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11-,~/o-1
~ ~ ~ INHERITANCE TAX RETURN
".'~1it.~ RESIDENT DECEDENT
COMMONIY[All" Of m'N5YlVANIA (TO BE FILED IN DlIPLICA TE
D~rAA.TMENT Of RfY(NUE
tl^Rn\5fJ:!d~or,11801>o, WITH REGISTER OF WILLS) COUNTY CODE YEAR.. NU.!.\B.~~
~~~~ .jiird~~1:";~':'ll~~'::1:7'T~":"ifil{i';'ili:iI'" "..,.",~~.=. l'iiI~;~'~~:~{::OI~~~ rch ~~~d
~ $()('Ai ,icueIlY'IU;,'"'' '1."1'''1''/''2"6'''/''9' 3 'lo.'l'..'~.o/'.1'."8'.i.i/'O'4 Camp Hill, PA 17011
o 207-07-7928 _ 1(0'"'1 Cum?~~~~lld.._.u...._.um_._._
~ X I 1. Originol Rolurn I I 2. S.pplomon'ol Ru'.rn I .I J. Romoiudor Rul.rn
It; ~l:! ('or do'ul 0' rJoo,h prio,lo 12,1 J.821
h1a..V :ri 4, lln.ltod E"C1lo ! 14('1. FlJturo InlortJsl Compromise [ 15. hdornl Estato '(O.ll,
:z: 00 ('or dolol 01 doolh olior 12.12,8~1 R,'.rn Roq.irod
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;: A. 6. Do(odonl Diod 1U510lo ! : 7, Decodonl MClinlCllnocl allying Trust __8. TOloINumborolSClfoDeposltBox61
.q; IAtlClCh copy 01 Willi (Alloch copy of Tr"11
ALLCORRlisPONLiENCE AtiilCONFlli"ENTiili', Ai(IN'F'ORMATioN SHOiJLOBi! DIRicf'DTO; - -....-. .-.------
. t; -FiAl-.iE---- -~-----.. .._h.._.___, -_. ----- - - '0IC5Mf'ITfrM^iLif;GMi1)Rf~'- ----- -- _0<4 ~--- ---.-.--.----
W m Betty J. Po1eshock 413 Rutherford Road
_.~..~. 'H;PI;O~';NV~'E~45_8279 I. Har.r.iSburg '. p~ ~1:'109.._~_~::=.,,==
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.[\,,1$00 fXt 111,8UI
1. Rool E "0'0 (Schod.lo AI ( I)
2, Slock> alld BOlldl ISchod.lo BI ( 2)
3, ClolOly Hold Sloc~/Pu'llIol\hip InloroIIISch.d.lo CJ I 3)
4, MorlgagOl "nd Nolul Rocuiv"blo (Schod.lo 01 ( d)
5, Co.h. 8ank Dopollll & Mi,collonoo" POllonol Proporly( 5)
ISchod.lo EI
6, Joinlly Ownod PropOlly (Schod.lo FI
7. Tronl'oll ISchod.lo GIISdlOd.lo LJ
8, To'al Groll AII.II ('ololllnOl 1,71
9. Funeral Expenses, Administrative Cosh, Mitcollaneous I 91
Exponlol (Schodulu H)
10, Dobll, Morlgogo Uobillllol. UOOl (SchAd.lo I)
II. To'ol Doductionl l'o'allinOl 9 & 101
12, Nol Vol.o ., Ello'o IlIno 8 min.. lin. III
13. Choriloble and Govornmonlol 80q'OIh ISched.lo JI
__. _ .... .!.4,.N..~~!~~ Su~ioc'l~ To x .Uino .12 m;nulJino.I~.
15, Amount of line 14 taxablo at 6% role
(Ind.do vol.OI from Schod.lo K or Schod.lu M.I
16. Amount olllne 14 taxablo 01 15% raltl
(Incl.de val.OI from Schod.lo K or Schodule M.)
17, Principal '0' duo (Add '0' Irom II no 15 ond !rom line 161
18. Crodih Prior Poymonls Discount
+
19, II line 18 II groo'or ,hon lino 17. on'or ,ho dilleronco on lino 19. Thil II ,ho OVERPAYMENT.
me]
20, IIlin. 17 II grenlOllhan lino 18. on'" tho dillorenco an lino 20. Thi. illho TAX DUE.
A. Enter the Intorosl on tho balance duc on lino 20A.
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See
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Schedule F
( 61
( 7)
.34.&72.35
0.00.
I 81
34 872.35
-..,-_,_,.1,..._,....--.-.-
4 173.00
,.._-f_. __'.__....,.
110).
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111)_.3},6.14.~~.~.._n...
112) ......JLU~.,.Q.L....u__
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115) .....n.. .._....m... ,06= '''n.....
116)
1,l7.8.02... .15=
176.70
176.70
1171
InlereU
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1181
1191
Chock ho,o if you oro ,0. uDsling a ,ofund of your ovo'pnymonf.
120)
(20Aj
(20BI
176.70
0.00
176.70
B, Enlor ,ho '0,,,1 of lino 20 and 20A on lino 20B, Thil II ,". BALANCE DUE.
. ....!-Ia~. .Check .Pavablo 10: Regl.ler of Willi, A.genl
=-u-."--:::'~-=:==~:_~.-'IESUR-E TO'ANSWER7,ii'QUESTIONS ON' REVERSE SIDE AND TO RECHECK MATH....
Under pnrloltie5 of perjury, I dtlchl-r~I~~vlJ ~~o-minod,his-;~r;;;-~~~.cludi~g ~occ'~-~pa~y~g~;C-hod~;;'Md~te-;;,~~;lt~-ih;-b~;'oT;y kno~lod90 and bo~~f.
It it !rue, corrflcl and complote, I cJeclaro Ihal all roo I OS'c.ttl hOI bllon roportod ot Iruo markot voluo, Doclmolion of p,opOfllr olhof than tho porsonal ropresontativo It
botod on 011 inlClrmotion 01 which propater llot any knowludgu
,";~i~~PEft~!I'~o~::~;til"'G'/I.~' (~;;~~~'iY' 'f'/(j',.J, 1!fjj, ii, /,7>>"2: ~r(,;-_'~-:'y.-
_1r'U~~:~~:~'~I.~~\~: '~)'::[I:\;~"~.'II\((I~~~':\I\' (b 1':; (J f\/I:i'/ <,// Abe;, Pi; JI/( I DA/~~)'.:i.;'u.
1E~tst ~lllfll nub Weghttttettf
OF
.IMIr.R f:. Cl,MK
I, J^MES E. C/,MlK, of tho C.lty of /lol'l'lnhlll'9, !lollpldn COllnly,
l'nnnnylvMI 0, hn Ing (Jf O(JIII'n mlnrl, momory MId IInnorntonnl nil, do
moke, pllblloh Md deClore tho' fOllowing tn bo my I,not Will nnd
Teot.ment, horeby revoking ond mnklng void, any and nil wlllo,
codlcllo and tootnmentory dioponlllonn by 010 nt nny tlmo
horotoforo made.
I'rRM r.
dlrnel Ih~1 oil my jnol debln nnd funerol
OXpnnoeo bo pnld nnd notloflod by my Exn"ulrlx hnrnlnnfter nomod
an noon ~B convoflJontly mny be aftor '"y do{!oono.
11'Efl I I.
^,l1 tho roat, rontduo nnct l'emalnctt'f of my entatn,
wbolhor rool, poroonnl or mixed of WhntnvM nnlllro onn whorOBoovnr
sltunlo, 1 give, devloo ond hoquoMh 11010 GIWRGR !'O[.f:SIIOCK olld
nE'Il/tv POl,F:AIIOCK, or tho Rurvlvor of thorn.
ITEM II I.
I nomlllolo, conntlllllo ond nppolnt RRTTY
POJ,RS/lOCK, 00 ExoclItrlx of t.hlo my LOAt Wll.1 ond Tootomont, In tho
ovont Botty POloshock 10 IInoblo or unWilling to oorvo in thlo
eopaeHy, I nomlnoto, eonUlltll!'o ond oppolnt GEORGE PO/,RS/lOCK, on
f~Kocutor in hor placn and stoar!.
l'rRM IV.
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^J} ostato, .lnhoritance, trnnnfnr, legncy,
Ollcenoolon, ond other dnoth toxoo of ony notllre, poyoblo by
rnnson of my ,'ooth, Illlteh mAY bo ""OOORod or lmpooon upnn or with
re~poet 10 proporly PAoolng IInnor thio Wlll or proporty not.
PORoing under thio Wi.1I, otwll bo pold Ollt of my notnto no on
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nxpenon of AdmlnlntrAtlon, nnn no port of Rold t~xoe ohol1 bn
apportioned or prorntod loony logotoo or dovlooo undor thln Will
or ony pernon Owning or rocolvlng ony prnpnrty not pnnolng under
"
t.hln Will,
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UY.U09 Ill., (12,",
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COMMONW!AllH 0/ p!NNmVANIA
INHUITANCI lAX !!TURN
RUID!NID!C!D!Nl
-
SCHEDULE F
JOINTLY.OWNED PROPERTY
!STATE OF
Clark, James E.
Joln""nGn'(I)'
------
. tLE NUMBER
-'---
NAME
A. Betty J. Poleshock
A,DDRESS
413 Rutherford Road
arrisburg, PA 17109
RI'LATlC)N!Hip'TODECiDENT
Friend
B.
C.
Jolntlv'~wnld proplrlVI
ITEM LEnER DATE TOTAL VALUE DECD'S DOLLAR VALUE OF
FOR
NUMBE JOINT MADE DESCRIPTION OF PROPERTY OP ASSET %INT, DECEDENT'S INTEREST
TENANT JOINT
'-------,
1. A /3/87 Checking Account 30,053.51 100 30,053.51
2. A 0/17/ 8 Bank Money Market Acct 1,818.84 100 1,818.84
3. A ./11/8 Certificate of Deposit 3,000.00 100 3,000.00.
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'-~TAL (Alia .n,.;~;ii~;6;-H.co~j;'u'atlonl -"$ 34, 8 72~-35-
----..,-~._--- --.-... --'_~'.__n__ "--------._____.__._ '_P'"
(1/ more .paco I, noodod Into" addllionir/.hoo" o'.omo .llO)
ESTATE OP' JAMES E. CLARK-
BETTY POLESHOCK,
BXBCUTRIX,
Petitioner
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
NO. 1994-00423
ORPHANS COURT DIVISION
PBTITION POR SBTTLEMENT OF SMALL BSTATE
~uant to 20 Pa. Cons. Stat. S3102
TO THB HONORABLE, THE JUDGE OF SAID COURT
AND NOW COMES the petitioner of the Estate of James E. Clark,
Betty Poleshock, Executrix, by and through counsel M. Peter Harer,
respectfully stating thatl
1. James E. Clark ("Decedent") died on November 26, 1993, a
resident of Blue Ridge Haven West, 770 Poplar Church Road, Camp
Hill Pennsylvania 17011.
2. Petitioner, whose address is 413 Rutherford Road,
Harrisburg PennAylvania 17109, is the executrix of the Decedent's
estate and on the date of Decedent's death held power of attorney
over Decedent's estate.
3. Decedent gave Petitioner power of attorney as of October
16, 1987.
4. Decedent left a will dated March 23, 1987, which has not
been probated. A copy is attached as Exhibit "A".
5. Deoedent was survived by the following persons entitled
to share in his estate under the terms of Decedent's willI Betty
polsshock and George poleshock.
6. The property owned by Decedent and the value thereof i.
a8 follows:
One 1971 Ford Thunderbird of negligible value.
The only other property belonging to Decedent at the time of
his death were the following bank deposits jointly held with
Petitioner, Betty Poleshock:
Mellon Bank Aocount No.
Amount
110-071591
112-113032
110-006612-C
$1,811.62
$30,053.51
$3,000.00
Said accounts are not part of Decedent's estate and are the lole
property of the joint acoount holder, Betty poleshook, by virtue of
Decedent's death.
7. The following disbursemente have been made by Petitioner,
Betty poleshock, on behalf of Deoedent I s estate prior to the filing
of this petition:
zimmerman Auer
Funeral Home
Date Nature of Payment
11/30/93 Funeral Expenses
Amount
Name of Person
$4,173.00
RJ Romberger & Sons 11/30/93 Headstone Engraving
Mount Olivet
Cemetery Association 5/10/94 Installation of
Veteran's Memorial
$125.00
$110.00
8. The names of all unpaid claimants against Decedent'.
estate of whom Petitioner has notice or knowledge arel
Blue Ridge Haven West
Residence and Care
$31,372.13
$741.20
$880.77
Sears
Credit Card Balanoe
Disoover Card
Credit Card Balance
9. A Pennsylvania Inheritance Tax Return was filed with the
"
1E~t!it ~mtll ctub, Qfestttmettt
OF
JAMES E. CLARK
I, JAMES E. CLARK, of tha City of lIarrisburg, Dauphin County,
Pennsylvania, being of sound mind, memory and understanding, do
make, publish and declare the' following to be my Last Will and
Testament, hereby revoking and making void, any and all wills,
codicils and testamentary dispositions by me at any time
heretofore made.
ITEM I.
I direct that all my just debts and funeral
expenses be paid and satisfied by my Executrix hereinafter named
as soon as conveniently may be after my decease.
ITEM II.
All the rest, residue and remainder of my estate,
whether real, personal or mixed of whatever nature and wheresoever
situate, I give, devise and bequeath unto GEORGE POLESHOCK and
BE'rT,Y POLF;SIIOCK, or the survivor of them.
ITEM Ill.
I nominate, constitute and appoint BETTY
POLESHOCK, as Executrix of this my Last Will and Testamentl in the
event Betty poleshock is unable or unwilling to serve in this
capacity, I nominate, constitute and appoint GEORGE POLESHOCK, as
Executor in her place and stead.
I'l'EM IV.
All estate, inheritance, transfer, legacy,
succession, and other death taxes of any nature, payable by
reason of my death, which may be assessed or imposed upon or with
respect to property passing under this Will or property not
passing under this Will, shall be paid out of my estate as an
expense of adminiAtration, an~ no part of said taxes shall be
apportioned or prorated to any legatee or devisee under this Will
or any person owning or receiving any property not passing under
this Will.
EXHIBIT "A"
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jv:ucx: IX. '112'~8J *'
COMMONWIAlTH 0' "NNSVlVAN'A
DI'ARTMINT 01 !!VINUI
om, 210601
HA!!ISIU!O.'A 11121.0601
N ' HAM IIAST, 'lAST, AND MIOOH INITIALI
Clark, James E.
IA~0;u~::~~28 ~T~~~~A79~1~~~~'~1;04
lO 1. Original R,lurn [] 2, Supplemen'al R,lurn
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COUNTV CODE
DE 0 NT' M l A
INHERITANCE TAX RETURN
RESIDENT DECEDENT
(TO BE FILED IN DUPLICATE
WITH REGISTER OF WILLS)
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VEAR
NUMBER
770 Poplar Church Road
Camp Hill, PA 17011
c"",, Cumberland
o 3, R,malnder R,lurn
(for dol.. of dealh prior 1012,13.92)
o 5, F,derol elIOI' To>
R,lurn R'qulred
_ 9, TOIal Number 01 Safe Depolll Bo.e.
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o oia, Future Inlertlsl Compromise
Ifor dolo' 0' deo", after 12,12,B21
J() 6. D",d", Died T..'ale 0 7, Decedenr Maln'alned a living TrUll
(Allach copy of Will) (Allach copy of TrUll) _
LL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO.
i"AMf---~ OMPllTl MAlllt-lG ADLlRE~$
Betty J. Poleshock . 413 Rutherford Road
I HON! IIUMllf Harrisburg, PA 17109
I 717 J~.~_t'_~~l2." _
1. Real Ella" ISchedule AI ( II___________Q,' 00__
2, S'ack, ond Bood, (Schodule BI I 21_________~~~___
3. ClolOly H,ld S'ock/Parlnerlhip Inroro"lSchodulo C) (31___,--D.._D.O__
4, Mar'gog" and No'., Rocolvabl, (Schodule 01 ( 41____.__ 0.00
5, Calh, Bank Depo,llI & MlscollanooUl Porsonal Praporly( 51 See Schedule F:___
ISchodulo EI
6, Joln'ly Ownod Proporly (Schod.l. F) ( 6) ___~U72 . 35
7, Tranlf", (Schodulo GI (Schedulell ( 7)____ .Q..o_o.-._
9, Ta'al G'OIl AllO" 1'0101 line I 1,71
9. Funeral EKpon,o" Admlnlll,.'iv. COllI, Mlscollaneous ( 9) __.JL.l 73. 00
expon." ISchedul. HI
10. Deb,., MOllgago liabilities, lIonl (Schedule II
11. Tolal D,ducllon, (10'01 line. 9 & 101
12, No' Val.. 01 E"o'. (Iin. 9 minUl iine 111
13. Charilabl, ond Govornmen,.1 Boquelll (Schedulo J)
lA, Nel Valuo Subj~cl10 Tal( lline 12 minus line 131
15, Amoun! or line 14 lox able 0,'6% role
Ilnclud, volu" from Sch,dulo K or Schodule M,)
16, Amounl 01 line 14 la.oblo 01 15% ro'e
(Includ, volu" from Schodulo K or Schodule M.)
17, Principal'" duo (Add 10. from Ilno 15 and from iine 16,1
18, Credi" Prior Payments Discount lnlereu
----------- + ------- - ----
19, If line 16 II greo'., ,hon IIn. 17, onl" lho dlfforence on line 19, Thl. II,h, OVERPAYMENT,
miD
20, If line 171. groo'.. Ihan lino 18. ,n'.r ,ho diffo"nco on lino 20. Thl. I"ho TAX DUE.
A. Enter the interest on Iho balance due on line 20A.
IJ 4. llmllOd Ella'.
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(101__29.521.31...
( 9)
34.872.35
(II)
(12)
(131 .
(141
1151_._____x ,06 C ___h
33 .?911. 33
1,178.02
0.00
.1,178.02
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(l61______~.!l~~!.._x .15 C
Chock horo if you oro let uesting n refund of 'your ovorpaymenl.
