HomeMy WebLinkAbout01-03978IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO. O l '~'r~ eI u ~~~`ri-~
Plaintiff
vs. CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. ]ANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
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 withoutyou and a judgment may be entered against you by the Court without further
notice for any money claimed in the Complaint, or document, or for any other claim or relief requested
by he Plaintiff. You may lose money or property or other right important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le hen demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en
las paginas, siguientes, used tiene viente (20) dies de plazo al partir de la fecha de lademanda y la
nodfiation. 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 nose 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 o otros derechos importantes pare used.
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABAJO PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennrylvania 17013
(717) 249-3166
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. o~- 3978 (~ 7iuti
vs.
GEORGIANNA BAKER, Individually, and
]ILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
CIVIL ACTION - LAW
COMPLAINT
AND NOW, this ~ day of , 2001, comes the Plaintiff,
HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law
firm of Wolfson 8i Associates, P.C., and files the within Complaint and in support avers
as follows:
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 17315.
2. Defendant, Georgianna Baker, hereinafter referred to as "Defendant
Georgianna"), is an adult individual with a last known address of 220 South Baltimore
Street, Dillsburg, Cumberland County, Pennsylvania 17019.
3. Defendant, Jill E. Janney, hereinafter referred to as "Defendant
Jill"), is an adult individual with a last known address of 220 South Baltimore Street,
Dillsburg, Cumberland County, Pennsylvania 17019.
1
4. That Defendant Jill represented herself to be Power of
Attorney for Defendant Georgianna. Defendant Jill is the daughter of Defendant
Georgianna.
5. That on or about February 19, 2000, through March 1, 2001,
Defendant Georgianna was a health care resident of Plaintiff, where she did receive
var'sous 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 Febnaary 19, 2000, Defendant Jill, as Power of
Attorney for Defendant Georgianna, 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 February 19, 2000 is attached hereto, incorporated herein, and
collectively marked as Exhibit "B".
7. By executing said Admission Agreement, Defendant Jill did assume and
accept responsibility for the debt to be incurred by Defendant Georgianna.
8. That Plaintiff submitted to Defendants a copy of the itemization of
services accurately showing all debits and credits for transactions with Plaintiff. Said
Statement of Account has been previously identified as Exhibit "A" and incorporated
herein by reference.
2
9. That Defendants did not object to the above-mentioned Statement of
Account submitted by Plaintiff to Defendants.
10. As of the date of this Complaint, the balance due, owing, and unpaid
on Defendant Georgianna's account as a result of said charges is the sum of Thirty One
Thousand Nine Hundred Eight and 98/100 Dollars ($31,908.98). See Exhibit "A"
previously identified and incorporated herein.
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 Georgianna's account balance, all to the damage and detriment of the
Plaintiff.
12. Plaintiff has made numerous requests to Defendant ]ill, as Power of
Attorney for Defendant Georgianna, demanding that the sums due and owing to
Plaintiff be paid, and Defendant Jill has ignored her fiduciary obligations to pay
necessary and appropriate bills and obligations for her mother, Defendant Georgianna.
13. Pursuant to Section 1, Paragraph 1.03, of the Admission
Agreement, Plaintiff is entitled to receive and Defendants have 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.
14. As of the date of the within Complaint, the amount of interest that
has accrued on the past due balance is the sum of One Thousand Four Hundred Fifty-
Six and 95/100 Dollars ($1,456.95).
3
15. Plaintiff has retained the services of the law firm of Wolfson 8i
Associates, P.C., in the collection of the amounts due from Defendants.
16. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement,
Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney's
fees and all court costs if the account is referred to an attorney for collection. See
Exhibit "B" 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 si 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 Sixteen Thousand One
Hundred Fifteen and 74/100 Dollars ($16,115.74).
19. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
20. The amount in controversy exceeds the jurisdictional amount requiring
compulsory arbitration.
4
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment in favor of Plaintiff and against Defendants,
Georgianna Baker, Individually, and Jill E. Janney, Individually, and on Behalf of
Georgianna Baker, in the amount of Thirty One Thousand Nine Hundred Eight
and 98/100 Dollars ($31,908.98), contractual interest in the amount of One
Thousand Four Hundred Fifty-Six and 95/100 Dollars ($1,456.95), reasonable
attorney's fees in the amount of Sixteen Thousand One Hundred Fifteen and
74/100 Dollars ($16,115.74), the costs of this action, and such other relief as the
Court deems proper and just.
Respectfully Submitted,
~~~~1/
Daniel F. Wolfson, Esquire
WOLFSON $t ASSOCIATES, P.C.
267 East Market Street
York, PA 17403
(717)846-1252
I.D. No. 20617
Attorney for Plaintiff
5
EXHIBIT "A"
06J14J01
(AR56}
RESIDENT RESIDENT RESIDENT
NUMBER TYPE NONE
RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE 1
GJL -- ACCOUNTS RECEIVABLE --
GATE QTY ACCOUNT CHARGES CREDITS BALANCE
20018 PRIVATE BAKER, GEOR6IANNA J 02J19J00 ADN CNTR RATE: 0.0D
ROOp 110 -A LEVEL 2 03J01J01 DIS PRIV PORT: 930.00
**PRIVATE - JUN @0
BAL FWD -LM- -30- -60- -90- -120+-
41.00 5.00 46.00
11600 CABLE RENTAL 06J01J00 -- 06J38J@0 1 59156401100 5.00
ADV PVT PORTION 07J01J0@ 13211800000 200.00
**ENDING BALANCE
**PRIVATE - JUl 00
BAL FWD -LN- -30- -60- -90- -120+-
2@5.@0 41,00 5.00 251.00
PAYMENT 01J25J00 11210002000 5.00
PAYMENT 07J2SJ00 11210882000 41.@@
11600 CABLE RENTAL 01J01J00 -- 07J31J0@ 1 59158401200 5.00
REV LAST MO PP 01J01J0@ 13211000000 20@.00
REV PVT PORT 6J00 06J30J00 14411050000 200.00
(BLIND) 07J20J00 14411050000 195.00
(BLIND) 07J20J00 14411050000 195.@0
**ENDING BALANCE
**PRIVATE - RUG 0@
BAl FWO -LN- -30- -60- -90- -120+-
19@.00- 190,00
11680 CABLE RENTpI @8(01J00 1 59158401200 5.00
11100 BEAUTY AND BARBER 08J08J00 1 59158101200 9.00
11180 BEAUTY AND BARBER 08J24J00 1 59156101200 36.A0
PRIVATE PORTION 06J01J0B -- @8J31J@@ 31 930.00
ADV PVT PORTION 09J01J00 13211000000 930.00
ADJ DONE IN ERROR 06J30J00 14411050000 200.@0
(BLIND) 08J22J00 14411D50000 190.00
**ENDING BALANCE (BLIND) 08J22J0B 14411050000 190.00
**PRIVATE - SEP 00
BRL FWD -LN- -30- -60- -90- -120*-
1720.00 2@0.00 1920.00
' 11600 CRBLE RENTAL 09J01J00 -- 09J30J00 1 59158901200 S.OB
REV LAST NO PP 09J01J00 13211000008 930.00
PRIVATE PORTION 09J01J00 -- 09J30J00 30 930.00
ADV PVT PORTION 10J@iJ00 13211000000 930.00
**ENDING BALANCE
**PRIVATE - OCT 00
BAl FWD -LN- -30- -60- -90- -120+-
1865.00 790.00 200.00 2855.00
11600 CRBLE RENTAL 10J@iJ00 -- 10J31J0@ 1 59158401200 5.00
REV LAST MO PP 10J0iJ00 13211800000 930.8@
PRIVATE PORTION 10J01J00 -- 10J31J00 31 930.00
