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02-6028
COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS JUDICIAL DISTRICT NOTICE OF APPEAL DISTRICT JUSTICE JUDGMENT NOTICE OF APPEAL Notice is given that the appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice an the ~4e and in the case mentioned below. 09-2-01 HCR Manor Care ~v ST^TI zeccx~ c/o Wolfson & Associates, P.C. 267 East Market Street York PA 17403 ~,~o~oce~ ~c^s~o~(~ Thomas Gregor, I~.~'~;o/b/© Francis 11/26/02 MCR Manor Care vsGra~mr. Deceamed CV 20 0?-403 LT 20 This block will be signed ONLY when this notatian is required under Pc~ R.CJ~.JJ>. N~ If 81~llal~ w85 CLAIMANT (s~ Pa. R.C.P.J.P. No. 1008B. 1001 (6) in action before District Justice, he MUST This Notice of AppeoJ, where received by the District Justice, will operate as o SUPERSEDEAS to the judgment for possession in this case FILE A COMPLAINT within twenty (20) days after filing his NOTICE of APPEAL. Signature of Prothono~y or Deputy PRAEClPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of fo~rn to be used ONLY when appellant was DEFENDANT (see Pa. R.C.P.J.P. No. 1001(7) in action before District Justice. IF NOT USED, detach from copy of notice of appeal to be sen/ed upon appellee). PRAECIPE: To Prothonotary , appellee(s), to file o complaint in this appeal Enter rule upon Name o~ ame#eeis) (Common Pleas No. ) within twenty (20) days after service of rule or suffer entry of judgment of nan pros. RULE: To , c~dlee(s). (1) You am notified that a rule is hereby entered upon you to file a complaint in this appeal within twenty (20) days after the date of service of this rule upon you by personal service or by certified or registered maiL (2) If you do not file a complaint within this time, a JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU. (3) The date of setwice of this rule if service was by mail is the date of mailing. Date: ,20 COURT FILE TO BE FILED WITH PROTHONOTARY AOPC 312-90 PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT {Thts ptool of set'wce MU.q,,T BF~' F/l ~:J) W/ThLN I'EN ( h:?) £)A t,,S AF TER hltt~,g the not~;e of at~l~e~/ COMMON WEALTH OF PENNSYLVANIA COUNTY OF AFFIDAVIT: t hereby swear of affirm that l served [] a copy of the Notice of Appeal, Common Pleas No.. .................. report he District Justice designated thereJe on (date o!service) L3 by personat se~,~ce ~ by (cedified) (registered) maii, sender's receipt attached hereto, and upon the appe ~e, (t ame~ on , = ' ~ by personae Sef'vJ~ ~ by (cedified) (reg s ered) maii, sender's receipt a~ached hereto D and fu~her that t served t :e ~Fife a Comptamt accompanying the above Notice of Appeai upon the appellee(s) to whom the Rule was addressed on ....................................... 20 ~ by persona~ service ~ by (certified) (registered) ma~t, sender's ~e(~ipt ~ttached he~eto SWORN (AFFIRMED) AND SUBSCRIBED BEFORE: THIS ..... DAY OF "~' Sigr alum, ef offiu el before whom afl, day t ;¥a~' ,'n,~de Signature of afl/an*. Title of My commission expires on _COMMONWEALTH OF PENNSYLVANIA COUNTY OF: CUI.~ERLAND Mag Dist NO: 09-2-01 DJ Name: Hon PAUI~ P. CORREAL Address: 1 COURTHOUSE SQUARE CARLISLE, PA (717) 240-6564 HCR MANOR CARE 267 E.MARKET ST YORK, PA 17403 17013-0000 NOTICE OF JUDGMENT/TRANSCRIPT CIVIL CASE PLAINTIFF: NAME and ADDRESS r-GREGOR, THOH~S, IND/& O.B.O.FRANCIS ~ 1306 DICKINSON DR CARLISLE, PA 17013 L VS. DEFENDANT: NAME and ADDRESS [-HCR MANOR CARE 267 E.MARKET ST YORK, PA 17403 Docket No.: CV-0000403-02 Date Filed: 10/17/02 CROSS COMPLAINT 001 T~iS IS TO NoTiFY YOU THAT: Judgment: ~-~-1 Judgment was entered for: (Name) [-~ Judgment was entered against: (Name) in the amount of $ ~0_ h0 on: [--~ Defendants are jointly and severally liable. ~ Damages will be assessed on: ~-~ Th!s case dismissed without prejudice. ~ Amount of Judgment Subject to Attachment/Act 5 of 1996 $ [---] Levy is stayed for__ days or ~'~ generally stayed. ! I Objection to levy has been filed and hearing will be held: FOR PT,ATN~IFF (Date of Judgment) (Date & Time) Amount of Judgment $ 350 o 00 Judgment Costs $ o 00 Interest on Judgment $ o 00 Attorney Fees $ .0O Total $ 350.0(] Post Judgment Credits $ Post Judgment Costs $ Certified Judgment Total tDate: Time: Place: ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT BY FILING A NOTICE OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON PLEAS, CIVIL DIVISION. YOU MUST INCLUDE A COPY OF THIS NOTICE OF JU~~SCRIPT FORM WITH YOUR NOTICE OF APPEAL. ~ Date d~..~_<,,~_ _~ '--/-~,¢,'u~, ,~ ,DistriCt JUstice. II certify that this is a trut~ edings co /he judgment,, ~c~ O~CO~O~ nt~j,~ . Date ~: ,/~)"k ~ ~ ..,/-./' : , District Justice My commission expires first Monday of January, 2006 *~, SEAL AOPC 315-99 PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This proof of serv/ce MUST BE F/LED W/THIN TEAl (1 O) DA YS AFTER filing the notice of appeal. Check applicable boxes) COMMON WEALTH OF PENNSYLVANIA COUNTY OF. _ I! I,IJ~, ~ _ ; ss AFFIDAVIT: I hereby swear of affirm that I served I~, a copy of the Notice of,App./al, Common Pleas No. ~ , upon the District Justice designated therein on (date of se,vice) [2.!2~1~00~ , [] by person~'~'rvice I~ by (certified) (registered) mail, sender's receipt attached hereto and"upon the appeile, (name) "rhh~QS C-~I('~' , on [ 2. ~ , 20 ~ [] by personal serv ~ ~ b-y (Certified) (N~istered) mail, sender's receipt attached hereto. ~ and f~rther that I served the Ru~ to File a Complaint accompanying the above Notice of Appeal upon the appellee(s) to whom the Rule was addressed on ,20 [] by personal service [] by (certified) (registered) Title ~f My commission expires on mail, sender's receipt attached hereto. SWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME Signature of officia/befor; wt,om or'davit wa; made -- Y City O~ Yo~k, Yo~k County My ~ ~ A~. 1~ ~ Signature of affiant zC'3 ~ Z COMMONWEALTH OF PENNSYLVANIA COURT Of COMMON PLEAS JUDICIAL DISTRICT NOTICE OF APPEAL DISTRICT JUSTICE JUDGMENT NOTICE OF APPEAL Notice is gi~n that Ihe appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice off the HCR Manor Care c/o Wolfson & Associates, P.C. 267 DAI~ O~ JIJDCdaENI' [ IN ?NE CAS~ Of:/P/a~rlt~) 11126102 IHCR Manor Care I ~ I~'T. NO. Oil NAME C~ DJ. o - -ol East Market Stree~ York' ~ /'PA 17403 Tho~s Gregor, I~o/b/o Francis ~Gre=or. Deceased 1008B. This Notice of Appeal, when received by the District Justice, will operate as a SUPERSEDEA$ to the judgmeflt for possession in this cas~ S~ of Prothonotary or Deputy 1001(6) in action before District Justice, he MUST FILE A COMPLAINT within twenty (20) days after of A O AL. PRAECIPE TO ENTER RULE TO FILE COMPL/AINTJI~I~D~'i{U£E T'0~'flLE (This section of form to be used ONLY when appellant was DEFENDANT (see Pa. R.C.P.J.P. No. 1001(7) in actio~ before District Justice. IF NOT USED, detach from copy of notice of appeal to be served upon appellee). PRAECIPE: To Prothonotary , appellee(s), to ~ea complaint in Ibis appeal el:~ee( s ) _.~ .:. . within twenty (20) days after service of rub or suffer en~'b_f jqdgment _of rm~pms. Enter rule upon RULEs Name ' ~ .. (1) You am notified that a rule is hereby entered upon you to file a complaint in this appeal within twenty (20) days after the date of service of this rule upon you by pmsonal service or by certified or registered mail (2) If you do not file a complaint within this time, a JUDC, MENT Of NON PROS WILL BE ENTERED AGAINST YOU. (3) The date of service of this rule if smvice was by mail is the date of mmling. Date: ,20 . AOPC 312-90 .-~ COURT FILE 13" Postage Certified Fee Return Receipt Fee ..'r (Endorsement Required) r-I Restricted Delivery Fee r--I (Endorsement Required) I-1 Total Postage & Fees m Postmark Here .................................... City, State, ZIP+ 4 'iqnbul Lie Ouiqem uaq~ e41 UI~M aoe!dl!em o41 ~Jew Jo ~JalO Jo eesseJppe e4~ ol pelopisaJ Jo~ Jea~eM ea~ e ealaoaJ o1 ',,~Isan~ ldle~ uJnlaH,, ~a~dl!e~ e~opua 'aaj G~I JeAOO O~ e~eisod alqeo!ldde ppe pue uJnle~ e q~eIle pue eialdmoo eseeld 'eol~es ld!e~ jo jooJd ap[A~d Oj pelsen~ 'l!e~ p~eIsl~e~ Jo ~nsul Jep!suoo aSeeld 'selqenleA Joa 'lle~ paulpeo qi!M ~3alAO~d 'llem leUOlIeuJelu! sJeeX o~ Postage $ Certified Fee Postmark Return Receipt Fee Hers (Endorsement Required) ReStricted Delivery Fee (Endorsement Required) Total Postage & Fees ~.'¢: _6.~.t...v~.~. ~: ....... ; .................. ~.~~--- -!Pa eql ~u~)se4d eseeld 'peJ!sep s! ld!eoeJ I!e~ ~!pe: Jo eesseJppe e~l ol peloplseJ eq Xe~ ~eNlep 'e~)t S! Jd!Go~J I~e~ ~g~O Jno~ uo ~JemJs~ JOt JGA]RM ~eJ B ~A~G~J 01 ',,~lsen~B ld~e~ uJnle~,, e~j JgAO00~ a~lsod elqeO~ldde ppe pug elO.Ue Jo JooJd eplAoJd o; pejsen~ ~ Xe~ ld!e~ 'l!e~ peJels!~e~ Jo peJnsul JGp~suoo asea cl 'salq~nleA Jo~ 'l!e~ pe!Jl~eO ql!M Q3QIAO~d SI "l!e~ IBUOll~uJelu! Jo SS~lO Xu~ 'l!e~ XJ!Jop~ JO I~e~ SSelO-lsJlJ ql!M peu!qmoo eq A]NO :s~apul~a~ 7ue~od~I s~ee~ o~l JO~ eo!~eS le]So~ ~e~lep uodn eJn]au~!s V eoeid :sapl~oJa Iie~ paijipa3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. THOHAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant NO. 2002-06028 CIVIL ACTION - LAW NOTIC~ You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice is served, by entering a written appearance, personally of by attorney, and filing in waiting with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation. Used debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, la torte tomara medidas y psedido entrar una orden contra used sin previo aviso o notificacion y pot cualquier qued o alivio que es pedido en la peticion de demanda. Used puede perder dinero o sus propiedades o otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. S! NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. THOMAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant COMPLAINT NO. 2002-06028 CIVIL ACTION - LAW AND NOW, this 8th day of January, 2003, comes the Plaintiff, HCR Manor Care, by and through its attorney, Amy F. Wolfson, Esquire, and the law firm of Wolfson S[ Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Thomas Gregor, is an adult individual with a last known address of 1306 Dickinson Drive, Carlisle, Cumberland County, Pennsylvania 17013. 3. That on or about July 13, 1999, the Defendant applied for the admission of his father, Thomas Gregor (hereinafter "Decedent"), into the Plaintiff's health care facility. A true and correct copy of the Application for Residency is attached hereto, incorporated herein, and marked as Exhibit "A". 4. That Defendant warranted and represented that the information he provided regarding the Decedent in the Application for Residency was complete and accurate and that the Plaintiff could rely on the information he provided therein. See Exhibit "A", page 4, previously identified and incorporated herein. .~rvices provided by Plaintiff that were not compensated. See Exhibit "B", specifically, the Imission Agreement's Conditions of the Responsible Party Appointment, as previously ied and incorporated herein by reference. 