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(171
176.70
176.70
0.00
1191 _____
(191 ____.____
176.70
1211) ___._ _ ..._.._________
120A) .._________.Q..:..Q.O______
(20BI __._.._.IJ,~_. 70__
O. En'" ,ho 'alai 01 line 20 and 20A on lino 20B. Thl. I"ho BALANCE DUE.
Make Che~k ~.vobl. 10: R_egl.le, 0' Will., Agent
, , . .OE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND TO RECHlCK MATH.... y" "",':", ,
U~d.r pII\olti.. of perlury, I dllclurf:l thol I havt; axomined thi, relurn, including orcomponying ,chodulo1 and I!olllmllnll, and 10 the bell 01 my knowledgo ~~d' b~I~~
It 1Ilrue, correct ond complele, I declare thot all rool ulole hat been roporled ot Irue markol volue, Declarotion of preporar other Iho;'! the penonal rep,,,enlotlve 1$
baled on all lnlormalion of which preparer hot any kno.....ledge,
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LAWOFFICIlS
MIRlN & .JACOnSON
HUll DURRY STRUBT
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ESTATE OF JAMES E. CLARK -
BETTY POLESHOCK, EXECUTRIX,
Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
NO. 1994-00423
ORPHANS' COURT DIVISION
ANSWER WITH NEW MATTER OP CREDITOR. BEVERLY ENTERPRISES. INC.
t/d/b/a BLUE RIDGB CONVALBSCBNT CBNTBR WEST. TQ
IXBCUTRIX'S PBTITION POR SETTLBMBNT OP SMALL BSTATB
AND NOW, comes Beverly Enterprises, Inc. t/d/b/a Blue Ridge
Convalescent Center West (IIBlue Ridge"), the primary creditor of
Decedent, James E. Clark, through its attorneys, Purcell, Krug &
Haller, and files the following Answer with New Matterl
1. Admitted.
2. Admitted.
3. Admitted. In further response, Blue Ridge Haven, as the
primary creditor of the De(Jedent, believes and therefore avers,
that the Decedent lacked sufficient capacity and/or was unduly
influenced in the award of his Power of Attorney to Petitioner,
Betty poleshock on October 16, 1987. Blue Ridge further believes
and therefore avers, that Petitioner may have abused her fiduciary
capacity as appointed Power of Attorney by converting all of
Decedent's monies into joint accounts with harself.
4. Admitted.
5. Admitted.
6. Admitted in part and denied in part. Based upon the
information provided, it is admitted that the Decedent's Estate
consists of a 1971 Ford Thunderbird, as well as the three Mellon
Bank accounts identified in Paragraph 6.
However, it is
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specifically denied that the accounts are not part of Decedent's
Estate. In further response, see Blue Ridge Haven's New Matter.
7. Denied. Blue Ridge is without sufficient knowledge or
information to form a belief as to the averment, and, therefore it
is denied.
8. Admitted in part and denied in part. It is admitted that
Blue Ridge is owed $31,372.13 as a result of its provision of care
and services to the Decedent from October 6, 1992 through November
26, 1993,
Blue Ridge is without sufficient information or
knowledge to form a belief as to the truth of the averments
regarding the other creditors and, therefore, such allegations are
denied.
9. Denied. Blue Ridge is without sufficient information to
form a belief as to the averment, therefore it is denied.
10. It is admitted that consent was sought from Blue Ridge/
however, Blue Ridge does not consent to the granting of this
Petition, based on its averments contained in the New Matter and
ita position that the accounts identified as joint should be deemed
assets of the Estate.
11. Admitted.
WHBRBPORB, Beverly Enterprises, Inc. t/d/b/a Blue Ridge Haven
Convalescent Center West, respectfully requests this Honorable
Court to decree that the Mellon Bank Accounts identified in
Paragraph 6 of the Answer are assets of the Estate of James E.
Clark, subject to distribution to all outstanding creditors.
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NBW MATTIR
12. The averments contained in Paragraphs 1 l:hrough 11 of
Blue Ridge's Answer to the Petition are :Incorporated herein by
reference.
13. On October 6, 1992, Petitioner, Betty Poleshock, signed
an Admission Agreement in her alleged capacity as Power of Attorney
for James Clark,
A true and correct copy of the Admission
Agreement and a copy of the Admission Agreement booklet are
attached her~to and marked as Exhibit "A".
14. Petitioner signed the Admission Agreement as agent for
James Clark.
15. Pursuant to the parties' Admission Agreement and
Admission Agreement booklet, an agent is defined as a "person who
manages, uses or controls funds or assets which may be legally used
to pay for the Resident's charges, or who otherwise legally acts on
behalf of the Resident... The agent's signing of this Agreement is
required for admission and signifies his or her agreement to
distribute to the facility, from the Resident's income or resour-
ces, payment when due for services rendered to the Resident".
16. In her capacity as the agent and Power of Attorney for
James Clark, Blue Ridge notified petitioner on October 6, 1992,
January 18, 1993, April 26, 1993 and May 31, 1993 that it was her
responsibility to complete an application for Medical Assistance
for subsidized nursing home coverage, otherwise, the Decedent,
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James Clark, would be billed privately for services and supplies
used during Mr. Clark's stay at the facility. Copies of letters
addressed to Petitioner are attached hereto and marked Exhibit "B",
indicating Blue Ridge's request for Petitioner to make the
application for Medical Assistance.
17. After nearly nine months of delay, on or about June 25,
1993, Petitioner formally filed an application for Medical
Assistance.
18. On or about the same date, based on the Department of
Public Welfare's finding that the Decedent jointly owned a checking
account valued at $489.00, two Certificates of Deposit valued at
$729.00 and $30,000.00, and a Money Market Account valued at
$729.00, it was determined that Decedent was not eligible for
Medical Assistance based on the Decedent's ownership of the
aforementioned assets.
19. Pursuant to the Admission Agreement, if the Decedent did
not qualify for medical assistance, he became liable directly for
payment of services rendered on behalf of Blue Ridge.
20. As indicated by Petitioner in the Admission Agreement,
all mail to the Decedent was directed to her attention, including
bills for Blue Ridge services.
21. During Decedent's lifetime and despite her receipt of the
Blue Ridge bills on behalf of Decedent, Petitioner failed to timely
remit payment,
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22. At the time of the Department of Public Welfare's
determination of Decedent's ineligibility, all of the aforemen-
tioned accounts were titled jointly in the names of James E. Clark
or Betty Poleshock.
23. Petitioner appealed the Department of Public Welfare's
initial determination, but by a Final Administrative Order issued
December 8, 1993 the June 25/ 1993 decision of the Examiner was
confirmed. A true and correct copy of the Order and Adjudication
are attached hereto as Exhibi t "c".
24. It is believed and therefore averred that Petitioner,
using her Power of At torney, transferred all of the Decedent's
monies, previously titled in his name alone, to joint accounts with
right of survivorship, listing herself as the joint owner.
25. It is believed and therefore averred that Decedent was
the only person who contributed the funds to the joint accounts.
26. It is believed and therefore averred that all interest.
income generated by the joint accounts was reported to the Internal
Revenue S~rvice under Decedent's Social Security number.
27. It is believed and therefore averred that at the time
Decedent signed the Power of Attorney to Petitioner on October 16,
1987. he was under the undue influence of Petitioner and/or lacked
the requisite capacity to sign such a document.
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ADMIS'SION AGREEMENT
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liS ADMISSION AGHEEMENT AND THE ACCOMPANYING ADMISSION AGREEMENT BOOKLET IS A LEGAl.L Y BINDINI
.1NTRACT, PLEASE READ Al.L Or: IT AND BE SURE YOU UNDERSTAND ITS TERMS BEFORE SIGNING,
, 111 Is facility accepts the following types of payment:
. :Ivate ~9 _JMedlcald
PARTIES The ~ar.tles to tI is Agrue,I~~~
a). :T/ L':::- ~'F~adlty" ) , d).
b), ( "~~ent" I . e),
'c), ("~'ent")
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, Ih s Agre~ment is slgn~d by someone otlwr than 11'0 RO$,o'onl, ploasu slala rolation~I'ip to Resident:
fhe parties me on Ih,s Co- day 01 () (f ,19 9.)., Ihat beginning on Ihe CO day
of , 199), Ihe faCility shall admit and provide the services specified herein to the Resident unlllth~
dale 01lt1e Resideni's dlscnarae and Ihallhe Res,dent or his Responslbl~ Party or Agent, n applicable, shall pay for In~
~arvlces provided b'llhe Facility pursuanllo tI,e lerms ar',d conditions set !orth in tills Agreement.
Iveteran's
Administration
( "l.egal Representative
( 'Responsible Pany' )
NOTICES
.1,11 notices shall be doomod sullicll:lntly g",on if mail co to I'd Resident and Rasponslble Pany or Agont at Ihe addleso
ndlcaled below. Ear.h s~c," person sllall b~ responsible lor notifying the Facility In writing of any change of addrp.ss In
"cdltion, Ihe Facillly lhall nOldy tile person designated b: !he Residen! 01 any signiflcanl change in Ihe Resident's
.ondlllon.
fhe Resident desigl1al~s Ino lollowing persons 10 ho nOldied of allY 5'gnlflcant Change in Ine Residenl's condil,On.
L~G,\L REPR~SENTATlVE RESPONSIBLE P,\~TY OR AGENT
Home Pt10ne
'sLf5 - Y JlCj
Slale ~
Wr;I'Y. P~,O(1tl
.:;.k ,cc:..k..-/
el Cit
~ L<...Vu.LioLd
OTHER f'EliSel TO BE NCTI;:IE,'
Zip
7 U"" '1
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"113
Home Phone
WCf'r\ Ph0r~t'
. _~re~~, Slroet
Cily
Slate
Zip
IAAIL
. he Resident authorIzes Ino facilily 10 handle lhe Resldenl'S mall as follows
o All mail given directly 10 tile Resident 0 All mail lead 10 Ihe Resident
o The Facility shall forward the Resident's mall to:
~erso~.ctkthe \?I~:~al: t~
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PHOTOGRAPH~
Ie Resident agrees 10 permllllw Facility to pholograph or videotape Ihe Resident for identilicatlon use by lI,e stall or fo'
"alth care purposes. These pllolograplls or vldeolap~s may be used to help locate the Resident In Ihe event 01
',aulhorized absence from 11111 r:acility, but shall be olherwise kepi confldonllai. The Resident agrees tllat the Facilily mn',
lolcgraph or vidoOIJpe tho llo~lCjolll 10 clocumollllhe Residents ph/slcal and medical condil'OIl at time of admissiOIl all'
Healler, The FHCll'ty "Ilall Ollldlll f1oslcJ'Jllt AulllQ1lzailoll lor u~e 01 1110 R\J!.ldenl pllOlographs c r vldootapes lor 01110r 11,<\1
'~tillcatlon or hoallll care PUIj)()!;OS,
~02 (3/91 )
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'. ~tlOWLEDGEMENT. ',', . '-. ':'.4Yi.~';':'
/~ave received and read a copy 0111\15 Agreement. the Admission Agreement Booklet and Slale . specific addendum,
" ,< II any ('Agreement') In their entirely,
I understand Ihe terms ollt\e Agreement and Ihat It Is a legally binding contract.
t'
Resident or l.egal Representative Date F IIlly Administrator or Design e
Responelble Party
Date
Witness II Resldenl Signature Is by mark
Oat.
~ Security Number (optional)
Agen /J h ..
,~ ",J-i-'--C ~ t.P-t..
Social S. urlty Number (optional)
lithe Resldenl IS unable to sign bec3Use of legallncompelence or his or her medical condllion, the admlltlng ptlyslclan
shall doc.umenllhe reason in Ihe f1esldent's medical record,
Wllness II Resident Signature Is by lTIark
Dal, '
Date
ACKNOWLEDGEMENT OF RECEIPT OF ADMISSIONS MATERIALS
I, -40f)1/ I () (1 ~ n ,I k.J , acknowledge that I have received Ihe lollowlnlllnformallon at or
Nal11a~R.sld.f\1 )
before admission 10 fl)f.(Cl
Nama 01 Facillly
Check here ( If not applicable, write N/A )
V- 1, If Medicaid eligible, a list 01 Items and services Included In the facility's services under the
Slale Medicaid plan, as well as Ihose lIems or services lor which a Resident may be charged and
tile amounl 01 ct18rges for IIlose Ilem& or services,
.......... 2, II private payor Medicare eligible, a list 01 lIems and services available In Ihe Facility and Ill!
charges lor Ihose services, Including the charges lor sONlces not covered under Medicare or by thl
Faclllly's per diem rale,
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3. A description of the way personallunds are managed.
......
4. A statement thai the Resident may Ille a complaint with the Slate survey and certiflcalion agenc;
concerning residenl abuse, neglect and mlsapproprlallon of resident property In the Facility,
5, The name, specially and way 01 contacllng Ihe phYSician responsible lor my care,
\../
l......
6. A written explanalion of how to apply lor and use Medicare and Medicaid benefits and how te
receive refund~ lor previous payments covered by such beneflls,
(~ 7, A copy of the Federal & Stale Resident Rights,
I have been Informed orally and In writing, In a language Illnderstand, of my righls and the rules and regulalions governing
:ny conduct and responsibilities during my stay althe Facillly,
'-Iesldenl or Legal Represent,lIlve
Date
'nsponslble Party
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BUSINESS OFFICE REVIEW (Sections VI . XI)
VI. AGENT .J,f.GA1, REPll!;~:::N1A-TIVE 08..fH;_SPONSIBLE PARTY
A, AGENT
For the purposes of this Agreement, an AgfJntls defined as a person who manages, uses or controls fUi
or assets which mclY IJe legully used to pay for the Resident's charges, or who otherwise legally acts
behalf of the Resident. The Agent's flnunclol obligations are limited to the amount of the funds recelve(
held by the Agent for the Resident, as the Agent does not assume responsibility for payment out of hlf
her personal funds. THE AGENT'S SIGNING OF THIS AGREEMENT IS REQUIRED FOR ADMISSI
AND SIGNIFIES HIS OR HER AGREEMENT TO DISTRIBUTE TO THE FACILITY, FROM 1
RESIDENT'S INCOME OR RESOURCES. PAYMENT WHEN DUE rOR SERVICES RENDERED TO 1
RESIDENT. It Is understood that If the Reslden\ has an Agent and not a Responsible Party, the Agent s
be required to procluce financial documentation to substantiate the Resident's ability to pay lor whate
oharges will be due for serVices rendered to the Resident.
B. LEGAL REPRESENTATIVE
For the purposes of this Agreement, a Legal Representative Is defined as an Individual who has b
appointed by a court of competent jurisdiction to manage the Resident and/or his or her financial affair
Legal Representative must present to the Facility a copy of the court document which verifies his or
status as a Legal Representative, The rlgl1ts and obligations of the Legal Representative are limite,
those rights and obligations II1dicoted by the court documents. A Legal Representative may serve a!
Agent or a Responsible Party to the Resident in fulfilling payment obligations to the Facility for cha'
Incurred by or on behalf of the Resident. At admission, the Legal Representative should Indicate If h
she Is also serving as a Responsible Party 01 Agent for the Resident.
C, BE.&ONSI8LEl'~[')TY
For purposes of thiS Agreement, a Responsible Party is defined as a person who agrees to be finane
responsible for the charges Incurred by the Resident under this Agreement. By agreeing to becon
Responsible Party, a Responsible Party becomes jolntiy and severally liable for all payments owed te
Facility by the Resident. This means that both the Resident and the Responsible Party are obligated te'
all the charges If the other does not.
The ReSident and ResponsllJle Party understand that even if the Resident's stay at the Facility IS CO\
by any Insurance, it is the Joint and several obligation of the Resident and Responsible Party to pI
charges incurred by or on behalf cf the Resident and to satisfy any coinsurance 0' deductible oblige
under Medicare, Medicaid or any private insurance.
THE SIGNATURE OF A RESPONSIBLE PARTY IS NOT REQUIRED AS A CONDITION OF ADMISSI
Regardless of payment sources or responsibility of payment. at least one person should be identifl'
admission by the Resident as the primary contact for the Facility regarding the Resident. The name,
Individual who will serve as the primary contact should be entered Into Section II of this Agreement.
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BUSINESS OFf,ICe. RE'VIEW (8eotlonl VI ' XI)
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1/11. PERSONAL FUNDS
The Resident t1as a right to manage his/her own personal funds, However. the Facility will, at the written
request of the Resident, hold, safeguard, manage and account for the personal funds of the Resident
deposited with the Facility as follows:
1, For funds in excei'1s of Fifty Dollars ($50,00), the Facility will deposit funds in an Interest bearing account
that is separate from any of the Facility's operating accounts, and that credits all interest earned on the
Resident's account to his N her account.
2. For funds less than Fifty Dollars ($50,00), the Facility will maintain a non.lnterest bearing account or
petty cash fund,
3, The Facility will maintain a system that assures a complete and separate accounting. according to
generally accepted accounting principles, of each resident's personal funds entrusted to the Facility on
the Resident's behalf, The system will preclude any commingling of a Resident's funds with funde of
the Facility or with funds of anyone other than another Resident, The individual financial records will be
available upon written request of the Resident or the Resident's Legal Representative,
4, For the Residents who receive Medicaid benefits, the Facility will notify any resident when the amount
In the Resident's account reaches Two Hundred Dollars ($200,00) less than the Supplemental Security
Income (SSI) limit for one person as determined by Federal law, Further, the Facility will notify the
Resident that if the amount m the accolmt, in addition to the value of the Resident's non.exempt
resources, reaches the 581 resource limit for one parson, the Resident may lose eligibility for Medioald
or SS!.
5, In the event of the death of a Resident with personal funds deposited with the Facility, the Facility will
promptly refund the Resident's funds and give a full accounting of those funds to the Individual
administering the ReSident's estate,
6, The Facility will assure the security of all personal funds deposited with the Facility and will not Impose
a charge against personal fu nds for any item or service for which payment Is made under Medicare or
Medicaid,
II. FINANCIAL ARRANGEM~NIQ
A. PRIVATE RATE
1, Dallv Rate, The Facillly's private pay daily rate Is determined In part by the type of room assigned to the
Resident and, therefore, may be changed if the Resident is transferred to a different room, Thfl
Resident and the Responsible Party agree to pay a sum equal to one month's private pay dally rate in
advance and thereilftor pay for each slIccessive month's stay in advance on or before the tenth (10th)
day of the month, Any unused advance payment shall be refunded if the Resident converts to Medlcairl
coverage or leaves the Facility prior to the end of the first month,
2, Rate Adlustment. The Facility may find it necessary, due to inflation or other factors, to Increase the
daily rate or optional service charges from time to time, The Resident shall receive written notice of all
such rate adjustments, If at any time the Resident's condition requires the Facility to make a chango In
the level of care, thE! Resident's daily rate may be changed without prior notice to the dally rate of the
new level of care.
