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Home My WebLink About01-5931 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. MARGARET RINEHART, Individually, and JOHN RINEHART, Individually and on Behalf of MARGARET RINEHART, Defendants NO. CIVIL ACTION - LAW 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 5ET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le ban demandado a used en la corte. Si used quaere defensas de esas demandas expuestas en las patinas, siguiences, used tiene viente (2.0) dias de plazo al partir de la fecha de lademanda y la notifiation. Used debe presentar una apariencia escrita o en persona o por abogado y archivar en la torte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se deflenda, la corte tomara medidas y psedido entrar una orden contra used sin previo aviso o notification y pot cualquier queja o alivio que es pedido en la pecicion de demanda. Used puede perder dinero o sus propiedades o otros derechos importances para used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAI¥1ENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVlCIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 24-9-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. CIVIL ACTION - LAW MARGARET RINEHART, Individually, and : JOHN RINEHART, Individually and on : Behalf of MARGARET RINEHART, : Defendants : COMPLAINT AND NOW, this tc~l ~lay---- ~~ 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Es~quire, and the law firm of Wolfson e~ Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, Margaret Rinehart, is an adult individual with a current mailing address of Arden Courts, 2625 Ailanthus Lane, Harrisburg, Dauphin County, Pennsylvania 17110. 3. Defendant, John Rinehart, is an adult individual with a last known address of 905 Hawthoen Avenue, Mechanicsburg, Cumberland County, Pennsylvania 17055. 1 4. That Defendant John Rinehart represented himself to be the Legal Representative and/or Responsible Party for Defendant Hargaret Rinehart. Defendant John Rinehart is the grandson of Defendant I~largaret Rinehart. 5. That on or about November 1 !, 2000, through on or about April 6 2001, Defendant Margaret Rinehart 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 November 11, 2000, Defendant John Rinehart executed an Admission Agreement, on behalf of Defendant I~largaret Rinehart, which Al~reement 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 is attached hereto, incorporated herein, and collectively marked as Exhibit 7. By executing said Admission Agreement, Defendant John Rinehart did assume and accept responsibility for the debt to be incurred by Defendant klargaret Rinehart in the event of a breach of the duty to provide payment from Defendant hlargaret Rinehart's income or resources or for failure to comply with completing and submitting an application for Medicaid. See Exhibit "B" as previously identified and incorporated herein. 8. That Plaintiff submitted to Defendants a copy of the itemization of 2 services accurately showing all debits and credits for transactions with Plaintiff. 9. That Defendants did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 10. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Margaret Rinehart's account as a result of said charges is the sum of Fourteen Thousand Four Hundred Sixty and 08/100 Dollars ($14,460.08). See Exhibit "A" as previously identified and incorporated herein by reference. 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Margaret Rinehart's account balance, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant John Rinehart, as Legal Representative and/or Responsible Party for Defendant Margaret Rinehart, demanding that the sums due and owing to Plaintiff be paid, and Defendant John Rinehart has ignored his fiduciary obligation to pay necessary and appropriate bills and obligations for his grandmother, Defendant Margaret Rinehart. ! 