15. That Plaintiff billed Defendant for Decedent's charges in ~July 1999 through ~ctober 1999 and which Defendant acknowledged his contracual duties and remitted ayment to the Plaintiff as required pursuant to the Admission Agreement. A true and '~orrect copy of the checks submitted by Defendant for the above period is attached hereto, ncorporated herein and marked as Exhibit "G". 16. That at the time of admission Plaintiff courteously agreed to assist the ndant with his third party payor and governement payor billing obligations and billed [edicare and Continental Life Insurance Company for their services pursuant to the policy ~rmation as indicated on the above insurance cards provided by Defendant. A true and :orrect copy of the Medicare billing statements are attached hereto, incorporated herein ~nd marked as Exhibit "H". 17. That Decedent's Medicare benefits were forwarded to Plaintiff for the ~ervices provided to Decedent but Continental Life Insurance Company denied benefits to Decedent. 18. That Plaintiff received no information from Continental Life Insurance ~any nor from Defendant regarding the outcome and or denial of benefits by Continental Life Insurance Company whereby in March 2000 Plaintiff initiated contact with Continental Life Insurance Company and was informed that there were no benefits available for the Decedent's care at Plaintiff's facility. 19. That Plaintiff immediately began billing Defendant for the Medicare co- payment of Decedent in March 2000 after learning that no benefits were available to I)ecedent from Continental Life Insurance Company and, Plaintiff continued to bill monthly thereafter throughout year end of 2000. See Exhibit "D", previously identified and incorporated herein. A true and correct copy of the monthly billing statements are attached hereto, incoroprated herein and marked as Exhibit "1'. 20. That the Decedent incurred a debt in the amount of Four Thousand Nine Hundred Ninety-Two and 00/100 ($4,992.00) Dollars to Plaintiff while a Resident of Plaintiff's health care facility for health care treatment and services provided pursuant to the Admission Agreement, that was not compensated by a third party payor or government program, and which is comprised of Decedent's co-insurance portion payments. 21. That Plaintiff sent Defendant a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. 22. That Defendant did not object to the above mentioned itemization of services submitted by Plaintiff to Defendant. 23. As of the date of filing of this Complaint, the balance due, owing, and unpaid on Decedent's account as a result of said charges is the sum of Four Thousand Nine Hundred Ninety-Two and 00/1 O0 ($4,992.00) Dollars. See Exhibit "D' as previously identified and incorporated herein by reference. 5 24. Despite Plaintiff's reasonable and repeated demands for payment, Defendant has failed, refused, and continues to refuse to pay all sums due and owing on Decedent's account balance, all to the damage and detriment of the Plaintiff. 25. Plaintiff has made numerous requests to Defendant, as Power of Attorney and Legal Representative/Responsible Party for Decedent, demanding that the sums due and owing to Plaintiff be paid, and Defendant, as Power of Attorney and Legal Representative/Responsible Party for Decedent, has ignored both his fiduciary obligation and contractual obligation to pay necessary and appropriate bills and obligations for his father, the Decedent. 26. That Defendant's willful failure to remit Decedent's monthly social security and pension benefits income to Plaintiff was a direct violation of the Admission Agreement Defendant executed with Plaintiff. See Exhibit "B" as previously identified and incorporated herein. 27. That at all times relevant thereto, said social security and pension benefits payments were not made available to the Plaintiff by the Defendant. 28. That the finances and income of the Decedent rightfully belonged to the Decedent for his necessary and appropriate medical services and treatment rendered by Plaintiff to the Decedent, however Defendant failed to utilize Decedent's finances for that intended purpose. 29. That Defendant voluntarily contracted with Plaintiff for services to be provided to the Decedent. 30. That Defendant knowingly violated his contractual dudes and responsibilities as the Legal Representative/Responsible Party for Decedent, under the ,~dmission ^greement, by failing to utilize Decedent's financial resources to pay Plaintiff when he knew or should have known there were outstanding medical bills for the care of the Decedent. 31. That Defendant knowingly ignored his contractual duties and responsibilities as the Legal Representative/Responsible Party for Decedent, under the ^dmission ^greement, by failing to pursue Decedent's insurance resources thus effectively forcing the Plaintiff to pursue Decedent's insurance company, Continental Life Insurance Company, to determine if any benefits were available for the Decendent's co-insurance responsibility. 32.. That during the year 2.OO! the Defendant made no inquiries on behalf of Decedent with Continental Life Insurance Company to determine Decedent's eligibility for benefits to compensate the Plaintiff for the services provided to Decedent while a Resident. 33. That Plaintiff believes and therefore avers that Defendant was informed by Continental Life Insurance Company that Decedent was not eligible for any benefits to compensate the Plaintiff for their services and that he failed to notify Plaintiff of that determination. 34. That Plaintiff believes and therefore avers that Defendant did not apply for l~ledical ^ssistance benefits on behalf of Decedent that may or may not have been available to compensate the Plaintiff for the services provided to Decedent while a resident with the Plaintiff's facility in direct violation of the fifth "Conditions" pursuant to the ,~dmission ,~greement. See Exhibit "B", previously identified and incorporated herein by reference. 35. Plaintiff has retained the services of the law firm of Wolfson ~ Associates, P.C. in the collection of the amounts due from Defendant. 36. Pursuant to Paragraph 8 of the Fee Schedule, which was attached as parc of the aforementioned Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay reasonable attorney's fees and all court costs if the account is referred to See Exhibit "B" as previously identified and incorporated an attorney for collection. herein. 37. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson ~ Associates, P.C. in the collection of the amounts due and owing by Defendant incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendant. 38. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of One Thousand Four Hundred Ninety- Seven and 60/100 ($1,497.60) Dollars. 39. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 40. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 8 WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against. Defendant, Thomas Gregor, Individually and on behalf of Francis Gregor, Deceased, in the amount of Four Thousand Nine Hundred Ninety-Two and 00/1 O0 ($4,992.00) Dollars, plus reasonable attorney's fees in the amount of One Thousand Four Hundred Ninety-Seven and 60/1 O0 ($1,497.60) Dollars, the costs of this action, and such other relief as the Court deems proper and lust. Respectfully submitted, o ?son, c Wolfson ~ Associates, t'.~. 267 East l~larket Street York, PA 17403 (717) 846-1252 Attorney ID 87062 9 VERIFICATION I, Michelle Thureson, being the Senior Financial Consultant for HCR Manor Care, verify that the statements made in the foregoing Complaint are tree and correct to the best of my information and belief. ! understand that false statements herein are made subject to the'penalties of 18 Pa. C.S. Section 4904, relating to unswom falsification to authorities. DATE: t ig~i6~ HCR MANOR CARE Senior Financial Services Consultant APPLICATION FOR RESIDENCY ManorCare Health Services To apply for admission at our Nursing Center, please complete the following questionnaire, sign, and return it to the Admissions Office. This application will become a .part of the "Admission Agreement" and should be completed in its entirety. All information will be held in confidence. The complete medical history and physical examination results will be recorded on another form. Name of Prospec~j.ve Resident: ,F-~,,,xl (..i Address: Telephone No.: Date of Birth: Month Place of Birth: City Marital Status: Married Name of Inquirer: Address: Sex: ,~/ld/~ Age: Social Security No.: /"~?"/~- - Day .~.,~ Year ,-~ Single State (County) Widowed ."~" Relationship: .~cc ,~ ! ~P/~'~"'-' Telephone No.: ~Q(:/~-' ~-~ ~'~ Name Other persons to contact (in case of emergency) Relationship, Address .,-.~,,~¢' Telephone No. ~.~ 9.~ 9- 9 ? ~-/ How did you hear about 1. Personal Referral 2. Hospital 3. Physician 4. Other Nursing Home/ACLF Nursing Center 6. Newspaper/Magazine 7. Television/Radio 8. Yellow Pages 9. Mailing/Brochure 5. Health Dept. S NO MHC-O08-6 (7/96) IF YES, WHICH ONES? MEDICAL/PERSONAL DATA Diagnosis: i~ ~' .- Resident's Current P~ysician: Physician to Follow at Facility: / 1. __~ Mentally Alert 2. ~ Slightly Forgetful 3. ~ Confused 4. _.._~ Ambulatory 5. ~ Walks with Assistance 6. ~ Requires Bedrails Admission Desired On: Reason for Seeking Admission: 11. 12 .... Bed Ridden Requires Special Diet Able to Eat Without Assistance Requires Assistance with Eating Incontinent }x'~' Continent Resident Now At: The Name(s) of the person(s), other than the resident, who will be financially responsible for the cost of care (the "guarantor"), if any. While a guarantor is not required for admission, the facility does require that a source of payment be identified to pay for the Resident's care. Name Address Home Telephone (Any person(s) whose names are listed here must also sign this application.) Has a trust account been established? Yes No Has a power of attorney conferred on the person(s) to be financially responsible? Yes No If yes, please provide a copy. 2 Has a legal guardian been appointed by a court? If yes, please provide a copy. Yes No FINANCIAL DATA To process your application, the following information is needed. The information supplied is confidential and allows us to assist you in your long-term planning. The financial data should be that of the Resident and/or the Guarantor. All income and amounts listed, whether under the Resident or Guarantor section, must either be owned by the Resident or in fact be available to the Resident to pay for the Resident's stay while at the facility. Your cooperation is appreciated in order to expedite admission. Please note that it is not mandated that a Resident have a Guarantor, only that an adequate source of payment be identified. Thus, any person who agrees to be a Guarantor is doing so voluntarily. MONTHLY INCOME Salary Social Security Pensions/Annuities IRA Interest/Dividend Income Rental Income Trust Investments/Other RESIDENT ! GUARANTOR (if any) $ TOTAL MONTHLY INCOME ASSETS: Cash (Itemize by bank/account #) Securities (Stocks/bonds) Trust $ $ $ $ 3 Real Estate (Description/location) Ex: 3 bdrm. hse., 3 Maple Ave., Anywhere, IL RESIDEHT GUARANTOR (if any) $ $ ~-- Other Assets: Cash Value of Life Insurance Vested Pension Benefits Business Interests Automobiles Other $ $ TOTAL ASSETS: Liabilities: Home Mortgage Credit Cards/Charge Accounts Loans other Debts Taxes Owed $ $ $ $ TOTAL LIABILITIES: $ $ NET WORTH (ASSETS - LIABILITIES): $ Please Sign Below: I hereby warrant and represent that the information provided is accurate and complete. I understand that the nursing facility will rely upon the accuracy and completeness of the above financial information in making an admission decision. I also understand that if any of the information is not accurate or not complete, the Facility will have detrimentally relied upon th~/above financial information and will suffer financial loss and harm. The assets listed a~ in fac~t,avai~ble to the Resident to pay for the Resident's care. -~/~R~Jd~ or Resp0'~Party's Signature .Date/ ~' Guarantor's Signature Date Reviewed by: Admissions Director's Signature Date Administrator's Signature Date EXHIBIT "B" ONTRACT..?BE WEEN PA IE,N RE ID N iiii!AND}ii!iEAC!M ,.. ManorCare Health Services ~THIS, ADMISSION AGRE~,.