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HomeMy WebLinkAbout98-03950 I " I, ~, J! ~. t,., ~" I, ",I >"'1 Ii 'j' H " ~ ~ ...q j ~ "I' " " ,. l' " ;1 j" .,. ',., ~~. . \'fi,,, "'I~ _I) ,1. n~_, '1',\ ',I '} \ " ~ .~ ," ,.1' " ....,>-.. ~ " e ~ " " " ,. ,j " '1 i( "I' " / 'f , ,. " i' " "" , ' I, o;,i" " .,'; ii, .' " i' ij' ,'., " II" " " " ,i q !i " ',-I '! " 1; ,iI' ri ,d ~ " " 'I' '! \l ;! .' ~ l~ " " ,. \ ;, .I' " " "If " 'j; ,t " , . ,.I:l ~ :j ". ,. iF; " " " i' ". ;, !;::) '~', ()... IV) I, " , ill ji 'I " r -,\' .,;> (~;s:."'< , -) /, " ,/ I' ,. " 'I' I I , I I I i i , I' I I I" I I IN TH~ OOURT OF QOMMQN PJ.,~M OUMI3~RJ.,ANPQOUNTY, PI=lNNSYJ.,VANIA ~~V~RJ., Y H~AJ., TH AND RpHAI3IJ.,ITATloN I S!:RVIDpB, INo, d/p!El" W~ST B~loRp HIEAI.TH AND R~HA~II..ITATION O!:NT~R, Pll'llntlff, V, I , I DIVI/., ADTION I GpRA/"D P, GI/.,l3gRT 60 Pi'll mer PrIV(l Dl'lmp Hili, PA 17011 Pefendl'll1t, , I I , , 'NO v' ,\', :J '(';() (lti,ie -r:f~(-t" I , I ,\ , OOMPLAINT " ANP NOW, COm(lS PI~lntl(f, /:leverly Hel'lllh I'lnd Rehl'lbllltl'ltlon Servloes, 1t1OorpQrl'lted, dlb/!,'l, West ShoreJlel1lth find Reh~l>llItEltlon Oent,er (herell1f:lfter 'West Shore Hel'llth Md Rehal>llItf.1t1ol1 ,Denter"), I>y and through Its attol'l1!;lYs, , Oapoi:i:I& Associates, p,O" Elnd I>rlngll thlsOomplalnt and avers In surport thereof ElS follows I " 1, PlfllnUff,Beverly HeEl/th I'll1d Rehfll>llItl'ltlon Services, Incorporl'lted; d/b/a West Shore HeEllth Elnd'RehEll>lIltatlon Denter, Is a corporEltlon I with Ita registered office looated Elt 770 PoplEll' OllUrch ~oad, Camp Hili, PA 170.11, I, " ,I, , H ". 'I II,' Pl1ploPoplell of Ihepullllt1ndlng Involoell refleollng Ihla pf:1h:1npeElrl'l llllmlhed l1erelo f:1ncl I'lra I1lmked f:1!l I=:xhlpl\ "~." 17, Upon Informl'l\lpn l'lnd peM, ~ertlll'l RodgeI'll Wf1a ellgl~le for Soolf:11 Sl'Iourl\y peneflla of f:1pproxhnf:1lely $1g,(300,OO qurlng her en\lre Iltl'lY .' 'I< ,. f:1t Weat Sl1orel-lel'l1111 f1nd Rel1f:1pllltf1tlpn Cenler, '10, From April, 1 PP6 Il1rough June, 109(3, Pf;1fendf1nt reoelved l'lncl/or exerolaed oontrol over l3erthf:1 R~qgerlll Soolf'll Seourlly oheollEl, " 10, .. We at S/wre Hel'lllhl'lnd Rehl'lpllltf:1l1on Cenler repef1tedly requelltecl . IIll'l\ pefendl'lnl fOIWf1rcl the Vl'llue of l3erlhl'l Roclgera' Sooll'lISeourlty oheollB to Il1em fof' pl'lymlilnl of l3erthl'l Rodgera' Of:1re l'lncl BervlneB, ~o, PefenOl'lnl fl'llled ,to fOIWl'lrcl 11113 Vl'lILle of l3erthf:1 Roogers' $ooll'll Seourlty ol1eollB to Wesl Shore Hel'llth Elno Rel1l'lbllllEltlon Center, " " " 21" Upon InformQtlon Q/ld belief, l3ertha, RoogerB' Was eligible "for , \ " pension benefits from., the Slate SmployeB' Retirement Syatem totall119 I'lpproxlml'ltelY $11,000,00 clurlng her entire Btl'lY I'lt WeBt shore Hel'llth I'lnd Rehf:1blllla\lon Denter, \, ',-1 I, I.. ! , , . flNt\NCMhA8/WC1W Of/' Tim t\mm/l'MI\'N1' '!'lIp '~Inl'f Ill' Ihl~ 1"IIvllll)~ 11'''1 Inl\ll li'hllllll'III' ,,",,; IH IWIlIIHHlII')' III nll~WPI' nil Ill' )'11111' 'IIIPHlhlllH nhlllll IhPH\llnll'p~, I'IIIIlHP Pflllllnlllll11 IIHI~ '1IIVHIIIlIIH 1"'1" )'1111 hlll/VI'I'''lnl )'1111 III11lPl'HllIIlIl, " MmN'I' I\NllIon 1;I~n!\l; nIWIH~HNN'I,^TIVIC" 1I'lhll HIIHtl'\lllll~' \II11Ihl\l111 IIlIIk\lII\l\lIHloIIs fpl' hll11s\llf 01' IWl',SOlf, 1111 All\J.uLIIIWpl' l&u,u Ui\llll]li\Ullllt~1! 11111)' \1\1 nVllllnl1!1' \\llllllkp 1I111'llllll 1IIIIIIslnlls Pll hohnlf of 1110 Hoslllolll, Thll~\ll\ll'llls 111'11 dolllwd hp OWl , AOENT, For Ih\1 pllrpps\ls of this AUI'POIl1PIlI, IIIl,AU\llllls 1\ pOI'SPIl whn 11111l111UOS, liSPs!, PI' opml'ols J\lmls/nsspls Ihl\ll11l1)' bl'lollnlly IIsolllo PIl)' l!w Hosl'lolll's IIhnrll\ls 01' wl!\l ol!wrwls\lllols pn bohnlf' of thl' Rpstllplll, 'rh\l Allonll~ fllHllwlll1 ohllllllllolls 1I1'\l Ihlllll.)lllo IlwlIIHPllnl of Iho fllmls rOo\ltvPII 01' IW, '" h)' l!lP A, llllnt for Ihp R\lsIIIPnt, ThP, All\lnlllp\ls nollls~'Il11\l I'Pspollslbllll)' fpl' 11,,\)'n1l1,' ~l PI' th\l \lOS,I.s of IhoRpslllPlll'H 0111'0 Pill pI' tho AllOnl's 11orsonlll nllllls, How\lVol', Iho AllPlll S 001111'1I011(1111)' !lolmll 11)' Ihp lorllls of Ihls nllrp0I110ll1 111111 III II)' 10\l0111\l 11111110 for fnll\1l'o Ip pprfOl'll1llllll\ls \11\'101' Iho . AllrppnWI1I, 'fllR AOHN'I' IS HEQUllmD TO ~ION THI~ AOREl1MRNT FOR ADMISSION, ANP AORRRS TO PISTIWl UTR TO nm FAC""ITY, FROM THll RRSIDRNT'~ INCOMR QR RESO\.1HCRS, PAYMUN'f WHRN DUE FO/~ I'/'RMS/smWICRS PHOVIDRD 'f01'HE RRSJ. DEN'f, Tl.lp AIlPlllls roqlllroll 10 prodlloo flnnnolnlllo\l\ll11olllllllon liS proof of Ihe R\lst~olll's nbUlly 10 pll)' for Ohlll'llOS wl1\lfl Iluo, WhC"~V~I' this Alll'C~I11~nt l'of~I'~ 10 thll n~sh/~I"'s Ilnllnllfnl obl/gllllons 11I11101' t"ls 1I1l1'0~I11~nt, lin~slllont"shllll b~ oonsll'noll to hlpllIIlc tllo oblllll\lllll1s of Allollt 10 1101 " 011 "ohlllf of nOSh/Dllt, . , ' LEOAL REPRESEN1'A1'IVf;j " POI' Iho purpOslls Qf Ihls AllroPll1cnl, L"lllll R\lPI'IlSlllllllllvo Is II\lOlled liS' II porsoll rooolllllzllct IIlldol' Sllllp lllw ns hllvlnll III11 IIl1thol'lI)' to I11l1ko honl,lh Ol\l'll nnd/or flnlllllltlll deolslollS for tho Roslctol1l, 1'ho LOlllll Ropl'osonlnllvo 11111)' 01' 11111)' 1I0tllo 00111'1 nppollllod, A telllll Rllpl'eSelllllllvo mil)' 110 nil IIl1omo)'-II1-fI\OII\Oltnll IIlldol' n dUl'llhle powor of 111101'110)' fOl' h\ll\hh Olll'll, . ' llllnrdtllll, oOllsorvnlor, 1I0xt-of-kln, or othol' pOI'SOIl nllowod (0 IIot fOl' tho Hosldolll \1I1,Iel' Sllllo IIIW, If J.,\lllnl HOPI'Os\llllnllvo stlllllS hl\s hooll OOnfOrl'lld b)' Il oNlrl of IIlIV 01' thl'oUllh I\ppollllmolll b)' tho R\lsldolll, v\lrlnolltlon of slloh slnllls mllsl bo provldodto tho Fn\lllil)' nl 1110 lime of Admission, " , 1~INi\NCIAL AUUANGlCMI~N'I'S .. l~tmlmAl~AND S'fA'I'ID LAWS l'UOIIIIIl'I' A NUnSING HOME IflWMImQUIIlING A 'rHIIlD I)I\I~'I'Y Gu.~\ItAN'mID OI~ PAYMIDN'I' '1'0 'I'lm Iii\CII,I'I'YAS A CONDI'I'tON OFADMISSION1 ICXI'EI>I'I'lm ADMISSION. on CON'I'INUlm S'Ii\Y IN 'rlllD Iii\CILI'I'Y, " ffilVATE JillSIDBNTS - A Rosldcnt Is cOllsldol'od Prlvnle (01' prlvnto pll)') Whollllo Sll\to or Fodol'lIl pro- Ill'nn,l Is llll)'ftlll for Iho Rosldent's Room & Uonl'd, A prlvnlo pll)' Rosldollt I11nY hnvo Pl'lVllhl IIISUl'nnCe 01' IInothol't lft'd pnrl)' whlllh pnys nil 01' somo of his 01' hol' c11nrllos, ,... . . " 'COllllllUlIlcnlftlll,plllllllllS In ASSIlIs,.llls oSS,lllltllll for Iho Rosldollt to oOll1nlunlcnle ChilllllllS In tho . Rosldont's Msols 01' 1'0SOlll'COS to tho PllellIl)' liS SOOIl liS )losslhlp, Tho Fllcllfty ncods 10 know If tho Rllsldlllll's pl'lvllto fllnds 111'0 Lloll1g 10 ho doplolod~o lhllt othcl' llI'l'lIngoll1ents fOl' pn)'mrllll cnh be 11111'10, 00110/'1111)', wlwn p/'Ivllto I'Undsn/'l1 doplo'lod, tho Rosldcl1lllppllos for Modlcnld ~ssISIIl/lC\l, ntld . .. ,! "'I ,," " (, ", ,., " "" ---~r-.-'''.. ,,' I I'I'''''lIlIn<< (\I'plll'IIIII", '"1'111'11I111111", 'l'lw HpshlplllllUIWs In p1'll\'ldu 1IIIIIlf\ll'lllll\l\l1l l'vl\ll\lslPII 1'\11' \.'\lmpIVlhlll 01' Ilw fyJPllklllllllpplll-'lllhlll, This 11l1'\ll'mmloll I11I1H\ 11\1 pI'O\'IIlvlI,III V\llllplIIllWII wllh IIIlY Ihllllllhws sUI hy 1111' IIPI'II\'lIhl\l SIIl\\I/('\lIII1IY MvdlPlIll1 p1'llB 1'11I 11 , ' I I~IlPI,lnIC IIIIl \f11l'1I11)' Inl'lIl'I\lPII, '1'1111 HVshlplIllI~IWS 1\1 ~Pvp liw FllvIIIIY 1111'\lI'IlWIIIlI' 111\1 sWills 1I1111 \ll'OUrVSH \11' Ilw M,Ulllu,'"IIIIIPPIIVII,IPI1' 'l'lw 1,~\lShIPI1II1UIWS III pl'o\'III\lllw IIlwlllly wllh \.'\lpIVH \If \IllY 111'\11'111\111\111 I'Ill\llllll 10 11\\1 MpdlvlllllllppllulIll\ll1, .. I '1'I'nnHfPl'I'lnll XHHlltH' II' Ihu 1~IIHhlpl11 Il'lIllsf\ll's IIsspls, Ihls Il'11l1Hful' IllIlY IIIHlI\llIlIfy Ihu HIIHldu1I1 fill' MIl,~I\lllhlllsslslIlIWUIIIHI/\l1' VII\lHUII dllillll11UIl\llll\l;.1l \If 11111 1~\lsldl'l1l'H MVlllcllhl hlllWllls, 'rhl' Rvsll\PIII IIVKllnwlollUllH Ihllllhls I11I1Y I'UHIII\IIl dlHI'hlll'll11 PI' Iho Husl(lolll Ihlll In IlPIl;pIlYI1WI1I, ' I Cllntlnnhlll "llY, 1,'lIlllt nl' IIl1PlI,ltY Chlll'UIIS I'IIIHIIIIIlIClhllhlllly, Wlwl\ \Ill \lpplloll\lnll fill' Mplllpllld Ilssls11111\l1l hllH boulI mpd, Hw gOHldpIlI111l1'0PH Ihll\l ' . whllPlh" l~oshlpIlI's \lppllCllllplI Is "pondIIlU,'1 IIw RoslllulI\'s IIslhlllltPII shnrp Ill' PPsl (liS dusol'lhpllln \lIP followlnu pllrllgl'lIph) shllll bo pnllllo Iho FlIlll\lly nil nr Ilpfnre Ihe IPnlh (1 OII1)\IIIY of Illlllh mOIl\h, . 01190 Ih\l l~oslllplH Is dpIlll'mlned 10 bll eligible 1'01' Mplllollld 1188IslIl1l0P, Ihe II111on11l PI' Iho, l~psldp11I'8ShI\\'0 of cusl shllll b\l pllld 10 \hp FlIlllllly pn pr bofOl'e thp 101llh(lOlh) dllY pf olloh mUlllh, This monthly shlll'P PI' llos1 Is dolormlllod by IIIP ~III\O/CO\lnIY M\ldlollll\ Prllgl'lImllnlll\1l1Y \10 l'efol'l'od to liS PrlvlI\O Porllon, !lhllro of Cost, Pnll\lnt Lln\llllly, PlIllont Hosonrco, oto, Any phnngos In resldonlllnbllllY will \lI,I oomnllllllontod 10 Iho FlIolllly OIl n thMly bllsls, . , '1\lIol1t ClIl1h'llllhlll UOHldol1l'a I1l1nda, If tho Rosldolll'sAgel1t hll8 conll'ol of or II1l0ess to tllo Resldalll's Inoonw IInd/OI' IIsS0ts, tho Allenllllll'eoS \q IIse thoso fllnds fOl' Ihp Resldent's lI'olfnro" 'fhls ," lno!\lIlos, bnt Is notllmltod to, IIlllklngpl'olllPI pllY1l10nt for 0111'0 IInd serxloes provIded to Ihl! Resident; 118 spoollled In the terllls of this Admlsslllll Agreomel1t, ' ,,', .. ,,/ ,,\ , I'l'Ovhlhlll 1111111ncllll IlIf(lI'l1\lItlllll, The Hosldont cel'tlOps thnt III1Y IInllllollll II1for1l1nllol1 'reIlIlHllnB'" tho Resldont's \ncpmc 1I1lflllllsllts I'c~nlrcd by the Fllolllty 111111 pl'Ovldod by Iho l~esldol11 IHoompleto ,', IIl1d IIconrnto, ' , ' " i: " ) I,' . , " . ' ,_ q , . 11 MBDICAID RillilDElITS. . A Mcdlcllld l~psldcl1t Is Ilno who reOolvllS bcnollts fmlll Ihe ~ll\lo McdlclIldi, Progl'lIl11 fOl' II 1l111jorlty of his 01' her I~ooll\ I'il. Bolil'd chllrgos, Mpdlcnld lI1nYOl'll\lIY 110t cOVal' ohnrllos Cpr) liddltlonl\t sel'vloes/ltems provldod by tho Fllclllty . this Vllrlos frolll ~tnto to SliM, if , . '0-1 II 'fl ,Tho following npply 1\1 McdlCllld, Rosldcnlsl 0'1 I"'. . - ., . , . , " '. ' , . ' " j" ;, , I>nlly Itnllll'n)'l\lllllt. Oil IIdmlsslul\,thc I~osldonl will bepl'Pl'ldcd wllh II 1181 of flllppllos nnq,$otf', 'vlcos thnt \\1111 bo plIld by tho Modlcllld pl'Ulll'lI1l1 111\11 Iho6e sllppllps nlld services lIol~lIld for bYlhe , Modlollld progl'lu\l; fol' which the IMldollt will bo sOPlIl'lItety chlll'god, Ado,tnllcd 11$1 of IIIld ch"tSl\~ ~ for suppllos I1l1d sCl'vlcps IIvlIllllblo In Iho Fllclllwbnt \lot oovore,d by Iho, dl\lly 1'1111\ Il~~or Ih~ i' Medlcllld progl'llln Is 111llll1tlll\lCd 11\ lho Busll\oss Offluo 1II.ld n\'l\lInblo for revlpw dlltll\gllon~nl bual. ! noss holll'S, , .;~ " " ~ 'j,., ,. " '!, ""., I' I 'I\JI'mlnlllllln Ill' (~II\'1II'IIHII, 'l'h\l 1~\l~I<I\'l1ll1l1l~' 1'1'111111'1111 11111 Fllvlllly fIll' II~ 1\l1l~1 IIshp 01' ~Iw I~r\lnl' nllll Ullll1l11\1 1'\lI'M\lIiIVIlIIi pll~'IlWIlI, PI' fill' II~ 1\lllllllS Imy slllll'P Ill' l'osl P\\'II<I h~' 111\1 H\lslIlulll Is plIIII liS Ihlll' ^ Il\lslll\llli lI'h\ll'cl11l1llls 1Illlw FlIl'lllly 11111l1' M\lIHclllll vm'\ll'Il~1\l hilS \lXp11'911 or \W\lll 1'\lII'PIW' 11V\l1~ 11l1'l11hll1WII PI' 1i\lllh!llllHISI pll~' FllvlIlI~ vhlll'Uus liS 11 PI'II'I!l\l Hpsill\II\\, 111 IhlH \l1'\l1\1, Ihll H\lslll(\llIwllI pll~ hlls\l1i ollllw pl'll'lI\\lI'llI\lS, \lhIll'V,\'~, 1I11l11\lI'l11S 111 1)1'1\11'1111 Ih\l111l1\l \If S\lI'I'IVIl' ,I' I n\l~hlpnl'~ lihlll'\l Ill' (JHsl, 'l'h\l 1\1\1111\l1l1l1 pI'Plll'llll1l'\ll'l\lwS IIWII\,lIlIlIhlcl11Plllhlylllvol11Pul' 1111 pCI" SPlIs I'cqll\1Sllllll MlllllvlIllllIsslsllIlll'C, IllI~CIIIlIl Ihls 1'111' III\\', IIw Mp\IIIlIIIII pl'lllll'lIl11 1'\1l1l1ll'lls IlMI Mllllkllhl HllsllIllllls 1\1 pll~ IIII' II I'CIISll1ll1b11l sllmll of Ilw 1l0Slllf Ilwll' eliI'll, (111~'Il1\l1l1 nl' Ihlll shlll'll Is Ih\ll'\lspolIsIlIIlIlY PI' Ilw HIlSllipllI, Thp~III!l1 \11111 clH\I1llPllw HpsllIoll\'s shmp nl' \lllNllIllIs IlIs\1I'OII\1Il, If Ihf! 1~'~shlplIl IlIlIlm 111\llllcs I'pwll'pd 1'1'0111 ~pcllIl Spc11rll); lll' II sll11l1l1l' S\l\II'\'PI\1ll1l~ I'pr shllr\lol' ollsl, 111111 IIIIl l~psIII\l1l1 fllllR In Illllkll prpl11pl pll)'1110111, Ihp Fllcllll)' mllY 1'011l10RI 1111'0111 111111111111 Ill' shch 111ll1111)s 10 Ih\l FnplHl~, III s0111\l ~Inl\ls, 1'1111111'0 III pll)' Ihc Hosldolll's shlll'o or Cllsl \1111)' I'e Sll II 111 1h.IlI~psldllll\'H IlIsllllllllIP, , ThpFIlO,HII~ \~HIIlIRo 11011f)' IIIP IIpprnpl'llIlll Slllle or F~de1'lll IIU0I10)' or Ihls 11011-pll)'1110111, ' , MEDICAIlB RP,SIDI~NT~. A MpIII\llll'e Hoslllel1lls ollC who rOCpll'llS bOlloflls 1'1'01111110 Fpllorlll MlllHoIIl'P , Prnllrnm I'm his \11' hUl'l1l11'sll1s IWl1w \lllre,80llwnddlllol1l1lltollls nlld sor\'lcps 11111)' bp lloVllred h~ Medlllllr\l, 'I'h\! followllIs IIppl)' 10 Modlllllro H~slllonlsl · Dnllynilt\l JlllY1l1011t, OI1l\(hlll~slol1,lllP Rosldel1l shllll ho pl'ovldod with II IIsl of snppll\lR nnd ReI" VIIlOR llonorlllly pnld by tho Molllcllre Ilrolll'lIlll. 1IIl1llhos\l RIlPpllos 111111 R\ll'vlcek 1101 plllll for lJ)' tho Medlonro prosrlll\l 1'01' whlllh tho RORllol11 will hp'scPlll'lIloly ohnrsod, ^ IlotllllplIlIRI of 111111 ohllrllPR ,J for s"11PHes 1111\1 sorvlcosllvililnblo 111 Iho Fllclllly bill I1llt oovcrollllndel' Ihe MOlllcllrp prosrnm, 11101"d 1111llw dllll)'ool11RIII'IH1CO mtll, IR 11111111tllll1011111 tho lJllslnossofl!lle 111111 IR nVIIHnblo 1'01' rcvloW IImll1l! nOI'l.I\n\ bllRll1PRS hOlll'H, . , I' · 1.I",ltolf Cove\'1I1l0, The RoHil.I,e111 Ill1dOrstlll1llH thlll MolllolIl'll c91'\lrnl!\lIR llRlllbllsholllJ)' Foctornl ' , l!lllrlollneR IIl1d 1101 b)' tho Filolllt)', MOlllcllro co\,el'lIge IR 111111\011111 thlll on\)' n Rp\lolllolllpl'el of Onr(\ Is ooverell 1'01' II RI1~clfled 1I1lllllllJr or IIII)'R (bOl1plll pcrlod), If Iho RCRldc111 110 \ol1gpr mcplR Molllol\1'o COVlll'ngo crlterlll. covol'ngll CIIIl bb elldpdbeforo thll \lsO of 1I11111101l0d dll)'s 111 tho Ollrrelll bll!loflt pori, od, ' · IC"llh'lItlon Ill' lIeneUts, PrillI' to ndl11lsHloll. Ihe HeRldol1t I11\\Rt bo IIblo \0 dpmollRtrnto Iho nbllh)' to pn)' (olthol' prlvntel)' 01' Ihrollgh Modlcllld IIssls11ll1co) for Fllclll\)' RorvlooR rondored IIftol' Modlonl'\l h\lllOfllsexplrc, Whcl1 Medlcllro COVOI'II110 cxpll'cs, Iho RCRlde1l1 nlll)' remnln h\ Iho FncllllY If prl\'l1lo " plI)' ol'llthel' PIlYll\OlIt IIlTIIIIgcl11cnts hlll'o bcolllllildll, If tho Rcsldelll wlsllCR to hl\ dlschnrlled from tho FllclIlty Upoll explrntl(ll\ (If ModlclIl'o hOI1OIlI~, 110 or sho I11llst slllld\'I~\l the FI\elllt~ III tho tl1110 of Iho llo~ldcI1I'~ IIdll1ls~lol1, " , ' " · Co!lIS\II'nuco nud Dodllctlhlcs, Tho I~Cfildol1l Is I'cspol1Hlblo fiJI' PllY111oll1 tlf IIny Modlcllro oolllR\lI'- I\lll;O IIlld/ol' dodlll:tlhlcs, ' If Iho RCRldol\lllltol1ds tll bCC1l1110,pl'l\'1I10 )lll)' II'hol1 MedlclIl'e houofHs oxpll'o, Iho RORldcl1\' ngrboR 10 llllY lu . IIdVlIl1CO fill' 0110 Illtll1lh's prll'lIlc dl\lI)' rnte \l'holllho Hcsldenl Chll11llOS III pl'l\'lIto pll)' stlllllS, Whir tho oX cop- Ihlll of pl'lvlllo (llll'tllll1! If Ilppllcllhlo, Ull 1I\ll'lIl1cC )lIlYIl\Cl1t Is I'cqull'od 1'1'0111 Modlol\l'lllloRlde11IS whn COllvcrt 10 Modlollld,' ,'. ., " j I-I,. iI' ,\ " " ',j" '! " I'IWI\II':NT INFlml\MTION RIJH PNl1ili.