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Home My WebLink About01-03976IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCRMANORCARE, NO. (~~-~2(o t~jU~~~~ Plaintiff vs. RICHARD BLACK, Defendant NOTICE CIVIL ACTION -LAW 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 wl'thout you and a judgment maybe 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 hen demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dial de plazo al pardr de la fecha de lademanda y la notifiation. Used debe presenter 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 defienda, la torte tomara medidas y psedido entrar una Orden contra,usedsin.previo aviso o notification y por cualquier queja o alivio que es pedido en la pedcion de demanda. Used puede perder dinero o sus propiedades 0 otros derechos importantes para. used. LLEVE ESTA DEMANDA A ;UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGARTAL SERVICIO VAYA EN PERSONA O LLAME POR TECEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249.3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. O l- 3 9 7G Cc~,~ ~.cw vs. CIVIL ACTION -LAW RICHARD BLACK, Defendant COMPLAINT AND NOW, this ~ day of ~'l,t,i-~P, , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Fsquire, and the law firm of Wolfson 8t Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCRManor 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 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Richard Black, (hereinafter referred to as "Defendant"), is an adult individual with a last known address of P.O. Box 692, New Bloomfield, Perry County, Pennsylvania 17068. 3. That on or about March 15, 1999, through May 14, 1999, Defendant was a health care resident of Plaintiff, where he 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., 4. That on or about March 16, 1999, Defendant executed an Admission Agreement which Agreementout(ined various terms of residential health care services to be provided by Plaintiff and ahe Respgnsible Party therefor. A true and correct copy of the Admission Agreemeht -dated March 16, 1999 is attached hereto, incorporated herein, and collectively marked as Exhibit "B". 5. That Paragraph Four (4) of the Admission Agreement did describe the various responsibilities of Defendant, which responsibilities did include payment for the daily rate and charges for supplemental services, supplies not paid by any third party, as well as applicable co-insuranC~`%and deductibles and all expenses of discharge or transfer. See Exhibit "B" previously identified and incorporated herein. 6. That Plaintiff submitted to'Uefendant a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been;p'Yeviously identified as Exhibit "A" and incorporated herein by reference. 7. That Defendant did not object to the above-mentioned Statement of Account submitted by Plaintiff to befendant. 8. As of the date of this Complaint, the balance due, owing and unpaid on Defendant's account as a result of'said charges is the sum of Eight Thousand Eight Hundred Forty-Six and 15/1'00 Dolla~s~ ('8,846.15). See Exhibit "A" previously identified and incorporated trerein' ' -- .. 9. Despite Plaintiff s 'reasorfa~te and repeated demands for payment, Defendant has failed, refused; aril"continues to refuse to pay all sums due and owing on the outstanding account belarice, which accrued due to residential health care services provided to Defendant, all to the damage and detriment of the Plaintiff. 10. That Defendant has been uncooperative in providing the necessary information to Plaintiff to assist Plaintiff in completing an application for Medical Assistance on behalf of Defendant. 1 1. Pursuant to Paragraph Eight (8) of the Fee Schedule which was attached to the Admission Agreement;'PCamtiff i5'e`ntitled to receive and Defendant has agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. ,, See Exhibit "B" previously identified and incorporated herein. 