~ENT (the "Agreement") is entered into this //~ ~" day of' //~//L// ,19 ~ , between M~,~O~r'_A_~_~ ~_A~_.?_-_ S~?.'ZT¢_~S (the "Facility"), and ~"-~/~'~ ~: ,'~ ~o ;g~,~,o,'- ithe "Patient/Resident"), and/or .'7-'j_,/,->~._S ~/"¢~ c~'-- (the "Responsible Party~ ). As used herein, the term "Patient/Resident" shall also mea~'the~esponsib~e Party, if any. The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. HoweVer, the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's discharge. 3. Responsible Party. The Patieni/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and Shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records nr information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to. government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. laHc.ooa-~o (Rev. 7/961 cg 3 1 of 3 men; ana car, e o1' an attending physician, and consents to the Facility rendering nursing dare, therapeutic, and other treatment under the general or special instructions of said physician or ~ case of emergency. 7. Attending Physician. The-'Pa~ient/Resident is solely responsible for selection of a lidensed. attending physician. The Patient/Resident ~grees 'that the Facility may require the Patient/Resideni to utilize another physician if the attending physician (1) has his/her own professional license limited, susp.end~d or revoked; (2) fails to follow the Facility's rules and regulations; or (3)is unavailable in case of emergency. The Patient/Resident is responsible for all charges for physician services. 8. Pharmacy_. The Patient/Resident shall execute the Pharmacy Agreement attached as Exhibit _C. 9. Independent Contractors. The Patient/Resident acknowledges and ag~:ees that all physicians; dentists and barbers/beauticians, including those whose services are arranged by the Facility, are independent contractors and are not employees or agents of the Facility, and the Facility shall not be responsible for their acts or omissions or for the consequences of following physician or dentist orders. 10. Private Duty Personnel. The Patient/Resident acknowledges that all pritL.'~e duty personnel that the Patient/Resident utilizes are not employees or agents of the Facility and that the Facility is not liable for acts or omissions by such personnel. Employees of the Facility may not be employed as private duty personnel at the Facility, Ali private duty personnel shall comply with all policies and ;s of the Facility as may be amended from time to time without notice. Failure to do so may result in their being denied access to the Facility. Patient/Resident and Responsible Party shall be solely responsible for the cost of private duty pers°nnel. 1 1. Facility Guidelines for "No Heroics" Requests. Decisions regarding life support should be con- sidered by each Patient/Resident or his/her authorized surrogate decision-maker. The Patient/ Resident acknowledges receipt of rights under state law to make decisions about medical care, in- cluding rights to accept or refuse care and rights to make an advance decision about care. The Patient/ Resident acknowledges receipt of a summary of the "Facility Guidelines for No Heroics Requests" (?e "Guidelines"). A full text of the Guidelines will be provided upon request. In part, the Guidelines provide that the Facility will not withhold or withdraw life-sustaining or life-prolonging measures from a Patient/Resident without a written and legally sufficient authorization of a competent Patient/Resident or legally authorized surrogate decision-maker and a physician order. The Patient/ Resident agrees to comply with the GuideJines. 12. Liability and Indemnification. The Patient/Resident understands that the Facility is liable only for injuries caused by the negligent acts. or omissions of the Facility and as required by law. The Patient/Resident shall inde'mnif:y~,and hold the Facility harmless from any and all claims, suits and actions made against the'.E, acflity by any. person resulting from any damage or injury caused by the. Patient/Resident. to any person..or'tbe, property of ~ny person or entity (including the Facility). 13. Patient/Rbsident:~.Handbook. The,. Patient/Resident:. acknowledges receipt of the Facility's Resident's Handbook:artd:.agrees.~to. comply with such Rules and Regula't~ons contained therein:' The Patient/Resident acknowledges.:ajt.d_.agrees, that he/she shall be responsible for and shall hold the Facility harmless foJ". any' injudes:.oc damages'.which are caused by the Patient/Resident's failure to Lt comply with 's~Jch rutes, a~d-:regtJlations: The policies, procedures, rules and regulations regarding he following areas, amang:'c[thers, are~ detailed in the Resident's Handbook: · Federal Resident Rights · Resident Responsibilities · Life Sustaining Treatment Policy · Medical/Nursing Education · Dental, Vision and Hearing Services · Interdisciplinary Care Conference · Utilization Review Meetings (if applicable) · Personal Laundry Policy · Barber/Beauty Services · Mail Policy · Voting Materials · Photo/Media Events · Personal Fund Account Procedure · Tobacco Policy · Grievance Procedures · State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default of this Agreement shall not operale as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the partie.%s, hereto have executed2 as of and/~/~/f/~2 //~.,,~'~-~"~year abov~ ~written.. .. (~'~ [ b'6¢'"' ~/~/// Admission Agreement the day ¢.._~ty"RE Cresentative -- signature t f' Responsible Party - S i~n .~, _ __ - ~a~ility R~ )resentative - Printed Name ~ Titl~ ResDonsibl~ Party - Printed N~e MHC.OOa.~O (Ftc', 4/96) pg 5 3 Of 3 Conditions (collectively referred to as "Conditions") 1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. All of the information, including but not limited to that contained on the attached Application for Residency, dated ,199 ____, and which is attached hereto and made part of this Exhibit and of the Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the Patient/Resident's assets and/or assets which are available for the Pat- lent/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. o When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives, If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges not covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and under~,, n¢ls and acknowledges that if the above warranties and representations are not true, or if the/~.,~ove covenants and agreements are not complied with, the Facility will have detrimentally relied,~n them and,]the Facility will suffer financial harm and loss. ....~ __ //.~ iR/e si~nsi"~bl~ ~a~r t y/_'~u re~__ -- Responsible Party - Printed ~ame aNc-oo..=o (Rev, 4196) pg 7 2 of 2 1. Daily Rate. The daily rate is $_/_~,~)-00. The monthly rate equals the daily rate multiplied by the number of days in the month. The daily rate is billed one month in advance and includes: · Routine Nursing Care · Linens · Social Services · Meals (additional fees may apply) · Activities · Housekeeping · Room (circle one): Private Semi-Private Triple The following are paid by Medicare in addition to the items included in the daily rate: · Approved Rehabilitative/Therapy Services · Approved Medications · Approved Nursing Supplies · Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): · Approved Rehabilitative/Therapy Services · Approved Medications · Approved Nursing Supplies · Approved Equipment · Approved Routine Personal Hygiene Items/Services · Other approved services/items covered and paid for under the state Medicaid program. 2. Supplemental Services & Supplies. The daily rate may' not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM · Private Room · Prescription & Non-Prescription Drugs · Nursing & Personal Care Supplies · Transportation · Nursing Care (Other than ordinary nursing care) · Physical, Occupational & Speech Therapies · Phone, Cable TV, Newspaper, Barber/Beauty · Special Equipment · Bed Hold Fees · Personal Laundry (Personal Clothing) · Nutritional Supplements · Alternative Nutrition (Tube Feeding, TPN, etc.) RATE Based on location & level of care As determined by pharmacy See business office for current prices As determined by transport company See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever a Patient/Resident leaves the Facility. For Medicaid Patien[/Residents, bed holds are pursuant to state law. 4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies which may be needed by and provided to the Patient/Resident, all additional costs/charges may not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in level of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the Facility no later than the day before the rate increase is effective. M/.IC-OOa-2o (Rev. 4/96) p~ 8 1 of 2 6. Refunds. F~efund~ shall be paid within thirty (30) days after discharge 'or tran'sfer. 7. Funding Sources. The Facility makes no assurances that the Patient/Resident's care will be covered by any third party payor. 8. Payment Policy. All amounts due. shall be paid promptly within ten (10) days of billing. Failure to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in full shall be subject to a one and one-half percent (11/~%) service charge on the past due balance each month until the balance due is paid in full. This amounts to eighteen percent (18%) annually on' the unpaid balance. If the maximum annual service charge allowed by state law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall apply. Should the Patient/Resident's account be turned over for collection to an attorney or collection agency, or should the Facility seek to interpret or enforce any other provision of the Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees of the Facility if the Facility prevails. 9. Responsibilities. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services/supplies not paid by any third party, as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/ Resident is transferred to a different room or the level of care or payor status changes. The Patient/ Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility is released from all liability for harm which may result. Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for all charges. The Patient/Resident is rosponsible for payment 'for items covered by Medicare supple- mental insurance and for applying for reimbursement from his/her insurer. Medicaid Beneficiaries: (circle correct number) 1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the Facility with at least four (4)_.?o_9.Qnt_hs..pr_ier-.~f;~ent/Resident,s becoming eligible for the Medica_id c~r thei~ being unable to pay privately; ~ MeOdRicaid 2) ,¢~~, e Fac!!i. ty currently participates in the program. I, the P~tient/Residen, believes ~e/s.~q. ualifies for Medicaid, he/sh¢;-~all promptly complete and s~ all documents required to apply-for--eever~ne lnclud~nQ ore admissIon Rnnrr~¢ot ~ -,.~' ' _. - ' ~'on ~n~L !f ,~¢m:jt0,~TS-~overage is denied, the Patient/ ~t will be liable for all charges from the admission date. When Medicaid pays for only a portion of the ~ncurred cha~s,-t-he-P~ien.t/Resident shall be responsible for paying his/her portion, as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay- ment of Facility's current charges for any requested non-Medicaid covered services/supplies. The Patient/Resident will provide financial information regarding monthly credits, increases/decreases in the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaid ~epresentatives. MNCoO08-20 (Rev. 4/96) icg 9 2 of 2 Facility has developed policies and procedures for drug therapy, distribution and control which provide for a uniform medication distribution system. The Facility has selected a pharmacy (the "Designated Pharmacy") to provide medication under such distribution system. The Facility reserves the right to change the Designated Pharmacy at any time. The Patient/Resident is hereby notified that the Facility's parent corporation (i.e., Manor HealthCare Corp. or one of its affiliates) has a significant financial interest in Vitalink Pharmacy Services, Inc. which operates under the following names: Vitalink, Northern Nursing Home Pharmacy, West End Family Pharmacy, Propac Pharmacy. Apothecary Pharmacy Services, Parker's Pharmacy, Home Intravenous Care and Brentview Pharmacy. The Facility may have selected one of these entities as the Designated Pharmacy. The Patient/Resident has the right to use any pharmacy so long as that pharmacy will furnish the same medication distribution system noted above, and comply with the Facility policies and pro- cedures and all applicable laws and regulations. For Medicaid Patient/Residents, the Designated Pharmacy will file claims for payment directly with the Medicaid Program for any covered claims. If the Patient/Resident utilizes a different pharmacy, the Patient/Resident must make arrangements with such pharmacy for similar filing of claims for payment. All charges shall be billed to the Patient/Resident or the Patient/Resident's third party payor directly and shall be payable in full. The Designated Pharmacy reserves the right to terminate any account for any reason after written notice of such intent has been given to the Patient/Resident. ~The undersigned selects the Designated Pharmacy (as may be changed by the Facility ! from time to time) as the supplier of medications prescribed for the Patient/Resident while at the Facility. The undersigned selects as the supplier of medications prescribed for the Patient/Resident while at the Facility. The undersigned understands and agrees that such pharmacy must comply in ali respects with the Facility's uniform medication distribution system, all Facility policies and procedures and applicable law. If such pharmacy fails to do so, the undersigned shall be required to select another pharmacy. The above pharmacy ,¢~all acknowledge and agree in writing that it will comply with the Facility's uniform me/Ci6ation distribution system, the Facility's policies and procedures and applicable ~ ~ esponsible ~arly -- Printed ~me MHC-OOe-20 (Rev. 4/96J Dg 10 1 of 1 The Admission Agreement is amended in the following manner, in order to comply with state law and/or regulation: (Indicate additions to, and/or deletions from, the Admission Agreement required by state law. If no additions/deletions are necessary, indicate "NONE".) NONE MHC-O08-20 (R~v. 4,/96} pg 1 I I of 1 ~NAME (Print or Type) I H.I, CLAIM NUMBER I Section I I appoint this individual: (Print or type name and address pi individual you want to represent you,) to act as my representative in connection with my claim or asserted right under Titles XI, or XVlll of the Social Security Act. I authorize this individua! to make or give any request or notice; to present or to elicit evidence; to obtain infor~tion; and to receive any notice in connection with my claim wholly in my stead. S~G~(Beneficii7~ ADDRESS Area Code) Section II I I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited frei practice before the Social Security Administration or the Health Care Financing Administration; that I am not, as a current or former officer or employee of the United States, disqualified from acting as the claimant's representative; and that I will not charge or receive any fee for the representation unless it has been authorized in acco-dance with the laws and regulations referred to on the reverse side hereof. In the event that I decide not to charge or collect a fee for the representation I will notify the Social Security Administration and the Health Care Financing Administration (completion of Section III (optional) satisfies this require- ment). lam a/an ADMINISTRATOR, MANORCARE HEALTH SERVICES TELEPHONE NUMBER~--~ (AreaCode! (717) 249-0085 Section III [Attorney, union rel3resentative, relative, law student, etc.) ADDRESS 940 WALNUT BOTTOM RD CARLISLE, PA 17013 DATE (Note to Representative: You may use thi?. portion of the form to waive a fee or to waive direct payment of the fee from withheld past-due benefits.) I waive my right to charge and collect a fee [or representing before the Social Security Administration or Health Care Financing Administration. SIGNATURE -(See important information on reverse) FORM HCFA-~6g6-u~ ('tO-$4tJ IDATE I of 1 MHC-O08.20 {Rev. 4/96) pg 12 "~ ManorCare Health Services This is to confirm that ,~-"7~'¢rP,~ ¢_.t ~ ~'3,( ~C'tc3¢"~ was reviewed at the time of admission and found to be eligible for~edie[are benefits. Of course, the Medicare program may change coverage, eligibility or co-payments at any time. It is understood that as long as the Patient/resident meets the criteria for coverage, at present Medicare Part A will pay for Medicare Part A covered services for the first twenty (20) days. Beginning on the 21st day, there is a co-payment of $ /---//¢. g)(~ per day for the next 80 days, a co-payment set by the federal agency which administers the Medicare program. But regardless of medical status, the maximum Medicare Part A benefit period is 100 days, which may include covered days at another facility. It is also understood that as long as the Patient/Resident meets the coverage criteria, at present Medicare Part B will pay 80% of the allowed rate for Medicare B covered services. There is a 20% co-payment for these services that is the responsibility of the beneficiary. Vitalink Infusion Services may be the supplier contracted to supply enteral/parenteral feeding products and is an affiliate of Manor HealthCare. At the time Medicare coverage is denied or expires, a 30-day advance payment on the current Daily Rate will be required if the Patient/Resident is to remain at the Facility and if the care will not be paid by another approved third party payor. '-I certify that the information given by me in applying for payment of Medicare Part A or Part B benefits under Title XVill of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or Carriers any information needed for this or a related Medicare claim. I further request that payment of authorized benefits be made on my behalf. I assign the benefits payable for the physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. For outpatient services, I request this authorization apply to t,~e period // .,o ..... ,___. ~F'~cilit~' I~present~tive - ~ignature,/ -- ~esponsible ~arty~ ~ure-- Facility :epresentative - Printe~Name & Ti~ ResBonsible Party - Pdnte~ame Date Date lofl MHC-~e-aO (Rev, 7/96) pg 19 INSURANCE COVERAGE ManorCare Health Services ManorCare Health Services wants to be sure that all possible sources of insurance to pay for the resident/patient's care while staying with us are identified properly. Some insurance companies require precertification before they will pay for care provided.- Please help us by listing all sources of insurance, and most important, by letting us know of any' changes in the insurance company or types of coverage as soon as you become aware of the changes. Please state the correct orde~r of the resident/patient's health insurance: 1. Primary Insurance: 2. Secondary Insurance: Is the resident/patient covered by Medicare? k'r-,'Y~s ~ No / Is the resident/patient covered by a commercial Medicare HMO? Does the resident/patient plan to change insurance carriers? ~ Yes Has the resident/patient stayed at a hospital or skilled nursing facility within the past 60 days? '"x/' Yes No /-. Yes .~No The information you provide will be used to bill the proper insurance company. If we are not given the correct information, or not informed of changes, the insurance company or Medicare may not cover care we provide. The resident/patient or the guarantor (if any) will then be responsible for paying for that care. Thank you for your help. Resident/dent ,~ . /Resp6nsible '~arty / I (If Resident is unable l~n) Date Dat~' MHC-001-128 (6/97) EXHIBIT "C" DURABLE POWER OF ATTORNEY KNOW ALI_, MEN BY THESE PRESENTS, that I, FRANCIS E. GREGOR, single person, of Cape Coral, Florida, appoint as my true and lawful attorney, THOMAS H. GREGOR, and JOLENE M. GREGOR (hereinafter referred to as "my Attorney"), of 1306 Dickinson Drive, Carlisle, Pennsylvania 17013. My Attorney is hereby authorized and empowered, on my behalfi (I) To demand, sue for, receive, collect and hold any and all moneys, securities and other property, of whatever nature, that I own or is payable to me, both now and in the future; (2) To d~Posit or withdraw assets from any account in my name in any bank, securities brokerage firm or financial institution and, specifically: to sign, endorse or assign any note, check or other instrument for deposit, discount, collection or whatever; to draw checks upon. or otherwise withdraw all funds in any account of which I am the owner; to offer for redemption, both at or prior to maturity, any bond, savings certificate, certificate of deposit, or similar instrument, or any obligation of the United States Government, and to collect the proceeds from such redemption; (3) To sell and convey or lease any asset which I own now or in the future for such price and upon such terms and conditions as my Attorney deems proper and to execute all deeds, assignments, contracts, stock powers and other instruments necessary for such purposes; (4) To invest in any kind of property, real or personal, as nay Attorney, in my Attorney's sole discretion, deems appropriate; (5) To