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Home My WebLink About01-03570 "'. ".., ~~ ~-~";'';'ilfill: " IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff No.N-~S'1'6 C(U~C /0LY\f vs. CIVIL ACTION - LAW JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice is served, by entering a written appearance, personally of by attorney, and filing in waiting with the Court your defenses or objections to ,the claims set forth against you. You are warned that if you fail to do so, the case may proceed witholJt you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la corte. Si.used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene yjente (20) dias de plazo ai partir de la fecha de lademanda y la notifiation. Used debe presentar una aparlencia escrita 0 en persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra' de su persona. Sea avisado que si used no se defienda, la corte tomara medidas y psedido entrar, una 'orden contra used sin prevlo avlso 0 notificacion y por cualquler queja 0 allvlo que es pedido en la peticionde demanda. Used puede perder dinero 0 sus propiedades 0 otros derechos Importantes para used. , ',;"- LLEVE ESTA DEMANDAA UNABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VA Y A EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE ENCUENTRA ESCRITA ARAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL " Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 "" '"j,!:i , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 0/- 3.5'70 ~ -r.tAA<- vs. CIVIL ACTION - LAW JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant COMPLAINT . ~ AND NOW, this ~ day of ,) Ufl0 ,2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson & Associates, P .c., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care (hereinafter referred to as Plaintiff), is a i. health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1700 Market Street, Camp Hill, Cumberland County,~ennsylvania 1 7011 . 2. Defendant, Jeff EStep, (hereinafter referred to as "Defendant"), is an adult individual with a last knoWn address of 41 3 Creekwood Drive, Chesapeake, Virginia 23323. 3. Defendant, Jeff Estep, on behalf of the Estate of Margarita Estep, (hereinafter referred to as "Defendant"), is an adult individual with a last known address of 413 Creekwood Drive, Chesapeake, Virginia 23323. 1 , ! ~ "".'-;'\"~ 4. That Defendant is the husband of Margarita Estep, Decedent, (hereinafter referred to as "Decedent"), and Defendant also represented himself to be the Legal Representative and/or Responsible Party for Decedent. 5. That on or about December 28, 1998 through October 12, 1999, Decedent was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein, and collectively marked as Exhibit "A". 6. That on or about D'ecember 28, 1998, Defendant executed an Admission Agreement on behalf of Decedent, which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement dated December 28, 1998 is attached hereto, incorporated herein, and collectively marked as Exhibit "8" . 7. That by executing said Admission Agreement, Defendant did assume and accept responsibility for the debt to be incurred by the Decedent. 8. That the debt incurred by the Decedent was also incurred as part of the marital estate. 9. That 23 Pa.CS.A.'g41 02 provides that both spouses are liable for debts contracted for necessarIeS by either spouse, absent formal separation 2 - ....'" 3 .',,, ..,.. "-~: " ,-, "~~ ';""-'-'"-i 15. Plaintiff has retained the services of the law firm of Wolfson & Associates, P .c., in the collection of the amounts due from Defendant. 16. Pursuant to Paragraph 8 of the Fee Schedule, which is attached to the aforementioned Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay re'asonable attorney's fees and all court costs if the account is referred to an attorney-for collection. See Exhibit "8" previously identified and incorporated herein. 17. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson & Associates, P.c., in the collection of the amounts due and owing by Defendant incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount ofthirtypercent (30%) of the principal balance which is due and owing. 18. That the amoun(ofattorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Four Thousand Three Hundred Ninety and 99/100 Dollars ($4,390.99). 1 9. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 20. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 4 .1 " .',Jo"""""A WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendant, Jeff Estep, Individually and on Behalf of the Estate of Margarita Estep, in the amount of Fourteen Thousand Six Hundred Thirty-Six and 65/1 00 Dollars ($14,636.65), reasonable attorney's fees in the amount of Four Thousand Three Hundred Ninety and 99/100 Dollars ($4,390.99), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, . .l; ~~ Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 1.0. No. 20617 Attorney for Plaintiff ., , - ~ '. .~ ,;. '"''''i'i, HCR.ManorCare Statement MANORCARE CAMP HILL 583 1700 MARKET STREET CAMP HILL, PA 17011 (717) -737-8551 JEFFREY ESTEP FOR MARGARITA ESTEP 431 APPALOOSA TRAIL CHESAPEAKE, VA 23323 HMO PRIVATE ROOM 201 -A Please Return This Portion With Your Payment ______~~~~~~_~~R9~~!~~__________________~~~~~___~~~~8!J~__~~~~~/JJ__~~~~~(0)____ DATE OF. SERVICE SERVICE RENDERED CHARGES CREDITS 02/01/01 BALANCE FORWARD 14,636.65 > PAYMENT DUE BY THE 10TH 14,636.65 AMOUNT DUE ~. .~. 031291.1 RKSIDKNT 1BDGBR AS OF DATB OF FIRST ACTIYITY PAGB IAR561 RKSIDBNT RESIDKNT RBSIDIlNT G/L -- ACCOUNTS RECEIVABLIl -- NUMBER Tm NAMK DAn QTY ACCOUNT CBARGKS CRKDITS BALANCK 11206 BMO KSTEP, MARGARITA 12/2B198 ADM cm Rm, 0.'0 ROOM 2&1 - A LEYKL I 18/ll/99 DIS PRIV PORT, .... "BMO - MAR 08 BAL FIID -LM- -30- -60- -9'- -120+- 23814.00 23014.08 "KNDING BALANCE 23014.00 "BMO - APU8 BAL FWD - LM- -38- -68- -90- -128+- 23814.08 13814.08 "IlNDING BAWCIl 23014.00 "PRIYAU - MAY 01 RIlV RIl AND BOARD 08131199 14411858088 4482.80 RIlV PBARIl CBG .8131199 1441lB58808 63.51 REY PRARM CRG 8BI31199 14411050000 53.84 REV NUTR TO PVT 8B/31/99 14411858888 312.80 RIlV PT B GLUC TO PVT 8BI31199 14411858888 111.99 RKV WD TX'S TO PVT .B131199 14411858880 232.80 RIlY FOLKY CATR TO 81 09/38/99 14411050008 lUB RKY RM AND BOABD PVT 89/38/99 14411858888 4402.88 RIlV GLUC TO PYT 89/38/99 14411058808 43.18 R&V PRAHM TO PYT 09130199 14411050808 411.34 REY PRARIl TO PVT 09/30199 14411858000 19.34 REY COM WOUND TX 89138199 14411858880 1155.80 llBY WOUND TX TO PVT 89138199 14411850000 4B8.08 REY NUTRT TO PYT 89138199 14411858080 360.88 llBY CATR TRAY TO PVT 09138199 14411850888 lU8 RIlV GLUC TO PVr 18131199 14411050R1lV 34,96 llBV PRARM TO PYT 18131199 14411858888 111.89 RKV PBARIl TO PYT 18131199 14411850808 15.18 llBV lID IX'S TO PVT 10131199 14411858808 288.88 RKV NUTRI TO PYT 18131199 14411.5...8 156.8' HIlY CATR TRAY TO PVT 10131199 14411058810 20.00 RIlY RM AND BD TO PYT 18131199 14411.50888 1160.16 "ENDING BALANCIl 14636.65 "BMO - MAY 00 BAL FIID -LM- -30- -68- -90- -128+- 23814.0. 