I agree that in the course of providing services to me, HomeCareNG may share my information with service providers. I understand that this information will be for the sole purpose of providing home care services to me. I have read, understand and agree to the Terms, Rights and Responsibility included with this application form. I understand that my Monthly Fee is essential in order to provide services to me. I agree that HomeCareNG can stop my home care services when and if I failed to pay my premium when due. I certify under penalty of perjury that everything on this application is the truth to the best of ability.