3. That Defendant John Rinehart violated his duties and responsibilities as Legal Representative and/or Responsible Party for Defendant Margaret Rinehart by expending Defendant Margaret Rinehart's finances for other purposes when he knew or should have known there were outstanding medical care bills for Defendant Margaret. 3 14. That the finances of Defendant Margaret Rinehart rightfully belonged to Plaintiff for the necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant John Rinehart's grandmother, Defendant Margaret Rinehart. 15. Plaintiff has retained the services of the law firm of Wolfson ~ Associates, P.C., in the collection of the amounts due from Defendants. 16. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay all court costs reasonable attorney's fees and contractual interest if the account is referred to an attorney for collection. See Exhibit "A" as 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 6: Associates, P.C., in the collection of the amounts due and owing by Defendants, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 18. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Four Thousand Three Hundred Thirty-Eight and 02/100 Dollars ($4,3:~8.02). 4 19. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, Plaintiff if entitled to receive and Defendants have agreed to pay contractual interest at a rate of eighteen percent (18%) per year on all past due balances. 20. The amount of contractual interest which has accrued from April 1, 2001 is the sum of One Thousand Twelve and 46/1 O0 Dollars ($1,012.46). 21. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 22. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Margaret Rinehart, Individually, and John Rinehart, Individually and on behalf of Hargaret Rinehart, in the amount of Fourteen Thousand Four Hundred Sixty and 08/1 O0 Dollars ($14,460.08), reasonable attorney fees in the amount of Four Thousand Three Hundred Thirty-Eight and 02/100 Dollars ($4,338.02), contractual interest in the amount of One Thousand Twelve and 46/1 O0 Dollars ($1,012.46), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel ~ WOLFSON ~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff VERIFICATION I, Michelle Thureson, Senior Financial Services Consultant for HCR I~lanor Care, verify that the statements made in the foregoing Complaint are true and correct to the best of my information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" MANORCARE CAMP HILL 17~ MARKET STREET CAMP HILL, PA 17B11 (717)-737-8551 JOHN R RINEHART FOR MARGARET RINEHART 905 HAWFTHORN AVENUE MECHANICSBURG, PA 17055 PRIVATE ROOM 221 Please R~um his Posen W~ ~ur Payme~ 85/~1/~1 ~ALANCE FORWARD PAYMENT DUE BY THE 10TH OF THE MONTH AMOUNT DUE 8612SI81 REBIDEUT LEDGER AB DP DATE O~ ~INSt ACTIVITY PAGE 1 REBIDEBT RESIDENT RESIDRBT GIL -- ACCOUNTS PJCNIVABL! -- 144 PRIVATE RIRRBAPT, NARGA~T E 82/19/81 ADa CNTR RATEs 5828.00 RUN 221 -B LEVEL I 141J61ll 018 PNIV ~8tl J.lJ t'PRIVAtE - NOV II 68181 Pt R CO-INS Pt EVAL IP ll/14/MI 1 11.92 S8189 PT S CO-INS Pt THSRRBEUtI llllA/S8 1 4.51 6Ol2J PT B CO-laB PT THR~PBUTI ll/li/fl 3 13.31 lllJJ BEAUTY ~O BARBER ll/27/fl 1 59158101120 21.Il *qBOlK BALA~! *'HIDICAR[ i - NOV Il 29109 PHA~ACY LKRBD ll/ll/fl 1 5455121J12J 81.39 lilJl PHYSICAL ~HS~PY VI8~ ll/13/IJ -- ll/3JfJ[ 13 5215121112J 6SI.lO 144Jl PH~HICAL THR~PT EVAL 11/13/08 1 52150210120 l?lJl OCCUP THE~PY ViSit ll/14/oJ -- ll/27/fl 9 5255Kl1120 17481 ~CUP THB~PY RVAL Il/lUff ] 52558610121 25.00 515i] N~flD ~A~RBT ]]/]?