Loading...
HomeMy WebLinkAbout96-01119 ~ ) .~ I ~ 't !r~ i ,1) I i I ~ I IJ I I i J I ! 1'[ J I . ~ ", -'L .-.. -) J ) 1 c:J Q-- -- ~/ ~ 'v.... ~ f" NOTICE Of APPEAL COMMONWIALTH O' 'INNSYLVANIA COUI,-g"'-COMMON-'LIAf..' - 0' CIIMllULAND COUllTt JUDICIAl. DIITlICl FROM DISTRICT JUSTICE JUDGMENT NO. 09-3-03 COMMON'UASNo. 1(. - ///'1 6.;.J. T.u-- NOTICE Of APPEAL Notic. is given that the appellant hen filed in the abo...e COUf' of Common Plem on oppeal from the judgment rendered by the Didrict Justice on tI,e date and in the ellMt mentioned bel"", "".tJ.D IRE JOB I.SOIl A(lf)IW 01 AJIf'ILLANT ..- - -.--n----~~.--__p_AGDi!rNOOi-NAMt:Ci1i 1 ._ ~_u______________L.su.SAlUL.J!M em !if AI! z.c:oor- NAMA 01 AIffUAN1' ~~~1lTII lIKST~5lOf"~_________-CAJ!.ISJ.,I.I-__-- PA "-...,,, a...~96 L~1Ul ~JIIQ._R~-----[~~_'&'nl'!M'M!'ic!\\' CV 19 9~111 LT 19 - :;." ." <'~.- ---. .---- 1M block wiil be signed ONLY when this nolaHon i. requir.d under Po. R.CP.JP. No. /I appellant CLAIM- NT (see Pa, R,C'p,JP, No, 10088. .L This Notic. 01 Appeal, when received by the Oi.lriel lu.He., w,1I operol. at a 1001(6) in action~! e Districl Justice, he MUST SlJPERSfOEAS 10 the judgment Iaf po.....ion in lhi. ca... FILE A COMPLAINT within twenty (20) days alter ___ filing his NOTICE 01 APPEAL, 11013 $q1a/Uro 01 ProthonOtaly Of Deputy PIAECI1'E TO ENTER RULE TO fiLE COMPLAINT AND RULE TO flU (T/lis section 0/1oIm to be'usecJ ONLY when appellan/ WJS DEFENDANT Isee Pa. Fic.P.J.P. No. tOO/(7) /n action before DisIT/c/. Jus/ico. IF NOT USED, detach from c~y 01 norlCo 0/ appeal to be served upon appellee). ' , , , PRAECIPE. To Prothonolary Enter rul. upon IF.ADER NURSTNr. DnMR f\ano 01 <JWl]11W( 5 J 4~' 11/'1 ~'J1.f T" n , oppeIIee(.), to file a eamplaint i~ this appeal (Common Pleas Nn ) within lwenty (20) dayM. . 9lc. of rule or /, "I...~lf (~(-t.. 01 non pro~ ,1'1""" //;1 --1 ~~"Of RULEI To tAD1!:1l NIIIISTNr. IIl1MR , appell..(.), ' Name 01 ,.._e/ll ',-' L (1) You are noHIied thaI a rule i. hereby ""tered upon you 10 fil. a eomploinl in thll app.al within twenly (20) day. of lhe dale of ....ic. 01 !his rule upon you by per""",1 ",,,ic. Of by eerlified or regi'lered rol (2)11 you do "';1 lite a eomploinl within Ihi. lime, a JUDGMENT OF NON PROS Will BE ENTERED AGAINST YOU, (3) The date o' service of this rule if servKe was by moil is the date of moiling. Date: Jet .;Jr, 'iL. .19_, (J.". _ C 7 I ~... I II ...- n~.(.r.#__. "l...~ S'f7>aIUu 01 Y a Deputy KJPC JI2-M 'J l ni , f" " '" '" r ". ~ IIr" " If.. (I " i: '- '-6~ llO !I.}JldlCj) UOli!HtUwO:l.i~ 1"':)/JlOJO dll'L ,ljUII(; ''''\4 It~"IJ'1I1! WlJtj!\t ",H);"'I ;jf' J'/J<I/I) 'Jill/Hull,S ,UIIII' 10 eJnlfwd/S -'--'-0< ----.---.-'--jO A\lO- SIHl ]~ :ltJO.Elf] O]EmnSSns ON\lla]~<iUj\l) N<iOMS (P9HJ,s,6aJ) (pallllJoJ,)) Aq 0 a:)IIlJ;J!i IIW05jaI1,(,q 0 ----Sl ....^__._.__H~.. --~~-._------._- uo PtlSS,iJppB SUM illntj iJlH W04^" Ol (s)aalladdo a~1 uodn /uad(hf ~o a:>IION .J^oqe <l41 t1\J1^lJI.Jdt:'IO~):lilIUIP.I,_1hJl):> l! .lll,-j 01 ",rll:J tllH piMji)S I U~~I HHjlJn) pUP. 0 019J04 pa4Jaue Id,;););)) S,JapUilS 'lieU) (P~Ji)I<;It3aJ) (P'J!J1UiU) Aq 0 ,l'11,\/ao,; IllU(j~H.Hf Aq cr--6~ . Uo' --------------'! tJwe(/) '.}dltdd(h~ dlH uodn pUB 'OjC)J,14 pa~peHe IdhlJtJJ S,Japuas '1lelU (paJ9lS16\JJ) (pa1IlpaJ/ Aq 0 r)')I^IiJ9 tUUOSJo-l<! tl'q [} .----.tH '---------...- fd::JMJOS JO alt~p) UO ulaJa41 palHuBlsap a'J!lSnr IJUIS10 ;)lH uodn' ._.._-~-~._~-- "-,_. '.('/N ';1'.lld lJO\;ll\hl::) 'jI10ddV lO d'JIION QIH jO A.dOJ e 0 OI.:JJdlj pa4:J'i!III? Idl.J:JilJ s,Japuas 'lleUJ pi"''''' II'HlIl""II" 10 '""fo" .1'1""'4 I :J.I^Yal~~Y II : ----- ------------- JO A.1NnO::l ItINltAlASNNld JO H! l\tlI\\NOWWO::l (SfUOq alqR:J1lddfJ If:J8IJ:J Il!iJddl! JO iJJljOlJ ,JIJi fjwllJ i:JJ 1. J V \ ,J, \{,J {()~ ,I N J L NIH J./,\1 a] 7/ j 39 1 St7;V a:)/.~ iIJS)O JOOJd ')UI1. j .1NIYldWO:::l 311:J 0.131ntl aNY lY3ddY :JO 3:::l1.10N ~O 3:::lIAtI3S :JO :JOOl:ld " CII Z \I \I 0< 0 \I II c.I .... \I II ...l E-< \I \I ~ . o<<<! \I II >< I>: \I \I ::E: '" ZE-< OCl Z \I \I 1>:3: '" OZ ~Z . 