SERVICE AGREEMENT

This agreement made on the______day of__________________19____, by and between_____________________________________herein after referred to as Purchaser, and _______________________________________herein after referred to as Provider, for services for_____________________________________herein after referred as client.

Provider and Purchaser agree to the following terms:

1. The Provider will have discussion with the Client concerning the purpose of the assessment. The Client agrees to sign a one page authorization to act as representative form.

2. The Provider will provide geriatric case management services for Client which were identified in the initial assessment.

3. The Purchaser agrees to pay Provider for geriatric case management services for Client. Services includes, but are not limited to, long range planning, negotiating for services, telephone calls, home visits, reports to purchaser, obtaining services, arranging transportation, scheduling for medical appointments, travel time, etc.

4. The Purchaser agrees that the assessment fee is $150.00 and the charge per hour is $75.00. The hourly fee begin when the case manager leaves the office and continues until the case manager's task is ended. Charges will be itemized and billed at (15) fifteen minutes increments. Mileage will be billed at $0.30 per mile. If the assessment has been completed, there is no assessment fee. A retainer fee is required.

5. The Purchaser agrees to pay a retainer fee of $100.00 to be applied to fees incurred for services to be rendered.

6. The Provider will bill Purchaser once a month. The amount billed is due and payable upon receipt by Purchaser. Purchaser agrees to pay a late fee of ($20.00) twenty dollars of any bill over (30) thirty days.

7. The Purchaser will make the greatest effort to refer out to those service providers of the highest quality services. The Provider will refer to community operated agents whenever possible. We will use community based Senior Citizen services as first preference. However, there will be times when these services are not available. It will be necessary to refer to other agents. We will take every precaution to refer only to reputable license, bonded agents. The Provider cannot warrant and do not assume liability for the actions of the third party vendors.

 8. The Purchaser may terminate geriatric care management services by giving the Provider written notice (15) fifteen days prior to the termination date. The Provider will provide the Purchaser with a summary of activities since the last monthly statement.

____________________________	Fortson Consulting, Inc.
Purchaser's Name	P.O. Box 618083
____________________________	Orlando, FL 32861-8083
Purchaser's Address
____________________________
Purchaser's City/State/Zip
____________________________
Emergency Phone Number
____________________________	____________________________
Customer's Signature	Fortson Consulting's Acceptance