borrow money from any person or corporation and to pledge or mortgage as security any real or personal property. (6) To litigate, submit to arbitration, or settle any claim or dispute arising between me and any other person, corporation or taxing authority; (7) To prepare, sign and file for me and on my behalf with any taxing authority any tax returns, forms and reports that may be required by law; to apply for and receive any refund payable to me by any taxing authority; and. to appear for me and in my place at any administrative conference with, or hearing before, any taxing authority, or at any Tax Court proceedings; (8) To retain agents, brokers, accountants, attorneys-at-law and other advisors; (9) To pay any obligations and debts that may now or in the future be owing by me or that are incurred by my Attorney on my behalf; (10) To have access to any safe deposit box registered in my name and to remove or add to the contents thereof; ~. (11) To hold property unregistered or in the name ora nominee; (12) To disclaim any interest in property; (13) To renounce any fiduciary position on my behalf; (14) To authorize any admission to a medical, nursing, residential or similar facility and enter into agreements for my care and to authorize medical or surgical procedures for me; and (15) Without limiting the above powers, generally to perform any other acts of any nature as fully and effectively as I could do if acting personally. Any person or corporation shall be fully protected in relying upon this Power of Attorney unless and until actual notice of its revocation or actual notice of my death is received. This Power of Attomey constitutes a "Durable Power of Attorney". This power of attorney shall not be affected by and shall survive my disability. No bond shall be required by my attorney regardless of any legal requirements to the contrary. ,4ND I HEREBYRATIFY,4ND CONFIRM any and all acts which my said Attorney shall lawfully do or cause to be done in the premises. IN WITNESS WHEREOF, I, Francis E. Gregor, has set my hand and affixed my seal on this __~ day of 1999. July, W'ITNESS: COMMONWEALTH OF PENNSYLVANIA : -' ss COUNTY OF CUMBERLAND : Gregor, known or satisfactorily pi'oven to be the person who signed his name to the foregoing instrument and acknowledged the same to be his act and deed. Witness my hand and notarial seal. NotarlaJ Seal Bddget Ann Corcoran, Not~rv Public Carlisle Bom, Cumberland County Commission Expires,June lO, ~)02 EXHIBIT "D" MA. NORCARE CARLISLE:-372 940 WALNUT BOTTOM ROAD C'ARLISLE, PA 17013 (717)-249'0085 THOMAS 6REGOR' ~OR FRANCIS E. 13Q6 DICKINSON CARLISLE, PA GREGOR ' DRIVE 17013 r MEDICARE PRIVATE ROOM 149 ~lease Return This Portion With Your Payment A -A GREGOR FRANCIS E ' !'~-:'~:' ..;,.:,,,:~.99t)68" ._68/12/99 09/30/99 BATE OF SERVICE, eS/3z/gg. _RDd -08/3z/99 -'- 09/30/g9 0:~/:~1/0o CHARGES' . '] CREDITS 288.ee 2,784.00 AMOUNT DUE 4,992.00 EXHIBIT "E" . ManorCaz'e Health Services RE'ADMISSION AGREEMENT Resident's Name.: / Responsible Party's Name: J Guarantor's Name: ?..:. I ..... , Date of Re-admission: t Relationship: Relationship: Daily Rate: Facility: Description of any additional or new terms and/or conditions agreed to by the parties: Except as set forth above, the Facility and the Resident and/or Guarantor "and/or Responsible Party agree to abide by all the terms and conditions of the Admission Agreement entered into by them on 19 The Resident/Guarantor/Responsible Party warrant and represent that all. of the information previously given in the application for residency is true and accurate. It is expressly understood that the Resident and/or Guarantor signing this Agreement shall be primarily and jointly and severally liable for any and all charges occurring hereunder. . . i.~,.._ , p.._-- "' '~ ' ~,..,C~ Signed this / -. Day of .l':,'~u $ ,19 . ,' Witnessed By Witnesse~ By Witnessed By Resident's Signature GuaranJ(d'r's Sig~t~¢/ /~esp~siJ:)le Pa,r~,Si~'re Authorized Sign o~f Facility This re-admission agreement can be used if a resident seeks re-admission to the. Facility within 21 days of transfer to a ho~pi~,~l. If re-admission is more than 21' days after transfer to a hospital, or resident left Facility for any other reason, a-new admission agreement must be signed. Patient/Resident Name: Service Dates: Medicare NO.: Ask all ~our questions of each Medicare Patient/Resident If the Patient/Resident responds "Yes" to any question, continue to page two asking all applicable questions. The Patient/Resident or repre, sentative should sign the form whenever possible. NOTE: It is important to ask al_] questions and document aJ answers regarding MSP. A provider may be held liable if an overpayment occurs and Medicare finds that the provider furnished erroneous information or failed to disclose facts it knew were relevant to payment. Is the Patient/Resident covered by the Veterans Administration, the Black Lung Program or Workers Compensation? ( ~<' ) No: Proceed to question #2 ( ) Yes: Bill the other insurer prior to Medicare Is tl~e illness or injury due to any type of accident? ( '-/~') No: Proceed to question #3 or #4 ( ) Yes: Complete next page and continue with questions below #3 IF 65 OR OVER #4 IF UNDER 65 3. Is the Patient/Resident 65 or over and employed, or is the spouse employed at time of service? ( ~ ) No: Retirement Date: Patient/Resident " Spouse ' · , Continue: See Note Below ": :(' ') ':~&~s:'comPl~temex~page - Medicare may not be primary 4. Is the Patient/Resident under 65 and covered under any Employer Group Health Plan (EGHP) or large Group Health Plan (LGHP)? ( ~) No: See note ( ) Yes: Complete next page - Medicare may not be primary Note: If answer to all questions is "No", bill Medicar/as primary;- ~ If any response is "Yes", continue to next p~,~e; Medicare ~ay not be primary. Patient/Resident/Representative ~,gnature, '~///~-'~,P~ /~-~' -/'~,~ Date ~--A'///~L /*~ ' f" ~ -- / / I of 3 MH~,-OQS-~S (10/96) Patient/Resident Name: Service Dates: Medicare No.: Check the appropriate box and answer the questions. 1. ILLNESS/INJURY CAUSED BY ACCIDENT A. ( ) Motor Vehicle: Name of Patient's/Resident's Automobile Insurer B. ( ) Another party .was responsible for accident. Name and address of Liability Insurer Name and address of attorney D. ( ) Other accident (Slip and fall, etc.): Explain where accident occurred: Has the Patient/Resident filed or intend to file a liability suit? ( ) No: Bill Medicare and send copies of all pertinent documentation ( ) Yes: Name and address of: Liability Insurer Attorney -Bilr other~lnsurer prior..to Medicare; submit documentation to Medicare if conditional payment requested. EMPLOYER GROUP COVERAGE FOR THOSE 65 AND OVER A. ( ) Patient/Resident employed at time of this service. Give name of Patient's/Resident's company/employer Does Employer employ 20 or more employees? ( ) Yes ( ) No Does the Patient/Resident have an Employer ~oup Health Plan (EGHP) by reason of his/her current employment? ( ) Yes If "No" give Date of Retirement If "Yes" give the name of the EGHP Bill EGHP prior to Medicare 2of3 (10/96) B. (-) Patient's/Resident's spouse employed at the time of this service. Give' name of spouse's company/employer Does the spouse's employer employ 20 or more employees ( ) Yes ( ) No Does the spouse have an EGHP by reason of current employment which covers the Patient/Res- ider{t? ( ) Yes ( ) No If No, give the date of retirement If Yes, give the name of EGHP Bill EGHP prior to Medicare 3. EMPLOYER GROUP COVERAGE FOR THOSE YOUNGER THAN 65 A. ( ) Patient/Resident is entitled to Medicare solely due to End Stage Renal Disease and in the first 18 months of Medicare entitlement. Date of first Dialysis treatment or date of Kidney transplant: MM/YY Does the Patient/Resident have coverage through his/her, his/her spouse's, a parent's or guardian's Employer Group Health Plan? ( ) No: Medicare Primary ( ) Yes: Give name of the employer Give name EGHP Bill EGHP B. ( have/has prior to Medicare ) The Patient/Resident is entitled to Medicare solely because of disability (does not not had ESRD). Does the Patient/Resident have coverage through his/her, his/her spouse's, a parent's or a guardian's Employer Group Health Plan? ( ) No: Medicare Primary ( ) Yes: Continue Does employer(s) employ 100 or more employees? ( ) No: Bill Medicare ( ) Yes: If yes, give name of each insured whose policy covers the resident: Give name of corresponding employer: a, Give name of corresponding EGHP: a,. Bill EGHP(s) prior to Medicare (10/96) 3 of 3 MEDICARE ACCEPTANCE POLICY ManorCare Health Services This is to confirm that ~"7'~t, !('~ '~ ~-'7,'~.,,c,/'"' was reviewed at the time of admission and found to be eligible for Medicare benefits. It is understood that as long as the resident meets the criteria for coverage, at present Medicare will pay for covered services for the first twenty (20) days. Beginning on the 21st day, there is a co-payment of $ per day for the next 80 days, a co-payment set by the federal agency which administers the Medicare program. But regardless of medical status, the maximum Medicare benefit period is 100 days, which may include covered days at another facility. Of course, the Medicare program may change coverage, eligibility or co-payments at any time. At the time Medicare coverage is denied or expires, a 30-day advance payment on the cU'rrent Daily Rate will be required if the resident is to remain at '[he Facility and if the care will not be paid by another approved third party payor. Date D Resident ! Signature D Responsible Party r-~ Guarantor Printed Name Relationship MHC.~3~18,..¢,.../'/96 AM3 - AM4 · EXHIBIT "F"' ...... F~ncls EGregor ;-~ CPi Device tmplant Date: 12~-2]1996 - : ~ -. Pacemaker '~3823 · 4285 216797 CPI -.' Le~d : :"-" - · ' ~' I .'. : ,:. :.:L .. · . ':-. - ., · · CP .--.:: .~ . ,...'-~. '. ,-. 'e ,~- -~ . , -. 't' '. ' ' '. : .... :.-- '--' ,~- ~ · ':" ."?-'-.':,;' '"": ~':~.';:':~?~::L'~?-.~,:~;~'~:'~; ::;:?,,~:.::. ' - :.~-.--..._;~., __~.~. ~ '.' .___:___ .................. ~ ......... '. :- .:". ~..'~ ~.'-.',..-'.:,:.~% .-..~ :~-:-=.',~F-.~,~.~'..-' t.:- --, --'--~-*--~- ...... ---~' ......... :'- .... -:---"Y'---:~. ..... ~":.": ..... :-'~-.---'~'.--'~ ........ ~ .... .'".-r:-'-'-;'----=--,'...'- .:v~r~_~-~--:~-~:.~.:--?~-~!:~'~.;"~.-~!~::,~" m'.'~':- ....... ~ ¢~lla~ PaCemakem ' c5~ · - :~.: .~. ~;.~t~. ~i.;'~.~_~.~;~.~.~, ~ :.;~ ;,% ;~.'~=~-,~=~. ~ ~-,...~.~: = ;t~..., ;.' .-: ~:; .~,-~?--~ '- --'~' . .... 't=~~F~=~-~,~-~ ~. ~,. ~,* ...... ~r,~, ~ ~,.-~. ~ -.-~ ,~ ....... ~~ '~- ~ ..... -"'-~ ..... . .~~~ ' ~~:~., ~;:; .-~<": ",~.~T'?~/~'''~ ~t~.t~= ;~:t=: ~' '.:,~,'."; :::~3: ~[ ~:; ';. ' ' .-':L ' 3' j ':. ~... '-.';: .- ......... ' ' o~.~ '. ,. , -::-.:. · . ~ v-- ~ - ' ' ' ~" EXHIBIT "G" 3056 132 FnANC~S ~ GRgGOR 4a? THOMRS .. aREGOR ~e Money Fund Alternative ~ 9auXin De~s~anz ~ ,:O~'~OO'GB4~: qG~'~'".~"' ~q 0~ :.. TOTAL EXHIBIT "H" GREGOR, 14 BIPTHD~E ¢4271920 ~ ..O~ENCE .' THOMAS 6REGOR FOR FRANCIS ED 130.6...DIOKINSQN CARLISLE, PA F'RANCIS E ~. :2...": ' ,'- ADMISSION -. 