0 \I \I <40< :t;j 0 ~::>o< O:....rzl \I II E-<...l ... CII ""' C ~ 0.... OCIIX... Z.... \I E-< II I J: < OUZ o C<l 0... ....e \I Z \I ..:lZ ;l'i i! ~ 0 0< OX,... i%l'" \I .... \I ....0 ~ ~ t=l> l>lZ .... 0'0 \I 0< \I >.... " .., E s: ~:Z..:l I>: :Ze I>:e \I ..:l \I HE-< ~ u '" 00<>- 0<1>:0,... > \I \I 00 ~ ~ al '" .f, c ..:lCII 0<4....'" tLI... \I X \I 0< ~ 5 E-<CO:Z :>::~E-<.. Zal \I 0 II '" 'i ... Olr:.4Z E-< 0< 0<", H~ \I 0 \I .......:l c:: Ii ~ \I II ""' Oi%ltLI ..:ltLIE-< ~ ......... 12 " ox~ O<..:l.... \I II .....> - r, ..:l a:> ~ Oi:> c.I o-l 0< \I \I ,.... 0 u x"'.... I>: \I \I \00 tLI ......i%l rzl \I II '" :>::.... o:.QO< Cl \I \I E-<O O......x \I \I Z'Orzl \I \I Z 0<......1>: \I \I H 2:.... \I \I . .. . . ." ... . ... . , .. "MPS Screening Questionnaire", "Medicare Acceptance Policy". and "Authorization of Payment of Medicare Benefits to Provider", true and correcl copies of which are appended hereto as E,'thibit "B" and are incorporated by reference and which will hereafter be referred to as "Admissions Agreements" 6. The" Admissions Agreements" were e~ecuted by the guardian pursuant to and within the powers granted to her by the order appointing her as plenary guardian of Defendanl. 7 On April 24, 1995, the appointment of the guardian was e~tended by order of court for an addilional period oflwenly (20) days. A lrue and correct copy of the order extending the appoinlment is allached hereto and incorporated as Exhibit "C". 8 On April 25. 1995, the powers of the guardian were limiled by order of court, a true and correcl copy of the order being allached herelo and incorporated as Exhibit "D", The powers of the guardian were limited to paying medical e~penses and changing locks on the residence of Defendant 9. By Ihe terms of orders of court, Ihe guardianship referenced above e~pired on or about May 14. 1995. 10. The Defendant continued 10 reside in the facilily operated by Leader continuously from April 28. 1995 to July 31, 1995. alllhe while receivinglhe benefits oflhe care and services provided by Plainliff lIOn or about July 31, 1995, the Plaintitl'signed herself out of the facility against the medical advice of her physician. 12 The services rendered by Plaintitl"to the Defendant during Defendant's stay at the facility were ordinary and necessary and conferred a benefit upon the PlaintilT. . . IJ As of July J I, 1995, unpaid charges for Defendant's care amounted to $8,01627. 14 The Plaintiff' provided Defendanl with an in'/oice for the services rendered. A true and correcl copy of an invoice to Plaintitl'is attached hereto and incorporated as Exhibit "E". 15. Plainlitl'has repealedly made demand upon the Defendant for payment oflhe amount due and owing. Attached hereto as Exhibit "F" and made a part hereof is correspondence from PlaintitT to Defendant demanding payment of the account balance. 16. Defendant has failed and refused to tender Ihe amounl due and owing. 17. Plaintiff's demand does not exceed the limits established for compulsory arbitral ion. COUNT I 18. PlaintitTincorporates by reference thereto the allegations set forth in paragraphs one ( I) through seventeen (17) as though set forth allength. 19, The PlainlitThas performed all conditions precedent to recover under the Admissions Agreements for services rendered to the Defendant. 20. Despite demand therefore, the Defendant has wrongfully failed and refused to pay the amount due and owing 10 PlaintitT 21. The PlaintitT has breached the agreement to pay for Ihe services rendered to her by Plaintiff. WHEREFORE, Plaintil1: Manor HealthCare Corporation, requests that this honorable court make an award to PlainlitT and againsl Defendant as follows: I. $8,016.27 for services rendered; 2. cosls and interesl; and .. . ..<' .' . .....,... .