Nursing Home Resident Agreement Form

Please fill out this agreement completely and accurately.

I. The Parties

This Nursing Home Resident Agreement ("Agreement") is made and entered into on Month Day, Year by and between Resident's Name, residing at Resident's Address ("Resident") and [Your Company Name], with a primary place of business at [Your Company Address] ("Nursing Home"). The Resident and Nursing Home may collectively be referred to as the ("Parties") or individually as a ("Party").

II. Residency Services and Amenities

A. Basic Services Provided

The Nursing Home shall provide the Resident with services including, but not limited to, personal care, meal service, housekeeping, and 24-hour supervision.

B. Optional Services

The Resident may elect to receive additional services not included in the basic package, which may incur additional fees.

III. Resident Rights and Responsibilities

A. Resident Rights

The Resident shall have the right to dignity, privacy, and quality care. The Nursing Home shall uphold these rights in compliance with applicable laws.

B. Resident Responsibilities

The Resident agrees to respect Nursing Home rules and policies, maintain their personal space, and comply with all health and safety regulations.

IV. Financial Terms and Payment

A. Monthly Fees

The Resident agrees to pay a monthly fee of Amount, due on the Day day of each month.

B. Additional Charges

Additional services will be charged separately. Payment for optional services will be due monthly, along with the regular fee.

C. Late Payments

A late fee of Amount will be charged for payments not received within No. of Days days of the due date.

V. Term and Termination

A. Term

This Agreement is valid from Month Day, Year and will continue until terminated.

B. Termination by Resident

The Resident may terminate this Agreement by providing No. of Days days’ written notice to the Nursing Home.

C. Termination by Nursing Home

The Nursing Home reserves the right to terminate this Agreement with cause, including but not limited to non-payment, misconduct, or violation of terms.

VI. Signature

By signing below, both Parties acknowledge that they have read, understood, and agree to abide by the terms and conditions outlined in this Agreement.

Resident/Authorized Representative Name: Date:

Nursing Home Name: Date:

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