Caregiver Agreement

CAREGIVER AGREEMENT (PERSONAL CARE CONTRACT)

TABLE OF CONTENTS

1. Parties
2. Recitals
3. Services to Be Provided
4. Schedule of Services
5. Compensation
6. Tax Obligations
7. Term and Termination
8. Caregiver Qualifications and Standards
9. Record-Keeping Requirements
10. Confidentiality
11. Relationship of Parties
12. Dispute Resolution
13. General Provisions
14. Signatures
15. Practitioner Notes

1. PARTIES

This Caregiver Agreement ("Agreement") is entered into as of [__/__/____] ("Effective Date") by and between:

Care Recipient:
Name: [________________________________]
Date of Birth: [__/__/____]
Address: [________________________________]
(Hereinafter "Care Recipient")

[If Care Recipient lacks capacity:]
Acting through: [________________________________]
Capacity: ☐ Agent under Durable Power of Attorney ☐ Guardian ☐ Conservator
Authority Document Date: [__/__/____]

Caregiver:
Name: [________________________________]
Date of Birth: [__/__/____]
Address: [________________________________]
Relationship to Care Recipient: [________________________________]
(Hereinafter "Caregiver")

2. RECITALS

WHEREAS, Care Recipient requires personal care assistance due to [________________________________] (describe condition or functional limitations);

WHEREAS, Care Recipient desires to remain in [☐ his/her home / ☐ the community] and to receive care from a trusted individual rather than an institutional facility;

WHEREAS, Caregiver is willing and able to provide the services described herein;

WHEREAS, the parties intend this Agreement to constitute a bona fide, arm's-length contract for fair value services to be rendered prospectively;

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, and for other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

3. SERVICES TO BE PROVIDED

The Caregiver shall provide the following services (check all that apply):

3A. Personal Care Services

☐ Bathing and grooming assistance
☐ Dressing assistance
☐ Toileting and incontinence care
☐ Mobility assistance and transfer support
☐ Feeding assistance
☐ Medication reminders (non-medical administration)
☐ Exercise and physical therapy assistance

3B. Household Services

☐ Meal planning and preparation
☐ Grocery shopping and errands
☐ Light housekeeping
☐ Laundry
☐ Home maintenance coordination

3C. Transportation Services

☐ Transportation to medical appointments
☐ Transportation to social activities
☐ Transportation for errands and shopping

3D. Companionship and Supervision

☐ General companionship
☐ Safety supervision and monitoring
☐ Cognitive stimulation activities
☐ Accompaniment to social events

3E. Care Coordination

☐ Communication with medical providers
☐ Scheduling medical appointments
☐ Managing correspondence and paperwork
☐ Coordinating with other service providers

3F. Other Services

☐ [________________________________]
☐ [________________________________]

Services Expressly Excluded: This Agreement does not cover medical services, nursing care, physical therapy, or any service requiring professional licensure. The Caregiver is not a medical professional and shall not perform medical procedures.

4. SCHEDULE OF SERVICES

Total Weekly Hours: [____]
Location of Services: [________________________________]

5. COMPENSATION

5.1 Hourly Rate. Caregiver shall be compensated at the rate of $[________] per hour. This rate is based on the prevailing market rate for comparable home care services in [________________] (geographic area), as documented by [________________________________].

5.2 Payment Schedule. Payment shall be made ☐ weekly / ☐ bi-weekly / ☐ monthly on the [____] of each [week/month].

5.3 Maximum Monthly Compensation. Total monthly compensation shall not exceed $[________________].

5.4 Estimated Annual Compensation. Based on [____] hours per week at $[________] per hour, estimated annual compensation is $[________________].

5.5 No Retroactive Payments. Compensation is for services to be performed after the Effective Date of this Agreement only. No payments shall be made for services performed prior to the Effective Date.

5.6 Prospective-Payment Review. Do not calculate or pay a lump-sum contract value until the applicable Medicaid agency's current treatment of prospective caregiver payments, actuarial method, required documentation, refund terms, and fair-market-value evidence has been verified in writing. Current authority and conclusion: [________________________________].

6. TAX OBLIGATIONS

6.1 Classification gate. Do not select a tax label by agreement. Record who selects, schedules, supervises, pays, and may discharge the caregiver; whether an agency, registry, fiscal intermediary, trust, guardian, or public program is involved; and whether there may be joint employment. Apply the current federal, state, and local tests to the actual facts.

Current classification authority and conclusion: [________________________________]

6.2 Current-year household-employment review. IRS Publication 926 supplies the current federal framework for household-worker status, household employment taxes, annual thresholds, records, and forms. Use the publication and form instructions for the payment year; do not rely on a fixed dollar threshold or assume that every caregiver is a household employee.