&..l.Ull"IQL\D12N,JnJWC:r\MLllS, . PII~I1IIY d\lll'tlPs I'PI' sprvlws pl'Pvillpll shllll \)U \1ll1pII 1111111\hly In Ihp !{pslllpl1l, Tlwsp phlll'llPS III'P IIII,P 111\11 pllYII\1lp \1y llw Wl1lh (101111 IIIIY PI' Plwh 1111l111h: " If PIlYl1wI111s IIllI IWP!I'PII hy 1110 ICl1lh (101111 (IllY Ill' PllPh 111\111\11, Ilw IIcpPI1111 hnllllwP Is PPl1sllI\IW,d 'pllsl \hlll Ill' IlulhH\lIalll, IIIHI"lh\l Fl1pllllY I11I1Y mill II Inlo phllrUIl \11 Iho gos\!lvl1liH IIVCI1l11ll, This llllp pllllrU\l sI11111 hll .. nss\lsHPII 1111 IIw \1llll1lhly \1nllll1oo mllw Ipsser of Ilw 111011\hly nllll nf I ,~% (nllll IIml 1l110-hlllf pprcPl1lll1r Ihll mn~ll11l1m 1II111111ll1 purllllllllll \1y IIIW, This lnlO ohnrtw 1\I1PS 11\11 IIl\ar I1I1Y l1\1llunlllll1s Ilflho FIWIIlIY Ill' 1~!!slllpl1\ 1I1l11\lr Ihls ^UruoI1WI1I, ' , Th!! gpsldpl1l rpllpgl111,Ps Ihm Ilw FnplIl\y IIpuH 1101 \ll'fllr orpdll or IIPCppllmlllllnwll\ plIYl1lUllls, Tho Fllulll\y'6 n~opp\IIl\ll!! Ill' n Pllrlllll PIlYI1IllI1II\1l0S Iwl IImlllho Fllolllly's rlghls IIIHlpl' lhls Agroolllolll, ' .' !/ '/;'1' I} , ',1 ,) , "'1 f I, i i I . I ' I"I'! I, i ' EPB FOR tmTURNBD CHECKS - ^ survlo!! fOPl1f$llp,OO (Iwllnly Hvc Ilollnl's) 01' \hp 1I\llllnl fpo ohnrgpQ 'r by Ih\l hnl1k, whlohuvol' Is gromol', will \10 oIH'rll:II~:I~::::~II':\lld ohpok, ' . "~I' j, , .~ Tho Roslllol1lmllY noe,d 10. bPllbsonl 1'1'0111 lho Fnolll\y lompornlily for hospllnllznllon 01' IlwrnpPIHlo Illnvo, I Tho Rosldpnl mny reljllosl IhllllllP Fnolll\y holll oponlho Reslllonlis hod 11l1rhl11lhls tllllB, This Is known na 1\ I Iibod hold. II The Rosldenl nnd 0 fl1lnlly 1110mb 01' or 10fJoI I'Bpl'esolltnllve shnll bo glvon nOlloo of Ihe bod 1101(\ I , oPllonl\1 tho IImoof hosp\lnllzntlon or thprnpPlltlo lenvo, , ' , ; . , ' rA1L\J~fl 'rD pAY. TIl\! FnplIlly's IIUlldlll\l fpl' pllYl1wnts fnlls 11l1l1w IPlIlh of olloh monlh, If Ow I~P&I\lonl fnllft 10 mnk\! n I'oljllll'oll pllynwl1l within IwenlY-(lIW (~I) Iloys of Ihp !lUll dnle, IlIp Flwlllly I11I1Y rpqlllr~ Ow ~\lsldonllo vnollllJ tho FIIPlllly, . If n Rosl~l\lnIIH rO(lnll'ed 10 vllonlp 1'01' flllllll'plO (1oy, 111Il Fnolll\y shllll provlllo IIdvl\IlPB nOllop ns spl forlh In Ih\l Rllslllol1\'s 1~lgllla soollon of Ihla Aweoll1enl, This nl1tl90 shllll ho OPnSlllpl'e(\ I'eoplvpd ollhol' on tllllnclIIIII. .110111 of I'eoplpl 01' 1\\'\1 (~) dllya nftol' mllllln!!, whlphllvPI' OOOlll's Ol'st, " MJIDICAID RESIDBNTS - If thp 1~08Id\lnt's 011I'0 Is pnld Imde,l' Iho ModlQlIld progrnm, Medlonld mny pn~ . for 0 001'lnln11l1lnbol' of bod hold dnys, If lho Modlonld Resldenl's hospllllll~1I110n 01' Ihol'npellllo lilliI'll oxceeds tho blld-hold porlod pnld IlI1dol' IhB Mcdlcnld prl1g1'll1111 tho I'osldontlllny I'oqllosl nl1nddlllonnl bed hol(\ period from Ihp 1111011\1>, by noroolng to. Pili tho nppllcnblo dnlly 1'1110 dllrlng Ihollddlllol1l1l bod hold period, Olhorwlsll, Iho I~osldolll qhnll be rondmlt- '. leI upon tho flj'slnvnllllblllly 01'11 bed 111 II non.prIVIIIIll'oom liS long liS tho Rosldonlll) roql1lreslho smlcos provldod by the FllolIl\Ylllnd 2) Is Ulllllblo for Mcdlcllld nlll'slng sorVlces, ,. ,. ' , E1ill!ATI~ AND MBDICARn RUSIDBNTS . ^n~ Prlvnla. or Modlcnre Resldont II1n~ 1'0ljl1osl11 bed hold f'l'omlhe Fllolllly, A Rcsldcnl's prl\'lIle hlSlll'lIl1Ce mny 01' mllY nolplI)' for bod holds, ,ThB Modlooro \1rogrnm doos 1101 rchnbllrso for hod holds, howovor, If the Medlollro Rosldentls I\\so Modlonld ollglblo, some Medlollld prOllrll\118 mllY PIlY for n cerlnln ,l1l1l11ber of bed hold dnys, Olhet\vlso, n Prlvnlo 01' Medlonre RBsldel11 roqllosllug II hed hold mllst PIlY Iho Fnoll\ly's pt'lvntB dnlly 1'0tB for Iho hed being hold durlng'lho bud hold porlml, ' , " " , , ~ ;'j(' " '--1' TI~HMINi\'I'IPN rw MlInq~l\mNT i~f.aW~.Q..:WllMll'h\'111 . Tlw F\I\!IIII)' ~hIlIlI1l1111'l\l1~fol' Ill' ~YI\!llh~ g~~I\lolH ~plpl>' II~ II 1'0~\11I PI' Ih\l HIlNI\lonl phlln~ln~ hl~ PI' hol' 11111111101' \11' pllynwlll fl'lllll PI'II'III\I PI' MOI,IIPIII'\l III Mo\llplIllI, IlllloNN 1hp Flwllll)' IN llnUlo\lIl~\l11 fpl' MO\IIPllhl, ' , ' enl~~ON,Ak.ERQeHnTY OF IWSUllim:.UPONJ)(SCIIAlliJU . Tlw 1'1101111)' ~hllllmllkll I'PIINOI1I1III\l" \lffpl'\N \n ~lIf\!~\llInl 11)11 H\lNhlol1t'N pOI'~\l11111 \1\!lpl1~hl~n lIf1ol' IlIschlll'!lo. Thll 1'1101111)', hIlW\lYPI', shlllll10t \lP IInl*~JIlI' \Ill)' \llInll1~olllnl' InnN Ill' 11111 go~hlolll'N Pl'llport)', Tho FIIPllh)' mil)' III~poHP of \In)' pl'oporl)' Ipn \1)' , Ihp R.pslcJolH If nol 011l1l11PII wlthllllhll'lY (~(l) lIn)'s pf IlInchnruonl' Irnll~fol', 01' III 1I0PPI'dl\lWo wllh IlppUPllhlp ~llI\llIIlW, lmFUNDS . If Ihp Honhlol1l IN \lIsphll1'Bl1d Ilofol'\! IINll1g filii pl'llp\lhl ohll1'BIlN, Iho 1'1101111)' shllll I'llf\I11Q tlll} III1IIsll\11l01'l1\ln or s\loh ohlll'~os wllhll1 II I'CIISOIIIIIIIIl pOI'II)d of 11111\1, If Ihll Pncllll)' Is I'pqllll'lld II)' IlIw l\l hold I'llsl, donI pl1l'snn,III flll1\ls In l\ d\l1111111\\ll'IIslllooo\lI1I, Ihc bllllllloc of Ihoso f\lmls shllll, PP 1'0f\l1111011 pl'\lll1pll)' IIftcr Ihc Rllslllonl's dll\~ of IlIscllIlI'UO, ' . ' " " " If II Roslllol1lls I'cll'onollvpl)' \lPPl'ovod fol' Mollle"l'\! or Mclllollhllllllloflls, pl'pvlo\ls pllymollls nwlcllllll will Pll QOvPl'l11l b)' Ihc Modlolll'o 01' MCIUol\ill pI'OS\'l\I11S will bc 1'0flll1(lcII pl'ompll)' In nor.ol'lll\l1CO with Ihp 'Fl\qllll)"s refund 110IlP)', COl1,ll\Ollho Foci III)' Iluslncss amoc for (lcll\l1s on Ihc 1'0f\II1\\ polio)', , h '(1 Iii J ~\> I, , , , 14 , 'I' \, Ii 1"< , '1' ! I . 11 '{,I', 'I' ,. /. .. A'l'TORNEY&~13I~s/COLl_EC'rION AQENCY FEES. .ll1lhccvcnlll)1I FO\lIHl)' losllllllcs I\nd Is nprovIIU,' " IllS pmW 111 II\lgl\\loll IIgI\II1SII\O)' pll\'l)' 10 Ihls Agl'CClllcl1t, "rising fl'ol11lhl\l PIII'I)"s (,111111'0 10 oompl)' whh.~:, Ili"""".'.j, Iho lorms of Il1llAgl'cclllOnl, Iho Fl\olHl)' shllll pc cnllllcd Ip racelVII from Iho losing PI\\W rCI\~ol1l1pl~ 111101" I,' lle)'ff'/collcOllol1l1gPI1C)' fccs, .. '" , " . ,/'I0N.ASSIGNA13LE ^QJW..EMENT . ThQ Hosl<lc11ll\gl'cos Ihl\t Iho right .9f thc RQsldol11 to re~lll~ lit Ihe 1"1\01111)' Is pCl'sollllllll1d llot I\sslgllllbltl, The RcsldclllllllI)' nol tml1sfor hl~or hor rights llIlller Ihlft AgreelUonl 10 I\ll)' othol' pOI'SOI1. " 'j, '-, " " , , " " " " '" " , . " 1 ,I' If, (I fj :"1:. {. ", I!F i~ll : I 'Ii fp'\ ,jl~ J1j it,! 1\; il ~ IUf8f!JUN1''8IUOIf1'8 (\NO IW81'ON8I1UUTWS " NUN!) IIWIU M' Nt\'l'H)NHTiVl'I~M ";N'I' Thp FII\JlIlly \VPIOIlI1W~ IIIlIWI'SOI1~ Il1lHloII of lis wl'vlcos 111111 dllOS \1ullllscl'llllll1l1l\l ol1llw hll~l~ \If ;l~\l, Ills. IIhl,I,IIY, 1'1100, \JilinI', 11111111nn pl'l!!ln, I\IWOSll'y,\'~IIl\lpn, \11' S\lX, Th\l Fllolllly dp\lS nol\lIscrllnl\1l1lo 11111(l\1~ pilI'- sP\1s 11I1S0(1 \111 1111111' SO\IIWS of pllynlOl1l, .. ,. QONlmN'I' ll'OH 'I'HlM'I'MIWI" NU~SINa FACILITY SI.1RV'.cES 'Ily sll\IIII111IIlI~ ^/Jro\l\1WIII, Iho Hllslclol1l CPl1sol1l~ tp Iho FlloIIIIY pr"- vlllll1s rOI1I1\1lll11ll'shl!! IIml ollwr 1101l1lh Ollr\l Rlll'vlcos ns dlroploll by Iho IIlIllmlhw physlpllln" From limo III ' limo, tlw I1l1pllltYll111Y pIIl'llolplllo In 11'1I1111\1s prolll'lIl1lS 1'01' pOI'S\1ns llooklnllllpcnsuro or Illlrllflollllon lis Iwnllh Q\\I'o WPI,'kIlI'S, '111hll co\ll'SIl PI' Ihls plIl'llolp"llol1, Ilnl'O I1wy bo [Ol1dOI'Olllo Iho ~osld(l\11 by sl10h lmlnllos "Illlpr sllporvlslol1 ns I'oqull'od hy III\\', ConsOl1llo 1'0nlll10 nmslnlJ 0111'11 pl'ovldlld by Iho Fllolllly shnll.hwludp POll- ~om for PIII'O b)' sllllh Imlnoos, . PIWSICIAN SEHY~CliS- Thll Ro~ldIlIlIIlOkl1owlodlJll~ Ihlll ho or sho Is Ilnelor tho nwcllOIlIpnrll of II porson. . 1I111l1llndhlll physlc!nn IInd thnllho Fllclllty provldcs ~orvlcos bllsod on tho gOllornllll1cl spoplllplnslrncllons oflhls physlllllln, 'rho l~osldol1l hilS II r1llhllo solcclhls or hcr 011'11 II110ndlnl! physlllllll1, If, hOWOVllI', IIw Rpslclonl dOlls nol SC'cctlll1 nllol1dhll! physlollll1, or Is unoblc 10 solccI 1m nltllncllng ph)'slclnn, nn IIllcildlns ph)'slolnn.mny bll dcslllnn,lod by tho Fnclllly, 01' In 1I0cordonop wllh StlllC IIIW, . ,. Tho Rllsldont recollnlzos 1II1\lnllrO~s thWIIH physlolnl1s provlclhl11 scrvlocs 10 tho'RcslclPIl\. InoludlnSlhosp' dcslllnolecl by tho Fnctllly, 111'0 !ndepondonl contrnclOl's, Tho Rcsldcll\ rooollnlzcsl1nd risrpos thot suoh phy~l- 'olnns nrc UOllIssocllltos 01' IIgonls of Iho Fnol1lty, IInd 1111\1 thp FlIclllt)"s tlllblllty f\w nny physlellln's 1101 or omlssloli Is tlmllod, .. , " Tho Rcsldonl shllll bcsolol)' rOflponslblo 1'01' pllymont (11' 1It1 chnrl!cs of nny nhyslclnn who I'cndcl's onrc 10 Ihll Hcsldcnl In ,tho FlIoI1lt)', unloss tho chllrgos 111'0 oovcl'od b)' 1\ third pnrl)' pnyol', " RIOI-I1' TO REF.llSE TlmA'I'MENT - Thc Resldont hllslhc rlghl fo rofusc IrclltmCn! nndlo rcvokc consent for Irclllment. Tho Rosldont nlso hilS Iho l'illht to bo InfornlOd of thc modioli I conse~ucnocsof suoh rcfusnl or , ro\'ool\tlon of oonsont, nlld to bo Inforlllcd of IIltcl'llllle lI'olllmonls IIVllllllblc, Whorc, In Ihc opinion of Ih" .' IIllcndll111 ph)'slollln (11' b)' Judgemcnt of 1\ oomt Oflll\\'j thc Rosillcnlls dotormlnod to tIC Incn\l1lty (noolllpo- 1011110 mllko II doolslt1n roglll'<llll11rofllslIl of Irelltmonl, thc dcolslon to refl\sctrolltm nl 11111Y bo mllclc by II .I.cglll Rcprosontllllvo 01: otllCl' SlIlToglllo c1oc!slon'l11l\kol" sl1bJool to Stntc IInd Fcdel'lI11 \\" I' , , ',. " . , , , 1 . . Ii s HICllmICN'I"I:lI'I':nIlUl'li\I I I'IHH'lm'I'V Thl' rovllll~ ~11'1I11~IY 11l~~II\II'II~~~ IIw ~pppll1!1 PI' \'1111111\111' .I\l\\'UII'~, pllp\lI'B, llll'~\l h\l1l1~ 111' I1Hlnp~, PI' Illlwr IIpll1a vlll1~III\lI'\l11 of \'IIIII\l 1I111w Fllvlllly, 'I'11\! 1111\llllly ~hnlll11l1k\l l'\ln~I1I1I1\1I\l \lff\ll'IB 1\1 fillf\lll\lI11'lllh\l H\lsl\lpnl'a PI'IlI1\lI'IY/vllhlllhl\lB whl\lh II1\! H\l~ld\lnl vholl~\ls 10 kp\lp 111 hl~ Ill' lwl' pl1~HPBBlpl1. 'l'lw Rpslllpl1ll1~I'PPB 10 Infol'll1 Ilwl'nplllly of 1111 1'111 II II 111 \l Pl'op\lrly \lponlllll11ls~lol1. 11',111 oily Ihn\lII1ll'll1lllh~ ,. Rpalllpl1l'a sIIlYII1~W IIpll1B of VIIIII\lIlI'\llllhlplllllllwl~\l~lllplll'a 11nN~p~~hll1a In II1\! FIIPlllly, Ihp R\l~lq\ll1ll1lsll 1I1l1'\l~S lo,so Infpl'lIIl11\! FIIPlllly Alh11ll1lslrllllll' Ill' IlpslIlI1PP, ., HlcRIUlcN'I"t:l H~COJmFl CQI'IPIDEN'I'I;\LI'I'V - Inflll'll1llllon 1119I1Hlollln Ihe Ro~ld\lnl'll n1\1(lIolIl l'\lool'lls Is opnfhlollll"i, UIH11l1hol'lz\ld pOI'SOI1S shlllll101 bo 11110\\'01110 I'ovlo\\, Ihllslll'oolll'lls \\'11 h 1111 I tho R\lsldolll'B \\'l'lllen OOllsonl, o'\oopllls rocll1lrPllor pnnnltl\ld by III\\" ' , <;ONSENT TO RELEASE R V P.AC~lTY - TIl\l Rosldpnt IIIlIhorl7.05 Iho Fllolllty 10 1'0101150 1111 orimy pllrl of tho Ruslllolll's n1Odlolll or fll1ll1wllIll'eoorcls loony p\lI'SOn 01' ol1l1lyll'hloh hilS 111'II10y hovoII 10!l1l1 01' OOnlI'IIP- ' 111111 ohll!llltlol1lO PIlY oil or II pOl'llol1 of Ihll oosls qf Ollr\l pl'ovldolllo Iho Roslclon\, Inolncllng hill not IImllecl III hOSI*1I1 01' moclloiJl Slll'vlOllS oompllnllls, hlS\lfllllOll oompllillllS, worklll's' oomp~nsllllon Olll'rl\lra, w~lfllr~ fun4s,1II1~/or thl! Rllsld~nl's llmploYllr, "". . .," " Thl!Rllsldenllllso 1II1l11llrl7.l!s r~I\lllse of lnformnllon from m~dlonl orfinnii\llnl rllOOrqS 10 IIny ll111IU\lnl prof\ls' slonnl 01' Inslllllllon rllspol1slblll.fol' tho l~ll5ldenl's ll111dlonl 01' nursln!l 0111'0 \\'hl!1l the Rosldent Is Irnnsformcl 01' dlsohlll'S\ld ft'olll Ihe Fnolllty, PHOTOGRAPHS - The Rosldqntllgroes 10 nllow tho FoolIllY to pholP!lt'llph or vlclllotllpll 1I111 RllSldenl ns n , lllollns Ofldlll1l1llell\'On 01' for helllth relnllld purpoRlls, Tho photogl'lIphs or vldllotnplls mlly nlso,be uSlld 10 , hlllp loollle th~ Rlls denllll thll llvont of 1II11\111\Ulhorl7.eclllbsenoll from Ihll FnoUtlY, bUI shnll olhllrwlsll ho ' kllPl oonfidenlllll, If Ihe,PnpllllY IlIlllnds 10 \ISll Ihll photog1'llph \11' vldoOlllPll for pUrpOsllS olhllr Ihlln Ihoso nOlll4 n~ovll, the Fllolllty shnll gllt wrlttlln permission froll1thl}~llsl4elllln 114vnnOll of s\1oh \lse, Thll Rllsldcnl rlllnll1s Ihe right 10 refuso thlllnklnll pf 1\ photogrnph ~l nny Illlle. ' '.. 'I'lm RI~SIPI~N1'IS DU'I'mS RULES AND IU~QJJLA'I'I6.NS. - The Rllsldont ngrocll IItnt thll FncUlty lllny, to lllllhlltiln .ordcrly IIn4 ~co. nomlonl opcl'lItlons, IIdoptl'llnSol1l1ble I'ulos nnd,l'llgulntlons to /JovonHhlloondllot nl1ll rllspon~l~llltle$ of thll Rllsldcnt, Thll Rosldonlllgrcos to folio\\' thoSlll'l1llls IInd regulnllons lIull hel'cby nokuowlQdllosllmt IIll 01' Shll hilS bllell glvel1 II written copy of sl1ch rl1lllB nnd roglllllllons, It Is,ullIlel'slood thntthll,rllllls ilnd rcgulnllons 11\IIY bo nmonded from tlmo to time ns tho Fnolllty mllY I'equ I I'll, Any Ohlllll!llS 10 Ih~ nllos nild rOS\lllIllot18 shnll bll glvonlo thll Resldont In writing, , , , , , I, , RUSmE~N01S. - Rosldllnts lit'll urgod to brll1ll nny UrlIlVnl\Q~S'OPllolll'llltlg Ihe FlloUlty 10 tlte nllel1llon of ,Ihll Fnolllly Admlnlstrntor 01' doslSIlOll, Tho Fnclllty nlso llffol'sn tlllHl'lle "HOlllnc'llcle~honll uUl11borthrtlllllh which Ilrlllvnnoos 01111 bll regl~torod dlroolly with thll corporntll plnoes, 'rhls number Is 1-800-572-998\, Rcsldents nl50 hnVlllhlll'lShl to coutl\OtlhoSlntll'Fnolllty llocnshlsnglll1PY, thlllOtllNqm\ ' onro ombudiillll\lI, 01' bOlh, to I'clll~tcl'Srlc,vnllces lI!llHllst tho Fnolllty, ", , " , !,if 'j 9 /1 , " ,. , .., J2urc. Th\l H\lslllpllllllHI~I'~IlIllIls Ihlll his (II' Iwl' !Illllls IlWIIIPlllly pl'llSvrlllll\llIlld, 111Il1'!!fol'o, 11111~llw I1I1HlI. tnl'Il11 hr Ilw I'!IVIIII~, TIl\lI{\J~I!lIlIlIIl~Il\IIIS In ~'ol1sIl11 wl\h NlI1'sll1ll PI' PI 1111I1'>' sIIlfT I'lllJllnllllll rpPllnl' Iwl'lll'- IIIlIlS hn>llllhllllll1llw FIWIIlI>', '. MUU1CATIQN~ . Nn 1111'11I1l1llill11s PI' Ilnllls 11111>' hll hrPlIllhlllPOI1 FIIIl1l11r IWllllsps 111111lSS Ihlll1wdllllllllll1S PI' 11rlllls 1I1'\!,lulllllllll IIPPllnlllllll1l Ih\! 1'1l111111'\!I11PI11~ nf SIIIIIlllllll FOIllll'Illl,IIW, PIIPkllllhwllf IlllllllpllIllll1S I1HIH hp Ilnl11pnllhlll wllh III1l FlWllllr's 111\1dfp1II11l11111sll'll1\1111l11 sysIIIIll, Nn 11nllls PI' 111\1111011111111S I11n~ 11(\ hl'n\1lll11 11110 Ihll Fnllllll~ 1I1110ss 'hll~ 111\1 Ilulll'ol'llllln IhIlIHII'SIlS' Slllll11l1, '.. " . " " , " cAnU OIlI!ACn.f'I'Y's 1~~Qj~lIITY . 