PERSONAL CARE AGREEMENT

(Medicaid-Compliant Family Caregiver Contract)

IMPORTANT NOTICE: This agreement is intended to compensate a family member for caregiving services in a manner that complies with Medicaid rules. To be valid for Medicaid purposes, this agreement must: (1) be in writing; (2) be executed BEFORE services begin; (3) provide for fair market value compensation; and (4) not compensate the caregiver for services already provided.

PARTIES

This Personal Care Agreement ("Agreement") is entered into as of [DATE] ("Effective Date") by and between:

CARE RECIPIENT:

Name: _______________________________________________

Address: _______________________________________________

Date of Birth: _______________________________________________

Social Security Number: _______________________________________________

(hereinafter referred to as "Care Recipient" or "Client")

AND

CAREGIVER:

Name: _______________________________________________

Address: _______________________________________________

Date of Birth: _______________________________________________

Social Security Number: _______________________________________________

Relationship to Care Recipient: _______________________________________________

(hereinafter referred to as "Caregiver")

RECITALS

WHEREAS, the Care Recipient requires assistance with personal care, daily living activities, and/or supervision due to [describe condition: age, infirmity, disability, cognitive impairment, etc.];

WHEREAS, the Caregiver is willing and able to provide such care and assistance;

WHEREAS, the Care Recipient desires to compensate the Caregiver fairly for services rendered;

WHEREAS, this Agreement is intended to document the caregiving arrangement and comply with applicable Medicaid regulations regarding personal care agreements;

NOW, THEREFORE, in consideration of the mutual promises contained herein, the parties agree as follows:

ARTICLE 1: SERVICES TO BE PROVIDED

1.1 Scope of Services

The Caregiver agrees to provide the following personal care and assistance services to the Care Recipient (check all that apply):

Personal Care Services:
☐ Bathing/showering assistance
☐ Grooming (hair, nails, shaving)
☐ Dressing/undressing assistance
☐ Toileting assistance
☐ Incontinence care
☐ Feeding/eating assistance
☐ Oral hygiene
☐ Mobility assistance (transfers, walking, wheelchair)
☐ Positioning/turning

Household Services:
☐ Meal planning and preparation
☐ Light housekeeping (cleaning, laundry, dishes)
☐ Grocery shopping
☐ Running errands
☐ Yard maintenance (as needed for safety)

Health-Related Services:
☐ Medication reminders (NOT administration of medications)
☐ Monitoring of health conditions
☐ Communication with healthcare providers
☐ Accompanying to medical appointments
☐ Picking up prescriptions

Transportation Services:
☐ Transportation to medical appointments
☐ Transportation for personal errands
☐ Transportation for social/recreational activities

Supervision and Companionship:
☐ General supervision for safety
☐ Companionship and social interaction
☐ Assistance with phone calls and correspondence
☐ Coordination with other care providers

Other Services:
☐ _______________________________________________
☐ _______________________________________________
☐ _______________________________________________

1.2 Services NOT Included

The Caregiver is NOT responsible for:
- Skilled nursing care (unless licensed to provide)
- Physical, occupational, or speech therapy
- Administration of medications (reminders only)
- Financial management or bill paying (unless separately authorized)
- Room and board for the Caregiver
- [Other exclusions]: _______________________________________________

1.3 Location of Services

Services will be provided at:
☐ Care Recipient's home: _______________________________________________
☐ Caregiver's home: _______________________________________________
☐ Other locations as needed for appointments and errands

ARTICLE 2: SCHEDULE

2.1 Hours of Service

The Caregiver will provide services according to the following schedule:

Option A - Regular Schedule:

Total Weekly Hours: _______________

OR

Option B - Flexible Schedule:

The Caregiver will provide approximately _______________ hours per week, with specific days and times to be mutually agreed upon based on the Care Recipient's needs.

2.2 On-Call Availability

☐ The Caregiver will be available on-call for emergencies.
On-call compensation: $_______________/hour or $_______________/day

2.3 Schedule Modifications

Either party may request modifications to the schedule with at least _______________ days' notice, subject to mutual agreement.

