I hereby acknowledge and agree:

Assumption of Risk and Release of Liability Agreement

Transportation, Home Visit, and Health Support Services

This Assumption of Risk and Release of Liability Agreement is entered into by and between:

Client Name: ___________________________________________
Date of Birth: __________________________________________
Address: ______________________________________________
Phone Number: _________________________________________

and

Provider/Nurse: _________________________________________
Business Name, if applicable: _____________________________
Phone Number: _________________________________________

Date of Agreement: _____________________________________

1. Purpose of Services

I understand that the Provider may provide one or more of the following services:

• Home visits

• Vital signs assessment

• INR testing or other point-of-care testing, if ordered or appropriate

• Medication review or health education

• Communication or coordination with my healthcare providers

• Accompaniment to medical appointments

• Transportation to and from medical appointments or health-related visits

• Assistance with understanding medical instructions, equipment, or care plans

I understand that these services are supportive and educational in nature and do not replace care from my physician, specialist, emergency medical services, hospital, or other licensed healthcare provider.

2. No Emergency Medical Services

I understand that the Provider is not providing emergency medical transportation and is not operating as an ambulance service.

If I experience chest pain, severe shortness of breath, signs of stroke, severe bleeding, loss of consciousness, sudden worsening of my condition, or another medical emergency, I understand that 911 should be called immediately.

I understand that transportation by private vehicle may not be appropriate in an emergency.

3. Assumption of Risk

I understand that there are risks associated with home visits, health monitoring, accompaniment to medical appointments, and transportation. These risks may include, but are not limited to:

• Falls, slips, or injuries while entering, exiting, or riding in a vehicle

• Injury while walking, transferring, or moving between locations

• Delays due to traffic, weather, road conditions, or unexpected events

• Worsening of a medical condition during travel or during a visit

• Exposure to illness or infection

• Misunderstanding or miscommunication of medical instructions

• Emotional stress related to medical care or appointment findings

• Risks related to my existing medical conditions, medications, mobility limitations, or equipment

I understand these risks and voluntarily choose to receive services from the Provider.

4. Release of Liability

To the fullest extent permitted by law, I release and hold harmless the Provider, the Provider’s business, employees, contractors, representatives, and agents from any and all claims, demands, damages, losses, expenses, injuries, or liabilities arising out of or related to the services provided, including transportation and medical appointment accompaniment, except where prohibited by law.

This release includes, but is not limited to, claims related to:

• Transportation by private vehicle

• Assistance entering or exiting a vehicle

• Assistance walking or moving between locations

• Attendance at medical appointments

• Communication with healthcare providers

• Documentation or explanation of medical information

• Health monitoring services provided outside of a hospital or clinic setting

I understand that this release does not waive rights that cannot legally be waived under applicable law.

5. Client Responsibility

I agree to provide accurate and complete information about my health condition, medications, allergies, mobility limitations, medical equipment, and any changes in my condition.

I agree to notify the Provider immediately if I experience symptoms such as:

• Chest pain

• Shortness of breath

• Dizziness or fainting

• Weakness on one side of the body

• Confusion

• Severe pain

• Unusual bleeding or bruising

• Sudden change in condition

• Any other urgent or concerning symptom

I understand that failure to share important health information may increase my risk of harm.

6. Transportation Agreement

I understand that if the Provider transports me in a private vehicle:

• The Provider is not an ambulance service.

• The Provider may refuse to transport me if I appear medically unstable.

• The Provider may call 911 if my condition appears unsafe for private transportation.

• I am responsible for wearing a seatbelt unless medically unable to do so.

• I am responsible for bringing necessary medications, supplies, equipment, identification, insurance cards, and medical documents.

• I understand that delays may occur due to traffic, weather, vehicle issues, or other circumstances beyond the Provider’s control.

7. Medical Appointment Accompaniment

I authorize the Provider to accompany me into medical visits when I request or permit it.

I understand that the Provider may:

• Listen to medical instructions

• Ask clarifying questions

• Take notes

• Help me understand information shared by the medical team

• Assist with follow-up planning

• Communicate with designated healthcare providers or caregivers, if authorized

I understand that my physician or specialist remains responsible for diagnosis, treatment decisions, medication changes, and medical orders.

8. INR Testing and Health Monitoring

If INR testing, vital signs, or other health monitoring services are provided, I understand that:

• Results may need to be reported to my ordering provider.

• The Provider does not independently change my medication unless legally authorized and operating under an appropriate order, protocol, or agreement.

• Abnormal results may require urgent medical follow-up.

• Testing and monitoring do not guarantee prevention of complications.

9. Permission to Communicate with Healthcare Providers

I give permission for the Provider to communicate with the following healthcare providers, clinics, family members, or caregivers regarding my health condition, care instructions, appointment findings, and follow-up needs:

Provider/Clinic/Person: __________________________________
Phone/Fax/Email: ______________________________________
Relationship: __________________________________________

Provider/Clinic/Person: __________________________________
Phone/Fax/Email: ______________________________________
Relationship: __________________________________________

Provider/Clinic/Person: __________________________________
Phone/Fax/Email: ______________________________________
Relationship: __________________________________________

Client initials: ___________

10. Personal Belongings

I understand that I am responsible for my personal belongings, including but not limited to medications, medical equipment, purse, wallet, phone, glasses, hearing aids, oxygen supplies, mobility aids, and documents.

The Provider is not responsible for lost, stolen, or damaged personal items unless the loss, theft, or damage is caused by intentional misconduct or is otherwise required by law.

11. Payment Responsibility

I understand that I am responsible for payment of agreed-upon fees, which may include:

• Professional service fees

• Home visit fees

• Transportation time

• Mileage

• Overnight travel fees

• Lodging

• Meals

• Parking

• Tolls

• Other agreed-upon expenses

Payment terms should be agreed upon separately in writing.

12. Right to Refuse or Stop Services

I understand that the Provider may refuse, pause, or stop services if:

• My condition appears medically unstable

• The situation appears unsafe

• The requested service is outside the Provider’s scope

• Payment arrangements are not followed

• The Provider determines that emergency care or a higher level of care is needed

13. Acknowledgment and Voluntary Agreement

I have read this agreement, or it has been read to me. I understand the contents of this agreement. I have had the opportunity to ask questions before signing.

I understand that I am voluntarily accepting the risks associated with these services.

I agree to release and hold harmless the Provider as described in this agreement.

Client Signature

Client Name Printed: _____________________________________

Client Signature: ________________________________________

Date: _________________________________________________

Representative/Power of Attorney Signature, if applicable

Name Printed: __________________________________________

Relationship to Client: ___________________________________

Signature: _____________________________________________

Date: _________________________________________________

Provider/Witness Signature

Provider/Witness Name Printed: ___________________________

Signature: _____________________________________________

Date: _________________________________________________