Disclosure of Services Form

 

Disclosure Statement version 1/1/2012

Options For Seniors LLC provides a personalized service designed to find appropriate care and/or housing services for our clients.  We will help you determine what level of supported care or housing is best for you by asking you a series of questions and reviewing your medical records.  Once the appropriate levels of care and services have been determined we will escort you to a number of communities. After touring these communities you can decide if you think one of them is right for you.  Our knowledge and familiarity with the local communities, services and amenities offered and the costs involved, allow you security in making your best possible decisions.  Our commitment is to you and your family not a particular community.

There are two ways Options For Seniors LLC collects its fees. Typically Options For Seniors LLC receives a payment from the housing or care provider our client chooses.  Options For Seniors LLC signs contractual agreements with housing and care providers.  If a client of Option For Seniors LLC decides to retain the services of a housing and or care provider, the housing and care provider is contractually obligated to pay Options For Seniors LLC a fee.  Our contracted payment from the housing and care providers vary from provider to provider.  Our fees range from twenty to fifty percent of the first and second month fees due after thirty and sixty days of occupancy.  Less than thirty days occupancy is a prorated at twenty percent.  THERE IS NO COST TO THE SENIOR or LEGAL REPRESENTATIVE FOR OUR SERVICE IN THESE INSTANCES.  The housing and care providers pay our fee out of their marketing budgets. You are entitled to know the exact amount of the fee paid in your individual instance, if you request this information.  On occasions Options For Seniors LLC signs contractual agreements with clients or their family for private pay consulting to locate appropriate care and housing services.  Should such services and payment be required for your individual situation, Options For Seniors LLC would enter into a contractual agreement with the client that requires a fifteen hundred dollar up front retainer. This base retainer represents ten hours of service to the client, billed at a rate of one hundred and fifty dollars per hour and will be non-refundable. The average consulting time runs fifteen to thirty hours, and any remaining balance will be invoiced at the start of occupancy or services for the client.

Options For Seniors LLC serves in a dual agency relationship, with responsibilities of offering information and guidance to the client or their legal representative while receiving funding from the housing or care provider for assisting the housing or care provider with gaining a new resident or client.

In order to assist you in locating appropriate care and services Options For Seniors LLC may be required to share confidential health care information with housing or care providers. Prior to sharing this information the client must sign the Options For Seniors LLC authorization to obtain and release health care information form.

Options For Seniors LLC and their employees, owners, and officers are not considered providers and will not be liable or responsible for the acts or omissions of a housing or care provider.  Options For Seniors LLC may not require or request clients or their legal representatives to sign waivers of potential liability for losses of personal property or injury, or to sign waivers of any rights of clients established by state or federal law.

Options For Seniors LLC will not require our clients or their legal representatives to work exclusively with one licensed individual or agency.  Options For Seniors LLC request you notify us of your desire to work with more than one referral professional.

Options For Seniors LLC does not regularly tour each of the hundreds of provider facilities with whom we contract. However, we tour communities with you.  When we recommend a housing provider, we will inform you in writing or electronically whether we have toured the housing provider’s community, and the specific date of that tour.

Any client or legal representative may, without cause, stop using Options For Seniors LLC and no penalty or cancellation fee will be charged.

If Options For Seniors LLC receives a fee from a housing or care provider, for a client who is referred to, and establishes residence in, supportive housing or care provider and within the first thirty (30) days of admission dies, is hospitalized and does not return to the supportive housing or care provider, or is transferred to another supportive housing or care provider setting for more appropriate care; then Options For Seniors LLC will refund a portion of the fee to the housing or care provider on a per diem basis taking into account the days the client resided or retained services with the supportive housing or care provider referred by Options For Seniors LLC.

For concerns regarding ethical practices or compliance to laws, a formal complaint may be filed with the Office of the Attorney General.  Consumer complaints require the initiator give their name, address and daytime phone number.  You may request your identity remain confidential from the individual or agency with whom the compliant concerns.  Attorney General’s Phone: Call Mon-Fri, 10 a.m. to 3 pm, (360) 753-6200 or 1-800-833-6384 (for the hearing impaired)  To mail a complaint:    Office of the Attorney General, 1125 Washington Street SE , PO Box 40100, Olympia, WA  98504-0100  Email: https://fortress.wa.gov/atg/formhandler/ago/ComplaintForm.aspx

Before Options For Seniors LLC may refer the client to any housing or care provider, this Disclosure Statement must be acknowledged in writing.

Acknowledge Receipt of this Document
Although it is not required that the client agree with the information appearing in this Disclosure Statement, the State of Washington requires that the client acknowledge receipt of this document.

Client is defined by the State of Washington as: “Client” means and elder person or a vulnerable adult, or his or her representative, seeking a referral or assistance with entering into an arrangement for supportive housing or care services in Washington State through an elder and vulnerable adult referral agency.  For the purpose of this chapter, the “client representative” means the person authorized under law RCW 7.70.065 to provide informed consent of an individual unable to do so, for example a Power of Attorney.  “Client” may also mean person seeking a referral for supportive housing or care services on behalf of the elder person or vulnerable adult through an elder care referral service: PROVIDED, that such a person is a family member, relative, or domestic partner of the senior or vulnerable adult.  Indicate below which best describes you:

Indicate which best describes you (required):
 Elder person or a vulnerable adult Client representative POA Family member, relative or domestic partner

By placing my name, email address and date in the boxes below, I acknowledge that I have received, read and understand this Disclosure Statement.

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