12. As of the date of th'e within Complaint, the amount of interest that has accrued on the past due balahce is the sum of Two Hundred Thirty-Nine and 80/100 Dollars ($239.80).- 13. Plaintiff has retaineii the services of the law firm of Wolfson st Associates, P.C., in the collectiorrbf the'amounts due from Defendant. ;. 14. As of the filingof'tflis Complaint, Plaintiff has incurred reasonable attorney's fees from the law office'of Wolfson Si Associates, P.C., in the collection of the amounts due and owing liq Defendants, incident to the within action, and Plaintiff shall continue to incur such acforr-ey's fees throughout the conclusion of the 3 ~~~ :. proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by Defendant. 15. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Two Thousand Six Hundred Fifty-Three and 85/100 Dollars ($2,653.85). 16. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 17. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. ` WHEREFORE, Plaintiff; HCR Manor Care, respectfully requests this Honorable Court enter judgmenti in favor of Plaintiff and against Defendant, Richard Black, in the amount of Eight Thousand Eight Hundred Forty-Six and 15/100 Dollars ($8,846.15); c'oa~tractual interest in the amount of Two Hundred Thirty-Nine and 80/100 Dollars'('$239:`80); reasonable attomey's fees in the amount of Two Thousand Six Hundred Fifty-Three and 85/100 Dollars *4 . ,'., ~ 4 ($2,653.85), the costs of this action, and such other relief as the Court deems proper and just. `Respectfully Submitted, L`,~ Daniel F. Wolfson, quire WOLFSON St ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717) 846-1252 LD. No. 20617 Attorney for Plaintiff 5 EXHIBIT "A" Statement I~CR •ManorC~ane MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)=249-0085 HMO RICHARD BLACK PRIVATE P.0. BOX 692 ROOM OUT PAT IYEW.Bl00MFIELD, PA 170680692 Please Return This Portion With Your_Payment BLACK, RICHARD 99022 06J01/99 06/01/99 05J31/01 -=------------------------------------------------------------------------ DATE OF CODE SERVICE RENDERED CHARGES CREDITS SERVICE 05/01/01 BALANCE FORWARD 8,846.15 t PAYMENT DUE UPON RECEIPT AMOUNT DUE 8,646.1', ~~ NFT27xNt~1;2E {iERLTH :i~HVlt:E;i 312 04106/59 tRR431 GHT LENT F'Rl IEN1 FK111EN1 NuNdtR TYS~ Ni~tE {+F1IIENT LEi6ER F15 t& 03!'51/55 VrKf 15 till - Ftt:f:Ulb1T1~ kLCE1URALE -- URTE UTY 12~;tX1lWt CNRRtiLS t:R;:Dfr:i ARLRr2~:c 990'c'2. 1N5~IkFIt~:EA ALRf:K~ R1L42RkD 0'5/15/59 RDFt t~1T(f kRTE: C'0`,i.6A Htb7N 1?2 -d L>:U~L 1 DIS ;,t?;21V ;hJRr: a. x0 +~PNIV. RLtiT 706 6RkEEk 8 AERUIY 6s125/99 1 ;t50'e06 bl A.66 *+~EPlDfN6 dRLfWL:: d.xx ~+~iN5UHRNL:EA 900 VkES[:k1F'11CM DktHil; 6:VIS/S5 -- 0:s/19/95 1 .ir'12~ 0t 4I.25 9a65x I~IN-At~.:~t:AlPr1t1P1 DtNltii a3li~t95 -- a3!•?4159 i 3:'.~G?Pa a3 l'2.:73 90101 F'. 1. E•VFIt.lV111UN 63/1x•/59 1 s612F?~b br: 126.60 5a1a~ F'. t. SKlW:D Tt2Nt. x3/16/95 -- x3/3a/95 5 351?0a 0d T::a.x0 50111 U. 7. EVFNURTION 63/16/99 1 s4"s?60 bt: 1c1P.66 9x112 p. t.:i(lLLr.D (D9Ir. x3/16195 -- x3/31/99 X10 3432xa 6:1 G7a.x0 96121 ::, 1. EVF~URIIIM 0:s/27/99 1 3k12P6 6F: 126.06 9x116 a. T.:,YIAS'LB:S a3/l9/99 1 3h32x0 b:i Id, t3 RNt:11LF;kY NRITE (d-E 65/31/99 "199660--% i'&K'2.21 R~A7N C1~112tit Rf 123.0a a3Ji~/59 - x3/•11/55 1! 3x1E00--7 2x91.xa R(dPi NkIlk. bf E bsli:./95 -- bval/99 17 %;;666-I 1394.66 +~r RWN CHRt2th: 3asixa ~ENDIN(i ARLFW[:E :5§A5.66 ~' ;,~. MANORCA~3E HEALTH SERVICES 3I2 @5/06/95 NAi1FNi LFD6Ek AS fIF" @4/3@199 FYI 22 (AR43I F~AiIENT {'A1fENT NATIENI NUMaER fYF~'c NAME 6150.00 9535.00 G/L -- A[:GUIWTS kECEIVI',BLE -- @AT:: CITY ACCUUNf L'HARh;:S CRcO[T9 BAiANCE 99@22 INSUkANLft: BLACK, k1EfiARD 0311:;/99 ADM C:Nik kATE: 205.@0 R@UM 15 -a LEUa 1 ols atuu ;~IRr: @.@@ +~~PRIV, fh:CT BAL FW@ -LM- -30- -60- -9@- -12(Rt- A. ~ +1.00 PRYF~NT B1AfK, kIGE1F;kB 04111199 1020G~ PAYMLNf aLACK, RICHA;IU 04/13/99 10;_'000 PAYb~NT a1A[:K, k1CHF:kU 04/13/9, i0?0@0 43A0.0@ ~t<~aINS a;aLANL *~ ] NE~IRAN[:Ef: BAL FND •LM- :t0- -60- -5@- -1?GN- 3485.00 3b95.00 900FK4 PRESi:k1PIICW @kUG't 03!29!99 -- 04/31/99 1 321!00 QM. bl.