ARTICLE 3: COMPENSATION

3.1 Hourly Rate

The Care Recipient agrees to pay the Caregiver at the following rate:

Hourly Rate: $_______________/hour

This rate is based on the fair market value for similar services in [County/Region], [State], as evidenced by [attach market rate documentation or reference]:

☐ Survey of local home care agency rates
☐ State Medicaid waiver rates
☐ Bureau of Labor Statistics data
☐ Other: _______________________________________________

3.2 Payment Frequency

The Caregiver will be paid:
☐ Weekly
☐ Bi-weekly
☐ Monthly
☐ Other: _______________________________________________

Payment is due on: _______________________________________________

3.3 Total Monthly Compensation (Estimated)

Based on _______________ hours per week at $_______________/hour:

Estimated Monthly Compensation: $_______________

3.4 Payment Method

Compensation will be paid by:
☐ Check
☐ Direct deposit
☐ Other: _______________________________________________

3.5 No Compensation for Prior Services

The parties acknowledge that this Agreement compensates the Caregiver only for services provided on or after the Effective Date. No compensation is provided for any services rendered prior to the Effective Date of this Agreement.

3.6 Expense Reimbursement

The Caregiver will be reimbursed for the following out-of-pocket expenses incurred in providing services:

☐ Mileage for transportation: $_______________/mile
☐ Groceries and household supplies purchased for Care Recipient (receipts required)
☐ Prescription pickup fees
☐ Other: _______________________________________________

ARTICLE 4: TERM AND TERMINATION

4.1 Term

This Agreement shall commence on the Effective Date and continue until terminated by either party.

4.2 Termination

Either party may terminate this Agreement:
☐ At any time, with _______________ days' written notice
☐ Immediately, upon the death of the Care Recipient
☐ Immediately, if the Care Recipient enters a nursing home or long-term care facility
☐ Immediately, for cause (breach of Agreement, misconduct, etc.)

4.3 Effect of Termination

Upon termination:
- The Caregiver is entitled to payment for all services rendered through the termination date
- The Caregiver shall return any property belonging to the Care Recipient
- The Care Recipient shall return any property belonging to the Caregiver

ARTICLE 5: TAX MATTERS

5.1 Tax Status

The parties acknowledge and agree that:

☐ Option A - Employee Status:
The Caregiver is considered a household employee of the Care Recipient for tax purposes. The Care Recipient (or the Care Recipient's representative) is responsible for:
- Withholding and remitting Social Security and Medicare taxes (FICA)
- Withholding federal and state income taxes (if requested by Caregiver)
- Filing Schedule H with Form 1040
- Providing Form W-2 to the Caregiver
- Complying with state unemployment and workers' compensation requirements

☐ Option B - Independent Contractor Status:
The Caregiver is an independent contractor. The Caregiver is responsible for:
- Paying self-employment taxes
- Filing quarterly estimated taxes
- The Care Recipient will provide Form 1099-NEC if compensation exceeds $600 in a calendar year

IMPORTANT: The IRS generally treats household caregivers as employees, not independent contractors. Consult with a tax professional.

5.2 Tax Documentation

The Caregiver agrees to provide a completed Form W-9 (or W-4 if employee status).

ARTICLE 6: DOCUMENTATION AND RECORDS

6.1 Time Records

The Caregiver shall maintain daily records of:
- Date and hours worked
- Services provided
- Observations regarding Care Recipient's condition

A sample Daily Care Log is attached as Exhibit A.

6.2 Record Retention

All records shall be retained for a minimum of seven (7) years or as otherwise required by applicable law or Medicaid regulations.

6.3 Inspection

Records shall be made available for inspection by the Care Recipient, the Care Recipient's representative, or authorized representatives of the Medicaid agency upon request.

ARTICLE 7: CAREGIVER REPRESENTATIONS

7.1 Caregiver Representations

The Caregiver represents and warrants that:

☐ The Caregiver is physically and mentally capable of providing the services described herein.