'nl pl'llSlll'l'O II1\! vnhlll PI' Ihll FII()llil~'s pl'nplllW fnl' f\1II11'P I'pslllllllls' IIslI, Ihll, RoslIllIlll n!ll'llOs In IISIl d\11l r.1I1'1l Ip Il\'plll dlll11nllll1lllho FIIPllllts pl'Pplln~ 111111 pl'umls\!s, The Resldlllll Shllllll\l respol1slhlll fnl' I'llpllll' PI' I'lIphWlll1lPlH nr Ihll FIlPilll~'S pl'llpun~ Ih'1l1l1!l\.l111l1' II\.lsII'Orllll hr Ihp Rpsfdllllt, 1illll'II1'PI', 1110 R\lsldllnl shllll nlll 111l1'IlSI1Ill1slhle fnl' snoh 111l1ll1I~0 IlS Is III ho \.l>\IWIIlII fl'PI11 nrdl. nnl1. Weill' 11111110nl', :, I . 'CARij bFTIIBJlliSIDEN')"S.ROOM - Th\l FnpUlI~ PIlPonrnll11S \lIP 1~\lslllolH III IHII'1l n hPIHo.llke Pllvlr\lI1' nWnl,nl1d will nllompl to llPClll11lllllllnl1l nil renfiPllnblp l'eqUllsts III lmll VllfulIll7-e l'eslllPllI 1'00111S, Fur sM1l1Y rensPI1S', Ihll FnollllY mllslllppl'nWIIIl)' 1111\11\1011 01' 1'0nrl'lll1p0ll1\l1l1 of fnrnhnl'c, hllllglllll of plotnI'P~, Pll&1IlI'S, or plhllr sll11l1lll' IIclll'llIlls, .. . , .. ,'I'llI\NSFlma i\Nl> UlSCrli\.ltmCS ", it, . T,hP,FIl cllhnh 1I111l1\'o,IlOlloo Ip Ihp RO,SldOI1I. nlld lfknowll,'I fnll111~ ll\Ombll\'.OI' LOIlIII RoprOs\lIlIIlIIVOof Ihll, '~', \,' Resllfolll, of tl'nllsfuI'or dlschlll'1l0 IlS followsl ' , . ,.".1 J " I I, .. f Wh~l'e loglllly rllqnll'od. Ihls Ilotice shnll bo !llvoll lit lellsl thlrlY (30) \fn~s prior 10 Ihe RllSldollt's' i .~) '..,' trnllsfpl' or dlschlll'llO, . I' ",,' 'fll Ol\ses whoro tho sllfel)' ol'hellllh of the Rosldlll\'t nl' olhol' Illdlvlchll1ls tlllhe Fncllll)' II1n~ be olldnil. " , ,;' ,Ilerod, or If othel' 101l1l1 rOllso/lS oxlsl, Ilotloo 11111)' be Ill\'elllls SOOIl IlS'Pl'notlonble bofol'e tfl1l1sfel' 01' IlIschlll'1l0, . , The rensllll(s) for Ihe Irllllsfor/di~ohnrge shlllt be provldlld lit tho limo of Ilotlce of Il'nnsfel'/lltschnl'lle, ' .' " . ,.' I ;1, , Notloe wllllllchlde l11fo1'l1111110n rOlllil'dlll1l Ihel'lllhllo 1I11peill.lltrllllSfor/dlschllrgo, Tho Fncltlly shllll olily tl'llllsfor 01' dlscl\nrgo II Rcsldollt IIl1der Iho tOllpwllI1l o~l\dlllOllSI , '}lle trllllSfor/dlsclllll'go Is Ilcoossllry fnl' Iho RosldclIl's welfllre IIlld tho R\lsldolll~~ 1100dsOllll11ot be,II101 I' . ..)n the FllolIlI~I' " '.' " . '.11 , I " · Tho Irllllsfol'/dlsclll;j'go Is IIpproprllllo bcclIuse tho Rcsldcllt's hOllllh hilS hllPl'Dvcd sllfllclelltl)' SO Iho , l~osldcl1t no IhllllCI'IlcQds tho sor\'iccs provldc(1 by tho FncllltYI " '. ,! . · Tl,il1 sllfot~ofllldlvldllllls In Iho Fllollli~ Is clldllngcl'cdl" " " 'I " · Tho hlllllth of IlldlvldulIls In tho Fllolllly WOllld otherwlso bo elldllllglll'Clh " /, " , , III , Tlw l~p~I\lpI11 hl1~ fllllod, 111'\01' rPII~(IIH\\llo il\1\llipp\,\)prlillp IWllpp, In pli~ fpr (prill hlll'\l plllll 11l1der Mvdl\lllro PI' Mv\lklllllll1 ~II1Y iiI 1111' FII\lIIlIYI " ' . ' 'Thv Fllcllll~ POI\~OH In \lpl'rIlIO, IU~~HlI~N'" 1H<H1'I'S PNl>Iq~ Iq~JlI~H^,J I,i\W .. Thl' FII\llllly Hhllll prnlPct II!HI prPlllnll' \Iw rluhlH pfOIl\lh gpsldpl11, hwllldll1u olloh PI' Ih\l fnllpwlnu rluhlsl , I Tlw l~oshlol1l hll~ II rllllll In 11 \I\Ul1lnl'll oXIHlpI10\l, Hclf,c\clcrmlnlllh% 001111ll11l1101111PtI wllh I1nd IIVOIISS In; pOrHnns 111\\1 ~crvlvc~.llIsl\ll'lIl1d PI\\sl(lllIIIP FIIPlllly, . 2, 'flIP H\lsldont hilS II rlllht Ip \lxercls\l hl.s or 1m rlllhls liS III~oslllol1l of Iho Fllolllly 1I1\\\I1S II olllil'll Dr r\lsldenl PI' 1111' \Jnllocl SillIes, ! ' ~, 'f1)(lI~OHI\l011l hilS Iho rl!lhl 10 bo 1'1'01' of 1111\lrf\lrello\l, ooerolol1, (\lsorI111Inllllon, PI' r(JprlslIl frol1llh(J Fllolllly 111 (Jxcr\lIHlnll his PI' hor rlllhls, , 1\, Tho H(JHlcI(J11I hilS Iho rlllhllp b(J fully Inforlllocl, 111I1Ii\11UI1II!lO ho or sho 01111 IIl\\lorsllll1(l\ of his PI' hilI' 101111 hOllllh sllllllS, Inolllc\lnll bllt nOI 1I11111(J\1 to, II\s or her 1110(\lclIl concllllol1, " ~, Thel~osl(I(J111 hilS tile rlllhl t\l rofus\l Ir\l1l11110111 1I11e1 10 rofuse 10 pAl~lolpl\lO 111 \lXperl\1101\I1I1 1'0sell1'ch, 6, Th(J R\lslcl011lluIsthe right 10 llxorols\l his PI' hor loglll rl!lhls, l11clmlhl!1 OIlng lIurlllvllnoo wllh Ih" , SIIIIO sl1rvoy IInd col'lll1cllllon IIllellOy conocmlng RIlSldcnlllbnse, 110glcCI, linn 1111sllpproprlllllon PI' Rosldonl proporly In Iho Fllclllly, ' 7, 'fh\ll~csldol11 hilS Ihe rlghllo monllgo hl~ or hor Onllnollllllfflllr~, ,. I , I , I 10, The Hosldenl hns II right to pllrtlqlpnte In plllnnlnll his 01' hol' cnre IInd \I'<l1l1l11Onl or chnn~os \lioOl'\l I . lI\1d Ir<l!\\Ii1enl nnless IIdjmlg\ld Incompetol1t 01' otherwise foUlld 10 ho Incllpllclllltod lindoI' the lows' I of Ihe'811110, ' 8, Tlw Rosldonl hilS II rlghl'to choosb IIIl ullel1llhlg physlcllln, " Il, 'rho I~Qsld<lnl hilS u rlghl to bo flllly Informod In lIc1vllnCO uboul Cl\l'o IInd Irolllnlo\1ll1nclll\1Y ehllng\lB In Ihlll pnl'o 01' Irolllm011llhuI mllY nffecl Ih\ll~ellldonl'S \vcll,b<llng, ' ' II i Tho, Hesldcnt hlllllho right to persol1l1l prlvucy und C0I111de\1lll1llly of,hl~ or hot' pcrsonnlnl1d ollnll:1I1 rccords,' ' " 12, Tho Rosldol1l 01' LCllnl.lteprcsentnllvo hilS Iho rlllhl, II pOll 01'111 01' wrlUoll roqllosl, 10 necess nil ropords pcrln\nll1g to himself ()I' horsolf,.II1c1l1cllng clll1lcnlrocorcls, wllhln Iwenly-follr hOIlI'S, Aflor recolptof his (}I' her records, Ih\l Itcsldcl1l or Legnl Heprosel1tnllvo hilS Iho rlllhl 10' plltehnse (1111\ COHt 110t 10 excoed tho c0ll1111l1l111y slnl1dn\'(l) \lhotocopl\ls of Ihe records 01' nllY Ilorllol1s of Ihem IIpOI1 roql1esllll1d wllh two dnys IIdVUl1ce 110tlco 10 Iho Fnclllly, .' " '. " ,," II " .' I, "I 13, Tlw gpsl\lpnll1l1l~ IIppl'o\,u 01' l'ufl1hU Ilw l'ululIsu PI' pul'S\l11111111111 ulh*:1I1 I'uupnls Ip 1I11~ 111\111'1\111111 P\lIshl\l Ilw 11111'1111)' u~~'pplll'l1\!n: II,Tlw lloshlul11 Is Il'IIl1slvl'l'pll IP III1Pllwl' lIul1l1l\ ~:Ul'o Il1s11111111l11, h,Hul'nnl l'ulpl1su Is l'ulI\lll'ull h~ 11111'01' II lilli'll plll1~ pu~mul1l ~'PI1II'1II'I; 14,T'w H\lslllunl hilS II 1'1~\hIIP volC\l ul'llll'llIwuS II'lth l'\lhlWIJI 1\lll'ulIll1WI1I PI' \llll'fJlhnl flllls III hu fill" I1lshuII, wllhulll IlIhcl'lmll1ullpl1PI' I'Ulll'lslIllil1' \'oII'II1Ulll'luI'IIIW\ls, 15, Tho Hushlol11 hllH n 1'11l11\ \11 prom pI ulTorls by Ih\l Fuullll~ 10 I'\lsolw urIOI'HI1\lOS, IIwl\llllng Ihnll\l. wllh 1'0SllpP\ In Iho huhuvl\ll'nf nlhul' H\lslll(II1\S, ' 16, Tho Hllsllllll1l hilS II rlllhlln \lxumll1o IIw l'us\llIs of Iho mnsl I'OUll111 s\lI'I'Il~ of Ilw Fncllll~ U\1111hICIIlII, , h~ FIlIIIlI'III ur ~\IH\lIl\ll'I'P~PI'S unli IIn~ phm nf \lnIT\llJllpn In pffu\l\ II'lIh I'llspoullnllw FIIOIIII~, ' " " ,17, Tho Hosllhil,1\ hus II I'luhllP I'pculvo Infnl'l1Hlllol1 fl'um lIl.!onclolI IIcllnu us cllpnl nllvpoul\ls 11111' hll .. lIffprll\llllho uppmlnnl1Y 10 O\1I1IUul Ihll UUOl1uIOII, '8, Tho Hosllllll1\ hus 1\ I'lghllOl'llfllHllln pOl'fnl'ln sCl'l'lCUH fnl' thp FII~lIl1y, 10, Thp ,RosllIOl1t i1l\s II rlghllu IIgroo to pPl'ful'ln Vuhlllllll'Y O!: pllld sOl'vlcps 1'01' Ihls PuoilllY If ho 01' she , Ilosll'os,lf IIWI'Il Is l1u nwdhlOll'pusol1 whlrh WOllld \lOl1ll'l\dlollhe pel'formhll.! of Ihe Rel'vlces, ond If OQlnpPl1sl\lloll 1'01' plllll sOl'vlops Is III ur IIbove prlll'lIll1llg rlllos, 20, The Roslllel1l hilS Ihe I'lghl to pl'lvlI\l~ In wrlllol1 COllllflllnlcllllons, lllallldlns the rlghllnsendlll1l1 .1'llcelve 1111111 pl'omplly Ihlllls \II\PIWnod, Thll I.~eslllenl hilS 0 right of OOpeSR 10 stollol1ol'Y, pORI lillo, IInd wrllln/! hnplol11ents III Iho Rosldul1l'R oWIl,oxpense, '. . ", 21, The I~esldollt IHIS Iho right Ip Il11l11odllltOOCl'ess to IInyuf the fullowlngl n, Any 1'0prosell\nlll'e of tho Secl'ctnr~ of Iho U,S, Popnrlmenl uf Honllh ond HUI11I1Il So..vlc~s, h, An~ ropl'osonlllllvo uf Ihe Stnlu, 0, The Resldol1l's IndlvldulIl ph~Rlelllll, " i' II"~: d, The SII\le's hlll/!,lol'll1 Cllro Ol11hlld~nHII1, i ; . 0, The ngolle~ rospollslblo fIll' the pl'ntO(111nn of IIlld odv[)cno~ s~stem fur Illenllllly III or devol, i iii oPlllonlllllydlHl\blelllndlvldul\ls, , , , i . 1', Subject 10 Ihu l~osldent's rlghllp dOI1~ 01' wllhdrllw eonS\lnl IIll1n)' 11I11e, \111mollll\lo fomll)' 01' othol' 1'01'11111'08 of Iho Rosldonl 01' othol's who 111'0 vlshlnBwllhtho OOnSOnl uf tho Rosldonl, . . " 22, The 11I1elll\~ nlllhl pl'O\llde ronsollllhlo nceess tn nn~ Rosldonl h~ IIn onlh~ or IndtvldulIl thlll pro' vi des honlth, SOCIIlI, loglll. 01' olhor sUl'vlcos.tn the Resident, sub.locl to thel~osldont!s right (u don)' 01' wllhdrll\V COusOlllllt IIn~ limo, ' " , , .. 23, Tho l~osldonl hilS 1\ I'lghllo hnvu f'(ll1Sllllnhlo IICCIlSS to tho I1rll'nto use 111'11 tolophono, ' , " 24, The Roslclont hns n l'lght to 1'Ol1l111 IInd uso pOI'Sllnnl pphsosslnns, Including ROI1l11fl'I'nlshln/!R nnd IIpl'l'Opl'lnte cJCtlhlnu, liS SpllCU pOl'll1l1s, un loss tn dn so \Yould Infringe, un Ihu rights 01' hOll1lh IInd . Sllfety of othol' Rosldonts, ' . . , " I , , 12 I, 'I I_ , " J~:':r,IW gv~hlvn\ hll~ 'II rllll1\ \II ~Iu\rv 1,1 rn11111' w\lh hl~ 111,' I", 'r'"'' 1'1",,,,,,",,'1<,11\"""""'" IIV/' InIIIW,' hlll1\\l FII~II\I)' 111111 \111111 ~PllllhV~ ~l1n.~nl In Ilw IIITllnllvnwl1\, , I ,JC1, I;II\)h l{cslllvllI hll~ II rlllhl III hplf.I\i1I11lnl~'or dnlU~ \lillvss \Iw FII~I\IIY In\vrllls~lpllnlll:Y 10lml hilS IlclCl'll1liwd fnr II plll'\l~\lll\r Hvsldonl IllIIl Ihls prncII~v Is nn!illfv, , n Tho Hcshlon\ hllH II rlghl III \10 1'1'1'0 1'1'11111 IIny phy~lonl rOhll'llll1\h II11pl1S011 \11' psy~hllll~llv\l 11\'l'U~ IlllmlnlM\lrVII fill' \lw p\lrpl1~VS nf IlIhdplhw 111' onnvonlvlWV, nlHlnnl rVIII\\rPlI IP Irl'nllho HVIi\II\lI1\'s nWlllenl hymp\l1l11S, 2B, ThoH\lslllonl hilS Ilw rlllhl 10 110 1'1'00 frul11 wr\ll1l, sex\lnl, physlelll, PI' nwnlllll\\l\lli\l, cnl'll\11'111 p\ln" Ishmonlllndln\'ohl11lnI'Y s\lol\l~lon, ' ' 2!J, Tlw I~\lshlcnl hilS n rlghl In OhOllSP II0II\'lllvs SOIWlhlllls I\1HllwlIlIh Ollrll oonslslenl w\lh his PI' ho,: 1i1lcrll~ls, IIliliosSl11onlS, 111111 phll\s of onro, 30, Tho HOlilllllnl hilS n rlghllo 1'0001\'0 1I11\'l1noo nolloonf Irnnlifcrs (jr IlIs\lhlll'j!OIi of Iho Roslllonll\SI' IWlllh'ollbylnw, Thll Roslllonl hns n rlghl In rcco,\\'\I nOlloo boforo Ihol~os\lIonl'S room PI' r\'IPll1ll11110 ., ' Is elulIlllod, . ':. I' 31, Tho R\llilr,lonl hl\s n rlghl IP nrglllll7.o I\nll I1l1rllelplllo 111 Roslllonl gro\lps In Iho PlIlllllly, n\10 tho l~osldol1l'li (IImlly hilS Ihll rlllhl 10 111001 ",lIh fl\1l1\1\oR of olhor I~oslllonls, ," , " i 4 ~2, Tho Rclildol1\hl\s 1\ right \0 pnnlclpn\o 111 soellll, rolllllollS, nml oOl11l11llnlty!\Ollvlllos Ihl\l ~Io 1I0t !I. hMrforc wllh thol'lghls of olhol' l~o~ldonls,.. ' , , . I 33,Tho gll~llI\ln\ hl\s n right 10 \,llns(ln1lblo I\cool1111\ollll\lon of Indl\'ldlH\lncllds I\l1d profll\'Il1100S Dxollpt! i whoro Iho hCl\lIh 01' ~nfolY of thc Rnsl(lollt or olhol' Rcsld\lnts WOI\III bo ondl\nllcrod, I ! 34, 1'110 Rcsldcnt hilS II rlghl \0 frccdol11 ofohololl ot' 1l1'llV'do\'s 11111000rdnll00 wllh I\ppllcllblo lnw n11l11. . ~ubjcOI 10 tho pro\'ldor's oOl11pllnnoo whh 1111 liP pI ollblo IIlWS 1111llrOIlSOnl\blo 1'I110s nmlrOll\III\\\onsi I . ,.ot' Iho Pnclllty, " ' ., ~ " " ,; " , , " I~ Im8'IJNN1hW'l~C'P'(} lNf~OUMM'lON Thl~ F/\\lIIlIY IICC\lP\~ Ilw followln!! IypuN nf pll~n1l!nl~1 (qwck nlllhlll IIpply,) ll11lrlvlIl\l l,fMcIl\cllru II'/MIl\\IcIIIII ~~c\llnlll~ Mlllnlalrllllnl1 .'I'h\lll11rllll~ \11 Ihl~ Allfllllmllnl ""UI ~ e.. \.\u.') (Nlln1\l of FlIllllllY) ~c..r.\.ll~ 'l.'L'I)ol~.u:.'" (NIIlIIll of RCNIIIIlI1Il. ~, ft, ~ lli\ n'l'lI~S (NII1\1u of Rusldlll\l's AIl\3nO' (~<>".C'\l;)(l G\\~tA.-\- (1'11\1\1\3 of Rllslllunl'~ l.ulllIl R\3pre~Ill\l!l\IV\l) If II 1.\3glll Rupr\l~ul1Il\llve algn~, Ill\\lo!\ Ihu '1)'1'0111' 1.Il11nl Hlllll'llsllnlnllVll (\leloW)1 [ ] conserYlllor (11' Person { ] COl1serVIlIOI' of Esllllo { ] Olhor, speolfy {] Qllllrdll\l1 { ] Pl1l'l1hlo power of ^"OI11CY for J-lunhh eliI'll (PPAHC) [] Al!onl^~\l111! Undor Ocnllrnl POA '" I' If YUI1 nro slgnlnl! Ihl~ Ai!rcenwllt on \luh~lf of tho Rusldul1l, nolo YOllr relllllol1shlp 10 Ihe rosldulI\! , ' " "'Bb..... RollI\lonshlp 10 Rosldenl 'I, On Ihls \~Il.l dllY of ~~ \ , 19~, Ihcllhovo \ll1rllOS IIl!rlle 111lI1 on Iho 19f-1~dllyof I 19~1he Itusldunt shllll bu IIdmlltcd 10 Ihls PliO II Iy, As of Ihlll dllY, Iho Pllol\llY shnl1 pro- ,vldo ho survlcos duscrlbed III Ihls Al!reemelll 10 Iho Re~ldentllnt\l Iho dllle of Ihe Resldol\\'s IlIsohnri!e or trnn8fer,"The Rosldel1t8hllll PIlY for Ihe services provldud by the Pllolllty I\ooordlnlllo tho lerms of Ihls Admission Agreemenl, .. ' ACI'NOWLlmGEMltN'IS By slgnll\1! Ihe Admission Allroel11ent Slllnlltlll'o rllge, Iho Resldont/Agent/Lugnl Reprosonllltlvol\cknowl- odges Ihlll ho 01' she hilS boen' Illvon lint! hilS rOlld Ihls Allrcel110nl In Its entirely, I\nd 1I11l1ddondums, Thll ': .' Rosldenllllso IIcknowlodgos Ihlll tho following Inforlllllllon WIIS provided upon or beforo IIdtlll~810n bylhe ' , Pllcllhy, Inltillllholhles below (If notllppllclIhlo, wrlto NtA)1 '" . ., ~ 1I..,r ."ppll" ",,' ",,',," ,hot "'"I""""" ,,, Ih, ""III"" ,,,''''':d.II, "''': Ih., wll\ h. , pllld for by thll Mot!lcllld or MedlclIl'o proijrllllls nud 1\ list of supplies lInd 80l'vlcos not 1"IlIUded In tho Pllolllly's pl'lvlllo dnlly 1'1110 ol'pllld fOl' hylho Me'dlcllld or Modlollro prOl!rlllns for whloh Ihe Resident will bo sopnl'lltoly chllrgod, ' .. ' 15 I' Whllo _ U\lslnoss Office l'lnk - McdlclI11\ccords Vellu'w ~ Resldenl " , , 21:# 2, Inflll'I111111PII q\1I1111 Ilw FII~II;IY'S h\l<lI1\1I\1 pl'ovcd'lr~s, . h.~~' A wrll\pn !lXpllllllllloll of 11\Iw \ollpplYl'llr 1I111111SIl MOIIII:llro 111\\1 MOlllpllhlllUl1ulllS IIIHllww III . I tilL, I'Il0plw rpl'lll1ll~ 1'01' prllvlollS PIIYIlWIIIS uPl'orcd 11>' IhllNO jJolwllls, .~ 4, A s\n\PIl1Il1l1 IlXpllllnlnll Ihlll Iho l~oshIIl1ll11\1I>' 1I1~ II ~rIOI'III\\l1l lI'ilh 111\!lIpproprllllll HIIII~ AIlPIIIlY Lc; __, 11\1\1\11 I'pslllonl III,l\ISO'110Il,.IUClt ,lIIHlfOr 1\1lsl1scltlwllPI rosldPIII pUI'~pnlll prupony In Ilw "'\pIIIIY, ~ 11, Cppllls PI' II1\! Hllllo H!lsldul\I HluhIS,. .." . -: Ci,A wrl1\cl\ c>\pllll1l1llPlllll: Ihp FllcIlH>,'~ I~nlcs 111111 Hu!!nlllllllI1S, ,7. If ~flllr ollndlllol1 wllrrnnl5, yP\l1\1I1Y IlU plnllcllll1 Ihll fllllllll)"s Mlllllllllrll-Cunll\llll Plsll1wt \1111'1 UnH.At slln\\l ppllII, plrcnmN\I\llot:S 11111)' POIl\ll' II'hlllh w\ll11111Kc rt:sllllnll In IInplhor 111111 11\prll IIrprllprlllll' ,for YP\I, III Ihlll cllSll, \l\\l flllllllly \1'111 dlscnss s\lph IIlrnnsflll' II'lIh YllII, UlIIlllr IIIW,. YOIl 0111\11011111 t1lsllhllrllC(1 from this fllollhy lll1lcss ylllll1l!l'OO or 1Il1lllss, fl1l1p\I'lng1111 IIPPIlIlI, II Is Ilclel'lnlnplllhlll YOIl1\1I1Y jJp Invohllllllrlly IIlSllhlll'IlU\! nr Irnl1sfpn'~II, J;JI22-8' A GOPy of Ihe 1'1101111>' Pl1llcy rOlllll'dln!!lmplollwnjPllon of Ihlll'lIlIunl !1plf polennll111111111AoI I . 11\1\1 of Iho IIppllollhlo SllIlu lilli', 1110 .