○○Visiting Nurse Station
Home Nursing (Long-Term Care Insurance)[personal proposal for reference][Table of Contents in This Booklet]
Section 1. Explanation of Important Matters ·························pp. ○~○(Contents)
1. Outline of the Provider (○○○○, ○○ Corporation) ····················· p. ○2. Outline of the Station (○○ Visiting Nurse Station) ·················· p. ○3. Meaning of home nursing and method of provision ················ p. ○4. Amount of Service Fee, etc. and method of payment ·············· p. ○5. Points to note when using home nursing services ·················· p. ○6. Term of Home Nursing Agreements ···································· p. ○7. Termination of Home Nursing Agreements ··························· p. ○8. Confidentiality and handling of personal information ··············· p. ○9. Handling complaints ························································ p. ○10. Response in the event of an accident ································· p. ○11. Records of home nursing provided ····································· p. ○12. Governing law and competent court in relation to Home Nursing
Agreements ·································································· p. ○Section 2. Home Nursing Agreement ··································pp. ○~○Section 3. User Checks ·························································· p. ○Section 4. Signatures ···························································· p. ○* Numbers inside square brackets [ ] refer to page numbers in thisbooklet.

User:○○○○, ○○ Corporation(Booklet #1. ○ ○, ○)1

Section 1. Explanation of Important Matters
Following is an explanation of important matters that are necessary for a userof home nursing services (hereinafter referred to as the “User”) to selectservices. The User’s family members (hereinafter referred to as “Family
Members”) should also check these matters.

□ 1. Outline of the Provider
Following is an outline of ○○○○, ○○ Corporation (hereinafter referred to as the“Provider”).
Table 1: Outline of the Provider
Name of Provider
Name of representative
Address
Phone number (switchboard)
Date of establishment

Business overview○○○○, ○○ Corporation
Representative: ○○○○○○○○○○○○○○○○–○○○○–○○○○○○ ○○, ○○In addition to home nursing services, preventive homenursing services and in-home long-term care support services
provided under long-term care insurance, the Provider also
operates home nursing services provided under medical
insurance.

□ 2. Outline of the Station
Following is an outline of the ○○ Visiting Nurse Station (hereinafter referred toas the “Station”).
(1) Name and address, etc. of the Station
Table 2: Name and address, etc. of the Station
Type of business
Category of facility, etc.
Name of Station
Address
Name of manager
Phone number (switchboard)
Date of designation,
designation number
Date of establishment
Normal areas of service
Station business days
Station business hours
Days on which services areprovidedTime periods during which
services are provided

Designated home nursing services (long-term care insurance)
Visiting nurse station○○ Visiting Nurse Station○○○○○○○○○○○○○○○○–○○○○–○○○○
Designated on ○ ○, ○○○○○ Prefecture, Number ○○○○○○○○○○ ○○, ○○○○○○, ○○○○, ○○○○, ○○○○
Monday to Saturday (excluding national holidays and December
29 – January 3)○:○○–○:○○
Same as Station business days above
Daytime8:00–18:00

Early morning
6:00–8:00

2

Night
18:00–22:00

Late night
22:00–6:00

Service provision systems

Attached stations

Systems are in place for each of the following supplements:
enhancing service provision systems, emergency home nursing,special management, terminal care, and enhancing nursing
systems.
Stations for designated preventive home nursing and designatedin-home long-term care support are attached. The station also
serves as a visiting nurse station for medical insurance.

Note: Users who live outside the “normal areas of service” above should also
consult with us.
(2) Purpose of home nursing services
The purpose of home nursing services is to support the convalescence of auser and to maintain and recover the user’s physical and mental functions andmaintain or improve their functions necessary for engaging in social life,
thereby enabling the user, as much as possible, to lead an independent daily
life in their own home according to their abilities.
(3) Management policy for home nursing services(i) Comply with the Long-Term Care Insurance Act and other relevant laws andregulations.
(ii) Respect the wishes and personality of the User and provide home nursing
always from the standpoint of the User.
(iii) Set medical treatment goals and provide home nursing in a carefully planned
manner so as to help reduce, or prevent the worsening of, the User’s state ofneed for long-term care.
(iv) Periodically evaluate the quality of home nursing services, and constantly
work to improve them.
(v) In providing home nursing, endeavor to closely coordinate with the attending
physician, in-home long-term care support providers and other providers ofhealth care services or welfare services.
(4) Station equipment and supplies
The Station has a dedicated office with enough space for conducting homenursing services. In addition, equipment and supplies necessary for providing
home nursing are always on hand.
(5) Staffing, etc.
The following personnel are assigned to the Station.
(i) Assignment of personnel

3

Table 3: Assignment of personnel
Occupation
Qualification(a) Managers
Nurse(b) Employees
Nurse
engaged in the
Public health nurse
provision of nursing Assistant nurse
carePhysiotherapist
Occupational
therapist
Speech therapist(c) Office staff

Full-timePart-timeTotal(ii) Duties of personnel(a) Manager:

Manages employees and services. However, also provides
home nursing as circumstances demand.
(b) Employee engaged in the provision of nursing care: Provides actual
home nursing services.
(c) Office staff: Performs clerical work related to the Station’s services. May
also visit homes as a nurse aide (someone who, under theguidance of (a) or (b) personnel engaged in the provision ofnursing care, assists such nursing duties as providing careduring convalescence, improving the living environment in
the User’s room, and keeping nursing supplies andconsumables tidy and in order).
(6) Service provision systems
The following service provision systems are in place at the Station.
(i) System related to the supplement for enhancing service provisionsystems(a) Training plans are prepared for each category of nurse, etc., and inaccordance with those plans, training (including external training) is
conducted, or is scheduled to be conducted, for all nurses, etc.
(personnel listed in (a) and (b) in Table 3 above; hereinafter the same in(i)).
(b) Health examinations, etc. are periodically conducted for all nurses, etc.
(c) At least 30% of the total number of nurses, etc. have worked continuously
for three or more years.
For more details about this supplement, see Note 7 in Table 4 and Note 2 inTable 5 in 4. below [p. ○].

