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Professional Medicaid Policy Payment Terms template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Required private-pay duration policy prior to accepting Medicaid contract rates.
State daily rate breakdown, resident participation copay obligations, and billing dates.
Notice requirements for Medicaid transition, room retention rights, and bed hold terms.
Legal sign-off agreeing to Medicaid conversion criteria and financial disclosures.
Or get this form included in the Operations & Records Bundle ($69)