23814.08 INS CaNT RATK ADJ 81131199 519571891BB 31.14 INS CaNT RATE ADJ 04138199 519511091BB 52.00 INS CaNT RATE ADJ 05131199 519511891BB 52.08 INS CaNT Rm ADJ 86130199 51951lB9108 1930.00 INS CaNT RATK ADJ 81131199 5U571091BB 2091.00 HBY ANC WIOJF 08131199 51551509100 838.60 INS CaNT ADJ 88131199 51957189180 3689,88 RIlY RIl AND BOARD 08131199 14411858008 4402.88 RKY PBARR CBG 88131199 14411058808 63.51 BEY PBARM CBG 88131199 14411050008 53.84 RIlY NUTR TO PYT 08131199 1441lB5B0ee 372.00 RBY PT B GLUC TO PYT 08131199 14411858008 111.99 ,-,^, -<'--:>" "'-"-~--'.' - - -, ,f- -1 n nnn' f' nf""ll'" i,f'''''' <," ~~r'tarY~"'if~'fiitl" - '-<-" . fl'- i3/Z9101 RISIDINT LEDGIR AS OF DATE OF FIRST ACTIVITY PAGE (AR56) RESIDBNT RESIDENT RESIDBNT G/L -- ACCOUNTS RECEIVABLE -- NUKBRR Tm NAME DAn QTY ACCOUNT CHARGES CREDITS BALANCE 11m HKO Esm, MARGARUA 12/28/98 ADM CNTR RATE, 0.90 ROOM m -A LRViL 1 18113/99 DIS PRIV PORT, 0.00 "SMO - MAY 88 ICONTI REV WD TX'S TO PVT 88/J1/99 14411858880 Z3Z." RIV FOLEY CATS TO 81 69130199 14411mm 16.08 REV ANC W/OFF 89/38199 57557589188 Z558.Z3 INS CONT ADJ 89/38199 51957U9188 34Z8.18 REV' RM AND BOARD PVT 89/38/99 14411858880 448Z. .. RRV GLUC TO PVT 89/3i/99 1441185m8 43.78 REV PSARM TO PVT 89/38/99 14411mm 411.34 REV PHARH TO PVT 89/38/99 14411858818 7U4 REV WOUND TX TO PVT 89/38199 14411mm 480.98 RRV COMP WD rx 89/38199 14411858m 1155.i8 REV NUTHT TO PVT 89/38/99 14411 818m 366.08 REV'CATS TRAY TO PVT 89/38/99 1441185m8 10.08 REV GLUC TO PVT 18/J1/99 14411mm 34.96 RIV PHARM TO PVT 18/31/99 14411mm 117.89 RIV PSARII TO PVT 18/31/99 1441105m0 15.18 HEV WD TX'S TO PVT 18/31/99 1441185im Z8U8 REV NUTRI TO PVT 10/31/99 14411058880 156.80 REV CATH TRAY TO PVT 18/31/99 14411858m Z0.08 REV ANC HIOFF 10131199 51557509180 692.57 INS CONT ADJ 10/J1/99 51 957U9l8i lJ71.24 REV RM AND BD TO PVT 18/31/99 1441185m8 1768.76 RIV ANC W/OFF 18/31/99 57557589180 ' 66.Z6 "ENDING BALANCE 17.51 "PRIVAn - JUNe0 BAL FWD -LM- -38- -68- -98- -IZ0+- 17U8 14468.65 14636.65 "ENDING BALANCE 14636.65 "HMO - JUNe8 BAL FWD -LM- -38- -68- -90- -lZ8+- 176.08- 193.51 17.51 "ENDING BALANCE 17 .51 " PRIVAn - JULt8 BAL FWD - LM- -30- -68- -98- -lZ8+- 176." 14468,65 14636.65 "ENDING BALANCE 14636.65 "HMO - JUL 00 BAL FWD -LX- -38- -68- -98- -lZ0+- 17U8- 193.51 17.51 "ENDING BALANCE 17.51 "PRImE - AUG 00 BAL FWD - LM- -38- -68- -98- -IZ8+- 17U8 14468,65 14636.65 "ENDING BALANCE 14636.65 " HMO - AUG .. BAL FWD -LM- -38- -60- -98- -lZ8+- 17U8- 193.51 17.51 Pj ~ "~.., ',_"' ""iUi(,lfitlir '.-.~,.,~.-~.-.-~,,-,-,,y-' -'trC'~"- -~ 03/29/01 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE 3 IAR561 RESIDENT RESIDENT RESIDENT GIL -- ACCOUNTS RECEIVABLE -- NUMBER Tm NAME DATE QTY ACCOUNT CHARGES CREDITS BALANCE 11206 allO ESTEP, M~aGARITA 12128198 ADM CNTR R~TIl: 0.00 ROOM 201 -A LEVEL 1 10/13/99 DIS PRI V PORT: 0.00 "HMO . AUG 00 ICONTI "ENDING BAL~NCE 11.51 "PRImE - SEP 00 BAL FWD . LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "HMO - SEP 00 BAL FWD - LM- -3i- -60- -90. -120+- 17.51 17.51 "ENDING BALANCE 17.51 " PRIVATE - OCT 00 BAL FWD - LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "HMO . OCT 00 BAL FWD -LM- -30- -60- -90- -120+- 11.51 11.51 "ENDING BALANCE 11.51 "PRIVATE . NOVi0 B~L ~WD - LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "HMO . NOVi0 m FWD -LM- -30- -60- -90- -120+- 11.51 17.51 "ENDING BALANCE 17.51 "PRIVATE . DEC 00 BAL FWD -LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "HMO . DEC 00 BAL FWD -LM- -30- -60- -90- -120+- 11.51 17.51 CIA INS 89/15/99 51551509180 11.51 "ENDING BALANCE .00 "PRIVATE - JAN 01 BAL ~ND - LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 " PRIVATE - FEB 01 BAL FWD - LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.1i6 I" - - ~ ,'." "', , -i'd-': EXHIBIT "B" ~ 'L~~_~Jii:_ , ~ ... ADMISSIQNAGREEMENT .. .'. . ..... . ManorOire CONTRACTBETWEEN;pAtIENT!RESfQENr<AND 'FACILITY'. Health Services THIS~DMISSION AGREEMENT (the "Agreement") is entered into this L~b day of ~~ 19 "\ ~ , between \'f\~.,).r Cc:..-<-- l~J4h ~"""~he "Facility"), and \'i\o.~c... S'tt..p (the "Patient/Resident"), and/or ,_I.:.. ~"'-- L 7 ST~'f (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also ~ean the Responsible Party, if any. The parties agree as follows: I 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (6) the Facility ceases to operate. However, the Patient/Resident may be transferred or diSCharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's discharge. 3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records or information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. MHC.OOS-20 (Rev. 7/96) pg 3 1 of 3 " ''''''''''''':1'"''''''''-'~''''"''''''~'~''~'''''''''''''''''''''''''''''''-'''''''''_':'~;!'l'jJJ~\\lIMJ!.~~II!!!ll~'L_liI"""'" 6. Consent to Treatment. Patient/Resident acknowledges that he/she is under the medicallreat_ . r,nent . and care of an attending physician, and consents to the Facility rendering nursing care. therapeutic, and other treatment under the general or special instructions of said physician or ir ( case of emergency. 7. Attending Physician. The Patient/Resident is solely responsible for selection of a licensee attending physician. The Patient/Resident agrees that the Facility may require the Patient/Resident to utilize another physician if the attending physician (1) has his/her own professional license limited suspended or revoked; (2) fails to follow the Facility's rules and regulations; or (3) is unavailable ir case of emergency. The Patient/Resident is responsible for all charges for physician services. 8. Pharmacy. The Patient/Resident shall execute the Pharmacy Agreement attached as Exhibit C 9. Independent Contractors. The Patient/Resident acknowledges and agrees that all physicians dentists and barbers/beauticians, including those whose services are arranged by the Facility, are independent contractors and are not employees or agents of the Facility, and the Facility shall no: be responsible for their acts or omissions or for the consequences of following physician or dentis: orders. 10. Private Duty Personnel. The Patient/Resident acknowledges that all private duty personnel tha' the Patient/Resident utilizes are not employees or agents of the Facility and that the Facility is no: liable for acts or omissions by such personnel. Employees of the Facility may not be employed a" private duty personnel at the Facility. All private duty personnel shall comply with all policies ane procedures of the Facility as may be amended from time to time without notice. Failure to do sc may result in their being denied access to the Facility. Patient/Resident and Responsibie Party sha be solely responsible for the cost of private duty personnel. 11. Facility Guidelines for "No Heroics" Requests. Decisions regarding life support should be con. sidered by each Patient/Resident or his/her authorized surrogate decision-maker. The Peilent! Resident acknowledges receipt of rights under state law to make decisions about medical care, in- cluding rights to accept or refuse care and rights to make an advance decision abcut care. ThE Patient/ Resident acknowledges receipt of a summary of the "Facility Guidelines fer No Heroic:: Requests" (the "Guidelines"). A full text of the Guidelines will be provided upon request. In part, thE CS-~ Guidelines provide that the Facility will not withhold or withdraw life-sustaining or life-prolongin~ measures from a Patient/Resident without a written and legally sufficient authorization of a competen: Patient/ Resident or legally authorized surrogate decision-maker and a physician order. The Patient/ Resident agrees to comply with the Guidelines. 12. Liability and Indemnification. The Patient/Resident understands that the Facility is liable ani:. for injuries caused by the negligent acts or omissions of the Facility and as required by law. ThE Patient/Resident shall indemnify and hold the Facility harmless from any and all claims, suits anc actions made against the Facility by any Gerson resultinq from any damage or injury caused by thE Patient/Resident to any person ~r the property of any person or entity (including the Facility). 13. Patient/Resident's Handbook. The Patient/Resident acknowledges receipt of the Facility'~ Resident's Handbook and agrees to comply with such Rules and Regulations contained therein. ThE \ Patient/Resident acknowledges and agrees that he/she shall be responsible for and shall hold thE Facility harmless for any injuries or damages which are caused by the Patient/Resident's failure te comply with such rules and regulations. The policies, procedures, rules and regulations regardin~ the following areas, among others, are detailed in the Resident's Handbook: "MC_ooa.20 tRev.4./961 00 4 2 of 3 ;~ '.~' 'J -_ " "'I - "-" -.:."'~!