Caregiver Agreement Template (US)
Updated on September 24, 2026
A caregiver agreement sits at the edge of contract, employment, health privacy, family finance and safety. The person receiving care may be an older adult, a person with a disability, a recovering patient or a family member. The person paying may be the care recipient, a child, a trustee, a guardian or another relative. A strong agreement has to name those roles clearly before it says anything about pay.
The Jotform caregiver contract has a useful skeleton: parties, care recipient, scope, schedule, pay, leave, termination and governing law. But it mixes employee-style leave and probation language with contractor-style contract language and never tells the user to check household-employment tax, wage/hour status, domestic-worker rules, medical-scope limits, health privacy, background checks, emergency authority or Medicaid/family-care transfer concerns. This US master keeps the practical skeleton and fixes the risk areas.
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Caregiver Agreement
This Caregiver Agreement is dated and is entered into by (the "Client") and (the "Caregiver") for services to (the "Care Recipient"). Payer, if different: .
1. Care location and services
Care location: . Included services: . Excluded services, skilled medical tasks or tasks requiring separate authorization: .
2. Schedule
3. Payment and worker status
Pay rate and payment cycle: . Overtime, premium pay, breaks, travel time or live-in treatment: . Reimbursement: . Expected worker-status treatment for review: .
The parties understand that worker classification, household-employment tax, wage/hour, workers compensation and state domestic-worker rules depend on law and facts, not only on this Agreement.
4. Privacy, records and communication
The Caregiver shall keep health, family, financial and home-security information confidential and may share information only as follows: . The Caregiver shall keep incident, medication-reminder, expense and schedule records requested by the Client.
5. Safety and emergency authority
Emergency contacts and authority: . The Caregiver may call emergency services when reasonably necessary and shall notify the Client or emergency contacts as soon as practical.
6. Review and termination
The parties will review the care plan on or before and whenever the Care Recipient's needs materially change. Either party may end this Agreement without cause on days written notice. Immediate termination may apply for abuse, neglect, theft, unsafe conduct, material breach, loss of required license or background clearance, or inability to provide safe care.
7. Final duties
On termination, the Caregiver shall return keys, access codes, records, equipment, medication lists and confidential information, and the Client shall pay undisputed earned compensation and approved reimbursements.
Client
Date signed:
Caregiver
Date signed:
Separate the client, care recipient and payer
Many caregiver arrangements have three roles. The care recipient receives services. The client may sign for the services. The payer may be a family member, estate, trust or benefits program. The agreement should say who has authority to direct care, who can change the schedule, who can access information and who is responsible for payment.
This template also gives space for a medical or family contact, but it does not turn the caregiver into a doctor, nurse, fiduciary or guardian. If the caregiver will administer medication, manage money, use a vehicle, access medical portals or make emergency decisions, those permissions need separate written authority and sometimes professional licensing or agency involvement.
Worker classification is not cosmetic
A caregiver in a private home is often a household employee when the household controls what work is done and how it is done. IRS Publication 926 helps household employers decide when federal employment taxes apply. The agreement should not simply label the caregiver an independent contractor and assume that resolves payroll, tax and labor issues.
The US Department of Labor also treats domestic service employment as a real wage/hour category. Its direct-care guidance explains that many direct-care workers are covered by the Fair Labor Standards Act and that third-party employers cannot use the companionship or live-in exemptions in the same way a private household might. Those rules are fact-specific, so the template frames classification as a checklist, not a conclusion.
Define care services and medical limits
Caregiving ranges from companionship and meal preparation to bathing assistance, mobility support, transportation, medication reminders and overnight presence. The agreement should list what is included and what is not. A vague promise to provide care is too broad for the family and too risky for the caregiver.
The document should also say when the caregiver must call emergency services, family contacts or medical professionals. It should avoid asking an unlicensed caregiver to diagnose, prescribe, perform skilled nursing or make health-care decisions unless the person has the correct license and written authority.
Privacy and records need plain language
A private family caregiver is not automatically a HIPAA covered entity, but health information is still sensitive. The caregiver may see medication lists, diagnoses, insurance cards, family conflicts, financial records and home security details. The agreement should require confidentiality even where HIPAA does not technically apply.
If a home-care agency, hospital, health plan or other covered entity is involved, HIPAA and related authorizations may matter. The template therefore asks what information may be shared, with whom, for what purpose and how incidents will be documented.
Use a real care-plan review cycle
Care needs change. A person may need more help after a fall, less help after recovery, or a different schedule after family support changes. A good agreement sets a review date and a process for updating the care plan rather than treating the first schedule as permanent.
Termination should also be humane and practical. Immediate termination may be needed for abuse, theft, neglect, unsafe conduct or serious breach. Routine changes should use notice, final payment, return of keys and records, and a transition plan so the care recipient is not left unsupported.
