Client Rights and Responsibilities Form

A 5-page Word document that explains a home care client's rights, the client's responsibilities, and how to raise a concern.

For USA non-medical home care agency owners and supervisors. Plus 1 agency instructions page to remove before use.

What's included

1. Page 1: section 1 summary of client rights
2. Page 2: section 2 client responsibilities, each with an initials box
3. Page 3: section 3 the Agency's responsibilities and section 4 grievance procedure
4. Page 4: contacts for concerns and section 5 acknowledgment and signatures
5. Page 5: Agency Use Only office record and grievance log
6. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the body says "the Agency," so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Fill in the notice days and the complaint contacts. Set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state's requirements. Not a license to operate, not HIPAA software, and no medical claims. Adapt the rights, notice periods, and contacts to your state rules. This form does not by itself meet any state requirement.