~ (11111111 .IL hllVo 11111\1\1'111100 t1lrollllvo, .,.. , " , I hllVll beol1lnformutl, blllh orlllly IInllln wrlllnll, In II 11I1111\lIl1lo I IInllor51111](I, of mnlllhls IIml Iho rllllls IInd rO!!lIlllllolls llovcrnlnll 111Y opnd\lol IIntl rPNpollslbllllloR dmlng my sIllY III Ihll FllollllY" I NO'l'lCICI'l Noll005 shllll \10 mullod IU Ihu IIdllross(us) Indlcl\lQd \101011', Tho AgOlllulllltor '"oglll HcpresPnllIllvp Is rosponslble fOl'nolltylnglhe Fllclllty III writing pI' OilY ohulIg!) of IIddrosN, " ,'... Tho l~esldulIl dosl!!1111l0H Iho followlll!! porsol\(s) 10110 I\otlflel! II'hol\ IIny IUllully rcqulrod 1101l00s\\ro provld- od 10 Iho Hoslllcl\l,Agol\l.Ul\dtl1l' LC~1l1 Hoprosl1nll1l\l'0. . " " LEOAL.lillEHESENTA'I'IVE ANDtoILAilllli! NII1l10 C e..n,-\)d... G,-. \\c.~)\+ Home Phollcllll'1".,"d.l~ ~_Work Phol\o -__ Slrupt ,~6 '~c&\1~u~'\:..'---1Clty ~""i( \-\.\\\ StlltoY~ , Zip \1C:l11 '._ ' QJ1lER PEliliQti ,\,0 BE NOTIElE.tl '-:' C''''i'n ~~h~ ,. NlIll10 ~A-~u. \ ,~ '\I!ti.S'" Homc Phollu IS';;), ~ "l,$<,L Work Phono . ('1\ 811'uol ~,,)~ FC"~'C:),ck h'l.' e\ly ~t\. N'~ \-\~~_,S~1I10 ~~\ , Zip --L:l.Q..\ I ,-, , '. While - 11I1!llles! orflce 1ft I'lIlk - MedlclIll\ecnrd! ValiDlY -Ilbshlblll " M)~1ftS,WON A OfUWM,mT 8IONM'UfU~ lHaff Hpshlpl1I PilIp ---r'------:-- Wl"\\ls~ If BOijldlllll Slglll'(\ wllh II Mllrk PilIp R~_ I ~ ~ f Wllnps~ If R\3shJolllllhll\pd wl,lh II Mllrk Plllo '" :-r' , !.PUIII Rp rosolllllllvo . 4 ) m) 'Ie;' Pllto _( ,n ) l(07''"Ib\~l( 1.1l!!!\l RpprQsolllllllvo's Tolephollll N\II11\ler J, t/ .i(L'--~'I-9?.3 ~ 1~llgl)1 RllprllsPllIlIIlvo's Sopllll S\\P\lrlly No, AgllllI " Pille -( ) Agpnt's Tolophollo Number n. Agont'sSoolnl Se1mrlty No, " \'1~\~L;l,,_ .. Pnlllllly A 11111\1~)oslgl1eo _ II !t~h)'- PlIlo I', NolO/ 1'110 s/n//(/llIroS (/11(/1'0 rofor 10 1110 //lforl/llll/rlll cO/lI(///lo(/ (11/ IJ(/nOS 1 IImllly/, 1 R 0111'0 llovorly U/llol1lr/sos At/miss/oil AI/I'OO/llOl", ' , Whll~ -lluslnosH Offlco 19 . ('Ink - Melllcnl RocnlllH YcllnlY -llc81~on\ " I " if , " ,," 4 ~;I:, " , \, , ' " '. .. ,. '" , , , " , ", " ,I. ' , . \ ' , " " , ,~ ( GE S I) TEUVISION NETWORK a/l/JPII EntO/1~I/lmPllIlipO/fl Tolov/llO/l ao I'^~M~R DRIVE cMlI' lil~~,I'^ \701\ (717)76N~411 May 24 1997 B1Qe Ridge Haven convale~cent Center We~t Here is another payment on account. I will see that you ge~ your . paymenta nn l:he f:irsl: of. eaoh monl:h, until I:he bF\lRno~ is I!lflrO, a~ per our agreement. 1';' f ,. iiJ ('; , ,";; ',I! 'rMnka ....'. " , , PLAINTIFF'S i eXHIBIt' · ..-1);.' ",j "1' , " '; . '; ... .1'" ~.\ 1 .{" ", ,,,'f -..,' ,\ \ p~., un t~..,1t.' ?\~. i, IL ~ ~Q." ~ n rt ~ W u It \11- \ II ~ ~ { \\ w\ n, \~ ~ Il.\f h, ~ \l.q ~ , ;"'l3hw 1~1(lgc Ilnvon OonvnlOflccnl; Ocn~el' " W(~f:lt, ' I .. (\II11"S' ~O, 1 !)P~ Mr. Ollrllhl Olll1m ~II JIlllm"r Qrlvll cAmll UIIl, J.li\ 17011 QlllIl' Mr. Qllhllrl, Ii .' .. .. 1'11I~1l.~1l\1 hllVill'llfllSOIIIIl rllllll'lI 11111' ~lIl\s 1 mllil ,VI'UIl!O 1111I1 II lit whr roll fl\lIelllll kllllll ~OIlI'IIrIlIllISIl tll \lilY lIS $ 1000,00 Ilel' m!,ln!h UIIl mr Ilrsl mlllllh rllll WIlI'IlIIl m,,111l " \l'Iymllllt. " Thill'll Is 1I1I1\1I1l5l11l11 III III)" mllllllhAt Ihlllllll)' I'llllSII" IIIAI tlllll'\lls " llllh! ' .Ilwed to Ihls fnellll}' Is 11110lll,",1 ~1I11r mll\hlll"~ Ineolllll WAs Ililld hy rOil or somllonll cIs II for rllll'\loses olhlll' Ihllll hilI' cnl'll, DlllnllIII Ihtl 111I11I1'" s\.lrvlCtlS ""\lll Ilnd Ihlll IInllonslllonlll111l, ' " , I hllVIlII'I\ld evm WAY poulhl\.l 10 hll Illlllllnl I'\lQlInll"1I Ihls IUIlIlIIIIII Wll,hllYfl IIU\lml'llld to work wllh yllll '"l'lllllvll thllmlltlol' IImlol\hly. OhvlOluly ~Oll IlI'Il nol I\plll'eclllllvll of 0111' Illforls to cllOplll'lIl1l wi'" YIlIl, l'nllwlnlllhAt )'Illll\rllll hlls\nmmllll Yllllmlf,l clln'l cllInprehllnd hllw yon Olin jl1illtY IIl1t II\lllplnll )'01',1' Illlymenl pI'OIllII\llllotlllon\ll\l\owtnll the II"IlIl\1I11 tll hl\vll dllvelo\l"lllll tllll "I'st pllllle, ',,' 1 hllVIl not hllslllltlld III pllll sltlllllloni to rtlporl the wronllfllll!sll of l\ relllplcllts mllncy to thll SIICllll SeCIlI'\ty i\dmlnlsll'lIIlllll or P\lllllonJ1Olll'lls, If " PAymcnt Is 1101 I'llclllvlIll on YOlll'lICCollllt IlImltlllllltllly I wlllllOt hcs\tlllc III report Ihls 'nstllllcll of mlsllSll,' ' Qt"ccrel~' , -- , .. , . .J.... 1~, , tl IlIls A, q Adrnllllstl'l\ dJL- . ..,...,mob,.., "',"~ , \lUll'6\1al~~H'"" , ,. '. ~\\OI\~\tl~\t~J~~' 1')(''"'.., 1l0\~\I1l91t1~60t\6~~~~901lIl\l~ . '0\'\ \\Ulled " " . ", - I OI'D :::.n. : .. \ .....11.. 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II "".{.,I') 'j /111,1 ,,J it 't, ii, I I,' '1_'[__ !\. fl" C'j ('I ') ," '...._..'..-"/' /.,'/,1.....', ".' 1, \l,et,...,. I'; ,.1 1II,dl"'!"',!;" 11./-., j i, hi" I 1'1 ",qLl.'~I( Ili'j'lll ,/\'.-. I.'il; " I 1 , r..O(JI'( ,," i,l! [, " ,', ~1, PI!'llnllff f.1nQ PefflnQ!'lnl luwp !'In ImpllPQ pOl1lmpl for PI!'llnllff'l! provlQlan pf nuralno hompP!'lra AnQ a13lVloea, ' " 'I,', a~, Pf3f13nQflnt h!'lQ fr:1l1llq 10 P!'lY PI!'llnllff Ih!3 f.10reecl wpon pompena\\\Ion for Ihe pr:1re !'lnQ IHlIVlooQ provlr:leel 10 ~l:lrll1r:1 ROQo!3rl!, WH~Rj;P()R~, PI!'llnllff reapeolfwlly rpqullala \I1!'lt Ihll! honample Oawrt enler JUQl]ment In fElvor of PIElll1l1ff !'ll1el f.11]!'llnal p!3fenel!'lnt In Ihe f:\I'T1Punt of $f),076.4p, plwa Inlereat, !'lllorney fllea ,!'!nel. poun ooala from the elate ~f the Oowrt'a JWQfjment, ~ 33, ,Pl!'llnllff hereby Inoorpor!'ltea the pl:1raorElpha one (1) Ihrough thirty" Iwo (32) of thla oomplalnt r:1S If SE;lt fClrth In full; 34, Wllh the Defendant'a. full knowlsdge' uncl !'lgreement thereto, PIr:1lnllff provIded Berth!'l Rocfgers wllh nwralng hci'me O!'lre flnd " servloea, 36, Pefendant Imew or shoUld' have known that Plaintiff expe()le~ . p!'lyment for Its O!'lra !'Ind selvloes, . 'I' 40, Aa l3arllm Rpclnma' 1-llonl 1~llprolllln\nllvo, pllfam.lnnl hl1Q 11 fiQuolary Quly to 1'1111 In l3arlhEl Rodollrll' hlll3llnlllrol3la, Inpluulno n (My Ip Use I3mll111 RpQOllra' InUOlnB and I'lallelalp serva her bflllt Interestll. , (" " t i : ~( .t IU\ , ~J Uj, iii, 41, The pest Interesla of l3er\l1E1 Rougarll were aervecl Py pElylng far her nurplng OElra In orc.lar tl1l'\\ l3erll1E1 I~oclgera ooulcl ra In 1'\ In . In Wast Shore l-leEllth Elncl Rehapllllflllon Oenter until puoh lime ElIl nurlllno Oare WElS no Ipnoer naoaspary, 42, Pefenclant vlolalad his fiduolElry cluty to 13erlhEl RodoarllPyfalllno to pay for her oare and aervloea IlY, fOIWMdlng the VEllua of 13erthEl I, Rodgera' Soolal Seourlty oheol~1l to We at Shore HeElith and ' Rehabllltallon Oenter" '43, Defendant violated his fiduolary duty to 13ertha Rodgera by falllnp to pay for her oare'and servloea by fOlWardlng the value of 13ertha ,. , Rodgerat pension to Weat shore Hel'\lth and RehElbllltatlon Oenter. , It:. 44. Defendant vloiated his fiduolary duty to l3ertha Rodgers by failing to " ", re~nlt payment for the oare and aervloea proVided py Weat Shore , Health and Rehabllltatlon Oenter to Bertha Rodgera' out of her"" .. . Inoomo and aBaeta. ,i' , t " #..--,,;, II ,I i ;2l2, Uppn InfmmClllon ClnQ pellef, frpm April, 109p Ihrouah ~\.lne, mae Pefeml~11I reo\3IVeQ Clncj/Or axerpllll'lcl opnlrpl oVer 13erllm ROQgl'lrll' penlllon plwollfl, ;23, Weill Shore 1i\3~llh f'lml Rehf'lpllltflllol1 OanlElr I'epaflleclly requellleQ Ihal PefEln~lanl forwarQ pflym\3nl for 13erlhfl RpQQarll' O~1fEl ClnQ aelVlpEllllo Weill Shprl3 Hef'lllh ClnQ RehClpllllallon Oenll3r, " . ;24. PefenQflnl fClllecj 10 fOrwClrQ Ihf.l value of 13erlhf'l ROQgerll' penlillon 19 Weal Shore 11eflllh f'lnQ Rf.lhf:lpIIltClllon Oenler, 25, Weal Shore Heallh ClnQ Rehf'lpllltf'lllon Oenler hEla QemanQeQ paymenl for Ihe oare flnQ aelVloellll provlQeQ 10 13erthCl Roclgera on many oooaalona, bulto Qale haa nol reoelveQ full pElyml3nl, 26, ,Weat Shore lieElllh ClnQ RellE1bllltallon Oenter haa reoelveQ only' $3,000,00 from Defendanl alnoe June 27. 1906, when the final Ilemlzed bill Waa aent, A true and oorreot aopy of R/:llcl Iteml;!ed bill.. .' '-, la alt/:loh~d h~relo, made a part hereof, and marlled Exhlbll"P,"., 27, The Agreement provldea Ihat In thl;! event that Weat Shore HeClllh .. /:lnd Rehabilitation Cenler Inltlatea and prevalla In lIt1gCltlon Clgalnat , Defendant III an /:lotion Clrlaln9 from Defenclant'B fE~lIure t6 oomply " ,_ ,I I' ,. " '" 11, "1'1__ ..~..~- i,'""'i\ ,....."',..', '" '1',4 ; :. ,~ ., , '''..; 1,-., ": r, "j." ."~ I!" ~/t' ..,~ I' .'':'',,\:. , , '~,I' 'I;l" .' ..;~. "'.. ~., ~'I, "~ "l . ..~ I' \,l aeVERL Y I!NTIIRPRlIlIIIl " , " " J' " " " " I'. . RESIDENT ADMISSION AGREEMENT I " r.t 'I, ;', , , " J, ,. " " , "';, " " )1 .... , , .IJINmu"y EN11tRNUSUS PLAINTIFP'S ,~'aIT , , "'!!MIII/II 'I ", I '(, '; \.' " '/ ., :'l ~\ " I' ~\ ('~', FlNt\NC1M,t\81'IW,(,8 ()/" ,(,UN MUUmMNN'(' Tho slllff nflhls l"n~I\lIY wll1ll1ll\l\\'hlll\l\'\lI' limp I~ 1I~\'\l~Sl\l')' In IIn~\\'\lI' 1It1 Ill' )'11111' 111l\lsllllnS IIIHIII' IhpsPtnlllps, 111\lIlSP ~lIlIlh\\l\lln IIsl~ 11\I~sllllns IInlll )'1111 h\l\l\l,'plhlll )'1111 II11!1\ll'slllllll, . MmN'l' Mlllton l,l~nA', Hlwm~HI~NTi\TlVW' 'I' Ihll R\l$I~\llllls \llIl1blu Il1l\1l1ko docls\l)IIN for hll\1~olf 01' horsolf,l\lI AUIlUL!llIll1nr Lc.jUlUW\WIUll1111~ l1\IIY . \w nVlltlllbllllo lI1l\kp cllrll\IIIIIllCINloIIN nil \10hlllf 111' \he HllSII.\olll, Thll~1l lorl\1N IIl'u IIIlOIIOII \)C OWl, ' , AOIlliT' POI' Iho pmpusos of Ihls Allrlllll\1ut\\, 1111 AI!\l1\l1~ II persoll who 1\11\1I111l1lS, 11508, nl' cOlllrol8' 1\\IIds!llssets Ihlll II\IIY \1\3 logl\l\y IIsce\ 10PllY \he Hpslllct\\'s chlll'llcs 01' who othol'wlslllIPts Oil bohlllf of Ihll RpslllulII, Tllll AgO Ill's OllllllClllll1hlllllllll1l1S IIrll IInlllllll 10 IhpI\l\1p\1\\1111' \l11l 1'1111\18 rooulvllll 01' ',1\3.,111 by Iho AIlIlIII for IhO. I~os\llolll, TIIP Allollt (Ious nll\ IISS11ll1ll, rospolIsl\lll1lY for PIIYI,lIPnl of the . coslS of Ih\l Roslll\lIlI's Cill'O 0111 of Iho AIlllnt'8 pOl'sol1l11 fllll(I~, UOWOVlll', Ihll AlloIIlls cOlllrl\Ollll\lIy \lo\llld by Ihu IUI'l1\s of IhlH IIllroul\1UIIIIIIHIl1\IIY bocomo IInblp for fnlllll'o 10 pPl'form ll\lIlos 1\11\101' Ihu AllrollmclIl, Tim A@N'f IS HHQUmep TO ~ION TIII~ AORUEMENT FOR ADMISSION, ANP AORIlES TO DISTRIIWTIl 'fo TI.-IU FAell,lTY, FHOM THE RESIPENTIS INcoMe OR RESOUI\CIl~, PAYMENT WIlEN pun FOR ITIlMStSERVICES PROVIDIlP TO THB RESI- DENT, Tho Allelllls I'oqllll'ed 10 prodlloo flnllllcllll dOOlll1\ClllllllolI liS proof Clf Iho Rosldenl's I\b\\l~Y to PllY fol' cl\lII'llus whollll\lo, WhOl'IlV01' this ^fll'oomollt l'ofcl'S to Iho Rosh1\lnt'!l flmllwllll obtlll!l\lons 111I11\11' this IIlll'oomonh"Hoshlont" shllll ho Consll'llollln Inchu1olho oh\lfl!l\lnns of ^Bont Ip !let . on bolllllf of Roshlol1t, . . . LEGAL REPRESEN'rATlVE -Fol' tho pllrposos of this Ai!l'ocII\Cnl, l.P1l1\1 I~opresolllllllvola doftnoc\ liS !I person rocolllIl~od \HI(lor S\lIle IlIw liS hnvlni! Iho nlllhorlly 10 InIlKe hOlllth olll'ollndlor flnlll1olll\ dool810ns fOl' Ihe Rosld\lnl. Thnl.olllll Roprosolllllllvo I11I\Y or l\1l1Y Hol bo 00111'\ nppolnled, A LCIlIlI ,. Roprosonlllllvo 1l1(1)' be 1\11 1I110rnoy-ln-fl\ct I\ollnll\lndol' II durl\blo power of 1I110l1IDY for hell\11I cllfo, IlUlIl'IlIlIn, oon~CI'VlI\OI', neXI-of-Kln, or olhel' person II110wod 10 I\ct fOI' Ihe Rosldelll\lndcl' SllIlllllIW, If Logll\ Roprosentllllvo SllllllS hl\s bcon conferrod by II OOlll't of IlIw or Ihro\lgh IIppolnllnelll by Ihe Rosldolll, verlftenllon of sl\ch sII\I\lS I1111s1 be provided to Ihe Fl\cllllY lit Ihe limo of Admission, . IrINANCIAI. ^IUtANGlCMItN'rS ". , , FEDEUAL AND S'rNI'lt LAWS PHOIIIUl'1' A NUltSING HOl\m IrnOM REQUHUNG A 'rIUltD IIAu'rv GUARAN'I'E1~ Ole PAVMI~N'I' '1'0 '1'1II~ FACII..I'rY AS A CONDl'f10N OF^DMISSION. .. EXlllCOrmll M>MISSION. on CON'l'lNUlm S'II\Y IN 'l'lm FACILITY, . PRIVA'rE RllSIDBNTS. _ A I~esldontls consldorcd Prlvllto (01' prlvnl.e pny) when no SInte or Fodorll\ pro- Ilrl\'" Is pll~'lnll for tho l~osldonl'8 Room & BOlin\' A prlvlIlo PIlY Hesldonl 1l1l1Y hllVo 11rlvlltll Insurllncc ot 'lInothel' third pllr\y which PIlYS 1111 01' sOmOilf his 01' hcl' chlll'gos, " . . .. .. , , . . COlllllllllllcnllllg Chnlll\os III A~sclS, 11 I~ CRRenllll1 1'01' Ihe HCRldonllo con\ll)lllIlclllo chllllllos III Iho . Rosldelll's IISRcts 01' 1'0SOlll'ces to the Fllclllty II~ soon liS pORRlbl~, Th\l \1l1clllty necds to know If Ihe Rosldenl's prlvlllo f\lnds 111'0 golilll to bo doplc!tod so Ihllt olhcr IIlTlIngclllcnls for PIlYIl1CIII CI\II bo , , ll1l\do, Oenctlllly, when 11r1vlIlo t'\lndN 111'0 depicted, Iho Ro~ldol\ll\ppllos fol' Mcdlcllld I\sslillllnce,lIl1d .. ,..." j"~ i, 'I " IIppllll\\IIPII pnwv~~ll1l.1ll1\1~ ~1\11 \11lIvIW\11)', '1'11\1 Flldllly \\'I\l1th 10~11~\lnl Ilw\, 11'.11111 1~\l~IIIIl\l1 I'II"~ \1111 qf pl'l\'IM 1I)tllllil~, Iw \11' ~11\1 \\'111 ~I\II b~ !1\11~ In pll~ fill' Ihll s\II'1'kl's p\'lI\'ill\I\111~ 11)11 FlldlllYI' ,: , t Plllh' IMp, Tho FIIV11l1is1i1'11'1111l llllY \ilill~ 111111 Is IIcI~I'I1\lIwllln 1'111'1 h~ 11\11 IYP~ 111'1'0\111\ IIssIUII\lII, ' . nill\ itWlill'cl \If Vllr\l pl'I1\'ldolllo I )II g~~hlill1l, Fol' Ihls I'UI1H\,% 11\11 mill IIl1lY 1:\111111.1\1 If \11\1 gllHIIllllII 1110WS 10 n l\lrfll I'll II I 1'11\111\, TI\\lI~oslllcIII IIllI'UI'H 10 PIlY 111\1 FI\\'IIIIY 1I1II1II'IIIw\\ 1'\11' 1I1\111\\11111h'K 1'1'11'11\11 , ,Iully ,rlllp, fpl' clwh 111111111011111 1I\lll1lh'S s,'IIIY, 111\l1~llsllll'lIl lIun'IIS Iii P,IIY Ilw FllvllllY 111 11I1 1'111 \1' Il 1111111' I' ~afol'o Ihp 10l,\Ih (\(lIl,l) \Iny I,ll' IIW1\1Plllh, AllY IIl\lIsGlIIIIII'IIIW\1 \',">'"1\1',"1 sl\llll Iw 1'0f\lIl1lclllf 1\1\1 Ril~lt.lollI ~ilC01\1ilH CI1\'Ol'illl by MillllvlIl\1 01' MillllclIl'o m \l111I'\IS I \11 FlwllllY Iwfilril Ihp 011\101' Ihu ' month, Tlw Rpslllillll \\'lIllw pl'pvlllPIllI'lIh II \lsll1f sIIpplll1K 111111 s\ll'l'lvos IIwhlllolllll Iho JlIIIlIlIIY's l \II\\Iy pr!VIIIO I'II\e 1111I\ Ihmo fillppllos 1111\1 slll'l'lclIS II'hll'h 111'11 11\11 1:111'11rUII hy IIHI \llIl\y p1'11'1II\l1'l1\ll ful' I whlllh Ihp RllSlllpn\ will bo HopllrlllolY ChIlI'IlUI1, ^ dOIIlI\lHIlIs\ \If 111\11 \!hIIIWIS fill' sllppllus 111111 ~\lI'VI~~H I 1101 po,"ol'p(1 b~ Iho mIll Is \I1l1hlll1ll1clI In Iho llllShwHK nrn~\II11111 \Ii IlI'IIlIlIhl\l fill' 1'1IvIIIII' Ilmllli! lIPI'I1\III . ~11~hlllas hO\1l's, ~, nlllo I\lljIlSllt\!l1\IS, '1'111) Fllc\l\ly \I1"Y o~cIIHloII"lly 1\111111 lollll1\l1I1S,11 1\1u lllllly 1'1I10 111' oplllll1111 8erl'lp\l Ohlll'all9, If Ihls hl\ppclIS, Ihc l~us\llc\II shllll I'uccll'u wrllllll\ IIo\I~\1 of t1w 1'1\\11 1lI\,\llHlnlCIII, If III ~lIY limo Ihll Rcslllont's oOIl(llIloIlI'O'lllll'oS Iho Iillcl\llY 10 ~hllllllll Ihll 101'111 of' 0111'1', Ihl! Hoslllol\\'ij dll\ly 1'1I111 1l\IIY \le ohllllgo(1 10 \IHl 1\oW IIl\l\y 1'1110 for Ihu IIOW lol'c\ of \lll\ll I\'\lholll pl'lol',l\olleo, 1I1110s8 nolloo 18 rllqlllrod by SIII\e Inw 01' rClllllllllolI. WlwlI II llilllell of 1\ 1'II11111llJnsln\lllllls I'lIllclvud, Ihp Husldclll clln ohoOSIl10 cnd Ihls Ai!r~c1\1olll, Any 1'1110 hWl\lllHU ~hllll hlll:Ol\lihhll'ullllS IIUl'uod In br fill pnrlles whon II nollo\lls \I11\\led. 1111\089 the Fllclllty Is 11.