251.00
190,80-
1920.00
2855.08
' 06(14(01 RESIDENT LEDGER AS Of GATE OF FIRST ACTIVITY PAGE
(AR56)
RESIDENT RESIDENT RESIDENT 6JL -- ACCOUNTS RECEIVABLE --
NUNBER TYPE MANE ORTE QTY RCCOUNT CNAR6ES CREDITS BALANCE
20018 PRIVATE BAKER, GEDR GIRNNA J 02(19(00 ADN CNTR RRTE: 0.00
ROOM 110 -A LEVEL 2 03(01(01 OIS PRIV PORT: 930.00
**PRIVATE - OCT 00 (CONY)
ADV PVT PORTIO N 11(01(00 13211000000 930.00
**ENOING BALAN CE 3790.00
**PRIVATE - NOV 00
BAL EWD -LN- -38- -60- -90- -120t-
1865.00 935.0@ 790.00 200.00 3790.00
10007 LAB SERVICES 08(04(00 1 56151901200 27,50
" 10007 LAB SERVICES 10(23(00 1 56151901200 1217
10201 BL000 GLUCOSE TEST 11(01(00 1 561519012@0 4.37
10201 BLOOD GLUCOSE TEST 11(01(00 1 56151901200 4.37
11600 CABLE RENTAL 11(01(@0 -- 11(30(00 1 59156401200 5.00
29001 PHARMACY LEGEND 11(01(00 -- 11(30(00 1 64651201200 428.66
30001 PHARMACY NON L EGEND 1LJ01J00 -- 11(38(00 1 54951301200 17.54
53601 OXYGEN CONCEN RENT DLY 1IJ01J00 -- 11(30(00 30 55353601200 540.00
102@i BIDOD GLUCOSE TEST 11(02(00 1 56151901200 4.37
10201 BLOOD GLUCOSE TEST 11(03(00 1 56151901200 4.37
10201 BL000 GLUCOSE TEST I1J04J00 2 56151901200 6.74
10201 BL000 GLUCOSE TEST 11(05(00 2 56151901200 8.14
10201 81000 GLUCOSE TEST 11(06(00 2 56151901200 8.74
10211 BLODO fiLUCOSE TEST 11(07(00 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(08(00 2 56151901200 8.74
11100 BEAUTY AND BARBER 11(08(00 1 59156101200 17.50
10201 BL000 GLUCOSE TEST I1J09J00 2 56151901200 8.74
10201 BL000 GLUCOSE TEST 11(10(@0 2 56151901200 8.14
10201 B100D GLUCOSE TEST 11(11(00 2 56151901200 8.T4
10201 B100D GLUCOSE TEST 11(12(00 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(13(00 2 56151901200 8.74
10201 B100D GLUCOSE TEST 11(14(00 2 56151901200 8.74
" 10201 B100D GLUCOSE TEST 11J1SJ00 2 56151901200 8.74
10201 BLOOD fiIUCOSE TEST 11(16(00 2 5615190120@ 8.14
10201 BL000 GLUCOSE TEST 11(17(00 2 56151901200 8.74
IA201 81000 GLUCOSE TEST 11(18(00 2 5615190120A 8.74
10201 BLOOD GLUCOSE TEST 11(19)00 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(20(00 2 56151901208 8.74
10201 BLOOD GLUCOSE TEST 11(22(00 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(23(00 2 56151901200 8.I4
10201 B100D GLUCOSE TEST 11(24(00 Z 56151901200 8.74
10201 B100D GLUCOSE TEST 11(24(00 2 56161901200 8.74
10201 BLOOD GLUCOSE TEST 11(25(00 2 S61S1901200 8.74
10201 OLOOO GLUCOSE TEST 11(26(08 Z 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(27(00 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 11(27(08 1 56151901200 8.74
10201
~ B100D GLUCOSE TEST 11(28(00 2 56151901200 8.19
~ 10201 BL000 GLUCOSE TEST 11729700 2 56151901200 8.74
10201 B100D GLUCOSE TEST IIJ30J00 2 56151901200 6.74
REV LAST NO AP 11101700 132110@0008 930.00
86j14jA1 RESIDERT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE
(AR56)
RESIDENT RESIDENT RESIDENT 6jl -- RCCOUNTS RECEIVRBLE --
NUMBEA TYPE MANE OATS QTY RCCOUNT CHARGES CREDITS BALANCE
20018 PRIVATE BAKER, GEOR6IANNA J 01j19j00 RON CNTR RATE: 0.@0
ROOq 110 -A LEVEL 2 03j01j01 DIS PRIV PORT: 930.00
**PRIVRTE - NOV 00 (CONY)
RDON CHARGE AT 133.00 ilj81jB0 - - 1ij30j80 30 51350001280 399@.00
AOV BOON CHARGE AT 133.00 12j01/00 - - 12j31/@0 1321100000@ 4123.00
PHARMACY NON-LEGEND 02j28j00 54951301200 3.03
ROOK CH6 2j0@ 02/28/0@ 513500@1200 1391.00
PHARMACY LEGEND 03j31j00 54551201200 3.52
PNARN NON-LEGEND 03j31j00 54951301200 11.23
RN CNG 3j00 03/31/00 51350001200 3937.00
PNARNACY NON-lE6EN0 04j30j08 54951301200 8.82
ROOM CH6 4j00 04j30j80 51350801200 3810,00
PNARNACY NON LEGEND 05j31j00 54951301200 13.3]
RN CHG Sj00 05j31j00 513500@1201 2921.00
LEAVE CHARGE A5/31j08 51350001200 889.08
WOUND TREATMENT @6j38j0B 54151501200 24.00
ROOM CHG 6j00 06j30j0@ 51350001200 1143.00
PNARNACY LEGEND O7j31/00 54551201280 1807.60
PNARNACY NON-LEGEND 07j31j00 54951301200 136.@3
WOUND TREATMENT Bij31j80 54151501200 48.00
ROp CH6 1j00 01j31j00 51350001260 3429.00
LEAVE CH6 07j31j80 51350801280 127.08
ROOK CN6 7j00 07j31j00 5136000120@ 381.80
REV PVT PORTION 07j31j00 14411150000 200.00
NON LEGEND ORU6S 08/31j00 54951301200 1185.40
NON LEGEND DRUGS 08j31j80 54951301208 187.56
N
T ~
~
BLOOO
GLUCOSE
TESiS 0@
31
@0 561519@1100 279.68
ROOM CH6 8jD0 88j31j0@ 51350001200 4123.08
REV PVT PORT 08j31j00 14411050000 930.0@
' BLOOD GLUCOSE TEST 09/30(00 56151901200 21.85
PNARN LEGEND 09j3Bj0B 54551201280 2i2J9
PNARN NON-lE6EN0 09j30j00 54951311200 58.88
ROOK CH6 9jB0 09j3/j00 5135000128@ 3990.08
REV PVT PORT 09j30j00 14411050000 930.00
OXYGEN CONCENTRATOR @9j30j00 54951381200 540.08
BL000 GLUCOSE TEST 09j3Aj0A 561519@1208 349.60
LAB SERVICES 10/31j00 56151401280 6.56
BL000 GLUCOSE TEST 10j31j00 561519012@0 8.74
LEGEND ORU6S 10/31j00 54551201200 487.66
NON-LEGEND DRUGS 18j31j@0 54951301200 26.61
OXYGEN CONCENTRATOR 10/31/08 54951301200 556.00
8L000 GLUCOSE 18j31j00 56151901220 161.69
RDON CNG 10j88 10/31/00 51350@01280 4123.00
REV PVT PORT 10/31j00 14411050000 930.00
- AOJ DONE IN ERROR 11/19/00 14411058008 200.80
**ENOING BALANCE 46442.39
**PRIVRTE - DEC BA
~ObJ14J01 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE A
~(AR56)
` RESIDENT RESIDENT RESIDENT GJL -- ACCOUNTS RECEIVABLE --
NUMBER TYPE NAME DATE QTY ACCOUNT CHARGES CREDITS BALANCE
20018 PRIVATE ROOMR110EOpGIALEVEI 2 03~A1~01 OIS PRIV PORT: 930.00
**PRIVATE - DEC 00 (CONY)
BAL FWO -LN- -30- -6@- -90- -120+-
39459.39 935.@0 935.00 190.0@ 4323.@0 46442.39
11600 CABLE RENTAL 12J01J08 -- 12J31J08 1 59156401280 5.00
53601 00YGEN CONCEN RENT DLY 12JB1J00 -- 12J31J00 31 55353601200 556.00
102@1 BLOOD GLUCOSE TEST 12J05J@0 1 5615190120@ 4.37
10201 BL000 GLUCOSE TEST 12J07J00 1 561519012@0 4.37
10201 BL000 GLUCOSE TEST 12JA9J00 1 56151901200 4.37
10281 BL000 GLUCOSE TEST 12J10J00 2 56151901200 8.74
10281 BL000 GLUCOSE TEST 12J10J00 1 56151901200 8.74
10201 BL000 GLUCOSE TEST 12(11(00 2 56151901200 8.74
1@201 BL000 fiLUCOSE TEST 12J12JA0 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 12J13J00 2 56151901200 8.79
10201 8L000 GLUCOSE TEST 12J14J00 2 56151901200 8.74
10201 BL000 GLUCOSE TEST 1T~16~A0 2 56151901200 8.74
10201 BLOOD GLUCOSE TEST 12J17J00 2 56151911200 8.14
102@1 BL000 fiLUCOSE TEST 12J18J00 2 56151901200 8.J4
10201 BL000 GLUCOSE TEST 12J19J00 1 561519@1200 4.37
111@0 BEAUTY AMD BARBER 12J19J00 1 59158101700 36.00
10201 REV IASTUNOSRCTESI 12~01~AA 1 13111@0 000 ~ 37 4113.00
ROOM GNAR6E AT 133.00 12J01J08 -- 12J31J00 31 51358001280 4123.00
AOV ROOK CHARGE AT 133.00 01JA1J01 -- 01J31J01 13211000000 4123.00
**ENDIN6 BALANCE
"*PRIVATE - JAN 01
BRL FWD -lN- -30- -6A- -90- -120+-
8954.25 35336.39 935.00 935.00 5113.00 51273.64
53601 ORYGEN CONCEN RENT DLY 01J01J01 -- 07J31J01 31 55353601200 558.00
REV LAST MO RC 01J01J01 13211000000 4123.@0
BOON CHARGE AT 133,00 01J01J01 -- 01J31J01 31 51350001200 4123.00
AOV BOON CNAAGE AT 133.00 02J01J01 -- 02J28J01 13211000000 3724.00
**ENDIN6 BALANCE
**PRIVATE - fEB 01
BAL FWD -LN- -30- -60- -90- -120+-
84@5.00 4831.25 35336.39 935.80 6048.@0 55555.64
11100 BEAUTY SHOP WJS CUTIJI6 A2J01J01 1 59158101200 11,50
11600 CABLE AENTAI 02J01JA1 -- 02J28J01 1 59158401200 5.00
REV LAST NO RC 02J01J01 13211000000 3724.00
PRIVATE PORTION 02J01J01 -- 02J26J01 26 930.88
ADV PVT PORTION 03J01J01 13211000000 930.@0
CABLE RENTAL AiJ31J01 59158401000 5,00
**ENDIN6 BALANCE
**PRIVATE - NAR 01
512]3.64
55555.64
53719.14
06J14J01
(AR56}
;RESIDENT RESIDENT RESIDENT
NUMBER TYPE NAME
20818 PRIVATE BAKER, 6EORGIANNA J
BOON 110 -A LEVEL 2
**PRIVATE - MAR 01 (CONY)
BAL FWD -LN- -30-
1882.58 4686.80
53601 OXYGEN CONCEN RENT DLY
' REV LAST MO PP
' **ENOING BALANCE