4

(ii) System related to the supplement for emergency home nursing
24-hour systems are in place to respond to requests for nursing advice madeby the User or their Family Members, etc. via phone, etc. Systems are also inplace to make emergency visits as required which are not part of a scheduledvisit. Such responses are taken with the consent of the User.
For more details about this supplement, see Table 9 in 4. below [p. ○].
(iii) System related to the supplement for special management
Systems are in place to systematically manage the provision of home nursing
for Users who require special management.
For more details about this supplement, see Table 10 in 4. below [p. ○].
(iv) System related to the supplement for terminal care(a) Systems are maintained ensuring 24-hour communication for Users
receiving terminal care. In addition, systems are in place to provide homenursing as required.
(b) In coordination with the attending physician, the plan and support system
for terminal care in home nursing is explained to the User or their Family
Members, etc., and terminal care is provided.
(c) In relation to the provision of terminal care, necessary matters such aschanges in the User’s physical condition, are appropriately recorded.
For more details about this supplement, see Table 11 in 4. below [p. ○ to p. ○].
(v) System related to the supplement for enhancing nursing systems (II)Systems for providing home nursing to Users with high medical needs arebeing enhanced.
For more details about this supplement, see Table 15 in 4. below [p. ○].

□ 3. Meaning of home nursing and method of provision(1) Meaning of home nursing“Home nursing” refers to medical care or necessary medical assistanceprovided by a nurse, etc. (Note 1) in a User’s home (Note 2) for Users who arein a state of need for long-term care and who are receiving long-term care in
their homes (Note 3).
Note 1: Besides nurses, also includes public health nurses, assistant nurses,
physiotherapists, occupational therapists, and speech therapists.
Note 2: Includes rooms in nursing homes for the elderly, low-cost homes forthe elderly and fee-paying homes for the elderly.
Note 3: Limited to Users whose attending physician recognizes that theircondition is in a stable stage with respect to the degree of need for5treatment, and that they require medical care or necessary medical
assistance provided by nurses, etc. at home.
While home nursing is limited to Users who find going to hospital
regularly as an outpatient difficult, it is also available to Users forwhom, regardless of whether they are capable of going to hospital
regularly or not, support at home is essential for their convalescenceand for whom it is determined that home nursing needs to be provided
as a result of care management. This excludes patients with diseases,
etc. listed in the box below as well as users of home nursing thatpertains to psychiatric home nursing and guidance fees andpsychiatric home nursing basic medical expenses (users of psychiatrichome nursing provided under medical insurance) because they are
eligible for home nursing services provided under medical insurance.
See 5. (1) below [p. ○].
Terminal malignancy, multiple sclerosis, myasthenia gravis, SMON, amyotrophic lateralsclerosis, spinocerebellar degeneration, Huntington’s disease, progressive muscular
dystrophy, Parkinson’s disease-related disorders (meaning progressive supranuclear
palsy, corticobasal degeneration and Parkinson’s disease (limited to patients at stage 3 orhigher on the Hoehn and Yahr severity scale and stage 2 or 3 on the scale of functional
disability in activities of daily living)), multiple system atrophy (meaning striatonigral
degeneration, olivopontocerebellar atrophy, and the Shy-Drager syndrome) , priondisease, subacute sclerosing panencephalitis, lysosomal storage disease,adrenoleukodystrophy, spinal muscular atrophy, bulbospinal muscular atrophy, chronic
inflammatory demyelinating polyneuropathy, acquired immunodeficiency syndrome,cervical spine injury, and conditions requiring use of a respirator.

(2) Method for providing home nursing
Once the consent of the User regarding the Explanation of Important Matters in
relation to home nursing has been obtained, and an agreement between theUser and the Provider in relation to the provision of home nursing (hereinafterreferred to as the “Home Nursing Agreement”) has been signed, the Provider,based on 2. (3) “Management policy for home nursing services” above,
provides the User with home nursing services as follows.
(i) Written instructions of the attending physician
At the start of providing home nursing, the Provider receives written
instructions from the attending physician.
(ii) Drafting of the Home Nursing Plan
A nurse prepares a draft of the Home Nursing Plan (meaning a document that
describes the medical treatment goals plus details, etc. of the specific services
for achieving those goals; hereinafter the same in this booklet) based on the
instructions of the attending physician and the physical and mental condition of
the User.
The Home Nursing Plan is drafted in line with the In-Home Services Plan if one

6has been prepared.
In cases where designated home nursing is provided by a physiotherapist,
occupational therapist, or speech therapist, the Home Nursing Plan and Home
Nursing Report are prepared to include details provided by the physiotherapist,
occupational therapist, or speech therapist in an integrated manner, and areprepared in cooperation between the nurse and physiotherapist, occupational
therapist, or speech therapist.
(iii) Consent of the User
The nurse explains the proposed Home Nursing Plan to the User or their
Family Members and obtains the User’s consent in writing.
(iv) Delivery of Home Nursing Plan to User
The Home Nursing Plan for which the User’s consent has been obtained isdelivered by the nurse to the User.
(v) Submission of Home Nursing Plan to attending physician
The Provider regularly submits the Home Nursing Plan to the attending
physician.
(vi) Provision of home nursing
Based on the Home Nursing Plan, the Provider provides home nursing using
appropriate nursing techniques commensurate to medical advances, while
maintaining close coordination with the attending physician.
In providing home nursing, the Provider briefs the User or their Family
Members on matters necessary for medical treatment in a manner that is easy
to understand.
In providing home nursing, the Provider constantly strives to accurately
understand the User’s condition, their physical and mental status, and theenvironment in which they are placed, and provides appropriate guidance tothe User or their Family Members.
Nurses, etc. engaged in the provision of nursing care carry their ID with themand present it when visiting for the first time and whenever requested by theUser or their Family Members.
For more information about emergency home nursing, special management,
and terminal care, see (ii) to (iv) in 2. (6) above [p. ○].
(vii) Provision of home nursing by physiotherapists, occupational
therapists, or speech therapists
If the focus is on rehabilitation as part of nursing services, home nursing isprovided by a physiotherapist, occupational therapist, or speech therapist
instead of the nurse or assistant nurse.
(viii) Preparation of the Home Nursing Report, and submission to theattending physician
The Home Nursing Report (meaning a document describing details such as
the dates of visits and the nursing care provided) is prepared by the nurse, and7

regularly submitted to the attending physician.
(ix) Monitoring the implementation of home nursing, etc.
The Provider monitors implementation of the Home Nursing Plan and makeschanges to it as required while maintaining close coordination with theattending physician.
(x) Home nursing manager
The Station appoints a home nursing manager for each User. If the manager
changes, the Station contacts the User in advance.
(3) Response in an emergency, etc.
In the event there is a sudden change, etc. in the User’s condition while homenursing is actually being provided by the nurse, etc., in addition to provisionallyproviding first-aid treatment as required, the nurse, etc. also takes necessary
measures such as promptly contacting the attending physician and requesting
instructions.
(4) Assistance in applying for renewal of certification of long-term care need
When deemed necessary, the Provider provides necessary support so that theUser can apply for renewal of the certification of long-term care need at least
30 days before validity of the current certification of long-term care needexpires.