~. , (" EXHIBIT A RESIDENTS RESPONSIBLE PARTY AUTHORIZATION AND AGREEMENT The undersigned has been legally appointed as the guardian, conservator, and/or holder of a power of altorne~ to act on behalf of the Resident and shall serve as Responsible Party for the Resident The undersigned has delivered to the Facility copies of the legal documents designating the undersigned as the guardian, conservator, and/or holder of a power of attorney of the Resident. In consideration of the Facility's agreement to admit the Resident to the Facility, the undersigned, individually and personally, hereby warrants, represents, covenants and agrees as follows: 1. That the undersigned will utilize the assets of the Resident to pay, when due, all costs incurred by the Resident at the Facility, at the rates set forth in Exhibit G (Fee Schedule), and arrange for the provision of personal clothing and care supplies as needed or desired by the Resident and as required by the Facility. It 2. That the undersigned will utilize the assets of the Resident to replace any and all furniShings or other property of the Facility or other residents or employees of the Facility damaged by the Resident. 3. That all of the Information, Including but not IImited~t the Financial Data section, which Is contained in the Application for Residency, dated _ "~ ,199 !S , and which Is attached hereto and made part of this Exhibi and made part of the Admission Agreement, Is true and accurate as of this date and all assets listed In Application for Residency are in fact available to Resident for the Resident's care while at the Facility. 4. That the undersigned, in both his/her Individual capacity and as ~....._ "'f'4( ,,-. \ . - . , will take no action to dissipate or otherwise trdnsfer tHe assets of t/1e.Resident and/or assets which are available for the Resident's care, and all of which are listed In said Application for Residency, nor allow any other third party to take such action, so as to prevent such assets from being used to pay for the care of the Resident while at the Facility. c 5. That when the assets available to pay for the Resident's care at the Facility are not sufficient to pay for four (4) months of such care, prospectively, the undersigned will so notify the Facility and will file, on behalf of the Resident, all applications and other documents neces- sary or advisable to qualify him/her for all third party payor programs for which hEI/she may be eligible, including Medicaid. 6. If the Resident Is a Medicaid Resident, that the undersigned will provide financial intor- mation regarding monthly credits, increases and decreases in the Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested financial data to Medicaid representatives. 7. If the Resident is a Medicaid Resident or a Medicare Resident, that the undersigned will utilize the assets of the Resident to pay charges not covered by the Medicaid or Medicare program in a timely manner, and to notify the Administrator of the Facility of any problem anticipated in paying such Charges. 1 of 2 ~ rJi '" ,..\- ~ . . , t ~ "; EXHIBIT "8" . AIw. "84 .41".."'2 1 ~ J _"4__ -.---.....__9". -..- --" ...~ ~. ~-.~_.........~,. '........ .',1 ..,\.... .. II ___ . " ,....,~. .,;lo _ .-11"" ~~.. - ,-"\I'" . .... '. "'#..1'", . .r EXHIBIT Q FEE SCHEDULE The ~lIo~rg ra\84l., ,B~all apply to services and supplies ~'('~ %Q!1!.I1,~ft at the Facility. provided to 1. Dailv Rate. The daily rate Is · . The monthly daily rate equals the daily rate multiplied by the number of days In one month. .See per diem rat$ schedule 2. Services and Supplies Included In Dailv Rate. The dally rate shall Include the following (insert other included services and supplies): · Routine Nursing Care · Unens · CJ Private Roo~Semi-Prlvate Room/D Triple Room (check one) · Meals · Activities 3. Supplemental Services ar.d Supplies, The daily rate does not include the following services and supplies, which will be provided by the Facility upon the Resident's request and attending physician order, at the rates set forth below: o Item Rate · Prescription Drugs As determined by pharmacy. · Non-Prescription Drugs · Nursing Supplies As determined by pharmacy. Current price list available at Facility's business office. · Private Room Determined by location and level of care required. · Physical Therapy $ $ $ $ $ 0.... ~0 <ce0 ,p ~c.