\11111011 Inlhll ~01l11'l\1~ InIVI'ltlnR wllhln 1111\ (10) dllYH of Ihll lnlll1lng, I( Ihe Rllaldolll dous 1I011lllrou iiI Iho 1'11\0 hWl'lII1N\l, Ihu 1~I1Khlolll il'uroos 10 101ll'lllh\l FIIOIIIIY 110 IlIlor Ihllll Iho dllY bcfpro thOI'IIIIlIIlCI'~IIHII \1\101.11\\0H IIffocllV\l, If Iho 1~IIHlllo1\1 flllls 10 IOIlVll by IhlH dlllo, IIIIII~osldcnl shlll\ bo consl\lol'cd 10 hlll'O cl1l1Holll011 \11 Iho hwrollso, I' ' . l'rlvlIl\l11\SI\I'1I1WIl, nl'on wholl Ihol'o Is prlVlllo \llslIl'I\1W~1 UOV111'1I1l1l, Ih'u H081donl romlllns \'rhl\~rlly rospon~lbl(l 1'01' pllylnlll\\l Fllc\lIIY chn1'll0s, All chnl'lloH 1\01 covored by Ilwlhll'd pl\rly pnyor 111'0 11180 Iho responsibility of 1110' 1~081do1Hl Ihoso I\UII-co\,O\'(lll ohnl'lIos hlOllIIllI IIny ooln811ff1nce IIndtol' dcdUCllblo fllllo\1nls I'oqllll'cd by I\le Ihlnl plll'IY PIlYOI', lolhll oxlonl ,,\lowed \,Imlol' Fllderll\lInd Slnto InIVs, " " APPLYING FOR MlllllCAlilllMJiJ2lCbIJ2-ASSlS:l'L\~l::U - 'I'hls IIIl11lllly 1I\II11OH no RUllrllnloo of llIl)' Idntllhllt tho Hcsldonl's 0111'0 wlll ho cnvol'od hy 1\1llcUcnl'll, ~llllllellh",Il\'l\nY Ihh'II purl)' hlSlll'lIl1ce,Q otlIO\'\'Cllllhlll'scll10nl sOIll'cc"The FllcllllY, lis 1I1l01lls 111111 IIssocllllos 111'0 hOl'ohy I'olollsod from filly. IIl1hllll 01' rcspollslblllly fOI' Iho Rosldolll'S polOllllll1 ollllm 1'1'11' I\1\Y 1'111\111'010 ohlllll\ ~1\llh 01)VOI'II110,' ", " ' MEDICAID ASSIS'I'ANCI~1 Wllh \'c~\1lloll\l IIppl)'I1\1.I 1'01' 111\11 1'01101\'11\11 Modl\lll\ll ('1'1110 XIX) nsRI81fillOl' Iho Rosldcl\tllgl'eos 10 the followli\IlI, ,:' ,I , ,. ., I." ,.' . Comlllunlcnllnl! AHsel HIIIl\lst'\11111)'1I1" 1'1'lIl11l'lIy fill' Ihl,,"I1IH, AI somo rllllll'O 111110, 1110 I~csldelll' I\ssols mllY ho I'ollllcoll 10 II POllllll'hlll'lIlhll l~lIkllllllll dOllS 11111 hllw slIfflulolll lIlolllhly Inoome It> 1'111 for,thll ollsl of CIII'U IIl1d 1i111'1'1c1IS, III Ihlll \'IISU, Ihll Hllkhhll\lllllrllos 10 IlIflll'!n Iho 1,11101llly ill of Iho sWillS of Iho HI1SIIII!III'S IISSIIIs, " " , '/ ,1,., .' :.. I . QlIlIlIfyhllll'lIl' I\lullli'lIl1l,\kslktl\lII'II, Il'lhlllMhll!lIll1lllcls OIl\'01'1I1l0,linUol'th~ Mo'dlcnldAB~lall\l\C I'rollrillll, Ihll 1~llslcluul 1I1\\lll1S III 111'1 liS 1IIIIddy 1111 \lllsslhlu In oktllhllsll I\\\d mlllnlnln'IlIlBlb\lIlY 1'0 Mcdlc:l1hl. 'I'hullo 1I01l01l1l Inllsl IlIl'IlIlh', hili !IIII 11111 Illn1l1i,ll tn, IlIkllllllluy IIl1d nllklcps IIUcosWy t cnslII'O Ihlll Ihu l~lIlihllllll'H IIHsuIH 11111 wllhlll Ihll 11!1\1I11\11I limits IIlIlI IIWI Ihllse IIsools tlll\1nh,\ Wl\hl II110Wllhlulllnllll 1'01' Ml!dll'l\hlllhlilhllllll"',' . ' ,\ ! ! ',1lI\I ,- (, '" l""-~--'-~'i!" d_'" ,.,.~~' .. ~,., , t 1 , '\ I llrIlVh""~ MP"\.'I\\Inll IlIflll'l1IlIlInll' 'j'lw RIl~hlcnl nllr~cs In pnwhlc 1111 Inf\lrl11nlipn r~q\,c~\P\1 fill' i C,'Il,II1,/lllllllll1 PI' Ih\l Medlenl,'l i1ppllcl1lllln, Thl~ IlIfpl'lllllllol1l11l1~1 \w pnwlllc\111I CPl1IplllllWC wl\h IIIIY dl1l1\ Ih\l1~ sel hy 11\11 IIPpllcnhl11 Hllllo/Co\IIlIY M~\llcni\1 prl1Urll11l, , ' ' I '~~PJlllI" Ih\3l1l1,clII,IY lll,I,'IlI'IIWII,' Tho RChldC,11I n~rel1s, In ~cep 11\11 Fnclllly IlIf,nrnW\1 prlhc~I,"III~III1(1' rrpi!rl1~8, of Ih\l M\lrll,IPnld IIP\,ll1cl\\II1I1' The, Rllslllelll llllreeB Ip prnVII,I\l Ihll FncIIIIY wllh cnplllB nf lllW! IlIfprll1l1llon rulnlP\1 10 Ilw MClllcnlllnppllcl\\lpn, " '. i 'l \ , . ~] I 'rr,Ill\~rPl'I'ln" i\Bs\lla, 11' Ihll RP*IC',1l ImllsfPrB"n~slllst, Ihls Irnllsfllr 11InYllIsCJ\H\lIfy 11\11 RuBIIlllll1 fpr n, \ M, PdIPII\I,IIISSIBII\I\PllntllIlPI' cnllhlln dWutlllu\lUllQ.ll PI' 11111 RllslIllllII's MelH~nlll \JIlIlOn\S, The RIls\(lel1l! ~', \ I\pknowlplli!\ls Ihlll Ihls 11I11Y rus\111111 dlscllll1'l!\l of Ihll Rcsldolll II\lc 10 lIon,pnY11l1l1l1, I. Ii r . COl1lhmhlQ Iln)'nwnt nf lrllpll\l)' Chlll'QPH rpl1Ilhl" ~IIBlhllll)', WllIln nllllppllclI\lolI 1'111' MClllpnl~\ I\.' lIss!allIlIPohns b\3cn OIPII, 111Il Rpslllcnl l\~rllCS Ihllll . r ',:t , whllp IhoRcslllelll'S nppllcllllon Is ."pelllllnll,1I Iho Rllsldlll1l'~ cSlhlll1\1111 Shllre of opsl (nB,': )" dpscl'l\Jcll,ln Ihe folll1wllllll1l\rl\lll'lIph) shnll \.10 pnld 10 tho Fllolllly on or \lefl1rll lhp l\lnlll"( , (lOth)tlllY of ellch 111Onlh, 'I I ", oncelhll {{eslllollt Is Ilolcrmlncd\o bo e\llllblo for MClllcllld lIsslstnnce, Ihlln1110\\nt pf tl\11, i: Rllsldol1l's slwo of cllsl shl\lI bo pllld 10 \he Fllclllly Oil 01' \Jefore the tClllh (\ Olh) dny 01 r onllh month, 'This mpnlhly shlll'll' of cost Is deteI'I\lhllld \:I)' 1\IIlIHnllllCPllnty Modlolllt\ "'.;.'\ P, rOIl\'nll1 IInd II1n,y bc roferred 10 ", s Prlvnle l~orllon, S, hllro PI' Cost, plI,llenl Lln\Jlllly, PlIlllln\ ' Rosoll1'ce, oto, Any chllnll\lS In resldellt 1l1lbllllY wlll \Je c0ll11nlmlcllted tl1 Ihe Fnplllty PI1 ~ tlmeJy bl\sls,' ' . Agent Contl'olllnll Resilient's F\II\lls, If Ihe R~sldont'B Agent hns conlrol of or 1I0c;ess to th~ ' Rosld\lnl's Inoomo IInd/ol' I\sselS, Ihe A~ont lIgrces to IIS0 these funds for Iho Resident's w\llfllre, Thll, , Inphldos, hilt Is not IImltcd to, ml\kllii! prompt pnymcnt for ollre nnll services provided 10 Ihe Reslden liS spcolfied In th~ lorms of Ihhi AdmlsslOIl Agroement, I , " I i I . Pi'ovlllhlG Flnnnclnl'lntol'Il\IlIlOll, Tho Rosldant certlfios \hlll nny nnl\nClllllnformlltlol1 r\llllll'lllnl ! .tI,lO Resldont's Inoome IIl1d nssels rC9\llrod bylhe Fncll\ty nnd provldo~\ \lY\\\O Resldcnllo opmPleti, 'I lInd I\ccUl'lIle, II' : I, , ", , ," ty1EDICAID RESIDENTS. ^ Modlcll\ll Rcsldent Is one who receives bcnofits from Ihe Stl\to Modloni" Progrllm for IIl11njorllY of his O\, he\, Room & BOlIl'd chnrgoB, Mcdlonldmny or m,IlY nol coVCI' ohnl'g~s fc nddlllonl\l scrv!oeslllems provldcd by tho Fncltlty . Ihls vl\rles from 8tnlo 10 Stille" i ,i ~ Tho following npply 10 Modlonld Rcsldentsl, ," ' :, . . n"lIy 1t,I' \'" "..... 0" ,,,h,,'''' 'P. II.. It,,""" I ~ 1\1 b' pro' ,,~, Wltl'" 11.1 ,r '"rrtl" ,,,d .J. II ( , vlc~s thl\l will be pnld by Ihe Mcdlcllld prognul1 IInl\ those suppllos nnd servlcos not pllld for by tt, I' Mcdlollld progl'llm, for which Ihe'l~csldcnl will bo scpllrlltely chnrgcd, A delll\lcd list of nnd ohllrg\ "i , 1'01' suppllos nnd servlcos nVllllnblc 11\ Iho !1no\llty bill nol ooverod by Iho dnlly rlllo under tt ( ," Mcdlollld progl'lIl1l Is lIlnllllnlncd 11\ tho Buslll,c,ss 01'1100 Md nvnllnblo 'for review d\lrlnll nonnlll b\l~ ncss I\ol\rs, . II "." , I , II \, 3 ~~ , L \ _~-II 'j,tti,' " " , "''''\ , 'fllfmlnnll(H\llf Cnm'nIW, Tlw HIl~ld\'lIlll1l1yn'l1.'1111111I1I1\I i"1I\'IIIIY 1'111' liS hllll\ lis IW\lI' shills \'01'11. 'fiodplli!lhl\l 1'111' Mo~II\'I\hl PIl)'IIWIII, 111'1'111' liS 11I1Il! lis IIIIY hlil\ll' III l'IIIII\1I1'I'd h)' 111\I1~llshlollllh plllll n~ 11110, A r~llsldlllll II'h\II'\ll11l1lnh 1IIIIw lllIl'illly 11111'1' ~hl!lll'lIhll'II\'11I1II\11 hilS Ilxpll'\!l1 III' IWI'lIlcll'lllIo" Ilvoly tpl'l11ll1l1lod Ill' ~h"ll\l!II11I1~I Pll)' 11111'1111)' I'hllllllls nli II 1'1'1\'I~1I1 l(I'shhl1ll, III ,Ihls 01'0111, Ilw Rllsl\lolII 11'11I PIlY \1l1so\11I1I Iho pl'II'IIIII 1'1I111S, I'hllltl"h, 111111 II' II I1h III Itlh'I'1 nl 11111 1111\11111 hlll'l'kll, I! ( I iJl, a\, i\1 , I If Ihll R\3sltlolllllllllr.us 1I11llllus rocolwll frllm HlIollIl HUl'IIIIIY \II' II hi 111 1111I' hlllll'\llllu PIIY fill' shllrollf Ol1sl, nllll f: I:, i Ihp R\lsl~\3nl fnlls In II1nko prnmpl pll)'I1\11nl, Iho FlldlllY mllY ,1I!I\IIIISl dhwl 11111111111101' slwh monlos In 111\3 i'~, Fllolllty, In 501l\\l Slnt08, fllllllru III PIlY 111Il l~usldll1l1's Shill'll III \lllsl 111I1Y 1'0h1111 In Ih!1 Hosldollt's dlsolHll'Uo, ,v I,:' 'fhu FlIolllly wllllllso nOllfy Ihu IIPPI'Olll'llIl1I HIIIIII 01' FudullIllIlIIIIHIY uf Ihls 1111 II " PII)'II1\l 11 I , I ,) ;:1". MF.DICAR13 RBSIDHN'I'S - ^,Mo(lIcllru HI1Nhhll1llH 1I111111'ho Iwul\'IIS hUlIl'lIlH fl'l1l11lhu FUllllrnl Mlldlonrll ;\ , prOarlllll fOl'hls Pl'lm IIl1rslllll homo 0111'11, Slll11olllhlllllllllllllul11SlIlId sUl'vlcus II1I1Y ho oo\'ol'od hy MOllloIII'O, I, :t Thll followllllll\Pply 10 MOlllclIl'u Hllsldulllsl , ' , DAily nnlllllllyn\llnl, 011 lI(hnlsslllll,Ihu1(11sldolll shllll ho pl'uVldud wllllnllst of sllpplle8 mlll sor-: ~ VIOllS i!onorrilly pllld h~ Iho MllIllpllI'll PI'IlIl I'll 111 , IIlllllhllso slIppllus 1111c1 survlpllS 1101 pllld fill' by tho Mll~lcllrll progl'llm fill' which Ihu HushlolltlVlII ho SllPlIl'lIluly Chlll'l!lHl, A clulllllo\lllst .of IInll ~hl\l'l!es , for H"llplleH I\nd SOl'vloos IIvllllllhlo In Iho Fllclllly hilI 1I0t Ilovo1'(I(1 lindoI' Iho MUllloRl'1l prOl! I'll 111 , , It\lllud nlllhll dolly olllns\l1'lInco I'IIt(l, IN mlllnllllno!lln 11\1\ Illlsllluss Off\cu IImlls IIVillll\blo for 1'0\'low , durlnl! nOl'!11nl buslnuss hllms, ' , nllsltlpnl'a ~hnrll lIf ~ItHI, 'I'hu M\llllvllhl PI',IlL\1'1I1ll I'\lVhl\\'H Ih\1 1II'II11nl1hl l1\1l1llhly hWllnwllf 1111 pur" , HOna rortll\3HIIIlIl MUlllcllhlnsslslnn~'II, IIl1slld (Ill Ihls IllVhl\\" 111\1 Mlllllclllll pl'nurllll1 1'Illlllh'llS I11(1S1 MIl\lI~III'1 '~Uslllllnls In pny I'llI'II r(lIlSllllllhlll hlllilll Ill' Ihll !I(lhl (If Ilwll' VII I'(l , 1'1I)'IIWnl of Ihlll Shlll'lI Is ' \hll rllHpPl1sl\ll1l1y Ill' Ill\! g(lNhll1nl, 'I'hu 11111111 VIII1 I'i III 11 111' 11111 Ill'shhllll's lihlll'll Ill' l:n~llIllls IIISVI'IIIIIlI1; : , , , , , Lhlllllld COVCI'IIUll. Tho Rusldul1\ 1I1\lluI'SIIlI\(IH lhilt Mllcllolll'u UllVUl'II1l0 In ustllbllshod by pcdol'lIl , ' guldollll08 IInd 1\01 by tho FllolIHy, Modlcllru Oll\'(ll'lll!O Is IImllud In thlllOl1ly 1\ spoolflod Iuvcl of CIII'Il Is povered fOl' II spoclllud numhel',nf dllYs (houolll purlod), If tho Hosldunl nolllnllor mlllllS Modlollre oovorllgo crltorlll, OOVOl'IlgO Olin hO(lI\l11ll1 hllfol'lIlhil usu of 1111 IIl1nltod dllYs In t1Hlllllrronl bOl\oOt,pol'l-, ad," .. · EXllll'lllhm of 1I1111ullls, Pl'll1l' In IIdmlsslnll, Ihu HlIsltlunl musI bo IIblo to dOlllonstrl\to thollblllty It) PllY (ollhur (1l'lvllloly (11: Iltrllullh Modlcl\hIIlSsIHlnllco) few Fllollhy sUl'vlccs I'ondcl'ed IIftor McdlclIro bonof1ts oxpll'u, Whon Mud\Cmo On\'lll'lIllll oxpln;s, Iho I~psldunl mllY rOlllllln III Iho rllcllhy If prl\'lIlo V: PIlY 01' nlhor J1l1ymlllllllt'l'lIl111ul1\lll1ls hllVIl IwolI IIl11llu, If tho Hllsltlul1l wishes 10 he dlsclllll'llctl from ' tho FllcllHy Upol1 (lxJ1ll'lIllollof Mod\C1I1'll hllllUflls, ho 01,' she !11l1sl sOlldvlso thu rllollllY III thc tll11eof tho Hosldollt's IIdmlsshm" ' · ,Cohlslll'nnoo 1I11e! UilClllctlhh,s, 'I'h(l I~osldllnt Is I'ospollslhlll for !1nYl1lolllof III1Y Medlolll'e oolnslll'-',\ i, IInco IInd/nl' duducllhlos, ",' , ' If Ihe Hllsld~ut IIIIolldH 101wl'1I11\11 pl'll'lIln PllY II'lll~1I M\l(lIclIl'o hOllonts oxplrll, Iho I~osldcill' IIllrcos to I1I1Y III IldvlInco fur OliO 11\0nlh's pl'l\'IIIO dlllly rllln Wholllhll Hot.ldolll chlllllluS tll\lrlvilto IlllY sllltllS, \Vhlt tho oxoop- IInll or prlvlIlo pori 1011, 1f'lIppllc'lhh', Illllld\'lInco pllYI1ll!lIlls I'lJqllh'od 1'1'011\ ModlclIl'o RoSldel1lS who COI1\'IlI'\ 10 Mcdlcllld, ' . " ' ,." I .. "I / , " ", ,I fjt...'-') I',Wr,mN'I'INJlUH"f,\TlON 12I.1E DA'IW; f~J2ll1.1QA:(:JQN-JILllA\L:rlMH~ - FllcllllY ~hllrl!cs fpr Hprvl~pH prnvhlpd Hhllll Iw hlllllll 111Plllhly IP IhlllMlllpl1l, ThpH\lCIHlI'~llij IIr~ Ihlu 111111 PIlYII\11\lllY Ih\ll\ll1l1,l (1 Dlh) IlllY Ill' \Ilwh 111f1nlh, , I .; """ ! ) If p"ynWI1\ Isup,\ r\ll1\1lwll hy 1Il\l 10111h (IOlh) IIIlY of ollch 1110111h, Iho II11cPIII1111111111WllIH \IPIIHI11Qrllll pllij\ lhlll I. PI' Ilplhl~\IQII\, 111\111111' !'Iwlllly I\lIlY ",hili 111\\1 chl\rllo In Hill g\lsl,lonl's lIo11l1ll1\t. 'fhls 11110 \IIHlri!O ~hllll hll lIamslld Oil IIwl11l1l1lhly \ll1ll\l\pp III Ih\llllSSllr PI' Iho IIlPI11hly l'I\\u of 1 ,~% (OliO 1111\1 ol111,hnlf pllrOOI1\) PI' Illu I 111 nx I 111\1 111 11111011111 plll'lIll\l\lll\lY IIlIV, This 11I1\l chnrll\l IIPIlS IIpl IIl1er III1Y p\lllgI11111118 (If Iho FlIlllllly or RllSlll\llI1 11l1\llll' IhlH Allrll\lI11\lIlI, Thp Rllslct\llll rllllP3111~cs 111lI1 \hll F"oUlly 1I0118 110\ pffllr cl'\llll\ or IIcccpl hlHIIIII111P111 PIlYIIlIlI1\6,Thll FIIPlllly's 11990pllll19\1 PI' 1\ pllf\11I1 plIYll1lll11 dpcs 110\ .llmll Ihe FIIIlIlIlY'8 rl/!hlR \\1111\11' Ihl8 Ai!rooll1\lnl, I fAIL\1RE TO PAY. ThoFIIlllllly's 11\11l dlllll for p"ymcnls flllls ol1\ho IUl\lh of olloh 111Pll1h, If Iho Roslllp111 II flllla 10 mll~\Il1 rQ'l111f\ld \1I1Yll111nl wllhln IWlllIlY'Ol1e (41) dl\Ys of Iho,lhlll drM, Ihll FII\lIIlIY mllY r\ll\\llr\llhll i ,R!lahlelll 10 VIIOl\lo Ihll fllllllllY, ::' , If 1\ RllsldclIl Is rll~llll'od 10 Vllolllo fpr fl\lllll'\llo \l11Y, Ihu Fllolllly shllll pl'ovldlllldVOIl\lOl1olllle lIB S\31 forth In Iho Resldcl1l'a 1~llllM socllplI of Ihls Agrelll11onl, This npllce 8hllll\111 oOl1sldcrlld rOllulvod clUm on Ih\lllcl\llIl diM of rOolllpl or Ovo (5) dllya lifter 1111\\1111[1, whlchevor o\lo\lt'S Orsl, fEE FO~ RETURNED CHECKS _ A scrvlco 1'110 of $2~,OO (lw\llny IIVllllQIlIII's) 01' IlwllllIIlII\ fee \llmrl!eel i" \ly Ihe \l~nk, whlph\lver la 1ll'lll\Illr,wlll bo ohlll'i!cd for ~lIY rctlll'lIclll,lheok, . ,~ IllCD UOLUS \ I Tho Rosldelltnmy need 10 be lI\lscnt from the Fllolllty tcmporl\rlly for hllaplll\lIzlItlon or Ihol'lll111\ltl\l \cII\Vll, Tho Rcsld\llll mllY requost 111M Iho Fllolllty hold opclIlho Resld\lIll'S Pllt! durlnsthla tl1l1e, This Is known liS 1\ I. "ped hoW' Thc Resldllntlllld'lI fnmlly mombel' or lellnll'cpres\lnlMlvo 51mll PIl SIVI'" notlqo of Ihc bed ho\eI opllon III Ihlll11l1u of hosphllllzl\tlon oI'IIl\lI'llP\lUllo \!llIVC, MJIDJCAID RESIOlllitS. .If Ihe I~\lsldcnt's o~rCl Is pllld 11I\\lel' Iho M\ldlcllld prOlll'llm, M\ldlolllel 1I111Y PIIY , ' fill' ncortl\ln l\umbel' of bcd hold dllYs, If tho MOdlonld Resldcnt's hospltllll7.lIllon 01' Ihllrllpcullc lellve cxceods the belHlold period pllld IInd\31' the II M.dl"ld p""nm, Ih. .,,,,,,,,1 mn,,,,""1 .\1 .'dlll'\I.1 "" h'" po,'" r",m 'h' F..III" b, ..".111' " ' ,., PI\Y tho IIppllCllblo dlllly rIIto dul'lnll Iho IIddltlol1l\\ bcd hold period, Othcrwlse, tho Rusldcnl shllll be rcadmlt- tod upon thll nl'st I\vl\lIl1bllhy of 1I bcd In II 110n.prlVllte room liS Ions liS Iho Rosldcnll I) roqulrcs Ihe s\ll'vloos h ,. , " provldc(1 by the Pllol1ltYlllnd 2) Is clllllblc for Mcdlcllld nurslnllsel'vlccs, ' ~ I ffilYATIiAND MEDlCARIl RESIDENTS _ Any PrlVlllO or MelllclIl'o Rosldent Il1I1Yl'cqUcsl1l bcd hold, fromllle Pllclllty, A. Rosldctll's pl'l\'lIlc Ins\lrnllCo I11I\Y 01' mllY not PIlY for bcd holds, The ModlclIre pl'ogrl\lll doos not I'cltl)hUl'SO for bod holds"holyovcr, If tho Modl\llll'o I~osldellt Is III so M\l(lIollld ollglble, somo Modlcllld progl'lIl\\s 11111Y PIlY for II curlllln ,lIumbcl' of bod hold dnys, Olhcrwlso, II l'rlvl\lo or Modlcllre i Resldct\tl'cqucsllllg II bcd hold musl PIlY tho 11llcl1Hy's 111'IvIIIU dlllly 1'1I10 for,l\l~ bcd bclng hold durhllllho bud hold pCl'lml, " , , ,,' " I It , , 5 " 1'1';I\HON,\I,I,'lINIlH Tho gosl<lcnl hnH II I'I/Jhl \II 11\1111nlIV his or h~r o\l'nl;~rMll1lll funds, Ii' Ihv I~vhldplll wnllls nhHlslnll~;\Iwlll Il1ll11ni!