Disclosure Statement and Information Release Form

Adult Care Solutions of I & R Senior Solutions, LLC
Disclosure Statement and Information Release Form

This document is to define the services provided by Adult Care Solutions. To best represent the interests of the older adult and/or responsible party, “Client,” and to comply with the requirements of the state of Washington, Adult Care Solutions, “ACS,” the Client’s confirmation of receipt of this information is requested and will serve as acceptance of services in order that ACS may be of assistance for you.

Information is managed by ACS based upon RCW 70.02.017. The identity of an older adult is only disclosed in relation to private health care information in instances where the older adult or the responsible party has provided consent. ACS works with both the Client and the Provider in the same transaction.

ACS may not require or request the Client to sign waivers of potential liability for losses of personal property or injury, or to sign waivers of any rights of the Client established in state or federal law as required in RCW 18.330. However, ACS cannot make any guarantee of services made by any provider.

About ACS: ACS is dedicated to provide help for older adults with transitioning to housing and care providers. ACS obtains personal information about older adults through its intake process, which helps to identify needs, interests and preferences of the Client. Based on this intake, ACS provides housing and care provisions that will be of interest to the older adult and/or responsible party. ACS provides the support to help older adults move or to encourage them to transition into new living conditions.

ACS manages the specific information about senior residencies and care providers, “Providers,” A list of questions, known as the intake process, helps ACS define the best geographic locations, style of life, personality and ambiance preferences, pricing and potential services for care. However, ACS is a referral agency and is not a resource of medical provisions. Older adults fare better if family members are involved with the transitioning process on a continual basis to support the older adult. ACS referrals range from skilled nursing to Medicare-certified in-home care.

ACS can suggest referrals to Clients for legal counsel, financial advisors, health care therapies, real estate, moving services or other types of services. No financial compensation is received by ACS for these referrals. However, the Client must apply due diligence of a Consumer. ACS does not warrant or guarantee the quality or performance of such services. ACS is held harmless for any loss, injury or harm that may result of using such services. It is the responsibility of the Client to determine their own personal choices regarding using such services.

The Client selects the residency and care: The Client selects the Provider of their own choice. ACS does not select a specific Provider or care on behalf of the Client. Also, the Client must negotiate move-in and monthly rent and care fees directly with the Provider. The Client must abide by the application process of the Provider to establish in-home services or residency and care services. ACS informs the Client of options and the Client selects any one particular option.

Although ACS does not negotiate on behalf of the Client, ACS obtains detailed information regarding any offers being made by Providers to the general public and makes such information available to the Client. ACS assures Clients the most favorable pricing from Providers so that they are not charged higher prices due to the involvement with ACS.

Medical professionals may be involved: To best determine the medical health condition, medication management, and appropriate care level prior to admission to a residency, the physician may be required to be involved for the best possible outcome. ACS offer assessments, paid by the Client, through qualified registered nurses or the Provider may provide assessment services. However, ACS does not offer medical advice, does not assess medical needs and does not offer care plans. Once the Provider reviews the assessment, the Provider decides whether to accept the Client.

Services are free-of-charge to Clients: ACS signs contracts with Providers and Providers pay a referral fee to ACS. ACS holds a policy of charging the Provider once the Provider receives compensation for housing and/or care from the Client’s private funds or from long-term care insurance funds. ACS does not receive a fee from the Provider if any portion of the monthly housing cost is paid by Medicaid/COPES or Medicare. Also, ACS pro-rates the Provider’s referral fee to the number of days the Client is actually in residence or receiving care if the Client passes away or moves out prior to the first month.

ACS referral compensation by Providers: The specific compensation a Provider pays ACS varies upon the type of residency and care services agreed by the Client. Upon the Client’s written request, ACS will provide the specific details as to the referral fee paid by the Provider to ACS. You may request the actual details of the referral amount by sending an email, fax, or letter to ACS.

The contracted payment of fees vary from Provider to Provider. ACS fees range from 30-50% [thirty to fifty percent] of the first and/or second month’s rent, which is due up to 60 days [sixty days] from the Provider.

ACS makes the initial introductions to all Providers of the Client, which ensures the best appropriate care and that ACS is compensated for their efforts.

Refunds made by ACS: ACS pro-rates the Provider’s referral fee to the number of days the Client actually resided or received care. However, if the Client passes away, is hospitalized, or is transferred to another supportive housing setting for more appropriate care within 30 [thirty] days of admission, then ACS will refund a portion of its fee to the entity or person who paid it. The amount refunded will be a pro-rated portion of the ACS’s fees, based upon a per diem calculation for the days the Client resided or retained a bed in the supporting housing.

Client with Long-term Care Insurance: ACS does not interpret long-term care insurance contracts but do offer complimentary services of reading long-term care policies to provide the Client insight as to the types of Providers that may be approved by the insurance company and to help the Client and their family to understand the residency and care industry. ACS is not held responsible for loss, harm or injury that may result of information given to the Client, or lack of information, about the insurance policy. ACS cannot guarantee whether claims are paid by the insurance company. ACS advises the Client and/or the responsible party to contact the insurance company and make their own determination or retain an attorney for such purposes.

