Admission Agreement

Form 1 of 12

  1. Introduction

    This agreement entered into by and between the Resident named above, herein after RESIDENT; the responsible person signing below, herein after RESPONSIBLE PERSON and Marwood Nursing & Rehab, herein after MARWOOD, a Michigan Not-For-Profit Corporation operating a Licensed Skilled and Basic Nursing Facility located at 1300 Beard Street, Port Huron, Michigan.

    This agreement will begin on the date of admission and will end on the earliest of the following events: (a) the discharge or departure of RESIDENT from the facility with no reasonable expectation of RESIDENT's return; (b) RESIDENT's death; or (c) termination pursuant to the terms of this agreement.

    It is understood that RESIDENT and RESPONSIBLE PERSON have the right to terminate RESIDENT’s stay at any time upon giving 72 hours written advance notice to MARWOOD, exclusive of Sundays and Holidays.

    It is further understood that MARWOOD has the right to terminate the stay of the RESIDENT at any time as provided under Public Act 368 of 1978. This includes, but is not limited to, for medical reasons, for nonpayment which means the failure to pay the full amount of the facility charges agreed upon in writing at admission or subsequently, or the failure of a Medicaid Resident to pay RESIDENT's stipulated contribution toward his/her care, medical reasons relating to the written orders of an attending physician. MARWOOD’s failure to exercise said rights at any time does not constitute a waiver of MARWOOD’s rights.

    MARWOOD reserves the right to place or relocate RESIDENT in whatever accommodations will, in MARWOOD’s sole judgment, result in a compatible RESIDENT relationship and/or appropriate and efficient care by the staff or MARWOOD. MARWOOD reserves the right to relocate a RESIDENT coming in for Rehab and plans to stay long term.

    Notification will be given to the RESIDENT prior to moving the RESIDENT to another room within the facility. In the event that a transfer or discharge from the facility is necessary, such action will be taken in accordance with MARWOOD's involuntary transfer/discharge policy provided to the RESIDENT upon admission.

  2. Routine Services and Basic Charges

    For the applicable fee listed on the Rate List for private pay Residents, or for the rate established by the Michigan Department of Human Services or the U.S. Department of Health and Human Services for those persons qualified under the Medicaid or Medicare programs, MARWOODshall provide routine nursing services, room and board (three meals per day), housekeeping and laundry services, and social, recreational and religious functions as determined by MARWOOD.MARWOOD reserves the right to adjust rates and charges commensurate with any changes in the nature and schedule of services provided to RESIDENT or with any changes in the cost of providing the appropriate care and services and agrees to advise the RESIDENT /RESPONSIBLE PERSON with 60 days notice. RESIDENT / RESPONSIBLE PERSON agree to pay the changed rate upon its effective date. The RESIDENT / RESPONSIBLE PERSON acknowledge that they have discussed with MARWOOD various alternatives available for payment for services rendered.

  3. Supplemental Services and Charges

    In addition to routine nursing services, there are other services provided to RESIDENT upon request and the charges for those services are included in the Rate List, which may be adjusted at any time by MARWOOD.

    Professional services by physicians, surgeons, physiatrists, dentists and podiatrists; prescribed medication; prescribed physical therapy, occupational therapy or speech therapy; diagnostic or therapeutic x-ray services; ambulance services; eyeglasses; dentures and hearing aids; and barber/beautician services are supplemental services. MARWOOD has arranged to make such supplemental services available to RESIDENT, through independent providers that are not employed by MARWOOD, if RESIDENT does not have or desire to have RESIDENT's own private providers render such services. Whether these services are furnished to RESIDENT through independent providers who have arrangements with MARWOOD or through the RESIDENT's private providers, these separate providers will set their own fees and will bill RESIDENT for their services. These fees will be in addition to the basic charges.

    A list of commonly used supplemental services and the approximate charge for such services is included in the Rate List. Additional information about the services of independent providers arranged by MARWOOD may be obtained from MARWOOD's business office.

    The basic room rates also do not include personal items such as clothing, grooming supplies or toiletries. MARWOOD has no arrangements for the furnishing of these items by independent providers.

    Special duty nursing services must be arranged for and paid by RESIDENT if said service is desired or needed, and MARWOOD will in no event be liable for any harm or loss for failure to provide the same. Special duty nursing services must be obtained according to MARWOOD’s policies and procedures.

    RESIDENT hereby authorizes MARWOOD to arrange for such prescribed medications and supplemental services as may be ordered by RESIDENT's attending physician and agrees to pay the cost of such medications and services, if not covered by Medicare, Medicaid, or other insurance.

    Hospice Care is available at Marwood Nursing & Rehab. For Further information, please contact Admissions, Nursing or Social Services.