~ 0" t::I' · Occupational Therapy · Speech Therapy · Laundry (Personal Clothing) · Nursing (Other than ordinary nurslng caN) · Personal Care/Comfort Items (e,g, T.V., telephone, clothing etc.) Determined by the Item requested. 1 of 4 ~"I'" A;J1. - .. . 'I i 1 . I ~l "i . . I ~ t....a_l . Special E~t $ $ $ $ r:,'f\ee.... ".sa ,,6 ~tF~ ~" r:,ee t. , (Insert other services and supplies not Included in the daily rate, but available at the Facility, with current rates.) See attached fee schedule Other charges available upon request in the business office 4. Additional Services and Supplies Paid Under Medicat9 PnxIram. In addition to the services and supplies included in the daily rate, the following are paid by Medicare: o · Specialized Rehabilitative/Therapy services · Approwd medications · Nursing supplies · Covered Special Equipment 5. Additional Services and Supplies Paid lJnder Medicaid Program, In addition to the services and supplies included in the daily rate, the following are paid by Medicaid: r · Specialized Rehabilitative/Therapy services (to the extent cOllered and paid uncler the stale plan.) · Approved medications · Nursing supplies · Routine pesonal hygiene items and services (to the extent COllered and paid fer under the state Medicaid plan.) · All other services and ilems covered and paid for uncler the state Medicaid plan. · Special equipment (to the exlent covered and paid for under the state Medicaid plan.) · (Add any additlonaJ items) 20f4 :., I .. ;; .' , ; j , i . , . _, "... A3lI. Me ".. <-" ",:",," 1_ G oan&l ( 11. ~I...nt of Charges. The Facility may adJuet any and all rates at the lime upon ltIirty (30) days r;lIlor written notice to the Resident, the Responalble Party and the Guarantor (I' any) or, in the caae of an emergency or i' the level 0' care changes, with such prior notice as is rusonably possible. I/We acknowledge receipt 0' this Exhibit G and agree to comply with, and pay in accor- dance with, this Exhibit a and with the Admla8ion Agreement. RECEIVED BY FACIUTY: , ,,/ #JJ //L~#. (j 7/L.... ~~_*~SlgnAlIa L)H,b~ r- '1'1. Gera/d/yu ~fr8~91&411 _lor R_* PIlIly . PrInl8d Nome FIOCIIIly R___. PrInted _. Tille c.re 4-:J'(.qS l./~t< C'f- 95 Date e - ---- GuallI1lor . SiQnatuN - ~ _lor. Prlnted_ .-/ IlQio I \ 40'4 , , '; f,'It.. ....." ,,^ ~. J '. _..... .p. Service Dates: MSP SCREENIN'G QUESTIONNAIRE 6er-ald/fU 7?ob/n Sd n Medicare No.: :(a t-J;-07'1&A lj-.:JY- 95 Resident Name: Ask all four questions ot each Medicare resident. It the resident responds "Ves" to any question, continue to page two asking all applicable questions. The residant or representative should sign the form whenever possible, NOTE: It is important tQ ask all questions and document all answers regarding MSP, A provider may be held liable if an overpayment occurs and Medicare finds that the provider furnished erroneous Information or failed to disclose facts it knew were relevant to payment. 1, Is the resident covered by the Veterans Administration, the Black Lung Program or Workers C;:oppensation? LX..,) No: Proceed to question ,;;2 ( ) Yes: Bill the other insurer prior to Medicare G 2, Is the illness or injury due to any type ot accident? (X,) No: Proceed to question 1;3 or ';;4 ( ) Yes: Complete next page and continue with questions below -31F 65 OR OVER -41F UNDER 65 3. Is the resident 65 or over and employed, or is the spouse employed at time of service? 0<) No: Retirement Date: Resident J 'l.1.J Spouse Al .I A Continue: See Note Below ) Ves: Complete next page - Medicare may not be primary 4. Is the resident under 65 and covered under any Employer Group Health Plan (EGHP) or L.afi8 Group Health Plan (LGHP)? p<:) No: See note ( ) Yes: Complete next page - Medicare may not be primary Note: If answer to all questions is "No", bill Medicare as primary, If any response Is "Ves", continue to next page; Medicare may not be primary, Resident/Representative Signature ':J/t;J/L~~ 1,dL Date t/~~r- '15 10t3 ~ - -+ 11\ " C't- ~ ~1 10 .. -t. ..0 ~ ~f "",1 1~ ~.: r:{) --\"'..