If the Client believes they were unfairly treated by the insurance company that relates to payment of benefits for long-term care from the insurance company, they may either or both of the following:

Contact the Washington State Insurance Commissioner’s Office:
Call 1-800-562-6900
Email: http://www.insurance.wa.gov/your-insurance/email-us
Submit a complaint online: insurance.wa.gov/complaints-and-fraud/file-a-complaint

Contact the Washington State Attorney General – Consumer Protection Division
Call 1-800-551-4636
Call 1-800-833-6384 (hearing impaired)
Call 206-464-6684 (out-of-state callers)
Submit a complaint online: https://fortress.wa.gov/atg/formhandler/ago/ComplaintForm.aspx
Mail your written complaint to:
Attorney General’s Office/Consumer Protection Division
PO Box 40100, Olympia, WA 98504-0100

No conflicts of interest: ACS and its personnel or business associates, who are directly involved in providing referrals to Clients, including their immediate family members, shall not have an ownership interest in the residence or care services to which the Client is given a referral, and, if such ownership interest exists, an explanation of that interest. However, ACS may advise the older adult or responsible party work with medical professionals (mental health professionals, ombudspersons, social workers, counselors and the like) to clarify the Client’s needs or preferences before working with ACS. In such situations, the older adult or responsible party will be responsible for costs of such services. At no time does ACS receive a referral fee from such professionals.

Providers compliance with State requirements: ACS reviews and records any licensing violations of all Providers as maintained on the website of the Department of Social and Health Services every 12 [twelve] months and within 24 [twenty-four] hours prior to offering the Provider’s residency or care to the Client. Unless Enforcement Letters indicate serious infractions, the existence of such letters are not necessarily the reason for a Client to pass over consideration of such Providers.

ACS shall have no liability or responsibility for the accuracy, completeness, timeliness, or currency of the DSHS website information shared in the prescribed format and are immune from any cause of action arising from ACS’ reliance on, use of, or distribution of this information under RCW 18.330.070(4).

ACS frequency of visits to Providers: ACS makes in-person tours of Providers, both scheduled and unscheduled. Dates of such visits are available upon request to the Client. Due to the ever-changing clientele with fluctuating needs, the Provider may alter their willingness to extend certain services to each individual Client. Clients and their responsible parties have the power to accept or decline services of any Provider. It is vital to note that frequency of visits by ACS should not guarantee future performance of a Provider. ACS, their employees, owners, acts or omissions of a Provider under RCW 18.330.150. The Client must be vigilant in analyzing and communicating with a Provider at their own discretion and in a manner that promotes quality communication and quality care.

ACS and mandatory reporting: ACS and its employees and independent contractors are required to reports abuse, neglect, abandonment or financial exploitation to appropriate authorities such as Adult Protective Services. Requests by a Client not to disclose such issues to Washington state authorities is against the law and is strictly prohibited by ACS.

ACS involves older adult as best practices: To provide the finest service possible, ACS involves the older adult in the selection process for residency and health care services. If the Client is unwilling or unable to be involved in this process, the responsible party may become involved in their place. At times, the older adult may suffer undue stress or be confused and unable to understand the process, ACS will communicate these matters to the responsible party. ACS treats each older adult with dignity and respect while involving them in important decisions.

Ending your relationship with ACS: The Client may end the relationship with ACS at any time for any or no reason without any fee or penalty. However, the Client should notify ACS by providing their name, the name of their responsible party, and a contact phone number or email:

Email to: Maria@AdultCareSolutions.Net
Call: 425-941-5163

Adult Protective Services: 800-487-0416 Snohomish, Skagit, Island, San Juan, Whatcom Counties ▪ 866-221-4909 King County ▪ 800-442-5120 Pierce County ▪ 888-833-4925 Kitsap County and 877-734-6277 Thurston County

To report abuse, neglect, abandonment, or financial exploitation:
866-363-4275 for consumers
800-562-6078 for mandatory reporters

Washington State Ombudsperson Program
800-562-6028 and website: http://www.LTCOP.org

Authorization granted to ACS and permission to release information

Pursuant to the requirement of the Health Insurance Portability and Accountability Act (HIPAA), the purpose of this disclosure, at this time, is for both non-medical and for medical purposes. Additionally, there is the potential for the protected health information to be re-disclosed by the recipient and thus, no longer is protected under this Privacy Rule.

I understand that this consent may be revoked in writing at any time with the exception and to the extent that disclosure of information may have already occurred prior to the receipt of revocation.

I give ACS, its employees, and its independent contractor(s) permission to access information regarding the older adult(s) named below. I also give permission to the Providers working with ACS (physicians, clinicians, ARNPs, licensed assessors, senior residency and care providers and/or paraprofessionals such as Certified Nursing Assistants, as well as regulatory or vulnerable adult advocacy organizations) to access this information as it relates to the Client’s interest in arranging for in-come care or relocating to a senior residence or care services.

ACS individual you are working with is:

Maria BurcheciEli Burcheci

Maria Burcheci
425-941-5163
Maria@AdultCareSolutions.net

Eli Burcheci
425-922-1647
Eli@AdultCareSolutions.net

Name of older adult 1 (required)

Name of older adult 2

I acknowledge receipt of the Disclosure Statement and Information Release Form of ACS contained in this document. I also verify that I am either the Older Adult(s) seeking assistance or I am a family member or related to the Older Adult(s) OR I hold legal documents such as Durable Power of Attorney or Guardianship to help the Older Adult(s).

By checking this box and completing this form, you are confirming receipt of the above documents. Additionally, you are confirming that ACS as well as its business associates of the agency are given permission to discuss your potential interest in them; or that the agency has permission to communicate with the potential providers on your behalf.

Yes, I understand

THIS AGREEMENT is entered into this
If using Internet Explorer or Firefox browsers, please use the interactive calendar popup to input date. Disregard date format discrepancy.

Client First and Last Name (required)

Client Signature
Sign in Box Below or Type Name as Signature

Client Phone Number (required)

Client Email (required)

First and Last Name of DPOA or Guardian (required)

Signature of DPOA or Guardian
Sign in Box Below or Type Name as Signature

Phone Number of DPOA or Guardian (required)

Email of DPOA or Guardian (required)

Address of DPOA or Guardian (required)

City, zip code of of DPOA or Guardian (required)

Δ