At eaoh notification of a rate adjustment, the Resident may elect to terminate this Agreement. Any rate
Increase shall be deemed agreed to by both Resident and Responsible Party or Agent upon the mailing
of said notice unless the Facility Is notified in writing to the contrary within ten (10) days of the mailing.
If the Resident and the Responsible Party or Agent do not agree to the rate increase, the Resident
agrees to leave the f;jcility no later than the day before the rote inorease becomes effective, If the
Resident fails to so vacate the Facility, the Resident and the Responsible Party or Agent shall be
deemed to have consented to the rate increase,
O? (5/92)
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BUSINESS OFFICE flEVIEW (Stotlonl VI . XI)
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3, Extra Services and _~\mplles, Tt1e Resident and Responsible Party or Agent shall be responsl,ble I
payment of nil charges of the Facility for supplies or services which are not included In the Facility s dE
rate,
;3, ,MEDICAID/MEDICARE
THE FACILITY DOES NOT MAKE ANY ASSURANCE OF ANY KIND THAT THE RESIDENT'S CARE WIl.L I
COVERED BY MEDICARE, MEDICAID OR ANY THIRD PARTY INSURANCE OR OTHER REIMBURSEMEI
SOURCES, ThE' Facility shall prOVide information on how to apply for and use Medicare and Medicaid benel
The underslgJHlll, however, relenses the Facility, Its Agents, servants, and employees from any liability
responSibility In connection with 1110 uncleHslgned's potential claim for or any lallure to obtain such coverap
The Facility muy requiro a pre.payment of one month's estimated share of cost, pending a determination
eligibility, for a Resident who has applied for Medicaid but has not yet received confirmation of his or I
eligibility at the time of admission. The estimated share 01 cost Is due monthly In advance on or before I
tenth (10th) day of the, month until MedicAid eligibility is grAnted, at which time adjustment will be madE
accordance with the aellml share of cost determined by the Medicaid Program, 11 Medicaid eligibility Is deni,
adjustment will be madtl In accordance Will) ttlG Facility's fllll daily private rate,
C. MEDICAID RESIDENTS
1, Dallv Rate Pavmen!. A list 01 the supplies and services provided fpr payment made under the Medic
program Is provided 10 the ReslClent on admiSSion. A list of the supplies and services requested or requi'
by the Resielent, wllieh are not covered by Medicaid and for which payment Is the responsibility of
Resident and Responsible Party or Agent, is also provided to Ihe Resident on admission,
2. Termination of Qov.!lraQe, The Resident may remain In the Facility only so long as certified eligible
Medicaid payments, or as long as any charges owed by the Resident are paid as due, Residents v
remain beyond the expiration of their Medicaid coverage, or who have their coverage retroacti\'
terminated ()( denied, shall be obligated to pay their account as private paying residents with rates i
charges for services rE!ndered at the regular rates and terms in effect at the time of the service,
3, Residel1t'~ Sl1ure oU~Q.~j, The Medicaid Program determines the available monthly Income of all pers'
receiving Medicaid assistance and, with respect to most Medicaid beneficiaries, requires that out of 1
Income the beneficiary must bear a reasonable share 01 cost, Payment of that share Is the responsiblllt,
the Resident. Responsible Party or Agent. The Resident's share of cost Is subject to change as authori
by law. If the Resident fails to make prompt payment of his or her share of cost, where appropriate,
Facility may rl:'quire direct mailing of such monies to the Facility, Such monies will be managed by
Facllliy in accordance with legal requirements, The Resident acknowledges that failure to pay
Resident's sham of cost may constitute grounds for discharge of the Resident and the Facility will notify
appropriate State or Federal agency of such non-payment,
D. MEDICARE RES1DE~JS
1, Dallv Rat~JJEjYill~I\t. A list of the services provided for payment made under the Medicare Program
those services which are not covered by Medicare, includll1g 111e daily coinsurance rates, is provided te
Resident on admission
2, L1mltM.., Coyeraq~, The Resident, Responsible Party and Agent understand that Medicare coverag
established by Federal guidelines and not by the Facility, Medicare coverage is limited both as to the lev,
care covered and tile duration of coverage, Thus, based upon Medicare criteria, Medicare coverage ma
termlnatecl prior to Il1e use of all allotted days If tho Resident ceases to meet such criteria,
'IF. 202 (5/92)
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BUSINESS OFFICE flEVII;!W (Seotlon. VI . XI)
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\, Expiration of B(Jng1l!.~, EVidence that the Resident Is able to pay for the services rendered In the Facility
upon expiration of the Resident's Medicare benefits, as either a private pay Resident or otherwise, must be
provided by the Resident prior to admission to the Facility In order to ensure the ability of the Facility to
retain the ReRldent after the expiration of Medicare benefits, If Ills the Resident's, Responsible Party's or
Agent's Intent that the Resident be dlsclwglJd from thu Facility on termination of Medicare benefits, he or
she must advise the Facility In writing at the lime of Ihe Resident's admission,
If the Resident will become Medicaid eligible when Medicare coverage stops or when private pay funds are
depleted, the Resident, Responsible Party or Agent IS responsible for making a timely and complete
application for Medicaid benefits, Where permitted by State law, the Facility will assist with the application
process when requested to do so. Tho Resident and Responslbie Party or Agent Is responsible for
periodically checking with the appropriate State agency to seek and receive informallon on Ihe status of the
Resident's MedlcRld application. In addition, the Resldont and Responsible Party or Agent give the Pacility
permission to seek <1nel IOCUlve l11Io,nl1ll10n on tile status of the Medic8id eligibility application from the
appropriate State agency.
If the Resident will convert to private pay status upon expiration of Medicare benefits, the Resident,
Responsible Party or Agent agree to pay the Facility's private pay dally rate for one month In advance upon
the Resident changing to private pay statLls, No payment in advance is required with respect to residents
who convert from Medicare to Medicaid coverage,
I'I.MEL Y OBLIGATION TOE'AY~N[)_Q1J.lJ)},J:r;
;he Resident's account for services rendered by the Facility shall be billed monthly to the Resident and
: lesponslble Party or Agent,
.\i1ls for services rendered to Resident by the Facility which are not paid by the tenth (10th) day 01 each month
fjail be past due or delinquent. When payment for services is not made by the tenth (10th) day or every billing
"onth, the Resident's account may be assessed a delinquency charge at the monthly rate of one and one-half
.,ercent (1-1/2%) (or the maximum amount permitted by law) of the outstanding balance, The Resident
'cknowledges that the delinquency charge does not alter any obligations of elthEJr the Facility or the Resident
'.'nd Responsible Paity or Agent under this Agreement. The Resident and Responsible Party or Agent
'oknowledge that the Facility does not grant credit or ailow Instailment payments, and the Facility's
. coeptance of a partial payment sllall not limit the Facility's rights under this Agreement.
.AILURE TO PAY
.fthe Resident, Responsible Party or Agent fails to make a required payment within fifteen (15) days of the due
'ate, the Facility may require the Resident to vacate the Facility, A reasonable period not to exceed thirty (30)
'ays from the date of receipt of the notice of failure to pay shall be allowed for the Resident and Responsible
'arty or Agent to make arrangements for the Resident vacating the Facility, The notice shall be deemed
1ceived eilher on the actual clay of receipt or five (5) days after mailing, whichever occurs first. The Resident
nd Responsible Party or Agent agree that the Resident shall vacate the Facility on the date specified by the
:aclllty under this section The Resident and Responsible Party or Agent shall be responsible for ail relocation
xpenses, in addition to all charges due to the Facility for all days of care received,
NSURANCE COVERAG~
. '1here the Resident's care at the Facility IS covered by Insurance or some other third party payer coverage, the
. 'esldent and Responsiblfl Parly or Agent shall noneth(jiess be primarily responsible for making payment
: ursuant to this Agreement regardless of such third party payer coverage, and shali be responsible for paying
. II oharges not paid by any third party payer, Including any coinsurance or deductible amounts required by any
',Ird party payer.
'016/92)
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BUSINES~ OFFICE REVIEW (Slotlons VI . XI)
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H, FEE FOR RETUR_NEI;LCHE~KS
A service lee as setlorth In the Facllily Credit Policy Statement shall be charged for any returned chI
IX. TERMINAT[QN OF AGR~EMENT
A, RIGHT TO TERMINATE
No Resident may be transferred or evicted from the Facility solely as a result of the Resident changln<
or her manner of purchasin~1 services from private payment or Medicare to Medicaid,
A Resident may elect to leave the FacllllY at any time, Should the Resident leave the Facility belorl
attending physician discharges the Resident, the Resident agrees to assume all responsibility for all reo
which may follow,
S, REFUN.Q
If the ReSident is disclHHged before using Lip tho entirety of any prepaid charges, a refund of the unl
portion of such chnryes sllall be made within a reasonable period of time, Resident funds which
required by law to be held by the Facility In a demand trust account shall be refunded promptly afte,
Resident's date of discharge,
C, PROPERJY..OF RE~QEtITJ)PON TERMINATION
The Facility shall attempt to safegLlnrd the Resident's personal belongings remaining at the Facility ·
discharge, but shall not be liable for any damage or loss to the Resident's property and may dispose 01
belongings left by the Resident If not claimed within thirty (30) days of discharge or transfer,
X. BED.HOLDS
The Resident and his ResponSible Party or Agent may request the Facility to hold open the Residclnt's
and room while the Resident IS absenl from the Facility for therapeutic leave or temporary stays In an (.
care hospital. However, except as provided below, the Facility shall have no obligation to hold oper
Resident's bed unless the Facility agrees to do so In writing,
If the Resident's care IS being reimbursed by Meclicaid and the Resident is transferred to an acute
hospital or 13 absent due to a therapeutic leave, the Facility shall offer the Resident a bed.hold for the nUl
of days, If any, requlled under State law, which may be exercised by the Resident or the Resid.
Responsible Party or Agent. If Mecllcald coverAge for a bed.hold does not exist, the Resident may be obliQ
to pay the Facility's private pay daily rate lor each day of the bed. hold that Is requested, If the Resid,
attending physician notifies the Facility in writing that the Resident's treatment at an acute care hospitf
exceed the number of days, if any, required for the bed to be held by State iaw. the Resident may be obli~
to pay the Facility's private pay clally rate for each day of the bed,hold that Is reque~ted that exceeds thai
by Medicaid, A Medicaid Reslclent will only be readmitted after a hospitalization or therapeutic ieav(
exceeds the number of days patd for by Medicaid if a Medicaid bed is available, and the Resident requirl
services provided by the Facility and contll1L1es \0 be eligible for Medicaid.
A private payor Medicare ReSident may request a bed.hold from the Facility, Any private payor Medl
Resident who requests a bed. hold ShAll pay the Facility's private dally rate for the period of the bed-hol
Resident's private insurance lIIay or Illay not cover the cost of a bed.hold, The Medicare program doe:
reimburse for ued.holtls
In order to ollect a beel.lwld, Illl' l~e~;ldent ur the ReSident's ResponSible Party or Agent must notif\
Facility withll1 twenty.fuur (24) Ilours of receipt of notice from the Faclllly concerning the discharge I
whether the ReSident wlslles to exercise his or her right to a bed.hold, The Facility is not required to of
bed-hold if tile Resltlent requlI os a lev'3l of care different from that previously received by the Reside'
greater than tllat abln 10 be plovlded by Ille Facility. In the event tile Facility Is unable to accommodat(
Residant's n8l1ds, tile Fac,lity shall offer the next available appropriate bed to the Resident,
,~ 202 (5/92)
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BUSINESS OFF,ICE f,lEYIEW (Slctlon. VI . XI)
I"", 'I
II, the Resident is transferred from the Facility and does not requeet 11 bed-hold or wlehes to return to the
Facility after the expiration 01 a requested bed.hold, the Facility ehall .have no obligation to readmit the
Resident except as provided above,
:.1, gMFORCEM.ENT
A. ~I.E AGREEMENT
This Agreement, along with any documents whloh are attached herein or Inoorporated herein by relerenoe,
Is the entirety of the agreement between the Faolllty and the parties. Changes to this Agreement shall be
valid only If they are set forth in writing and signed by the parties, Should ohanges In Federal or State law
render any part of this Agreement Invalid, the remainder of the terms shall stand as a valid agreement.
So mORNEY'S FEES
II a legal action Is commenced by any party to this Agreement, including any disputes arising from this
Agreement, the prevailing party shall be entitled to recover his or her reasonable costs, Including
reasonable attorneys' fees, Incurred In defending or prosecuting suoh action,
C,.AGREEMENT NOT ASSIGNABLE
The Resident and/or the Responsible Party or Agent aoknowledge that the right 01 the Resident to reside at
the Faolllty Is personal and Is not assignable, The Resident may not transler his or her rights under thlE
Agreement to any other person,
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SOCIAL SERVICES REVIEW (Sections XII . XVII)
XII. ~ONDISC[=\IMINATIOt:l
The Facility welcomes all persons in need of Its services and does not dlsorlmlnate on the basis of agf
handicap, race, color, national origll1, ancestry, religion or sox, While the Facility must receive paymel
for Its services, the Facility does not discriminate among persons based on the source of that payment
'<III. SERV.lQES
A, NURSING SERVIQ!;Q
The Facility ohall provide general nursing care and room and board and other related services ,
specified In the list of items & services provided to the Resident on admission,
If the Facility is certified by IIle Medicare or Medicaid programs. the Facility shall provide beneflclari
with all sorvices roqu,red to IJO provldod by State and/or Federal law. Lists of the services and Itel
covered by Medlcalcl in this Slate, optional Items and services and the extra costs of those servlc,
Medicare coverocl Hill! 1l01l,,,ovorell sorvicos, and 1I)f) costs of Medicare non-covered services are a
provided to the Rosident 011 admiSSion,
B. PHYSICLI1N SERVICES
The Resident acknowiedges that he or she is under the medical care 01 a personal attending physic
and that Ihe Facility renders services under the general and specifiC Instructions 01 said physician,
signing this Agreement the Resident consents to the Facility providing such routine nursing and 01
health carll services as may be directed by the attending physician.
The Resident has a right to select his or her own attending physician; however, If the Resident does
select an attending physician or IS unable to select an attending physician, an attending physician ma
designated by the Facility,
The Resident agrees that the Facility may require tile use of an alternate licensed physician il
attending physician is barred from practice in the Facility dlle to violations 01 the Facility's rules
regulations or by order of State or Federal regulators, or if any emergency requires an immel
response to the Resident's medical needs,
The Resident and Responsible Party or Agent recognize and agree that all physicians, jr,ch
physicians arran\jfld for by the Facility, who are providing services to the Resident, are indepel
contractors and are not employees or agents of the Facility and that the Faclllty's liability lor a<
omissions of the physician IS limited because tl1e physician Is an independent contractor. The Ref
and Responsibie Party or Agent shall be solely responsible for payment of all charges 01 any phy!
who renders cara to the Resident while in the Facility,
C, RIGHT TO REFU.~U!3_~6.TMENl
Residents have tl1e rl(JllI to refuse treatment to the extent permitted ~ la~ and to be informed
medical consoquences 01 such rolusai. Where, in the professional judgment of the Facility, the Re
Is not mentally competent to make a deCision regarding refusal of treatment, the Facility may requlI
an order Irom a court 01 competent Jurisdiction be obtained before it wlli withhold necessary rr
treatment,
0, PERSQt)lAL r>.BQ.PERTY
The Resident anclnot tl10 FaCility shall be responsibie for the prOVISion of certain personai comfort
Clothing and petty casl1 for the Resident's incidental expenses, AIi clothing and other personal iterr,
be clearly marked to indicate that the Resident Is the owner,
!IE 202 (5/92\ -8-
, ,.,'
SOCIAL SERVices Review (Section, XII . XVII)
'fII/t& ' '.
The Facility strongly discourages the keeping of valuflble jewelry, papers, large sums of money or other
items considered of value in the Faciiity, The Facility shall make reasonable efforts to safeguard the
l1esldent's property and valuables that are 111 possession of the Resident. However. the Resident and
Responsible Party or Agent aclmowlodge that the Facility may most effectively safeguard the personal
property of the Resident only if the Faciiity has possession of and control over such property, Therefore,
the Resident agrees to store all valuable personal property In the Faclllty's safe or other secured storage
area as Facility may provide,
t:_SIDENT'S RECORDS
CONFIDENTIALITY
Information contained In the Resident's medical records Is confldentl(ll and disclosure to unauthorized
persons shall not be made without the Resident's (or his or her Legal Representatlva's) written consent,
excapt as roquired or permitted by law,
1. CONSENT TO DISCLOSURE BY FACILITY
The Resident authorizes the Facility to disclose all or any part of the Resident's medical or financial
records to (lny person or entity which has or may have a legal or contractual obligation to pay all or a
portion of the costs of care provided to Resident, including but not limited to hospital or medical services
companies, Insurance companies, workers' compensation carriers, welfare funds or the Resident's
employer, The Resident also authOrIZes release of information from medical or financial records when the
Resident is transferred from the Facility to any medical professional or Institution which assumes
responsibility for the medical or nursing care of the ReSident.
THE RESIDENT'S DUTIES
A. RULES AND REGULATiONS
The Resident agrees that the Facility may. to maintain orderly and economical operations, adopt
reasonable rules find regulations to govern the conduct and rElsponsibilltles of the Resident, The Resident
agrees to follow those rules and regulations and hereby acknowledges nlat he or she has been given a
written copy of such rules or regulations, It is understood that the rules and regulations may be amended
from time to time as the medical care ana/or orderly operation of the Facility require, but any changes
shall be provided to the Resident in Writing before taking effect.