17 0~1~ 071399 ~ OCCURRENCE COOE DATE 1306 DICKINSON DRIVE, CARLISLE, PA ~'7013 42 REV. CO. 43 DESCRIPTION 23-~EDICAL RE~ORD NO. 24 '* 99068 - 6RE60R DRIVE ............................ 17013 HCPCS / RATES 4~ SERV. DATE ~ SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 0022 MEDICARE ASSESSMENT O,,M~BO'ARO'~PVT 0250 PHARMACY .... 042'~-: Hys:i~HERP/VISIT '- 0431 OCCUP~.THERP SIT.. 0001 TOTAL CHARGES ~ PAYER ,,~ MEDICARE A CONTINENTAL LIFE 51 PROVIDER NO. ~8 t~UREO'S ~ME GREGOR, FRANCIS E GREGOR,'-FRANCIS E -;3 T'RE~TMENT AUTHORIZATION CO~E$ EMPLOYER NAME PPS01 071399 14409 .:: . 000 :.._ ~ 60 CERT.. SSN - HIC, - ID NO. 171126160A 9205053095 050 PRIOR PAYMENTS ,61 GROUP NAME .... :.' * '.TL.:' '" 62 INSUPANCE GROUP NO. EMPLOYER LOCATION 155 EST. AMOUNT DUE 13 PATIENT ADDRESS ~ , -. --: ~ '": ' ' .~.:- ' ': :7.:':' 23 MEDICAL RECORD NO. " OCCURRENCE ~ ~CURRENCE ~.- ~ ''~. ~OE -- .... .DATE THONAS GREGOR~. FOR FRANC~S ,.E, GREGOR' ~3e6--D-:CK:NSON"OR~VE ~ 0ESCRI~ON.-;~-*~-T--- ::' :* · '.- ;- ,..';. '; ~ HCPCS/~TES ~..,t~ OCCURRENCE SPAN VALUE CODES ?..*: ~ ' ] 45 SERV. 0ATE. - 48 SERV. UN~TS ,: ~.,. ~ ..:., .; ,. ..... · ·TOTAL CHARGES - .VALUE CODES AMOUNT 50 PAYER · S1 PROVIOER NO. : 56 INSURED'SNAME - ' 80 CERT.-$SN-HIO.-IO NO. ~ j:ST./U,'lCUm'.lXlE ' CARLISLE '070'399 071399 ~ :,FRIOR.P..AyblENTS_.',:~.~;~ 55 EST. AUOUNTOUE 80 CERT.-,~N-I~C. OHO. ~..T~ ~,%:~. ,,..~ :.. 81 GROUPNAME 171125'16eA '* J (7'~-7)-249-0985 12 PA13ENT NAME ,~. EOOR, FRANCIS E ~4 ~IR~DATE AOMISSION 17 ~ ~4271926 ~81299 32 ~RRENCE ~ ~CURRENCE CODE - CODE DATE THOMAS GREGOR' FOR FRANCIS E. GREGOR 13~6 OICKINSON DRIVE CARLISLE. PA 17013 REV. CD.-' 002~' 0022. 0022 0259 1306 DICKINSON DRIVE, CARLISLE, PA 17913 23 MEDICAL RECORD NO. 99968 43 OE~CRIP~ON MEDICARE ASSESSMENT MEDICARE--ASS MEDICARE ASSESSM"~NT sS'C02 PHARMACY '. .... ~ HCPCS/RATES ~ SERV. OATE RMC07 999399 -S S C38 ::-:-:-:' -09 ~ 099 092099 OCCURRENCE SPAN e7e VALUE CODES 2784100 i i 48 SERV. UNFrS 47 TOTAL CHARGES 902 ....... :-00 8 '--:-:-:' -'e.0 ~0 0 919 ee~ee :"-929 48 NON-COVERED CHARGES TOTAL CHARGEs 029 457~12 i 0 PAYER ~- ~- ~ " - ~ . ' COnTiNEnTaL L~FE I . . . ~ I~. .~ . GREGOR;;FRANCIS E ~ ~ . ~ .... ~~;~:m'.--t:.::--*: . :. ~'*.-.',.F- ' ...... :~.-- ..,.;~=.~.-~-:.~'~:~=:T' *T..,,. ...'- ............ " ." ' ~ · :':-' .... :-~='~ ~~.,~-~~i~ '" ~-:-': - - .... ' i ___ __ ._- _:j EXHIBIT "!" MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 THOMAS GREGOR FOR FRANCIS E. 6RE60R 1306 DICKINSON ORIV~ CARLISLE, PA .17613 MEDICARE .PRIVATE· ROOM lZ19 Please Return This Portion. With Your Payment 08/12/99 09/30199 eq/o~./ee ~: " ' : 4,992-.00 o4/3e/ee CREDITS AMOUNT DUE 4,992.00 HCR .Manor MANORCARE CARLISLE 1372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 MEDICARE A PRIVATE .THOMAS GREG0'R .................. ROOH t49 -A FOR FRANCIS E, GREGOR ..... 1306 DICKINSON DRIVE CARLISLE, PA 17013 .-,:S DATE OF . coDE :~ .:,,. · .../: .: . . 'Please Return This Portion With Your Payment \ 08/12/99 09/30/99 GRE.GOR,' "FRANCIS E . : '?9068 ~. ::?:,".: .:. :!: ".: L SERVICE RENDEREI~. : ..... I' CHARGES ~ .' !' 4,992,00 'e5/33../oo CREDITS AMOUNT DUE 4.992.e 'T MANORCARE CARLISLE '372 940 NALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-{)085 TH.O~AS GREGOR ' . FOR FRANCIS E. GREGOR 13{)6 DICKINSON DRIVE CARLISLE, PA 17{)13 MEDICARE A PRIVATE ROOM 149 -A PleaseReturnThisPodion WithYourPayment 6RE60, R, FRANCIS E 99068 0)8112199 09/3{)/99 {)6/30/00) ................. ---i-.-. ~.- ~- ......... . : · '06/{)3./00)' - '/BA'LANCE 'FORWARD ' · :~ ' '. '4,.992'o00 CREDITS AMOUNT DUE ~,992.00 IORCARE ,C'ARL'ISLE 372 'IT'BOTTOM ROAD ~- :FOR MED]:CARE A PRIVATE ROOM 149-A Return'This Portion -AMOUNT DUE BOTTOM! I~OAD.' i~ MEDZCARE A AMOUNT DUE 4,992,0¢ -FOR "-.: '-~: 13 0 . '.'CARLISLE ~ - - "' MEDI CAR,.E A :.-~ Wi~,,Your, payment : .. FOR F-RANCIS RE CARL[$,LE ~372 BOTTON_ ROAD A AMOUNT DUE 4,992.00 TH01~/~S . ,:NEDICARE /~ P R TV/~TE 4.992.e0 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff THOMAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant NO. 2002-06028 CIVIL ACTION-LAW AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania : ss. County of Cumberland : AND NOW, TO WIT, this _~_~day of January, 2003, comes Amy F. Wolfson, Esquire, who being duly sworn according to law, deposes and says that she is the Attorney for the Plaintiff in the above-captioned action; that on December 23, 2002, she caused a true copy of the Complaint in the above-captioned action to be sent by Certified Hail, Return Receipt Requested, To Addressee Only, Certified No. 7000 1530 0004 4999 0780, hereto attached, to the said Defendant, Thomas Gregor, at his last known address, 1306 Dickinson Drive, Carlisle, Pennsylvania 17013, and that said copy was received by the Defendant, as indicated by the return receipt card attached hereto dated December 24, 2002, and bearing the personal signature of the Defendant. I.D. No. 87062 [' Attorney for Plaintiff SWORN and SUBSCRIBED to before me this \~¥x day of .. csc , · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: .uto. P. oce t A. Sig,,nature [] Addressee B. Received by (Printed Name)(~ ~L~D~.te of Delivery D. Is delivery address different from item 17 [] Yes If YES, enter delivery address below: [] No (Transfer from ssrvice/abe/) PS Form 3811, August 2001 Domestic Return Receipt 3. Service Type ~ Certified Mail [] Express Mail [] Registered [] Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 102595-01-M-2509 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: by (, O. Is deliver, If YES, enter deliv§ry ? [] Agent C. Date of Delivery Yes 3. Service Type ,li~J3ertified Mail [] [] Registered [] Return Receipt for Merchandise [] Insured Mall [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. Article Number ~ 1~3~ 0009 I..{. ,~ 0'-'/~} (Transfer from service/abe/) PS Form 3811, August 2001 Domestic Return Reft. eipt 102595-01-M-2509 HCR MANOR CARE, Plaintiff Ye THOMAS GREGOR, IND/& OBO FRANCIS GREGOR, DECEASED, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2002 - 06028 : : CIVIL ACTION - LAW PRAECIPE TO THE PROTHONOTARY: Please enter my appearance on behalf of Thomas H. Gregor, Defendant in the above case. February 12, 2003 c: Amy F. Wolfson, Esquire BROUJOS & GILROY, P.C. "" ~ B~~uire A n .ey I.D. No. 06268 4 h Hanover Street Carlisle, PA 17013 717/243-4574; FAX 717/243-8227 HCR MANOR CARE, Plaintiff V. THOMAS GREGOR, IND/& OBO FRANCIS GREGOR, DECEASED, Defendant : 1N THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 2002 - 06028 : : CIVIL ACTION - LAW DEFENDANT'S ANSWER TO COMPLAINT; NEW MATTER; AND COUNTERCLAIM Thomas Gregor, through his attorney, John H. Broujos ofBroujos & Gilroy, P.C., sets forth the following: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted that Defendant signed the application, which contained a section on Financial Date and that there was as part thereof a warranty and representation and that the document states "the facility will have detrimentally relied upon the above financial information and will suffer financial loss and harm". However, the questions of detrimental reliance and suffering of loss and harm are factual matters to be determined in the proceedings of this case. Defendant makes no averment and does not represent that Plaintiffwill or :should have "detrimentally relied" and "will suffer fmancial loss" as a consequence of Defendant's actions. Proof is demanded. 5. Admitted. 6. Admitted. 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. However, denied that this is all the information that was provided by Defendant to Plaintiff with respect to benefits. On the contrary, Defendant made representation directly and by phone to agents and employees of Plaintiff with respect to hospital coverage for decedent by Legionnaire Insurance Trust Program (Legionnaire), including a note with the name and phone number and certificate number thereon, which are not set forth in the complaint and its exhibits. 11. Admitted that the itemization of services indicates the outstanding balance represents a Medicare co-insurance responsibility; denied that Medicare was the only entity that had a co- insurance responsibility to decedent. 12. Admitted that Plaintiff would rely on some conditions of the Responsible Party Appointment; however, there was another co-insurance party responsible for co-insurance contribution. Denied that Plaintiff had a right or justification to rely on the conditions, which is a matter for factual determination in the court proceedings in this case. Denied that if Defendant did not follow through with any conditions (which averment is :not admitted) Plaintiff would necessarily have detrimentally relied upon said conditions and suffer harm. There is no admission that Plaintiff at any time relied upon any conditions or acts of Defendant that were justifiable. On the contrary, there were conditions and acts that Plaintiff did not have a right to rely on and that were detrimental to Plaintiff, as will more fully develop in this case. 13. Defendant admits executing the Re-Admission Agreement. However, Defendant denies that he agreed to abide by the terms and conditions of the Admission Agreement as set forth in several of the averments of the complaint. On the contrary, there were facts and conditions, such as with the additional co-insurance entity, Legionnaire, and the verbal presentation of information thereon, which should have been part and partial of the Admission Agreement as shall be more fully set forth in the course of the proceedings. 14. Denied. After reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the truth of the averment. By way of further answer, Plaintiff undertook the responsibility of making claims to co-payors. 15. Admitted. 16. Admitted that Plaintiff billed Continental Life Insurance 'Company (Continental) for services. However, Continental did not provide coverage. 17. Denied. After reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the truth of the averment. 18. Denied. After reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the truth of the averment. 19. Admitted, except for the time of commencement of bill, which is denied. After reasonable investigation Defendant is without knowledge or in:formation sufficient to form a belief as to the truth of the averment. 20. Admitted that a debt in the amount stated was incurred by the decedent and that the amount was not compensated by a third party payor or government program. Denied that a third party payor or government program was not responsible for payrnent. On the contrary, there was an obligation for payment by Legionnaire, as set forth on Exhibit J, made a part hereof. Denied that Defendant is obligated to pay Plaintiff such amount, since Plaintiff failed to perform the obligation it undertook at the time of admission of decedent as :set forth above and failed to provide a claim form to Legionnaire, as required for the claim, and as more fully set forth in New Matter. 21. Admitted that a copy was sent. Denied that the copy accurately showed all debits and credits. On the contrary, Plaintiff did not provide an accurate record, since there was nothing but a single line entry of $4,992, with no other relevant information. After reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the troth of the averment. 