  4. Resident Rights and Responsibilities

    RESIDENT acknowledges receipt of a copy of the Resident Rights and Responsibilities adopted as required by law. MARWOODRESIDENT / RESPONSIBLE PERSON agree that the parties will have additional responsibilities as follows:

    RESIDENT / RESPONSIBLE PERSON agrees not to transfer or otherwise divest or give away assets of RESIDENT, including any assets held jointly or in common with others, for less than fair market value to any third party. RESIDENT / RESPONSIBLE PERSON agree to use these assets for payment of the RESIDENT's stay at the facility until the assets are exhausted or until the RESIDENT leaves the facility and all moneys owed to MARWOOD are paid in full.RESIDENT / RESPONSIBLE PERSON acknowledges that it is not the policy of MARWOOD to exclude individuals who cannot pay the basic charges for their stay but only so long as their assets have not been improperly transferred or divested in violation of this contractual requirement.

    It is the duty of the RESIDENT / RESPONSIBLE PERSON to cooperate with MARWOOD to establish and maintain a viable financial plan for the payment of RESIDENT's stay at MARWOOD to the extent that RESIDENT has private funds available to pay these charges or RESPONSIBLE PERSON has the authority to apply RESIDENTS assets to RESIDENTS charges.

  5. Attending and Alternate Physicians

    Since MARWOOD does not have an available physician on its staff, it is the responsibility of RESIDENT to secure the services of a licensed physician to attend to RESIDENT as is required by law no later than the time of admission and is medically necessary.  MARWOOD is authorized to have its Medical Director or Alternate see RESIDENT, if RESIDENT's personal physician does not visit RESIDENT often enough to satisfy the requirements of the Michigan Department of Community Health dealing with physician visits. RESIDENT's personal physician, or another physician (in case of an emergency), may be called by MARWOOD whenever deemed necessary in MARWOOD’s sole judgment, and the expense incurred thereby will be RESIDENT's responsibility.

    RESIDENT / RESPONSIBLE PERSON have a duty for following the recommendations and advice prescribed in a course of treatment by the physician and are duty bound for providing information about unexpected complications that arise in an expected course of treatment. They have a duty for making it known whether they clearly comprehend a contemplated course of action and the things they are expected to do.

    MARWOOD shall include pain and symptom management in RESIDENTS medical treatment.

  6. Billing

    RESIDENT / RESPONSIBLE PERSON agree to pay all charges when due, except to the extent that the charges are paid for by Medicare, Medicaid or other insurances. RESPONSIBLE PERSON shall not be personally liable except to the extent that RESPONSIBLE PERSON does not apply RESIDENTS assets under his / her control to the payment of RESIDENTS charges. The basic charges are billed to RESIDENT on a monthly basis and are due in advance for the current month, on or before the tenth day of the month. All charges for supplemental services which are not included in the basic charges will be billed separately by MARWOOD or by the independent provider which provided the services and will be due within thirty days of receipt of the billing. Any amounts that are more than 25 days overdue will be subject to a late charge of the maximum amount allowed by law.

    There will be a fee assessed if checks are returned to MARWOOD for any reason. Should the account be referred to an attorney for collection, the undersigned agrees to pay all reasonable attorneys’ fees along with all collection costs and all other costs in the collection of the account.

    Private pay residents, prior to admission to Marwood will pay the daily rate multiplied by the number of days they are staying.

    The daily room charge for routine nursing services will begin on the day of admission. There will be no charge for the day of discharge unless RESIDENT leaves the facility later than 11:00 a.m. In this event, there will be an additional charge equal to the daily rate for routine nursing services.

  7. Third Party Benefits

    It is the duty of RESIDENT / RESPONSIBLE PERSON to apply and provide all necessary information for Medicare / Medicaid benefits, private insurance coverage, or any other third-party payments, and to pursue, at their option, any protest or appeal of any denial of third-party payments.

    If RESIDENT is insured by an out-of-state carrier or a carrier who does not have a contract with MARWOODMARWOOD will bill RESIDENT directly. RESIDENT has a duty to pay the bill and make their own arrangements to secure reimbursement from their carrier.

    If for any reason RESIDENT's benefits are delayed or denied in whole or in part, or if there is a dispute as to covered services, RESIDENT / RESPONSIBLE PERSON agree to pay all charges incurred during the period covered by the third-party delay, denial or dispute, at prevailing rates.

  8. Notification of Change in Source or Amount of Payment

    RESIDENT / RESPONSIBLE PERSON agree to notify MARWOOD within 90 days of any change in the source or amount of payments for services rendered to RESIDENT byMARWOOD.

  9. Failure to Comply

    RESIDENT / RESPONSIBLE PERSON agree to personally reimburse and compensate MARWOOD to the extent that any payments for services rendered to RESIDENT by MARWOOD would have been but were not made to MARWOOD because of a failure to comply with this Agreement.