~IlWIlI PI' \llll'sol1nl !,II1HIH, Ih,ll Fn~IIII~' hhnllllhslsl If I'CI,IIICS1~'11 10,110 so III \l'I'IIII1/J. Alii1\! Hv~hlvl1I'~ WI'I,II~1I I'P~IIIlSI, Il\l FII~'IIII~ shnllhohl, NnrcUIlIll'd, 1I11\1l11L.\Il,Ulld l\I:cO\1111 for Ilwso fIlIHIH, , I Hpsl~OIlI pPl'Hollol fUllds IlvlHlHllvl! \l'llh Ilw FliClllly shnll bv hlllldlullnh rollplI'HI i, ( '~ I , Thl! PllvllllY Hhnllllppphll fllmfs III u~~'m PI' Fifty Poll III'S ($!i(),(l(l) III 111I IlIlvroHI.\Jpl\l'lll!lncvnlllll' ' I ~ I " InS\lI'Plll,l~ Iho Flldlll'nl, PUp!,lSI1 ',"NIII'IIIWIl (::llI'pPl'llllnl1 (FPle),lhnlls sV,I1nl'nll! from nllY Fnclllly nppl'-, "l~ olln!ll\ccll\l1lls, ^,lIll1lcrllsl unrncll nil Ihl! HcsIlluIH'8 flllHls shnll bu crlllllcll IP his ul' Iwr I\CI10\ln1, r,hll: 'I','," Fllulllly shnll hlll'\3 lho ppII\111 PI' llpposllln!l r\l1Hls of Ipss 1111111 FlflyPolh\l's ($~O,OO) III PilI! pflho 1'01-;", , ,:, I 10\l'hli!11I nPIHlllprusl \lPlIl'hlll IIcC\111 11\ , 111I Illlorosl t,ollrllli! IIccPIIIH, or pCllY clIsh 1'111111, 'f1111 Poclllly, i \ shlllllllform Iho HOHlllunlUS In hilI\' his 01' hol' f\l111ls urll bollllllwlll, Thll FIICIIlI~'8 J1pIIIlY Is Ip tnl\hljl/! i,:f' 111111,011 rosllllllll ,flllldH III n H,Cpllrnl\lIlCCOIlIlI, o~copl for n IInmlllnlnmolllll 1l1111111nll1cllIII 1\ polly ollsh"', ) flwl fill' lho rusillc11\H' CPIlI'OllloIlCO, 'r ' 11" , Thlll'IIC,III1Y shull hnl'o II systPIl1 Ihol unsuro, s II COllljllulellnd sllpnrlllo ncco\lIl1lll!k\lllspll on !lPlloroll~, f\, ,0, cooplcd OC,CO\111111l1l prh,1ClplCs, of Ihp p,crsonnl flllll sdcposllpd ',VII,h Ih\lFl\ulll,IY b~ ullch RIl~lllunl or, on his or her bohll1f, This systom shill! nl~o ons\ll'C lhnllho Rosldo1\I's flHlds lire nol oommlnlllocl wllh lhl! Fnollhy'sfnnds Ql' \\'lIh IIny olhor fllnds bosldcs Ihnsll of nlhur Reslllelll~, Tn IIddllion 10 Ihe", rOljnlrel1 q1\lIrlllrl~ IIccPllnllnll, Iho FncllllY slmll provide Indlvldnnl fl1\lI1\cll\\ reconls IIllho wrl\lun '~ roqllosl of Iho RIl~ldcnt, " ,I I - 'fh\l pel'~onlll fll'nd pn\nnccs of I~cslllcnls who reccive Modlcnid bcnufll~nllls1 rOllllllllwllhlnn c\3r1l1lnl ,I dolinI' I'IInllO IP sl\llsfy SllIIe n1\d pcdel'llllnws, '1'11\1 Fl\clIllY shllll1\Ollfy 0 Modlollld resldo1\llf his o~ , her IIccOIHlI bnlnncu 15 wllhl1\1\vp l'IlIlIdl'Cl1 poll II 1'5 ($200,00) of Ihll Fodol'lIl SUPplulllollln\ SocuritY' I1\COll\ll (SSI) 111111\, Tho Fnclllly shllll nlso nOllfy Iho Roslde1\tlf Ihe nCCOll111 blllllnco, 11\lIl1dlllo1\ t9 ! tho Resldolll's known 1\On-oXempll\ssols, I'ol\chos Ihe SSI rpSOllrOQ IImll, A PlIllIIIOO In 1ll\00Ss of Ihls, , IIml\l11l1Y cnuse Ihe Residonllo lose ollglblllty for Mocltcllld or SSI, " \;" I' ',. " . i -If,lI Resldcnl Wh9 hilS pcrsonnl funds dcposllcd wlththo Fnclllty explresllho Pl\olllty shnll refU1\cl thq Rosldent's IICcount bllln1\oe within thirty (30) dll~s IInd provldo 1I fulIlIccoul1ll1\/J of Ihcso fllnd8 10 Ihc IndlvldulIl, pl'obnlo Jllrlsdlcllnn ndmlnlslcl'lnll Iho Rosldonl's osll\le, 01' oll,lcI' onlhy I\Ii rcqnh'llc! p~ ,Slnlo lnw or rogllllllio1\,' .' " .' , - Tho FnclIl\y shllll CnSUI'O tho SOO\ll'lt~ or nil pOl'sonnl funds clcposltcd \\'I\hlhe rncllllY, , ,'iIj · Tho FlIclllly shnllnol Inl;o nlOnoy frOIl\ n Modlcnro IIndtol' Modlollld Resldenl's pcrsonl\l fUllds for i, lIuyltom or scrvlce for which pllYl1lunt onn be modc \'l1dol' McdlclIl'o nndltlr Mcdtonld, I ; " I '(If the Re, sidulll d~os wnnltho Fnc\lIty's nsslstl1l\cu with mlll\lllllng pcrsonnll\1I1ds,lho Resldont Is required ld,l: 'Ii:".',','.,". 00111111ele 1I1Hl sign Ihe IwslDBNT TIWST FUN)) AUTHORIZATiON FORM on PlIgo 18 of lhll' ! ,;,J . AIlI'oolllcnl,) . " iii, i (.:~t , )"J"'l{t ',(, Wl. " .~~ " ii"!: ~;.;h", '/'",8' , , , , " I, II' .'''.. " 'I'Im M I Nt\'1'I ON (lI" t\<ll\I';I~"\I';N'I' IUOUX_:rOJm~MI~i\'m . Tlw FII\!II11~ hhlllll\ll\ IliIllhf~r Ill' c\'I~'1 Ilw 1\\lh\llplll hol\lly liS II Illhllll or Ihll gl'8111pnl plllllllllnu his 01' IWlllHIlllm \If IllIynwllI fl'lllH PII,'1I111 Ill' MUIlIvIII'u In M\llllllllhl, \llllllhS I.lw FlI\!lIlw I~ nl1ll1ullnSoll 1'01' Mulllpllhl," ' " Jl~Jl~Q~AL...eRQ.Cllg'l'Y oUJms.II2U~t_UI11NJ)ISClJA.lWU - 'I'llI' \!lIpIIIIY hlllllll11l1~P I'PII~nnll\lll' ", ' pffprlQ \p sllfC~, 1IIII'IIIhp I~Ph\llunl'8 Iwrsonll\ \1lllpl\ulnus lIf1el' IlIh\lIIllI'j!U, 'I'h\l I,I11pIIIIY, hoWU\'OI', shllll npl \111 IIl1llll' fpr IIny llillllllUI' 10 PI' Ipss PI' Iho g\lshllllll's pl'npulW, Thll FlI\llllly llIny IlIspllhO PI' nllY prp\1011Y luft \IY 1I1\l Rl'slll\lnllf npI cllIll\I\l11 wllhlll Ihlny (~O) IIIIYS PI' IIls\!hnl'U\llll'lrnnsfol', or IlllICCPI'dllllUl.I wl\ \ nppllulI\llo $IIIII'IIIW, ' , i. , I.- ,~ " lWFUI'IDS. .. If IIIll Rosldol1lls dlscllllrllud \10fOI'Il Ilslnll filII proplllll llhllrllOs, Ilw Fl\c\lllY sllllll r\lflllll1 Ihll pl1l,"sed pOl1lol1 PI' sll11h chlll'lluS wllhln II rUllhPllllbl\ll1ol'lol\ of Ill\w, If Ihu FIIIlIlIIY 18 l'ul\lIlrell \1y \IIW Ip hpll\ I'l'sldllnl pmonlll f\1lvls In II dOl\llll\l\ InlsIIlCOP\11\I, Iho bllllll\o\l of IIWSIl fllmls shllll \1e l'ef\11HlulI pl"lmpl\~ !IfillI' 11113 Rllsldolll'Q dill!? of dlslllllll'Bll, ' If II Rosl~enlls rCIl'ol\cllvoly IIpproved for Medlol\l'\l PI' Mcdl\lllll\ bunllOls, pl'llvlolls pllY1l1cnls nwl\llhlll will \1e oov~rud \1, Y ,Ih\l ModioliI'll or Mlldlcl\lll prOllrll1H8 will hI' 1'0f\Hldell pr01l1plly In IIccprdlll\\l1l wllh Ihe FlIollllY's rqfllllll policy. CpnlllOllhe Fl\clllly 13l\hllloss orocc for Ilollllls pn Ihoruf\lIId polloy, :, ' " I" ; lIt, ENFORCEMEN1' OF THIS AGREEMICN'f ~OLE AGREEMENT _ This Al!rcemelll, II10nl! whh ,!IllY dou\11ncnlslllll\ohor.\ or Incl\ldcll by rllf\lrUnllll, Is Ihll onlY I\llreomClI1 belW\l1l1l Iho FlIollllY 1II111 pllrllos, ChllllllcS \0 Ihls Agrecmollt 111'0 vlIlld only If mlldeln writ- ,l,l\llllnd slllned by 1I11 plItlles. If ohlll\g\ls In S\nIP 01' Podornlll\w tnnkol\ny plll't of Ihls A~rllenwnllnvlllld, Iho I'omlllnhm \emlS shll\l Sllllld ns 1I vlI\ld I\llrcOn1Cn\, " , ' , A'l'TORNijYS' FEEStCOLLEC'rION A01lli.cY FEES - lnlhe oven\ Ihe FncllllY IlIa\II\11~s IInclls 1\ provlllI- hIll pm1y In lI\1gl\tlon 1I1ll\Inslllny pl\rlY 10 Ihls Agreomenl, IIrlslnll frQnl \Ill1l plUly's flllhlfo 10 oomply wllh the tonns of' \ho Al!rec\n\lIl\, tho FII91llty shll\l bucntllled \Q rocelvo frQm the losing p(\\1y rel\sollllblollllor- l1Cys'luo\lcctlon lI11cllOY fees. NON-ASSIONABLE AGREBMIlliI ' Tho Rcslllcnl lIllrccs thl\t Ih\l rlght pf the Resldel1110 reside lit Iho FlIcl\llY Is persQl1nl nmlllot IIsslglll\ble, The Rcsldcnl1111\Y 1\01 \rllllsfer his or hor rlghls \mder Ihls Allreemcnl ' \0 IIny other persoll.' " " '11 " " if. , , , : (', lJ' ;' I ' " " " 1'1 I ", , 7 ,I .. ! r'''' f""', Ulf8f1JUNTW Umfl1',~ AN/) fUmNJN8ffUU1'fRS NONIlIRPBII\IINNI'H)N HIIWI'I~I\IIWI' Tho FIIPIlI,IY wplpnl11ll~ IIlllwr~ol1sll1 IIcelllll' II~ fiPI'\'IP\l~ 1H1l1 ,lops 1101 IlIslJl'll11lnnlonll Ih\llll,ISls of nlJ\3,III~- IIhllllY, 1'0, Cp,Plllol',nlllhlllll 1l1'1~lnl IIIlPIlSII')', 1'01l1J11ln, 01' SPX, Tlw FII\.'IIIIY Ihws not IlIscl'lmlnlllu Illl1nll~ PPI'- ~ons 11IIso(1 Oil Ilwh' filllll'PP~ of PIlYIl1UIlI," , , " Ii .. , CONRI\N'I' I'OH ,'I'lmNI'MI~N'r' ".1(;' 'WlRSlI'lOFI\CILl1'Y sm~YJQI1'.i - ny slunllllJ Ihls AlJrcPIl1Pn\, IIw Hosltlpn\ conscllls 10 IlIp FllcllllY pm- f'( it vlf1lnlll'oll1hl\3 nllrslni! 1\1111 011101' hplIllh ClIrp s\lrvkps ns dlrpclcll by Ihll III1Pllllln/J physlplnn, From 111Il1l 10 I", ,(,: Ihn\l,lhll J1l1plllly mllY pnl'Ilclpnl\lln Irllllllnll pl'Ollrllll1S 1'01' pPI'SOn8 slloklnl! lIconslIl'o 01' cortlOPlIllon liS hpll1th ':[11 Pllrll, worklll's, In ,Ihll pOlII'SIl nf Ihla PllrtlclpllII11II' plI,l'e mllY 11\1 rllndlll'lllt 10 Ihll Hualdon\ by slIPh Irlllnoos IIlIdllr \ ) allpllrvlslon n~ r\lqlllr\lll by IIIIV, Consollllo I'ollllnllnlll'slni! pnru provldod 1>y Iho Fllclllly shllll hlPhlll\3 con. ;, ! S\3nt for PlIre hy sllPh Imlllcoa, ' ' , ' , eHYSrCr{\N SERvreES - Tho Roslchlnl ncknolVlcd~oHthnl he or shills IIndpl' lIill mudlcl\l Pllr\l of II' parson- Illllllolldhli! physlcll\nllllll Ihllllhll Fllcl1llY pl'ovldos Slll'vlclls bllSlll1 on the gonlll'1I11lnll speclfio Inslnlcllons i ~ 01' Ihls physlcllln," , .. !' The Roslcllln! IllIs 1I1'1Ilhll0 Slllocl his or hcl' OWnlltlendlnll physlollltl, If, howllvor, thp Re8ldClltdo\ls nOl' I , ' , s\31ccllln I\tlpndlnll physlcllln. 01' Is Illll1ble 10 solccllln IItllllllllnll physlollln, IInl\l11111dhlg physlpllln mllY bll dllSIi!lllllod by Iho Fncl1lIY, or InllCCorclnnce wllh Sll\te II\IV, , I '010 Rpsldolit rccognlzc8 1Il\lIIlIlI'IlCS 11111I nil physlclllns pl'llvldlnu sorvlces to tho Re'sldenl, hIPllldlni!tho80I" dllslgnnlcd bYlho Pllclllly, lire IlIdcpcndplIl contl'lIplor8, Tho Resldonl rllPognlz\ls I\nd lI11rees thl\tsuch p11)'81- i cllI~s nro nblllssoelllles 01' I\gents of Ih~ Fnclllty, IInd Ihllllho Fllclllly's Ill\bl1l1y fol' IIny physlclilll'S lIet 01' , ollllsslon Is Ihnllcd; , . ',,! " ",. i " '010 Rcslclllnl shpl\ bc~olcly I'ospolllilblo fOl' pll)'IIICnl of 1I11 chllrgcs of IIn)! phYslplnn who rondcrs ellrO to tho i '~osldc'nlln Iho FlIclllty, unless Iho chlll'lluS III'C cO\'Ol'cd by l\ third plll'\y Pll)!ol', , ,,' " : !,I RIClHT TO REFUSE TRI~AT.MJ~l'fC : Tho Rcsldonl hilS Ihc I'lllhl to rofuse Irelllmontllnd,lllreyoke, cOllsolH i~ ! for Irclltmcnt, The Rosldcl1lllls11 hns thll I'lllhtto be Informod oftho mcdlcl\l conscqulll1C08 of such rcl\lslIlllr I i ~, I'e\,ocl\t!on of con set\!, IInd"lll bo Infllrlllod of IIltcnWlo Il'elllmonts nVllllnblo, Whoro, h11ho opll1lon Qf 1110 i : ' II110ndlng Ilhyslclnn 01' by Judllcnwnt of n cotl\'lllf Ill\\', IhnRcstdont Is dotcl'lIllned 10 bll lIlol1ll1lly hwompo. ,I leUt l? IIlllkc II doclslon I'cllll1'Cllng I'cfnslIl of 1I'0llllllO,Il1, the doclslon 10 I'efuse l1'olltl110n( mil)! be ml\do by n 4,,' :"jl LoglIl Ropl'llsontnll\'o or olhcl' S\IITl1lllllo c1cclslol1-lIlnkol', subJccl to SllIlo nnd Fedel'lIlll1\\', " " " , " , /......" ,.! '. ,. ," " '" '" :"1 ( , ,.: i'IJ~: ,;I':il~,b ! -., " ,.~;., " " , , , , , s .I'!'.. .~~.~_...,~"~---"- 'OJ, ,"'''''''tr (""\ , 1~'~lil\mN.'l"lnlm:iPNr\I. l'l~U11'CHTY Thll fl\cllllY monllly IlIHCO\lt'IIIlCll \llll keeping of 1'111\111\1111 jllwlIlry,p"plIl'll' Inl'lll! H\lI11S PI' I11nnll~, PI' oll1\l1' 1I1l11111 c\1l\shlorll\lof Vllhl\l In Ihl' Fnclllly, 'l'11\l FI\IIIlIW ~hllllmllk\l 1'Il118pnl\hl0 Ilffpr\8 IP 8n~ull\ll\nlll)!l Rellhllln\'s prpponytvllh\ll\ll\ls which Ihll HusIIIIlnlchl10811S III kllllpln hill PI' hilI' rOll~e8slpn, ' i 'fhll Rosldllnll\~rll\lllll1 Inform IIIIl Fllcll\ly of nil \'nl\lll\ll\l pl'Ppllrl~ \lpO\l I\\h1l18811111o If,lIIl1ny lhlll' Ilmlnll Ihl' Hllsldllnl's SillY, nllW lIlll11s of vlIl\lllllrO mille\! 10 ,hll gosllllliH's PPS8IlSSI11nllln Iho Fllolllly, Ih\l HIl~lllen\ 11180 IIllrlll'S IP 611 tnI'llI'm \IHI Fncl\\ly Atlmlnlslrll\or or Ill'sli!nllo, , , lm~lmCNT'~ RECOHP/i ~Ol'lFlDllliTIf\l.ITY -lnformMlon InollHlollln Ihll Rosl(lonl's m\3111olll rOllonls Is cpnflql'nlllll, Unlllllhorl~o\! IWSP\l8 nhllll \lol PO I1ll0wc(1 10 rllvlow IhllSII roponls wllho\\l Ihll Rusldonl's wnllon ppnsOnl, . IlX?OPI liS I'llqlllrllrl PI' pormlll\ltl hY IIIW, ' ' . ' , CONSllN:UO,.RELUASE BY FA.ClLrP'. -TlIIl Rosldonllllllhorl~us 111\3 Fl\pllll~ Ip rllloll81'1111 or IIny Pllrt of Iho"Rllllldllnl's 1Il0dlp~1 0\'Ollllno11l11'1lPon1810 lIny pllrson ol'llnlllY whloh hilS PI' I\1I1Y hllvP II 1IlllIIl or 001111'1\0- 1\1111 pbllll"llon 10 PllY 1111 or 1I portion of Ih" cosls of ellro pl'ovl(IIl(IIO thll Jl.oslrlllnt, lnohldlnll bill nol Ihnlled 10 h08plllll PI' mlldlol\l SIll'VhlllS C0l\1plllll1l8, InS\lrllnOll 0?1I1pllnlos, workors' oompllnsllllon ollfflers, Wlllflll'\) fllntl8,1I1\11!0I'lhl'l Rllsl(lllnl's emrloyor, . :. " , ' ,- ;"', " ,. Tho RIl~ldonl "Iso lI\l\horlZelll'1l11lllS0 of Informllllon from modlclIl or 01lllnollll reoords 10 lIny modlelll I1rofos- ", slonll\ PI' IIISlllllllolI rpspons!blo for Ihlll~osldelll'~ IIwdlolll or nmshlll Cnrl,\ whlll\lhp R081dol\I Is trnl\sfpffoq or dlschllrlllltl from Ihll FlIclllly, ' ' , , pHOTOGRAPHS ~ The Itosldllllt 1I11I'OC8 101l1\0\V Iho Fnoll\IY 1011holOBl'llph ~r vldcOllll11'1lhll Jl.osldllnl liS q,. I1\llllns of ldel\lIftclIllol\ or for hlll\lth rclllled plll'pnsOS, Thll phololll'llphs 01' vldpotllpes ,11\1I~ 1I1sQ be mpd IQ . help loonlo Ihq Reslde\llln Iho evel\t' of elll IlIlnUlhorlzctlllbsel\co frol\) Iho FlIlllllly, bill shlll\ olhol"Wlsll bo kepi confldel\lllIl, If the Fllclllly Inlonds 10 IISC Iho pholelQrnph or vldolllllpll for purposes olhpr 11Innlhoso I\Ollltll\boVll, Iho FlIolllly shllll 1101 11'1'1\\01\ Pllftl118s101\ from Ihe Re81dent In I\dYlIllllO of slloh IISO, The ,Roslde1l11'011\11I8 Iho.rlllhl 10 rofUse the IlIklngof II pholollrl\ph lit 1I11Y Ilmll, ' " ' " 'mE RERIDitN'f'S DU'fIES RULES AW2 REGULATIONS..- The Rcsldelllnlll'olls Ihl\\ Ihe FlIclllly mny, 10 ml\lnltllll orderly nnd coo. 1\0mlcIII opcrllllol1s, I\dopll'OIlSOlll\blol1lles IInd I'olllllntlol\s 10 ~oVcI'1\ 11Ill cPlldlllllllnd resp\lnslblllllos of Ihe Rllsldellt, 'rhe Resldclltlllll'OeS 10 follow Ihpso nllqs l\nd rellllll\llol\s 1I11d hcr~by lIokl\owledllos 111M hll or sho, " hilS becl111lvell 11 wrlllclI copy, of such I1lles IIl\d rellllllltlolls, It Is \I1\(lcr8100[\ IhM Ihll "llos IIl1d rcgulllllQlIs Il1I\Y bc 1II1"Clldod from tlmo 10 time 'IS the Fnclllty mllY requlro, AllY ohllllgc,slOlhc ",IllS lInd reglllnllo~~ r""..,,: .shnll bog VOI\ to Iho Rcsldollllll wrlthlll' ' ".. , I'v RBSIDEN'I' ORlliYL\N.CUS. - Resldcl1ls I\\'(i IIrllccllo brll1ll (IllY lll'lovnllcos ,0011001'1111111 ihO' FlIolI\ly I~ Ihe fl!~, nl\lllltloll of the Fncl,lltY Admllllslrl\Ior 01' de!lllll1eo, The I1l1clllty IIls~ offors n toll-frco IHoIIIIIO" Icllllpllone 1,',;' lIumber Ihrough which grlovl\lIcos CIII1 be rcglsterod dlrootly with Iho corpllrllto orooPs, This "umboI' Is,:; l.ll()O.S'72-\J981, Rcsldollts I\lso hnvo tho right to cOIIIIIC\ tho Sinlll'Pllolllty l\oell8111g "geIIOY, Ihlllang'lerm " ~~ cl\l'e ol'llhl1dsllll\lI, 01' hoth, 10 I'cglster grlovnnoes II1llilh81 the FlIcl\ltY" ' I,:.li . , '"" I f" ;.