**PRIVATE - APR 01
BAL FWD -LM- -30-
18.00 952.50
**ENDING BALANCE
"*PRIVATE - MAY 01
BRl FWD -LM- -30-
18.00
REV GLUCOSE
REV PHARN LEGENO
REV PHARN NON-IEGENO
REV GLUCOSE
REVR6B
PRIVATE PORTION
NCB PREMIUM
INSURANCE PREMIUp
REV OXYGEN
REV GLUCOSE
REV RX
REV OTC
REV OXYGEN
REVR6B
PRIVATE PORTION
NCB PREMIUM
INS PREMIUM
LAB
REV RX
REV OTC
AEV OXYGEN
REVRGB
PRIVATE PORTION
NCB PREMIUM
INS PREMIUM
REV LAB
REV GLUCOSE
PRIVATE PORTION
qCB PREMIUM
INS PREMIUM
REV OXYGEN
REY OXYGEN
REVRGB
RESIDENT LEDGER AS OF DATE Of FIRST RCTIVITY PRGE 5
GJL -- ACCOUNTS RECEIVABLE --
ORTE QTY ACCOUNT CNAR6ES CREDITS BALANCE
02J19J00 ADM CNTR RATE: 0.00
03J01J01 DIS PRIV PORT: 930.00
-60- -90- -120+-
4831.25 35336.39 6963.00 53719.14
03J01J01 1 5535360120A 18.00
03J01JA1 13211000000 930.00
52807.14
-60- -90- -120+-
4686.00 4831.25 42319.39 52807.14
52807.14
-68- -90- -120+-
952.50 4686.00 47150.64 52807.14
09J30J00 56351901200 21.85
09J30J00 54551201208 272.79
09J30J00 54951301200 58.88
09J30J00 56151901200 349.60
09J30J08 56151901200 3990.00
09J3@J00 14411850000 982.61
09J30J00 33430400500 45.50
09J30J00 33430400500 70.00
09J38J00 54151001200 540.08
10J31J00 56151981200 110.43
10J31J08 54551201200 487.66
18J31J00 54951301200 26,61
10J31J00 54151001200 550.00
10J31J00 51350001200 4123.00
10J31JB0 14411050000 982.61
10J31J00 33430400500 45.50
10J31J00 33430400580 70.00
10J31J08 56151901200 6.56
ilJ30J00 54551201200 428.86
11J38J00 54951301200 17.54
i1J30J00 54151001280 540.00
3998.00
11~30~00 14411050000 982.61
1IJ30J00 33430400500 45.50
11J30J00 334304A0500 10.00
I1J30J00 56161981200 39.67
SlJ30J00 56151901200 262.20
12J31J00 14411050000 982.61
12/31j00 33430400500 45.50
12J31(00 33430408500 70.00
12J31J80 54151001200 556.00
12J31J00 54151001200 109.25
12131108 51350001200 4123.00
06/14/01 RESIDENT LEDGER AS OF GATE OF FIRST RCTIVITY PRGE 6
(AR56)
RESIDENT RESIDENT RESIDENT 6/L -- RCCOUNTS RECEIVABLE --
NUNBEA TYPE NRME DRTE QTY ACCOUNT CHARGES CREDITS BALANCE
20016 PRIVATE BRKER, 6EOR5IRNNR J 02/19/00 ADN CNTR RRTE: 0.00
ROOK 110 -R IEVEI 2 03/01/01 OIS PRIV PORT: 930.00
**PRIVATE - NAY 01 (CONT)
REV OXYGEN 01/31/01 54951301200 558.00
REV R A B 01/31/01 51350001200 4123.00
PRIVATE PORTION 0131(01 14411050000 1018.11
NCB PREMIUM 01/31/01 33430400500 50.00
REV PP 02/26/01 14411050000 930.00
PRIVATE PORTION 02/28/01 19911050000 1018.11
NCB PREMIUM 02/28/81 33930408508 50.00
REV OXYGEN 03/31/01 54151001200 18.00
**ENDING BALANCE 31908.90
EXHIBIT "B"
~A
HCR Manor Care
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Caze, the Resident, and the
Legal Representative, for the purpose of providing for the rights and responsibilities of the parties
with respect to the Resident's stay at this HCR Manor Caze's Health Care Center ("Center").
Center;
Resident:
Legal Representative: _.17"- I ; ~~ ~~)5 ~ r1`1 + ~. 1 + rV E%~n er ~+ ~ ~ ~ ~ c~~On ey
Admission Date: ~~/ Deposit: $ ,
Term: This Agreement shat( begin on the day the Resident enters the Center and end on
the day the Resident is dischazged.
I. RIGHTS AND RESPONSIBILTTIES OF THE RESIDENT
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 (l0a') 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
Organization (see Section 1.06).
1.02 Ancillary Charges. 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
(10's) day of the month.
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be
subject to a service charge equal to the highest legal rate of interest permitted by State law as set
forth in Attachment A on the past due balance each month until such time as the 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 Indeoendent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Resident's attending physician for any health or
personal program in accordance with the terms of the program.
1.05 Governmental Programs. If the Resident is eligible for coverage under any
govemmental program, such as Medicare, Medicaid, or through the Veterans Administration, and
the Center participates in such program, 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 all 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 following programs: ~rlGledicare, Medicaid and/or A.
Medicare may pay for some or all of the Resident's are. If Medicare agrees to pay or 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 and/or 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 from 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 Part~Pavors and Managed Care Oreanizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity 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 chazges,
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 Center
2
will bill the Resident's third party payor 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 responsibility of the Resident and/or Legal
Representative to notify the Center and to provide any needed information regarding all third
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) dam 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 reties 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 chazges 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 Agreement.
1.09 Application for 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 Responsibilit fy or 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, HMO, 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
3
Agreement serves as a written notice that the Center has notified the Resident and/or Legal
Representative that services provided at the Center may not be covered by a governmental payor,
third 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.11 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 fhb 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
and procedures and the pharmacy has a medication distribution system similar to the Center's
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 from the Resident's income or resources all fees and changes 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 from the
Resident's income or resources for the fees and charges provided for in this Agreement.
2.03 Requested Items. 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 Legal 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 for Financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such information about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally responsible
for any charges denied the Center due to any lack of cooperation.
2.06 Acceptance Upon Discharee. 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 al! charges.
2.07 Additional Responsibilities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set fortfi in this Agreement and
Attachments.
III. RIGHTS AND RESPONSIBILITIES OF THE CENTER
3.01 Room and Standard Services. As part of the Room and Board Rate, 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, with 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, if any, noted at
the beginning of this 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 frame required by
State law. In the case 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. GENERAL 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
reviews or payment audits performed by such; the personnel of any hospital or other health 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 caze, 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 from 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 deliveeed to the Center, and that such Legal Representative
hereby consents on behalf of the Resident to the Treatment described above.