-t" l~ " Q1 J~ . u '. , . ~.. r. f C.:: jJ-',:t .,.... ;-. DEPAR11ENI' OF '.' ; HEALTH AND HUMAN SERVICES "L'J :.l ~~_f1~\N~AD~I~~~N,. ';j. I"~ , . r Section I H.I. CLAIM NUMBER ~/I?S(J. fltJ7-:l~ -tJ7 lj/J APPOINTMENT OF REPRESENTATIVE I appoint this Individual: I""nl or type name and add_ oIlnd..oduaI you wonl to fWl)I'Oeenl yOU,) to act as my representative In connection with my claim or asserted rlghl under Titles XI, or XVIII 01 the Social Security Act I authorize this Individual to make or give any request or notice; to present or to elicit evidence; to obtain inlormatlon; and to receive any notice In connection with my claim wholly In my stead. ADDRESS :337 N. w~5f ":;'-f-"eel- (!.nplis/e ,PJ) 1701 s.. tj-;;Y- 95 TELEPHONE NUMBER 4 -'10 '8.5 (A1e7tl., :li:/9 5'17:;' DATE Section \I ACCEPTANCE OF APPOINTMENT I, ' hereby accept the above appointment. I certifY' that I have not been suspended or prohibited lrom practice belore the Social Security Administration or the Heallh . Care, Fin1J1Clng Administration; that I am not, as ll' current. or. lormer olllcer or' employee. of the United :States, dlsQualllled.lrom acting as the claimant's representative; and that I will not charge or receive any lee lor the representation unless It has been authorized In accordance with the laws and regulations referred to on the reverse side hereof, In the event that I decide not to charge or collect a lee lor the representation I will notify the Social Security Administration and the Health Care Financing Administration !comoletlon.Df Secllon III (ocllonal) satisfies .this reauirement), I am alan L~censeC1 Nurs~nq Home Aa.ml-n...stra't.or (Attorney, unm repreaentallYe. rela~I~I.W student, etc.) SIGNATURE (Representative) ADDRESS 940 Walnut Bottom Rd " ,,-', 'Carlisle, P1. 17013 ' TELEP~IONE NUMBER (AreaCodeI (717) 249-0085 DATE ~- J Section III WAIVER OF FEE OR DIRECT PAYMENT (Note to Representallve: You may use this portion of the lorm to waJve a fee or to waive direct payment 01 the fee from withheld past-due benellts,) , "<, . " ' ,'.' '.<, I waive my right to charge and collect a fee for representi"g~'(:;-e:rald/tt.i .1?ob//l5~'1''': '- ~. ... " . . ~ ", ,. . belOl8 the Social Security Admlnlatratlon or Health Care Financing Admlnlatrallon. I DATE SIGNATURE (See ~l "*""..do' en_I FORM HCFA-1898-U4 \10-84) 1 of 1 . _, 1/9+ AlII. loa Q. ;:"\,. _"I .1 CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE THE SOCIAL SECURITY ADMINISTRATION An attorney, or arher representative. who wishes to charge a tee tor services renoered In connection with a claim oetore the Social Security Administration IS reQulled by law to oOtaon approval of the fee from the Social Security Administration or the He 11th Care FinanCing Administration (sections 2061a) and 1631(d)(2) of the Social Security Act; sections 404,1720 and 416.1520 of Social Security Admini- stration Regulations Nos, 4 and 16, resoectively I. If lhe representative Wishes to waive a fee or to waive direct payment of the fee from past-due Social Security benefits, he may do so. Section III on Ihe front of this form can be used for that purpose, The form SSA-1560-Y 4, 'Petltlon to Obtain Approval of a Fee tor Representing a Beneficiary belore the Social Security Administration, eliCits the Informa- tion required to be submitted in support of fee petitions, It should be completed by the represent- ative after services are completed and the original and third carbon copy of the SSA-1560-U4 flied with the office of the SocIal Security Administration or the Health Care Financing Administration which took the lalest action on the claim, The represent- ative is required to furnish the "Clalmant's/Beneficlary's Copy" of the SSA-1560-U4 petition to the claimant for whom the services were rendered, Social Security Administration approval of a fee IS not required where the fee is for services (11 rendered in an ottlclal capaCity such as that of legal guardian, committee, or Similar court-appoonted ottice and the court has approved the fee in Question, 12) in rep- resenting the beneficiary before a court of law, or (3) in representing the benefiCiary in a claim for reimbursement