%R 50105 f~. T.:Y11LL±:a f;7Mf. 04/01/99 - 04/x/99 .i9 351:?00 @d 1770.00 40111 @. T. EItILLEll TkMi. 04101799 -- 041f4/99 :sv 343P00 0C 1050.0@ 5010 NUN-VRE:~;RlVfUIN @ttUti; 04Id3/99 1 d::~?4uD 0d 5.41 5$] 16 U. i. 511f5+C lf5 04/0%/55 1 34:f~@@ ~ i?.91 ANCILLRRY WRITc OF 04/30/99 79900@-1 8.00 4.p?0.00 .00 ~~o l ~~ @, l0 239 R[NAM (MFIk6E AI 1'rs.00 04/01/99 - 04/1f:/95 18 301200--7 214.00 Rtn]M WRifc ~>rr 04/01/99 - N41l8/99 1a 799090-7 1476.00 RIWM f~iAkFE Ai 11:3.0@ @4/19/99 -- @4/30/9;' 1? 3@120@--% 14%6.@@ RUfIM WRIfE ~~- 04!19/99 - @4/3@199 12 759000--7 9:14.00 .. +EtdEl kQCW (fIAkUE *+~VDlNS aALANCE M:2NQ;A:.9;L: ]{rA1.TH :;;ERUfUE5 3!? 05/05/99 F'fIT1ENT Il'DGf k P.l. (d 0:J31/99 F'M+f c'3 {R8h.31 DR2ICNT F'RTIENT F'R1IEN2 MJMa22 fY~r NAME It/l -- Rti#dddT:c kECE1URalE' •- trlTc: OTY AC:~)sJNT tt$I;2;>7::i ;:l8:0[f:i OIN~2NCc 990c2 1NI;UNFdVCEa NLfKl{, k1GiWkU OS11:'i/95 RUM GN2k kRTE: F0.`,.00 ;2:DIM 1?5 -$ L'cUtiL 1 0"/14199 OIS OR{U }hB2f: 0.00 +~Ir~{Jal~w:~a bRL EWD •LM- :+0- -60- -90- -1701- 61.`,0.00 34;1:;.00 9535.00 pRYMENf 9E.Rt#{, klt#'dSkU 05/F5/99 102000 's4t'S.00 9010'.; P. 'f.:D{{LL::U f;1Mi. 05103199 -- d5/t3l99 1 351?00 a1 Sh0.00 1 90000 1'kE:~[:k1V71UN UkIK+a N:JN6199 1sca.`'00 Guy {/. N6 `1\h\' RNCII.LAt1Y WRtf%::1~'r ~Fi/3i/99 7')9000--/ u51.05 ~,,~( -,/ R[dIM (EG`.kC•E f:2 123.00 0EJ03/99 -- 0.~l13/9'.: 13 ;01c00--"/ L'~99.00 ~~/~ 7t1tJM W;tlf%: :): ;' O:;MI/')9 •• 0:i/t3/')9 l3 T39000-•/ 1055.00 ~NE:1 ktdd7 t#U:kEI. ",E.:~.00 ~ ^\Q~ x~.fTlO(NG OtY-AMa: %YIt5.00 "T~ 06f14 01 RESIDENT LEDGER AS OF DATE Of FIRST ACTIVITY PAGE 1 (AR56~ RESIDENT RESIDENT RESIDENT Gfl -- ACCOUNTS RECE IVABLE -- NUNBER TYPE NAME DATE QTY ACCOUNT CHRR6ES CREDITS BALANCE i 99822 HNO BLACK, RICHARD 06fO1f99 ADN CNTR RATE: 215.00 AOON OUT PAT IEVEI 1 06f01f99 DIS PRIV PORT; 0.00 I **PRIVATE - OCT 00 TRRNSFER fRON NMO 04f01f99 14411050000 8815.00 **ENDING BALANCE 8815.00 ' **PRIVATE - NOV 00 BAL FWD -tN- -30- -60- -90- -120+- = 8815.00 8815.00 **ENDING BRLRNCE 8815.00 **PRIVATE - OEC 00 BRL FWO -LM- -30- -60- -90- -120+- 8815.00 8815.00 **ENDING BRLRNCE 6615.00 **PRIVATE - JAX 01 BAl FWO -LM- -30- -60- -90- -120+- 8815.00 8815.08 **ENDING BRLANCE 6815.00 **PRIVATE - FEB 01 BAl FWD -lN- -30- -60- -90- -120+- 8815.00 8815.00 **ENDING BRLANCE 8815.00 **PRIVATE - NAA 01 BRL FWD -LN- -30- -60- -90- -110+- 8815.@0 8815.00 REV ADJUSTNENT 04f01(99 14411050000 8815.00 R% 04f30f99 54551201100 61.78 DT 04~30~99 52550601100 1050.00 OTC 84f30f99 54951301100 5.41 OT SUPPLIES O4f30f99 52550601100 2.91 A 6 B 04f30f99 51350001100 3690.00 PT 05f31f99 52150201100 640.00 R% 05f31f99 59551201100 27.05 R & B 05f81f99 51350801100 1599.00 **ENDING BRLANCE 86-06.15 **PRIVATE - APR 01 BAL FWD -LN- -30- -60- -90- -120+- 8846.15 8846,15 **ENDING BALANCE 8846.15 **PRIVATE - NAY 01 BRL FWD -LN- -30- -60- -90- -120+- 8846.15 8846.15 **ENDING BRLRNCE 8846.15 ,, ,: EXHIBIT "B" . ADMISSION AGREEMENT Manoi°Care CONTRACT BETWEEN PATIENT/RESIDENT AND FACILITY HeafYh Services THIS ADMISSION AGREEMENT (the "Agreement") is entered into this ~~~ day of 1MAr~_ , 19~- ,between p411p1~1~S11PE x~xr,~x SERVICES (the "Facility"), and ~tr.1~r~ ~ i~-tlc~/t~aC_-- (the"Patient/Resident"),and/or (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean 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 Patienf/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 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. P9 1of3 ~~, • 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 Materiais • Photo/Media Events • Personal Fund Account Procedure o 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 patties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default of this Agreement shall not operafie 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. Facility Representative -Signature Responsible Party -Signature Facility Representative -Printed Name R Titles Responsible Party -Printed Name ~Y1~_~~ Date -I (c ~ `7q Date MRC•ooe-zo (Rev. 4/96) pg 5 3 of 3 EXHIBIT A -RESPONSIBLE PARTY APPOINTMENT