4.03 Consent to Photoeraah. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifying the Resident, for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to 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 opportunity to ask questions and questions have
been answered satisfactorily.
a. 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.
f. 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
6
Authorization and any other related documents. See Attachment H-I and
H-2.
g. The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
h. Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
i. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
j. 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 fraud controi.unit. See
Attachment I (Center Supplement).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who 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).
m. The Resident Handbook. See Attachment J.
n. Resident/Patient Rights. See Attachment K.
o. 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.
p. 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.
q. Privacy Act Notification. See Attachment N.
r. Inventory sheet and/or policy of personal items. See Attachment O.
,~, , .
Kr
s. ASM Form. See attachment P.
t. Consent to Photograph See Attachment Q.
u. See Attachment R.
v. See Attachment S.
w. See Attachment T.
x. See Attachment U.
y. See Attachment V.
z. See Attachment W. ~`
4.05 Assienment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to
me or on my behalf for any service famished by or in the Center. The Resident and/or Legal
Representative hereby authorizes the Center and any Bolder 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 injury caused by the Resident to any person or the property
8
of any person or entity (including the Center), except in the case of negligence of the Center's
employees and agents.
4.08 Chane,.es in the Law. Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal law will not invalidate the remaining
provisions of this Agreement and, it is agreed that to the extent 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 THEII2 SATISFACTION.
Signature of Resident:
Date:
i
Date:
Signature of Legal Representative, signing on his/her own behalf:
Date:
Center Representative: ~~0 (Nli r ~ r ~-(~ ~l~ Date:
~" '' ~
Signature of Legal Representative, if signing on behalf of Resident:
W
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P6 .. _ - _ _ _. _ _. _. ... - ~.itirru r m~.,.a ,ba, ~rym~-s*'m~t~~ri€ .. _3^~`W'~-E!9'~~~
SHERIFF'S RETURN - OUT OF COUNTY
` ~AS~ N0: 2001-03978 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
BAKER GEORGIANNA ET AL
R. Thomas Kline
Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT
to wit:
BAKER GEORGIANNA
but was unable to locate Her
deputized the sheriff of YORK
in his bailiwick. He therefore
County, Pennsylvania, to
serve the within COMPLAINT & NOTICE
On July 18th 2001 this office was in receipt of the
attached return from YORK
Sheriff's Costs: So answe ~ j`.~--,>
Docketing 18.00 „~. ,./J !°"`~
Out of County 9.00 d, ~"
Surcharge 10.00 R. Thomas Kline
DEP YORK CO 43.56 Sheriff of Cumberland County
nn
• J V
07/18/2001
WOLFSON ASSOCIATES
Sworn and subscribed to before me
this :t3,c,t day of
~srv~ A.D.
~~.no Q ~ J
Prothon t
SHERIFF'S RETURN - OUT OF COUNTY
CASE N0: 2001-03978 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MAIQOR CARE
VS
BAKER GEORGIANNA ET AL
R. Thomas Kline Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT to wit:
JANNEY JILL E
but was unable to locate Her
deputized the sheriff of YORK
in his bailiwick. He therefore
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 18th 2001 this office was in receipt of the
attached return from YORK
Sheriff's Costs:
Docketing
Out of County
Surcharge
.00
16.00
07/18/2001
WOLFSON & ASSOCIATES
So answer
6 . 0 0 ~ ,,,~~ '
.00
10.00 R. Thomas Kline
.00 Sheriff of Cumberland County
Sworn and subscribed to before me
this ~3,~ day of ~"~'
,
~~~ A.D.~~ ~~
~P othor~n ar
COUNTY OF YORK
1 of 2 OFFICE OF THE SHERIFF S(R,V)I,C719601L
28 EAST MARKET ST., YORK, PA 77401
SHERIFF SERVICE INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINE 1 THRU 12
DO NOT DETACH ANY COPIES
7. PLAINTIFF/S! - _ - 2. COURT2JA1M8E C1V11
HCR Manor Care Ul i~/i3
3. DEFENDANT/S! '4. TYPE OF WRIT OR COMPLAINT
Georgianna Baker et al Notice _& CaTgDlaint
SERVE 5. NAME OF INDMDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED, OR SOLD.
Ceorgianna Baker - _ _
6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO.. CITY, BORO, TWP., STATE AND ZIP CODE)
AT X20 S ~ast~nr~ a +- i11 ~t~'r-~7,_-~"T'"~°~'31 -}7F rR ~.~
7. INDICATE SERVICE: ^ PERSONAL ~ PERSON IN CHARGE ~ DEPUTIZE -~ER~T~,MAIL ~ ^ tST CLASS MAIL O_pOSTED - O OTHER
NOW Julv 2 , Zp01 I, SHERIFF OFD COUNTY, P do hereby deputize the sheriff of
York _ __ _ -COUNTY to execut~d make retur _ f according
to law. This deputization being made at the request and risk of the plaintiff. ~°~_ - _~---r ~
OUT OF COUNTY
CUMBERLAND
ADVANCED FEE_PAID BY SHERIFF
NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN -Any deputy sher'rff levying upon or attaching any pmperty antler within writ may leave same
without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff
herein for any loss, destmdion, or removal of any property before sheriffs sale thereof. - _ _ __
9. TYPE NAME and ADDRESS of ATTORNEY! ORIGINATOR antl SIGNATURE - - ig. TELEPHONE NUMBER 71. DATE FILED
WOLFSON & ASSOC. 267 E. MARKET ST. YORK, PA 17403-2000 846-1252 6-26-O1
CUMBERLAND CO. SHERIFF
SPACE BELOW FO_R__US_E O_ F THE SHERIFF - DO NOT WRITE BELOW TH S 1
73. lacknowletlge receipt of the writ R. AHRENS 74. DATE RECEIVED i6. ExplretionlHeadng Date
or complaint as indigted above. _ 7-5^D1 7-26-O1
76. HOW SERVED: PERSONAL ( ) RESIDENCE (.) _ POSTED ( ) POE ( ) - SHERIFF'S OFFICE (-) OTHER ( ) SEE REMARKS BELOW
77. I hereby certiry and return a NOT FOUND because I am unable to locate the individual, company, etc nametl above. (See remarks__below.) _
78. IJP.ME AND TITLE OF INDIVIDUAL SERVED! LIST ADDRESS HERE IF NOTSHOWN ABOVE (Relationship to Defendant) ~~ 19. Date of Service 2~. Time of Service
22. REMARKS:
M
23. Advance Costs 24. Service Costs 25. N/F 26. Mileage 27. Post
100.00- 18.00 5.00 16.56
34. Foreign County Costs 35. Atlvance Costs 36. Service Costs 37.
47. AFFIRMEOantl subscribed to before me thi 1 ~
a2. day of JULY ,2g 0}~ /U '
/Nor RY 46
Nr3ta~l $~ai
JartIDS V, v~ngfefan,'Nattsry Publla _ WI
City bf YdFk, YOFk ~ObYfty~ AA
My CtlfnfiiaSlbYt ~7tplyde Mar. 29, 200.sT aa.
26. Sub Total 29. Pound 30. Notary 31. Surchg. 32. Td. Cos
39.56 4.00 43.56
HOSE
r~ai
Due cfRefund i{Check NO.,
or
7-13-O1
50. I ACKNOWLEDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE - = 57. DATE RECEIVED
OF AUTHORIZED ISSUING AUTHORITYAND TITLE
i. WHITE-Issuing AUlhoriry 2. PINK-Attorney 3. CANARY-Sheriffs Offide 4. BLUE--Sheriff50Rde _ -. -
x -
` COUt~TYOF YORK ~
1 °f z~ • OFFICE OF :THE SHERIFF 3(R )ICE 96 1L
~ - - ..
'- 28 - ST MARKET ST., YORK, PA 17401
• SHERIFF SERVICE ~ f INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINE 1 THRU 12
DO NOT DETACH ANY COPIES
- ---- - --- -a---~- `
1. PLAINTIFFIS/ 2. C TN R
_ _ ACF'e9anor care dig--~~~ civil
3...DEFENDANTlS/ ~ -- _-4r TYPE OF WRIT OR COMPLAINT
Geo3:gianna Baker et al 'tiatice S Carlpiaint
- __ . _ - _. _ -- s_
_..._-_ .~ ..~__ -.~ --i _- .. ....._.. _ ___ ,
S»~ E 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC TO SERVE OR OE$CRIPTION OF PROPt?RTY TO BE LEVIED, ATTACHED, OR SOLD. _ -
Georgianna Baker _ _ _ _ __ _ _ _ _
6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO CITY, BORO, TWP-, STATE AND ZIP CODE}
AT _ 2~?_D~~.~s-~,'-t-re~r~g,-PK'_178~4~ 1~- f LF~J~-.