Caregiver agreement clause guide
- Parties and care recipient
- Identifies the caregiver, client, care recipient, payer and emergency contacts so authority is clear.
- Care plan and services
- Lists companionship, personal care, meals, transport, medication reminders, household tasks and excluded skilled services.
- Schedule and location
- Sets regular hours, overnight care, respite care, live-in terms, attendance records and schedule-change process.
- Pay and tax treatment
- States rate, overtime or premium pay, reimbursement, payroll method and household-employment tax checks.
- Worker status
- Records whether the parties expect household employment, agency placement or independent contractor treatment, subject to law.
- Privacy and records
- Protects health, family, financial and home-security information and sets incident-reporting duties.
- Emergency authority
- Explains when the caregiver may call 911, contact family, accompany the care recipient or use transportation.
- Safety and background checks
- Documents certifications, driving permission, abuse reporting, home-safety notes and prohibited conduct.
- Termination and transition
- Covers routine notice, immediate termination grounds, final pay, keys, records and transition of care.
US caregiver agreement checklist
Caregiver rules vary by state and by whether the worker is hired by a household, agency or facility. Use this checklist before signing.
Check household-employment tax treatment
IRS Publication 926 helps decide whether a household worker is an employee and whether federal employment taxes apply. Do not rely only on the label used in the agreement.
IRS Publication 926Review federal wage/hour coverage
DOL direct-care guidance explains the FLSA framework for domestic service employment and the companionship/live-in exemptions. Third-party agencies face different limits than private households.
DOL direct care guidanceConfirm the companionship-services limits
DOL Fact Sheet 79A explains that fellowship and protection are narrow concepts and that direct care work can fall outside the companionship-services exemption.
DOL Fact Sheet 79ADo not assign unlicensed medical tasks casually
Medication administration, wound care, injections, clinical judgment and skilled nursing may require licensing, agency supervision or medical orders. Put excluded tasks in the agreement.
Treat health and home information as confidential
HHS HIPAA materials apply directly to covered entities, but the agreement should still protect private health, family, financial and home-security information even when HIPAA does not directly govern the family caregiver.
HHS HIPAA for professionalsCheck state domestic-worker and elder-abuse rules
States may add minimum wage, overtime, paid leave, workers compensation, background check, mandated reporting, home-care registration or domestic-worker notice duties.
Consider Medicaid, benefits and family-payment issues
Paying relatives for care can affect Medicaid, tax, estate and benefits planning. Use a written agreement before payment begins and get advice where benefits eligibility matters.
How to complete this caregiver agreement
- Name every role. Identify caregiver, care recipient, client, payer, emergency contact and any person authorized to change the care plan.
- Write the care plan. List services, excluded skilled tasks, medication limits, transportation, meals, mobility support and household duties.
- Set schedule and pay. Enter regular hours, live-in or overnight terms, rate, overtime or premium pay, reimbursement and payroll method.
- Add safety and privacy rules. Complete background, certification, driving, incident reporting, confidentiality and home-access fields.
- Plan review and termination. Set review dates, notice, immediate termination grounds, final pay, return of keys and transition of care.
Frequently asked questions
Is a caregiver an employee or independent contractor?
Often a caregiver hired to work in a private home is a household employee, especially when the household controls the schedule and how work is done. The label in the contract is not enough. Check IRS Publication 926, DOL guidance and state law before deciding how to pay and report the worker.
Does HIPAA apply to a family caregiver?
A private family caregiver is not automatically a HIPAA covered entity, but health information is still sensitive. If an agency, hospital, health plan or other covered entity is involved, separate HIPAA authorizations or business arrangements may be needed.
Can the caregiver administer medication?
The agreement can include reminders and assistance only if lawful for the person and setting. Actual administration, injections, wound care, clinical judgment or skilled nursing may require a licensed professional or medical order.
Should family members use a written caregiver agreement?
Yes, especially if money changes hands. A written agreement helps show what services are being paid for, when payment started, and whether the arrangement is compensation rather than a gift. Medicaid, tax and estate rules should be checked before paying a relative.
What should the emergency authority say?
It should state when the caregiver may call emergency services, contact family, accompany the care recipient, use transportation, release information and stay until relief arrives. It should not pretend the caregiver has medical decision authority unless a separate legal document gives it.
Can a caregiver agreement include paid leave?
It can, and state or local law may require leave depending on worker status and location. The agreement should state leave, backup care and notice rules clearly so the care recipient is not left without support.
What is the difference between a caregiver agreement and a care plan?
The care plan describes services and routines. The agreement adds pay, schedule, worker status, confidentiality, emergency authority, safety, termination and legal terms. This template includes both because separating them too much often causes confusion.
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Disclaimer
This template and guide are general information only, not legal, tax, employment, advertising, intellectual-property, environmental, health-care, construction, licensing, or insurance advice. No attorney has reviewed your facts. Check current federal, state, local, and industry rules before signing.