The Patient/Resident's Responsible Party may be any person legally responsible for the Patient/ Resident. ^, competent Patient/Resident shall not be required to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. ^ 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). ^ 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 a?lthorize 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 '-~~\ P,~tierfC/Resident -Signature _, r-~ /~. Facility Representative -Printed Name & Tjtle~- ~- P, a\t/Resident - Pr+nted Name i' \` [~, The Patient/Resident is competent and does not have acourt-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). MHO-a08RO (Rev. 4/96) pg 6 t Of 2 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 cover-;:) 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 (``nt~cp~ ~~ , 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 al! 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 Condition: 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 no' complied with, the Facility will have detrimentally retied upon them and the Facility will suffer financia harm and loss. i Responsiblensible Pa~atur~ ~~-~-~"C Responsible Party -Printed Name 3-1~-~i~ Date /nRC•ooeao (Rev. 4/96) pg 7 2 Of 2 EXHIBIT B -FEE SCHEDULE 1. Daily Rate. The daily rate is $ ~-00 . The monthly rate equals the daily rate multiplied by the number of days in the month. The daily rate is billed one month in advance and includes: • Routine Nursing Care • Linens • Social Services • Meals (additional fees may apply) ivities • Housekeeping • Room (circle one): Private Semi-Private Triple The following are paid by Medicare in a i ion to the items included in the daily rate: • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment • Approved Routine Personal Hygiene Items/Services • Other approved services/items covered and paid for under the state Medicaid program. 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM • Private Room • Prescription &Non-Prescription Drugs • Nursing & Personal Care Supplies • Transportation • Nursing Care (Other than ordinary nursing care) • Physical, Occupational & Speech Therapies • Phone, Cable TV, Newspaper, Barber/Beauty • Special Equipment • Bed Hold Fees • Personal Laundry (Personal Clothing) • Nutritional Supplements • Alternative Nutrition (Tube Feeding, TPN, etc.) RATE Based on location & level of care As determined by pharmacy See business office for current prices As determined by transport company See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever aPatient/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 Faciiity 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. Mxc-ooeeo (Rev. 4/96) pg 8 1 p{ ? 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. Ahy account not paid in full shall be subject to a one and one-half percent (1~/z%) service charge on the past due balance each month until the balance due is paid in full. This amounts to eighteen percent (183'°) annually on the unpaid balance. If the maximum annual service charge allowed by state taw 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 ail court costs and reasonable attorney's fees of the Facility if the Facility prevails. 9. Responsibilities. The Patient/Resident is responsible for, and shalj 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 transterred 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 shaA 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 ~) e Facility currently participates in the Medicaid program. If the Patient/Resident believes she 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 it the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicai~ representatives. rnee.ooe-2o IRev. A/9F1 nn 9 n ..a n __ *~._~ n ~ ~~ ~ ~ ~' ~' C ~ ~, ~ ~ c ~ -v ~ ~ h~ .. _ .. _.. ... ._. _ _,~.. ~.. ~~ ~ rwr.. ~-~ . x .,e ar=.3~iez.N w~~ r~ -.: ~msus;~l'~5 SHERIFF'S RETURN - NOT FOUND '" 4 CASE NO: 2001-03976 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND HCR MANOR VS BLACK RICHARD