Agreement Amendment Phase 5 — Run Your Practice

When to use this form

1Use this any time a term in the original service agreement needs to change — rate, schedule, services, payment frequency.
2Never make verbal-only changes. Every change to your agreement should be in writing and signed by both parties.
3Print two copies. Both parties sign both copies. You keep one, they keep one. Attach a copy to the original agreement.
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Service Agreement Amendment

This document modifies the original Private Care Service Agreement listed below.

Original Agreement

Original agreement date

Amendment date

Caregiver name

Client name

Amendment effective date

Reason for amendment (brief)

Changes to Agreement Terms

List each change below. Write the original term exactly as it appears in the agreement, then the new term.

# Original Term Amended Term

Effect on Remaining Terms

All other terms of the original Private Care Service Agreement dated [original date] remain in full force and effect. This amendment is incorporated into and made a part of the original agreement.

Additional Notes (optional)

Signatures

By signing below, both parties agree to the changes listed in this amendment, effective [effective date].

Caregiver Signature

Date

Client or Authorized Family Member Signature

Printed name

Relationship to client

Date

Both parties should retain a signed copy of this amendment attached to the original service agreement.