I have reviewed and received a complete copy of the Ambition HomeCare LLC Welcome Intake Package.

I understand the scope of services offered, including which services are and are not provided under non-medical care.

I understand my rights, responsibilities, and the agency’s policies as outlined in this packet.

I have had the opportunity to ask questions and receive clarification about any item in this package.

I acknowledge that I have disclosed all relevant medical, safety, and support needs to ensure appropriate care is delivered.

I understand and accept the agency’s financial policies, including payment terms, fees, and billing schedules.

I understand the procedures for filing complaints or concerns, including contact information for the Maryland Department of Health.

I understand that services may be modified or paused if payment is not received according to the agreed schedule.

I authorize Ambition HomeCare LLC to assign qualified caregivers based on my needs and preferences.

I understand that my care may be monitored for quality assurance, safety, and compliance purposes.

I agree to comply with the mutually agreed-upon care plan and to notify the agency of any changes or issues.

I understand the agency reserves the right to discontinue services for non-compliance with safety, payment, or conduct policies.

I agree not to solicit or hire agency staff for private services outside of Ambition HomeCare LLC.

I confirm that I have been informed of my right to designate a representative to make care decisions on my behalf if needed.

I understand that any falsified information may result in service denial or termination.

I authorize Ambition HomeCare LLC to begin providing non-medical in-home care services as outlined.

I understand that Ambition HomeCare LLC is a non-medical agency and does not provide skilled nursing, medical diagnosis, or medication administration.

I agree to maintain appropriate professional boundaries with staff and understand that personal requests outside the scope of services may be declined.

I authorize Ambition HomeCare LLC to document care-related communications and interactions as part of my client file.

I understand that services may be suspended if unsafe conditions exist in the home, including harassment, unsanitary environments, or threats to staff safety.

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.