☐ The Caregiver is not the spouse of the Care Recipient. (Medicaid rules generally prohibit compensation to spouses.)

☐ The Caregiver has no legal obligation to provide the services described herein without compensation.

☐ The Caregiver will perform services in a competent and professional manner.

☐ The Caregiver will report any significant changes in the Care Recipient's condition to appropriate family members or healthcare providers.

☐ The Caregiver will respect the Care Recipient's privacy and maintain confidentiality of personal and health information.

7.2 Background Check

☐ The Caregiver consents to a background check.
☐ A background check has been completed (Date: _______________)
☐ A background check is waived by the Care Recipient or representative.

ARTICLE 8: CARE RECIPIENT ACKNOWLEDGMENTS

8.1 Capacity

☐ The Care Recipient has the mental capacity to enter into this Agreement.

☐ If the Care Recipient lacks capacity, this Agreement is signed by the Care Recipient's authorized representative:

Representative Name: _______________________________________________

Authority: ☐ Power of Attorney ☐ Guardian ☐ Conservator

(Attach copy of authority document)

8.2 Medicaid Acknowledgment

The Care Recipient (or representative) acknowledges:

☐ This Agreement is intended to comply with Medicaid personal care agreement requirements.

☐ Payments under this Agreement may be reviewed by Medicaid during the lookback period if the Care Recipient applies for Medicaid benefits.

☐ This Agreement must be in effect BEFORE services begin to be valid for Medicaid purposes.

☐ The Care Recipient has been advised to consult with an elder law attorney regarding Medicaid implications.

ARTICLE 9: GENERAL PROVISIONS

9.1 Entire Agreement

This Agreement constitutes the entire agreement between the parties and supersedes all prior negotiations, representations, or agreements relating to this subject matter.

9.2 Amendments

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

9.3 Governing Law

This Agreement shall be governed by the laws of the State of _______________.

9.4 Severability

If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

9.5 Waiver

The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver of such provision or the right to enforce it at a later time.

9.6 Notices

Notices under this Agreement shall be in writing and delivered to the addresses set forth above.

9.7 Counterparts

This Agreement may be executed in counterparts, each of which shall be deemed an original.

9.8 Relationship of Parties

Nothing in this Agreement shall be construed to create an agency, partnership, or joint venture relationship between the parties.

SIGNATURES

CARE RECIPIENT:

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

OR CARE RECIPIENT'S REPRESENTATIVE:

Signature: _________________________________

Print Name: _________________________________

Title/Authority: _________________________________

Date: _________________________________

CAREGIVER:

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

WITNESS (Recommended):

Signature: _________________________________

Print Name: _________________________________

Date: _________________________________

EXHIBIT A: DAILY CARE LOG

Instructions

The Caregiver should complete this log daily, documenting services provided and any observations about the Care Recipient's condition. Retain all logs for at least seven (7) years.

Daily Care Log

Week of: _______________________________________________

Care Recipient: _______________________________________________

Caregiver: _______________________________________________

Weekly Total Hours: _______________

Caregiver Signature: _________________________________

Date: _______________

EXHIBIT B: MARKET RATE DOCUMENTATION

Fair Market Value Verification

This section documents that the compensation rate in this Agreement is consistent with the fair market value for similar services in the geographic area.

Geographic Area: _______________________________________________

Date of Rate Research: _______________________________________________

Comparison Rates

Average Market Rate: $_______________/hour

Rate in This Agreement: $_______________/hour

☐ The rate in this Agreement is at or below fair market value.

EXHIBIT C: CAREGIVER QUALIFICATIONS

Caregiver Name: _______________________________________________

Qualifications and Experience

☐ Prior caregiving experience: _______________________________________________

☐ Relevant training: _______________________________________________

☐ Certifications (if any): _______________________________________________

☐ CPR/First Aid training: ☐ Yes ☐ No

References (Optional)

This template is provided for informational purposes only and does not constitute legal advice. Personal care agreements have significant Medicaid and tax implications. Consult with a qualified elder law attorney and tax professional before executing this agreement.