SAMPLE

THIRD PARTY PROVIDER AGREEMENT

As a third-party provider (“Provider”) at _______________, (hereinafter referred to as

1. Prior to working in the building provider has received and signed a copy of the
residence handbook and reviewed policies as required by this agreement and the
residence's Administrator.

2. The Provider will provide a criminal conviction/history check and registry review
as required by state guidelines, or agency certifies that they have been
completed.

3. The Provider will provide TB Clearance, or agency certifies that they have been
completed

4. Provider is responsible for providing all services for which it was hired. The
Administrator, who integrates the services you provide into the resident's Service
Plan, will coordinate all provider services.

5. Provider will report to the Administrator on the same day any changes of
condition noted in the resident’s medical condition, any unusual occurrences,
and/or the results of any services provided, medical appointments, or other
observations made or information received. Provider may not leave the residence
without making the report of medical condition and if necessary will contact the
Administrator by telephone if the Administrator is out of the building.

6. Provider will record all appropriate information about the services provided and/or
changes in the resident’s condition immediately. The Administrator will provide
Provider with instructions on documentation following Residence policies.

7. Provider will review with the Administrator any follow-up instructions that it
wishes the Residence staff to implement and incorporate into the resident’s
Service Plan. Provider will familiarize itself with all of its client’s service needs
and preferences and report any potential conflicts with the plan of care,
medication and/or treatment records.

8. The Residence nurse is responsible for monitoring all nursing services provided.
Provider will notify the Residence nurse if/when delegation of any nursing task is
proposed. If a Provider delegates a nursing procedure, the process must be
documented according to the Residence’s procedures for delegation and be
within the state board of nursing rules and regulations on nurse delegation.

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9. Provider will follow applicable policies of the Residence. This includes smoking
only in designated areas, violence free and non-solicitation. Parking also is
permitted only in designated areas.

10. Provider may eat a meal while at the Residence, and must make arrangements
with the Administrator (guest meals have a nominal charge of $_______).

11. While in the building, Provider must abide by the Residence employee rules
regarding attire. Provider must also wear a name badge for identification
purposes to include the name of the caregiver and the agency.

12. Provider will support and adhere to our company’s principles of choice, privacy,
dignity, independence, and individuality while providing care to the resident in the
residence.

13. If Provider accompanies a resident out of the building, the Provider must follow
the procedures of the Residence for signing the resident and itself in and out of
the building.

14. Providers are not allowed in the Residence kitchen.

15. Provider’s children are not allowed in the Residence unless prior approval is
obtained from the Administrator or they are visiting a resident at resident’s
request.

16. Provider must not solicit its clients on behalf of any other assisted living facility.

17. Provider must not solicit any employees of the Residence nor may the provider
sell anything in the building, i.e., raffle tickets, Girl Scout cookies, etc.

18. The Provider shall indemnify and hold harmless the Residence, its members,
principals, officers, directors, representatives, employees, legal counsel,
predecessors, successors and assigns from and against any and all debts,
obligations, losses, claims, liabilities, damages, deficiencies, actions, suits,
proceedings, demands, assessments, orders, judgments, writs, decrees, costs
and other expenses, including, without limitation, reasonable attorney's fees and
accountant's fees, incurred by any of them in defending or compromising actions
brought against them arising out of or related to the acts or omissions of the
Provider or its personnel, agents contractors, any misrepresentation made by the
Provider, or in the provision of services or performance of duties by the Provider
pursuant to this Agreement, including any delivery of services to the Residence's
residents.

19. Nothing in this Agreement contemplates or requires the referral of any client or
patient to the Provider or to the Residence. This Agreement is not intended to
influence the judgment of either the Resident, Provider or the Residence in

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choosing the Residence appropriate for the proper treatment and care of their
respective residents or patients. Neither the Provider nor Residence shall
receive any satisfaction or remuneration for referrals, if any. The parties hereto
support a patient/resident's right to choose the medical or residential Residence
of his or her choice. The parties specifically intend to abide by all federal and
state anti-fraud and abuse laws.

20. Provider will maintain liability insurance with minimum coverage of One Million
Dollars ($1,000,000.00).

21. The provider will maintain WC insurance meeting the minimal state requirements.

22. Provider will obtain all necessary professional/occupation license issued by the
state to provide services to its clients. The Provider will immediately notify the
Residence if it should lose its license or become a target of an investigation by
the state licensing authority.

23. Both parties recognize the importance of the HIPAA regulations in maintaining
security, privacy and confidentiality of patient information. Therefore, to the
extent that each party's business functions are governed by the HIPAA
transaction, security and/or privacy regulations, each party shall have appropriate
organizational and technical policies and procedures and safeguards in place to
comply with the applicable provisions of the HIPAA regulations as they are
enacted.
24. This Agreement shall not render the provider an employee, partner, agent of, or
joint venturer with the Residence for any purpose. The Provider is and will
remain an independent third party contractor in the Providers relationship to the
Residence. The Residence shall not be responsible for withholding taxes with
respect to the provider’s compensation hereunder. The provider shall have no
claim against the Residence hereunder or otherwise for vacation pay, sick leave,
retirement benefits, social security, worker’s compensation, health or disability
benefits, unemployment insurance benefits, or employee benefits of any kind.

Notice necessary under any provision of this agreement by the Provider should be given
to the Administrator of the Residence by certified mail.

The person signing below on behalf of the Provider represents and warrants that they
have the authority to enter into this agreement on behalf of the Provider.

We appreciate your cooperation in following these guidelines. If you have any

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I have read and understand the above stated guidelines for third-party providers.

__________________________________________ _________________________
Signature of Third Party Provider Representative Date

_________________________________________ ________________________
Agency Represented, if applicable Date

__________________________________________ _________________________
Administrator Signature Date