Longterm Care Referral Agent Disclosure and Advisory Form
Agent Business Information
Agent Name/Business Name: Vanguard Care Advisors LLC
Address: 830 NE 34th PL Canby Or, 97013
Telephone: 503.442.3204
Email: [email protected]
Website address: www.seniorvanguard.com
General Information for Oregon Consumers
Oregon Long Term Care Referral Agents are required to provide consumers and clients seeking assistance finding long-term care options the following information.
Mandated Disclosures
Oregon law requires Long Term Care Referral Agents to make the following disclosures to a client:
1) Description of the referral. The types of facilities being referred to the client, include the following:
Adult Foster Home, Residential Care, Facility, Assisted Living Facility, Memory Care, Nursing Facility, Independent Living, Continuing Care Retirement Community (CCRC), Medicaid Contracted
2) Limitations on referrals. The client will be referred only to facilities with which the Referral Agent has a business-to-business contract: No
3) Referral fees. Any fees paid to the Referral Agent for services will be paid by the admitting home/facility: Yes
4) This Referral Agent’s right to a referral fee expires if the client does not move into a referred facility within a specified period from the time of the referral: No
5) Privacy Policy. A copy of the Referral Agent’s privacy policy is attached to this advisory form. A copy can be found at the following web link: https://seniorvanguard.com/disclosure-page
6) Facility Complaint History. The Oregon Department of Human Services (ODHS) website listing complaints concerning facilities/care communities is found at: https://ltclicensing.oregon.gov
Additional Information
The following additional information beyond the mandatory disclosures is provided to assist the consumer in understanding Oregon laws regarding referrals.
A Referral Agent Must:
1) Discontinue providing services to a client who notified the Referral Agent in writing that the client no longer wishes to use the services of the Referral Agent. If the Referral Agent has received compensation from the facility for a referral that has been made, the client may notify the Referral Agent in writing that he/she wish to use the services of another Referral Agent in the future for referral to another facility in a subsequent move. The client’s written notice shall identify the name of the facility and the move-in date of the original referral made by the Referral Agent.
2) Provide the required disclosures to the client in writing in a conspicuous and clear manner. The disclosure may be made orally first if the agent makes an audio recording with the consent of the client and thereafter provides the client a written disclosure.
A Referral Agent May Not:
1) Provide a referral to a long-term care facility/home for compensation unless registered with ODHS.
2) Refer a client to a facility in which the Referral Agent or an immediate family member has an ownership interest.
3) Contact a client or authorized representative who has requested in writing that the Referral Agent stop contacting them.
4) Share a client’s placement information with or sell a client’s placement information to a facility or marketing affiliate without obtaining affirmative consent from the client or his/her authorized representative for each instance of sharing or selling such information.
Authorization to Share Placement Information
I have read, understand, and consent to this agreement and I authorize this Referral Agent to share my placement information with the facilities to which I will be referred or with this Referral Agent’s marketing affiliates.
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Receiving Individual – (electronic) Signature Date
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Receiving Individual – Printed Name
