Day, Year].

[Your Job Title]

[Your Company Name]

Notary Public:

State of [Your State]

My commission expires [MM-DD-YYYY].

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