~ . Federal Resident Rights .: Resident Responsibilities .. . Life Sustaining Treatment Policy . Medical/Nursing Education . Dental, Vision and Hearing Services . Interdisciplinary Care Conference . Utilization Review Meetings (if applicable) . Personal Laundry Policy . Barber/Beauty Services . Mail Policy . Voting Materials . Photo/Media Events · Personal Fund Account Procedure . Tobacco Policy . Grievance Procedures . State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE Sl:ATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15, Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day and year above written. r: ~ss:\) , FacWty Representative - Signature Res n bl a - Sl nature , ~'LR--L.&1-.~r. sx..~ <~^"\v-= :SEfFeG-V L , aht2 Facility Representative - Printed Name & Tltie Responsible Party ,L Printed Name it-LI-'l1 IOL-c3-!r-9r Date 'Date MHC-008-20 (Rev. 4/96) pg 5 3013 -- ~ '< 1,.~I~~.-,-, ~ - ,~. _ "" ~.~, \ , ' (EXHIBIT A ,- RESPONSIBLE PARTY APPOINTMENT) The Patient/Resident's Responsible Party may be any person legally responsible for the Patient/ Resident. A competent Patient/Resident shall not be required to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. o The undersigned has been legally appointed guardian, conservator and/or holder of a power of attorney to act on the behalf of the Patient/Resident and shall serve as Responsible Party for the Patient/Resident. The undersigned has delivered to the Facility copies of the legal documents designating him/her as the guardian, conservator and/or holder of a power of attorney of the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned, individually and personally, hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined), o The Patient/Resident does not have a legally appointed representative and wishes to give the responsibility to someone else. I hereby appoint as my representative (the "Responsible Party") and hereby authorize him/her to handle my finances, pay my expenses, receive my personal funds and,if I am unable, to execute the Admission Agreement on my behalf. Any signature of Patient/Resident or Responsible Party on the Admission Agreement and/or this or any other exhibit or document attached thereto or referenced therein shall be considered binding on both the Patient/Resident and the Responsible Party. The undersigned hereby agrees to the Conditions (as herein after set forth and defined), Facility Representative - Signature Patient/Resident - Signature Facility Representative - Printed Name & Title Patient/Resident - Printed Name Date Date o The Patient/Resident is competent and does not have a court-appointed guardian, conser- vator or power of attorney and has not appointed a Responsible Party, but alone shall execute the Agreement. In consideration of his/her admission to the Facility, the undersigned hereby agrees, warrants and represents to the Conditions (as herein after set forth and defined). ~ The Patient/Resident is mentally or physically incapable of executing this Agreement, handling his/her own affairs or appointing a Responsible Party and does not have a guardian, conser- vator or durable power of attorney. The Patient/Resident's physician will certify in writing that the Patient/Resident is incapable of executing the Agreement and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on behalf of the Patient/Resident, to act and serve as Responsible Party for the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned individually hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined). MHC.008.20 (Rev. 4/96) pg 6 1 of 2 "' ~ ~jJ .",d-.,'''' """-->""__!iWll!l!i41- , , Conditions (collectively referred to as "Conditions") .. 1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated - , 199 ~ , and which is attached hereto and made part of this Exhibit and of the Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the PatientlResident for the Patient/Resident's care while at the facility. 4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the Patient/Resident's assets and/or assets which are available for the Pat- ient/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. 5, When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. 6, If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives. 7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges not covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above warranties and representations are not true, or if the above covenants and agreements are not complied with, the Facility will have detrimentally relied upon them and the Facility will suffer financial h8'm~_ .~~ . ~ ~ ' " is) i_Y: " - Res on_ ~ _ :~ Ignatur y . -n-26 l. tSS Responsible Part Printed Name Id-- ~S'-q,r Dale MHc.ooa.20 (Rev. 4/96) pg 7 2 of 2 ~- , I " =, _. -~......l.i,L . < ~~,! . (EXHIBIT B.- FEE$CHEDULE ) 1. Daily Rate. The daily rate is $ 6~ o~ . The monthly rate equals the daily rate multiplied by the number of days in the month. The daily rate is billed one month in advance and includes: · Routine Nursing Care · Linens . Social Services · Meals (additional fees may apply) · Activities . Housekeeping · Room (circle one): Private Semi-Private Triple The following are paid by Medicare in addition to the items included inthe daily rate: · Approved Rehabilitative/Therapy Services . Approved Medications · Approved Nursing Supplies . Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): · Approved Rehabilitative/Therapy Services · Approved Nursing Supplies · Approved Routine Personal Hygiene Items/Services · Other approved services/items covered and paid for under the state Medicaid program. · Approved Medications · Approved Equipment 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ~M ~E · Private Room Based on location & level of care · Prescription & Non-Prescription Drugs As determined by pharmacy · Nursing & Personal Care Supplies See business office for current prices · Transportation As determined by transport company · Nursing Care (Other than ordinary nursing care) See attached fee list · Physical, Occupational & Speech Therapies See attached fee list · Phone, Cable TV, Newspaper, Barber/Beauty See attached fee list · Special Equipment See attached fee list · Bed Hold Fees See attached fee list · Personal Laundry (Personal Clothing) See attached fee list · Nutritional Supplements See attached fee list · Alternative Nutrition (Tube Feeding, TPN, etc.) See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever a Patient/Resident leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law. 4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies which may be needed by and provided to the Patient/Resident, all additional costs/charges may not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in level of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the Facility no later than the day before the rate increase is effective. MHC_Q08_20 (Rev. 4(96) pg 8 1 of 2 - __I'I ._~ ""-!lOlllli 1lI61il!j~~",,'-.JI~._- 6. Refunds. Refunds shall be paid within thirty (30) days after discharge or transfer. 7. Funding Sources. The Facility makes no assurances that the Patient/Resident's care will be covered by any third party payor. 8. Payment Policy. All amounts due shall be paid promptly within ten (10) days of billing. Failure to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in full shall be subject to a one and one-half percent (1'12%) service charge on the past due balance each month until the balance due is paid in full. This amounts to eighteen percent (18%) annually on the unpaid balance. If the maximum annual service charge allowed by state law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall apply. Should the Patient/Resident's account be turned over for collection to an attorney or collection agency, or should the Facility seek to interpret or enforce any other provision of the Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees of the Facility if the Facility prevails. 9. Responsibilities. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services/supplies not paid by any third party, as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/ Resident is transferred to a different room or the level of care or payor status changes. The Patient/ Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility is released from all liability for harm which may result. Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident. enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for all charges. The Patient/ Resident is responsible for payment for items covered by Medicare supple- mental insurance and for applying for reimbursement from his/her insurer. Medicaid Beneficiaries: (circle correct number) 1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the Facility with at least four (4) months prior written notice of the Patient/Resident's becoming eligible for the Medicaid coverage or their being unable to pay privately; ;, OR (( 2)''''rhe Facilitv currentlv participates in the Medicaid program. If the Patient/Resident believes ''''/ ",he qualifies for Medicai;d,;;he/she shall promptly complete and submit all documents required to apply for coverage, including pre-admission approval. If Medicaid coverage is denied, the Patient/ Resident will be liable for all charges from the admission date. When Medicaid pays for only a portion of the incurred charges, the Patient/Resident shall be responsible for paying his/her portion, as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay- ment of Facility's current charges for any requested non-Medicaid covered services/supplies. The Patient/Resident will provide financial information regarding monthly credits, increases/decreases in the Patient/Resident's bank ad'90unt(S), and other assets to the Facility for provision to Medicaid representatives. MHC-008-20 (Rev. 4/96) pg 9 2 of 2 ~~~!l~lh~:i-.i:Fili~;@jlIt:1Hfr'.Jif.'ll,i},'B;itfu''''0'':it''''j<!..!1".,,,,.,' ,A' '~"""'~'"".c,".~"'!i",~~a0~,"':0.[-<,&tW.!,ji*~jiat"1l:iI!...!ii&..~~~I1lW<~"-J~~~~'-__"""''''''''-," 0 (~ 0 c. c: -n () ~ ?: , --~ t- ~ -ocr} ~:\;~ ~Q c5 '0 rncrl -'.," { z:;~ ..-"'- :-n 0 6; ~,~;~ , \=-;J ~ co '::::;\~} 8 F' --- (1 2t-=; -r:.J {;~ ~~ & ~ (Jl -- -.- ~ ~() _.-;:... l' .::::: C> --n ,;:- (,)';1 :J (J"" I :$'<= ~ 90 ( z c::> AS cO 4:. :::<: :< ...J " <.n r t2 G Lv l.h r ~ 1 T iJ );1 ." 21 :10 in -l : S1 J \);:0 i.... ~f mi' 0: Vl: O. :-I i )>~ > r;:I5 .~ o~ ~. c< t H ~ ~ ~"', ,-~=.~,'" - ~ -"""". , .., ,~, <,.,.<, ",,, .",,~ ,. ., _ ., ,~,,__;",' "..,_,,'~, ,~ ~," ,'c. >e,. <__ ,." _""'~"".O'{'''''L_ ~7'''' > ,,,.~ ,.,_,_",,~, . ,,,",,='~ ,. .,,_, .."""" ' ,'7.'~_" __"" _ ~ , .L..I ~ ..--~"" IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01-3570 CIVIL TERM V5. CIVIL ACTION - IN LAW JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant PRAECIPE TO REINSTATE COMPLAINT Please reinstate the Complaint in the above captioned matter. Respectfully submitted, Dated: I BY'~~~ Daniel F. Wolfson, Esquire . WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, Pennsylvania 17403 (717) 846-1252 I.D. # 20617 Attorney For Plaintiff ~Ei,; '}:~'i,;i, ~-'~t";~-~~~i_~Mg:Wn'lr~'rfMJl\li/i~~~",jM"",J';"";. _"_"_'J<"'''-.1!f.:',)Mj'l'ikfk;~:t:il~iiiI~~h:&b!!!lEJ'i.lm'll:!l1l!~~ o ~ t{t:It;;;~i!<'>""'-_'='L~ ,m .L','-. - ~ .." 0> f t: \S"" --I( IhliliI-,,-<m -~ o C -;;;?' ~'Ot~':'; r-n r--;-; "2:iL .?-- ~.2-,; ~:~~ :pc ~/ ::! 8 ::,. :s (',','": ::=; I C' - -U~ ""I :P'" -"~e. - - ? C) l. ~ . '-' UI -L ,.,"'.IlU_ .~.~" SHERIFF'S RETURN - U.S. CERTIFIED MAIL CASE NO: 2001-03570 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND HCR MANOR CARE VS. ESTEP JEFF IND & ON BEHALF OF R. Thomas Kline , Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law served the within named DEFENDANT ,ESTEP JEFF IND & ON BEHALF OF ESTATE OF MARGARITA ESTEP by United States Certified Mail postage prepaid, on the 7th day of November ,2001 at 0000:00 HOURS, at 413 CREEKWOOD DRIVE CHESAPEAKE, VA 23323 , a true and attested copy of the attached COMPLAINT REINSTATED Together with The returned receipt card was signed by 00/00/0000 on Additional Comments: Returned marked: moved left no forwardinq. Sheriff's Costs: Docketing Cert Mail Affidavit Surcharge 18.00 4.63 .00 10.00 .00 32.63 R. Thomas Kl'ne Sheriff of Cumberland County Paid by WOLFSON & ASSOC on 11/21/2001 . Sworn and subscribed to before me this 2"f:!f,-' day of ~j..... \ cJlM I A.D. qrlG (l. )w.ell I, .~"-r' othonotary . ., ,'. 1'1 ~ 0 _,_ ~""Ai' it 'i:~_- \, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01-3570 vs. CIVIL ACTION - LAW JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant PRAECIPE TO REINSTATE Please reinstate the Complaint in the above captioned matter. Respectfully submitted, Dated: 3)LloJ- BY: Amy F. Wolfs , Esquire WOLFSON ASSOCI 267 East Market Street York, Pennsylvania 17403 (717) 846-1252 1.0. # 87062 Attorney For Plaintiff ',-,:~~ii.Zw1 ~i -11 } , A'~~'~nrilill._~W.~~~j[t;;@II"!Of"",::;.-i,t'i,,,;,;'-;L','O' ",.t_d,'f.1')li.';~&--,;~!:,i&;o;v,!.\,lli~~.J!t!liI!"~W'I~,}j8<1#~,"",~Gll;i~JiM&"~~~- ,~ l!IlWli!1l7 m () 0 0 0 C N ('.J -uS: -0 u:' :Ji: ___I 1'11["": :f=- ~ ;;;:::c' ;;0 !It:'T~; ~ Z:C;:: ~'ln CD ",'~ -r)') :-<2- ,...)~, T ~Cj v ., ~ )s: (j -ri ?-(~) 2: ~~2S ~ "". ~~ ~ -c orn z: );! :~ ;"'.) r" ::D VI.> -< " f'\J I\) :t> ~ ~ ~ ,.(1 lli.l !lIT ![ _ . ~~~.L~!!!U~ll. D, L"~,JU_,,, ,~,~. :<_~, _h ~~,_I."<h~_"'TI-~ _ ,^_'>>._!,,~,_',X, ",._,~.,,~-, ,,~" '" _ ,'<' _~.t . .,-,,"," t,",'" '"""""'''''''"-'~_c.__~,_ " ~ ,"' ,_ ,~,_ _~_o__" __>~,.~,~ LA L II" . . , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01.3570 Civil Term vs JEFF ESTEP, Individually and on behalf of the ESTATE OF MARGARITA ESTEP, Defendant CIVIL ACTION. LAW CERTIFICATE OF SERVICE I hereby certify that on March 26, 2002, a true and correct copy of the Court of Common Pleas Complaint was served upon Defendant by depositing same certified, first class mail, return receipt 7000 153000044984 8920 requested, and addressed as follows: Jeff Estep 619 South Main Street Rocky Ford, CO 81 067 Respectfully submitted, Date: t/ / 'd-l-( i?J;;v- ! I I l Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATE, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff ~~~..4i,~lM!i'j:l'l11*liWiiirl!1&1I@;;~'-~ii1~t#.0i~!!;;illH,jNl~;;""!";~L<';',';~1"'b,,,';k<_"""~:;h,j",!J;i''1,;,,,,,*~'''''''''' .,; -~il~Iil!a";/\il." , ii:'.~~~~~~"~""~'~1ll -~.."~ '~JIilIl~6j < '-_1 ! . II I' ii :1 I 2 0 D ~ N 0 [R~~' "'" " ~ -0 -~g;L; ") ti.5:~'; ::0 N [r _.-- ,._, \,.0 ~~i ~~ f\) .-':::::';:', ~ :..~- \_~ -;:::- V .-"-' t', ~[~ --=~" " [5 C) '" -c:: ~~ "---.-i f'il "'- S;! [0 N :~ ......,) fA (N ~1 :0 -<: S ,_,IIIU _,~"=~ ,__ ..1!l111, JlU,~;-"",""%'"~,~~-r-JWL~b''>~'',~~.~lm,, .~J.t""".yt;;,,, .~''',),''_'' , ".<_,;<' .,0 " ",,,_<,)"__,';~; ""t-- .-.j ~,- ~,,,,,,:-,,,, ,.", -" _,~;, ,,,, ;""")""c -''' ,''''f",',_ .- ,<~, e, " ',c_ ,<" '---," .~ ,d,_ h~: ; -'.'-"'" .-1 o'mpletEi--items'~r; 2, arid '3. Also campi'at'€;" item 4 if Restricted Delivery is desired. . Print your name and address on the reverse so that we can return the ~rd to you. . Attach this card to the bac:::k of the mail piece, or on the front if space permits. . 1. Article Addressed to: 'Y<::- \'\\ B--t~ lo \.q ~. fYtk'"," \:J 'Ro0'-t~ fu(~ I to . ~l()\..ol 3. SaNlce Type '~ertified Mail tJ Registered o Insured Mail o Express Mail o Return Receipt for Merchandise DC.D.D. 4. Restricted Delivery? (Extra Fee) Domestic Return Receipt DYes 102595-00-M-0952 ,c,__~,' , 10' ,~_-- "'--_U~_~!jf__ .__< . . ~.. ...llnT!!.. .~ J" "lJ. I,IJ . ~, - 1 ;u,;'fu' ?-~ . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE No. 01.3570 vs. Action in: Civil-Law JEFF ESTEP, Individually and on Behalf of THE ESTATE OF MARGARITA ESTEP, PRAECIPE FOR JUDGMENT ENTER JUDGMENT in the above case for failure to file, enter, an ANSWER TO THE COMPLAINT against lEFF ESTEP in favor of HCR MANOR CARE in the sum of j 19,027.64 with interest AS ALLOWED BY STATUTE Total: .$ 1 9.027.64 + COURT COSTS -A7a-Jfh~ Attorney for Plaintiff Daniel F. Wolfson, Esquire 20 t'l :2 Judgment entered by this day according to the tenor of the abOve statement. j ~ ~-~ ,d, . _" ~ ~uL I " ,~' ''-'Ii.' ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-3570 Plaintiff vs. CIVIL ACTION - LAW JEFf ESTEP Individually and on Behalf of THE ESTATE OF MARGARITA ESTEP, Defendant CERTIFICATE OF RESIDENCE I, Daniel F. Wolfson, Esquire, due hereby certify that the last known address of the above referenced Defendant is as follows: JEFF ESTEP 619 SOUTH MAIN STREET ROCKY FORD, CO 81067 Respectfully submitted, Date: '5 ~\O& ~~~~ ame . Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 10 No. 2061 7 Attorney for Plaintiff "~ ~- , ,.f, 11 -'. "':. .' ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. NO. 01-3570 JEFF ESTEP, Individually and on Behalf of THE ESTATE OF MARGARITA ESTEP, Defendant AFFIDAVIT OF NON-MILITARY SERVICE COMMONWEALTH OF PENNSYLVANIA COUNTY OF YORK I, Daniel F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my knowledge, information and belief, Jeff Estep, Defendant, above named; is over 21 years of age; is last know to reside at 619 South Main Street, Rocky Ford, Colorado,81 067; is not in the military service ofthe United States or its Allies, or otherwise within the provisions of the Soldiers' and Sailors' Civil Relief Act of Congress of 1940 and its Amendments. Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, Pennsylvania 17403 Attorney I.D. # 20617 Attorney for the Plaintiff Sworn and subscribed to b~\~ day of , 2002. Notarial Seal Michele M. McHugh, Notary Public City of York, York County My Comm1ssion Expires Aug. 12, 2002 Member, PennsylvaniaAssociationofNo1aries ~\(\~~~t\* Notary Public " oS - .' 1--- IJl .' , ti~-'" .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01.3510 Plaintiff v. JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant CIVIL ACTION-LAW CERTIFICATION I, Daniel F. Wolfson, Esquire, due hereby certify that on April 23, 2002, 1 caused a true and correct copy of the 10 Day Notice attached hereto to be served on the Defendant, Jeff Estep. Date: '5 \ {'-\ \ O;L , . 4~~ Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATE, P.C. 267 East Market Street York, Pennsylvania 17403 Telephone No. (717) 846-1252 I.D. # 20617 Attorney for Plaintiff ~~~~~~~- d '" :' ..-0 WOLFSON & ASSOCIATES, P.C. Attorneys at Law ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic Caprice Hicks Bunting Donald L. Hoage* 267 East Market Street York, Pennsylvania 17403 PARALEGALS Margaret L. Burg Michele M.McHugh (717) 846-1252 (800) 321-8467 FAX (717) 848-1146 .. Licensed to Practice in Maryland e-mail: dfwolfson@debtcollection.net April 23, 2002 Jeff Estep 619 South Main Street Rocky Ford, CO 81 067 Re: HCR Manor Care vs Jeff Estep, Et. AI. Docket No. 01.3570 Civil Term (CP Cumberland County) Collection Matter ..............~~"* BRANCH OFFICE: 8 Manchester Street Glen Rock, PA ] 7327 (717) 235-50]4 PLEASE FORWARD ALL CORRESPONDENCE TO THE YORK OFFICE Dear Mr. Estep: We enclose a 10-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civil Procedure. Sincerely, WOlFSON & ASSOCI%!o/ ~~~~. ~ Daniel F. Wolfson, Esquire DFW/cc enclosure I -c' 'l _ " - ,h.'_."-', -1,'1 , - , Ill.lL~k ,. , .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, NO. 01.3570 Civil Term vs. JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant CIVIL ACTION .LAW TO: Jeff Estep 6] 9 South Main Street Rocky Ford, CO 81067 DATE OF NOTICE: April 23, 2002 I IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717)249-3166 , BY' ~ Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, Pennsylvania 17403-2000 Telephone: (717) 846-1252 I.D. # 20617 Attorney for Plaintiff "'- . ~L u ,'. . .'.~ -- ,c,' ..' ~i"'~\l .,. ,.. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION HCR MANOR CARE, Plaintiff vs. NO. 01.3570 JEFF ESTEP, Individually and on Behalf of THE ESTATE OF MARGARITA ESTEP, Defendant NOTICE OF ORDER, DECREE OR JUDGMENT TO: ( ) PLAINTIFF (X) DEFENDANT ( ) GARNISHEE ( ) ADDITIONAL DEFENDANT YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS BEEN ENTERED AGAINST YOU ON IN ACCORD.cl&~~~AO~~;S'bF PA.R.C.P. 236 ( ) DECREE NISI IN EQUITY ( ) FINAL DECREE IN EQUITY (X) JUDGMENT OF () (X) ( ) CONFESSION DEFAULT NON-PROS ( ) ( ) ( ) VERDICT NON-SUIT ARBITRATION AWARD (X) JUDGMENT IS IN THE AMOUNT OF $19,027.64 PLUS COSTS $45.50 FORA TOTAL OF $19,073.14. () DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF $ PLUS COSTS. () IF NOT SATISFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF TRANSPORTATION BY IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE CONTACT: NAME OF (A HORNEY/FILING PARTY): ADDRESS: TELEPHONE NUMBER: WOLFSON & ASSOCIATES, P.c. 267 EAST MARKET STREET YORK, PENNSYLVANIA 17403 (717) 846-1252 OR 800-321-8467 NOTICE SENT TO: JEFF ESTEP 619 SOUTH MAIN STREET ROCKY FORD, CO 81067 ,---,--~----,----------- ~~kM.\~41i'.0lMifu1&lk3i"1'!#.*_o!~J~'{~k;;V~~;W!"Jl ;';:-'"U",,,,-,,,,,.~,,;,-,. ,';:'":,"~i6",.".;!"g;1i~jii,\li;l~_~~~~'..t.#I~ t f? ~~ If=. ........ ~ !...J ,)J tJ ~~ ~ --.J ~ ~ '--.(, \.,0 \.-,0 ~iIILc. N,QJ!ll~I!I!!MI.JI.ltMILll,~~."U~'c~.c",,,,".:.JI'JMUl!UJ.J1U1.,.Ic,. '.,M. .,...,..!.. '..' ,,,,,, " '" ,.. .'"",. 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(J)~ ~~ ~ ~ lfi-~ ~ g; -< ~ . m c. iil c." ! a' 0-3 ~ ft ~ 3 en <C' ~ i!l c iil '0 DODD ~if~l' .. c. m (jl a o o m m -,,-,-,".,"~ _In?" ,: '1i!iH&~i\tNl~\.$5Z&~IV;~1%1~:f:J,,~1i10f~~I~ f- f I' I ~f 1: l , .. .<' .. t,j F /. L ". ^~ I II ~ ,--. 0''''''''''''_'__, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 0\ - dS?6 Co .r--'0L/f Plaintiff LLEVE ESTA DEMANDAA UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFlClNA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue TRUE COpy . . " Carlisle, Pennsylvania 17013 I li . FRO,;"lJ RECORD (717) 249-3166 n &stlmOlllf Wher~f, I !IilTa umr)Jsat illY i,c;rtd Md the seal ji)f SiiiliJ Call - at (;<11",1.-10 "'~ .day .: . ".... rw. vs. (") C~) CIVIL ACTION '~A't -Or,) c- nll'~-' ,- z,:d :;::: ~~;: ~) -<.. ~CJ -0 ~() ~-o >c .. Z ~ i;~ JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice is served, by entering a written appearance, personally of by attorney, and filing in waiting with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA te nan demandado a .used en la corte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation. Used debe presenlar una apariencia escrila 0 en persona 0 por abogado y archivar en la corte en fonna escrita sus defensas 0 sus objeciones a last demandas en contra de su persona. Sea avlsado que sl used no se deflenda, la corte tomara medidas y psedido entrar una orden contra used sin previo aviso onotlflcacion y por cualquler queja 0 alivio que es pedido en la petlcion de demanda. Used puede perder dlnero OSUS propledades 0 otros derecnos Importantes para used. o 'n ---, t:;;:; -'-1(n --'cr C) -0'{ C-J "i, ;',..J ~~ t,.- '.,.c _ > I ,I _0_-' ~ -- ,-,,-. ":rr:i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. vs. CIVIL ACTION - LAW JEFF ESTEP, Individually and on Behalf of the ESTATE OF MARGARITA ESTEP, Defendant COMPLAINT ~ 1 AND NOW, this ~ day of, UflG-- , 200 I, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson & Associates, P.c., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care (hereinafter referred to as Plaintiff), is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1 700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1 7011. 2. Defendant, Jeff Estep, (hereinafter referred to as "Defendant"), is an adult individual with a last knoWn address of 413 Creekwood Drive, Chesapeake, Virginia 23323. 3. Defendant, Jeff Estep, on behalf of the Estate of Margarita Estep, (hereinafter referred to as "Defendant"), is an adult individual with a last known address of 413 Creekwood Drive, Chesapeake, Virginia 23323. 1 ,f' ,-,!_,l. - , -~ -~ v-;-~,--", .-~,-, -'''-;~'':'." '"'",, '__i' '-""a 4. That Defendant is the husband of Margarita Estep, Decedent, (hereinafter referred to as "Decedent"), and Defendant also represented himself to be the Legal Representative and/or Responsible Party for Decedent. 5. That on or about December 28, 1998 through October 12, 1999, Decedent was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein, and collectively marked as Exhibit "A". 