22. Denied. On the contrary, Defendant did not object to entering the single figure of $4,992, which was not an itemization of services, nor did the document itemize services; but Defendant did object to the obligation of payment by Defendant to Plaintiff. On numerous occasions, Defendant asked for an explanation of the billing, which at no time was forthcoming. Otherwise, after reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the truth of the averment. At and about the time of admission of decedent, Defendant had notified Plaintiff of a policy, Legionnaire, that provided additional coverage. At that time, Plaintiff, through its agents and employees, not only were told of an additional co- insurance payor but insisted repeatedly that Plaintiff would bill f6r and process and demand payment from the co-insurer, as will be more fully set forth in New Matter. 23. Admitted that the balance due for services is $4,992. Denied that Defendant is obligated to pay Plaintiff such amount, since Plaintiff failed to perform the obligation it undertook at the time of admission of decedent as set forth above and as more fully set forth in New Matter. 24. Admitted that demands were made. Admitted that Defendant refused to pay the sums as claimed as owed, for the reasons set forth in paragraph 23 above; to wit, that it was the duty of Plaintiff to bill and to recover fi.om Legionnaire co-payor for the services, which Plaintiff failed to do and which is set forth in New Matter hereto. 25. Admitted that requests were made. Denied that requests were made in the proper form with proper information on services and on availability of co-payor contribution. Denied that Plaintiff has ignored any fiduciary or contractual obligation. On the contrary, Plaintiff has failed to perform its duty as set forth above and in New Matter, since Plaintiff was obligated to undertake the commitment they made at the time of admission :to collect fi.om co-payors. 26. Denied that Defendant had a willful failure to remit Social Security and pension benefits. On the contrary, Plaintiff did receive monthly Social Security benefits directly. And Plaintiff had undertaken the obligation to apply funds fi.om co-payors, which they did for Social Security, but failed to do for Legionnaire. Denied that the allegation was a violation of the Admission Agreement. On the contrary, Defendant did not violate any agreement. 27. Denied. On the contrary, the responsibility to bill and to obtain benefits was the duty of Plaintiff as undertaken at the time of admission as set forth herein. 28. Admitted that finances and income of the decedent were for his medical services and treatment. Denied that Defendant failed to utilize the finances fbr that purpose. On the contrary, Defendant either utilized finances for that purpose or relied upon the contractual undertaking of Plaintiff to bill for and to obtain the finances. 29. Admitted. 30. Denied that Defendant knowingly violated his contractual duties. On the contrary, at all times Defendant met his duties and responsibilities under the Admission Agreement. Defendant reasonably relied upon Plaintiff to comply with its obligation to bill payors, as set forth herein and in New Matter. Denied that Defendant knew of medical bills, since Plaintiff was asked and never responded to inquiries on the nature of services and efforts to obtain co-payor funds. Denied that Defendant forced Plaintiff to pursue any co-payor, 31. Denied that Defendant ignored his duties. On the contrary, Plaintiff had undertaken to bill and obtain benefits from co-payors. At no time did Defendant force Plaintiff to pursue any companies; Plaintiff insisted on undertaking this duty. 32. Denied that Defendant made no inquiries. On the contrary, the obligation to make inquiries and to collect from any co-payor was the duty undertaken by Plaintiff. 33. Denied that Defendant was informed. On the contrary, Plaintiff had made inquiry of Continental in accordance with its contractual undertaking with Defendant; and found that decedent was not eligible, all as set forth in averments above. 34. Admitted that Defendant did not apply for Medical Assistance benefits, in that Plaintiff insisted that Plaintiff would apply for and receive any benefits ,directly. If any provisions required Defendant to make inquiry, that provision was modified by Plaintiff's insistence on applying for benefits. With respect to other averments, after reasonable investigation Defendant is without knowledge or information sufficient to form a belief as to the troth of the averment. 35. Admitted. 36. Admitted that paragraph 8 refers to Fee Schedule, which Schedule speaks for itselfi Denied that Plaintiff is entitled to receive reasonable attorney fees and all court costs under the circumstances of this case. On the contrary, it was the fault of Plaintiff that no claim was filed with Continental. Claim of the attorney can arise no higher than that of Plaintiff. 37. Denied that Plaintiff has incurred reasonable attorney's fees for collection. Denied that any amount is due and owing. On the contrary, no amount is due and owing. 38. Denied that any attorney's fees are owed. On the contrary, no attomey's fees are owed. 39. Denied that averred conditions have been performed by Plaintiff. On the contrary, any services performed were not eligible as conditions precedent to any fee. 40. Admitted. WHEREFORE, Defendant prays the Court to dismiss the complaint. NEW MATTER By way of further Answer, Defendant submits New Matter. 41. Paragraphs 1 through 40 are incorporated herein by reference. 42. At the time of admission and at the signing of documents for his father's admission, Defendant was told by the admitting staff persons that Plaintiff would file the claims to co-pay entities for benefits. Plaintiff insisted on this procedure. 43. On or about the date of admission, Defendant by phone calls and verbal direction provided Plaintiff with the name of the Legionnaire as a co-pay. Defendant also submitted a piece of paper with the name, telephone number, and policy number of the co-payor. 44. After the death of decedent, upon receiving a statement from Plaintiff, Defendant would ask for specific details as to what the claim was for. He talked to different persons. He talked to a business manager. He asked if they had applied for co-pay as they had insisted the company would do. 45. Each time Defendant received excuses, such as "the person who did that work previously was gone"; ''the computer was not operating"; "the limited billing was computer generated and we will call back after we review the former manager's book"... At no time did Plaintiff suggest or advise that Defendant should contact co-pay. 46. Plaintiff insisted on receiving the Continental card, again claiming that Plaintiff would apply for coverage. 47. In spite of any document providing otherwise, Plaintiff insisted that Plaintiff would contact the co-pay company. 48. After the complaint was filed, Defendant contacted Legionnaire, which said the time had expired for filing a claim, since there was a fifteen-month deadline for application. 49. After the complaint was filed, Defendant obtained a claim form, which required an attending physician's statement on the back of the form. In other words, the claim could not be submitted without an attending physician's statement; and the attending physician was a physician provided by Plaintiff. 50. By demanding from the beginning of admission that Plaintiff file claims with co-payors and stating that "we will take care of making a claim against Medicare" or words to that effect, Plaintiff made a promise to perform that task, effectively modifying the provisions of any document to the contrary attempting to impose that function on Defendant. 51. Plaintiff intended that Defendant rely upon that promise.i 52. As a result of the promise of Plaintiff as averred herein and of the course of conduct consistent with that promise, Defendant did rely upon that promise and conduct and did not file any claims. 53. Plaintiff did make claims, to Medicare, receiving checks directly, and to Continental, receiving a refusal to pay for lack of coverage. 54. A. Under the circumstances, Defendant was justified in filing no claims and relying on the promise of Plaintiff. B. Plaintiff is estopped from asserting that Defendant had a duty pursuant to prior averred agreements to file claims; and is estopped from denying that Plaintiff had a duty to file the claims with co-payors, and specifically Legionnaire, for the reasons set forth herein. C. For these reasons the agreements and documents are modified accordingly. 55. After filing of the complaint, Defendant did send a request to Legionnaire for a claim form. It was received and recently forward to counsel for presentation to Plaintiff, since it requires a physician's comment and signature. 56. Defendant's recovery of any co-pay benefits has been jeopardized by Plaintiff's promise of processing, the reasonable reliance thereon by Defendant, and the failure of Plaintiff to file a claim and perform the obligation he undertook with his promise. 57. Defendant relied upon that promise to his detriment. This is submitted as a defense to the claim of Plaintiff herein. Defendant denies any liability to Plaintiff. 58. Defendant avers that Plaintiff was poorly organized; had a continuing turnover of personnel; made an independent decision not to apply to Legionnaire co-pay, because of the expiration of the fifteen-month deadline, or for other reasons; failed to advise Defendant of a specific detailed claim; reversed its policy in his case and insisted on Plaintiff's filing of claim and payment by Plaintiff, without any explanation or warning; until after filing of the complaint. 59. The contract that was entered into at the time of admission was a document prepared by Plaintiff, to be construed strictly against Plaintiff as the maker. 60. At no time did Defendant deny that he would pay the bill for services. At no time did he deny that he would pay any amount due after exhaustion of co-pay. Co-pay was not exhausted. 61. A major circumstance which indicates that Defendant was justified in reasonably relying upon the promise of Plaintiff to file the claim was Defendant's occupation around the time of admission and after admission with tragedies in his family, losing a brother, a mother, an aunt, an uncle, a cousin, and his father. WHEREFORE, Defendant denies liability and asks the Court to dismiss the complaint. COUNTERCLAIM By way of further answer, Defendant sets forth this Counterclaim. 62. Paragraphs 1 through 61 are incorporated herein by reference. 63. Defendant asserts a counterclaim against Plaintiff for any loss 64. Plaintiff is liable for the expenses of care, based upon the averments herein. 65. In the event of refusal of Legionnaire to pay any benefits to which Decedent and/or Defendant is entitled, for any reason, Defendant claims a set-off against Plaintiff. 