7. INDICATE SERVICE: ^ PERSONAL ^ PERSON IN CHARGE_Yt~DEPUTIZE _ ~~, p~Aq -^ 7ST CLASS MAIL ' O pOSTED ^ OTHER
NOW ~ .Duly 2 ` ' ,_20 ~~`__ I, SH~RIFF OF COUNTY, PA' do hereby deputize the sheriff of
_-_ _
Xork - __ COUNTY to execu~~ turn~P~ ording
to law. This. deputization being made atthe request and risk of the plaintiff.
• _t ~ .._ ~_~__...~_..._..~. ..-._-....a.....:,_....-._._.......$k1E81F~-QF -' - -OUNTY..- ..
e. SPECI}1L INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: _ '~ - t0(?r... - _
~'
- OUT OF CIIUNTY
CUMBERLAND
JfiANGED FEE PAID BY SHERIFF _ __ __ __ _
NOME: ONLY APPLICABLE ON WRIT.OF EXECUTION: N.B, WAIVER OF WATCHMAN -Any deputy sheriff levying upon or attaching any property antler within writ may leave same
without a watchman, in cestody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff
hererrl,~or any lass, desVUdion, a removal of any property before sheriff's sale thereof. _ ~~ - _ _ _ .... ,
. 9~-TYfYENAM~and ADDRESS Of ATTORNEY! ORIGINATOR antl SIGNATURE 10. TELEPHONE NUMBER 17. DATE FILED
WGLFS> E ASSOC. 267 E. MARKET ST, YORK, PA 17403-2000 846-125 6-26-OI
- 72, SENR N6 - E OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if nobce is to be matled). _ -
CL'FfBE~LAYD CO. SHERIFF __ -
_;
,'. SPACE BELOW FOB-USE ~ SHERIFF - DO 1!LOL1tIt81TEBELOW THIS LINE ______._._ _._
. 13. I adenowledge receipt of the writ 74. DATE RECEIVED 15. Ex imtionlHearing Oate
_ acomplamiasindiratedabove. R. AHRE~S __ 7_5_01 1~-26-D1
-~- - - - _.__. Y _.-_.-~._ _.-__ - ~~-__. _ _.-. _ - -
18. HOW SERVED: PERSONAL ( ) RESIDENCE ( ) POSTED ( ) POE ( ) SHERIFF'S OFFICE ( ) OTHER ( ) SEE REMARKS BECOW
77. I hereby_certify and return a NOT FOUND because 1 am unable to locate the intlmtlual, company, etc. named above. See remarks below) . __. _ ___,_ •„_
78. AME AND TITLE OF INDIVIDUAL SERVED /LIST ADDRESS HERE IF NOT SHOWN ABOVE (Relationship to Defentlant) 19. Date of SeNice 20. Time of Service
- ~_ ~,.ya_,..~ - - _---__..__.. ._ _ -. .. ..... ,~. ... .. ._. - _ _
' 29. ATTEMP Date Time Miles Int Date Time Miles Int. Date Time Miles Int. Dale, Time Miles Int. Date Time Miles Int. Date Time Miles Int.
22 REMARKS: -~ - - ~ -~, - - - ~ - --
- ~ x:09.
~ `ta.
v .G •_r
~29. Atlvance Costs 24. Service Costs 25. N/F 26. Mileage 27. Postage 28 Sub Total 29. Pound 30. Notary 3i. Surchg. 32. Ta. Costs 33. C~DUea Refund Check No.~.,
~ ,~ iDO.Q~t 18.00 5.0 16.96 3Q.56 4,00 - 43.55 .,~G-•F/4 ~`f~7
_- - _
X34. Foreign County Costs 35. Advance Costs 36. Service Costs 37, Notary Cert. 38. Mileage/Postage/Not Found 39. Total Costs 40. Costs Oue or Refund
47-AFFIRMED-and subscdbetl to before me(t~his 1? -- __ _ SO ANSWERS .- .__ -
~ 42, day of ~)ti~Y ,20 _'W3~~'_~~-'^DePnSheefff 45. DATE
~R€37fi~ NOTARY q6. Signature of York 47. DATE
- County Sheriff „rr _ -
'= WILLIAM M. HOSE f'` ~ 'F7?~F'f/ 7-13-01
~. 48. Signature of Foreign _ 49. DATE -
' ~ Coun_ty Sheriff
50.I ACKNOWLEDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE_ - - ~ ~ _ - _~ ~~ - ~ St DATE RECEIVED
OF AUTHOi21ZED ISSUING AUTHORITY AND TITL)_ _ , - ~ ._ -. _ _. ____~, - __,_. „__ __,
t. WHITE- Issuing Authority 2. PINK- Attorney 3. CANARY - SherilPS Office - 4. BLUE -Sheriffs Office
z_
.~. .i
COUNTY OF YORK _
~~v OFFICE OF THE SHERIFF $ER~I~ 1 9 OIL
28 EAST MARKET ST., YORK, PA 17407
SHERIFF SERVICE INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINE 1 THRU 12
DO NOT DETACH ANY COPIES
t. PLAINTIFFlS/ 2 CO1 83978 Ci-V11
HCR Manor Cart - 4, TYPE OF WRIT OR COMPLAINT
3. DEFENDANT/S!
Georgianna Baker et_al Notice and CaclPlaint
S~ E 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY T0.6E LEVIED, ATTACHED, OR SOLD.
Jill Janney
6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT, NO., CITY, BORO, TVJP., STATE AND ZIP CODE)
AT 220- S. Baltimore St Dillsburg, PA 17019
7. INDICATE SERVICE: ^ PERSONAL O PERSON IN CHARGE ~.~[DEPUTIZE _ ~ ^ 7ST CLASS MAIL ^ POSTED ^ OTHER
NOW J~-y 2 , 20 Ol I, SHERIFF OFD COUNTY, PA do hereby deputize the sheriff of
York COUNTY to ezecu~~~make retur according
to law. This deputization being made at the request and risk of the plaintiff. __ _ _ _
OUT OF COUNTY
CUMBERLAND
ADVANCED FEE PAID BY SHERIFF
NOYE: ONLY APPLICABLE ON WRR OF EXECUTION: N.B. WAIVER OF WATCHMAN -Any deputy sheriff levying upon or attaching ariy property under within writ may leave same
without a watchman, in custody of whomever is found In possession, otter notirying person of levy or attachment, without liability on the part of such tleputy or the sheriff to any plaintiff
herein for any loss, deshuction, or removal of any property before sheriffs sale thereof.
9. TYPE NAME and ADDRESS of ATTORNEY/ORIGINATOR and SIGNATURE 70. TELEPHONE NUMBER 77. DATE FILED
WOLFSON & ASSOC. _ 6-26-01
72. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be cbmpletetl H notice Is to be mailetl). - - _
CUMBERLAND CO. SHERIFF
or complaintas indicated above. R. AHRENS ~7- -0 _ - 6-D
16. HOW SERVED: PERSONAL (~ RESIDENCE POSTED ( ) POE ( ) SHERIFFS OFFICE ( ) OTHER ( ) SEE REMARKS BELOW
77. ^ I hereby certify and return a NOT FOUND because I am unable to IocAte the individual, company, eta named ahoJe. (See remarks befowJ
16. NAME AND TITLE OF INDMDUAL SERVED/LIST ADDRESS HERE IF NOTSHOWN ABOVE (Relationship to Defendant) 79. D eof~rvice 20. Time of Service
/ZcFUS~D To SZ~N ~- ~iLL ~Ar~Fy -'t ~///a 1 loZ~ 3~}~
27. ATTEMPTS Dd Time Miles Int. Date Time Miles Int. Date Time Miles Int. Date Time Miles Int. Date Time Miles Int. Date Time Miles Int.
23. Advance Costs ~ 24. Service Costs 1 25. N!F ~ 26. Mileage X27. Postage) 28. Sub Total 1 29.
31. Surchg. 132. Tot. Costs) 33. Casts Due or Refund ~ Check No.
47. AFFIRMED antl subscdhetl to before me this i ~ -- - - -
44
Signature of - - -. - -
46
DAT
42. da of JULY , 2D 014 Gi ~, ~a'!
y .
ep. Sheriff .
b
- PRE>ZlSY/ NO RV 46
Si
t
of Y
rk 47
D T -
NethrialSea¢- ~ -,~~'- .
gna
ure
o
_ _ _
County Sheriff .
Jam+az4 V, V~nsr~en, Nmtafq•Pulallc 7-13-O1
pity ai 1~rkc
`torn CtiulSt
PA I'
,
y,
My Gtlfnmi@5i6fl ~~IFe@M~A.2'1, 2005 4 . igna ure o oreign 49. DATE
- County Sheriff
60. I ACKNOWLEDGE RECEIPT OFTHE SHERIFF'S RETU
RN SIGNATURE
- -
~ -
- 6t DATE RECENED
_
_
_
_
OF AUTHORIZED ISSUING AUTHORITY AND TITLE - --- - - --
t. WHITE-Issuing Authority 2. PINK-AHOmey 3. CANARY-Sheriffs Office 4. BLUE-Sheriffs Office
`i~~'
i
_ SHERIFF SERVICE ( INSTRUCTIONS
- PROCESS RECEIPT and AFFIDAVIT OF RETURN i'LEASE TYPE ONLY LINE 1 THRU 12
DO NOT DETACH ANY COPIES
3.