□ 4. Amount of Service Fee, etc. and method of payment(1) Amount of Service Fee, etc.
Users are required to pay the total amount of 1) User contribution or 2) Service
fee, plus 4) Other expenses. In this booklet, these are collectively referred to as“Service Fee, etc.”
1) User contribution
In cases where insurance benefits under the Long-Term Care Insurance Act
are paid to the Provider on behalf of the User (Note), the user is required to pay
the “User contribution” listed in Table 4 or Table 5 in 3), as part of the homenursing service fee. In addition, where there are grounds for any of the
supplements listed in Table 6 to Table 14 in 3), the user is also required to pay
the “User contribution” for the respective supplements.
The User contribution rate is the rate indicated on the Payment Rate Card
issued by the municipality (10%, 20% or 30%).
Note: In the event that none of the cases in A to F listed in the Note in 2) below
apply.

8

2) Service fees
In cases where insurance benefits under the Long-Term Care Insurance Act
are not paid to the Provider on behalf of the User (Note), the user is required to
pay the “service fees” listed in Table 4 or Table 5 in 3). In addition, where there
are grounds for any of the supplements listed in Table 6 to Table 14 in 3), theuser is also required to pay the “service fees” for the respective supplements.
When the User pays a service fee, the Provider will issue the User with a“Certificate of Service Provision” (limited to cases where insurance benefits
can be claimed from the municipality).
Note: In the event that any of the following cases applies.
A. Where the User has not been certified as in need of long-term care
B. Where the validity of the certification of long-term care need has lapsed
C. Where notification has not been given to the municipality regarding thereceipt of in-home long-term care support
D. Where home nursing has not been designated in in-home services (careplan)
E. Where home nursing has exceeded the maximum benefit payment
according to the User’s state of need for long-term care
F. Where insurance benefits under the Long-Term Care Insurance Act are
restricted due to non-payment of premiums, etc.
3) Details of User contributions and service fees
If you have any questions or required more detailed information about thefollowing items, contact the Station or your home nursing manager.
Table 4: User contribution and service fee by duration (per visit)
Duration
Service Fee, etc.

Less than Less than
20 minutes 30 minutes

30–59
minutes60-89
minutes

User contribution
Amount according to User contribution rate
Service fee¥3,110¥4,670¥8,160¥11,180
Note 1: These amounts are for nurses or public health nurses. Amounts forassistant nurses are as described in Note 4.
Note 2: Method for calculating the User contribution: Service fee - Service fee
× User contribution rate (90/100, 80/100 or 70/100)
Note 3: Method for calculating the service fee: Service fee is calculated bymultiplying the prescribed number of units by the price per unit (¥10),in accordance with the provisions specified by the Minister of Health,Labour and Welfare. When calculating the number of units, any
fractions are rounded to the nearest whole unit, and when converting
into monetary amounts, any fractions are rounded down to the nearest
one yen.

9Note 4: In cases where home nursing is provided by an assistant nurse,
calculations are made using a number of units equivalent to 90/100 of
the prescribed number of units.
Note 5: In cases where home nursing is provided to a User who resides in abuilding located on the same or adjacent premises as the Station, or in
the same building as the Station (hereinafter referred to as a “buildingon the same premises, etc.” in this Note) (excluding Users who residein a building where at least 50 monthly Users of the Station reside inbuildings on the same premises, etc.), or to a User who resides in thesame building where at least 20 monthly Users of the Station reside,
the number of units is calculated equivalent to 90/100 of theprescribed number of units per visit. In cases where home nursing isprovided to a User who resides in a building where at least 50 monthly
Users of the Station reside in buildings on the same premises, etc. thenumber of units is calculated equivalent to 85/100 of the prescribed
number of units per visit.
Note 6: “Duration” is not the actual time spent for home nursing, but thestandard time needed to provide the home nursing as detailed in the
Home Nursing Plan.
Note 7: Home nursing of less than 20 minutes is calculated in cases where the
In-Home Services Plan or the Home Nursing Plan includes at least
one home nursing visit per week by a nurse or public health nurse of atleast 20 minutes.
Note 8: The service fee amount is the amount after supplementing forenhancing service provision systems (supplement of 6 units per visit)(see 2. (6) (i) above [p. ○]).
Table 5: User contribution and service fee (per visit) where visit is by aphysiotherapist, etc.
Visits2 or fewer visits per day
More than 2 visits per day
Service Fee, etc.
User contribution
Amount according to User contribution rate
Service fee¥2,960¥2,660Note 1: This is the Service Fee, etc. in cases where home nursing is provided
by a physiotherapist, occupational therapist, or speech therapist.
Home nursing by people in these occupations is conducted for at least
20 minutes per visit.
Note 2: Calculations in Notes 2, 3 and 5–7 of Table 4 also apply in this case.

10Table 6: Supplement where home nursing is provided in the early morning,night, or late night (per visit)
Reason for
supplement
Early morning
Night
Late night(time period)(6:00–8:00)(18:00–20:00)(20:00–6:00)
Supplemental
Service Fee, etc.
Supplemental User
contribution
Supplemental Service
fee

Additional 25% toeach User
contribution listed
in Tables 4 and 5
Additional 25% toeach service fee
listed in Tables 4
and 5

Additional 25% toeach User
contribution listed
in Tables 4 and 5
Additional 25% toeach service fee
listed in Tables 4
and 5