  10. Transfer to Hospital or Nursing Home

    MARWOOD will arrange for RESIDENT to be transferred to a hospital when this is deemed necessary by RESIDENT's attending physician or MARWOODS acting Medical Director and will notify RESPONSIBLE PERSON about this transfer. MARWOOD has made arrangements with area hospitals to accept Residents from the facility. Accordingly, RESIDENT will be transferred there unless services required by RESIDENT are not offered by that hospital or unless RESIDENT / RESPONSIBLE PERSON requests RESIDENT go to another hospital.MARWOOD will also transfer RESIDENT to another nursing home should RESIDENT’s nursing care needs exceed the scope of MARWOOD's license or its capabilities. The bed hold policy and RESIDENT’s right to return to the facility following a hospital or therapeutic leave will be explained to RESIDENT / RESPONSIBLE PERSON at the time leave is taken.

  11. Authorization to Release Medical Information and Photograph

    MARWOOD is authorized to release medical information about RESIDENT as may be necessary in MARWOOD’s sole judgment for the completion of claims to all third-party payors responsible for payment for RESIDENT's stay for the purpose of facilitating payment to MARWOOD, or other purposes permitted by law. MARWOOD agrees to keep medical information confidential as is set forth in the Resident's Bill of Rights and the Health Insurance Portability and Accountability Act of 1998. MARWOOD is also permitted to publish RESIDENT's name and photograph for purposes of identification, documentation of the medical record, and for participation in in-house activities, birthday parties, special announcements, facility publication (such as newsletters), and the like, while RESIDENT is under the care of MARWOOD, or for the purpose of assisting in training of personnel to better assist RESIDENT at MARWOODMARWOOD is also permitted to publish RESIDENT’s information as defined in the Notice of Privacy Practices. No publication outside MARWOOD shall be made without consent of RESIDENT / RESPONSIBLE PERSON.

    This consent will remain in effect so long as RESIDENT is at MARWOOD and for so long after RESIDENT leaves as is necessary for MARWOOD to submit bills to the third-party payors but will expire as soon as MARWOOD is fully paid for all charges concerning RESIDENTRESIDENTmay revoke this consent at any time before it expires unless MARWOOD has taken action in reliance upon it.

  12. Authorization and Release for Events and Activities

    RESIDENT / RESPONSIBLE PERSON agrees to and grants permission for RESIDENT to participate in social, recreational, and similar events and activities sponsored by MARWOOD, including but not limited to sponsored events and trips away from the MARWOOD facility.RESIDENT / RESPONSIBLE PERSON releases MARWOOD, its management and staff, andRESIDENT's physician from any liability or responsibility for injury or change of condition that may occur while RESIDENT is being transported to or from, or involved in, any event or activity sponsored by MARWOOD, or that may occur as a result of participation in such event or activity.

  13. Care and Safety of Resident

    MARWOOD, its management and its personnel, accept no responsibility for any accidents resulting in injury while RESIDENT is on a planned temporary absence from the MARWOOD’sfacility and therefore is out of the custody and control of MARWOOD. Furthermore, should RESIDENT permanently leave the MARWOOD facility with or without physician or management consent, MARWOOD, its management and personnel are absolved from all responsibility of injuries resulting from RESIDENT so leaving.

    MARWOOD will not be responsible or liable for acts or conduct of any physician, other resident or guest at the MARWOOD facility which may result in personal injury or property loss toRESIDENTMARWOOD does not accept any duty to diagnose or prescribe treatment forRESIDENT's condition when RESIDENT designates an independent physician.

  14. Personal Funds and Valuables

    MARWOOD will not be responsible for any of RESIDENT's valuables or money. Personal spending monies may be kept in an individual Resident trust account established by separate written authorization by RESIDENT allowing home custody of such funds. Records of deposits and withdrawals will be kept by MARWOOD, and RESIDENT has the right to a complete accounting of these funds upon request, as outlined in the Trust Fund Authorization.

    MARWOOD cannot and does not accept responsibility due to loss, damage, theft or misplacement for any personal effects of RESIDENT left in his or her room, including but not limited to eyeglasses, dentures, and hearing aids.

  15. Removal of Personal Effects

    Because of limited storage, upon RESIDENT's discharge/expiration, all personal property must be promptly removed. Items left in storage at the facility in excess of 30 days will result in a charge of $10.00 daily until the property is removed.

Acknowledgement and Certification

The undersigned acknowledge receipt of the Admission Agreement and agrees to be bound to all terms, conditions and duties.

We hereby certify: that we have read the attached Admission Agreement or have had it read to us, and that we understand it; that we have had the opportunity to raise questions relating to the Admission Agreement which is the entire agreement between the parties; and that we agree to the terms of the Admission Agreement.

If signing on the Residents behalf, please provide the Resident's name in the Resident section.


At time of admission, please provide a copy of Guardianship, Power of Attorney, Durable Power of Attorney, or Medical Power of Attorney paperwork.
Facility Representative empty box for administration
Date empty box for administration

By submitting this Authorization, please be aware that an electronic signature is as legally binding as a handwritten signature.