T
~-_ _ -
COUNTY OF YORK
_ OFFICE OF THE SHERIFF SIR )I771 96 iL • ,
28 EAST MARKET ST., YORK, PA 17401
e - - _-- __
s!
_,~ HCR Manor Care
caia-1na Baker
28. Sub Total 29 Pound 30. Notary 31. Surchg. 32. Tot.
2.
Notice and
Jill Janney
6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO., CITY, BORO, TWP., STATE AND ZIP CODE)
AT 220 S. Baltimore St Dillsbur~, PA 17019
T. INDICATE SERVICE: O PERSONAL ^ PERSON IN CHARGE RXFbEPUTIZE ~CE~~idAI~L~ ^ 7ST CLASS MAIL O pOSTED ^ OTHER _
NOW JAY 2 ~ , 20 01 I, SH OF`'4000N~T~Y',P^,~~Av,"do hereby deputize the sheriff of
"` Fork _COUNTY to execu7~~~~~/ " make return according
to law. This deputization being made at the request and risk of the plaintiffi. ~-~•r ~ _
_ sNERIFF of
e. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXP~DITFG SERVICE: -~ ~- ~~ (] IIii~'PT~ ailfj ~ -
OUT OF COUNTY
CUMBERLAND
ADVANCED FEE PAID BY SHERIFF
_ NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B, WAIVER OF 6YATCHMAN -Any tlepuly sherrff levying upon or attaching any property under within wnt may leave same
_ wi~out a watchman, in custotly of whomever is fauntl in possession, a([er notifying person of levy or attachment, without liability an the part of suU tleputy or tha sheriR to any plainliR
heri:in for anylnss, destrugion, a removal of any property before sheriffs sale thereof.
9. TYPE NAME and ADDRESS of ATTORNEY! ORIGINATOR ahd SIGNATURE - - 70. TElF3HONE NUMBER 17. DATE FILED -
WOLFS9N 3r ASSOC. _ 5-Z6-O1
12. SEN OTipE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed'R notice is to be mailed) _ - - -
- CUMBERLAND CO. SHERIFF - ,-__
__ _-.. ._
~"". ~`.-_SPACE BELOW FOR USE OF THE SHERIFF - DO NOT tNRITE BELOW THIS LINE
t3. laoKnowlep-Se receipt of [he wnt 14. A EIVED 15. Expi on fan Date
or wmplaintas indicated above. R, AHRENS - - - D-~t~.
-' - - - - - -
\\(( - -
16. HOW SERVED: PERSONAL (/7~ RESIDENCE ( ~ POSTED ( ) POE ( ) SHERIFF S OFFICE ( ) OTHER ( J SEE REMARKS BELOW
17. ^ I hereby certiy and return a NOT FOUND because 1 am unable to locate the intlivitluat, company, etc. named above. (See remarks below) _ _ _ _
78. NAME ANb TITLE OF INDIVIDUAL SERVED /LIST ADDRESS HERE IF NOT SHOWN ABOVE (Relationship to Defendant) 19. Dat~ of gervice 20. Time of Service
ri~~i~SE.~ TO S?~N - ~?f.L- ~<rnSE.i` -- ._ --f ,)~'"o t %...`r.".>„ j~
21. ATTEMPTSI Date+rTime I Miles I Int. 1 Date 1 Time I~Miles I Int. 1 Date~l Time I Miles I Int 1 Date" I Time I Miles I Int 1 Date I Time I Miles I Int. B Date I Time I Miles I Int
a-
29. Advance Costs 24. Service Costs 25. N!F 26. Mileage
34. Foreign Cbunty Costs 35. Atlvance Costs 36. Service Ca
47. AFFIRMEb and subscdbetl to before me this
ea. day or ~lULY , 20 OI43.
'PRDTA~mv NO7A
~¢r, Signature of
Dep. Sheriff
46. Signature ofl
County ShedH
:-..'%v
(
^.
33. COSls DUe or Rotund Check NO.
~~.- , ,
45. DATE /
-~ir- y
47. DATE
7-13-O1
49. DATE
OF AUTHORIZED ISSUING AUTHORITY AND TITLE _,
1. WHITE-Issuing AUthonty 2. PINK-Attorney 3. CANARY-SherifYS Office "4. BLUE -Sheriffs Offibe - -~ - _ - -
- ~ r' -
.. - w
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, No. O(- 397 ~I~~~~~
Plaintiff
vs. CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
NOTICE ~ o
,, -r,
_ -~
You have been sued in Court. If you wish to defend against the claims set forth in the foilta6ving ~c ~,
pages, you must take action within twenty (20) days after this Complaint and Notice is served, by ~ o rn
entering a written appearance, personally of by attorney, and filing in waiting with the Court yblar %~ -~
defenses or objections to the claims set forth against you. You are warned that if you fail to do so,xlle -~ ~ a
case may proceed without you and a judgment may be entered against you by the Court without furtGe~ _' ~ =
notice for any money claimed in the Complaint, or document, or for any other claim or relief requeste&
by he Plaintiff. You may lose money or property or other right important to you. r.
u'~
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en
las paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita o en persona o por abogado y archivar en la
corce 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 o otros derechosimportantes para used.
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue T~E, '~~ F~ AE~QRD
Carlisle, Pennrylvania 1701
(717) 249.3166 ~ T ~ ' I Ise S~4 ICiq l~11d
~II® ~ ~ s2id 8t. , PSI.
T!
hanelrMy
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO.
Plaintiff
vs. CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
C®MPLAINT
AND NOW, this ~1(~ day of J~t~~, , 2001, comes the Plaintiff,
HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law
firm of Wolfson 8L Associates, P.C., and files the within Complaint and in support avers
as follows:
1. Plaintiff, HCR Manor Care (hereinafter referred to as "PlaintifY'), 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 17315.
2. Defendant, Georgianna Baker, hereinafter referred to as "Defendant
Georgianna"), is an adult individual with a last known address of 220 South Baltimore
Street, Dillsburg, Cumberland County, Pennsylvania 17019.
3. Defendant, Jill E. Janney, hereinafter referred to as "Defendant
Jill"), is an adult individual with a last known address of 220 South Baltimore Street,
Dillsburg, Cumberland County, Pennsylvania 17019.
4. That Defendant Jill represented herself to be Power of
Attorney for Defendant Georgianna. Defendant Jill is the daughter of Defendant
Georgianna.
5. That on or about February 19, 2000, through March 1, 2001,
Defendant Georgianna 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 February 19, 2000, Defendant Jill, as Power of
Attorney for Defendant Georgianna, 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 February 19, 2000 is attached hereto, incorporated herein, and
collectively marked as Exhibit "B".
7. By executing said Admission Agreement, Defendant Jiil did assume and
accept responsibility for the debt to be incurred by Defendant Georgianna.
8. That Plaintiff submitted to Defendants a copy of the itemization of
services accurately showing all debits and credits for transactions with Plaintiff. Said
Statement of Account has been previously identified as Exhibit "A" and incorporated
herein by reference.
2
9. That Defendants did not object to the above-mentioned Statement of
Account submitted by Plaintiff to Defendants.
10. As of the date of this Complaint, the balance due, owing, and unpaid
on Defendant Georgianna's account as a result of said charges is the sum of Thirty One
Thousand Nine Hundred Eight and 98/100 Dollars ($31,908.98). See Exhibit "A"
previously identified and incorporated herein.
1l. 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 Georgianna's account balance, all to the damage and detriment of the
Plaintiff.
12. Plaintiff has made numerous requests to Defendant Jill, as Power of
Attorney for Defendant Georgianna, demanding that the sums due and owing to
Plaintiff be paid, and Defendant Jill has ignored her fiduciary obligations to pay
necessary and appropriate bills and obligations for her mother, Defendant Georgianna.
13. Pursuant to Section 1, Paragraph 1.03, of the Admission
Agreement, Plaintiff is entitled to receive and Defendants have 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.
14. As of the date of the within Complaint, the amount of interest that
has accrued on the past due balance is the sum of One Thousand Four Hundred Fifry-
Six and 95/100 Dollars ($1,456.95).
3
15. Plaintiff has retained the services of the law firm of Wolfson 8i
Associates, P.C., in the collection of the amounu due from Defendants.
16. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement,
Plaintiff is entitled to receive and Defendanu have agreed to pay reasonable attorney's
fees and all court cosu if the account is referred to an attorney for collection. See
Exhibit "B" 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 81: Associates, P.C., in the collection of
the amounu due and owing by Defendanu, 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 Defendanu.