Additional 50% toeach User
contribution listed
in Tables 4 and 5
Additional 50% toeach service fee
listed in Tables 4and 5Note 1: Method for calculating the supplemental User contribution:
Supplemental service fee - Supplemental service fee × 10/100
However, if the insurance benefit rate is not 90/100, that rate is used in
the calculation.
Note 2: Method for calculating the supplemental service fee: Supplemental
service fee is calculated by adding the basic number of units to thenumber of units obtained by multiplying the basic number of units by
the supplemental ratio and multiplying this sum by the price per unit(¥10). When calculating the number of units, any fractions are rounded
to the nearest whole unit, and when converting into monetary amounts,
any fractions are rounded down to the nearest one yen.
Note 3: The supplement is added if the home nursing service starts during thetime period subject to the supplement.
Note 4: See Note 3 of Table 9 regarding the relationship with emergency visits.
Table 7: Supplement where home nursing is provided by more than one
person (per visit)
Duration
Supplemental
Less than 30 minutes
30 minutes or longer
Service Fee, etc.
Supplemental User
Amount according to User contribution rate
contribution
Supplemental(I)¥2,540¥4,020Service fee
Supplemental(II)¥2,010¥3,170Service fee
Note 1: With the consent of the User or their Family Members, etc., homenursing by more than one person is provided in cases where: (a) it isrecognized that home nursing by one person would be difficult due tophysical reasons with respect to the User; (b) acts of violence,
significantly disruptive behavior, or acts of property damage, etc. arerecognized; or (c) there is another situation recognized as equivalent11to (a) or (b) judging from the circumstances, etc. of the User.
Note 2: (I) indicates the service fees in cases where more than one publichealth nurse, nurse, assistant nurse, physiotherapist, occupational
therapist, or speech therapist provides home nursing to the same Userat the same time.
Note 3: (II) indicates the service fees in cases where a nurse or other person
listed in the previous note provides home nursing to the same User at
the same time as a nurse aide (someone other than a nurse or otherperson listed in the previous note).
Table 8: Supplement where extended home nursing is provided (per visit)
Reason forCases where, after home nursing of 60-89 minutes insupplement
duration has been provided, home nursing continues to be(aggregate
provided to a User requiring special management withduration)
respect to home nursing, and the total duration of the
Supplemental
whole home nursing is 90 minutes or longer
Service Fee, etc.
Supplemental User
Amount according to User contribution rate
contribution
Supplemental¥3,000Service fee
Note: A “User requiring special management with respect to home nursing”
is a person in any of the following situations.
(a) The person is receiving at-home guided management for
malignancy patients or at-home guided management fortracheotomy patients or is using a tracheal cannula or an indwelling
catheter.
(b) The person is receiving at-home guided management for
self-peritoneal dialysis, at-home guided management for
hemodialysis, at-home guided management for oxygen treatment,
at-home guided management for intravenous hyperalimentation,
at-home guided management for elemental diet tube feeding,
at-home guided management for self-catheterization, at-homeguided management for continuous positive airway pressure,
at-home guided management for the self-management of pain, or
at-home guided management for pulmonary hypertension patients.
(c) The person has an artificial anus or artificial bladder.
(d) The person has bedsores deeper than the dermis.
(e) The person is recognized as needing an intravenous drip at least
three days per week.

12

Table 9: Supplement for emergency home nursing (per month)
Reason for Cases where, with the consent of the User, systems aresupplement in place ensuring 24-hour communication for the Userand their Family Members, etc., and where systems are
Supplemental
in place to make emergency visits as required which are
Service Fee, etc.
not part of a scheduled visit
Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service¥5,740fee
Note 1: For information on establishing a system related to the supplement for
emergency home nursing, see 2. (6) (ii) above [p. ○].
Note 2: Depending on the situation, the Provider may respond by phone or
may make an emergency visit, etc. as described in the following note.
Such emergency visits are not always conducted.
Note 3: In the event an “emergency visit that is not part of a scheduled visit” isactually conducted, the Service Fee, etc. is calculated based on theprescribed number of units for that emergency visit (the Service Fee,etc. listed in Table 4 or 5; however if the visit is “less than 20 minutes,”
calculations are made using “less than 30 minutes”; if the emergency
visit is conducted by an assistant nurse, calculations are made using
90/100 of the prescribed number of units). In this case, supplements
for home nursing provided in the early morning, night or late night are
not assessed (see Table 6). However, regarding second andsubsequent emergency visits made within one month for a User with acondition for which the supplement for special management in thefollowing table is assessed, supplements for home nursing provided in
the early morning, night or late night are assessed.
Table 10: Supplement for special management (per month)
Reason for Cases where the Station has systematically managedsupplement the provision of home nursing for a User requiring
special management with respect to home nursing
Supplemental
Supplement for special
Supplement for special
Service Fee, etc.
management (I)management (II)Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service¥5,000¥2,500fee
Note 1: The supplement for special management (I) is a supplement assessed
where the provision of home nursing has been systematicallymanaged for a User with a condition listed in Note (a) of Table 8
above.
Note 2: The supplement for special management (II) is a supplement
assessed where the provision of home nursing has beensystematically managed for a User with a condition listed in Note (b),13

(c), (d) or (e) of Table 8 above (for information on this and the previous
note, see 2. (6) (iii) above [p. ○]).

Table 11: Supplement for terminal care (month of death)
Reason for Cases where a User who dies at home was provided
supplement terminal care by the Station for at least two days on the
day of death or within 14 days prior to the day of death(or for at least one day in cases where home nursing
was provided to the said User on the day of death or
Supplemental
within 14 days prior to the day of death) (including cases
Service Fee, etc.
where the User died outside their home within 24 hours
of being provided terminal care).
Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service¥20,000
fee
Note 1: “The said User” is limited to a User with a terminal malignancy or anyof the following conditions:(a) Multiple sclerosis , myasthenia gravis, SMON, amyotrophic lateralsclerosis, spinocerebellar degeneration, Huntington’s disease,progressive muscular dystrophy, Parkinson’s disease-relateddisorders (meaning progressive supranuclear palsy, corticobasal
degeneration and Parkinson’s disease (limited to patients at stage
3 or higher on the Hoehn and Yahr severity scale and stage 2 or 3
on the scale of functional disability in activities of daily living)),
multiple system atrophy (meaning striatonigral degeneration,
olivopontocerebellar atrophy, and the Shy-Drager syndrome) ,prion disease, subacute sclerosing panencephalitis, lysosomal
storage disease, adrenoleukodystrophy, spinal muscular atrophy,
bulbospinal muscular atrophy, chronic inflammatory demyelinating
polyneuropathy, acquired immunodeficiency syndrome, cervicalspine injury, and conditions requiring use of a respirator(b) Acute exacerbation or other conditions recognized by the said
User’s attending physician as requiring frequent home nursing inthe short term
Note 2: For information on establishing a system related to the supplement for
terminal care, see 2. (6) (iv) above [p. ○].