☐ Current IRS Publication 926 reviewed

☐ Social Security, Medicare, federal unemployment, and withholding treatment determined

☐ State withholding, unemployment, disability, paid-leave, and workers' compensation treatment determined

☐ Schedule H, business payroll return, Form W-2, Form 1099, or other filing determined from the verified classification and current instructions

Payroll or tax adviser and conclusion: [________________________________]

6.3 Wage-and-hour review. If the caregiver performs domestic service in or about a private home, verify current minimum-wage, overtime, live-in, companionship-services, compensable-time, recordkeeping, and state or local domestic-worker rules. A third-party employer may not claim the federal companionship-services or live-in domestic-service exemptions. 29 C.F.R. § 552.109.

Employment counsel and conclusion: [________________________________]

7. TERM AND TERMINATION

7.1 Term. This Agreement shall commence on the Effective Date and shall continue until terminated as provided herein.

7.2 Termination. This Agreement may be terminated:

☐ By either party upon [____] days' written notice;
☐ Immediately by Care Recipient if Caregiver engages in misconduct, neglect, or abuse;
☐ Automatically upon the death of the Care Recipient;
☐ Automatically upon the permanent placement of Care Recipient in a nursing facility;
☐ By mutual written agreement of the parties.

7.3 Upon termination, Caregiver shall be compensated for all services rendered through the termination date.

8. CAREGIVER QUALIFICATIONS AND STANDARDS

Caregiver represents and warrants that:

☐ Caregiver has no felony convictions
☐ Caregiver has no history of abuse, neglect, or exploitation of vulnerable adults
☐ Caregiver is physically capable of performing the services described herein
☐ Caregiver agrees to submit to a background check at Care Recipient's expense
☐ Caregiver will perform services with reasonable care and diligence

9. RECORD-KEEPING REQUIREMENTS

9.1 Caregiver shall maintain a daily log documenting:

• Date and hours of service
• Specific services performed
• Care Recipient's condition and any changes observed
• Any incidents or concerns

9.2 Daily logs shall be signed by the Caregiver and, where possible, by the Care Recipient or a witness.

9.3 Retain the signed agreement, contemporaneous service logs, time records, proof of payment, payroll filings, fair-market-value evidence, authority documents, and Medicaid submissions for the longest period required by current federal, state, local, tax, employment, and Medicaid rules. Record the verified retention period and authority: [________________________________].

10. CONFIDENTIALITY

Caregiver shall maintain the confidentiality of all personal, medical, and financial information of the Care Recipient and shall not disclose such information to any third party without the Care Recipient's written consent, except as required by law.

11. RELATIONSHIP OF PARTIES

Nothing in this Agreement creates a partnership or joint venture. This clause does not decide employee, independent-contractor, household-employment, joint-employment, or agency status; governing law and the actual working relationship control. A family relationship does not by itself establish that the arrangement is arm's-length or that payments receive favorable Medicaid treatment.

12. DISPUTE RESOLUTION

☐ Option A — Arbitration. Any dispute arising under this Agreement shall be resolved by binding arbitration in [________________] (location) in accordance with the rules of the American Arbitration Association.

☐ Option B — Mediation, then Litigation. The parties shall first attempt to resolve disputes through mediation. If mediation fails, either party may pursue litigation in the courts of [________________] County, State of [________________].

13. GENERAL PROVISIONS

13.1 Entire Agreement. This Agreement constitutes the entire agreement between the parties and supersedes all prior negotiations and understandings.

13.2 Amendment. This Agreement may be amended only by a written instrument signed by both parties.

13.3 Governing Law. This Agreement shall be governed by the laws of the State of [________________].

13.4 Severability. If any provision is held invalid, the remaining provisions shall continue in full force and effect.

13.5 No Assignment. Neither party may assign this Agreement without the other party's written consent.

14. SIGNATURES

CARE RECIPIENT:

_______________________________
[CARE RECIPIENT NAME]
Date: [__/__/____]

CARE RECIPIENT'S REPRESENTATIVE (if applicable):

_______________________________
[REPRESENTATIVE NAME]
Capacity: [________________________________]
Date: [__/__/____]

CAREGIVER:

_______________________________
[CAREGIVER NAME]
Date: [__/__/____]

WITNESS:

_______________________________
[WITNESS NAME]
Date: [__/__/____]

15. PRACTITIONER NOTES

Sources for the employment and tax verification gates

• U.S. Department of Labor — Fact Sheet #79: Private Homes and Domestic Service Employment
• eCFR — 29 C.F.R. § 552.109, third-party employment
• IRS — Publication 926 (2026), Household Employer's Tax Guide

Statutory citations in this template were verified against official and primary sources on the last_verified date shown in the frontmatter. Caregiver agreements have significant legal, employment, tax, and Medicaid implications, and eligibility rules and dollar thresholds change frequently. Confirm current federal, state, and local requirements and consult qualified elder law and employment counsel and a tax professional before execution.