There Is a Facility procedure for suggesting changes in the rules and a Facility grievance procedure for
resolution of Resident complaints about FaCility practices, Copies of these procedures shall be available
from the administrator and posted in the Facility, ReSidents are urged to bring any grievances concerning
the Facility to the attention of the Facility administrator, The Facility also offers a toll.free "hotiine"
telephone number where complaints may be made dlrectiy to Faclllty'S corporate offices, This number Is
1.800/572.9981. Residents also have the right to contact the State facility licensing agency or the
long,term care ombudsman, or both, regarding grievances against the Facility,
B. DIEI
The Resident understands that the diet of the Facility's residents Is medically prescribed and, therefore,
must be monitored by the Facility. The Resident, therefore, agrees that he or she shall not bring any food
or beverages into the Facility without permission from the administrator.
C, ~EDICATIQNS
No medications or drugs may be brought Llpon the Facility's premises unless the medications or drugs are
labeled aocording to the requirements of State and Federal law. Packaging of medications must be
compatible with the Facility's medication distribution system, No drugs or medications may be brought to
the Facility unless they are delivered to the nurse's station,
_0..
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SOCIAL SERVICES RI'VIEW (Seotlonl XII . XVII)
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The Facility shall not reqUire residents to purchase dnlgs, or rent or purchase medical supplies
equipment. tram any particular pharmacy or other source, However, nothing In this paragraph oh
prevent the Facility from requiring the Resident's pharmacy or other source to comply with the Faclllt'
policies and procedures and any legal requirements,
D. pARE OF FACILlTY'S_PR_9EERT\
In order to preserve the value of the Facility's property for future residents' use. the Resident agree~
use due care to avoid damaging the Facility's property and premises, Pictures. posters or ott, ,
ornaments may be hung on walls, and furniture may be rearranged In the Resident's room only with tl I
consent of the administration of the Facility, The Resident shall be responsible for repair or replace mE .
of the Facility's property damaged or destroyed by the Resident, However, the Resident will not I
responsible for such damage as Is to be expected from ordinary wear and tear,
XVI, TRANSFERS OR DISCtlARGE$.
The Facility shell provide notice to the Resident and, If known, a family member or Legal Representatl
of the Resident, of the transfer or discharge, and the reasons for It. at least thirty (30) days before 1 I
Reoldent Is transferred or discharged, However, where the safety or health of the Resident or 011
Individuals In the Facility may be endangered, or other legal reasons exist, notice ma~' be made as Be
as practicable before transfer or discharge,
The Facility will only transle, or discharge a Resident under the following conditions:
1, The transfer or discharge is necessary for the Resldent's welfare and the Resident's needs cannot
met In the Facility;
2, The transfer or discharge is appropriate because the Resident's health has Improved sufficiently
the Resident no longer needs the services provided by the Facility;
3. The safety of individuals In the Facility is endangered;
4, The health of individuals in the Facility would otherwise be endangered;
5, The Resident has failed, after reasonable and appropriate notice, to pay tor (or to have paid un
Medicare or Medicaid) a stay at the Facility;
6. The Facility ceases to operate or ceases to participate In a program which Is providing payment for
Resident's care,
XVII. VISITORS
Residents can consent to have visitors at any reasonable hour, If any of the Resident's guests fall to a
by the Facility's rules for visitors, the Resident and the Responsible Party or Agent agree, upon the Fac!1
request, to arrange for the prompt removal of such visitors from the Facility,
~~ 202 (6/92)
-10-
ATTACHMP:NT'A"~. Page 1 of 2
RESIDENT RIGHTS
(Federal Law)
, Facility will protect and promote the rights of each Resident Including each of the following rights:
.
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The Resident has a right to a dignified eXistence, self.determll1ation, and communication with, and access
to, persons and eervlces inside and outside the FaCility.
The Ratlldent has a right to exercise his or her rights as a Resldsnt of the Facility and as a citizen or resident
of the United States,
The Resident has the right to be free of interference, coercion, discrimination, or reprisal from the Facility in
exercising hi" or her rights,
The Reeldent has the right to be fully Informed, in a language he or she can understand, of his or her total
health status Including, but not limited to, his or her medical condition. .
The Resident has the right to refuse treatment and to refuse to participate in experimental research,
The Resident has a right to exercise his or her legal rights, including filing a complaint with the State survey
and certifl\)atlon agency concerning Resident abuse, neglecl, and misappropriation of Resident property in
the Facility,
The Resident has the right to manage his or her financial affairs,
The Resident has a right to choose an attending physician,
Ths Resident has a right to be fully II1formed in advance about care and treatment and any changes In that
care or treatment that may affect the Resident's well,being,
The Resident has a right to participate In planning his or her care and treatment or changes In care and
treatment unless adjudged incompetent or otherwsie found to be incapaCitated under the laws of the State.
The Resident has the right to personal privacy and confidentiality of hi3 cr her personal and clinical rElcords,
fhe Resident has the right to inspect and purchase photocopies of all records pertaining to the Resident
upon written request and 48 hours written notice (excluding holidays and weekends) to the Facility, .
The Resident may approve or refuse the release of personal and clinical records to any individual outside the
Facility except when:
1, The Resident is transferred to another health care Institution,
b, Record release is required by law or a third party payment contract,
The Resident has a right to voice grievances with respect to treatment or care that falls to be furnished
without discrimination or reprisal for voicing grievances,
The Resident has a right to prompt efforts by the Facility to resolve grievances, including those with respect
to the behavior of other Residents,
The Resident has a right to examine the results of the most recent survey of the Facility conducted by
Federal or State surveyors and any plan of correction in effect with respect to the Facility,
The Resident has a rigtlllo receive Information from agencies actll1g as client advocates and be afforded the
"oportunity to contact these agencies,
. Federal law was amended by OBRA '90 to include the right of the Resident to access to current clinical
recorda of the Resident upon requast by the Resident or the Resident's Legal Representative, within 24
I')urs (excluding weekends or holidays) afte: rnaking such a request.
(5192) _, , _
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. ATTACHMj:N.T,A/,u Page ~ of 2
I '" .
. '7, The Resident has a right to refuse to perform services for the Facility,
The Rosldent has a right 10 ngre!! to perform voluntary or paid services tor this Facility If he or she desires,
there Is no medical reason which would contradict the performing of services. and compensation for paid
servloes Is at or above prevniling rates,
'. '.
The Resident has the right to privacy In written communications. Including the right to send and reoelve mall
promptly that Is unopened, The Resident has a rlghl of nccess to stationery, postage and writing Implements
at the Resident's own expense.
The Resident has tile rlghlto immecllate access to any of the following:
a, Any representative of tho Secretmy of ttlO Uniled StntEls Department of Health and Human Services,
b. Any representative of Ihe Slate
0, The Resident's Il1cJivldual phYSICian,
d, The State's long term care ombudsman,
e, The agency responSible for the protection and advocacy system for mentally III or developmentally
disabled Individuals,
f. Subjeot to the Resident's right to deny or withdraw oonsent at any time, Immediate family or other
relatives of the Resident or othAIS who are VIsiting with the oonsent of the Resident.
The Facility must prOVidE' reasonable access to any Resident by an entity or Individual that provides health,
soolal, legal or other services to the ReSident. subject to the Resident's right to deny or withdraw oonsent at
any time,
The Resident has a right to have regular aocess to the private use of a telephone.
The Resident has a right to retall1 and use personal possessions, Including some furnishings and
appropriate clothing, as space permits, unless to do so would Infringe on the rights or health and safety of
other Residents,
" The Resident hfls the right to share a room With his or her spouse when married Residents live in the same
Faollity and both spouses consent to the arrangement.
Eaoh Resident has a rlgllt to self.,tclllllnister drugs unless the Facility interdisciplinary team has determined
for a particular Resident that this practioe IS unsafe,
The Resident 11as a rlghl to be tree from ilny ptlyslcal re~trarnts imposed or psychoactive drugs administered
for the purposes of diSCiPline or convenience, and not required to treat the Resident's medical symptoms,
The Resident has the rr9tH to be free from verbal, sexual, physical or mental abuse, corporal punishment
and Involuntary seclusion.
The Resident has a right 10 choose actiVities schedules and health care consistent with his or her Interests,
assessments, and plans of care,
ihe Resident has a right to receive advance notice of transfers or discharges of the Resident as required by
law. The Resident has a rlgtH to recelvo notice before the Resident's room or roommate Is ohanged,
The Res/dent has a right to organize and participate In Resident groups In the Facility, and the Resident's
family ha~ the rrght to meet With families of other Residents,
The Resident has the rrght to partiCipate in social, religious and community aotlvltles that do not Interfere
with the rights of other Residents,
The Resident has a right to reasonable accommodation of inrJlvldual needs and preferences exoept where
the health or safety of the ReSident or other Residents would be endangered.
The Resident has a right to freedom of chOice of providers in accordance with applicable law and subject to
the prOVider's compliance With all applloable laws and reasonable rules and regulations 01 the Faolllty.
,"2 (6/92) -12-
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DATE. January 18, 1993
~lrs. Detty poleshock
413 Rutr.erford Read
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!:~7]:r.~^:t1 Z~
Harrisburg, PA 17109
REI Ji\:lES CU'\PJ(
96411
Dear Mrs. poleshock:
On Octol::er 9 ,J. Clark was admitted to our facility. Based
on the information provided at the time of admission, it was determined that
Medical Assistance (MA) coverage might be needed to assist with the costs of
Nursing Home carp.. At that time, we classified J. Clark as Pendint; !!A.
The actual MA Determination ia completed hy Cumherland County Board of
Assistance (CCaA) office.
An applicntion for Medical Assistance must be completed immediately and retu~ed
to our Business Office (Attention, T. Arnold). The application will then bp.
fot"'.;a~ded to COM for review. ceDA will then infot"":l you when your financial
revieW appcint,ment with the CCllA Casel/orker will be scheduled. YO\l Dl"S~ attend
th:la apPl,intment - only after this appointment can the MA Dctermiuati'Hl hI!
~de io:: Nursi~g Horlo coverago,
U MA":rursin~ heme coverage is not approved). yo~ will' he billed printely for
aL eer'lic\,s end "-t:i'plieu used during J. l,;1a=;, 's stay at our facj,l:l:].
T1\ege servir,os and BUl'plies iuc1udo!, but are not limited to, RoC1:l and Scard
(~97 pet' d,lY for Sk111~d rOOlUS I $87 per day for 10;;- rooms), medical sUPi'lies.
phsnt!!cy, therapifls, erc, In the event Medicare Part A can be billed, you
are still responsible for the coinsurance amount. (1993 coinsur:mca rate
is $34.50 per day from the 21st thru the 100th day of Medicare coverng~./
If MA-Nursing Home coverage is approved, CCBA will determine how much per
month you will be responsible to pay towards the coat of J. Clark's care.
This amount is referred to as the "PRIVATE PORTION". Until CCM has mado!
their determination, we have estimated your PRIVATE PORTION at $ _500. ~, pe::
month. This amount do~s not include items such as Beauty/Darber Shop, Cable
Services, Personal Laundry service, etc. The current month's PRIVArl PORTION
amount, as well as anyadditonal item 'charges , is due by the tenth (10th) of
each month. (You will \~eceive a monthly statement around the 25th of each
month:) Payments not received by the tenth (lOth) of each mooth are considered
past due. (NOTE: Continual late payment a or no payments will result in
discharge of the resident.)
If you have any questions or concerns regarding thi~ matter, ptease feel free
to contact me at 717-763-1070 extension 218,
SincerelY'1\ ~
'- . \ '
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Tina Arnold
Assistant OfficeB~lJii<1llill'GE HAVEN CONVALf.i.SCENT CENTER WEST
770 Poplar Church Roa~l1fp.!f.ut PA 17011.717763,7070
r/?~~ ;:'''~'_''''''_M~_'_'; ". :.'.-... ""'-~-'~"--'-~.,..,l~(,~~.. ~",:!"'-'~'"" ,.t '~''1:'"''7'' ""1
'7)( I;J ~ Cn t . com~tl~i1fm. 1 ond/or 2 fOl .ddlllonol..;"",. " ;}~}i~" I' .1.0 WI.h to i.cirv~i\ih~" I
e . ComP"1fIt.m. 3, 'od 4. · b, " following Ie,vlco. 'lfo, on lilll. j' !
- . Print yoUt n.m. and '0'0'"" on thl ,tv".. 0' thli fOfm 10 lh~t' w~ c."
tttvm Ih'. oud 10 you, fee):. .' :
I . Allleh IN. 'olm 10 the ',ont 0' thl m.lfpl.ct, or on tho back I' 'Plct 1, 0 AddrelSue'. Add"..
40fl nol perml,.
~ . Wrlll "RIM" R.ellpl "l<luIII.d" on Ih.m'ilpJ,c. b..low lht .nlelt numbe, AOlllrloted Delivorv .i
e . The RIM" A.cllpt wUl.how to wllom th, .rllcll WI. d.livtt.d .nd lh, 0"11 B
o d.lIvtlld. Conluh oltmali.or for fee. ~
~ mtsoAdd'B'trr'l PO/.lSNex: 4., 1I'I'b~
f Uo /J 0.... 4b, 5",1,. Typo ~ ~ 55 i
l:l (/..;) 1'\ /.JTHF:l. Fo~ II...D 0 R.gl,'.,od Oln.u,od a:
~ /lA,Rt IS 8 tJ I!. 6 fA 17 IIJ~ ~~:;:~~:d Moll g ~~ern R co/plio, J
~ _ 7. 0"0 ~,y \' i
}Irs, Be tty Po leshock I 5, ''''','U'. IAdd,es .;{. 8, Addroll.o', Add'd88 (Onl;\ifiOqUO'IOd!
413 Rutherford Road i: ~ ond 100 I. poldl
Harrisburg, PA 1710! ~ 6, Slgn.MO (Agonll , I! 1 \
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RE I James Clark 961.11 ~S Fo,m 3811, Docember 1991-;u:s.-QPo: 1II1-U:l-102 DOMESTIC RETURN RECEIPT
~
April 26, 1993
Dear Mrs. poleshockl
As per your telephone request on Januar:' 21, 1993, r mailed to you
an application for Medical Assistance benefits. You were to complete
the application and return it as soon as possible. On April 23, 1993,
Cumberland County Board of Assistance Office infor~ed our office that
an application for Medical Assistance benefits had never been submitted
for review.
\,
Enclosed please find another application, The application muse be
completed and returned to our office With your payment of $3,119,50
(current amount due on this account) by May 10, 1993. Failure to comply
will result in this account being reclasseu to a private pay status
(the current amount due on private pay status is $15,675.50).
Sincerely,
;:;;::: ~.
Therese M. Finney .. -.J
Office Manager
mjl
Enclosure
<,
BLUE RIDGE HAVEN CONVALESCENT CENTER WEST
770 Poplar Church Road' Camp HIli, PA 17011 . 71776307070
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Mrs. Betty Poleshock
413 Rutherford Rond
lIarrisburg, PA 17109
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JAMES Cu\RK 96411
BALANCE DUEl $22,524.87
Dear Mrs. Poleshock,
On Hay 28, 1993, you spoke With Tina Anlold; Assistant Office Hanager, regarding
your account. During your conversation with Ms. Arnold, it was revealed that
you had NOT completed an application for Medical Assistance Nursing 1I0me coverage
and that you intend to pay the account with private funds.
Based on this conversation, I have prepared an itemized statement (see attached),
indicating all charges incurred by Mr, Clark since his admission to our facility
on October 9, 1992. (Charges billed and paid by Medicare Part A and Blue Cross
for Part A coinsurance arc not reflected on this statement.)
,
The balance of $22,524.87 is due by JUNE 10, 1993. Plnase be reminded, if funds
are not available to pay the bslance due of $22,524.87, you MUST apply for
Medical Assistance coverage t!lru Cumberland County Board of Assistance Offige
IMMEDIATELY I If eligible for Medical Asoistance benefits, Cumberland County
Board of Assistance will only approve coverage ninety (90) days prior to
receiving the application. Any service dates and charges incurred which are
not approved by Cumberland County will be billed to you.
Failure to remit your payment of $22,524,87, or to complete an application
for Medical Assistance benefits and remit an estimated Medical Assistance
Private Portion payment of $4150.00, by JUNE 10, 1993, will leave our facility
with no other option than to initiate discharge proceedings of Hr. Clark and
to sond this account to our attorney for collections,
~Si co ely, /'<'
, ~ ~~ " SENDER: I also wish 10 10c,l.o tho
~ / ~ :g . Compleu Hems 1 and/or 2 lor additional u'vlcu. following sorvlcos (for an oxtra 9<l
~ . Complete items 3, and 411 & b. ,~
~ . P,lnt you, namo and addr'n on Iho revette of lhls 101m to lhal we ean fool: ~
Therese M. Finney "'''"'" 'hl, ,,,' to v,", 1. 0 Add,o",,'s Addr,ss Jl
Office Manager ~ . Alllch Ihls ,form 10 Iho fronl ollho mlllplace, or on Ihe back II space
"" does not Jletmll, 0 I Q.
e . WlltO "Relurn neClipt ReQ,ulllld" on the maUple'e below theaf1lc1e numb". 2. Rostrlctod Dol vory' ~
oS . Tho Ro."," Rac,I,. >i>11I show 10 whom Ihe aulele wu deUverod and Ihe date
" .. Consult poslmastor for fee. -; ~
6 doll"",. 4a.. A\I4'lo Nl!\'b'Y/911 7"/...:','. E
II 3, Anlol. Add,oss,d 10: ~ 0(" 7 _ 7 _ g
-! 1eHv.. Po/eShoc.1c '. 4b, Sar.looTVP"I"~a:
g IlIa R.~Ae" ron ,r ~d OR,gISIOr~~ OlnslIIod '.":';, Cll
"'17 UT 1"- t'O~l:t 1)!.Carllll'd , 0 coo '.6
"'I J/ I fA / 7/0 9 tJ E,prass MslI 0 ROlurn Roc,lpl fo, ~
~~ /1;4,4i! f./SjjUIt ~ lt1arohomllsn ~
' ;/;) 7. oa.o :073 ~
<l .P1t. /J 1l~/.]~ ,/ _ ~
a: 5, .- ilatura I dd ossool -. 8', Add,os",'s Addrass 107 II roquDSl,d 1!
and'I,o Is paldl ..
