1. a) Client consent to receive services;
2. b) The name, street address, mailing address and telephone number of the agency;
3. c) The name, mailing address and telephone number of the persons designated as the agency manager and/or other individual beyond the in-home worker to contact in regard to questions, problems, needs or concerns;
4. d) A statement describing the agency license status;
5. e) Indication and assurance of compliance by the agency with the requirements of the Act, including compliance with the Health Care Worker Background Check Act;
6. f) The duration of the contract;
7. g) The rate to be paid by the client and a detailed description of services to be provided as a part of the rate;
8. h) A description of the process through which the contract may be modified, amended or terminated;
9. i) A description of the agency complaint resolution process;
10. j) The billing and payment procedures and requirements;
11. k) A statement regarding the agency's policy on notification of a relative or other individual in case of an emergency;

12. l) A notice as developed and provided by the agency, indicating the responsible party for the following:

    1. 1) Employer of the in-home/licensed worker;
    2. 2) Liability for the in-home/licensed worker;
    3. 3) Payment of wages to the in-home/licensed worker;
    4. 4) Payment of employment taxes, unemployment insurance, and worker's compensation for the in-home/licensed worker;
    5. 5) Payment of Social Security taxes for the in-home/licensed worker;
    6. 6) Day-to-day supervision of the in-home/licensed worker;
    7. 7) Assignment of duties to the in-home/licensed worker;
    8. 8) Responsibility for hiring, firing and disciplining the in-home/licensed worker; and
    9. 9) Provision of equipment or materials for the in-home/licensed worker's use in providing services to the consumer.

A contract shall be in force between a home nursing or home services agency and a client. A copy of the contract shall be provided to the client and a copy shall be maintained in the client file at the agency. If the agency has both a home services license and a home nursing license, the agency shall maintain two separate client contracts, one for skilled medical care and one for non-medical services. The contracts shall be printed in no less than 12-point type, and shall include at least the following elements in the body or through supporting documents or attachments:

(Source: Amended at 39 Ill. Reg. 16406, effective December 10, 2015)