R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named defendant, DEFENDANT BLACK RICHARD but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND as to the within named DEFENDANT BLACK RICHARD MOVED LEFT NO FORWARDING Sheriff's Costs: So answ ~ ~i` Docketing 18.00 Service 3.25 Not Found 5.00 R. Thomas Kline Surcharge 10.00 Sheriff of Cumberland County .00 36.25 WOLFSON & ASSOCIATES 07/13/2001 Sworn and subscribed to before me this .Z 3.u( day of Pr h notary IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. ~ I -.34?,L ~~~ ~ ~~~ Plaintiff vs. RICHARD BLACK, CIVIL ACTION -LAW Defendant ~-:, ~ , NOTICE ~: __._ T; =., -- You have been sued in Court. If you wish to defend against the daims~~Yfortldn the -.,~_ following pages, you must take action within twenty (20) days after this Compl ~and_I~otice? ~'-7 is served, by entering a written appearance, personally of by attorney, and filin~~'iT~i'~`~graitiii~ witF_ :.-, the Court your defenses or objections to the, claims set forth against you. You ~r~,;yvarnetl that{' if you fail to do so, the case may proceed without you and a judgment may be e~red1~ain you by the Court without further notice for any money claimed in the Complaint, opt document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dias de plazo al pardr 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 defienda, la torte tomara medidas y psedido entrar una Orden contra used sin previo aviso o notification y por cualquier queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades 0 otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFiCIENTE DE PAGARTAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 1701~R~1E Ch?PY ~ R~~QRD (717) 249-3166 k~ T '~&#iBtif, I hire;& ilti$03~$ mp~S!;1d ®f Gtxe at , Pa. TM '~ Iy IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. Plaintiff vs. CIVIL ACTION -LAW RICHARD BLACK, Defendant COMPLAINT AND NOW, this day of ~'ix,h~, , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 8t 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 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Richard Black, (hereinafter referred to as "Defendant"), is an adult individual with a last known address of P.O. Box 692, New Bloomfield, Perry County, Pennsylvania 17068. 3. That on or about March 15, 1999, through May 14, 1999, Defendant was a health care resident of Plaintiff, where he 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„ 4. That on or about Match 16, 1999, Defendant executed an Admission Agreement 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 March 16, 1999 is attached hereto, incorporated herein, and collectively marked as Exhibit "B". 5. That Paragraph Four (4) of the Admission Agreement did describe the various responsibilities of Defendant, which responsibilities did include payment for the daily rate and charges for supplemental services, supplies not paid by any third party, as well as applicable co-insurance Wand deductibles and all expenses of discharge or transfer. See Exhibit "B" previously identified and incorporated herein. 6. That Plaintiff submitted to Defendant a copy of the itemization of services accurately showing ali debits and credits for transactions with Plaintiff. Said Statement of Account has been `previously identified as Exhibit "A" and incorporated herein by reference. 7. That Defendant did not object to the above-mentioned Statement of Account submitted by Plaintiff to Defendant. 8. As of the date of this Complaint, the balance due, owing and unpaid on Defendant's account as a result of said charges is the sum of Eight Thousand Eight Hundred Forty-Six and t5/100 Dollars ($8,846.15). See Exhibit "A" previously identified and incorporated herein. 2 9. Despite Plaintiff's reasonable and repeated demands for payment, Defendant has failed, refused; and continues to refuse to pay all sums due and owing on the outstanding account balance, which accrued due to residential health care services provided to Defendant, all to the damage and detriment of the Plaintiff. 