/ll ] 5~]515]112i 8.11 51511 MONO ~AtflB~ 11/2110i 1 541515~1121 9.11 5150] K~D tUA~Bt 1]/23/00 ] 54151518120 8.lO 51581 ~OUND tREAtNiHt UIZ611I 1 5415151112l 8.11 5]50] MOUND ~BA~BT 11129100 I 541515~0128 MIC[LLARY ~R[Y80~F ll/3llll 5755751112l 2i 513588]ii21 3?Bi.il 21 51557111l~1 ROOM CHARON AT 188.88 111111fl -- 11136/10 800N HPJT80PF 11111/81 -- lll311ll **RBDIKBALMiCE tt#RDICAB8 8 - NOV Il 60191 Pt EVAL IP ll/14/Ii 61111 Pt U CO-INS PT EVAL IP 11/10108 60189 PT THNRBPBSTIC IX IP 11/]Jill 6Jlj9 Pt R CO-IRS Pt tSSRAPSUT[ 11114180 61120 PT ~HRBAPBUTIC ACT IP ]1/]4/i6 6812l Pt B CO-INS Pt THSSAPEUtI 11/14/88 "ERBIK BALAHCR '*PRIVATE - DEC J8 CO-IS8USAKE CO-INSUrE 1111411l Pt COI8 RRV 11/14188 Pt COIN REV I1/14/18 PT COIN NSV **ENDING 8ALMICB '*HIDICASE A - DEC II BAL VN~ -LM- -38- 5161,6i PAteNT MDZCANE A 11/68 14101 PEYEICAL tEERAPY VIii! 1426.32 52156211120 59.62 11,92 521582]1128 22.56 4.51 52158211128 66.5? 13.31 BAL f~ -LN- -3l- -66- -9l- -120+- 58.74 51.74 Ill# BEAUTY MID BARBER 12/131fl 1 59156181126 12.50 At 97.18 1211l/ll-- 1Z/Il/ii 1{ 978.ll AT 9?.ii 12/11/81 -- 12/311B8 21 2i3?.ll 11/14188 14411858888 11.92 11/14/8E 144118588RB 4.51 11/14/88 14411858888 13.31 -68- -98- -121+- 5161.68 12/26/88 11218682800 II/il/il 1 52156218128 25,61 5161.68 58.7A 5161.68 119.01 3041.56 B6120181 BBRIDLq! LIDGSR AR Of DATE OF FIRST ACTIVITY PAGE 2 (AR56) USlDBRTRBSlDERT RB$IDEST G/L -- ACCO~JJ~B RBC8IVASLB -- PRIVST8 RI#IRA~, RA~ARBY B 821191B1A~ CSTR RSTR~ 5828.88 RC~ 221 -R LIVKL 1 04/06/01 DX8 PB[V POSTI J.lJ "NED[CAB! A ' DBC 80 (CORY) 51801 TOTAL [~OIIT-DLY FEE 12/01/00 -- 12131188 31 56151810120 31.# 53101 RYBYNL/BSTRL BEST GRP 1 12/01/80 -- 12/31/00 62 56153118121 29009 PHA~AA¢¥ LIGRI~ 12/09/80 1 54551218120 46,96 3Ill9 PRABI(AC~ RORLBOEND 12/80/08 1 54951310120 2.29 51501 RO~#D YRIRT~NY 12/26/80 -- 12131100 6 5415151012B 48.08 A#CILLAST MR[YE Off 12/31/10 5755751B121 233.85 BOON CBA~B AT 188.08 12/811B8 -- 22110/01 18 51350010128 1888.00 ~00# NBIY8 OF! 12111100 -- 12/lllB! II 5155701012l 7Bi. B! DEDU¢? C0-INR AT 9?.80 18 970,80 BOOM CHABG! AT 1BE.Il 12/lille -- 12/311ll 21 51350811121 M ~IIB Off 121111# -- 121al/Il 21 51557i11128 1308,51 DKDUC~ CO-ZN8 ~ 97.08 21 2137.08 *'NBDICARi 8 - DiC Il B~ ~ -~- -30- -60- -O0- llg. I1 119,ll 11/1~/# ~I BVA~ 11/14/eJ 5215121112e 59.62 11/14/11 ~I C0IN BIV 11/14/~ 14~1115B#1 d.51 II/N/# P~ C0IR BST Il/N/il N~IlISIIIB "BNDIR~ BAL r~ -~- -30- -50- -98- ~119.51 2~.11 ~141.51 PA~RT MC~-12/ll J]/2]/ll 1121#t2tll FAr. ST KCB-I2/II lI/2]/ll 112~1112111 221LJ8 lllll BEAUTY ~n B~iB II/03/11 1 59158111121 ll.JO lllll BIAU~ ~O BARBER 01127101 1 59158111121 11.11 CO-IBS~AEB AT 99.08 Il/il/il -- 81131181 31 3069.00 BAL~ -~- -31- -61- -9,- -121+- 2213.29 221L29 29119 PaA~Cg LSGIH0 IX/OX/el -- lUll/Il I ~4~12111~1 ]0#9 PHA~CY ~BLBGEND Il/Il/Il -- ll/I81ll 1 54951318128 21.66 51511 ROUND ~ArMiRr Il/Il/Il -- Jl/21/Jl 21 541~X518120 IDB,JR 53111 ST~L/INT~ 8BBV ~ 1 II/il/Il -- BI/RI/BI 62 5615~11812i 81.6l 515ll ROUND ~USTKSST Jl/~l/ll 1 5~151511121 8;IJ ~ClLLABY BRITE OFF 01/31/81 57557518121 441.98 ~M CHA~B A~ 188.JJ lUll/Il -- Jl/31/ll 31 5135ll11128 5828.10 M W~TB orr II/Ollll -- Jl/~llll ]1 5155781012l 19~1.61 2213.29 .BO 6131.51 (MiSSl RJNIDBI~ BINIDENT RASlDBK O/L -- ACCOUNTS RBCSlVABLS -- 1,H PNIVA~ NIRANAR~, NMIOAUT S ES2/IHIESI i00K 221 -B LESVEL 1 HIIS/II "{IE)ICAMI A - JAN ESI (COHTJ DEDUCT C0-IN8 A! 99.ESS PP8 AD3 121{illl "RADIK RAISE *'PRIVATES ' FUN ES1 RAL ~IID -LN- -3S- -SS- {IH1.ESI 3E19.SS 21.H lllRA MIAIFFY MiD RARBNN E2/191Sl 53111 NTRTSLIUNTRL 8RAV OD 1 S2/19/II -- ES2/28/81 CO-IKURMICES AT 99.EES S21Sl/Sl -- S2/18/01 M CHAKE AT 828.fl I2/19/ES1 -- S2/28/ES1 ADV KO[q CRABS{ S3/01101 -- 03131/11 'EBD[K RALASCES *'{(BDICMI{ i - FEN Il RALLY) -UI- -3So -6ES- -9ES- 827,39 PA~NENTIgB-I/Sl ES212AISl 531ll BTRFB~IIBYR~ 8gEV G~ 1 O21lllll -- 021181ll 515S2 ~D ~A~ERT 82182101 29ll9 PHAi~CY LKBND IZ/lSlJl -- i2/l?lll 311J9 ~A~CY ~MLBO~D 02/17/01 ~CILLMIY ~ITB OF~ i21281ll BOON CNMIOE AT 188.fl i2/lllll -- ES2/18/tl SOON#BIt! OFF 121ll/41 -- S2/1ESI{1 DEDUCt C0-INS '*IISDIK RALMICES "PRIVATES ' NAN I1 RAL F~ 9?28.48 PAYMENT PAYIIBNt llSll CABLE PJKAL 531ES1 StRtSLIBSTNL SBNV ~]]11 BBAU~ MID RARABB RAV ~Mit NO UC AT 99.H -3t- 3lHl.ll AD# CHtB RATE, 5828.fl DIS PNIV ADV RO~CSMIOE *'ESDIK BALANCE "NESDICMIB A - NAR I1 HAL FND 481,42 31 3169.H 51557ESII1ESI .21 6111.54 1 591581SlI2S II.US 2S 561531ESl124 26,H 18 1182.AS 14 51354ESSI12ES 2ESESI.