-l- 9, 'I /, I, '_.10...... ' ...110,; , (' " , r \ D.lU't, TIIP Hp&IIIVI1I ,"ldVl'hllllHlh Ihlll hl& or Iwl' IIIPII& IllPI*'.,IY prPhnlbulllIllIl, IIWl'cfnrp, 111\lhl,bp I11PI1I' Inl'P11 by Ihp FllvllIIY, Tlw I~Phhlpl\\ 1I~l[\)P~ 10 ~'l1nh\llIlI'!ih Nllrhl11U PI' PlpIIII'Y hlllff I'IlUl1nllnl! flHlll,pl' 'lpwr-: ""PH Ilrl1\luhllnlo 11111 Flwll!iy, ," , , ',. MEPICA'UClliS - N\lllWlllpilllol1h PI' \I/'Illlh Il1I1Y 1111 \l/'1ll1uhl \IPIIIl FIIPlllly prlll11lhllS 1I1llllhh Ihlll1l\llllplIllIlI\hi or ~nli!flllrllllll)plplllI\'Vpnllnllllllhp rPlll1ll'PIlWIllS PI' 1\llIlp 111111 f1pllprn! lillY, PIIPkllullli! or 11\\lIllPIIII\lIl~ III 11M · bll \lPll1pl\lIhlll w!ih Ihll FIIPlllly'h 1I1P1IlVIIIllll1l1lslrIl1\\\I\lI,l syslpl11, N\lltnlllh PI' I1lUlllplIlIlll1H I1lIlY Ill' Ill'olll!hll Il1t!lllw FIIP\IIIY IlnluhS Ih\lY lII'p tlpllwl'Plllo Ihlll11ll'SPR'sll1l1pn, " , I . ,. ' . " " ' CAllij OF ~'tY'S..eI~milrI:Y , Tn prPhPI'VP Ihu Vllhtllllf lhp FIIPlllly's proporty for I'll III I'll I'psltlplII8' IIfl\l,lhp ~PHltlpII11I!lrpPR In liSp chill CIII'P In 1I1'1*IIIIIIIH11\Ini! Ihll FIIPlIllr'n pl'npmy 111111 pl'pl1llsps, 'flll'i i I HpPllhlfll shl\lI 1l11I'Psponhlblp for I'Ppnll' or I'CpIIlCPIl1\l1l1 of lhp FIIPlllly's propal1y tlnl1lllSpl1 (11' dpsll'!lyod bY, i,. Ihp RpHlltpnl, Iioll'uwr, Ihl' RusldplIl shnllllol Ill' I'pspPllsll>l1l for sllPh dll11111SP lis Is 10 110\lXppCI\l(\ 1'1'\1111 prill. i I',~ I lI~~,w~,lIr~mlllll\r" ',I" If p~~U bF 'rHU ~~SIDEN'I"S IwoM - 'fhll Fllclllly PI1COIIl'l11lllS1ho RosllI\l111 10 hllVlllI hOnl\l-Ukepnvlrp,,"", ), lIwl1l.lInd wll\'II\!pnlpllP nCPOl11l1lPcllllP 1111 1'\l1l5011111>11' 1'\lIlIlIlSI8Io Il1dlvl(hll\ll~1l l'usld\ll1l roolllStllor 5[11'131)',1' ' i\~l reASPllS'I1htl Fllclllty II111M lIppl'Ol'U lIllY IIdllltlon or rellrrllnllllll1l'l\\ of fnmltnrll, hnl1ghlg of plclurps, ppslllrs, i ' or Plher ahnUllr 1I0llvlllos, 'I I.', , 'rIlANSl"ERS ,.\ND D1ScUAll.OES' ',,' . " '. ,. T1111 FncUlty 8hll1l glvu nOllce 10 Ih~ Rdslclenl, I\nd If knowl,l,lI rlllnu)' 1l111Il1~or 01' Loi!1I11~oprp511I\lllllve PI' Ihe I! Re~ldpnl, pC l!'llllsn:\, 01' dl8chlll'I!p liS follows I . ' ;' " i · Whlll'e Illgl\lIy rpqlllrotl, Ihls nOllop shllll ~P slvcn III lellSIIhlrty (30)dIlYs 111'101' 10 the ll.P81tlP1lt's"i i Irnnsfer or dlschllrll\l, ' ' , ,Ii . ;:,1', In Ollses whorp the slIfelY or hOl\llh of Ihp Rusldolll or olhertntllvldllllls In tho FnolJl1Y II\n)' bp cnclnll' " "i',llornd, 01' If olhur 10lllllrollsolls P1\181, nollcolllll)' bplllven liS sopn ns pl'IIctlclIblo bofore t1'llnsfcr or tllsohnrllo, : · The rOl\son(s) 1'01' tho II'lInsrol'/dl5chhrgp shIll! bepl'ovldcd I\tlhollmo of nollco of trnnsfcr/dl81lllllrgo. ,I ' ;-.. I I'. I, ", I. · Not!ce wllllnclllde Inforl11l\llon l'egnl'dlng tho rlShl to np(1allll\ Il'lInsforttllsclWllo, : ! I The Pl\cllity shllll on I)' 1t'lIllsfol' Ot' dlsclwge n Rosl;lclll IIndel'lhp followlnll conditions I ,- ", .. ~ I , · ,JIIOIl'nnsfol'/dlschlll'go Is nacllssOI')' for the Resldallt's "',elfllro nnd tho Rosldenlls nceds cRnnol.bc mot hi tho FlIcllltYI ' , ,'/' , , · The tl'1Il15fol'/dlschnl'gl) Is nppl'Opl'lllto bcclluse tho Rosldcnl's honllh hilS hnprovad 8nftlolclltly 80 tho ' Rosldellt 110 10l\gcl' neods tho sorvlecs pl'ovldcd by the FocllItYI, " ' , i , " ,,' 1'110 sofel>' of IndlvldulIls In tho Fnclllty Is ondnngcl'clh . . .. . · The hcnlth of Indlvldunls In tho J1nclllty lI'ould othol'lvlso ~e al1lhmgnradl ,,' II '.. 1,.' , " " '" , , .'t, 10 " ',. I' "". '\ 'r I' "", , ' " Tlw I~~hlll~n\ IIlIH fnllllll, lIf1cr rUI\H\lnl\hl~ I\\HI II\l\1\'\lprllll~ 1I0llc!!, In p"Y for (or Inll\"'\! p\l1I1 \1I\\I~r Mu\llcl'r~ or M\llllclIIIIlI\ hlll~ Iii ,\lu FIi\'I\I\~\ " ' , I Tlw jll\clll\~ IlllnHUH III npllrn\c, ' " nmmH~I'l'l' iHHlI'''I' ~JNlHq\ llltlllmt\" l.,Wv " ''filII FIIPl\\ly hlmll prolupl IIIHlpro1\w\1l IIIIl rl~hlsof pilch noalllllll\, 1II\lIl\\I\1\i! \In\lll of Iho fnllpwlll~ rl~hlsl 1 Tlw \~esllllllll hns n rllllll 10 II IlIllnlflell 1l~lsI\l1\t;O, solf.llelcrmlnnllon, 1l0mmllll\pnllplI willi 1111\1 OIll)\lsS Ip\ persol1s IIml mVlllCS \1\sldllll1\\1 p\\lslll\l Ilw Pllclllly, ~, 1'lw Rllslllelll \1118 0 rlllhl 10 u~crlllse hIs PI' hcr rlghl8 I\S II Reslllcnl of I\W !1I\IlIl\IY \lm11l8 1I1l\II~cl\ l:W res\llo\llpf Ihll Ullllud'SIIIIIlS, ' " " ~, Tile "dahlenl hilS IIIll rlllhl 10 bo frell PI' Inlllrfllr\l1\lle, QPerlllol1t IlIsorlmlnlltloll, or r\lpr181\1 from Ihll ' POIlI\lIY Inol\l'rcls\lIg hlft or 1I0r rl(lhls, ' ' .. , 4, The nesldcnl hilS Ihll rlghl Ip b\l f\IIly Infol11Wd, III IIll1nQ\\ogG he or 8he CIIII IlI\dorslolld, of hili PI' her 1011\1 hellllll slllllls,lnplmllng bill no\lIl11llod to, h\8 or her 11\\ldlclI\ 001\11\11011, .,' . 'f ;' ~, 'fhe ResilIent hl\s Ihc rluht 10 rllfl\Se tr~I\\I\ICIIIIl\1l\ 10 refllso to pllrtlllllllltlllll \I~perlmel1lnlresollrch, 6, The Resldenl hilS tho rlllht 10 e~erols\3 his or har lognl rluhl8, Inal\1lllng filllli! II grlovllncc wllh Ihll , SII\\O sllrVey I\nl\porllfillllllon ngunllY concemlng Resldenl 1\\1I\SO, neglllct, IInd mlsllpprpprlolloll of Reslllolll prppe\t~ III Ihe FocIlIIY,' ' 7, fl'hc Rosldonl hilS Iho right 10 monogo his or 11Orft1\l\1\cllllllfflllrs, 8. Thll Rllsldo1\t hl\s 1I rlllhl 10 chooSOIl1\ 1\\le'ldlnll physlclll1), 9, Tho Rosldenl \lI\S II rlght 10 bo fnlly Informod 11\,lIdVl\11pe nbOIl\ Cill'O lI11d trolll1\1011\ I\nd I\nyol1l\1\gos , III Ihntal\l'o PI' tral\llllcnt Ihl\t \l1I1Y IIffoot Iho Resldcnt's well-being, " ' ' 10, 'rho Resldont hilS 1\ rlghl to pnrllclpl\lo III plll11nlnll his or h~r Clll'O IInd trolllmo11t 01' chlll\Bos III 0111'1,' , IIl1d lI'elllnlO1\1 1IIIIoss lIdjl1dgcd Il1compO\C\1t or olhel'wl~O fOlll1d \0 bo ,ll1clIpncltl\tcd undor tholllWs of Ihe SllIlO, II, 'rho HC81dcIII hilS tho rlg\lllO pcrsolll\l prlvl1cy IIl\d conlldcntlnllty of his or,\ler pOl'SDlIlIl ~nd oUlllclI\ rccords, . ' \ 2, '\'I\OI~lls\dollt 01' Lognl Reprcscl\\lIllvo hilS Iho rlllhl, \lpOI1 omlor wrl\lolI I'eqllost, \0 IIccess 1I11 , rccords pclllllnhlg 10 hlmsclf or hlll'sclf. Inchllllng clll1lclIl rccords, wlthlll Iwenly-fo\\r holll's, MIaI' , rocelpl of.hls or hilI' I'ccord8,lhe Rcslllollt 01' Lcgll\ RCjlreSel1ll1t\Ve hl\s the right lO'pllrchnso (lit n cosl nL1110 excecd Iho comm\lllllY S\lll1dllrd) 11holocoP cs of Iho records or lI11Y portlol1s of ,lhol11, 111\011 roqllcstlll\d w,\lh IWO dllYs IIdVl\l\ce 1101lco 10 the Pllc\lIly, ", " " I, " \I "i 'l ' 1\ ii" I i ,I' ',I I,i" I II I i I: , .~ \J~\ l'i') I .I, I ") ) "',.., ('-", " It '1'1'0 HOHhlllnl 1\1I\~ 111'1'1 \1\'ll Ill' 1'1lf\ISll \hlll'ol~nsCllf pm\1'nnIIIlHI vllnk:IIII'1'\'ll1'\I~ 1011l1Y hllllvhllllll \1IIIHhhl \110 FII~'llIIY ll~l'llplll'll\In: n,Th~ l\uHIIllln\ IH Il'lInsflllWlllolll\Plhcl' hllllllll lllll'lllnsllllllhln, 11,HCf\ll:iI rlllllnSll h Ill'lllh'llll 11Y IlIw I,ll' nihil'll pll\W pnYl\wl\\ \!\11111'1WI, I IfI, Th\3 Hu&lllll1l\ hn& n rlghl In \'OllllllllloVIII1'llOH wllh rcspocl \\1 Irlllllllwnl 1,1\' flll'O Ihlll 1'1111& tll \10 fill" I nlshed, w IIholl\ dlscrlmlnllllllll or 1'0prlsI11 for \'olfllllllll'lo\'IIIWllS, ' 15, Thl' Hoslllcnl hll~ II I'llIhl III pl'Ul11plllrrnl'ls \l~ Iho FlloIIIIY In r\lsull'll gl'lovIIIW\ls, h\Cll1dlnlllhosl' willi respeol 10 Iho ll\lllllvlor of ollwl' Heshlonlh' ' 16, 'fhl' R\'slllllnl hns n r1i!hllo \1Xl1ll1ll\o Ihu rOhllltH uf Iho 1lI11s1 rOPlll\1 ~\II'VI1Y of IIII' Ffwlllly 0111\111101\l11 hy 1'\31101'1I1 01' ll11lle Hllrvuyors nl\d nllY plnn of (;01'1'0011011 III 01'1'\101 wllh r\1SpoCI 111 Il\\l rl\olllly, , ,17, Tho lloslll\1nl hilS II I'lg11l1!l rcpel\'o IlIfol'1l1l1llon frollllli!ollClllS lIolll\lllls VIl\1l1ll\dvllqll\\l$ IIml bll IIffoffloll Ihe oppot1\lt1l1y \0 \11111111CI Iho II1l0nc11lS, I~, Tho Resldcnl hl\s II rlllhl 111 \,\1fIIS\1 lu pcrfol'm Hel'l'lcos for Ihll FI\cllllY, r , II>, Th\3 Rllsl(lolllhns 1I rlllht 10 1I1lrce to porform vohmwy 01' pl\ld sorvloc& for Ihls PlIclllly If hI' or sho I doslres, If Ihero Is 1\0 l\1\ldlclIl \'Cllson which \\'011\[1 conll'lldlollho porfol1\\lnll of Iho 8orvlpos, I\nd If , oomponsnllon for (ll\ld sllrvloos Is nl or IIbo\'e pruvIIUln!ll'lllu8, , 20, Th,O ResilIent Illls Ih\l rlllhtlo prlvllcy 111 wrltlonoOmmllt1lcllllolls, IlIchldlllg Iho r1i!hl,to send IInd rucolvo Inllll promptly Ihl\l Is Ullopol\od; Tho Rosldolll hlls II rlllhl of I\CpeS8 10 slllllonor)'. p081alle, ' : IInd wrltlllll hllplomellls 1111110 RcsldclIl'S O\\'n oxpense, , " 21, l'ho Resldont hl\s Ihlll'IIlhllO Iml11odll\tlll\cCCSS 101111)' of Iho fol1owln~1 I'.,., I " II, AllY rcpresontll\lve of Ihll Socrow)' of Iho U,S, De\ll\rtmolll of HClllth IIl1d HUtlllln Sorvlllas, b, Any rcpl'escntallvo of Iho Stllle, . . c, Tho Rosldenl's IndlvldulIl physlcllln, d, The Slato's \ollll-Iornl carc omblldsllllln, 0, Tho agclley rospoll~lblo for Ihe protection of alld lIdl'OCIICY syslom for \1\cntally III or dcvel- . opnwlIlally dlslIblod tndlvldul\ls, 'I 1', Subjcct 10 Ihe l~esldotH's I'lllht to dallY 01' II'lthdrl\w cOllselllllt allY 1111I0, hnmcdlllte fllmlly '~ or olhor rolll\l\'cs of tho l~osldunl 01' olhcl's who IIro \'Isllhlg wilh Ihoconscnl of Iho:' ': l~csldclll, " " '. r 22, 'ma FlIclllty \1\Ust provide' nlllsllllllblll lIems 10 III1Y RosldclIl by 1111 cnllly 01' IndlVldlll\llhl\tJ1ro- j, I vlllos hCIII,Ih, SOCIIlI, IOIlIlI, or olhol' Hcr\'icus lolho Rcsldelll, subjccI 10 tho Rcsldont's lillhtl6 cllY I 0\- I, or wllhdrll\V COIIsClltlllllllY 11\110, 'Ij 23, The l~csldcllt hilS II rlshllo hllVo ;'cnSllllllblo IICCOHS lolho prlvalo uso,~f," Iclcphol;~' ,,(i\,)', 24. Tho RosldclIl hilS II rlghl tn rotnlll IInd IlSU pel's()nllll~osHCSsloIlSI IlIcllldlllg So\11O fUl1\llihlllllS IIl\d I, ' \,':,',: IIppropi'lllle clothlll!!, liS HpllCO pOrll1ltRl ",nloss In do 51? would IlIfrhlllo 011 Ihc rights or hCllllh ,lIl1d ., '\ "",,''- SllfCIY of olhcl' Resldcllts, I ' , , , ' ' , , . , r 'N( ,. if' ',' "" " 'u. 12 ", ",' FT'9 L.. ',",1..,\ :i', ;~~;i .~. II , , ,." '; , , I " ", r ," ," .. t"'"'''' ('" '! . J!\, TI,W IMI,II~IH hll~,' IIrl1l111 \ll hlllll~ IIrl1PI11 ",'IIh h,lh or IWI' RpOllh\l WIWl1l1l1llTllllll{llhhl'~IlIS II vi' III ,IHI hllll1ll J1l1clll'~ 11I111 \111111 hllll\lhC~ ~'llllhPIIIIIlII1\lIlITIIIIIlPI1WIlI, J(), 1~IIPh HPhhlll111 hll~ II rlllhl \II ~clf'lIdIl1II1ISlllr \II'IIU~ Ul1lps~ Ihp FII\lllllr l1l\vnllsplplll1l1l'Y Illli 1 hll~ I Ilollll'l\1i1WII I'll I' II PI1I'1IP\IIiIl' H\lRlllplIl Ihlll Ihl~ pl'IWllpll Is UIIHllfp, , n Thp I~PHI\11l1H hll~ II rlllhl In hll frail fl'nl11 IIllY phy~lpnl I'PHII'III1l\s Ill1pn~M' Ill' psychnllcllvo Ih'IIi!H nlhnll1lslpr\l,11 1'111' Ilw l1\11'pmcR Ill' dlHPlplll1u \11' PPI1I'IlI1IIlIWP, nnl' ,wlrp~lIll'pllln Irolllllw RIIShllll1l'fl! 1l101llPIII ~Yl\1plol\1s, . ~n, Thl'l~~HltleI11 hnfi Ihu I'Ii!hl10111l 1'1'011 1'1'\1111 vprbllh S01\ulIl, ph;Hlplll, 01' 1\1\l11111\ IIbuHIl, cOll1prll\ PUII-/ Ishll1\l1l\ nl1(III1\'Qhllllnr~ HIIPlusllll1, '. , ' ' , 1'+ , , " ' , II' 21>, 'fhl' R\lsldol\l hlls IIrlllhl 10 phllnS\l IIcllvltl1l8 slIhlldu\os nnd 11ll1lllh Ollr\l opnslSlllnl wllh his PI' Iwr" i 11l\III'OHIS, nSHusSI\111nls, IInd plllllS PI' CllrO, " J" '~O; Thll Rl'sldol1l hilS II rluhl III l'oeil I\'o 1I(II'l\nco nnllll,II, of II'IIIISf\31'8 or IlIsQhllri!os Qf Ill\! Rosldllnl liS I'\l'llllrcd h)' IIlW, 'fho RUHlllont hilS n rli!hl tp roculw nplloll 111lfore Ill\! R\lsldenl1s JPOI\\ or rpol11mnll! Is ohlin god, :,' 'i- , ,i- I ~ I, Tho ,1~\3Hldontlll\s II rlllhHP ol'lll\nlio 11111\ pm11Qlplllll \1.1 Rosident Bro\lps in Ihll rllllllll)', IInd Ih( ~': " Resldont's fmnll)' hlls Iho rlllhtlo 1\1001 With fllmlllus of olhur RllSldc.nls, .. I , " ", I,; .' ~2, Tho I~Qsldol1l hilS 1I rlgl)t 10 pnrllclpl\lo In SOCill11 rolllllous, ~nllllomm\lnlty notlvlllus lhllldo nJ [!.!) , lntcrforo with tho rights of othor Rflsldonl8, , " ,,' Ii:') " " , I ' ~~, 'fhe RQsldent hilS II rlllht 10 1'01l~onllbloIlCf101llITlodllllon of Indlvld\ll\l needs I\nd pl'llferenlles eXfll'V , whcl'o the henit\1 or 811foly of IhoRe~ldonl 01' othor RosldllntR WO\ll(\ bo ondllnlloroll" , " i. ~4" Tho Resldontlllls II rlghlto freodom of choloo of provldors In 1I000rdlllloo with lIppllfll\ble Inw III' , subJect 10 Ihe provldcr's cOll1plll\l1ce wllh 1\1I11pplllll\ble lllwa IIndrulISOnllblo mles lint! reg\lIn\lofi of tho Fllclllly, ! 1"0' " jI " , . I , " I. ,., II , /;,*', " " L !"(\ClI,!'!''' "UW:1\' IH~n(\ HIl'Nnl~II'I,!C~I":N"Wl'HlN <W IWI'lI~N'I'IHq,"\IlWI'I~H~IIN(\'I'I()N r\(J'l' Th~ fIlIlOlViI"lll,llll'nnl1l1llnIlIS,!lP,IIlIl/lnll'hlpli In Ilw g,cSlllllIII liS II l'usl/II nl'l\ j1PI!pnlllllll' II'hlllh I'IlIJIIII'PH I!pri ' 11110 hllllllh cllrll '"slIlllIhlIlS. i1Whlllllllll\ll'sll1l.l hnl11\ls. In IllsP!psp In 111\1 HIl~1111l111 his Ill' Iwl' I'lllhls 1I11lhlll FPII~1'I11 flllIl ~ll1lllll1w In IlIl\kllllpc'islolls /'Plll1nllllll his 01' hilI' IWllllh 1!111'1l, ' " I I ...,' This FnpllllY rll~OIlIlI1-1l8 Iho IlIllllllY IIml vllhl!1pf Ill\ph l~o~lllp'H'8I1flll1l1ll Ih~rlghl nr IlIl11h HllslllplIl 10 III II ko! ;~) "pplslplls rlllll1nllllll his PI' Iwl' Ill\ro, Whlll'PII HpshlPlllls IllllOI11j1PI\lI1I. Ihls FIIPIIlI~ rUllni!l1lm IIw Hpsllh'l111~ M' r~~~lIln hllvPlhps,p Ilpplslnl1s 11I111lp (Ill hlsthllr I1phlllf l1y II Nl1l1sll\lllo dll,lllslllll-l11l1klll' Illllc\loI'lIOll\lP \vilh ~lrlip Ii , . I" I .. . " . \"~~- 'nlls f1nllllllY rllcOllnlm Ilw rlllhl11f ollch HllSldol1lln 1\11I11-p,lhnsl1ll\lVllfWllliil'pcllvll8 rOPollllt1-oli Iflllllir ~Inll\" i f III,IV 111111 IV III hpl1pr mll'llIwolllrpPlll'os II0Vull,'j1PIIIII IlllPorlilllWo II'lIh Slnl,P, IIIIV 111111 cPl1slSlo.l11 wilh IhP, 10VI'l '( PI' I1nrlllhls 1'1101111>, Is IIppnsulllo provlllu, All 1Illl'lIl1cll.lllrllcll\'ll Is n wl'illon IIOP\llllPllllhnl 8Ullus clmlcps fp~' ) henlth cllrlllllHl/or I1I\IllPS son1\1I11\O 10 Illllko thosp cllPlccs, Thcsp eholpus I1II1Y 1110111110 IIIP rofll8nl of pol1nhr: i',1 IY\lPS of onro. A Llvlllll WlIIlIlld n PI\1'I1hl\l PolI'PI' of A I\nrncy 1'(11' Honllh Cill'O nre ulWllIplps of IIllvnnpp I dlruollvoR, . ,," , ' An I1(lvllnop Ilh'o,lI\'o IR nOI1\Il, CPR~lIr>, IlIllrdp,' 10 l,lP I1(hnlUcd to 01' ,to pOlllllln,olP resl"" In this rnplIh>', I,' Howovu,', If thll Relildpnl hnR IIn ndvnnOPIHrllollv,u, ho or shll mllsl I\1n~o, II kllPwn 1/:1 Ihll FIIPHhy' i~ AdmlnlRlllllol' or duslllllOO RO thlllll PIIIl bo rp\'leWud IIn11mndll n pnrt of hlR 01' hUI' 1\1cdlPIII I'llool'll, ' 'I. Qli(lsllolI~ Ilholll Iho Fnolllt>,'s polloi Os rUlllll'dlnll hOIl1th PIII'\l dllClslon-mllkllllll\nd/ol' IIdVllnolllitrec,ltvlls mll~1 I ~,;, bo prllsclIllld 10 thll Fl\olllly Adml1\lsll'lIlpr. QlloRllolIS 1'1l1l1l1'CtllI/J whother to OXOlllI\e IIn ndVIl1\ce (UreclIYll o? ' , . " I\bOlllllR 1l01\11l1I1 Rhollltl bu dlsclIssotl with lhp Roslllentl8 fllll1lly, physlolnll,l\ncl nttornllY, .. ,II i~ . . , I ' ' , , , I' I I 'Ii '/ I. I I , ,. i 'I I. I ,. I.-..i., , , " " "I< ,j 1 'i . I, 'LI , , ,; I" ' '! " , " I' "', ", ' l?m)fPlm'/~I~'lli:Cl(flC 'N(fOl~Mti1'fON I \}1lrlvlll\l 'l'hlK Jlnlll\llY IIPPllpls Ilw ro\lpwln~ Iypos PI' pnynwl,IIKI (c\1pt:k 1I\\lhIlIIlPpIY,) . ;,' !~l\lII\CI\1'Il t~M\',(l\pnhl -HYIl\llrllIlS ^'lmlnlsl1'll11\ln Thlllll1l1lll~ 10 Ihl~ Ai!rIl1l1\lpn\ 111'111 ~ e.. \-\W (Nnl1w of FIIP\llIY) , "~\1 rt~ "1 "'~U-...L (1'11111113 of Roslde\l\) , ~I ~ ; "~ I l'i\WI'U~~ (1'IlImo of Rllsl~enll~ Allonn c,.,t:'n l;) r\, G,.. \ \cLJ\...