14

Table 12: Initial supplement (one month)
Reason for Cases where the Station provides home nursing to a
supplement User, for whom a new Home Nursing Plan has been
prepared, for the first time or in the month containing
Supplemental
the date on which the initial home nursing was
Service Fee, etc.
provided
Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service fee¥3,000Note: The initial supplement is a supplement assessed where the User has
not been provided home nursing (including home nursing services
provided under medical insurance) from the Station during the past
two months, and for whom a new Home Nursing Plan has been
prepared.
Table 13: Supplement for joint guidance at discharge (in principle, once perdischarge)
Reason for Cases where a nurse, etc. (excluding an assistant
supplement nurse) at a Station provides joint guidance atdischarge at the time of discharge for a User currently
admitted to a hospital, clinic, healthcare facility for the
Supplemental
elderly requiring long-term care or integrated facility for
Service Fee, etc.
medical and long-term care, and later visits that Userfor the first time after being discharged
Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service fee¥6,000Note 1: “Joint guidance at discharge” refers to an attending physician together
with other practitioners at a hospital, clinic, healthcare facility for theelderly requiring long-term care or integrated facility for medical andlong-term care jointly giving a User, or the person in charge of nursingthat User, necessary guidance for their treatment at home, andproviding that guidance in writing.
Note 2: Although the supplement is assessed at each discharge, for Users
who require special management (that is, Users with a condition
specified by the Minister of Health, Labour and Welfare; see the Notein Table 8 above), if joint guidance at discharge is provided on multiple
days, the supplement is added only twice.
Note 3: When calculating the initial supplement of Table 12 above, thesupplement for joint guidance at discharge is not assessed.

15

Table 14: Supplement for enhancing cooperation between nursing
personnel and long-term care personnel (once per month)
Reason for Cases where, in cooperation with a home-visit nursing
supplement care provider that is registered under the provisions of
the Certified Social Worker and Certified Care Worker
Act, a Station provides support to facilitate a homecarer, etc. from the home-visit nursing care provider incarrying out activities for the User which are specified
Supplemental Service
by Order of the Ministry of Health, Labor and Welfare,Fee, etc.
such as the suction of phlegm from inside the mouth,
under the direction of a physician
Supplemental User
Amount according to User contribution rate
contribution
Supplemental Service fee¥2,500
Table 15: Supplement for enhancing nursing systems (II)Reason for Cases where a Station that has notified the
supplement prefectural governor that it conforms to standards
specified by the Minister of Health, Labour and
Supplemental
Welfare has enhanced systems for providing homeService Fee, etc.
nursing to Users with high medical needs
Supplemental User
Amount according to User contribution rate
contribution¥3,000 per month
Supplemental Service fee
Note: “Standards specified by the Minister of Health, Labour and Welfare”
means that it conforms with all of the following standards:(i) During the six months prior to the month in which the calculation dateoccurs, the percentage of all Users at the Station for whom the supplement
for emergency home nursing (Table 9) was calculated was at least 50%.
(ii) During the six months prior to the month in which the calculation dateoccurs, the percentage of all Users at the Station for whom the supplement
for special management (Table 10) was calculated was at least 30%.
(iii) During the 12 months prior to the month in which the calculation dateoccurs, there was at least one User at the Station for whom the
supplement for terminal care (Table 11) was calculated.
4) Other expenses
Each of the expenses listed in Table 16 are to be borne by the User.

16

Table 16: Other expenses
Details of service, etc.
ExpenseTransportation expenses
Home nursing provided at a home
Actual costs of transportation
located in an area outside the “normal
areas of service” listed in Table 2 ([p. ○])1 x black-and-white copy (A4): ¥○ (excl. tax)
Delivery of copies
1 x black-and-white copy (A3): ¥○ (excl. tax)
The User may request a copy of records
regarding the provision of home nursing 1 x color copy (A4): ¥○ (excl. tax)
1 x color copy (A3): ¥○ (excl. tax)(2) Method of payment for Service Fee, etc.
The Provider calculates the total amount of Service Fee, etc. for each month,and sends an invoice for the month in which home nursing was used, by the20th of the following month.
The User is required to pay for the month of home nursing by the last day of
the following month by way of account transfer from the financial institution
designated by the User.
Service Fees, etc. for periods of less than one month are calculated based on
the number of days used.
(3) Change in Service Fee, etc.
(i) In the event of changes in the Long-Term Care Insurance Act or in theprovisions of the Minister of Health, Labour and Welfare or systems basedon the Act, the Provider may change the User contribution and service fee
amounts described in 4. (1) above.
(ii) In the event of price fluctuations or other unavoidable circumstances, theProvider may change the respective amounts of “Other expenses”
described in 4. (1) above.
(iii) In the event the Provider will change the amount of Service Fee, etc. inaccordance with (i) or (ii), the Provider shall explain the reasons anddetails of the change to the User in advance.

□ 5. Points to note when using home nursing services
Users and their Family Members are asked to cooperate in the smoothprovision of home nursing services by taking heed of the following points.
(1) Persons eligible for home nursing services provided under medical
insurance
Patients with diseases, etc. listed in the box below as well as users of
psychiatric home nursing provided under medical insurance cannot use homenursing provided under long-term care insurance because they are eligible for17home nursing services provided under medical insurance (see Note 2 in 3. (1)above [p. ○]). In this case, please contact the Station for advice.
Terminal malignancy, multiple sclerosis , myasthenia gravis, SMON, amyotrophic lateral sclerosis,
spinocerebellar degeneration, Huntington’s disease, progressive muscular dystrophy, Parkinson’s
disease-related disorders (meaning progressive supranuclear palsy, corticobasal degeneration andParkinson’s disease (limited to patients at stage 3 or higher on the Hoehn and Yahr severity scaleand stage 2 or 3 on the scale of functional disability in activities of daily living)), multiple system
atrophy (meaning striatonigral degeneration, olivopontocerebellar atrophy, and the Shy-Drager
syndrome) , prion disease, subacute sclerosing panencephalitis, lysosomal storage disease,adrenoleukodystrophy, spinal muscular atrophy, bulbospinal muscular atrophy, chronic inflammatory
demyelinating polyneuropathy, acquired immunodeficiency syndrome, cervical spine injury, andconditions requiring use of a respirator.