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BLI a: 5, Slgnalura IAg,ntl ';:""i;
770 ~ I. I i II I. I " : !; III I' I; 11 I I ! III ii, , , ;" ::' ~
.. PS Form 3811, Docomber 1991 : Qu.S.OPq;lI~~~, "DOMESTIC,RE,Tlm~I~.!iCEiiiTMi
'Jl ,....,.".. "'{>I1\"""'" "'''''!'~II!\'''''':i'f:''''\W1!l'!il~',I~"'''(''i\'., '\~~
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ATTAcmmNTS
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In this case,
hearing, ,lncluding the
POleshock, leads the Hearing
cor~ect in considering the
deposit as owned by and available
resources f3~c~Hded the ihcomf'
t.he tes t llnon'y
oomll1fnc1Clble
Off ir.el'
total
Clnd evidence presented at the
rOl'thl'ight: t.estimony of M~.
to r.onclude that. the CAD Was
value of both certifir.ates or
the appellant. 'The, total
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llmIts.
Accol'dingly,
the appeal of the appollant. '~ust be
dallied.
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ESTATE OF JAMES E. CLARK -
BETTY POLESHOCK, EXECUTRIX,
Petitioner
IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
NO. 1994-00423
ORPHANS' COURT DIVISION
ANSWER WITH NEW MATTER OF CREDITOR. BEVERLY ENTENPRISES. INC.
t/d/b/a BLUE RIDGE CONVALESCENT CENTER WEST. TO
EXECUTRIX'S PETITION FOR SETTLEMENT or SMALL ESTAT~
AND NOW, comes Beverly Enterprises, J.nc, t/d/b/a Blue Ridge
Convalescent Center West ("Blue Ridge"), the primary creditor of
Decedent, James E. Clark, through its attorneys, Purcell, Krug &
Haller, and files the followJ.ng Answer with New MattE'r:
1. Admitted.
2. Admitted.
3. Admitted. In further response, Blue Ridge Haven, as the
primary creditor of the Decedent, believes and therefore. avers,
that the Decedent lacked sufficient capacity and/or was unduly
influenced in the award of his Power of Attorney to petitioner.,
Betty Poleshock on October 16, 1987. BlUe Ridge further believes
and therefore avers, that Petitioner may have abused her fiduciary
capacity as appointed Power of Attorney by converting all of
Decedent's monies into joint accounts with herself.
4. Admitted.
5. Admitted.
6.
Admitted in part and denied in part.
Based upon the
information provided, it is admitted that the Decedent's Estate
consists of a 1971 Ford Thunderbird, as well as the three Mellon
Bank accounts identified in Paragraph 6.
However, it is
.
specifically denied that the accounts are not part of Decedent's
Estate. In further response, see Blue Ridge Haven's New Matter.
. 7. Denied. Blue Ridge is without sufficient knowledge or
information to form a belief as to the averment, and, therefore it
is denied.
8. Admitted in part und denied in part. It is admitted that
Blue Ridge is owed $31,372.13 as a result of its provision of care
and services to the Decedent from October 6, 1992 through November
26, 1993. Blue Ridge is without sufficient information or
knowledge to form a belief as to the truth of the ayer.ments
regarding, the other creditors and, therefore, such allegations are
denied.
9. Denied, Blue Ridge is without sufficient information to
form a belief as to the averment, therefore it is denied.
10. It is admitted that consent was sought from Blue Ridge;
however, Blue Ridge does not consent to the granting of this
Petition, based on its averments contained in the New Matter and
its position that the accounts identified as joint should be deemed
assets of the Estate.
11. Admitted.
WHEREFORE, Beverly Enterprises, Inc. t/d/b/a Blue Ridge Haven
Convalescent Center West, respect fully requests this Honorable
Court to decree that the 11ellcm Bank Accounts identified in
Paragraph 6 of the Answer are assets of the Estate of James E.
Clark, subject to distribution to all outstanding creditors.
I'
2
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NEW MATTER
12. The averments contained in Paragraphs :L through 11 of
Blue Ridge's Answer to the Petition are incorporated herein by
reference.
13. On October 6, 1992, Petitioner, Betty poleshock, signed
an Admission Agreement in her alleged capacity as Power of Attorney
for James Clark. A true and correct copy of the Admission
Agreement and a copy of the Admission Agreement booklet are
attached hereto and marked as Exhibit "A".
14. Petitioner signed the Admission Agreement as agent, for
James Clark.
15. Pursuant to the parties' Admission Agreement and
Admission Agreement booklet, an agent is defined as a "person who
manages, uses or controls funds or assets which may be legally used
to pay for the Resident's charges, or who otherwise legally acts on
behalf of the Resident, .. 'rhe agent's signing of this Agreement is
required for admission and signifies his or her agreement to
distribute to the facility, from the Resident's income or resour-
ces, payment when due for services rendered to the Resident".
16. In her capacity as the agent and Power of Attorney for
James Clark, Blue Ridge notified Petitioner on October 6, 1992,
January 18, 1993, April 26, 1993 and May 31, 1993 that it was her
responsibility to complete an application for Medical Assistance
for subsidized nursing home coverage, otherwise, the Decedent,
3
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James Clark, would be billed privately for services and supplies
used during Mr. Clark's stay at the facility. Copies of letters
addressed to Petitioner are attached hereto and marked Exhibit "B",
indicating Blue Ridge's request for Petitioner to make the
application for Medical Assistance.
17. After nearly nine months of delay, on or about June 25,
1993, Petitioner formally filed an application for Medical
Assistance.
18. On or about the same date, based on the Department of
Public Welfare's finding that the Decedent jointly owned a checking
account valued at $489.00, two Certificates of Deposit valued at
$729.00 and $30,000,00, and a Money Market Account valued at
$729.00, it was determined that Decedent was not eligible for
Medical Assistance based on the Decedent's ownership of. the
aforementioned assets.
19. Pursuant to the Admission Agreement, if the Decedent did
not qualify for medical assistance, he became liable directly for
payment of services rendered on behalf of Blue Ridge.
20. As indicated by Petitioner in the Admission Agreement,
all mail to the Decedent was directed to her attention, including
bills for Blue Ridge services.
21. During Decedent's lifetime and despite her receipt of the
Blue Ridge bills on behalf of Decedent, Petitioner failed to timely
remit payment.
4
"
"
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22. At the time of the Department of Public Welfare's
determination of Decedent's ineligibility, all of the aforemen-
tioned accounts were titled jointly in the names of James E. Clark
or Betty Poleshock.
23. Petitioner appealed the Department of Public Welfare's
initial determination, but by a Final Administrative Order issued
December 8, 1993 the June 25, 1993 decision of the Examiner was
confirmed. A true and correct copy of the Order and Adjudication
are attached hereto as Exhibit "C".
24. It is believed and therefore averred that Pet~ti.oner,
using her Power of Attorney, transferred all of the Decedent's
monies, previously titled in his name alone, to joint accounts with
right of survivorship, listing herself as the joint owner.
25. It is believed and therefore averred that Decedent was
the only person who contributed the funds to the joint accounts.
26. It is believed and therefore averred that all interest
income generated by the joint accounts was reported to the Internal
Revenue Service under Decedent's Social Security number.
27. It is believed and therefore averred that at the time
Decedent signed the Power. of Attorney to Petitioner on October 16,
1987, he was under the undue influence of Petitioner and/or lacked
the requisite capacity to sign such a document.
5
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ADMISSION AGREEMENT
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liS ADMISSION AGREEMENT AND THE ACCOMPANYING ADMISSION AGREEMENT BOOKLET IS A LEGALLY BINDINI
)NTRACT, PLEASE READ ALL OF IT AND BE SURE you UNDERSTAND ITS TERMS BEFORE SIGNING,
, rhls facility accepts the following types of payment:
. :Ivate ~~l) IMedlcald
PARTIES The pMles to It Is Agreem
,
a).~ <i? LV' ' d),
b), ( "~~ent") . e),
. c), ("~'ent")
,
, Ih S Agreement is signed by somoone olller than Ihe Re:.:;nt, ploase slalo relationship 10 Resident:
The parties rue on tllis lP day of () 0 ,19 S':6.lhat beginning on the (0 day
of . 199.J" the facility shall admit and provide the services specified herein 10 the Resident untlllr,e
dale of Ihe Resident'; r1lschar~e and that Ihe Resident or his Responsible Party or Agent, i1 applicable. shall pay for tne
survices provided by tile Facility pursuanlto Ihe lerms and conditions setlorth in Ihis Agreement.
[veteran's
Administration
( "Legal Representative'
( "Responsible P any' )
NOYICES
.\11 noUces ~hall be deemed sufliclently given if mailed 10 I,"e Residenl and Responsible Party or Agent atlha addross
'ndlcaled below, Each SuCh person shall be responsible for nolllylng the Facility In wr!tlng of any change of addresz In
addition, Ihe FacllilY shall nOldy tile person designated b) !he Residem of any significant change in the Resident's
;ondillon,
The Resldenl designatfls Ihe lollowlng persons 10 be nOlifled of any signlficanl change In Ine Resident's condit,on.
LEGAL REPRESENTATIVE, RESPONSIBLE PMlTY OR AGENT
Home Pllone WI,r'K pnone
ccr~ ,'=:;45 - 'Y c:J iCj :
el c)!,Y ):).f Slale
~ kVu.Gj.OLd O~~R'F'ERSON TOilE NCTIFIE,. ~' l{J-A-
Home Phone
Zip
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MAIl.
'he Resident aulho(lzes the Facllily 10 handle tho Resident's mail as follows
o All mall given direclly 10 tI,e Resident 0 All mall read 10 Ihe Resident
o The Faclllly shall forward the Resident's mall 10:
!4:erso1j~the \ll~~ailto:
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eJ:iQTOGRAPHS
18 Resident agrees 10 permll 1I1e Facility to photograph or videotape Ihe Resident lor Identiflcalion use by Ihe slall or 10'
"nllh care purposes. These p/lolograplls or vidoolapes may be dsed :0 holp looate Ihe Resident In the event 01
"authorized absenco from 1111) Filcllily, IJut shall be otherllise kept confidenllal. The Resident agrees that the Facilily ma'l
lotcgrapl1 or vldoolape Ihe H"~lClelll 10 documolll tllO Res,denl's pllyslcal and medical cOl1d;t:on at time 01 admissiOIl alii:
!reatler, T'lO Facllily 511nllIJIJlatll Hesldullt AUUll)rllallon lor use 01 1110 RO!;ldenl p/lolograplls (( vldeolape~ lor olller lI,ar
'''lillcallon or Iwaltll caro PlllPO:;I)!;
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,dNqWLEDGEMENT, ' ~iE'IlEiIlL'1
/1 have received and read a copy of this Agreemelil, Ihe ~misslon Agreement Booklet and Stale . speclfl~ ad~;n:;m,
,"/ il any ("Agreement') in their enllrely.
I understand the terms 01 tile Agreemenl and that il is a legnlly binding contract.
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Resident or Legal Represenlalive Dale F Iflfy Administralor or Design e
Responsible Party
Date
Witness II Resident Signature Is by man<
Dal,
/ Security Number (optional)
Agen
Witness II Resident Slgnalure is by man<
Dati
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Social S urity Number (optional)
IIlhe Resident is unable 10 sign because of legallncompetenee or his or her medlcai condition, the admitting physician
shall document the reason in the Resident's medical record.
Date
ACKNOWLEDGEMENT OF RECEIPT OF ADMISSIONS MATERIALS
I, -4aml/O (t ~a.'I,~
Name'orRosidO'lI )
before admission to .~IJI/(~
, acknowledge that I have received Ihe following inlormation at or
Check here ( If nol applicable, wrile N/A )
v-- 1, II Medicaid eligible, a list of items and services Included in the laclflly's services under the
Slate Medicaid plan, as well as Ihose hems or sorvices lor which a Resident may be charged and
the amount 01 charges for those lIemb or services, .
......... 2. II private payor Medicare eligible, a list 01 lIems and services available in the Facility and Ifl(
charges for Ihose services, Including the charges lor services not covered under Medicare or by thr
Facility's per diem rate,
Namo 01 Facilily
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3, A descripllon 01 the way personal funds are managed,
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4, A statement Ihat the Resident may fife a complaint with Ihe State survey and certiflcallon agene,
concerning resident abuse, neglect and mlsappropriallon 01 rosldent property in the Facility,
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5. The name, speclaity and way 01 contacting the physician responsible lor my care,
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6, A written explanation 01 how to apply lor and use Medicare and Medicaid benellls and how Ie
receive refunds lor previous payments covered by such benefits.
(_ 7. A copy ot Ihe Federal & Slate Resident Rights.
I have been inlormed orally and in writing, In a language I understand, 01 my rights and the rules and regulalions governing
my conducl and responsibilities during my Slay at tho Facility.
"iesldent or Legal Reprosenlalivo
Dale
'r.sponslble Party
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AGREEMENT
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BOOKLET
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BUSINESS OFFICE REVIEW (Sections VI . XI)
,
VI. AGENT. LEGAL REPRFS,ENT,t.TIVE QELj1~.13l',ONSIBLE PARTY
A. AGENT
For the purposes of this Agreement, an Agent Is defined as a person who, manages, uses or controls fUI
or assets which may be legally used to pay for the Resident's charges. or who otherwise legally acts
behalf of the Resident, The Agent's fmancial obligations are limited to the amount of the funds recelvec
held by the Agent for the Resident, as the Agent does not assume responslblllly for payment out of hi!
her personal funds, THE AGENT'S SIGNING OF THIS AGREEMENT IS REQUIRED FOR ADMISSI
AND SIGNIFIES HIS OR HER AGREEMENT TO DISTRIBUTE TO THE FACILITY, FROM 1
RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR SERVICES RENDERED TO 1
RESIDENT. It is understood that if the Resident has an Agent and not a Responsible Party, the Agent s
be required to produce IInancial documentation to substantiate the Resident's ability to pay for whall
charges will be due for services rendered to the Resident.
.
B, LEGAL REPRESENTATIVE
For the purposes of this Agreement, a Legal Representative is defined as an individual who has b
appointed by a court of competent jurisdiction to manage the Resident and/or his or her financial affair
Legal Representative must present to the Facillly a copy of the court document which verifies his or
status as a Legal Representative. The rights and obligations of the Legal Representative are limile,
those rights and obligations Indicated by the court documents, A Legal Representative may serve a!
Agent or a Responsible Party to the Resident in fulfilling payment obligations to the Facility for chal
Incurred by or on behall of the Resident. At admission. the Legal Representative ehould indicate If h
she is also serving as a Responsible Party or Agent for the Resident.
C. RESPONSiBLE PARTY
For purposes of this Agreement, a ResponSible Party Is dellned as a person who agrees to be flnanc
responsible for the charges incurred by the Resident under this Agreement. By agreeing to becon
Responsible Party, a Responsible Party becomes jointly and severally liable for all payments owed te
Facility by the Resident. This means that both the Resident and the Responsible Party are obligated to
all the charges lithe other does not.
The Resident and ResponSible Party understand that even if the Resident's stay at the Facility IS CO\
by any insurance, it is the joint and several obligation of the Resident and Responsible Party to pf
charges Incurred by or on behalf of the Resident and to satisfy any coinsuranCE! or deductible obliga
under Medicare, Medicaid or any private insurance,
THE SIGNATURE OF A RESPONSIBLE PARTY IS NOT 11EQUIRED AS A CONDITION OF ADMISSI
Regardless of payment sources or responsibility of payment. at least one person should be Identifl,
admission by the Resident as the primary contact for the Facility regarding the Resident. The name (
Individual who will serve as the primary contact should be entered into Section II of this Agreement.
".
'''IQ'~t
. 15/92)
-2-
BUSINESS OFFICE REVIEW (Secllc,"e VI . XI)
'lll. PERSONAL FUNDS.
The Resident has a right to manage his/her own personal funds, However, the Facility will, at the written
request of the Resident, hold, safeguard, manage and account for the personal funds of the Resident
deposited with the Facility as follows:
1, For funds in ~_x_ce~s 01 Fifty Dollars ($50,00), the Facility will deposit funds in an interest bearing account
that is separate from any 01 Ihe Facil'ty's operating accounts, and \hal credits all Interest earned on the
Resident's account to Ilis or l1er accounl.
2. For funds [Qi~ than Fifty Dollars ($50,00), the Facillly will maintain a non-Interest bearing account or
petty casl1fund,
3, The Facility will maintain a system that assures a complete and separate accounting, according to
generally acceptEld accountll1g principles, of each resident's personal funds entrusted to the Facility on
the Resident's bel1all The system Will preclude any commingling of a Resident's funds with funds of
the Facility or with funds of anyone other tl1an another Resident, The individual financial records will be
available upon written request of the Resident or the Resident's Legal Representative,
4, For the Residents who receive Medicaid benefits, the Facility will notify any resident when the amount
In the Resident's account reaches Two Hundred Dollars ($200.00) less than the Supplemental Security
Income (SSI) limit for one person as determined by Federal law, Further, the Facility will notify the
Resident that if the amount in the account, in addition to the value of the Resident's non,exempt
resources, reacl1es the SSI resource limit for one person, the Resident may lose eligibility for Medicaid
or S81.
-
5, tn the event of the death of a Resident with personai funds deposited with the Facility, the Facility will
promptly refund the Resident's flJl1ds and give a full accounting of those funds to the Individual
administering the ReSident's estate.
6, The Facility will assure the security of all personai funds deposited with the Facility and :wlll not impose
a charge against personal funds for any Item or service for which payment Is made under Medicare or
Medicaid,
. 'I. FINANCIAL Af1I3ANG~M~t':!.TS
A, PRIVATE RATE
1. Dally Rate The Facility's private pay daily rate is determined In part by the type of room assigned to the
Resident and, therefore, may be changed If the Resident Is transferred to a different room, The
Resident and the ResponSible Party agree to pay a sum equal to one month's private pay dally rate in
advance and thertlaftN pay for each successive month's stay In advance on or before the tenth (10th)
day of the month, Any unused advance payment shall be refunded if the Resident converts to Medicalc1
coverage or leaves the Facility prier to the end of the first month,
2, Rate Adjustment. The Facility may find it necessary, due to inflation or other factors, to Increase the
daily rate or optional service charges from time to time, The Resident shall receive Written notice of all
such rate adjustments. II at any time the Resident's condition requires the Facility to make a change in
the level of care, tile Resident's dally rate may be changed without prior notice to the dally rate of the
new level of care,
At each notification of a rate adjustment, the Resident may elect to terminate this Agreement. Any rate
Increase shall be deemed agreed to by both Resident and Responsible Party or Agent upon the mailing
of said notice unloss the Facility is notified in writing to the contrary within ten (10) days of the mailing,
If the Resident and the ResponSible Party or Agent do not agree to the rate Increase, the Resident
agrees to leave the facility no later than the day before the rate increase becomes effective, II the
Resident fails to so vacate the FaCility, tllO ResicJent and the Responsible Party or Agent shall be
deemed to have consonted to Iho rate Increase,
'? 15/92)
..3..
