Back-up Caregiver Agreement

  1. Administer prescribed medication, treatments and accompany the Member to medical appointments as needed.
  2. Serve as primary back up caregiver for all personal care, physical assistance and supervision at any time the home care worker is absent from the home, and to provide additional assistance in the as necessary.
  3. Provide assistance with laundry, cooking, shopping and errands as needed.
  4. Assume responsibility and 'perform all needed care to meet the member's needs.
  5. 1 also agree to be an active. participant in the Member's Plan of Care to enable the Member to maintain independence, safety and dignity while living in the community.
  6. If, for some reason, I am unable to fulfill this obligation, an alternate adult member will take my place as the back-up caregiver.
  7. If a family member/adult is unable to fulfill #6 above and there is an issue impacting the health or safety of the Member Integra MLTC, Inc. may initiate an alternate plan of care.
    I agree to assume responsibility for issues listed above.
Name (Print) of Back-Up Caregiver
Relationship to Member
Telephone Number
Signature of Back Up Caregiver
Signatureof Member (If able)