(2) Where the attending physician has given special instructions
If the attending physician has given special instructions that the User requires
frequent home nursing in the short term due to acute exacerbation, etc.
(issuance of Special Instructions), since the home nursing will be covered by
medical insurance for up to 14 days from the date of issuance, during this time,home nursing provided under long-term care insurance cannot be used. In thiscase, please contact the Station for advice.
(3) When using other visiting nurse stations
If you intend to use another visiting nurse station, please advise us as services
will need to be coordinated.
(4) Provision of accurate information on the User’s condition and their
physical and mental status, etc.
In order to provide appropriate services according to the User’s condition andtheir physical and mental status, etc., please provide as much accurate
relevant information as possible.
(5) Free use of electricity, gas, water, etc.
(i) When necessary for the purpose of providing home nursing, nurses, etc.
will use electricity, gas, water, etc. free of charge.
(ii) When necessary to contact the Station, etc. with respect to the provision ofhome nursing, nurses, etc. will use the phone free of charge.
(6) Communication when cancelling home nursing
If you wish to cancel the use of home nursing on a specific date, please contact
us by ○:00 on the business day preceding the date on which you wish to cancel(phone number: ○○○○–○○○○–○○○○). This will, however, not apply in the caseof emergency hospitalization or other unavoidable circumstances. Furthermore,
if you wish to cancel the use of home nursing on a Monday, since Sundays are18not a business day, the preceding business day would be the Saturday.
Similarly, if you wish to cancel the use of home nursing on January 3, thepreceding business day would be December 28 in the previous year.
(7) Prohibited acts
In using home nursing, the following acts are not permitted.
(i) Acts that cause, or may cause, physical or mental harm to nurses, etc.
(ii) Acts that interfere, or may interfere, with operations of the Provider or theStation(iii) Other acts that impede, or may impede, the provision of appropriate homenursing□ 6. Term of Home Nursing Agreements
The Term of the Home Nursing Agreement shall be from the date specified in
the Home Nursing Agreement until the date on which validity of the User’s
certification of long-term care need expires.
The Home Nursing Agreement will terminate upon expiry of the term ofagreement. However, the agreement shall be automatically renewed under thesame conditions, unless the User makes an application to the Provider toterminate the agreement by the date on which the term of agreement expires.
The same shall also apply after renewal.

□ 7. Termination of Home Nursing Agreements(1) Due termination of the Home Nursing Agreement
Even during the term of agreement, the Home Nursing Agreement will duly
terminate for the following reasons:(i) The category of the User’s state of need for long-term care is determined
to be “independent” or “support required”(ii) The attending physician recognizes that there is no need for homenursing(iii) The User is admitted to a welfare facility for the elderly requiring long-termcare, a healthcare facility for the elderly requiring long-term care, or asanatorium ward(iv) The User has started using care in a small group home setting for theelderly with dementia(v) The User has died(vi) Provision of home nursing has become impossible due to destruction orserious damage to the Station(vii) The Station has had its designation revoked pursuant to the Long-TermCare Insurance Act

19

(2) Termination by the User cancelling the agreement
The User may terminate the Home Nursing Agreement by making a request forcancellation to the Provider at least ○ days prior to the termination date.
However, in any of the following cases, the User may terminate the agreement
immediately by making a request for cancellation:(i) The User has been admitted to hospital(ii) The Provider has violated its obligations specified in the Home Nursing
Agreement(iii) There are other unavoidable circumstances.
(3) Termination by the Provider cancelling the agreement
The Provider may cancel the Home Nursing Agreement in any of the following
cases:(i) The User has delayed payment of the Service Fee, etc. for at least threemonths, and despite the Provider giving notice specifying a reasonable
period of time, the User has failed to make payment within that period oftime(ii) The User or their Family Members have committed any of the prohibited
acts described in 5. (7) above [p. ○], and provision of home nursing to theUser has become extremely difficult.
(4) Termination by the Provider cancelling the agreement due todiscontinuation, etc. of services
Where the Provider discontinues, suspends, or reduces its home nursing
services (including reductions in areas of service), it may cancel the Home
Nursing Agreement by making a request for cancellation at least 30 days prior
to the termination date.
(5) Cooperation at the termination of agreement, etc.
At the time of termination of the Home Nursing Agreement, in addition to giving
appropriate guidance to the User or their Family Members, the Provider strives
to provide information to the attending physician and in-home long-term care
support provider and to cooperate with health care services or welfare
services.

□ 8. Confidentiality and handling of personal information(1) Confidentiality
The Provider takes necessary measures to ensure that its current or former
employees do not divulge secrets about the User or their Family Members,
which they have learned in the course of providing home nursing, to a third
party without justifiable cause. The same applies even after the agreement is20

terminated.
(2)

Handling of personal information
The Provider handles the personal information of the User or their Family
Members, etc. in an appropriate manner in compliance with the Act on theProtection of Personal Information and other relevant laws and regulations.

□ 9. Handling complaints(1) Provider’s system for handling complaints
The Provider handles complaints as described below.
PersonManager of the Station
responsible forhandling
complaints
System forComplaints are accepted during the business hours of thehandling
Station (see Table 2 [p. ○])complaints
Complaints can be made via:
Phone: ○○○○–○○○○–○○○○
Fax: ○○○○–○○○○–○○○○
Interview at the Station or the User’s home
Basic method for Upon receipt of a complaint, the Provider promptly confirms
handling
the facts relating to the complaint, and based on thosecomplaints
results, examines and formulates necessary improvement
measures, and briefs the User or their Family Members. In
addition, the Provider implements the improvement
measures, and subsequently checks the implementation
status of those measures, and strives to prevent recurrence.
(2) Government agencies and other grievance bodies
The following organizations are also available as grievance bodies external to
the Provider.
○○ City
Address: ○○○○○○○○
Long-Term
Phone:○○○○–○○○○–○○○○
Care Insurance
Section○○ Prefecture
Address: ○○○○○○○○
Federation of
Phone:○○○○–○○○○–○○○○
National Health
Insurance
Associations21

□ 10. Response in the event of an accident(1) Emergency contact and other necessary measures
In the event an accident occurs as a consequence of providing home nursing
to the User, the Provider immediately contacts the municipality, the User’s
Family Members, the in-home long-term care support provider, etc., and takes
necessary measures.
(2) Analyzing the cause of the accident and measures to prevent recurrence
The Provider analyzes the causes of an accident that occurs as aconsequence of providing home nursing and implements measures to prevent
recurrence.
(3) Compensation for damages
In the event the Provider violates its obligations specified in the Home Nursing
Agreement subsequently causing damage to the User, the Provider shallpromptly compensate the User for that damage. However, where the damage
is due to circumstances not attributable to the Provider, the Provider shall not
be liable to compensate for the damage.

