Nursing Home Affidavit of Support
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 provide this affidavit of support for [Your Client Name] ("the Resident"), who is seeking admission to our care facility.
2. Consent for Support:
I hereby affirm that I will provide financial support for the Resident for the duration of their stay at [Your Company Name]. This support includes covering the cost of accommodation, medical care, personal care, and any other services deemed necessary for the well-being of the Resident during their stay at our facility.
3. Financial Responsibility:
As a responsible party, I have thoroughly reviewed and fully comprehend the financial obligations associated with the Resident's care at [Your Company Name]. My agreement includes, but is not limited to, the assurance of payment for:
Monthly Fees: These encompass charges for room and board, basic nursing care, utilities, and access to facility amenities.
Incidental Expenses: Costs incurred for services and items not included in the standard monthly fee such as special medical supplies, personal care products, and non-routine services.
Additional Care Needs: Financial responsibility for services that arise from special care needs, including but not limited to advanced medical treatments, specialized therapies, and emergency care interventions that exceed the scope of regular care provision.
I am committed to timely payments of all fees as stipulated in the care agreement and acknowledge that failure to meet these financial obligations could result in adjustments to the provided services.
4. Understanding of Resident Needs:
I recognize and affirm that the level of care provided by [Your Company Name] is necessary for the Resident’s well-being and health. I am actively involved in:
Personalized Care Plan Development: Collaborating with healthcare professionals to create and refine a care plan that comprehensively addresses the specific health and personal care needs of the Resident.
Ongoing Care Assessment: Ensuring the care plan remains dynamic and responsive to the Resident's evolving health status, adapting interventions as necessary to meet their changing needs.
Resource Allocation: Allocating the necessary resources to support the implementation of the care plan, ensuring that all prescribed services and interventions are effectively delivered.
5. Legal and Voluntary Commitment:
This affidavit of support is provided under my own volition, representing a legal and moral commitment to support the Resident’s care. I affirm:
Voluntary Agreement: The support stipulated herein is provided without any form of duress or undue influence.
Legal Awareness: I understand the legal implications of this document and the obligations it entails, ensuring compliance with all relevant laws and regulations governing the care and support of nursing home residents.
Full Understanding of Responsibilities: Acknowledging my responsibilities under this agreement, I commit to adhering to the terms set forth to ensure the welfare and proper care of the Resident.
6. Confidentiality and Data Protection:
In my role as the financial and personal advocate for the Resident, I consent to the handling of personal and financial information necessary for:
Care Administration: Utilizing personal data to coordinate and manage all aspects of the Resident's care.
Financial Management: Processing and oversight of financial transactions related to the Resident’s care expenses.
Legal Compliance: Ensuring all data management practices comply with state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA), safeguarding the Resident's sensitive information from unauthorized access or disclosure.
All personal and financial information will be treated with the highest level of confidentiality and integrity, maintaining the privacy and dignity of the Resident.
7. Duration of Support:
My commitment to support the Resident is intended to last for the duration of their stay at [Your Company Name]. Should my circumstances change in a way that affects my ability to fulfill this commitment, I agree to notify the facility immediately and make alternative arrangements to ensure the Resident's care is not interrupted.
8. Execution:
This affidavit is executed to serve as a binding agreement affirming my responsibility to support the Resident financially and ensure their well-being while they reside at [Your Nursing Home Name].
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].
Nursing Home Templates @ Template.net
