Clients – Apex Eldercare Consulting

Disclosure Statement

As a client of Apex Eldercare Consulting, LLC (Apex); you, your family and representatives have the right to a disclosure statement.

Apex is a senior housing and care provider referral agency mandated under the elder and vulnerable adult referral agency act, Chapter 18.330 RCW. Apex does not charge a fee to their clients or representatives as we are paid directly by the senior housing and care providers. Apex does not charge a referral fee for assisting families with placement where Medicaid is the payee.

Apex makes referrals, and offers options, but does not make direct recommendations.

Apex does not require or request that clients sign waivers of potential liability for losses of personal injury, or waivers of any rights of our clients established in state or federal law.

Apex works in a dual agency relationship with the responsibilities of offering information and guidance to their client or their legal representative while receiving funding from the senior housing or care provider for assisting the senior housing or care provider with the addition of a new resident or client. Apex’s contracts with senior housing and care providers mandate that no part of our fee can be passed on to the client.

The fee ranges from 25%-100% of one month’s equivalent rent and care charges for respite, hospice and permanent placements. Payment terms are due anywhere from 10-130 days after the client has begun receiving services with the care provider. (depending on the type of services procured) There will be a prorated refund to the provider if the client should move out or pass away within 30 days.

We typically conduct routine visits of the senior housing provider facilities we refer our clients to at a minimum annually. We will inform our clients in writing or by electronic means when the property was previously toured, and share DSHS website enforcement findings.

A client may without cause stop using Apex’s services or switch to another agency without penalty or cancellation fee to the client or representative.

A client may file a complaint of violations with the Attorney General’s office.

Attorney General Phone: Mon-Fri, 10am-3pm, 360-753-6200. Office of the Attorney General 1125 Washington Street SE, P.O. Box 40100, Olympia WA 98504-0100

Apex will inform the housing and care providers with details regarding the potential clients housing and care needs. Private health care information will be shared with senior living providers, clinicians, hospitals, social workers, nurse assessors, and representatives. In order to do so, Apex must obtain authorization to disclose confidential health care information and information identifying the client.

Client Authorization for Release of Protected Healthcare Information

I authorize the representatives of Apex Eldercare Consulting to access information regarding the older adult(s) named below. I give them permission to review and discuss records and health care information from to and with any long term care facility, hospital, physician, or other health care provider, senior living associate, and or staff associated for the purpose of senior housing and care referrals.

I agree and understand that such information may be shared via email, fax, telephone, electronic mailings and during care plan meetings.

The authorization of this disclosure and Release Form may change with the written notification of the client or their representatives. A printed version, photocopy, fax, electronic mailing, or website agreement shall be valid as original.

NAME *Person filling out this form

PHONE *Person filling out this form

EMAIL *Person filling out this form

NAME *Person whose health care information and records are to be released:

Date of Birth *Person whose health care information and records are to be released:

By signing this form you agree to Apex Eldercare Consulting, LLC’s Disclosure of Services and Medical Healthcare Release. Printing your name here is considered a digital signature for this electronic form. *I certify I am either the authorized healthcare representative (DPOA) or the client (patient/resident) whose medical records are being released:

SIGNATURE

DATE