of medical expenses exclusively handled by a private intermediary, Where a repre- sentative has rendered services In a claim before the Social Security Administration and a court of law, the regulations require that the amount of the fee to be charged, if any, for services performed before the Social Security Administration be speCified, If any fee Is to be charged for such services. a petition for approval of that amount ",ust be submitted, In this connection a claim which has been remanded by a court to the Social Security for lurther administrative proceedings Is considered to be before the Social Ser.urity Administration after the remand by the court. FORM HCFA-18e8-U4I to-e41 AUTHORIZATION OF FEE The SOCial secunty regulations contemplate that J representative Will receive fall 'Ialue tor the serVices perf':lrmed before the SOCial Security Administration on behalf of a claimant while at the same time gIVIng J measure of secunty to the benefiCiaries, In appro'lIng a requested fee, the SOCial Security Administration or the Health Cdre FinanCing Administration conSiders the nature and type of services performed, the comple.,ty of the case, Ihe level of skill and competence required In rendition of the services. the amount of time spent on the case, the results achieved, the level of administrative review to which the reprasentative carned the claim and the amount of the fee requested by the representative, When a fee is authorized, both the representative and the claimant are notified and allowed 30 days In which to request an administrative review in case of disagreement. CONFLICT OF INTEREST Sections 203, 205 and 207 of Tille XVIII of the United States Code make it a criminal offense for certain officers, employees and former ottlcers and employees of the United Stales to render certaon services In mailers atfecting the Government or to aid or assist In the prosecution of claims against the United States. c ";" , .. .. ~, r . RESIDENT JRESPONSIBLE PARTY AUTHORIZATION FORM '1-;)<;-95 ',' ~'e.YaJd;JU 'Ko/;/115tJlL Dal. R._r. Neme (For the purposes of this document, the term I references the Resident/Responsible party or Guarantor as noted on the signature line page 2.) AMBULANCE I hereby give my permission to the Facility that, in the event I have to be trans- ferred to a hospital and must go by ambulance, the Facility hss my permission to order !Sid vehicle and I will assume responsibility for payment. PODIATRIST: I hereby authorize use of the services of Dr, , who will examine the Resident and bill me directly. I assume full responsibility for payment of aU charges, I will arrange transportation for the Resident to the Podiatrist's Office. -i . I prefer Dr, Ci"~Q'^. provide podiatric care. , who is willing to visit the Facility to DENTIST: x: I hereby authorize the use of the services of Dr, , who will examine the Resident and bill me directly for each visit. I assume full responsibility for payment of all charges. I will ar~ar.ge transportation for the Resident to the Dentist's oHice. f)c .tee\-", Dr. 't . \\ f will visit the Resident In the Facility, G CUNIC APPOINTMENTS: The Responsible Party or Guarantor agrees to accompany the Resident on regularly scheduled clinic or hospital appointments ordered by the Resident's physician. The Responsible Party/Guarantor will be notified In advance In order to make the necessary arrangements for the clinic or hospital appointments. The Facility will, when medically necessary, accompany the Resident. A charge will be made for the employee's time, based at their hourly wage for the number of hours reQUired for the appointment. RESIDENT OUTINGS: I hereby desire/give my permission for the Resident to go on outings with Facility supervision. I understand that the Facility would be doing this service and I therefore will remain In full NtANOR HEALTHCARE ll4ANLlR c.UU!' 1.lAVOl. AAIlJUf..:ANA' tQ.;.. ~ -. -- ...._~_., -_.'~~._,-- ~18"1"",._""""..L/I. 1 of 2 4;'.". "'-II I. ~ ' ~ \' . t t.' t - ,!' ~.' (' _~ ,~. ......~ . .. fana. _. . . . ....... ~ " .. ,',:;~':' ~'" 'f~'"'\."IO~U.