□ 11. Records of home nursing provided(1) Maintenance and retention of records
The Provider maintains records regarding the provision of home nursing to theUser and retains those records for a period of ○ years after the termination of
the Home Nursing Agreement.
(2) Inspection or copying of records
The User may make a request to the Provider to inspect or copy the records
regarding the provision of home nursing. In this case, the Provider responds
appropriately in accordance with the Act on the Protection of Personal
Information and other relevant laws and regulations. Costs for copying areborne by the User as described in 4. (1) 4) above ([p. ○]).

□ 12. Governing law and competent court in relation to Home
Nursing Agreements(1) Governing law
The Home Nursing Agreement shall be regulated and construed in accordancewith the laws of Japan.

22

(2) Jurisdiction
All disputes arising from or with respect to the Home Nursing Agreement are
subject to the exclusive jurisdiction of the ○○ District Court in Japan.

The Provider has explained the important matters above, and the User has
agreed to them.
(Person providing explanation at Provider)(User)(User’s representative)

23

Please add your signature and seal
in the Signatures section ([p. ○])Section 2. Home Nursing Agreement(hereinafter referred to as the “User”) and ○○○○, ○○Corporation, as mentioned in part 1. of Section 1. Explanation of Important Matters(hereinafter referred to as “Important Matters”) above (hereinafter referred to as the“Provider”), enter into a home nursing agreement (hereinafter referred to as the“Agreement”) as follows. Numbers inside square brackets [ ] refer to page numbersin this booklet.
(Purpose of this agreement) [p. ○]Article 1 The Provider promises that the Station mentioned in part 2. of Important
Matters (hereinafter referred to as the “Station”) will provide homenursing to the User in accordance with the Long-Term Care Insurance
Act, enabling the User, as much as possible, to lead an independent
daily life in their own home according to their abilities, and the User
requests this.
(Meaning of home nursing) [p. ○]Article 2 The meaning of “home nursing” shall be as described in Important
Matters 3. (1).
(Method for providing home nursing) [p. ○ to p. ○]Article 3 The Provider shall provide home nursing to the User in accordance withthe method of provision described in Important Matters 3. (2).
(Response in an emergency, etc.) [p. ○]Article 4 In the event there is a sudden change, etc. in the User’s condition whilehome nursing is actually being provided, the Provider shall takenecessary measures such as promptly contacting the attending physician
and requesting instructions, as described in Important Matters 3. (3).
(Assistance in applying for renewal of certification of long-term care need)[p. ○]
Article 5 When deemed necessary, the Provider shall provide necessary support
to the User so that they can apply for renewal of the certification of
long-term care need as described in Important Matters 3. (4).
(Payment of and changes to the Service Fee, etc.) [p. ○ to p. ○]Article 6 1. The User shall pay the Service Fee, etc. mentioned in Important Matters
4. (1) (including the User contributions or service fees pertaining to
supplements) to the Provider in accordance with the payment method
described in Important Matters 4. (2); provided, however, that the User
shall pay the following checked (☑) User contributions or service fees
pertaining to supplements listed in Important Matters 4. (1).
□ Early morning supplement (Table 6 in Important Matters 4. (1) 3)[p. ○])

24

□ Night supplement (Table 6 in Important Matters 4. (1) 3) [p. ○])□ Late night supplement (Table 6 in Important Matters 4. (1) 3) [p. ○])□ Supplement for home nursing provided by more than one person(Table 7 in Important Matters 4. (1) 3) [p. ○])□ Supplement for extended home nursing (Table 8 in Important
Matters 4. (1) 3) [p. ○])□ Supplement for emergency home nursing (Table 9 in Important
Matters 4. (1) 3) [p. ○])□ Supplement for special management (I) (Table 10 in Important
Matters 4. (1) 3) [p. ○])□ Supplement for special management (II) (Table 10 in Important
Matters 4. (1) 3) [p. ○])□ Supplement for terminal care (Table 11 in Important Matters 4. (1) 3)[p. ○])□ Initial supplement (Table 12 in Important Matters 4. (1) 3) [p. ○])□ Supplement for joint guidance at discharge (Table 13 in Important
Matters 4. (1) 3) [p. ○])□ Supplement for enhancing cooperation between nursing personnel
and long-term care personnel (Table 14 in Important Matters 4. (1)3) [p. ○])□ Supplement for enhancing nursing systems (II) (Table 15 inImportant Matters 4. (1) 3) [p. ○])2. The Provider may change the amount of Service Fee, etc. as describedin Important Matters 4. (3).
(Important points for Users) [p. ○ to p. ○]Article 7 The User shall use home nursing in accordance with each of theimportant points listed in Important Matters 5(7).
(Term of the Agreement) [p. ○]Article 8 1. The term of the Agreement shall be from ○ ○, ○ to the date on which
validity of the User’s certification of long-term care need expires.
2. The agreement shall be automatically renewed under the same
conditions as the Agreement, unless the User makes an application to
the Provider to terminate the agreement by the date on which the termof agreement in the preceding paragraph expires, as described inImportant Matters 7. The same shall also apply after renewal.
(Due termination of the Agreement) [p. ○]Article 9 Even during the term of agreement described in the previous Article, as
described in Important Matters 8. (1), the Agreement shall duly
terminate when any of the following events occurs:(i) The category of the User’s state of need for long-term care isdetermined to be “independent” or “support required”(ii) The attending physician recognizes that the User does not needhome nursing(iii) The User is admitted to a welfare facility for the elderly requiring