10. That Defendant has been uncooperative in providing the necessary information to Plaintiff to assist Plaintiff in completing an application for Medical Assistance on behalf of Defendant. 11. Pursuant to Paragraph Eight (8) of the Fee Schedule which was attached to the Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" previously identified and incorporated herein. 12. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance is the sum of Two Hundred Thirty-Nine and 80/100 Dollars ($239.80). 13. Plaintiff has retained the services of the law firm of Wolfson St Associates, P.C., in the collection` of the amounts due from Defendant. 14. As of the filingof this Complaint, Plaintiff has incurred reasonable attomey's fees from the law office of Wolfson Si Associates, P.C., in the collection of the amounts due and owing liy Defendants, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the 3 proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by Defendant. 15. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Two Thousand Six Hundred Fifty-Three and 85/100 Dollars ($2,653.85). 16. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 17. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff; HCR Manor Care, respectfully requesu this Honorable Court enter judgment ih favor of Plaintiff and against Defendant, Richard Black, in the amount of Eight Thousand Eight Hundred Forty-Six and 15/100 Dollars ($8,846.15);'tontractual interest in the amount of Two Hundred Thirty-Nine and 80/100 Dollars ($239:80), reasonable attorney's fees in the amount of Two Thousand Six Hundred Fifty-Three and 85/]00 Dollars 4 ($2,653.85), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, quire WOLFSON gt ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717) 846-1252 LD. No. 20617 Attorney for Plaintiff 5 EXHIBIT "A" ^,~ • _ `~„^r'r.~,'~ Statement MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)=249-0085 HMO RICHARD BLACK PRIVATE P.O. BOX 692 ROOM OUT PAT NEW BLOOMFIELD, PA 170680692 PleaseRetumThisPortion . With Your,Payment BLACK, RICHARD 99022 06/01/99 06/01/49 05J31/01 DATE OF CODE SERVICE RENDERED CHARGES CREDITS SERVICE 06J01/01 BALANCE FORWARD 8,'846.15 t PAYMENT DUE UPON RECEIPT AMOUNT DUE '\ 8,846.1'. NANURL'Nf1E HtALTN :icRVlL'E9 3/•? 04/06/95 IfIR431 RRIIENI LEbiiER H5 OE' 03/3I/59 PR[iE 15 RHIIENT F'H1IEN1 RHIIENi NUNdER TYGF. NflNt fill - Fll'{;GLVITt: kt.GElUIaSLE - GRTc t1TY clu:uUNf L'FiilRtic5 CRcafl'i `Sf1LfWCc 55022 1N5UkNNCSd bLACii~ kIL4INkD 8:x/15/55 pDPI CNTk HNIE: 1'05.88 RUs]N 12 -d LEVcI 1 xL'] RfllV Mufti: x.00 +~RRIV. Flt);T 70688 bNHbEk & IiENU1Y 8312`.r/9S 1 :s502a0 81 A.ON +*ENDING dpLtV~lC~ a.xx +~1NSi1kRNCEE 500xx F'kE5ik11'i1CA! DkUtiS 0:VI5/S5 -- 83/ISlSS i scl?00 0P• 41.25 9a0`,x NIIN-'at7E:A:A1PflDN UINJh`,i 03/i~/94 - a3/:?4/59 1 3:':~S?Nk1 03 l?.li 98101 i'. 7. EV8Lt1AIlUN 83/16/55 1 s612a0 0ts f28.bx 9a1x5 R. f.:]HlLLsid iflNi. x3/16!39 - x3/:ia/99 9 'soli?0x 0d T?a.a0 981}1 C6 7. EVfdlIF:11IV! 03/1615: 1 's4"s2.0x Sts 1f'0.0x 9x112 u, i. ;d(tLl,~ tANf. x3(!6/99 -x3131/99 ,t8 343200 0:l 97x. a0 90121 ::. 1'. EV{•LUkiI[4! 03/1"//95 ! 341200 0ts 120.00 9a116 x. (. ;~11}.~!<S x3/19/93 1 3432a0 a:3 id. 13 NNCItU1kY WR1TE [IFE 03/"St155 755000-7 i~•2.r1 NU~7N L'1#Uc~t ai 1.?3.8id x3/15/93 -x3/31/93 I/ 3x1~7x--7 2a31.xa RU(0i WkIIF.IVE 03/I.J59 -- 03/31/55 17 '155000-% 1354.08 +Frl~r RuuN cilafn;L .~,IS.aa +~EFU;IN6 &iL11NCE 34E~.00 ~~ MANUt2CAftE HEALTH 6'ERVICES 3I2 0`,!06/99 (AN431 ppTIENT fY27Il:MT RflTIEtTI MiMBER (YA'~ NAME 99022 INSUhHNL~B SLACK, RICHARD N~NM 1~?y -d LEUcL 1 +~ARIV. AL'CT RH7IENT LFD6tk AS UE 04/30/99 f+ASE 22 G/L -- A(tUL!NTf: NECt-.IVF:aLE -- DATt: UTY AL'UIUNC L'IiAd!i:S CtYcUIT5 !iA!ANL'E 0;a1I:;/99 IutM CN7k kHiE: 205.00 OI:i NR[V 9Udf: 0.00 SAL FWD -I.M- -30- -60- -50- A.00 pAYP1EN7 aiAI:K, killiAkD 04/13!99 RAYM~lI BLAB(, AICHAAU 04/13/95 PAYb1FNT alA(:K, NIL'NI:kU 04/13/S9 *~cNUINti d9L9EA, BAL FWD -1,P1- -30- -60- -50- 34:17.014 90000 PkE6tikiV71UN D6'Ui~t 03/c~;/99 -- 04/11/99 501; A. T.:iKILt;:D ti291t. 04/01155 - 04/:x@/55 9011: U. T. 6RILLEU ikMT. . 