~!: .JA~',I '.' '1.'.;"\" ,: '::':1.. ,..;.', ie' ! For.:\, responeiblllty during this time, I also understand that participation Is subject to physician permla8lcn, Some outings may require a small lee, which will be added to the regular monthly statement. ~ I do not desira/give permission for the Resident to go on C'Utings with Facility supervision. The Ambulance, Podiatrist, and/or Dentist listed above are Independent contractors and providers and are not employees, agents or representatives of the Facility and thus they, and not the Facility, are responsible for their own actions, lj-)1- 16 U1'rJbl ~ (SEAL) 08101 R8l1ldanr. S1Qnalure it' - :(fj'-rS _~~~:I- g' &(, (SEAL) Oal. '. Signature - Oata Quo,."lOf'a SIgnature (SEAL) . ACCEPTED BY FACIUTY ..... \.. 20f2 .' ... ._,-_......._--~--~'-_._.,-_.- ..,......-_.. .,.,.,---~'~.-_rA _ -- ,,~-;,_...~..,f"~~.';r. ;".r-, If . T~ ,p.- . f/If'#-,rJ . to.. .;'.1 ...- 'Wi_." , ..": 1.-'........ ( The underalgned ReaIdent andlor the undersigned Responsible Party acknowledges receipt of the Resident Personal Fund Account Procedure and halle had explained, to their satisfaction, all of their questions. t;~~-9S ~./k..-1~ '"'1'Ie nt Of Reeponeible Perty. lQ/1lllure G eya/d/j(J 1(f;/;IJ.?StJJ1. Resident or Responsible Perty . PrInted Name Oete I/We authorize the Facility to establish a Resident Account for melthe Resident in accordance with the Resident Personal Fund Account Procedure. In addition to the Resident, the following persons are authorized to withdraw monies from the Resident Account (if none, write in NONE): N 0 "'--l "Name \ . Resident or Responalble "Witness. required In the State 01111111018 " Name \ , "Name o Oete Name 01 Reaident * Cannot be Employee of Facility or have any financial interest in the Facility, '- 20f 2 -,'Ie.. ( o c' __ -L__ .:.. - ~. . 11 ..,.... ADMISSION AGREEMENT CONTRACT BETWEEN RESIDENT AND FACILITY pjTHI$.ADMISSIO~~GREEMENT (the "Agreement") is entered into this ~V_ day of _!:.l.1 ,19 _ __ ,between Lea er - a 1 sle (the "Facility"), rnklt'iu J::} ~.f(J}f (the "Resident"), and/or (the "Responsible Party"). As used herein, the term "Resident" shall also mean the Responsible Party, if any, The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer, a Termination by Resident. The Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice, The Resident is responsible for payment of all Charges for five (5) days after notice is given, or until the Resident actually leaves the Facility whichever is last. It the Resident leaves tl'.e Facility (i) before the attending physician discharges the Resident, or (iI) against medical advice, the Resident and Respon- sible Party agree to assume all responsibility for injury or harm to the Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Resident upon at least thirty (30) days prior written notice if (1) the Resident's needs cannot be met; (2) the Resident presents a danger to the health or safety of other Indivi- duals; (3) the Resident fails to pay Charges for supplies or services after notice; (4) the Resident's health has improved sufficiently so that the Resident no longer needs the services provided; or (5) the Facility ceases to operate. However, the Resident may be transferred or discharged upon less than thirty (30) days notice if: ( 1) an immediate trans- fer or discharge is required due to the Resident's medical needs; (2) the Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Resident has not resided in the Facility tor thirty (30) days. Such notice shall be given as soon as practicable. The Resident acknowledges receipt from the Facility of materials as to the Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Resident is discharged by the Facility, the Respon- sible Party agrees to accept custody of the Resident upon discharge and cooperate with the Facility to facilitate the Resident's discharge. 