BUSINESS OFFICE REVIEW (Secl/cnR VI ' XI)
3, Extra SElrvlces and Supplies, The Resident and Responsible Party or Agent shall be, responsible I
payment of 011 chorgos of the' Facility for supplies or services which are not Included In the Facility's de
rate,
a. MEDICAID/MEDICARE
THE FACILITY DOES NOT MAKE ANY ASSURANCE OF ANY KIND THAT THE RESIDENT'S CARE WILL'
COVERED BY MEDICARE, MEDICAID OR ANY THIRD PARTY INSURANCE OR OTHER REIMBURSEMEI
SOURCES. Thl~ Facility sllall provide information on how to apply for and use Medicare and Medicaid benef,
The undersignod, however, releoses the Facility, Its agents, servants, and' employees from any liability
responsibility in connection with the undersigned's potentlol claim for or any failure to obtain such coverag
The Facility may requiro a pre-payment of one month's estimated share of cost, pending a determination
eligibility, for a Resident who has applied for Medicaid but has not yet received confirmation of his or ,
ollglblllly at the time of admission, The estimated share of cost Is due monthly In advance on or before I
tenth (10th) day of the month until Medicaid eligibility is granted, at which time adjustment will be made
accordance with the actual share of cost determined by the Medicaid Program, If Modlcaid eligibility Is deni,
adjustment will be made in accordance with the Facility's full daily private rate.
C. ~EDICAID RESIDENTS
1, Dalll'. Rate P_avment, A list of the supplies and servic'es provided for payment made under the Medic
program Is provided to the Resident on admission, A list of the supplies and services requested or requil
by the Resident, which are not covered by Medicaid and for whlctl payment is. the responsibility of
Resident and Responsible Party or Agent, is also provided to the Resident on admission.
2, Termination of Cover~~, The Resident may remain in the Facility only so long as certified eligible
Medicaid payments, or as long as any charges owed by the Resident are paid as due. Residents v
remain beyond the expiration of their Medicaid coverage, or who have their coverage retroacti~
terminated ()( donied, shall be obligated to pay their account as private paying residents with rates I
charges tor services rc'ndered at the regular rates and temls in effect at the time of the service,
3, Resident's Shure of Co~t. The Medicaid Program determines the available monthly Income of all pel'S'
receiving Medicaid assistance and, with respect to most Medicaid beneficiaries, requires that out of I
Income the benetivlc"y must bear a reasonable share of cost. Payment of that share Is the responslbillt'
the Resident, Responsible Party or Agent. The Resident's share of cost Is subject to change as authori
by law, It the Resident fails to make prompt payment of his or her share of cost, where appropriate,
Facility may r~'quire direct mailing of such monies to the Facility, SLlch monies will be managed by
Facility in accordance with legal requirements, The Resident acknowledges that failure to pay
Resident's share of COSt may constitute grounds for discharge of the Resident and the Facility will notify
appropriate State or Federal agency of such non-payment.
D. MEDICARE RESIDENTS
1. Dalty Ra1iU~9Y..I1J.~Ll!, A list of the services provided for payment made under the Medicare Program
those sorvices which are not covered by Medicare, including the dally coinsurance rates, Is prov/deej to
Resident on admission,
2, Limited CoveraCl€!, The Resident, Responsible Party and Agent understand that Medloare cove rag
established by Federal gUidelines and not by the Facility, Medicare coverage Is limited both as to the lev,
care covered and the duration of coverage, Thus, based upon Medicare criteria, Medicare coverage me
terminated rrlor to the Lise of all allotted days it the Resident ceases to meel such criteria,
'1F. 202 (5/92)
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BUSINESS OFFICE REVIEW (Seotlons VI . XI)
. ,
\. Expiration of Beneflt~, Evidence that the Resident is able to pay for the services rendered In the Facility
upon expiration of the Resident's Medicare benefits, as either a private pay Resident or otherwise, must be
provided by the Resident prior to admission to the Facility in order to ensure the ability of the Facility to
retain the Resident after the expiration of Medicare benefits, If It is the Resident's, Responsible Party's or
Agent's Intent that the ReSident be d,schargrJd from the Facility on termination of Medicare benefits, he or
she must advise the FaCility In writing at the time of the l'lesidenl's admission,
If the Resident wlli become Medicaid e"gll)le when Medicare coverage stops or when private pay funds are
depleted, the Resident, Responsible Party or Agent is responsible for making a timely and complete
appllcat!on for Medicaid benefits. Where permitted by State law, the Facility will assist with the application
process when requested to do so, The Resident and Responsible Party or Agent is responsible for
periodically checking with the approprrnte State agency to seek and receive information on the status of the
Resident's Mecticaid applicallon. In addition, the Resldont and Responsible Party or Agent give the Facility
permission to seok ancl rocolvo Inlo,mollon on tho status of tho Medicaid eligibility application from the
appropriate State agency,
If the Resident wlil convert to private pay status upon expiration of Medicare benefits, the Resident,
Responsible Party or Agent ogree to pay the Facility's private pay dally rate for one month In advance upon
the Resident changing to private pay statLls, No payment In advance is required with respect to residents
who convert from Medicare to Medicaid coverage.
"IMEL Y OBLIGATION TO PAY,AND,-R.1JLQt.TI;
~he Resident's account for services rendered by the Facility shall be biiled monthly to the Resident and
:~esponslbla Party or Agent,
.~i1ls for services rendered to Resident by the Facility whicll are not paid by the tenth (10th) day of each month
'1all be past due or d(Jlinquent. When payment for services is not made by the tenth (1 Dtil) day or every billing
"onth, the Resident's account may be assessed a delinquency chargCl at the monthly rate of one and one.half
,Jercent (1-1/2%) (or tile maximum amount permitted by law) of the outstanding balance. ;rhe Resident
'cknowledges that tile delinquency charge does not alter any obligations of either the Facility or the Resident
':nd Responsible Party or Agent under this Agreement. The Resident and Responsible Party or Agent
'.oknowledge that the Facility does not grant credit or allow Installment payments, and the Facility's
. cceptance of a partial payment shall not limit the Facility's rights under this Agreement,
;AILURE TO PAY
,f the Resident, Responsible Party or Agent fails to make a required payment within fifteen (15) days of the due
'ate, the Facility may require the Resident to vacate the Facility. A reasonable period not to exceed thirty (30)
. 'ays from the date of receipt of the notice of failure to pay shall be allowed for the Resident and Responsible
. 'arty or Agent to make arrangements for the Residenl vacating the Facility, The notice shall be deemed
)celved either on the actual day 01 receipt or live (5) days after mailing, whichever or.curs first. The Resident
. nd Responsible Party or Agent agree that the Resident shall vacate the Facility on the date specified by the
:acllity under this section, The Resident and Responsible Party or Agent shall be responsible for all relocation
:,xpenses, In addition to all charges due to the Facility for all days of care received,
NSURANCECOVERAG~
.Vhere the Resident's care at tile Facility is covered by Insurance or somo other third party payer coverage, the
~esldent and Responsible Party or Agent silall nonetheless be primarily responsible for making payment
.cursuantto this Agreement regardless of such third party payer coverage, and shall be responsible for paying
, II charges not paid by any third party payer, including any coinsurance or deductible amounts required by any
'lird party payer.
,015/92)
-5-
I
,.,
BUSINESS OFFICE REVIEW (slolion. VI ' XI)
.
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H. FEE FOR RETURNED CHECKS
A service fee as sellorlh in Ihe Facility Credit Policy Statement shall be charged for any returned chl
IX. TERMINATION OF AGR~-FMENT
A. RIGHT TO TERMINAT~
No Resident may be transferred or evicted from the Facility solely as a result of the Resident changln\
or her manner of purchasing services from prlvale payment or Medicare to Medicaid,
A Resident may elecl to leave the FacllllY at sny time. Should the Resident leave the Facility befor!
attending physician discharges the Resident, the Resident agrees to assume all responsibility for all rei
which may follow,
B, REFUND
If the Resident is discharged before using up the entirety 01 any prepaid charges. a refund of the unl
portion of such charges shall be made within a reasonable period of time, Resident funds which
required by law to be held by Ihe Facility in a demand trust account shall be refunded promptly aftel
Resident's date of discharge,
C. PROPERTY OF RESIDENT UPON_TERMINATION
The Facility shall attempt to safeguard the Resident's personal beionglngs remaining at the Facility,
discharge, but shall nol be liabie for any damsge or loss to the Resident's property and may dispose of
belongings left by the Resident If not claimed within thirty (30) days of discharge or transfer.
X. BED,HOLDS
I
The Resident and hIS ResponSible Party or Agent may request the Facility to hold open the Resident's
and room while the Resident is absent from the Fscility for therapeutic leave or temporary stays in an f
care hospital. However, except as provided below, the Facility shaH have no obligation to hold operl
Resident's bed unless the Facility agrees to do so in writing,
It the Resident's care is being reimbursed by Medicaid and the Resident is transferred to an acute
hospital or 13 absent due 10 a therapeutic leave, the Facility shall offer the Resident a bed-hold for the nUl
of days, if any, required under Slale law, which may be exercised by the Resident or the Resld!
Responsible Party or Agent. If Medicaid coverage for a bed-hold does not exist, the Resident may be obllg
to pay the Facility's private pay daily rate for each day of the bed-hold that Is requested. If the Resldl
attending physician notifies the Facility In writing that the Resident's treatment at an acute care hosplte
exceed the number of days, if any, required for the bed to be held by State law, the Resident may be obll~
to pay the Facility's private pay daily rate lor each day of the bed, hold that Is requested that exceeds thai
by Medicaid, A Medicaid Resident will only be readmitted after a hospitalization or therapeutic leaVE
exceeds the number of days paid for by Medicaid if a Medicaid bed Is available. and the Resident requirE
services provided by the Facility and conlinues to be eligible for Medicaid,
A private payor Medicare ReSident may request a bed-hold from the Facility, Any private payor Medl
Resident who requests a bed.hold shall pay the Facility's privata dally rate for the period of the bed.hoi
Resident's private Insurance mayor may not cover the cost of a bed-hold, The Medicare program doe!
reimburse for bed-holds.
In order to effecl a tJed,llOld, till' I~esldonl or tho Reslden['s Responsible Parly or Agent must notif)
Facility within twenty-four (24) hours of receipt of notice from the Facility concerning the discharge (
whether tre Residenl wishes 10 exercise his or her right to a bed-hold. The Facility Is not required to of
bed.hold if the ReSident requlles a level of care dilterent from that previously received by the Residel
greater than that able 10 be proVided by Ihe Facility, In the event the Facility Is unable to flccommodall
Resident's nOllcls, Iho Fncllity shall offer the next available appropriate bed to the Resident.
'1' 202 (5192)
..6-
BUSINESS O~FICE R~VIEW (S80Uon8 VI - XI)
. . ,
If the Resident Is transferred from the Facility and does not request a bed-hold or wishes td return to the
Facility after the expiration of a requested bed-hold, the Faolllty shall have no obligation to readmit the
R~sldent except as provided above.
.
. :, ENFOF\CEMENT
A, ~MENT
This Agreement, along with any doouments whloh areattaohed herein or Incorporated hsreln by reference.
Is the entirety of the agreement between the Faolllty and the parties, Changes to this Agreement shall be
valid only If they are set forth In writing and signed by the parties, Should changes In Foderal or State law
render any part of this Agraement Invalid. the remainder of the terms shall stand as a valid agreement,
B. ATTORNEY'S FEES
If a legal action Is commenced by any party to this Agreement, Including any disputes arising from this
Agreement, the prevailing party shall be entitled to recover his or her reasonable costs, Including
reasonable attorneys' fees, incurred In defending or prosecuting such action.
C. AGREEMENT NOT ASSIGNABLE
The Resident and/or the Responsible Party or Agent acknowledge that the right of the Resident to reside al
the Faolllty Is personal and Is not as~lgnable. Ths R.esldent may not transfer his or her rights undsr this
Agreement to any other person',
~.
l,
:01.
'l':
"
,'!, .'
.'1 "
? 11;/92)
-7-
-"i ': if.." '."'.\;,f, t'
, ,.
SOCIAL SERViCeS REVIEW (Sections XII . XVII)
XII, NONDISCRIMINATION
The Facility welcomes ull persons in need of Its services and does not discriminate on the basis of agl
handicap. race, color, national ongin, ancestry, religion or sex, While the Facility must receive paymer
for Its services, the Facllily does not discriminate among persons based on the source of that paymenl
'(III. SERVICES
A, NURSING pERVICES
Yhe Facility shall provide general nursing care and room and board and other related services.
specified In the list of items & services provided to the Resident on admleslon,
If the Facility is cerlified by \he Medicare or Medicaid programs, the Facility shall provide beneflclarl
with all services reqLllred to be provided by State and/or Federal law Lists of the services and ito'
covered uy Medicaid in Ihis Slate, optional lIerns and services and the extra costs of those servic
MediciHe covered and non.covered services, and the costs of Medicare non-covered services are e
provided to the Resident on admiSSion.
B. PHYSICIAN SERVICES
The Resident acknowledges that he or she is under the medlcai care of a personal attendlnft-physlC
and that the Facility renders services under the general and specific Instructions of said physician
signing this Agreement the R3sident consents to the Facility providing sllch routine nursing and 0'
health care services as may be directed by Ihe attending phy~lcian,
,
The Resident has a right to select his or her own attending physician; however, If the'Resident does
select an attending physician or Is unable to select an attending physician, an attending physician me
designated by the Facility,
The Resident agrees thaI the Facility may require the use of an alternate licensed physician '
attending physician is barred from practice in the Facility due to violations of the Facility's rules
regulations or by order of State or Federal regulators, or If any emergency requires an imme
response to the Resident's medical needs,
The Resident and Responsible Party or Agent recognize and agree that all physicians, Inc'l
physicians arranged for by the Facility, who are providing services to the Resident, are Indepe'
contractors and are not employees or agents of the Facility and that the Faclllty's liability for a:
omissions of the pl1ysician IS Iimiled because the physician is an independent contractor, The Re:
and Responsible Party or Agent shall be solely responsible for payment of all charges of any ph)'
who renders care to the Resident while in the Facility.
C, RIGHT TO REFUSE TREATMENT
Residents have the righl to refuse treatment \Q the extent permitted Qy ~ and to be informec
medical consequences 01 such refusal. Wl1ere, in the professional judgment of the Facility, the F"
Is not mentally competent to make a deCision regarding rofusal of treatment, the Facility may rea..
an order from a cOLlrt of compelent jurisdiction be obtained before It will withhold necessary'"
treatment,
D, PER_ll.Q.~AL PBQPE.BJ.Y
Tho Resldonl anclnot tl10 facility 511[111 bo responsible for the prOVision of cortain personal com'er,
clothing und pOlly cash for the Resident's inCidental expenses. All clotl1lng and other personal 11,,-
be ciearly markod to ind,cate IIIat the Resident is the owner.
qe ao? 15192\ -8..
SOCIAL SERVICES REVIEW (Seotlon8 XII - XVII)
The Facility strongly discourages the keeping of valuable Jewelry, papers, large sums of money or bther
Ilems considered of value In the Facility, The Facility shall make reasonable efforts to safeguard the
Resident's property and valuables that are in possession of the Resident. However, the Resident and
Responsible Party or Agent acknowledge that the Facility may most effectively safeguard the personal
property of the Resident only If the Facility has possession of and control over such property, Therefore,
the Resident agrees to store all valuable personal property In the Facility's safe or other secured storage
area as Facility may provide,
, ::e.SIDENT'S RECORDS
. , CONFIDENTIALITY
Information oontalned In the Resident's medical records Is oonfldentlal and disclosure to unauthorized
persons &hall not be made without the Resident's (0'1' his or her Legal Representative's) written consent,
exoept as required or permitted by law,
), CONSENT TO DISCLOSURE BY FACILITY
The Resident authorizes the Facility to disclose all or any part of the Resident's medical or financial
reoords to any person or entity which has or may have a legal or contractual obligation to pay all or a
portion of the costs of care provided to Resident, including but not limited to hospital or medical services
companies. Insurance companies, workers' compensation carriers, welfare funds or the Resident's
employer, The Resident also authorizes release of information from medical or financial records when the
Resident Is transferred from the Facility to any medical professional or Institution which assumes
responsibility for the medical or nursll1g care of the, Resident.
" THE RESIDENT'S DUTIES
/1" RULES AND REGULATIONS
:
The Resident agrees tllat the Facility may, to maintain orderly and economical operations, adopt
reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident
agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a
written copy of such rules or regulations It Is understood that the rules and regulations may be amended
from time to time as the medical care and/or orderly operation of the Facility require, but any changes
shall be provided to the Resident In writing before taking effect,
There is a Facility procedure for .suggesting ctlanges in the rules and a Facility grievance procedure for
resolution of Resident complaints about Facility practices, Copies of these procedures shall be available I
from the administrator and posted in the Facility, Residents are urged to bring any grievances concerning r
the Facility to the attention of the Facility administrator, The Facility also offers a toll-free "hotline"
telephone number where complaints may be made directly to Faollity's corporate offices. This number is
1-800/572-9981, Residents also have the right to contact the State facility licensing agency or the
long.term care ombudsman, or both, regarding grievances against the Facility,
B, DIET
The Resident understands that the diet of the Facility's residents is medically prescribed and. therefore,
must be monitored by the Facility, The Resident, therefore, agrees that he or she shall not bring any food
or beverages Into tile Facility without permission from the administrator.
C, MEDICATIONS
No medications or drugs may be l)rouglllupon the FaCility's premises unless the medications or dnlgs are
labeled according to the requirements of State and Federal law, Packaging of medications must be
compatiole with the Facility's medication distrlblltlon system. No drugs or medications may be brought to
the Facility unless they are delivered to tile nurse's stalion,
.ltl~)
0_
SOCIA~ SERVICES REVIEW (8eollOni XII . XVII)
. ,
The ~aclllty shall not require residents to purchase drugu, or rent or purchase medlclIl s4Pplles
equipment, from any parllClJlar pharmacy or other source, However, nothing In this paragraph sh
prevent the Facility from requiring the Resident's pharmacy or other source to comply with the Faclllt\
polloles and procedures and any legal requirements.