04101/99 -- 04/14/99 500:30 NUN-P!2E:iCAtf7(LlN Ui2Ut,`J !44/l~3/99 9011b l~. 7. 6tIR'pL1E5 04/07/99 ANL'ILLAflY WRITS U'rF 04/30/99 RDUM LNHk6E A7 1'r'3.4a0 0fi/01 /99 - 04/1R/99 RU!IM WNlfc !>''F 04/01/59 - 04/!B/95 R~tM I:!#1I~E Al 123.00 04/19!99 -04130199 RUOM WRtfE UF.- 04/15/99 - 04/30/95 ~NE7 kUI01 CNAk6E +!~alDING BALRNCE -120+- d. ad 1~20a0 B. BO luk?000 4.3?0.00 10P000 43'0.00 .00 -Ic~s- Sc'1200 0t: 3612tNd 0d 34.00 0c"• 3:M200 0d 34s'e00 Nt: 759000--1 -601200--7 755ea~e-7 -301200--'1 755000--7 1 :,9 ,s<, 1 1 1R 18 Is! 12 3M7:i.00 61.71: 1770.00 1050.00 1.41 r.91 239f 214.00 1416.00 1476.00 5;74.00 61`,0.06 963:1.00 ~~o l M:WUtU.'1 v: NSAI.TH 'A:t?V11::5 31'? 06/6.5/99 E'fiT1ENT LI'DHEk P:; Ed 65/:U 199 E'R6F F'3 {AtNF3) PAl1CNT E'R11ENT PFIl1EN7 6l1 -- AE:[ddPiTS kECEIV[IDLE -- h~1Md~R fYf'I: N:L+i~E t1ATc: CITY ACi:~AJNf f,EiliA~'Ii L'I?~i01f:i dRIJL~c 996ct 1N[dt(tf;N[;Efi BLREM, kl[UiRkD 0sl1:'J99 P,DM t:Nik kATE: ?05.00 t?~A1M 125 -d L'cV:1 1 05/14/99 Uf:i t7t?(U }»iEf; 0.00 NAL EWD •LM- :;0- -66- -90• -1~'0;- 61`,kI.:10 .34:1~.0Q 95.1'5.:36 PRVMEN7IfIRlK, k1CEdlEtll 65/25/99 1[&'660 :34['.5.60 9014:+ ~. T.:D[[Ll'c0 I~?Mf. Q5/:t3/99 -- N.ill3/99 ! 361:?00 6J u~i6.00 961900 E'kELx:R1E'71[6! UkliCv't 6516[J99 1 5'160 6;: 2T.FC; ANCIILIttY W1?E[.. q;;~ :Y;/3EP39 T)9000--1 uti1.05 ~,, ~( V R[dM1 E:t#:kFE Rl 11':1.60 6:J63l9`:: -- 65lf3/99 13 36726A•-7 15;9.60 I,~/• (~~v{~ ROiIM WR[f1i ~Y-'r 051H1/')9 -• Q:i/13/99 1.3 79'3000--f l6`v6.66 U ~J \ \ +~NF.i kfdd'1 [#IRRGE. - "•E•5.66 ~~ Q . x<~iOIMi IU?t.AN~:: 1)15.00 6J14J01 ftESI0E11T LEDGER AS OF DATE OF FIRST ACTIVITY PRGE 1 ARSE) ESIDENT RESIDENT RESIDENT GJL -- ACCOUNTS RECEIVABLE -- UN6ER TYPE NRNE DRTE piY ACCOUNT CNRRGES CREDITS BRLANCE 9022 HND BLRCY„ RICHARD 06J0iJ99 ADN CNTR RATE: 215,00 RDON OUT PAT IEVEI 1 D6J01J99 OI5 PRIV PORT: 0.00 **PRIVATE - OCT 00 TRANSFER FRDN NND 04JO1J99 14411050000 8615.00 **ENDING BRLANCE 8815.00 "*PRIVATE - NOV 00 BAL FWD -LN- -30- -60- -90- -120+- 8615.00 8815.00 _ **ENDING BRIAhCE 8815.OC "*PRIVATE - DEC 00 BAL FWD -LN- -30- -60- -90- -120+- 6815.00 8815.00 **ENDINfi BALANCE 8815.30 **PRIVRTE - JRN 01 BRL FWD -10- -30- -60- -90- -120+- 8815.00 8815.00 ""ENDING BALANCE 8815.00 **PRIVATE - FE8 01 BAL fWD -LN- -3C- -60- -90- -120+- s615.oa Ba15.Da *"ENDING BALANCE 8815.00 *"PRIVRTE - NAR O1 BAL FWD -1 N- -30- -60- -90- -i2D+- 8 8815.00 REV ADJUSTMENT 04J01j99 84411050000 8815.00 RX 09(30J99 545512D1100 61.76 PT 04J30(99 52150201100 1770.00 OT 04j30(99 52550601100 1050.00 OTC 0Aj38(99 54951301100 5.41 . OT SUPPLIES O4J30/99 52550601100 T.41 R & B 04J30(94 51350001100 3690.00 PT 05j31J99 52150201100 640.00 RX 05J31(99 54551201100 27.05 R & B 05j31(99 51350001100 1599.00 *"ENDING BRLANCE 8846,15 *"PRIVRTE - APR 01 BAL FWD -LM- -30- -60- -90- -120+- : 8846.15 8846.15 "*ENDIIiG BALANCE 6646.15 "*PRIVRTE - NRY 01 BAL FWD -LM- -30- -60- -90- -12A+- 8846.15 8846.15 "*ENDINfi BALANCE 8696,15 EXHIBIT "B" ADMISSION AGREEMENT ManorC'are CONTRACT BETWEEN DATIENT/RESIDENT AND FACILITY xealth services THIS ADMISSION AGREEMENT (the "Agreement") is entered into this (~_ ~ day of ~rarr 19~ ,between r~~te~sn~~ x~~~~x siravicFs (the "Facility"), and '{~ ~ r. _r~ a ~~j~c~1~aC_._ (the "Patient/Resident"), and/or {the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean 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 decisiori 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 entitlee or authorized to receive such information by law or by the Patient/Resident. raxc•ooe•ao inev. iiam cgs 1 of 3 . •Federal Resident Rights • Resident Responsibilities • Life Sustaining Treatment Policy • Medical/Nursing Education • Dental, Vision and Hearing Services • Interdisciplinary Care Conference • Utilization Review Meetings (if applicable) • Personal Laundry Policy • Barber/Beauty Services • Mail Policy ' • Voting Materials • Photo/Media Events • Personal Fund Account Procedure • Tobacco Policy • Grievance Procedures • State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE-WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the patties, 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. Facility Represent/tative - Sire R~onsible PJn~e - I~! 