18. That the amount of attorney's fees which represenu thirty percent
(30%) of the principal amount due and owing is the sum of Sixteen Thousand One
Hundred Fifteen and 74/100 Dollars ($16,115.74).
19. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
20. The amount in controversy exceeds the jurisdictional amount requiring
compulsory arbitration.
4
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment in favor of Plaintiff and against Defendants,
Georgianna Baker, Individually, and Jill E. Janney, Individually, and on Behalf of
Georgianna Baker, in the amount of Thirty One Thousand Nine Hundred Eight
and 98/100 Dollars ($31,908.98), contractual interest in the amount of One
Thousand Four Hundred Fifty-Six and 95/100 Dollars ($1,456.95), reasonable
attorney's fees in the amount of Sixteen Thousand One Hundred Fifteen and
74/ 100 Dollars ($16,115.74), the costs of this action, and such other relief as the
Court deems proper and just.
Respectfully Submitted,
G~ :~~
Daniel F. Wolfson, Esquire
WOLFSON si ASSOCIATES, P.C.
267 East Market Street
York, PA 17403
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
5
EX~IIBIT "A"
5J1aJ@1
RB56)
ESIDENT RESIDENT RESIDENT
1NBER TYPE NpNE
RESIDENT LEDGER AS Of DATE Of FIRST RCTiVITY PAGE 1
6JL -- ACCOUNTS RECEIVABLE --
DATE PTY RCCOUNT CHRRGES CREDITS BALRNCE
J018 PRIVATE DRKER, GfORGIANNA 3 02J19J00 RDN CNTR RRTE: C.D@
ROON 110 -A LEVEL 2 03J@1JD1 DES PRIV PORT; 93@.00
**PRIVATE - JUN 00
BRL FWD -LN- -36- -60- -90- -12@+-
41.00 5.@D 46.00
i16D0 CABLE RENTAL 06JDiJDO -- @6(30JBD I 591584011@0 5.40
AOV PVT PORTION 01J01J0@ 1321100@00D 200.00
**ENDING BALANCE 251.00
"*PRIVRTE - JUL 00
BRL FWO -LN- -30- -60- -90- -12@+-
205.00 41.0@ 5.0@ 251.@@
PRYNENT 07J25J00 1121D0020DD 5.00
PRYNENT 07J25J00 112100020D@ 41.00
11600 CABLE RENTAL D1J01J00 -- D7/31JOD 1 59158481200 5.00
REV LAST NO PP 01JD1J0@ 13211@A0000 20D.00
REV PVT PORT 6JD0 06J30JD0 1441105D00@ 2DD.0D
(BLIND) @1(20J00 14411@50000 195.@0
(BLIND) @IJ20JD@ 14411050000 145.OD
**EtIOINfi BALANCE 190.00-
**PRIVRTE - AUG @D
BRl FWD -LN- -30- -60- -9D- -12A+-
190.00- 190.00
11600 CR81E RENTAL D8J01(00 1 59158401200 5.00
11104 BEAUTY AND BARBER 08J08JD0 1 591581012DD 9.00
ii1DD BEAUTY AND BRRBER 06J24J06 1 591581D120D 36.00
PRIVRTE PORTION @BJDiJ00 -- 08J31J6@ 31 930.00
RDV PVT PORTION 09jD1(00 13211@00080 930.00
RDJ DONE IN ERROR D6J30J00 14411050060 200.00
(BLIND) 08J22J00 14411D50000 190.0@
(BLIND) @8(22J0@ 1441105D600 144.OD
*"ENDING BALRNCE 1920.00
**PRIVRTE - SEP @D
BAl FWD -LN- -30- -69- -90- -120+-
1120.06 20@.@0 1920.00
11600 CRBLE RENTAL 04J@1(00 -- 09J30J00 1 59158901200 5.00
REV LAST NO PP 09JO1J00 1321100DOOD 930.00
PRIVATE PORTION 09JB1J00 -- 09/30J00 30 93A.00
ADV PVT PORTION 10JO1J00 132110A@D60 930.00
"*ENOINfi BALANCE 2855.0D
**PRIVRTE - OCT OB
BAl FWD -LN- -30- -6D- -40- -120+-
186S.D@ 79@.00 200.00 2855.00
1160D CRBLE RENTAL 10J01J@0 -- 1AJ31J00 1 591564D1200 5.@0
REV LRST NO PP 10J01j00 13211800000 930.@0
PRIVATE PORTION 10JOiJ00 -- JOJ31JA0 31 930.00
6j14J01
BRSb)
ESIDENT RESIDENT RESIDENT
UNBER TYPE lIANE
0018 PRIVATE BANER, GEOR6IANNA J
ROON 11P -A LEVEL 2
**PRIVATE - DCi 00 (CORY)
ADV PVT PORTION
*ENDING BALANCE
**PRIVATE - NOV 00
BAL FWD -LN- -30-
1865.00 935.00
10001 LAB SERVICES
10007 LAB SERVICES
10201 BIODD GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
11600 CABLE RENTOL
29001 PHARNRCY LEGEND
300@1 PNARNACY NON LEGEND
53601 OIYGEN CONCEN RENT DLY
_10201 BLOOD GLUCDSE TEST
19201 B100D GLUCOSE TEST
10201 B100D GLUCOSE TEST
10201 BL000 GLUCOSE TEST
10201 Bt000 GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
10101 BLOOD GLUCOSE TEST
11100 BEAUTY GND BARBER
10201 BL000 GLUCDSE TEST
1020! BL000 GLUCOSE TEST
10201 BL000 GLUCOSE TEST
10201 B100D GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
18281 BLODD GLUCOSE TEST
10201 BLOOD 6LUCDSE TEST
10201 81000 GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
10201 B100D GLUCDSE TEST
102@1 BLOOD GLUCDSE TEST
10201 81000 GLUCOSE TEST
10101 BLOOD GLUCDSE TEST
10201 BLOOD fiLUCOSf TEST
10201 BLOOD GLUCOSE TEST
10201 BL000 GLUCOSE TEST
10201- 0L000 GLUCOSE TEST
10201 BLOOD 6LUCDSE TEST
10201 BLOOD GLUCOSE TEST
10201 BLOOD 6LUCDSE TEST
10201 0L000 GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
10201 BLOOD GLUCOSE TEST
REV LAST NO PP
RESIDENT LEDGER AS OF DATE OF FIRST AGTIVITY PRGE
-60-
190.00
IiJ01j00 --
11)01(00 --
11J01J00 --
11)01(00 --
GJ1 -- ACC BUNTS RECEIVABLE --
BATE QTY ACCOUNT CHARGES CREDITS BALANCE
02ji9JOD ADR CNTR RATE: 0,00
03(D1j01 DIS PRIV PORT: 93@.08
i1J01f06 13211080000 939.D4
379D.00
-90-
200.00
041D0
-12A+-
3190.00
S615i90120A 27.50
561519@120@ 12,17
56153901209 9.3]
55151401200 4.37
591584@12@0 5,00
54551201200 428.85
54951301200 11.54
55353601200 540.00
Sb15O9012D0 4.37
56151401200 4.31
56151901200 8.74
Sb1519A12A0 8.74
Sb151901200 8.74
56151901200 8.74
5615190120@ 8.74
591581912@0 17.5@
561519012DA 8.74
Sb151901200 8.14
56151901200 8.74
56151901200 8.74
5b151901200 8.74
5615190120@ 8.74
56151901200 6.74
55151900200 8.14
561519@1200 8.14
56151901200 8,14
56151901208 8,14
561519012@0 8,74
56151901200 8.74
56151901200 8.14
56151901200 8.14
56151901200 8,74
5b151901200 8.74
551519@1200 8.74
56151901200 8.74
561519@1200 8.74
56151981200 8.74
5b1519012A0 8.74
561519@1200 8.74
13211000@00
930.00
6/14/01
AR56}
ESIOEMT RESIDENT RESIDENT
UMBER TYPE LARNE
0018 PRIVRTf BAKER, GEORGIAN NA J
ROOK 110 -R lfVEt 2
**PRIVATE - NOV 00 (CONT)
ROOK CHARGE AT 133.00
ADV BOON CHARGE AT 1'33.00
PHARNACY WON-LEGEND
ROOK CHG 2(00
PHARXACY LEGEND
PHARN NON-LEGEND
RN CHG 3J0D
PHARNACY NON-LEGEND
ROOM CHG 4)00
PHARNACY NON lEGR10
RN CHG 5j00
IEAVE CHARGE