0, CARE OF FACILITY'S PROI:1;RTY
In order to preserve the value of the Facility's proporty for future residents' use, the Reeldent agrees
use due care to avoir! damaging the Facility's properly find premises. Pictures, posters or oth
ornaments may be hung on walls, and furniture may be rearranged In the Resident's room only with \I
consent of the administration of the Facility. The Resident shall be responsible for ropalr or replacemE
01 the Facility's property damaged or destroyed by the Resident. Howover, the Resident will not I
responsible for such damage as Is to be expected from ordinary wear and tear.
XVI. TRANSFERS OR DISCHARGES
The Facility shall provide notice to the Resident and. If known, a family member or Legal Representatl
of the Resident, of the transfer or discharge, and the reasons for It, at least thirty (30) days before t
Resident Is transferred or discharged. However, where the safety or health of the Resident or oU
Individuals in the Facility may be endangered, or other legal reasons exist, notice may be made as sc
as practicable before transfer or discharge,
The Facility will only transfor or discharge a Resident under the following conditions:
-
1, The transfer or discharge is necessary for the Resident's welfare and the Resident's needs cannol
met In the Facility;
2. The transfer or discharge is appropriate because the Resident's health has Improved sufflolently
the Resident no longer needs the services provider! by the Facility;
3. The safety of individuals In the Facility is endangered;
4, The health of individuals in the Facility would otherwise be endangered;
5, The Resident has failed, alter reasonable and appropriate notice, to pay for (or to have paid un
Medicare or Medicaid) a stay at the Facility;
6. The Facility ceases to operate or ceases to participate In a program which is providing payment for
Resident's care,
XVII. VISITORS
Residents can consent to have visitors at any reasonable hour, If any of the Resident's guests fall to a
by the Faclllty's rules for visitors. the Resident and the Responsible Party or Agent agree, upon the Facil
request, to arrange for the prompt removal of such visitors from the Facility.
"IF 202 (6/92)
-10-
''',
, ~..
.
ATTACHMENT A,.. Page 1 012
RESI(')ENT RIGHTS
(Federal Law)
, Faolllty will protect and promote the rights of each Resldsnt Including each 01 the following rights:
, '
The Resident has a right to a dignified eXistence, self.determinatlon. and communication with. and access
to, persons and services inside and outside the Facility,
The Resident has a right to exercise his or her rights as a Resident of the Facility and as a citizen or resident
of the United States, '
The Resident has the right to be free of Interference. coercion, discrimination, or reprisal from the Facility In
exerCising his or her rights,
The Resident has the right to be fully informed, In n language htl or she can understand. of his or her total
health status Including, but not limited to, his or her msdlcal condition. '
,. The Resident has the right to refuse treatment and to refuse to participate In experimental research,
The Resident has a right to exercise his or her legal rights, including filing a complaint with the State survey
and certification agency concerning Resident abuse, neglect, and misappropriation of Resident property In
the Facility.
The Resident has the right to manage his or her financial affairs,
The Resident has a right to choose an attending physician,
The Resident has a right to be fuliy informed in advance about care and treatment and any changes in that
care or treatment that may affect the Resldont's well,being,
The Resident has a right to participate In planning his or her care a~d trealment or changeg In care and
treatmant unless adjudged Incompetent or otherwsle found to be incapacitated under the laws of the State,
The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records.
The Resident has the right to Inspect ann purchase photocopies of all records pertaining to the Resident
upon written request and 48 hours written notice (excluding holidays and weekends) to the Facility, .
'fhe Resident may approve or refuse the release of personal and clinical records to any Individual outside the
Facility except when:
a. The Resident Is transferred 10 another health care institution,
b, Record release Is required by law or a third party payment contract.
The Resident has a right to voice grievances with respect to treatment or care that falls to be furnished
without discrimination or reprisal for voicing grievances.
The Resident has a right to prompt efforts by the Facility to resolve grievances, Including those with respect
to the behavior of other Residents,
The Resident has a right to examine the results of the most recent survey of th!! Facility conducted by
Federal or State surveyors and any plan of correction In effect with respect to the Facility,
The Resident has a right to receive information from agencies acting as client advocates and be afforded the
:,oporlunily to contact these agencies,
. Federal law was amended by OBRA '90 to include the right of the Resident to access to current clinical
rllcords of the Resident upon request by \l1e Resident or the Resident's Legal Representative, within 24
Ilurs (excluding weekends or holidays) nfter making such a request,
/5/92)
-11.
, ATTACHMENT A.. Page ~ of 2
,7, The Resldenl has a right to refuse to perform ,services for the Facility,
The Resident has a right to agree to perlorm voluntary or paid services for this Facility if he or she deSires,
there Is no medical reason which would contradict the performing of services, and compensation for paid
services Is at or (\bove prevailing rates,
The Resident has the right to privacy in written communications, including the right to send and receive mail
promptly that is unopened, The ReSident has a right of access to stationery, postage and writing Implements
at the Resident's own expense,
The Resident has tile right to immediate acces~ to any of the following:
a. Any representative of the Secretary of the United States Department of Health and Human Services,
b, Any representative of Ihe State,
c, The Resident's individual physiCian.
d, The State's long term care ombudsman,
e, The agency responsible lor the protection and advocacy system for mentally III or developmentally
disabled Individuals,
f, Subject tc the Resident's right to deny or withdraw consent at any time. immediate family or other
relatives of the Resident or others who are visiting with the consent of the Resident.
The Facility must provide reasonable access to any Resident by an entity or Individual that provides health.
social, legal or other services to the Resident. subject to the ReSident's right to deny or withdraw consent at
any time,
The Resident has a right to have regular access to the private use of a telephone,
The Resident has a right to retain and use personal possessions, including some furnishings and
appropriate clothing, as space permits, unless to do so would infringe on the rights or health and safety of
other Residents,
The Resident has the right to share a room with his or her spouse when married Residents live in the same
Facility and both spouses consent to the arrangement.
Each Resident has a right to self.cldminister drugs uniess the Facility interdisciplinary team has determined
for a particular Resident thai this practice is unsafe.
The Resident has a rlghl to be Iree from any phYSical restraints Imposed or psychoactive :lrugs administered
tor the purposes of diSCipline or convenience, and not required to treat the Resident's medical symptoms.
The Resident has the fight to be Iree frol11 verbal, sexual, physical or mental abuse, corporal punishment
and Involuntary seclusion,
The Resident Ilas a right to choose activities schedules and health care consistent with his or her interests,
assessments, and plans of care,
The Resident has a right to receive advance notice of transfers or discharges of the Resident as required by
law, The Resident has a right to receive notice before the Resident's room or roommate is changed.
The Resident has a right to organize and participate in Resident groups In the Facility, and the Resident's
family has the right to meet with families of other Residents,
The Residont has the fight 10 partiCipate in social, religious and community activities that do not Interfere
with the rights of other ReSidents.
The Resident Ilas a IIglll to reasonable accommodation of Individual nlleds and preferences except where
the health or safllty of tile Flesldllnt or other Residents would be endangered,
The Resident has a flghl to freedom of chOice of providors in accordance With applicable law and subjoct to
the prOVider's compliance With all applicable laws and reasonable rules and regulations of the Facility,
'012 15/92) ..12-
. .
,..... .
e
e
/.
,''./,/
(I . ,
II
,
DAn I Januaxy 18, 1993
Mrs. Betty po1eshock
413 RutJ1erford Road
i!l
~~W~~ib ~7
!:d7:!:::~~~~!~
Harrisburg, PA 17109
RE I Jl\11ES CLl\RI: 96411
Dear Hrs. I'oleshock:
"
On October 9 "J. Clark was admitted to our facility. Based
on the information provided at the time ot admission, it was determined that
Medical Assistance (MA) coverage might be needed to assist with the costs of
Nursing Home carp.. At that time, we classified J. Clark as Pending MA.
Tbe actual MA Determination is completed by CumbcrIand County Board of
Assistance (CCllA) office,
An application for Medical Assistance must be completed immediately and returned
to our Business Offic~ (Attention I T. Arnold). The application Will-then be
for~a!ded to CCBA for review. CCBA will then info~ you when your financial
revieW appc111t.ment with the CCBA Casc'~or!<er will be scheduled. YOIl lIlust attend
this apP(lintment - only after this appointment can the }loA Determinl!citlll be
~de tor Nursi~g Home cove.rage,
_.
U MA-:lursing hcme coverage is not a~proved.l. yo~ will"be billed pri-,ately ror
81. servic\,s e::d r.t:?pli~s useci during J. Lla::,~ I S stay at our faci,!i:7.
T~ese sen.ices and supplies include, but are noc--rimited to, Roem and Bcard
(1;97 per day fl)r SkU l~d roolllB; $87 per day for IC", rooms), medical supplies.
pharmacy, therapies, ccc. In the event Medicare Part A can be billed, you
are still responsible for the coinaurance amount. (1993 coinsur~ca rate
iJ $84.50 per day from the 21st thru the 100th day of Medicare cover~g~.)
If HA-Nursing Home coverage is approved, CCBA will determine how much per
month you .ill be responsible to pay towards the cost of J. Clark 's care,
This amount is referred to as the "PRIVATE PORTION", Until CCBA has made
their determination, we have estimated your PRIVATE PORTION at $ 500.00 per
month. This amount do~s not includ" items such os Beauty/Barber Shop, Cable
Services, Personal Laundry service, etc. The'current month's PRIVATE PORTION
amount, as well as any additonal item 'charges, is due by the tenth (10th) of
each month. (You will receive a monthly statement around the 25th of each
month.') Payments not received by the tenth (10th) of each month are considered
past due. (NOTE I Continual late payments or no payments will resul: in
discharge of the resident.)
If you have any questions or concerns regarding this matter, please feel free
to contact me at 7l7~763-7070 extension 218,
Sincerely, ,~ ~
~-_~~<i. t-\N'~\C~~~)
Tins Arnold
Assistant OfficcBlHJUnBillGE HAVEN CONVALf.;t>CENT CENTER WEST
770 Poplar Church f1os~~mp.!'E1Ii PA 17011 .717763-7070
. ,
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r .....-....~ v,..... ,..,. , '. ",;~,,~,;'i{'...,:~f':''':;~'1:1:' ~.' "11rtTr'7"''''
, 9X' I;) ~ c;, i ~~~~~~il.m: 1 'oO/or ~ 'or .ddll'on.' ..;,,"', . ".~\\~~i', .,' III~" wllh' t~ ..;tcoi~~\~~ ' .
i . C"",pl... lI.m. 9,.nIl 4. "b, , :. following Ilrvlc.1 'If 01 In lie,'t,rl j'
~ . Print yow n.m"oo '''dl,,, on thl '1'1"" ollhl. 101m 10 lh;lj~~ c:~n
return Ihl, c"d to you, feol:.r, . I
~ . Atl.ch lhl. 101m 10 the Itonl 01 Ihl m.llpl.ce, 0' on the b.ck II 'Plc. t. 0 AddrulIoo'. Addr~~~ . I
z: do.. not p.,011l,
~ . WIll. "R'MnR""pl Roqu""d".n lh. m"'pl", b,'ow "",t1". numbel 2, A.ltrloted Delivery .5.
. The R.turn R.celpl wHl .kow 10 whom th, Irtlel. wu dllf""'lId Ind thl dtl, W
a dllly".d. _ Conlu~alm88cor for feo, a::
'll 3. Alllol. Add."".d to: tiel. N~mb,.. 'CC
i fYJR.s /jETry P6L1SNex: Ora.:> t:,{)~ ~S5~
e ) L/ ,,/J . 0..... 4b, S.rvle. Tvpe D
B "T(..::J 1\ LJTHEl.rof-.'D 11.-1) [J n.glllered Ol".ur.d a:
li1 / /Ji IJ tJ /S /J tJ. tJ" f' A 17 Q ~C.rllfl.d 0 COD ~
II! I7l'1l'-f- D ^- D !t; / eYexPI... Mill 0 n.t,urn A e.lpl fOI '~
~ 7, 001.0 Ivery ~ ~
2 W.~
~lrs, Be t tyPo Ie shock CC 6. SI .I B, Addl.....'. Addr... (Only II r.qu..tod ~
41J Ru t he r ford Road ~ t'/Z. Ind f.. I. poldl
Harrisburg, PA l7l0! ~ B. Slginl:t~r., IAg.nU
o
REI James Clark 961~PSFolm
~
April 26, 1993
. D.t.mb.r 1991
.u,&, OPO, 1112-32>-<02
1111
DOMESTIC RETURN RECEIPT
Dear Hrs. Poleshock.
As per your telephona request on January 21, 1993, I mailed to you
an application for Medical Assistance benefits. You were to complete
the application and return it as soon as possible. On April 23, 1993,
Cumberland County Board of Assistance Office informed our office that
an application for Medical Assistance benefits had never been submitted
for review.
\.
Enclosed please find another application, The application mUH be
completed and returned to our office with your payment of $3,119.50
(current amount due on this account) by Hay 10, 1993. Failure to comply
will result in this account being reclassed to a private pay status
(the current amount due on private pay status is $15,675.50).
Sincerely,
~~
~~~
Therese M. Finney ~
Office Manager
mjl
Enclosure
"
,I'
BLUE RIDGE HAVEN CONVALESCENT CENTER WEST
770 Poplar Church Road. Camp HIli. PA 17011 . 717763,7070
..
. &y 3'1, 1993
, ,
Mrs. Betty Poleshock
413 Rutherford Road
IIl1rriaburg, PA 17109
]j~~~[gl[!J1
REI
JAMES CLARK
BALANCE DUE I
~~'!:]::;:::::~~::~
96411
$22,524.87
Dear Mrs, Poleshock,
,.
On May 28, 1993, you spoke with Tina Arnold', Aasistant Office Manager, regarding
your account. During your conversation with Ms. Arnold, it was revealed that
you had NOT completed an application for Medical Assistance Nursing Home coverage
and that you intend to PAY the account with private funds.
Based on this conversation, I have prepared an itemized statement (see attached),
indicating all charges incurred by Mr. Clark since his admission to our facility
on October 9, 1992, (Charges billed and paid by Medicare Part A and Blue Cross
for Part A coinsurance arc not reflected on this statement.)
,
The balance of $22,524.87 is due by JUNE 10, 1993. Please be reminded, if funds
are not available to pay the balance due of $22,524.87, you MUST apply for
Medical Assistance coverage thru Cumberland County Board of Assistance Offi~e
IMMEDIATELY I If eligible for Medical Assistance benefits, Cumberland County
Board of Assistance will only approve coverage ninety (90) days prior to
receiving the application. Any service dates and charges incurred which are
not approved by Cumberland County will be billed to YOIl.
Failure to remit your payment of $22,524.87, or to complete an application
for Medical Assistance benefits and remit an estimated Medical Assistance
Private Portion payment of $4150.00, by JUNE 10, 1993, will lesve our facility
with no other option than to initiate discharge proceedings of Mr. Clark and
to send this account to our attorney for collections.
~s ce ely, ~,
,. ;; ~~ a SENDER:. I al.o wl.h 10 rocolvo Iho
~/ ~ :g . Compllle ileml 1 andlor 2 lor addltlon.l lorl/lelll, following sO/vlcos (for an extra 9?
~ ~ . Comploto llltml 3, ,nri 4. & b, ,~
~ . PIli'll YOUf namo and add".. on the rel/elSG olthh form to thaI WI can fool: ~
Therese M. Finney I) return thl, card to you, 1. 0 Addressao's Addreas 4)
Offi Ma > . AIUch lhl. fOlm 10 tho front afthO! m.ltp!oclI, or on lh, baclr.lf IpaclI II)
roe nager ! dou nol pormll. b 0 I dOli ' . ' 0.
I) . Wrlle "RelUlI1 RlIClllpt AoquOIled" ,lnlhllmllllplllcobelowthll.ftlclllnum er, 2. ROHlf eta a v~rf"." ,'. 'a:;
-6 . The Return Recelpl will show 10 whom Ihelll1lclll WII delivered .nd Ihe dati Consult ostmaster for foe, . ",M
C dollvoUld ..".a:
i 3, A~lclo Addr...ed 10: ;.; 4~~~b49 ~ 7 tf I. "':~
"6. /3,e-tf4 Po Ie ShO cK. 4b, So,vleo Typo ", :'I,"a:
E 11/:3 n-)LA Po td '1Zd 0 noOIUolod [J In.urod .. :.,', Ol
8 '11 "llr eR., ort. Tf!.cOltIlIOrl:~ 1:1 coo . ,5
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w /1AI(i!..IS ()U~ I. -=-___ ~. c--- Mo,ehnnrll.n. (;
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tt 6, < iIilture 1(lrI 0"00 "'Hi' foo is "airll ~
BlI ~ G:<:,;;;;ai;~;;-{Ago;;il un___________. ..-- ',:..~;
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770;; 1.1111 I ii', ,: '111 I'., . , , .'.' " , ""~,,,.:
~ PS Form 3811. OQeombor 1991:, .u,s,~po\ 1~;-=!"',.DqMEST!<;: ,R~Tl!~~,~~,~~II~t,
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ATTACIDIENTS
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CmlHONlmAL'rH OF rr.NNflYI,VflNT A
, 08PM'nmN'I' OF PlIIlI,TC WP,I,F~RP,
.,' I I
APPEAL OF:
James Clarl<
770 Poplar Church Road
Camp Hill, PA 17011
Case #210069855-001
"
, FIt!N<-.M,NINIB'rRA1'IVE ACTION ORD8Ji
It 's h~raby nR08R80 And OP,CREP.O thAt the dp~lslon of th~,
RXAMlner iA Afflrmpd.
r..IthE'r pArty to 1'111" pror'pprUng hAS ftft.APn (15) cIl1ennar
nllYR from thA dAt.e of this necision to rPQIIE'st re()onsineration
t,f) thp. Bp.r.rpI:Ary of tllp Oppllrt,mpnt., 'rhp l'f'qlJp.st milsI' DR in.
writing nncl mllst. r.f~t: fort.h In c1Pt.Ail t.hp baRis IIpon whIch the
rf'C111E'r.t Ir. mAdp, 'fhA rl'!Qllest. "hA1.1 hfl ilddresspn 1:0 t:hfl
f!A()retary, hilt. nell\'''!l'pd to thfl Director, Office of HeArlngf1
IHHl Appeals, P.O. B(1~ :Hi7!i, Ilarrisbllrg, PA 17105 !lnd must be
gost,marken within fifteen (15) cAlenc1ar davs fr.om the date of.
t.hlJuLe cis iJl.!J-'.. "
,:1
The Apppllant mllY tilke isslle with t.hl" Adjlldicatlon Ilnn
Orr1pr ann may appall 1 th"!rpfrom to thfl CommonwPIl 1 th COllrt of
PpnnRy1vilnlll within "hlrt.y (30) rlllYs f.rom I:hp c11ll:a of thIs
,Ordpr,
Olfles 01 Heanngs and Appeals'
'[IC'" u~ c 1,r,(I~
,,',/ '. I....'..\},
Final Admmistrative Action
and Mailing Date
"~~~
Peter Bpeaks, ESQII, .e
Director. .
