3Care4U Personal Care Agency: 3Care4U
Agency Address: P.O. Box 1312, Manitowoc, WI 54220
Agency Phone / Fax: Ph: 920-663-1225 | Fax: 920-614-2004
Agency Email Address: [email protected]

Client Rights and Responsibilities Form

This form outlines the rights and responsibilities of clients receiving personal care services by our agency and the rules and policies the agency upholds as a provider.

Client Rights

All clients have the following rights while receiving care from 3Care4U:

  1. To be fully informed of these rights and of all the provider's rules governing client responsibilities
  2. To be fully informed of service available from the provider
  3. To be informed of all changes in services and charges as they occur
  4. To participate in the planning of services, including referral to a health care institution or other provider and to refuse to participate in experimental research
  5. To have access to information about the client's health condition to the extent required by law
  6. To refuse service and to be informed of the consequences of that refusal
  7. To confidential treatment of personal and medical records and to approve or refuse their release to any individual outside the provider, except in the case of transfer to another provider or health facility, or as otherwise permitted by law
  8. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs
  9. To be taught the service required so that the client can, to the extent possible, help himself or herself
  10. To have a person designated by the client taught the service required so that, to the extent possible, the person designated can understand and help the client
  11. To have one's property treated with respect
  12. To complain about the care that was provided or not provided, and to seek resolution of the complaint without fear of recrimination
  13. To have the client's family or legal representative exercise the client's rights when the legal representative is legally authorized to do so
  14. The provider's rules and the client's responsibilities under the provider's rules
Client or Client Representative Initial:
Client's Responsibilities
Client or Client Representative Initial:
Provider's Rules

3Care4U shall assess prospective client's appropriateness to be served by the agency without delay, unless the reason for the delay is justifiable and documented, and accept a client only if there is reasonable expectation that the client's needs can be met by the agency.

If the agency accepts the applicant as a client, the agency shall promptly provide services to the individual. If the agency does not accept an applicant as a client, the agency shall inform the applicant of other personal care service providers in the area or how to obtain a list of those providers.

Client or Client Representative Initial:
COMPLAINT STATEMENT: We encourage our clients or client representatives to file a complaint with DHS - Division of Quality Assurance / Bureau of Health Services with the information provided below in the event that our clients or client representatives are unsatisfied with the services we provide or any other complaints our clients or client representatives may have with our agency.

Division of Quality Assurance / Bureau of Health Services
P.O. Box 2969
Madison, WI 53701-2969
608-266-8481
800-642-6552
To file online: http://www.dhs.wisconsin.gov/bqaconsumer/healthcarecomplaints.htm
By signing this form, I , attest to being fully informed of my rights and responsibilities as a client receiving personal care services provided by 3Care4U and the provider's rules and policies as a provider.

My signature above confirms that my rights and responsibilities and the provider's rules and policies were explained to me in the language in which I understand whether this language is in English or in another language that I speak.

I also attest to receiving written as well as verbal information on my right to file a complaint with the Division of Quality Assurance for any reasons that I may wish to file the complaint.