{8 13211ES#RAES 5828.fl -12N+- 821.39 I12IESRA2ESH 821.S8 36 5615311ES12ES 16.81 1 5415151ESI2E 1 5455121112ES 121.64 1 5495131S12S 2.29 5755151412l 184.13 18 5135HIS12S 3384.H 18 51551ES1ES12ES 1121.58 18 l?82.JJ -6S- -HS- -12S+- 3119.54 21.1l 15859.98 S3119/S1 1121SH2SH 21.SS I3119/ESI 112188121ll 2i79.11 J3/ll/E1 -- i3/31/0] ] 5915841112S 5.11 431ES1111 -- U31261ll 52 561531ESl12l6?.SEE S31IA/NI 1 591581ESI12ES 8]1{1/Jl 13211lml! 5828.6ES AT 828.H ES3/Sl/Sl -- ES3/31/ESI31 5135flSlI2ES 5828.fl EH/ESI/ES1 -- 4{/]ES/ESI I]211HESESIES 5828.ESES -31- -6i- -HS- -12A+- .31 J3/21/ll ll2IRAI2Sfl 46S.24 821.39 15859.98 19311.58 .49 16/21111 RIBIBEB? L~DGBB BB O~ DA?E Ol ~IB~ AC?IVI?¥ PA~! 4 lAB561 BNGIDEBT UBZD~T 8SEIOlB! G/L -- ACCOUNTB BBCEIVABL! -- 144 PBIVATB RZBBBBBT, NABBABB? E ROON 221 -B LEVEL 1 *tPBIVATE - APB E! BAL FNG -U(- -38- 11779,6! 3911,48 115# CABLE RENTAL REV LAB! BO BC BOON CHAISE **NEBICABE A - APR B! BAL ~NG -LN- -30- .18 29#9 PEABNACY LBGBNG **INGIN~ BALANCE **PBZVA!B - NAY 02 BAL FNG -~- -30- 976.5A 5951.58 t*ENGI#$ BALANCE **~DICABE a - NAY 61 BAL FNG -L#- -38- PPA ADJ PPA ADJ *'ENDING BALANCE J2119/l! ADB CBTR RA?iz 5828.# 0416618! DIS BBIV POB!~ 1.6l -BE- -ge- -220+- 3191.86 541.58 193tl.58 641AllJ! 1 5915B#112! 5.00 JAil!Il! l]2!!llllll AT 828.# e4/Ol/Jl -- la/ES/E! 5 5135100112E 971.58 -6i- -9l- .31 .49 lille/l! ! 54551210120 J4/]J/il 5755751112E 37.96 -60- -ga- -12O+- !9Il.18 3191.i! 511,5l !i461.18 -60- -ge- -!2l*- .IB .31 .49 l!/31/Jl 5155711612! 12128/1! 51557111121 5628.il 37.96 .3! .lB 14466.18 .49 1446E.16 .# EXHIBIT "B" HCR iglanor Care ', ' ADMISSION AGREEMENT TbJs Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities oftbe parties with respect to the Resident's stay at tt~s HCR Manor Care's Health Care Center ("Center"). Center: HCR Manor Care Camp Hill Resident: Legal Representative: Admission Date: ,, li[it/~ Deposit: $ /U/~ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. T 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10th) day of each month. The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organi?ation (see Section 1.06). 1.02 Ancill~. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary. Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10th) day of the month. I:03 Late Payments. Accounts not paid in full within thirty (30) days of billing sh~ll be · subject to a service charge equal to the highest legal rate of interest permitted by State law as set tbrth in Attachment A on the past due balance each month until such time as (he balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not l/raked to, the Resident's attending physician for any health or personal program in a~cordance with the terms of the program. 1.05 Govemrnenta~. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such prograra, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with ail program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the fo[lowing programs: X Medicare. X Medicaid and/or VA. Medicare may pay for some or all of the Resident's care. If M~icare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident andqor Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate fi.om their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Manaqed Care OrganiTations. Ifa Resident is a participant in a plan offered by a third party payor such as a Heakh Maintenance Organization ("HMO"), PretErred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entry with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Cemer 2 will bill ~'he Resident's third party p~ayOr as'a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibLlity of the Resident and/or Legal Re?