1 S -~ Cc~~ Q G,~ i ~~ ~~! n c1 ~D V~ ~(.c.C~ Facility Representative -Printed Name Title Responsible Party -Printed Name ~~~`9~ Date ~•- f C~~~ Date MRC-GOB•RO (ReV. 4/96) pg 5 3 of 3 EXHIBIT A -RESPONSIBLE PARTY APPOINTMENT The Patient/Resident's Responsible Party may be any person legally responsible for the Patient% Resident. r: competent Patient/Resident shall not be requir?d to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. ^ 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). ^ 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 ''-~` P3tierff/Resident -Signature ~~~~. `~ ,.. Fanility Ronroscn}a4i~ro _. Prin}arl Namo R TiHa ~~ Pa4ian}/Rocirlun} - Prin}cr1 Name C~, The Patient/Resident is competent and does not have acourt-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). MfIC•og8-sa (Rev. 4/96) pg 6 1 of 2 Conditions (col(ectivefy 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 cove. sd 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 al! furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. A!I of the information, including but not limited to that contained on the attached Application for Residency, dated J~~~ ~ ~ , 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 ail 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 Responsibie 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 no complied with, the Facility wiii have detrimentally relied upon them and the Facility will suffer financia harm and loss. Responsible Party - Signatur~~~~~-~-~G I~' r (tirs ~, 6~('A 7 ~t~- Responsible Party -Printed Name 3-I ~-aG Date MNC-BOB•2o (Rev. 4/98) pg 7 2 Ot `~ ~EXHiBiT B -FEE SCHEDULE 1. Daily Rate. The daily rate is $ 3-~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) ivities • Housekeeping • Room (circle one): Private Semi-Private Triple The following are paid by Medicare in a i ion to the items included in the daily rate: • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies ~ Approved Equipment • Approved Routine Personal Hygiene Items/Services • Other approved services/items covered and paid for under the.state Medicaid program. 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM • Private Room • Prescription &Non-Prescription Drugs • Nursing & Personal Care Supplies • Transportation • Nursing Care (Other than ordinary nursing care) • Physical, Occupational & Speech Therapies • Phone, Cable TV, Newspaper, Barber/Beauty • Special Equipment • Bed Hold Fees • Personal Laundry (Personal Clothing) • Nutritional Supplements • Alternative Nutrition (Tube Feeding, TPN, etc.) RATE Based on location & level of care As determined by pharmacy See business office for current prices As determined by transport company See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached tee list See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever aPatient/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. eMC.ao6.2o IRev. 4/967 oa 8 ~ ,.t n 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. A!I 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'/z%} 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 cos#s 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. (f 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) e Facilit current) articipates in the Medicaid ro ram. If the Patient/Resident believes she 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 it the Patient/Resident's-bank account{s), and other assets to the Facility for provision to Medicai~ representatives. MHC•ooe-s° (Pev. 4/86) pg9 2 of 7 ~((~ NJ~~~ u!! /C~ `s`a E.~ v rw 4 r ~ '~~ -.) ~~~~ ~~~~~~~ ~a, as at ~ ~~ vt•~;i~~ ~~~`,.. ~ phi _ .. ~+ vou-;imas~.v~n e crt~ ,~ rs~ mw ~+. .~¢P r, •T ~ow~?at-.ssa~:aw~rrti