25

long-term care, a healthcare facility for the elderly requiringlong-term care, or a sanatorium ward(iv) The User has started using care in a small group home setting forthe elderly with dementia(v) The User has died(vi) Provision of home-visit nursing care has become impossible due todestruction or serious damage to the Station(vii) The Station has had its designation pursuant to the Long-Term Care
Insurance Act revoked(Cancellation by the User) [p. ○]Article 10 The User may terminate the Agreement by making a request forcancellation at least ○ days prior to the termination date as described inImportant Matters 8. (2); provided, however, that, as also described, theUser may terminate the Agreement immediately by making a request forcancellation in any of the following cases:(i) The User has been admitted to hospital(ii) The Provider has violated its obligations specified in the Agreement(iii) There are other unavoidable circumstances.
(Cancellation by the Provider) [p. ○]Article 11 1. The Provider may cancel the Agreement in any of the following cases
as described in Important Matters 8. (3):(i) The User has delayed payment of the Service Fee, etc. for at least
three months, and despite the Provider giving notice specifying areasonable period of time, the User has failed to make payment
within that period of time(ii) The User or their Family Members have committed any of theprohibited acts described in Important Matters 5. (7), and provisionof home nursing to the User has become extremely difficult.
2. Notwithstanding the provisions of the preceding paragraph, as
described in Important Matters 8. (4), where the Provider discontinues,
suspends, or reduces its home nursing services (including reductions
in areas of service), it may cancel the Agreement by making a request
for cancellation at least ○○ days prior to the termination date.
(Cooperation at the termination of agreement, etc.) [p. ○]Article 12 At the time of termination of the Agreement, in addition to giving
appropriate guidance to the User or their Family Members, the Provider
shall strive to provide information to the attending physician andin-home long-term care support provider and to cooperate with healthcare services or welfare services, as described in Important Matters 8.
(5).
(Confidentiality, etc. [p. ○]Article 13 1. The Provider shall take necessary measures to ensure that its current
or former employees do not divulge secrets about the User or their

26

Family Members, which they have learned in the course of providing
home nursing, to a third party without justifiable cause, as described inImportant Matters 9. (1). The same shall apply even after the
Agreement is terminated.
2. The Provider shall handle the personal information of the User or their
Family Members, etc. in an appropriate manner as described inImportant Matters 9. (2).
(Handling complaints) [p. ○]Article 14 The Provider shall handle complaints regarding the provision of homenursing as described in Important Matters 10.
(Response in the event of an accident) [p. ○]Article 15 In the event an accident occurs as a consequence of providing homenursing, the Provider shall take necessary measures as described inImportant Matters 11. (1) and (2).
(Liability for damages) [p. ○]Article 16 In the event the Provider violates its obligations specified in theAgreement subsequently causing damage to the User, the Provider
shall promptly compensate the User for that damage as described inImportant Matters 11. (3); provided, however, that where the damage isdue to circumstances not attributable to the Provider, the Provider shallnot be liable to compensate for the damage, as described in Important
Matters 11. (3).
(Maintenance and retention of records, etc.) [p. ○]Article 17 1. The Provider shall maintain records regarding the provision of homenursing to the User and shall retain those records for a period of ○years after the termination of the Agreement, as described in Important
Matters 12. (1).
2. The User may make a request to the Provider to inspect or copy therecords set forth in the preceding paragraph, as described in Important
Matters 12. (2). In this case, the Provider shall respond appropriately inaccordance with the Act on the Protection of Personal Information andother relevant laws and regulations.
3. Costs for copying as set forth in the preceding paragraph shall beborne by the User as described in Important Matters 4. (1) 4).
(Governing law) [p. ○]Article 18 The Agreement shall be regulated and construed in accordance with thelaws of Japan.
(Jurisdiction) [p. ○]Article 19 All disputes arising from or with respect to the Agreement shall be
subject to the exclusive jurisdiction of the ○○ District Court in Japan.

27

(Discussion)
Article 20 In the event problems arise in relation to a matter not stipulated in theAgreement, the Provider and the User shall hold talks in good faith inaccordance with the provisions of the Long-Term Care Insurance Act
and other relevant laws and regulations.
In witness whereof, this Agreement has been prepared in duplicate, and theProvider and the User shall each retain one copy.
(User)(User’s representative)(Provider)

Please add your signature and seal
in the Signatures section ([p. ○])28

Section 3. User Checks* Check (☑) the items you have been briefed about.

□

Outline of the Provider (○○○○, ○○ Corporation)… Explanation of Important Matters p. ○□Outline of the Station (○○ Visiting Nurse Station)… Explanation of Important Matters p. ○□Meaning of home nursing and method of provision… Explanation of Important Matters p. ○, Home Nursing Agreement
Articles 1–5 (p. ○)□Amount of Service Fee, etc. and method of payment… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 6 (p. ○)□Points to note when using home nursing services… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 7 (p. ○)□Term of Home Nursing Agreements… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 8 (p. ○)□Termination of Home Nursing Agreements, etc.
… Explanation of Important Matters p. ○, Home Nursing Agreement
Articles 9–12 (p. ○)□Confidentiality and handling of personal information… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 13 (p. ○)□Handling complaints… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 14 (p. ○)□Response in the event of an accident… Explanation of Important Matters p. ○, Home Nursing Agreement
Articles 15 and 16 (p. ○)□Records of home nursing provided… Explanation of Important Matters p. ○, Home Nursing Agreement
Article 17 (p. ○)□Governing law and competent court in relation to Home Nursing
Agreements… Explanation of Important Matters p. ○, Home Nursing Agreement
Articles 18 and 19 (p. ○)29Section 4. Signatures* Check (☑) the applicable boxes □.

1. Provider Signatures□

At the start of providing home nursing, the Provider explained the importantmatters to the User or their Family Members as per Section 1. Explanation ofImportant Matters and explained the details of the agreement as per Section
2. Home Nursing Agreement.
○○ ○○, ○○Address
ProviderStation○○○○○○○○○○○○, ○○ Corporation○○ Visiting Nurse Station

Person providing explanation□

seal

The Provider has entered into an agreement with the User as per Section 2.
Home Nursing Agreement.
○○ ○○, ○○Address○○○○○○○○
Provider○○○○, ○○ Corporation
Station○○ Visiting Nurse Station
Provider representative ○○○○

seal

2. User Signatures□

I have been briefed by the Provider about important matters as per Section 1.
Explanation of Important Matters, and I agree to them.
○○ ○○, ○○□I have been briefed by the Provider about the details of the agreement as per
Section 2. Home Nursing Agreement, and I have entered into an agreementwith the Provider as per the Home Nursing Agreement.
○○ ○○, ○○(User)

Address
Full nameseal□ (Person writing on behalf of User)□ (User’s representative)
Address
Full nameseal30