Sample Assisted Living Resident Agreement

Assisted Living

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Welcome to Senior Service Maps. We are a company that sends referrals to Assisted Living facilities with no referral fees. We also offer free support. Below is a copy of a sample Assisted Living Resident Agreement; We strongly encourage you to let your attorney review this before you use it. If you are interested in receiving clients from us please click (here).
Thank you








  1. This agreement is between ____________________________ and________________________________________ (Residents Name)


Your residency at _________________________ begins on____________________. After this agreement is signed

this agreement will at such time become valid and in effect and with the understanding that the charges of all required fees for the current month is to be collected by ___________________________.




2.____________________ is licensed to provide low, moderate, and high levels of care.

3.Based on the information provided by your doctor and an assessment performed by this facility, you require ______ level of care. if your care needs change and you need a higher level of care, which this facility is not licensed to provide, we may request a level of care waiver from the Department in order for you to remain here. if the waiver request is not granted, we will give you ample time notice that you will be discharged, and will assist you in finding an appropriate facility.



4.The monthly fee for your care at _____________________ is $_______________ with an entry fee of $________________. This monthly fee includes the services listed below. This fee does not include medications, personal phone line/long distance calls, medical equipment, outside entertainment or trips, purchasing of clothing, adult day care, barbering, hair styling, manicuring, burial and funeral expenses and arrangements. Assisted Living facility that are participating in the older Adult waver may not charge waver participants any additional fees such as entry fees, late payment fees, etc. We do not charge Waiver participants any additional fees. Such as entry fees, late payment fees etc.


  • Medicaid Subsidy: ____________________________
  • State Subsidy: ________________________________
  • Facility Subsidy: ______________________________
  • TOTAL FEES: ________________________________


  1. In consideration of your monthly payment, the facility agrees to provide the following services:
  2. A private/semi private room which includes a bed, bedside table lamp, chair, dresser; bath linens and bed linens;
  3. Meals which include three meals a days and additional snacks
  4. Personal care services which include assistance with eating, personal hygiene, transferring, toileting„ and dressing.
  5. Laundry and housekeeping services,
  6. Assistance with access to health care, social services, and social activities.
  7. Reminders or physical assistance to residents who can self-administer medications/administration of medication.
  8. basic hygiene, grooming, bathing and oral hygiene, shaving equipment, lotions, powders, deodorants, shampoo, comb/brush etc.



6.You are assigned to bedroom #____________     and bed #_______________

7.If it becomes necessary because of health, safety or other conditions to move your bedroom or bed assignment, the facility will give you at least 5 days advanced notice.

8.If your care needs become greater than the facility can safely handle, it may become necessary to transfer you to another facility. In that event, you will be given at least 30 days notice before the transfer and assistance with transmitting to your new home.

9.Locks are available for your use in securing personal belonging.

10.This facility follows security provisions to ensure your safety and well-being:

  • Alarmed entry and exits
  • Requirement to notify staff when leaving facility and length of absence
  • No locks on residents’ room door. Door locks(inside and out) are required on all residents rooms controlled by resident with staff access by permission or in case of emergency.
  • Log for residents, staff and visitors to sign in/out facility.
  1. Residents have full use of their own rooms and the common areas of the facility.
  1. To ensure your safety and wellbeing, the staff has the right to enter your room; however, the staff will make every effort to be respectful of your privacy and will always knock before entering.
  1. In the event you are on leave of absence from the facility for hospitalization, vacation or other reason, the facility will hold your bed provided you are able to provide payment for the duration of leave and the facility is eligible to meet the care needs of the resident. The Medicaid waver program does not pay for bed hold services, that is the sole responsibility of the resident.


  1. In the event of an emergency situation which could make it unsafe or unhealthy to continue to provide services at the facility, the facility will make arrangements to temporarily relocate you to another location as directed by the Director of the facility, all residents will be relocated to _______________________________________________________
  1. The resident rules of the facility are attached to this agreement and incorporated by reference. By signing this agreement, you have indicated acknowledgement and receipt of the resident rules and agree to abide by these rules.
  1. The following special information is required in the untimely event of death:


Burial Arrangements



Person Who has burial responsibility:

Name:____________________________ Relationship_________________







  1. You may be discharged from the facility for the following reasons:
  • Non-payment of fees
  • Care needs exceed what the facility is able to provide
  • c Behavioral reasons, including but not limited to destruction of property, violence, sexual misconduct, and not abiding by house rules.
  1. in the event the facility decides to discharge you, you will be given at least 30 days advanced notice prior to the date of discharge in the event you are discharged because of health emergency, the facility may not be able to give you 30 days notice.
  1. If you wish to leave the facility you are required to give 30day notice of date you wish to terminate this agreement: However if you are leaving because of health emergency 30day notice is not required.




20.A copy of resident’s rights is attached and incorporated by reference into this agreement. This facility will honor and respect your rights.

21.You have the right to make suggestions, register complaints or present grievances about the care of service you or another resident receives here. You may address these concerns to the Assisted living Manager at _________________ Assisted living program manager, or you may contact Assisted Living Complaint Unit at _____________or tool free at ___________________.

22.If your Complaint is directed to ALH manager, you will receive a response to your complaint within 5 days If you are not satisfied with that response or the ALH manager does not respond to your complaint, you may contact the Assisted Living Complaint Unit. at _________________ or tool free at _______________________.

23.Phoenix Rising is responsible for monitoring and recording residents health status.

24.The facility will not handle residents finances if resident is unable.

25. The Assisted Living Facility is responsible for arranging for or overseeing your care and for contracting for services including equipment and supplies not provided by the facility. It is the facilities responsibility to oversee the residents care and contract for services not supplied by the facility. Case manager will assist waver participant to procure needs medical supplies and medical equipment as authorized in their plan of care waver participants may identify the assistive devices and equipment waver provider of their choice through their case manager.

26.If for any reason you have not taken your personal property with you upon discharge, the facility will pack up your belongings and safely store them for 20 days. If you or your family have not retrieved them within 20 days of discharge, your property will be disposed of.

27.Residents are not mandated to attend adult daycare. He or she has the right to choose weather they want to attend. The facility will comply with the residents’ plan of care regarding the number the number per week of the attendance in the day care program.




ON THIS_________ DAY OF_________ YEAR__________________



Whitness:___________________________ Facility:























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