66. The amount claimed as set-of is any sum claimed by Plaintiff, including the sum of $4992. WHEREFORE, Defendant claims a verdict of damages as prayer for herein. Johri~H. t,oujos, Attome3{ for l~efendant Brk0UJq 4 ~ ianover Street Carlisle, Pennsylvania 17013 717/243-4574; 717/766-1690 FAX# 717/243-8227 Date: February 14, 2003 Date: I verify that the statements made in this pleading are tree and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unswom falsification to authorities. / NOTICE TO PLEAD In accordance with PRCP 1026 and 1361, you are hereby notified to file a written response to the enclosed New Matter and Counterclaim within twenty (20) days from service hereof or a judgment may be entered against you. ohnH. Bmujos, Attorney for Def~mt HCR MANOR CARE, Plaintiff V. THOMAS GREGOR, IND/& OBO FRANCIS GREGOR, DECEASED, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2002 - 060:28 : CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, John H. Broujos, Esquire, hereby certify that I have served a tree and correct copy of the foregoing Defendant's Answer to Complaint, New Matter, and Counterclaim on the following person and at the following address by United States, First Class Mail, on February 14, 2003 to: Amy F. Wolfson, Esquire Wolfson & Associates, P.C. 267 E. Market Street York, PA 17403 February 14, 2003 ~ J~o~h~o.. }-~_¢rn ~yB[o( ?~)' ~fnSdqan~re No. 6268 BROUJOS & GILROY, P.C. 4 North Hanover Street Carlisle, Pennsylvania 17013 (717) 243-4574 (717) 243-8227 FAX L s zm ee Tz- s You Can Help Us to Handle Your Claim PrompUy. A. Check to De certain all information requestect ia shown Dy you end :he O~ctor. B. Sign form In Claimant's StatemenL C. Be sure Pstlenrs Au(hodzation is signed:, by 13silent. if adult; by Insured, il patient is a minor, D. Attach copy' ot hospital biff and nursing home bltl. if appficab~e, Must be Supported by a Pathologist's Report CLAIMANT'S STATEMENT A~ ~No. a~d Slr~l) ~ {01~ ~ S~tef ~ ' (~ ~) Dale ~ Bi~ Date al ~ ~ea~l ~,e~'~ ~ Na~p~n'Ra~ Rr~ Tre~ent H~I41 -~RTANY: ~aC~ Copy af Ho~ Biff ~ ~ ~a~a~ , PATIEnT's AUTHORiZATiO~ , Print N~4 ~ ~eni · lo re-N~os~? ~ s~ Inaction to rel~ng aom~lee, t~e ~1 Informulon aureau i~ s~h omr ors Ihs ~ee er mi~l~ng, ~nform~t~ c~iflg any ~ The A~endmg Physic,an Mu~omplete The Reverse Side of T~is Form · Hospital Bill Must be AUached to This Form A~ENDING PHYSICIAN'S STATEMENT Paints ~me ] ~ la Condign Due to I~JU~ or $1o~ne~ · [~ing Out of PatiOs ~mpl~mem? NI~ of ~me~ or In~ (~H~e ~ons It ~) [] Yes Whe~ Did 8ympl~nlS Fir~l AplM.r or Ao;;igenl Ha~13eA? Did Pallent Fi~ Co~lt You For Thia C~tlen? Oescdbe Any Other o~ee~e o~ In~tmlly Affecllng Pmae.-,I C3ndltlon. Has P~lan! Em Hm2 ~ or ~ 'yea' af~m when and C~r~ ~r Calf .Chicgl par Call $ Charge I~r Ca!! $ Chlir~e Oar Ca~ $ Print Nanle Be Sure All Information Is Complete Then Mail Your Claim Form. To: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff THOMAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant NO. 2002-06028 CIVIL ACTION - LAW PLAINTIFF'S REPLY TO NEW MATTER AND ANSWER TO COUNTERCLAIM AND NOW, TO WIT, this/D ~'f~Lday' of March, 2002, comes the Plaintiff, HCR Manor Care, by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of Wolfson 8: Associates, P.C., and files the following Response to Defendant's New Matter and Counterclaim as a statement herein: The allegations and averments contained within paragraphs One ( 1 ) through Forty (40) of the Plaintiff's Complaint are incorporated herein by reference as if set forth in full. REPLY TO NEW MATTER 41. Paragraph 41 of Defendant's New Matter is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in Plaintiff's Complaint, are incorporated herein by reference as if set forth in full. 42. Admitted. By way of further answer, Plaintiff did file claims for benefits to Medicare and to Continental Life Insurance Company, as at the time of Decedent's stay at Plaintiff's facility, those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained any information, and Plaintiff received no information concerning any other companies until December 2002. 43. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. By way of further response, there is no such documentation/information contained in Plaintiff's file concerning Decedent. 44. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 45. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 46. Admitted. By way of further response, Plaintiff did bill Continental Life Insurance Company, but Continental Life Insurance Company denied benefits to the Decedent. 47. Admitted. By way of further response, Plaintiff did bill Continental Life Insurance Company, but Continental Life Insurance Company denied benefits to the Decedent, and Plaintiff did contact them when no payments were received. 48. Admitted. 49. Admitted. By way of further response, said form was not forwarded to 2 Plaintiff until December 20, 2002. Further, due to the fact that the deadline to submit said application has expired, even if Plaintiff now does submit an application, it will ultimately be denied. 50. Admitted in part and denied in part. By way of further response, Paragraph 50 of Defendant's New Matter is admitted as to Medicare, and Medicare was billed by Plaintiff and paid what it was required to pay. 51. Denied. The allegations contained in Paragraph 51 of Defendant's New Matter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. 52.. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 53. Admitted. By way of further answer, Medicare was billed by Plaintiff and what it was required to do. Further, Plaintiff was informed that Continental Life Insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. 54. Denied. The allegations contained in Paragraphs 54 (A) (B) and C) of Defendant's New Matter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. 55. Admitted. By way of further response, due to the fact that the deadline to submit said application has expired, even if Plaintiff now does submit an application, it will ultimately be denied. 56. Denied. The allegations contained in Paragraph 56 of Defendant's New Hatter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. By way of further response, Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 57. The allegations contained in Paragraph 57 of Defendant's New Hatter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. By way of further response, Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 58. Denied. By way of further response, any and all allegations or insinuations by the Defendant of any wrongdoing on the part of the Plaintiff are hereby specifically denied and strict proof is demanded at Trial. 59. Denied. It is specifically denied that the Admission Agreement which Defendant knowingly, voluntarily and intelligently executed on behalf of the Decedent was a contract of adhesion. 60. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. By way of further response, Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life Insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 61. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court dismiss Defendant's New Matter, and enter judgment in favor of Plaintiff and against Defendant, along with the allowable costs of this action, and such further relief as the Court deems appropriate. ANSWER TO COUNTERCLAIM 62. Paragraph 62 of Defendant's Counterclaim is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in Plaintiff's Complaint, as well as the within Reply to New Matter, are incorporated herein by reference as if set forth in full. 63. Admitted. 64. Denied. it is specifically denied that Plaintiff is liable for the expenses of care 5 concerning Defendant. To the contrary, Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life Insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 65. Admitted in part and denied in part. it is admitted that Defendant claims a set-off against Plaintiff. It is specifically denied that a set-off is warranted in this matter as Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life Insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 66. ^dmitted in part and denied in part. it is admitted that Defendant claims a set-off against Plaintiff. It is specifically denied that a set-off is warranted in this matter as Medicare was billed by Plaintiff and paid what it was required to do. Further, Plaintiff was informed that Continental Life Insurance Company that it denied benefits to the Decedent, but Plaintiff did not receive such information until March of 2000. Those were the only two (2) co-pay entities that Decedent's file with Plaintiff contained information regarding until December of 2002. 6 WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court dismiss Defendant's Counterclaim, and enter jud~Tnent in favor of Plaintiff and against Defendant, along with the allowable costs of this action, and such further relief as the Court deems appropriate. Respectfully submitted, ~mY ~/Woifson, Esquire WOL~ON e~ ASSOCIATE~, P.C. 267 East Market Street York, PA 17403 (71 7) 846-1252 ID No. 87062 Attorney for Plaintiff VERIFICATION Amy F. Wolfson, Esquire, hereby states that she is the attorney for the Plaintiff, HCR Manor Care, and she is authorized to take this verification on behalf of said Plaintiff in the within action and verifies that the statements made in the foregoing Reply to New Matter and Counterclaim are true and correct to the best of her knowledffe, information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relatinff to unsworn falsification to authorities. Date: WOLFS( 267 Easl York, PA [/olfson, E~quire v -., // N ~ ASSOCIATES, P.C?' Market Street 740:3 (717) 846-1252 ID No. 87062 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. THOMAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant NO. 2002-06028 CIVIL ACTION - LAW CERTIFICATE OF SERVICE AND NOW, this l0th day of March, 2003, I, Amy F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Reply to New Matter and Counterclaim upon the counsel of record by regular mail, postage pre-paid and addressed as follows: John H. Broujos, Esquire BROU]OS ~ GILROY, P.C. 4 N. Hanover Street Carlisle, PA 17013 (Counsel for Defendant) ~n~y F.~olfson, Esquir~ - ' ~'/ '~ ~6~LE~a~t ~a r~ SsSt rOe eC~ AT E S, P.C. York, PA 17403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. THOMAS GREGOR, Individually, and on Behalf of Francis Gregor, Deceased, Defendant NO. 2002-06028 CIVIL ACTION - LAW RULE 1312-1. The Petition for Appointment of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Amy F. Wolfson, Esquire , counsel for the plaintiff/defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions) is (are) at issue. ~ 2. The claim of the plaintiff in the action is $4,992.00~:Lus Attorney's t.;ees The counterclaim of the defendant in the action is $4,992.00. l'he following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: John H. Broujos, Esquire WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. ORDER OF COURT AND NOW, (";~t:a_ ~. ~3 ,~, in co.nsideration of the , [bregoing petition ~ ~d~6/4~ Esq.,~ ~ ~-a 73 /] - ' - ' theft/above ca t~oned acgn 'or Esq., and /~_ z~~,oY'~ f Esq., are appointed arbitrators in P' t actions) as prayed for. P.J.