-\- . (N1\1\Ill of Rosl~pn\'S "l'lllll Rllpre~\3nlll\lV\3) I'" If II "ei!1I11~llpro~cnlllllvo 811lns, 9hcp~ Ihp 'l'ypll Ilf "Pll"1 RPllrOS\lIlIIlHv\l (\leloW)1 { 1 COIIsorvlllor of rpr8pII t 1 COII~ervll\or of Eslllle ' t 1 011\1\1'. 8pllPlfy t 1 OUllrdlll1l { 1 P\lfll~lo rowor PI' A\\Ofl\IlY for Hllllllh Cill'O (OrAliC) llAllllII\AIl\11I1l Under Ol'no\'1I1 rOA -" If YO\lnrll slgnltllllhls Agrll\lmenl on \lllhlllf of Ihl' Resl~llnt, note yom' rllllltlonshlp 10 It III ro~l~olll1 " "'BD'" ReMlon8hlp to.l~usldont 011 Ihls ~ dny of , CI. r'. \ I 19~, t\lIlI\~OV\l pllr\les n~reo thn\ 011 \\lll .J.!1.:!d>.. dllY of , A~" ,\ , 19~thlll oBldellt shl\U bOlldlillltotl to IIIls Fllolllly, As of IIIntdlly,thll Flwlllty ahllll pro' vldo ho scrvlccs dll80rlbed In tltls Agrocmcnt to Ihe R081donl \\1\1\1 Iho dlllll of thll Rosldont's r,\laohllrgll Qr Irnnsfor, Tho Rosldcnt shnll pny for thc Kervloos provldo~ \ly IhllPnol\lty nooordhlll \0 the t\llmS of this Admlssllm AllrcomOlll, " " . , ACICNOWLEDGEI\1EN'I'S By slllnln& lite Admission Agrcemont Slglllllme Pnge, Ihe Rosl~cl\t/AllenIlLol!l\1 Roprosollllltlve nokllowl. odges tltnt he or she hl\s been glvon nnd hns rCl\d this Mrcl,ltnl'tlt In \lK onllroty. IInd nllll\l~ol\~umsl Tho Rosldollt 1\\80 nQkllowlodges Ihnt tho fo\lowlnlllnfortnllllon WIIS Ilrovldod Upotl'Or bofore lidmlsslonby tho Fl\olllly. 111111111 tho \Inos bolow (If notllppllonblo, wrlto NIA)1 ' " '. . , ~ II" .,".ppll'" ,,,d "",.", Ih" ""' \.",.,." \11"" P"II\IY'. pt\,;,: d,lI, "I' ,; II";' will \I. .., pnld for by tho'Mcdlcllhl or Medlcn\'o proijrlll11S IIl1d 11,1181 of supplies nlld servh;os not 1l\\\luded hi Iho pncllllY'Bllrlvllle dnlly.tlltll 01' ptlld for by the MO'dlCI\ld, or MelllclltC pt,Ollrnms for W,hll1h'" lhe Rosldent wlI be Se\ll1rnloly ohnrllcd, " , '" ,,' 15 \'II,k _ Mcdlc~' Itccotdl 'talloW -Itealdent jll ,...~t!\ ,'. .', . r'"~-;~- ,(,'J, f...,.2, Il1forlHllllol1llbo\1\ Ilw FII~lIily'~ \lll\ll1\lhl pnl~~lIl11'll~, , ' (' 3, A wrlll~11 ~~phll1l111ol1 Ill' h\lW 1\llIpply for 1111\\ \1~1l Mc\lI~rll'lllll1l1 M\llll\lllhl b~l1cnl~ IIIHlhlllV III -:- V~ r~pplvp r~flll1Il~ 1'111' 11I'PvIO\I~ PIlYI1WI11~ \!()\WIlI\ ily Ilws\l il\l\wl\l~, ' ~ 4, A HIIII~1111l11l ~!\pII1I111I1U IIHlI, Ih~ 1~IlHlllol11111l1Y I1IIlII !!rlIlVIII1\l1l ,\vilh IIHll1ppr,llp, rllllll SliM A!!~lwy ,1I\lP\11 nISllloI1II1IIIIH~, IwUI\lIlI,III\Wor I11ISII~~tll1\ln PI' roslllul1l p~rsolHlI pr()plln~ 11'1 Ihll rll~III1~, , .. , , 5, Cllpl\l~ of 111\' SliM BIlHhl~t\\ 1~lghls, fi, A wrlll\ln P!\plOl1l1llpl1 PI' Ilw FIIPlllly'~ HllIIlS 111\11 Bo!!\I!l\\lpl1R, , , ,. 7,lfiyoll\' 1I011111110n WIIITlIl1la, YOll1\lllY Illl phlCllr~ III Ihl' fI\IlIIlIY's MO\IIPllrll-C\3rlll\~11 PlallnPI rll11 Unll, AI apl1111 pohll! plrlllllllHlllnpos I11I1Y OCQ\It' whlllh wllI,1I1l1korllalllllli! In IInplhor 111111 Inpro , IIpprpprllll1' for YPII, 1II,Ihlll PIIRO, \lIP, JllcIIIIY WI,II dlsQIIS8 s\IPh II In\l1&f\3~ wllh YPII, Undpr low. " ~oll oonnPlllolllschllrgol1 1'1'0111 Ihls fl\clllly IInlpss yoU lIurpp or 11IIIm"follpwhli! IIn IIPPIlIlI, Ills Ilplonnhwlllhlll YOII mllY bo 1l1vohllllllrll~ tllscIHII'i!\311 or Il'IlnHfmol\, " , /;11)2), A ,popy of Ihll fllclllly policy rogllrdlnll hnPlul1.I~~llon oflhp PlI\lOnl IMf Dotllr,mlnnllon Api , ' lllld oflho oppllcoblll Stolplllw, I do .~donol hllVo nn'lIdvlInCll dh'opllvll, l hllvP bllol) InfpI'I\l\ld, both omlly IIl1d III wrlthlll, In nll1nSlll\llo 111lI1IOrRllllld, of my rli!hl~ I\IIQ tho millS "lid rlllllllllllplIS Ilov\ll'lllns lilY cOl1lhlPllIlld rpsponal\Jlllllos dllrhli! ln~ sl"y IItlh\3 FlIclIlty, ,:, , I ,< I' NO'I'ICES , , " 'Nollces shllll bli I11l1l1cd 10 Iho 1I~ldrC66(cs) Indloolo" bulow, Tho Agllll\lltldt9r LPSlll ~eprpsllntIlIIV\3 Is responsible for nOllfyliii! Iho FlIclllty In wrltlllg ofmw chllnllO of IIdd~ess, " J' j, The Besldolll doslllnlllos Iho followlllll pcr801l(8) 10 bllllo\lnell'\vhellllllylolllllly roqnlred lIo\loos l\r~ provlej. , od 10 tho Resilient, Ai!CIII, 1Il1d/or Lllglll RopresclIllIllvll, .. " " ".'i' II " 'LEGALREPRI~SEN'1'ATIVE ANDtOR AGENT, ,. NlIl11e G. e.~~~c.tcl G'. \"'JV\~l' Homo I.'hollo !'lD'1,~ Id.l\ \? W~\'k I'hol1ll , 1'.." SCl "'1 Q..\) (N. 1\ ~..:-- City c...n.,~ ~ ,\'\'lli- Stlll~ ~_ Zl~; , \.s <:ilt , . .' II . " " "SI\'oCI , OTHER PEI1S.llli..IQJ},IlllDTlFIBD -~;~U~\\~.' ," ., , i , NlIll\o ~ ,::dsf\,9...'S. Home 1"\10110 IS? ~ <"S~L- Work,Pl~olle ", Slreot \.';d'i( E\,Sl1S'\~~_CltY~~L-_,S\I;IO 01:\,. ZIp 1'1011 "., .\., Whllo - 11118111055 Offlcd " 16' " I'll1k - Mcdlonlllccllrds, Vellow;' "ellden" . "H \ I t l{il WI;jHjij, H f a~, ;' ~ H d H ~ H f Ii II fmllllPJ ....,.'1 ~ j. \ .,,- '.0, .. ", ~\ '.....'1t .. '--' ,"', ,I31uo I{lll~o Ilnvon Convnlm~oon~ Con~(w ~ Woa~ 1f1u', " . .. ,..... f'! '. ''l'-, ~"l\l ~R, 1096 " 'Mr, GtlrRld (IlIhlll',," ~U rRlmor PrlvlI c'l\mp nnltM 17011 PilAr Mr, GllhllrH Ylm hlld Jll'llml~1l11 mlllhM rOil Wllllhl hllln 10 "'1l1l1 wllh IlIlllh'. IlIlIrnlnll \lllllllllrnlnlllhlllllUllhlll I\OIlIlIllU fill' rill'" mlllh"r's Il II I'll 111\11 Rpllln roll llhl nIlt IltleJl' '~ollr JlI'llmhll' " Slnlltl 1\11811.1 of 190~ rllllr 1lI0thol' rllllolvllllllh,IlO.1 ill ~J,UOOiOO of hlllomll whlllh II In 1I~Il\ls."f $ ,.OUO,UII Jllll' mllnlh, (llnlll rllellnlly WIl were ollly IIWllre IIf Ihll $ ~oo,OO Jlllrmlllllh III SOIlIIlI SllcllI'lIy Ihl\l ynll hllll toh! II. IIhlllll AI IImll of. IIllmlulon), Mill, .Ince 1\11111151 Ilf 19911, YQII hnVllJlnhll..1I 1IlIIII of $11500.90, . Uslno 11111 lI11IlVll Ilml\l"'lS, IlIllrll wII11Irproxlmlllllly $ 14,411(1,00 of.lnllomll thAI WM l\ll1r.llltl to I" for hor \lllrll, alnce YIlIII' molhlll' WIU nr\llh!llnlln Ihl. fl\ellll)' 1~lIrl"Q Ihlll t mil 111111 1\11 of her nllllds Wllre 111'IIIg mlllllllll ill 14,400,00 .hllllltl hnvll' ' helln lIVlIlIlIIIl1l to PIlY for hill' ellrlll ", ,. " , Slncer,oly, ...A, a'~'--":';~ IV ..c?'-' 7~ McGo\J, Admlllbtrlllol' I, '\1 ' , I tl THE NATION'S L!ME~ ", PS., Onleillhllllccollnlls pl'lIlln lilll by 7t6t96 01' I1lIle51 YOIl hnvII ",ndllll Illbstlllltllll pJlymenlof ill 6000,00 01' morll IIy Ihlll dlllll, I wllIllot\f)' the I\lIl1nclel who werll providing hor Income of Ihe fll\llthllllhll money Will IIollll11d for her ellre "III. '~t them Invlllllllllto the dllllJlllllllrnn\le oflhll nlOlley, , ' '~~'o~~~~.., ~ ~r.~~ A Ilatllmellt Is llllcloll1d. .........--~e\~)~:A( , ,'~~~.., ',: .. ','.-_lff,l~'1"~~'V-e',~".. f?,~~ ,I ~ ~(11 ..\"....0 , ~rJ.fI>~t IJ.!Ilnlll , 15 o<J.~<'? ' 1:1 Ill'Uflll ' ..-I,. 0~~~:' ~ ' .~~.. 1:1 OOD, ..~~..~~\ ,4-' ....00- ~)(~ ., \ ~ ~ :\1; I..... I ~ "'~ , ,'\ /lfIdf../.paldl PLAINTIFF'S ~ lU(HIBI'r .~ ,,_hi i ",'~,\ 'c"; '-' '; :'. o"~"';'~;;.\"" } " I'; ""'11'; ., '~,\' 1 ',f' 1 'I' ," '''\ ~"'C, I I I I \ '" H\,tlt..~1.J\11;l:i1~~NT STATgMgNT 1m 'J,~pn II~~.' ' " , ?':'H 1I\:~~ ,Q .:..A C'dlA.~ fM1'fiIY I!~~' , n I' ~--. ~\,;~'1<-.A", I t-\~~ STAT\:;M\:;NT TYF'~ t P INTt:RIM PISOH^AGe Q IT~MI;!I=P PAT~ I P~RIOP COV~R~P I P~~t1RIPTION S/~l'~is' '~"^. ,;-:\...!... ~ "~:~t':~5~ ':~'. :~::: --- , 'B, I;l.r<~/", I~~ I" : . . .....-r" H ^'" T. ' ~I! ~S .'"17~ ',,~ :)..~. .^~ t\ ~ """,," . ..!,...,.. . 151 ~~~.&ll')f: >- ~ !. ....'T CI ~,N\1'. !.., "II~\I lre::.\ 111lo. 9f: ,J A .',. ",,", r R _A. J..__ \\IO'~:-'; , ;:{",,,,:. .nA. ~ ~^~. /J;I, ~. 1{lJIA lC\", i)...:., ,,"''' l\ l_~ ' 'h~ 1I~.' lI..\ II. l),,'... n '"''' --+., j &7iFl'ift.cl '^Cl ~LD ~..:. ,.."" "C -=",", ~ ~-;sq I ft Q "" ~ '. I . ~X . ^"'" 'is.. " ","" . '!!}, ~i.D.~J.~1\9(. '..'. .,,,,,'T n U ,,-T. I ~/sl(. (11 " ""It. ' . /I ~. -- ~,,~, ,"1.ilI~'b,Lo " ""ro',. /1;;- ,~- ~""~t '1 \C)/.1t.4i&e:..9!.L ..J^:......Tro I..)^"~~.!.. s IQi.ll.S,311Q/. ;>}"......,"\",,, ~,.."h~ ~~ '" ro,,^:.n~"":' \....~. ~~qlql. \-I..'~ . . ~ ,,\=r ~ t".',~ . , f\IJI"'HT tP, ' QI n'i \ '/lCi~TV tf'l, .. DI\~ , l"IT~ r~'~ '~.,Q~lql.D' PAV~ Pt1ARQI!Q PRl!lJl I 9,'1S: \p.,/ ft ~~ ~f"\ s.'OA j\ ~ "~,, I'" .""7 . .~f"\ I_I^' &:i'7 .~ \ 1\ \ \1.. T 1 ' ~ ...l6\f1l."" I' '], :.5^~\ - , 3;-1\ ^' a. ...,,; sz.\ c:R,.....IlI,.lo..!:; ,,' ~ ..; ^ULU"~ . '\.~~ ~~\ 1\ 1\1..11.1 LRt:: " . , !~ ^....... ~ ~-^uLlI..~ '.bl ., ^t.I~II_C" " , .. ,1\, C:\ \'-:-"UU....... " , " " ; PLAINTIFF'S .., ~ aXr'T " . " . , t, !!. ',. J)AI.ANO~ fORWARP " C. (:)C) OHMQ~1l 'd\ I '6 lo1 " &5 Onl!DIT9 c;!t',59D,"O' 'AMOUWN)U 1~;i'1lo, II IOlIlltell 'I' ~ ~ ' "" t'ti'i'<~ , In 'I'h" Court 01' Common l'l,;!w or"'''''''1 Cl\1I1\)C I'll, nd C:oullj;y Pc::nnl3ylv11 nin 01Vi~ potion ~~W "B0\,til'ly IItlfllth l')OI'V:looS '!i~6t f,;(ltJru IIf;ull'.h And ' , n.J)lll\Jiliti.ltion f;1J1'Vioull Gornld ~, Oilbe::rt bCJ 'f'I\lme l' !;I'j, V\1 co-mp Hill pa, ;2, ~ ,I, If, b, 6, 7, 8, 9, 10, 11. 12, 13. 1h. 15. 16. "17. Hi, , 1<;1. '\ gO. 21 . .' 22. ~). 24. :< 5. ~6. 27. 28. "9 .. . 30 :; 1 . 32. COr'1'\Jot Coi'l'eot 001'I'e ot Corpaot CQ:t;l'80t FAles I Mra Rotlge'l"B Wttp I)dmi ttod J.n o1'dol' to get hol' And WAlking ~t"te. Falss thif wua to bo pUJ.d fol' by MadioDl'o. C Pl'\'O 0 t COl'reot COl'reot false thi s was to ,ba I](.(id out I did sond this letttil'beonuse applied fOl'pounty assistanoe balanoe I ' ~~uppof3:lQely so, " False. Not shure of the oorreot bnlAnoes 1"u11)e not shure of' the 001'1'ect Halnnoes Th:l:f3 PU1'f.lg1'llphsdoS not roqui1'o, D. fltlltemEHlt COl'1'Elot COl'rbot Bnd We d:ld so Not 'j'rue ' I'al'ugraph requireI' no i'tfltement Supposingly so Not true Nottruo Vie did f'O!lWLll'd Ghu ol,s OOrl'eot ' False figul'es ore inoorreot NO WAY. " Suppos:lngly so " FalsB Be~YioeBWere to be paid by InBul'onoe oal'rier~ initi.ly nnd then Inter by County Asuistnnoe ond her pension oeeoke. NO . No Inp1.yec\' Oont,l'aat Thif' if, ft\lfHl v;, , I I I I II I I, I , I .' NQ, ~ .... 98....39li ,,'~Ntm . f1/r6W ('./,.. 1, C01'l'oot .' ( I: ~. ' .,11" I.UI, I ! ~. ~ i ,;/<, " . baok" to:'E1 ",', (' , t'. o t I i..,.'1 ."'t . ,... ';:.1 ',.1 q\ 1,:1,1 ilt .t.. o ;:j ;..j 1....1 , -./J /") II 'I' \ 'q " ...\1\ "'I' . "(') I_r. MPR~le l:,Il"ll ,I , I ~ ,- ~ I '! ,,"-, of C'l'Y EW1'vioea pever1.y Mepsed up SB bud when thoy that there V/a13 u tl'em\!lndus outadund:lng " " .' ,/, ;1 .' ~ L!t:~1~1-1I~hQ~J.lt-/~~h({I:')/4~;~,ff'\ a~/~y1!d JM1) IJ;Jj C:'fuQ. !/liJlff--. ~~~~0iiYr-;" 0hl~;;::__ ' Va, - (\).)y\Q ((1/ ~, -6:[~,Jir.~___ ~-- _._~...._..-.~----._-......;------_._-.- '" IIIP I.'lllll'l Ill' CJIlIl1I1Il1I1 fl'PII,~ IIr 1.'1""hl'I'''"lff 1.'1l1l1l1)', flVIIl1Hl'h'lIl1ll1 , ')8 '0-;>9 SC: 9f,' Np, ._...-:...,~-.2._1:..,_,~,_,_ Civil, '!I -.:., \ ~-. --._._-'~--_..~.._--........._~---_....-._.~- ~) ~(,"'-'t9d;i:;M~I~=~-~~=:=:_=:=::::::'=== '- -------,--,...., ---"'- -_c~____~,__, .. , · 't/f.:[i1~O>;;;;,li''J!r c0:1~; -::7:~~f!Y{':1'r;;;~2-~':1L --d ,~-----l'i"..i--~~0"__:l' --l1::1,~-.~_-..L , '...-.....'-..---"--- '--"----'-"----,..,_.._----,------ ------- ------....--..-'_c.._...._...___..__._.."__...".."___...._....__ --,. ------'-'-------'-----'--,.._--,.._._----,..,...._---,-- 'fu _ ----'--'-----_.._-_...._---_.._~--._-- ' -0._----.--- I'nllhllllPI11f)' -----.-. . I!I '.....______ --... ...-,., .,~~ ---;;~~?,;' -~2-0l:...4'~~:::~_ __ ~~(/. ( 1\11(11110)' Ihr '.'111111/1/'1' u1fFr7:tLI!(" ,-11J:"t!'Ll~K I"~ \', .: 'f .,t, '" ,/,' ': ...' ' \, }t '. d~f~"""", , II" , pr '''' , \;~ ,"', " '..~ , , '.' .. " , }tivf- , I ! I I , . \',' " I. ,. jl ile " " 'Ii H .''', \;\\ cnO\1\.\Cr:. . OF II'r n,(),'r\(li\OfNW ~~ .1\lN ,,\ . \)\\ :II fl \ G\Jlv\gf. .I)\.J.\~IP .G~)\JH\Y raN ~!WW~N\A ". ., /' ,," ,. !/I 'I. ,. ii" " :;,' ./' I' I Ji if Ii " .' j, !' I. h '1, I' ,. " " I' ji H ,/ j; 'j , I. " " I I " ,. " "I" -,,' IF' '\ .. !3(::V(::R~ y H\:A~ TI-\ ANP R(::HA(3I~ITATION !3\:RVIO(::S, INO, P/13/A W\:8T sHaRi: , '" I~(::A~TI~ AND R\:I.IAI3I~ITATION O(::NTpR, r~AINTIFF V, G(::RA~P(:!,GI~l3gRT . pgFgNPANT : IN THr: oPURT OF OOMMON r~\:Aa OF : OUM\3r:R~ANP QOUNTY, P\:NNIWI.VANIA " , 'JUN 0 31990 . ,. , , : 9B,(3fJpO olVIl. Tl3RM . ID1EQBE.MY.lJiY-~NP H!;jB6, .1. p~oeRQF- COURT AND NOW, Ihls 1'1 of ~~me, 1999,II1e mollol1 of plfllnllff for al~ldgmenl upon admll.lslon,pursuanl 10 Pa, R~lle of Olvll Prooedure 1037(0), 18 GRANTep, Juclgmenl Is " enlereo In favor of plaln\lff'l3everly Heflllh a~o Rehl'\\Jllltfltlon Servloes, Ino, o/\J/I'\ Weal' Shore Health and Reha\Jllltatlon cenler ano agalnsl defendant Gerl'\ld 1;, GII\Jerl ItilhEl I'\mount of $9,976.46 pl~ls pre')~ldgment Interest In the amount of six perqent from .June 27,1996, ;i Ii " f. Samuel 8, Fineman, Esq~ilre For Pll'\lntlff 'I. , \ " Geralo \:, Gilbert, Pro Be 60 Palmer Drive Ol'\mp Hili, I~A 17011 " . ,. :sal'\ ,. j,' " ", f. , ,. ., 0;, ,. ,. I' " ~~ ;(_. :J" ~ \\ ~ ~~ r:; .... " l " "" " , ,il I' , 'Sb 5D \~\ ,. , 81 ~ ~ ~ 'I., n ' Q ?\- ~ L~ \1 6'- I!. ~, ~~, ~U [;~ ~ ~ , I' F\ ,~ t~~' -S .,.. \ ~i) \ ......... ~ ~~ '~f) ~ {~ ......... c...:-; . \ I. i' 'I; \, ;lo (; n \C~ n C' \.( 'tt ,.1= ~'llr ;~ 'jJ r) JI ti: Ill/Ii '," I' '. i"~ P (ii.' , m ,.( ." t:~l I '"'' 'U!f~ ";0' .. ,J;!c:, n:; 1....\ ""C" 'F .... I :l~!~~:' - !:J II f;1 .~ -. !; " .... p' " " ,i " WRIT of JiXJ:PUTIPN aml/pr ATTAPHMI=NT NO, __2B"30liO OIVI~ 19,_ OIVI~ AOTION . ~AW QPMMPNWf:A\- TH OF Pf:NNsYI.VANIAl QPUNTY OF OUMIWRI.ANP) .. TP nlr; sHlml!'F PI' _.___~ruIMlmIH1MiL.., ,..., ..,._oOlJNTY: To sllllsfy Hw Qopl11nlllrosl lInQ ponls d\1O ,!l<:IYHEly. .lltlf]ltlLnmUlttl]g\)iJJ.tI~\::J~jll11,lIl-Yio~f.1! TIlO, I -. c:l.lJ~{I:LW~m,\:_~1l!~E~1.Jj~1~!:1:tl)..BmLEt:l](1\~11:l\:11 \:}Iln _ g~II]':.l:'r. ...._.,..,........ .....---~,--_-.-_-__ PI.AINTII'F(S) lroi" Sl_tlJ.~_l.~U'l.L91!J~.\:J.!:,!_.5-~J,llftJ!nt:r.pl? u ...~t:lnIP.J lJ.l..:L...J'.0.... ..1:.'1!.)..:~:~_!'n'_.__.._______~_. .._______.~_._._,.._.._._-.--..-~.---...-......-.---.-.-.___......_.._____..._n__..... ...__..______~ _ u__ __ ...... ..n_....~_~___ .....~.~.._.__. ._....._.__...__---'.M_____ _' _ .m,__" ,___,...,,_._ ....._.._....,...._...,...._.:_._____..___.._..__,___Pi:!'f:NPANT(S) '."-"''''.i;) ~~\l m~~lroP\!~IIOlllVy \lpan 1"0 prppolly 01 Iho (lolomJonl(s)III1Q \0 ooll~~:~~~~:~.~ny ~ nn .t111 pM~~on~l prur~rtyill u~~lIr tu ~t1ttf.1fy this judom~nt, ________~_.____.____......__.__._......._.....,...._.____...._u. ..M' .._.,...__.__.. .,...,.......-._...__.__________._.,_______~___ , ' . ~-~_.~.,...__~._.__--Hn.--~..........----..----._u....~._..--.--.----..~..........--...--~.----.--...---._-.-._---;---_..-----.------ ________....._______...._...__..__u......_....'......___.._.u." ......n__'_._.__.._._.._._...__.._...._...,....._.~______-_...--:"'._.__..~-~-- (?) :You l\IP ohio dlroolod 10 nllllol1 1110 proporlY of 1110 dOlo"(lnn\lo) l1ollovloQ Ilpol1ln'\IlO ponoooolol1, 01 ._.____.._.n..~___~__.____....._____._m.._...___._______-..........-- ._.._~-----_...__. ....-.... .....--_.-.-.-...__.._.__._--~-~-- _~.__......___., ....._._......_ __.._._.__~_._.n_. ... .... 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