Offflne of HAArings ann APpeals
Dllte
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4. The t~o certificates of deposit were in the name of
",lames E. Clllrk or B,~t.ty poleshoek",
5. ~ls. poleHhod, did not contrlbutt'! ,~r1~' money t.o thl!!
eertiflr.~te of deposit.
Ii. On 01' ilbout. ,J 11 1\\' 25, J9'13 , tho> (;:\0 notHied the
appellant via form PA/FS 162 that he ~as not eligible for NHC
benefits becausfo! his rOIH)UrCeS e:-:ceeded tlH~ limitfl.
7. The rt'5(lllrCI~ Undt,; for :\HC ,we $?,OOO.OO for Non-
None~' Pa~'lt\l~nt (N'IP) and ;;1.,400,00 rill' >led.ic.1.1.ly Needy On.l~: (~l"nl.
8. In response to the PA/rS 162, ,~ t imely app,~a 1 W!\s r ill'ld
on July 1-1, 1993, ,;hir.h was received by th'j OEfir.'e of Heildlll;JS ,:\11'.\
Appeals on July IS, 1993.
DISCUSSION
The alldio l'lH:ord and exhibits introduced at: hearinl;J h,'\"p'
been reviewed by the Hearing Officer. -
This is an appeal from a denial of NHC benefits.
1.
The appellant cont.ends that one half of the certifica:es of
deposit belong to Betty Polashock since both his ilnd her na~e6 ilre
on the certificates. ~s. polesho(:~ testified that halt oWll8rs~ip
was a gift from the appellant and thilt shl'! had not put i:1ny Illone~'
into the nccounts.
The CAD ma~es its decision based On regulations whi0h
provide, in pertinent parts that
".. , Resources which are availilble to t.he
applicant/recipient are applied against the MA resource
limit in AppendiX A tor the appropriate MA Program. This
includes resources in which the applicant/recipient has
only a partial ownership interest...
...If ownership is shared by applicants/recipients and a
person who is not an applicant/recipIent and if the
applicants/recipients have a separate legal interest which
can be disposed of without the consent of the other owners,
the applicants' /recipients' share of the resource is
presumed available., .
.., Persons who own an account jointly - for example, "and",
"or" ,"and/or" - own the ac.:count in proportion to their
contributions.. ."
.
55 PA con~ ~178.4
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In this case, the testimony and ~vidence presented at the
hel\/."ing, inr:luding the r:ommo.>ndable tCll't.hl'ighl: testimony of Ms.
Poleshock, leads the Hearing Officer to conclude that the CAO was
correct ill considering the total value of both certificates ot
deposit tis owned by and availtlble to the appellant. "The totlll
resources exr:~eded th~ income limits.
Accol'clingly, the appalll of tilt'! nppl~lll,\llt must be dl!Jllied. .'
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CERTIPICATE or SERVIQI
I, ,JILL M, WINEKA, ESQUIRE, do hereby certify that I served a
true and correct copy of Plaintiff's Answer with New Matter to
,Executrix's Petition for Settlement of Small Estate upon the
following by depositing same in the United StateD Mail, First Class
Postage, Postage Prepaid, addressed as follows:
M. Peter Harer, Esquire
Mirin & Jacobson
8150 Derry Street
Harrisburg, PA 17111-5260
At:tol"ney for Petitioner I
'Betty poleshock
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Ji M. Wineka, Esquire
At orney ID # 58802
PURCELL, KRUG & HALLER
1719 North Front Street
Harrisburg, PA 17102
(717) 234-4178
Attorneys for
Beverly Enterprises, Ino.
t/d/b/a Blue Ridge Haven'
Convalescent Center West
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Datedl
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LAW OPJllCES
MIRIN 8< .JACOBSON
"ISll DERRY STREET
HARRISBURO, PA 17111.S260
-,----.-.-
(717)S61.lm
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IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF JAMES E. CLARK -
BETTY POLESHOCK, EXECUTRIX,
Petitioner
NO. 1994-00423
PETITIONER'S ANSWER TO NEW MATTER
OF CREDITOR, BEVERLY ENTERPRISES, INC.'
t/a BLUE RIDGE CONVALESCENCE CENTER WEST
The Petitioner, Betty Poleshock, Executrix of the estate of
James E. Clark, files this answer to the new matter of Creditor,
Bev&rly Enterpri,ees, Inc., by and through her attorneys, Mirin &
Jacobson, and statesl
12. No response required.
13. Admitted.
14. Admitted.
15. Admit ted .
16. Admitted. By way of further response, Pet! tioner
informed the agent for Blue Ridge Haven West at the time of the
Decedent's admission to the nursing facility that the Decedent was
,
the owner of several certificates of deposit and a bank account.
Petitioner was informed by the agent for Blue Ridge Haven West that
Medicare would cover Decedent's charges for approximately ninety
(90) days, and that thereafter, she w"uld l'eceive monthly bills for
Decedent's nursing home care. On or about January 18, 1993,
Petitioner reoeived a letter from Blue Ridge Haven West indicating
that she was to pay $500.00 per month as the private pay portion
toward Decedent I s nursing home care (See Exhibit" B" to Answer and
New Matter of Beverly Enterprises, Inc.).
'. '.
17. Admitted. By way of further response, Petitioner had to
cancel her first appointment with the medical assistanoe office
scheduled for sometime in early May of 1993 due to her illness.
18. Admitted.
19. Admitted.
20. Admitted.
21. Denied. To the contrary, Petitioner paid on a regular
and timely basis the $500.00 monthly private paid port.ton of
Decedent's bill at Blue Ridge Haven West pursuant to Blue Ridge
Haven's correspondence of January 18, 1993.
On at least one
occasion, Petitioner transferred her own funds into Decedent's
checking account in order to make a payment to Blue Ridge Haven
West.
22. Admitted.
23. Admitted.
,
24. Denied. Decedent's funds were placed in joint accounts
with Petitioner at Decedent's instruction and direction at least
four years before Decedent's admission to Blue Ridge Haven West.
Jlddi tionally, Deoedent' s checking account was placed in joint names
prior to the time he granted Petitioner power of attorney over qis
bank accounts. At the time the joint aooounts were established,
Decedent indicated to Petitioner that he was doing so 80 that she
could more easily manage his funds and because he wanted her to
have the funds when he died.
25. Admitted.
26. Admitted.
27. It is specifically denied that Decedent was under the
~
ESTATE OF JAMES E. CLARK -
BETTY POLESHOCK, EXECUTRIX
Petitioner
IN RBI
I
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I NO. 1994 - 00423
I ORPHANS' COURT DIVISION
I
I
PETITION FOR SETTLEMENT OF SUIlU. ESTATE
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
mORE SHEELY. P. J.
MEMORANDUM OPINION AND ORDER OF COURT
On July 8, 1994, Betty Poleshock, as Executrix of the Estate
of James E. Clark, presented a petition to this court to settle a
small estate under 20 Pa.C.S.A. S 3102 (Settlement of small
estates on petition).
The assets listed on the petition were a 1971 Ford
Thunderbird vehicle and joint bank accounts between decedent and
petitioner. The petition alleged the bank accounts were not part
of decedent's Estate. The petition further alleged that twenty
(20) days notioe of petitioners intent to file the petition had
been given to Blue Ridge Haven West.
I signed the requested deoree on July 12, 1994.
On August 1, 1994, Blue Ridge Haven West filed an answer.
with new matter to the Petition for Settlement of a Small Estate.
An answer was filed by petitioner to the new matter on July
8, 1994. Section 3102, supra, provides that within one year
after a decree of distribution is filed, any party in interest
may file a petition to revoke the decree. If such a potition is
\,
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L'I 0
CD
REV-1!47 EX AFP (100093*
Cal1HOHllEAI TH Of PENHSVlVAHU
DEPART"E"T OF REVEHUE
BUREAU OF INDIVlaUAl TAKES
Of'T. 2B0601
HARRISIURO, PA 17128-0601
NOTICE OF INHERITANCE TAX
APPRAISENENT, ALLOWANCE OR OISALLOWANCE
OF DEDUCTIONS, AND ASSESSNENT OF TAX
ACN 101
DATE OF DEATH 11-26"93
FILE NO.
COUNTY
DATE 09-13-94
21 94-m3
CUMBERLANO
NOTE I TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBNJ.T THE UPPER PORTION OF THIS FORN WITH YOUR TAX
PAYNE NT TO THE REGISTER OF WILLS. NAXE CHECK PAYABLE TO "REGISTER OF WILLS, AGCHT"
REMIT PAYMENT TOl
BETTY J POLESHOCK
413 RUTHERFORD RD
HBG PA 17109
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, FA 17013
A.ount Roolttod
-
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CUT ALONG THIS LINE ... RETAIN LOWER PORTION FOR YOUR RECORDS ~
iiEV: iscij" ii(""Fii" f 1 ii:m" "NoYi or -OF -YNHEiii TAiic Ii" "fA'irA"1i Ii ilA"i S EifiNr; -" L. i."oWANc Ii - iili - - ..-...... -."""....
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF CLARK JAMES E FILE NO. 21 94-0(123 ACN 101 DATE 09-13-94
TAM RETURN WAS I (x 1 ACCEPTED AS FII.ED
b""
( I CHANGE "
RESERVATION CONCERNING FUTURE INTEREST .. SEE REVERSE
APPRAISED VALUE OF RETURN BASED ONI ORIGINAL RETURN
1. Rool Eltoto (Sohldulo A) (1)
2. Stookl Ind Bondi (Sohodulo BI 12)
5. Clololy Hold Stook/Portnorlhlp Intorolt (Sohodulo C) 151
4. Hortgogol/Hotol Rocolvoblo (Schodulo D) 141
5, COIh/Bonk Dopollto/Nloc. Porlcnol Proporty ISohodulo EI (5)
6, Jointly Ownod Proporty (Schodulo F) 16)
7, Tronl1orl (S~hodulo G) 171
8. Totol A..oto
.00
.l1Q..
,00
.00
.00
34.872.35
.00
(8)
34 ,B72. 35
APPROVED DEDUCTIONS AND EXEMPTIONS.
9. Funorol Exponlol/Ad.inlltrotlvo COltol
"tla.llenIDua Expen... (Soh.dull Hl
10. Dobto/Ncrtgogo LlobUitlOl/Llonl (Sohodull I)
II, Totol Doduotlcnl
12, Not Voluo of Tox Roturn
15. Choritoblo/Govorn.ontol Boquoltl (Sohodulo J)
14. Not Voluo of Eltoto Subjoot to Tox
NOTEI
191
(10)
4,173.00
29,521.33
(11)
(12)
(151
1141
33,694.33
1,178.02
.00
1,1711.02
If an aB.,sBment waB iBluad previOUSly, linl.
r.fl.ct figurls that includ. thl total of ALL
ASSF.SSHENT OF TAXI ---
IS, A.ount of Lino 14 toxoblo ot 6Yo rot. 115)
16, AMount of Lino 14 toxoblo ot 15Yo roto (16)
17. Prlnolpo1 Tox Duo
TAX CREDITS I
PAYHENT
DATE
14, 15 and/or 16 and 17 will
rlturn. I......d to dat..
.00 X.06 .
1,178.02 M.IS'
(17)
.00
176.70
176,70
RECEIPT
NUHBER
DISCOUNT (+)
INTEREST (-)
ANOUNT PAID
05-06"94
886043
.00
176,70
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTERES'"
TOTAL DUE
176.70
.00
,00
,00
. IF P,IIO AFTER DATE INDICATED, S~E REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST,
IF TOTAL DUE IS LESS THAN .1, NO PAYNENT IS REQUIRED.
IF TOTAL DUE 15 REFLECTED AS A "CREDIT" (CRI, YOU NAY BE UUE
A REFUND. SEE REVERSE SlOE OF THIS FORN FOR INSIRUCTIOHI,)
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RlIlRYATJONt Elt.t,. of dlcld.nt, dvln2 on or blfor. Dletlb., 12, 191Z ww If bnY futur. l"t.r..t In thl I.tlt. 1. trlnlferrld
In ,o"...lon or enJoy""t to ClI.. . (ooll1t",1) ben,Hol'r... of thl deoldlnt Ift,r thl Ixpl"Uon of env ..tlh 'or
'l1f. or 'orvI.r., thl COIlllOn....1th hlr,bY IlCpnllly r,,,,\I&11 thl rlDht to .ppr.l.. and ...... trln.f,r 1nh.rH,ncI 'IMII
at thl t.,..,ul CI... a (col111'ta1) rat. on anv such future l"t.r..t.
PURPOS! Ill'
HOllC!'
PAYNENT I
,Rl!FUHD (CRT,
OIJl!CTIDHt.
AOHIN
IITRATlYl!
C_CTIDHt,
OIICOUNT I
INTEREST,
"
To fulfill thl "CI\llr"lntl 0' Station 21U of the Inhtlr!tenol and Eltlt. Tile Act, Act 22 of 1991.72 P,S.
Ioo\lon 2140.
o.t"~ the top portloft of thh Hotlcl and tub. It with your paVN"t to thl Rlght.r of W11l1 printed on the river.. llde,
--Nok. chock or _. ordor p..obl. tOI REGISTER OF HILLS, AGENT
AU PIVHntl r.celv.d ,hlU fir.t bt appUtd to any Inhr..t which .ay ba d~ with any ra.llndar IPplled to thl tenc.
A ra.und a. a tlX credit, which WII not raquuhd on thl TIM Raturn, al~ tN requI.tad by o'o.phUng an "Application
.or Ra'und a. P.nn.ylyanl, Inhlrltanca and E.t,te T.~" (REV-1S1S). Appllc.tlon, .re Iv.llabl1 at th, O..lc.
a. tha Ralllttar o' NUll, any a. the 2S Aav.nuI Dhtrlot Offlca., or b~ cllllng the .p,ol.l 24-hour
,"'''Iring .arylcij nu~.r. 'ar 'or.. orderlnGI In Pwnn.ylv,nla 1-800-362-2050, aut.lda Pann.ylvlnl, and
within 10011 Hlrrltb\lrg ar.. (717) 787"8094, TODI (717) 112-2252 (Htlrlng Ilpalred Onlv),
Any party In Intarllt not ..tI.fI.d with thl IPprll..."nt, allowanc:a or dltlUowMca o' dlduaUr,n., or ........"t
of tllC (inoludlng dhcaunt or Intlr..t) al ohe"," on thlt Natlol IUlt cbJlot within .llCty (60) dl~' a. r,c.lpt of
thlo Netic. bVO
"-wrIUan protISt to th. PA O'Plrt.,"t of Aevenut, Board a. App..h, DEPT. 281021, Harrisburg, PA
--llIoHen to hlv' thl ..tt.r d.t.raln.d at audit a. tha IOCount a. the Plr.onal rIPr..lntaUvl,
--""11 to thl Orphan,' Court.
OR
mla-1021,
OR
hotull' .rror. dltoov"ad on thlt u......nt .hould ba addra..td In wrlUng tal PA D,part..nt o. RI"anutl,
.unlY of Indl"ldual TaMa., ArTNI POlt A.......nt Rlyll.. Unit, DEPT. 210601, Uarrhburg, PA 17121-0601 ,
Phonl (717) 787-6505. S.. pip 3 o. the l300kllt "In.truatlon. 'or Inhtrlt,nu TllC Return 'or I Rlllant
Uteldlnt" CAEV-lS01) 'or an Ixplanatlon a. ldalnl.traUv.lv corrlotablt .rroro.
If anv 11M due II plld within thrt. ~S) olllndar lonth. "ftlr thl IMcadant'. dlath, I five p.rcent (S:O dhcount of
tM tllC paid 11 allowld. . , '
tnt.r..t I. charg.d blllnnlng with fir.t dlY of dlllnquency, or nine (9) lonthl Ind on. (1) day'rOl the dltl ~f
delth, to the detl of pavant. TalC" whlClh bee,.. d.llnquent bl'ora January I, \982 b..r lntarllt It thl ratio'
.he (6l0 p.rcent par aMUII cIICUlltld at a dall~ rat. of .000164. All taXII which bacaa. dellnquant on and Iftar
Janu.ry 1, 1912 ~ll1 be.r Int.r..t It I rat. which will vftry 'roa oalandar y..r to calandar ya.r with that ratl
announcIld by the PAO.p.rt..nt o. R.venu.. Th' applloabl1 Internt "tu for 1912 through 1994 Irll
'!!.!!: Inttrott Aat. Dilly Intarllt Factor :!!!r Jnter..t Rita O.lh Inter..t Flctor
1982 lOX .00054a 1916 lOX .000174
19&! I6X .000451 1917 9X ,000147
1984 IU .000501 1918-1991 IU ,000501
IUS m .000156 1991 9X .000247
1995-1994 7X .000192
--Intarllt 11 ClJoUlltld .. follo~"
INTEREST . BALANCE OF TAX UNPAID X RUXBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
.....nv Notlcl J..uad .ft.r thl taM b.oo... dlllnquant will rafl.ot an lntarllt c.lculatlon to flU"" nS) day.
beyond thl dati of thl ......lInt. If plYllnt 11 aide aftar the Interllt cOlJpUtaUon dltl .hown on the
~t1CI, additional Intar..t lIU.t be c.lculated.