3, Responsible Party, The Resident's Responsible Party may be any person legally responsible for the Resident, including a court-appointed guardian or conservator, or a person holding a power of attorney, A Responsible Party who Is also a guardian, conser- vator, or holder of a power of attorney must execute this Agreement and the Resident's Responsible Party Authorization and Agreement attached as Exhibit A, and must provide the Facility with a copy of legal documentation regarding his/her appointment. MANOR HEALTHCARE ,\4ANORC,\JU. L.iADO. AMEJUC.\.""A. KILl SlA:Al'oI' ---... -.-- Qo.uin 1lr.p.1""","""l ~ '. L/<- 1 of 7 Aw. tll4 AI. Aa I G I....., .~'-l .il} '.- ~': b. Medicant Beneflciarfes. The services and supplies ir.eluded in the Facility's dally rate will be provided to Medicare residents, as well as services and supplies noted on the Fee Schedule sa being Included in the Medicare rate, The Resident is responsible for paying any Medicare co-insurance amounts. The Resident understands that Medicare eligibility and coverage is established by federal guidelines which currently limit payment to a fixed number of days. If the Resident enters the Facility and the Medicare application is denied, the Resident shall be liable for all charges as provided In the Fee Schedule, The Resident is responsible for payment for items covered by Medicare supplemental insurance. and the Resident is respon- sible for applying for reimbursement from his/her insurer, (Choose one and cross out, date, and all parties Initial the inapplicable Section 7(c),) c. Medicaid Benefi 'ries, The Facility does n rrently participate In the Medicaid program. Accordingly, perso who are ad' as private pay residents will be unable to COlllltlrt to Medicaid status. In 0 er to f ' ate proper discharge planning, the Resident and/or ResponSible Party agree to provl e Facility with at least four (4) months prior written notice ot the Resident's becoming 'Ible f coverage under the Medicai9 program or their not being able to pay privately, itial Date ~ Ql y - '15 or c. Medicaid Beneficiaries. If required by the Medicaid program, a Resident must have pre-admission approval. If the Resident believes he/she qualifies as a Medicaid Resident, he/she shall promptly complete and submit all documents necessary to apply for Medicaid coverage. It Medicaid coverage is denied, the Resident will be liable for all Charges as provided in the Fee Schedule, from the admission date, When Medicaid pays for only a portion of the incurred charges, the Resident is responsible for paying his/her portion, as determined by state Medicaid regulations. This charge will be billed to tr.e Resident by the Facility and shall be paid in accordance with Section 7(a), The Resident shall also be responsible for payment of Facility's current charges for any requested non-Medicaid covered services or supplies. The services and supplies Included in the Facility's daily rate, and all other services and supplies noted on the Fee Change Sheet as being included in the Medicaid rate, will be so provided. If the Resi- dent is a Medicaid resident, he/she will provide financial information regarding monthly credits, increases or decreases in the Resident's bank account(s), and other assets to the Facility to enab"-lhe ~aciVt;f~to provide req~r~;nF~ data to Medicaid representatives. InitiaIUl'~ ~ Date d. Insurance Coverccge, The Resident is responsible for, and shall pay, the daily rate and Charges for supplemental services and supplies not timely paid by any insurer, as well as applicable co-insurance and deductible amounts. e. Rate Adjustments. The Facility may adjust the daily rate or the Charges for supple- mental services or supplies for any or all residents, with at least thirty (30) days' written advance notice or, in the event of an emergency or in the event the level of care changes, with as much notice as is reasonably possible. Ally such adjustment shall be deemed agreed to by the Resident or Responsible Party unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice, If the Resident does not consent to the rate adjust- ment, the Resident agrees to leave the Facility no later than the day before the rate increase is effective, 3 of 7 Rev. t/94 A4. AS