*eentativ~. *,, ,~,,,; .fy *be Center and *~, party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreemem. 1.09 ~Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered. under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, I-fiMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This Agreement serves as a written no'fic~' th/it the Center has notified the Resident and/or'Legal · Representative that services provided at the Center may not be covered by a governmental payor, th/rd party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. I.I 1 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 Legal Authority The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority,, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative agrees to pay promptly fi.om the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment fi'om the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 ~ The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or I. egal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 _2.05 Cooperation tbr Fina~cl~l Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Nledicaid representative shall require for continued coverage o_f' the Resident and be personally responsible tbr any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician.and the Center, w/th the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, fi.any, noted at the beginning ofth/s Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time fi.me required by State law. In the ease of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. G ENEIL-kL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance rkviews'or payment audits perfo'rm&t b3' st~ch; the personnel of any hospital or other healtl{ care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required fi-om time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to .~.xs,.n ................... 6 - v,.,~,~,,~p,i ,~ -,'.~,,ac~L /or use in iaenthS, ing me Kes~dent, lr0r placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staffto identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opporturfity to ask questions and questions have been answered satisfactorily. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds jo Authorizat'ion"and any other related documents. See Attachment H-I' and H-2. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fi'aud control unit. See Attachment I (Center Supplement). The name, specialty and way of contacting the attending physician, medical airecmr ana omer pnys~cmns wlao serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). The Resident Handbook. See Attachment J. Resident/Patient Rights. See Attachment K. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-I and M-2. Privacy Act Notification. See Attachment N. Inventory sheet and/or policy of personal items. See Attachment O. U. W. X. y. Z. ASM Form. See attachment p. See Attachment Q. See Attachment R. See Attachment S. See Attachment T. See Attachment U. See Attachment V. See Attachment W. 4.05 Assi nment of Benefits. The Resident and/or Legal Representative hereby requests that payment o£autnOr~zed governmem ano/or tram party payor ~netits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to th. is Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharge and Transfer~ This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or ~njury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result ora change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the ex'tent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: Signature oflkegal Representative, signing on his/her om behalf: Date:~ Date: Center Representative: ~ ~,.~.rv,..