6. That on or about December 28, 1998, Defendant executed an Admission Agreement on behalf of Decedent, which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement dated December 28, 1998 is attached hereto, incorporated herein, and collectively marked as Exhibit "8". 7. That by executing said Admission Agreement, Defendant did assume and accept responsibility for the debt to be incurred by the Decedent, 8. That the debt incurred by the Decedent was also incurred as part of the marital estate. 9. That 23 Pa.C.S.A. 9 4102 provides that both spouses are liable for debts contracted for necessaries by either spouse, absent formal separation 2 - - I , :,.u.',d ,. '. ~'__ ".,' ~ ,_o.;~-> -,','',r,.,, 'D - ," -""",.~c;.,;i'~l'j, agreement or support order addressing the matter, and said obligation is imposed by law as an incident of the marital status. 10. That Plaintiff submitted to Defendant a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously identified as Exhibit "A" and incorporated herein by reference. 11 . That Defendant has not objected to the above-mentioned Statement of Account submitted by Plaintiff to Defendant. 12. Plaintiff has made numerous requests to Defendant demanding that the sums due and owing to Plaintiff be paid, and Defendant has refused his obligation to pay necessary and appropriate bills and obligations for his wife, the Decedent, as part of the marital estate. 13. As of the date of filing of this Complaint, the balance due, owing, and unpaid on Decedent's account as a result of said charges is the sum of Fourteen Thousand Six Hundred Thirty-Six and 65/100 Dollars ($1 4,636.65). See Exhibit "A" previously identified and incorporated herein. 14. Despite PlaintiWs reasonable and repeated demands for payment, Defendant has failed, refused, and has continued to refuse to pay all sums due and owing on Decedent's account balance, all to the damage and detriment of the Plaintiff. 3 ,_ ,. ,_ __, .~ ~ "'~ ,jl 4 IT ,'- '"i~~,,,,,-,,-,;n"<,._ ',~._,_"_,, . -,- '~ '. t" " ~ !"" _>ie, '-~'b:.."""~' "'_n_ --"'-3-'''f':i WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendant, Jeff Estep, Individually and on Behalf of the Estate of Margarita Estep, in the amount of Fourteen Thousand Six Hundred Thirty-Six and 65/100 Dollars ($14,636.65), reasonable attorney's fees in the amount of Four Thousand Three Hundred Ninety and 991100 Dollars ($4,390.99), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, ~~;;?h;~ Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 1.0. No. 20617 Attorney for Plaintiff ^>-. ,H ,." .,I,J" ' ,- . EXHIBIT "A" -,- ~ ' J ..' ,_,' ~ ,;,;.0,' ,,~ ,-._,' , 'c,-':'it - "", I -, ~,b' """'. HCR.ManorCare Statement MANORCARE CAMP HILL 583 1700 MARKET STREET CAMP HILL, PA 17011 (717)-737-8551 JEFFREY ESTEP FOR MARGARITA ESTEP 431 APPALOOSA TRAIL CHESAPEAKE, VA 23323 HMO PRIVATE ROOM 201 -1\ Please Return This Portion With Your Payment _____~~!~~~_M~~?~~!!~__________________~~~~~___!~~~~y~__!~~~~(9Y__~~~~~(0}____ DATE OF. SERVICE SERVICE RENDERED CHARGES CREDITS 02/01/01 BALANCE FORWARD 14,636.65 ~ PAYMENT DUE BY THE 10TH 14,636.65 AMOUNT DUE ... -, '"" j, '"'"" '-l..k-.--i.. ~. 03129101 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE (AR56) RESIDENT RESIDENT RHSIDENT G/L -- ACCOUNTS RECEIVABLE -- NUMBER TYPE NAME DArE gTY ACCOUNT C6ARGES CREDITS BALANCE 11206 BNO ESTEP, NARGARIrA 12/2B/9B AD/I CNTR RATE, 0.00 ROOM 201 -A LEVEL 1 1011J199 DIS pm PORT: 0.00 " HMO - m 00 BAL FWD -LM- -30- -60- -90- -120+- 23014.00 23014.00 "ENDING BALANCE 23014.00 "6MO - APR 00 BAL FWD - LN- -30- -60- -90- -120+- 23074.00 23014.00 "ENDING BALANCE 23014.00 - "PRIVATE - NAY 00 REV llN MID BOARD 08131199 14411050000 4402.00 REV P6ARM C6G 0B/31199 U41l050000 63.51 REV P6ARN C6G 08iJl/99 ]4411050000 53.04 REV NUT6 TO PVT 0B/31/99 14411050000 372.00 REV PT B GLUC TO PVT 0B/31199 14411050000 111.99 REV WD T~'S TO PVT 0BI31/99 14411050000 232.00 REV FOLEY CATR TO 01 09/30199 14411050000 10.08 REV llN AND BOARD PVT 09130199 14411050000 4402.00 REV GLUC TO PVT 09/30/99 14411050000 43.10 REV P6ARM TO PVT 09130199 14411050000 411.34 RHV PRARR TO PVT 09/30/99 14411050000 19.34 REV COM WOUND T~ 09/30/99 14411050000 1155.00 REV WOUND TX TO m 09130199 14411050000 4B0.00 REV NUTRT TO m 09/30199 14411050000 360.00 REV CATR TRAY TO PVT 09130/99 14411050000 10.00 REV GLUC TO m 10/31/99 14411050000 34,96 REV PRARN TO PVT 10/31/99 14411050000 117.09 REV PRARM TO PVT 10131/99 U41l050000 15.18 RHV WD TX'S TO PVT 10131199 14411050000 280.00 REV NUTRI TO PVT 10131199 14411050000 156.00 . REV CATR TRAY TO PVT 10/31199 U4110500i0 20.00 REV RM AND BD TO PVT 10iJl199 144110500001160.16 "HNDING BALANCE 14636.65 "HMO - MAY 00 m FWD -LI!- -30- -60- -90- -120+- 23014.00 23074.00 INS CaNT RATE ADJ 01iJll99 51957109100 31.H INS CaNT RATE ADJ 04130199 51957109100 52.00 INS CaNT RATE ADJ 05131/99 51957109100 52.00 INS CaNT RATE ADJ 06130/99 51951109100 1930.00 INS CaNT RATR ADJ 01/31199 51957109100 2091.00 REV ARC WIOFF 08iJl 199 57557509100 838.60 INS CaNT ADJ 08/31199 51957109100 3689.00 REV RM AND BOARD 08/31199 14411050000 4402.00 REV PRARM CRG 08/31/99 14411050000 63.51 REV PRARM CRG 08/31/99 14411050000 53.04 REV RUTR TO m 08/31199 U41l050i00 J12.00 REV PT B GLUC TO PVT 08/31/99 U411050000 111 . 99 ,-,'"' ''''''4':'<''"" , - ' ~." ..;.;; ! ,~.: '0 I t. < H.',I".;, _, ,," . 03/29/01 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY ~AGE 2 (AR561 RESIDENT RESIDENT RESIDENT GIL -. ACCOUNTS RECEIVABLE -- NUMBER TY~E NAME DATE QTY ACCOUNT CRARGES CREDITS BALANCE 11206 HMO ESTEP, MARGARITA 12/28/98 ADM CNTR RATE, 0.00 ROOM 201 -A LEVEL 1 19/13/99 DIS ~HlV ~ORT, 0.00 "RMO - MAY 00 (CONTI REV WD TX'S TO PVT 08131199 14411050000 232.00 REV FOLEY CATR TO 01 09/30/99 14411050000 10.08 REV ARC WI OFF 09/30199 51551509100 2558.23 INS CONT ADJ 09/30/99 51951189108 3420.90 REV RM AND BOARD PVT 09/30/99 14411850000 440U8 REV GLUC TO ~VT 09/38/99 1441185m0 43.18 REV PRANK TO PVT 09/30/99 14411050000 411.34 REV ~RARM TO m 89138199 14411850118 19.H REV WOUND TX TO PVT 09/30/99 14411050000 480.00 REV COMP WD T~ 09/30/99 14411mm 1155.00 REV NUTRT TO PVT 09/30/99 14411850000 360.00 REV CATR TRAY TO ~VT 09130/99 14411850000 10.00 REV GLUC TO PVT 10/31/99 14411050080 34.96 REV ~RARM TO PVT 18/31/99 14411858008 117.09 REV PHARM TO PVT 10/31/99 14411050000 ]\.18 REV WD T~'S TO PVT IIIll/99 14411050080 288.00 REV NUTRI TO PVT 10131199 14411850000 156.00 REV CATR TRAY TO PVT 10131199 14411mm 20.00 REV ANC WIOFF 10/31/99 51551509100 692.51 INS CONT ADJ 10131199 51951189100 1371.24 REV RM AND BD TO PVT 10/31/99 14411050000 1160.16 REV ARC W/OFF 19/31/99 51557509100 66.26 "ENDING BALARCR 11.51 "~RImE . JUR 00 BAL FWD - LM- -30- -60- -90- -120+- 116.00 1446&.65 14636.65 "iNDING BALANCi 14636.65 "RMO - JUNi0 BAL FWD -LM- -30- -60- -90- - 120+- 116.00- 193.51 11.51 "ENDING BALANCE 17.51 "~RmTB - JUL00 BAL FWD - LR- -30- -60- -90- -110t- 116.00 IHG0.65 14636.65 "iNDIMG BALANCi 14636.65 "RRO - JUL 00 BAL FWD -LR- -30- -60- -90- -120t- 116.00- 193.51 17.51 "ENDING BALANCE 11.51 "~RImE . AUG 00 8AL FWD -LM- -30- -60- -90- -120+- 116.00 IHGU5 1463ti.65 "ENDING BALANCi 14636.65 "RKO - AUG 00 BAt FWD - tR- -30- -60- -90- -110t- 116.00- 193.51 17.51 ,- . ;-0;'-;=".'. '_",~',-,\, ,,' ~.,-,~ -., . .<-:-[.,: - -"'.; ,'~ . " , J , . ~I;, j 03/29/01 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE 3 IAR561 RESIDENT RESIDENT RESIDENT GIL -- ACCOUNTS RECEIVABLE -- NUMBER mE NANE DATE QTY ACCOUNT CBARGEB CREDITS SALANC! 11206 BNO ESTEP, MARGARITA 12/28/98 ADM CNTR RATE, 0.00 ROOM 201 -A mEL 1 19113/99 DIS pm PORT: 0.00 "BNO . AUG 00 (CONTI "ENDING BALANCE 17.51 "PRIVATE - SEP 00 BAL FWD -LII- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "BNO - SEP 00 BAL FWD -LN- -30- -60- -90- -120+- 17 .51 11.51 "ENDING BALANCE 17.51 "PRIVATE . OCT00 BAL FWD -LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "BNO - ocre0 BAL FWD -LN- -30- -60- -90- -120+- 17.51 17.51 "ENDING BALANCE 11.51 " PRIVATE - NOV 00 BAL FWD -LN- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 " ENO - NOV 00 BAL FWD -LM- -30- -60- -90- -120+- 17.51 17.51 "ENDING BALANCE 17 .51 " PRIVATE - DEC 00 BAL FWD -LN- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "SMO . DEC 00 BAL FWD -LM- -30- -60- -90- -120+- 17.51 17.51 CIA INS 09/15/99 57557509100 17.51 "ENDING BALANCE .00 "pmm - m 01 BAL FWD -LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 "PRIVATE - FE8 01 BAL FWD -LM- -30- -60- -90- -120+- 14636.65 14636.65 "ENDING BALANCE 14636.65 , '__ _J ,. " -,'_;J>~.."",x~ ,,,,,_,<~",,.:. --~:.."".,;~; .. "j ""'-.'