~ fl. ~,~ Date: 9 SHERIFF'S RETURN - CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCRMAIqOR CARE VS RINEHART MARGARET ET AL OUT OF COUNTY R. Thomas Kline duly sworn according to law, and inquiry for the within named DEFENDANT RINEHART MARGARET but was unable to locate Her deputized the sheriff of DAUPHIN , Sheriff or Deputy Sheriff who being says, that he made a diligent search and in his bailiwick. County, , to wit: He therefore Pennsylvania, serve the within COMPLAINT & NOTICE to On November 16th , 2001 , this office was in receipt of the attached return Sheriff's Costs: Docketing Out of County Surcharge Dep Dauphin Co from DAUPHIN. 6.00 9.00 10.00 ~_ z~. ~T~6mas Kline 29.25.00 --~ff/ of Cu~erland County 54.25 11/16/2001 WOLFSON & ASSOC Sworn and subscribed to before me this &- day ~9o-~ ! A.D. ' ' Prothonotgry SHERIFF'S RETURN - CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS RINEHART MARGARET ET AL REGULAR DOUGLAS DONSEN , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon RINEHART JOHN INDIVIDUALLY the DEFENDANT , at 2000:00 HOURS, on the 5th day of November , 2001 at 905 HAWTHORNE AVENUE MECHANICSBURG, PA 17055 CHERI RINEHART, WIFE a true and attested copy of by handing to COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 7.15 Affidavit .00 Surcharge 10.00 .00 35.15 Sworn and Subscribed to before me this ~-~ day of ~ ~/ A.D. / P~rothonotar~ So Answers: R. Thomas Kline il/16/200i WOLFSON & ASSOC Deputy Sheriff SHERIFF'S RETURN - REGULAR CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS RINEHART MARGARET ET AL DOUGLAS DONSEN , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to says, the within COMPLAINT & NOTICE was served upon RINEHART JOHN ON BEHALF OF MARGARET RINEHART the DEFENDANT , at 2000:00 HOURS, on the 5th day of November , 2001 at 905 HAWTHORNE AVENUE MECHANICSBURG, PA 17055 CHERI RINEHART, WIFE by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service .00 Affidavit .00 Surcharge 10.00 .00 16.00 Sworn and Subscribed to before me this ~L ~ day of ~ ~! A.D. 'P~othonotary So Answers: R. Thomas Kline ii/16/200i WOLFSON & ASSOC Deputy Sheriff Mary Jane Snyder Real Estate Deputy William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255-2660 fax: (717) 255-2889 Jack Lotwick Sheriff J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy Commonwealth of Pennsylvania County of Dauphin AND NOW:November 9, 2001 NOTICE & COMPLAINT RINEHART MARGARET HCR MANOR CARE vs : RINEHART MARGARET Sheriff's Return No. 3127-T - -2001 OTHER COUNTY NO. 01-5931 at 9:15AMserved the within upon to CHERYL BUMGARDNER, of the original NOTICE & COMPLAINT to him/her the contents thereof at 2625 AII2%NTHUS LANE HBG, PA 17110-0000 by personally handing DIRECTOR OF FINANCING 1 true attested copy(ies) and making known Sworn and subscribed to efore me this 9TH day of NOVEMBER, 2001 PROTHONOTARY So Answers, /puty Sheriff Sheriff's Costs: $29.25 PD 11/01/2001 RCPT NO 156064 TORO In The Court of Common Pleas of Cumberland County, Pennsylvania HCR Manor Care Mar§aret Rinehart et al SERVE: same No. 01 5931 civil ' October 30, 2001 , I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Daughin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Curaberland County, PA Affidavit of Service Now, ,20 , at o'clock M. served the within upon at by handing to a and made known to copy of the original So answers, the contents thereof. Sworn and subscribed before me this __ day of ,20 Sheriff of County, PA COSTS SERVICE MILEAGE AFFIDAVIT IN THE COURT OF COl~klON PLEAS OF CU~4BERLAND COUNTY, PENNSYLVANIA HCR HANOR CARE, Plaintiff VS. HARGARET RINEHART, Individually, and JOHN RINEHART, Individually and on Behalf of MARGARET RINEHART, Defendants NO. 2001-05931 CIVIL ACTION - LAW PRAECIPE TO WITHDRAW COklPLAINT Please withdraw the Complaint with prejudice in the above captioned matter. Dated: Respectfully submitted, WOLFSON ~ ASSOCIATES, P.C. ~'my F./~lfs~TEs~uir,// 267 ~t Iqarket. Stree~ ¥ork,~Pennsylvama 1740~ 71 ~/846-1252 I.D: ~87062 Attorney for Plaintiff