. -.., " EXHIBIT "B" l;,l;;;~~ .', ,," ,_ - ,',.. -. '--'~.JJ" ,- -', ;' ,\ __ ".; - '" '-:~ ~ ,~ ~ .~' r _ _.. ---"-,,1-;; ;.,: ....... , .,_ .._'~~ _.'" ..;.'-;'"1;' -'~, '"_,_ ,-,~ ~ ADMISSION AGREEMENT Manor care CONTRACT BETWEEN PATIENT/RESIDENT AND FACILITY H~althS~rvices THIS~DMISSION AGREEMENT (the "Agreement") is entered into this 'Z..'ii'-'"b day of ~~ ,.19 cW , between \'l\Qv-\,y C~..-<- l*Jcth .de"-""=1'the "Facility"), and 1'fID~c." 'Lsizp (the "Patient/Resident"), and/or J~.. ~~^- L.7 <;T'<..'f (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also ~ean the Responsible Party, if any. The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and . hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's discharge. 3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit 8, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records or information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. MHC-008-20 (Rev. 7 ;9S1 pg 3 1 of 3 .. ~ I.-. I '~'....~' ~::.:.,.~:...:.~~~_,I :..::~ ".~~~~_,~~~'~'~~~~~;,:~~_:~~.~:-,.::.~.:;.~.~::~~.~.':,.~:~~~:.~~;~ -'.:.~_:~..~~;:::.~~~.;~:.:. '-, "'I '....~. ,.,,_., y,~, .....',... 6. Consent to Treatment. Patient/Resident acknowledges that he/she is under the medical tr t- men! and care of an attending physician, and consents to the Facility rendering nursJ.ng cea th . d a~. erapeutlc, an other treatment under the general or special instructions or said physician'or . . fin case 0 emergency. ( 7. Attending Physician. The Patient/Resident is solely responsible for selection of a licensee attending physician. The Patient/Resident agrees that the Facility may require the Patient/Resident to utilize another physician if the attending physician ( 1) has his/her own professional license limited. suspended or revoked; (2) fails to follow the Facility's rules and regulations; or (3) is unavailable ir case of emergency. The Patient/Resident is responsible for all charges for physician services. 8. Pharmacy. The Patient/Resident shall execute the Pharmacy Agreement attached as Exhibit C. 9. Independent Contractors. The Patient/Resident acknowledges and agrees that all physicians dentists and barbers/beauticians, including those whose services are arranged by the Facility, are independent contractors and are not employees or agents of the Facility, and the Facility shall no: be responsible for their acts or omissions or for the consequences of following physician or dentis: orders. 10. Private Duty Personnel. The Patient/Resident acknowledges that all private duty personnel tha' the Patient/Resident utilizes are not employees or agents of the Facility and that the Facility is no: liable for acts or omissions by such personnel. Employees or the Facility may not be employed a~ private duty personnel at the Facility. All private duty personnel shall comply with all policies ane procedures of the Facility as may be amended from time to time without notice. Failure to do s: may result in their being denied access to the Facility. Patient/Resident and Responsible Party sha be solely responsible for the cost of private duty personnel. 11. Facility Guideiines for "No Heroics" Requests. Decisions regarding life support should be con- sidered by each Patient/Resident or his/her authorized surrogate decision-maker. The Patient; Resident acknowledges receipt of rights under state law to make decisions about medical care, in- cluding rights to accept or refuse care and rights to make an advance decision abcut care. The . Patient/ Resident acknowledges receipt of a summary of the "Facility Guidelines fcr No Heroic~ Requests" (the "Guidelines"). A full text of the Guidelines will be provided upon request. In part, tr",E =;;:: Guidelines provide that the Facility will not withhold or withdraw life-sustaining or liie-prolongin~ measures from a Patient/Resident without a written and legally sufficient authorization ot a competen: Patient/ Resident or legally authorized surrogate decision-maker and a physician order. The Patient/ Resident agrees to comply with the Guidelines. 12. Liability and Indemnification. The Patient/Resident understands that the Facility is liable on I:, for injuries caused by the negligent acts or omissions of the Facility and as required by law. ThE Patient/Resident shall indemnify and hold the Facility harmless from any and all claims, suits ar,c actions ".,ade aaainst the Facility by any oerson resulting from any damage or injury caused by thE Patient/Reside;t to any person ~r the property of any person or entity (including the Facility). 13. Patient/Resident's Handbook. The Patient/Resident acknowledges receipt of the Facility'c Resident's Handbook and agrees to comply with such Rules and Regulations contained therein. ThE Patient/Resident acknowledges and agrees that he/she shall be responsible for and shall hold thE Facility harmless for any injuries or damages which are caused by the Patient/Resident's failure. tc comply with such rules and regulations. The policies, procedures, rules and regulations regardln, the following areas, among others, are detailed in the Resident's Handbook: \, 2 of 3 "HC.~.20 (Rev. 4./961 PO 4. c ~ -, 'l , , l"1 ~d:h,,-'--.oJ.- "",-. ~'- '-l.-""" "~"'--~i '. Federal Resident Rights , ResiClent Responsibilities . Life Sustaining Treatment Policy · Medical/Nursing Education . Dental, Vision and Hearing Services . Interdisciplinary Care Conference . Utilization Review Meetings (if applicable) . Personal Laundry Policy . Barber/Beauty Services . Mail Policy . Voting Materials · Photo/Media Events . Personal Fund Account Procedure . Tobacco Policy . Grievance Procedures . State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day and year above written. .,] .. /' I , I 11../ .. I Fac~ty Representative - Signature Res .. n bl a - Si nature /, . ~,,,-,,-L.&1-....f'~r. sx.-: .~A..o~ 3EFFe.G-v L , aie..p Facility Representative - Printed Name & Title Responsible Party I- Printed Name it-7..l-'l1 102--0.&--1r Date ~S5D ~ 'Date MHc-ooa-20 (Rev.4/96) pg 5 3013 ~ I ,~ "" ". "-1 "'1 " _ J,t~ . _.' ,~,. ,\ -. '_,- -c ';". "..~,"-> i~1 (EXHIBIT A - RESPONSiBLE PARTY APPOINTMENT) The Patient/Resident's Responsible Party may be any person legally responsible for the Pattent/ Resident. A competent Patient/Resident shall not be required to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. o The undersigned has been legally appointed guardian, conservator and/or holder of a power of attorney to act on the behalf of the Patient/Resident and shall serve as Responsible Party for the Patient/Resident. The undersigned has delivered to the Facility copies of the legal documents designating him/her as the guardian, conservator and/or holder of a power of attorney of the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned, individually and personally, hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined). o The Patient/Resident does not have a legally appointed representative and wishes to give the responsibility to someone else. I hereby appoint as my representative (the "Responsible Party") and hereby authorize him/her to handle my finances, pay my expenses, receive my personal funds and, if I am unable, to execute the Admission Agreement on my behalf. Any signature of Patient/Resident or Responsible Party on the Admission Agreement and/or this or any other exhibit or document attached thereto or referenced therein shall be considered binding on both the Patient/Resident and the Responsible Party. The undersigned hereby agrees to the Conditions (as herein after set forth and defined). Facility Representative - Signature Patient/Resident - Signature Facility Representative - Printed Name & Title Patient/Resident - Printed Name Date Date o The Patient/Resident is competent and does not have a court-appointed guardian, conser- vator or power of attorney and has not appointed a Responsible Party, but alone shall execute the Agreement. In consideration of his/her admission to the Facility, the undersigned hereby agrees, warrants and represents to the Conditions (as herein after set forth and defined). ~ The Patient/Resident is mentally or physically incapable of executing this Agreement, handling his/her own affairs or appointing a Responsible Party and does not have a guardian, conser- vator or durable power of attorney. The Patient/Resident's physician will certify in writing that the Patient/Resident is incapable of executing the Agreement and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on behalf of the Patient/Resident, to act and serve as Responsible Party for the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned individually hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined). \. MHc.ooa-20 (Rev. 4/96) pg 6 1 of 2 "'.' IJ.... _, -", .'-.-,,-,,- '1_;1_ -': _ ,~-:...',- "-"'C - ~- - ,~ >, j;;;'~'i ( Conditions (collectively referred to as "Conditions") . . 1. The assets of the Patient/Resident will be utilized to pay, when due, all costs iilcurrea by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit 8). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated . n_-1...~ ,199 ~ ,and which is attached hereto and made part of this Exhibit and of the Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. 4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the Patient/Resident's assets and/or assets which are available for the Pat- ient/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. 5. When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party Or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. 6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives. 7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges not covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above warranties and representations are not true, or if the above covenants and agreements are not complied with, the Facility will have detrimentally relied ul?on them and the Facility will suffer financial harm and loss. : j / I '~ ~$) Respon~I~# - .gnat"r j . :-rr:: rh2L.c,. L c &> Responsible Part - Printed Name I d- - J-S'-qg/ Date fl/lHC.008-20 (Rev. 4/96) pg 7 2 of 2 -'.= .- " 'tl' .~', ~ L,l~ "'." .'--' -', ' "'~-~i1 ( EXHIBIT B - FEE SCHEDULE) 1. Daily Rate. The daily rate is $ 6~ o~ . The monthly rate equals the daily rate multiplied by the number of days in the month. The daily rate is billed one month in advance and includes: · Routine Nursing Care · Linens . Social Services · Meals (additional fees may apply) . Activities . Housekeeping · Room (circle one): Private Semi-Private Triple The fOllowing are paid by Medicare in addition to the items included in the daily rate: · Approved Rehabilitative/Therapy Services . Approved Medications · Approved Nursing Supplies . Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): · Approved Rehabilitative/Therapy Services · Approved Nursing Supplies · Approved Routine Personal Hygiene Items/Services · Other approved services/items covered and paid for under the state Medicaid program. · Approved Medications · Approved Equipment 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM RATE · Private Room Based on location & level of care · Prescription & Non-Prescription Drugs As determined by pharmacy · Nursing & Personal Care Supplies See business office for current prices · Transportation As determined by transport company · Nursing Care (Other than ordinary nursing care) See attached fee list · Physical, Occupational & Speech Therapies See attached fee list · Phone, Cable TV, Newspaper, Barber/Beauty See attached fee list · Special Equipment See attached fee list · Bed Hold Fees See attached fee list · Personal Laundry (Personal Clothing) See attached fee list . · Nutritional Supplements See attached fee list · Alternative Nutrition (Tube Feeding, TPN, etc.) See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever a Patient/Resident leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law. 4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies which may be needed by and provided to the Patient/Resident, all additional costs/charges may not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in level of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the Facility no later than the day before the rate increase is effective. MHc.ooe.20 (Rev. 4/961 pg 8 1 of 2 - ~LJ ~,'" ~"I ",. oj:,;"",- j, ;:rJ:',-,_",j,':, - "--' '......... 6. Refunds. Refunds shall be paid within thirty (30) days after discharge or transfer. . . 7. Funding Sources. The Facility makes no assurances that the Patient/Resident's care will be covered by any third party payor. 8. Payment Policy. All amounts due shall be paid promptly within ten (10) days of billing. Failure to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in full shall be subject to a one and one-half percent (1112%) service charge on the past due balance each month until the balance due is paid in full. This amounts to eighteen percent (18%) annually on the unpaid balance. If the maximum annual service charge allowed by state law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall apply. Should the Patient/Resident's account be turned over for collection to an attorney or collection agency, or should the Facility seek to interpret or enforce any other provision of the Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees of the Facility if the Facility prevails. 9. Responsibilities. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services/supplies not paid by any third party, as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/ Resident is transferred to a different room or the level of care or payor status changes. The Patient! Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility is released from all liability for harm which may result. Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident. enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for all charges. The Patient/Resident is responsible for payment for items covered by Medicare supple- mental insurance and for applying for reimbursement from his/her insurer. Medicaid Beneficiaries: (circle correct number) 1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the Facility with at least four (4) months prior written notice of the Patient/Resident's becoming eligible for the Medicaid coverage or their being unable to pay privately; OR ~ 2)' he Facility currently participates in the Medicaid oroqram. If the Patient/Resident believes ."."..",he qualifies for Medicaid, he/she shall promptly complete and submit all documents required to apply for coverage, including pre-admission approval. If Medicaid coverage is denied, the Patient! Resident will be liable for all charges from the admission date. When Medicaid pays for only a portion of the incurred charges, the Patient/Resident shall be responsible for paying his/her portion, as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay- ment of Facility's current charges for any requested non-Medicaid covered services/supplies. The Patient/Resident will provide financial information regarding monthly credits, increases/decreases in the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaid representatives. MHC.008-20 {Rev. 4/96) pg 9 2 of 2 ;' ~": ' j ~ -, , I 1 , , I -,j , 1 " ~ "1 j ij -:! . ii ;'. , :1 :) it i , .! ,.i i :1 , :1 ,01 ! "j , i , I I I I I , , I :i I I" _~. O--"_"~ nnrrr."lf"llIIi1il"""" -lW'i!'~~~~,k. ." " . ".",n'""m ......, ... ,__ ._ rs (0 ,~'t.::" :~'j Noy ;..1 _:_ " ~' " r o .-,;;f.';f?iFf ':''vir 3 '..'" ..;c: rh " '" " ,': -~~. If<l!l!!lllll,-_ ~~." ,1 nL'1'l',*"'m;,,,,~y.~<I't:'n'''~'''~li',!,~..-,,,,_,,,!,,,,,,q.,\,",,.,p,m~~ilIli'!!@'.r~lIfl.,.,.,...A~~41~,~W