WOUND TREATMENT
ROOM CH6 6j60
PHARNACY IEGEN-
PHARNACY NON-LEGEND
WOUND TREATMENT
RON CNG 7(00
IEAVE CNG
ROOM CHG IJ06
REV PVT PORTION
NON lE6END DRUGS
NON LEGEND DRUGS
OXYGEN CONCENTRATOR
BL000 GLUCOSE TESTS
ROOK CNG 8(00
AEU PVT PORT
BLOOD fiLUCOSE TEST
PHARN LEGEND
PHARN NON-LEGEND
ROOK CHG 9(00
REV PVT PORT
,'~ OXYGEN CONCENTRATOfl
BL000 GLUCOSE TEST
LAB SERVICES
BLOOD 6L000SE TEST
LEGEND DRUGS
NON-LEGEND DRUGS
OXYGEN CONCENTRATOR
BLOOD GLUCOSE
ROOK CHG 10(00
'~ REV PVT POAi
AOJ GONE III ERROR
'*ENDING BRIRNCE
"'PRIVATE - DEC 00
RESIDENT LEDGER RS DF DATE OF FIRST ACTIVITY PRGE
G/L -- ACCOUNTS RECEIVABLE --
GRTE QTY ACCOGNT CHARGES CREGITS BALANCE
D2jI9/DD ADM CRTR RATE: 0,00
03(01j01 DIS PRIV PORT: 930.00
11J91~00 -- 31/
12JB1j00 -- 12/
021
Da
04
30)06 30 51350001200 3990.00
31j0A 13211000000 4123.00
26)40 84981301200 3.03
26j 5135000120A 1397,00
31( 54551201206 3.52
31j 54951301260 11,23
31/66 51350001260 3937.00
30j00 54951301200 8,82
30)00 51350001206 3810.04
31j0D 54951301200 13.37
31)06 51350001200 2921.00
31( 51356001200 889,60
3A(OB 54151501100 24.00
34(A0 51350001260 1143.00
31/60 S455E201200 1801.69
31(06 54951301200 136,03
31Jp0 54151501290 48,04
31j00 51350001200 3429,06
31(66 51350001200 121.06
31 (0D 51350001200 381.00
31)60 14411050000
31j00 54951301200 1105.46
31)00 54951301200 161.56
31j00 54951301266 558,00
31)00 56151901200 279.68
31j00 81380081200 4123.00
31)60 14411050000
30(60 56151901200 21.85
36/00 54551201206 272.79
30)00 54951301200 58.88
30/60 51350401200 3996.00
36(00 14411050000
30)60 54951301200 540.00
3D/A0 56151901200 349.60
31)60 56153961200 6.56
31/00 56151901200 8.74
31jD0 54551201200 467.66
31)00 54951301260 26.61
31)00 54951301200 556.00
31)00 56151901220 161.69
31)00 51350001200 4123.00
31)00 1441105DD00
19JA0 14411050000 260.60
00
DO
0D
00
200.00
930.0@
930.00
930.@0
46442.39
6J34J0i RESIDENT LEDGER AS OF DATE OE FIRST RCTIVITY PAGE 4
AR56)
ESIDfNT RESIDENT RESIDENT Gjl -- ACCOUNTS RECfIVABtf --
UMBER TYPE NRNE DATE QTY ACCOUNT CNRRGES CREDITS BRlBfICE
0018 PRIVATE BRKER, GEORGIRHNR J 02Ji9J00 ADN CNTR RATE: 0.09
ROOM 110 -p LEVEL 2 03J01J01 OIS PRIV PORT: 930.08
**PRIVATE - DEC 00 (CONY)
8AL FWD -LM- -30- -68- -90-
39459.39 935.00 935.00 790.00
1!600 CRBLE RENTAL 12(61/00 -- 12(31/00
53603 OXYGEN CONCEN RENT DLY 12JO1j00 -- 12/31JA0
10201 BL000 fiLUCOSE TEST 12JOSJ00
10201 BLOOD 6L000SE TEST 12j01J40
10201 81000 GLUCOSE TEST 11J09J00
10201 BLOOD 6L000SE TEST 12J10J@0
10201 BLODD GLUCOSE TEST 12J10J00
30201 OLOOD GLUCOSE TEST 12J11j00
10201 BLOOD 6l000SE TEST 12j12J00
10201 81000 G[UCOSE TEST 11(13(00
10201. BLDOD GLUCOSE TEST 12J14J09
10201 BL000 61UCOSE TEST 12JISJ0A
10201 B100D fiIUCOSE TEST 11J16J00
10281 BLOOD GLUCOSE TEST 12j11J00
10201 BLODD GLUCOSE TEST 12J18j00
10201 01000 GLUCOSE TEST 12J19JBA
1110@ BEAUTY AND BARBER 12J19J00
10201 BIDOD GLUCOSE LEST 12J2SJ00
REV LAST NO RC 12J01J00
AODM CNRA6E RT 133,60 32JBSj00 -- 12J31J00
ROV BOON CHARGE RT 133.00 91j01/01 -- 01J31J01
**ENDING BALANCE
**PRIVATE - JAN 01
BRl FWD -LN- -30- -60- -90-
8954.26 35336.39 935.00 935.00
53601 OXYGEN CONCEN RENT DLY 01j01/01 -- 0LJ31J01
REU LAST NO RC B1J01J01
BOON CHARGE RT 133.00 01f0IJ01 -- 0iJ31J03
ROV BOON CHARGE RT 133.00 02J01/01 -- 02J28J01
**ENDING BALANCE
**PRIVATE - FEB 01
8RL FWD -LN- -30- -60- -90-
8405.00 -0831.25 35336.39 935.00
11100 OEOUTY SHOP WjS CUT1J18 02J01J01
11600 CABLE RENTAL 02J01J01 -- 02J28f01
REV LAST NO RC 02JOIJ01
PRIVATE PORTION 02J01j01 -- 02J26j01
ROV PVT PORTION 03J01i03
CRBLE RENTRI 91J31J01
*aEN0IN6 BALRNCE
**PRIVATE~ - NAR O1
-120+-
4323.00 46442.39
1 59158401260 5.00
31 55353601200 568.00
1 56151901200 4.3T
1 5b1519A1200 4.31
1 5b151901200 4.37
2 55151901200 8.74
2 56151901200 8.74
2 5b 151901200 8.14
2 56151901200 8.74
Z 56151901100 0.74
2 56151901208 8.74 '
2 56151901200 8.74
2 56151901100 8.74
2 56151901200 8.74
2 56151901200 8.74
f 56151901200 4.37
1 591581012P0 36.00
1 56151901200 4.37
13211000000 4123.00
31 51358001200 4123.00
13211800000 4123.00
51273.64
-120+-
6113.00 51273.54
31 55353601200 558.00
13211000000 4123.00
33 51350001200 4323.08
13211000000 3724.00
5S5S5.64
-120+-
6048.00 55555.64
1 59158101200 17.50
I 59158401200 5.00
13231080084 3724.00
26 930.00
33211000000 930.00
54158401000 5.00
53719.34
oJ14J0i RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE S
4R56)
ESIDENi RESIDENT RESIDENT GJL -- ACCOUNTS RECEIVABLE --
JNBER TYPE NRNE DATE pTY ACCOUNT CHARGES CREDITS BAIRNCE
'. 8018 PRIVATE BAKER, GEORGIANHA J 02J19JOD ADN CNTR RATE: 0.00
ROOK 110 -A LEVEL 2 03JOiJ01 DIS PRIV PORT; 930.00
**PRIVATE - NAR Dl (CONT)
8AL FWD -Lq- -30- -60- -90- -120+-
1682.SD 4686,00 483i.2S 35336.39 6983.00 53719.14
53601 OXYGEN CONCEN RENT DIY 03JOiJ01 1 55363601200 18.00
AEV LAST ND PP 03J03/Oi 13211960000 930.GD
**ENOINfi BALANCE 52801,14
**PRIVATE - APR 01
BAl FWD -LN- -30- -60- -90- -120+-
18.00 952.50 4686,00 4831.25 42319.39 52807.14
**ENOII4G BALANCE 52807.14
*"PRIVATE - qAY 01
BAL FWD -Lq- -30- -60- -90- -120+-
18.00 952.50 4686.00 47150.64 52807.14
REV GLUCOSE 09J30J00 56151901209 21.85
REV PHARN LE6EN0 09J34/08 54551201200 212.79
REV PHARN NON-LEGEND 09/30JD0 54951301200 58.88
AEU GL0008E 09J30J90 56151901200 399.60
REV R G B 99/39/96 S61S1901200 3940,00
PRIVATE PORTION 09J30J00 14411050000 982.61
NCB PRENIUN 09/3A/0A 3343040A509 95,50
IiISURANCE PREgIUN 09J30J00 33430400500 70.00
REV OXYGEN 09J30JD0 54151001200 540.00
AEV GLUCOSE 19J31J00 56151901200 170.43
' REV RX 10/31 /D4 54SS1201200 467.66
REV OTC 1AJ31J00 54951301200 26.61
REV OXYGEN' 10J3iJD0 54151001200 558.00
REV R G 8 19J31J00 51350001200 4123.00
PRIVATE PORTION 19J31JA0 144110500A0 982.61
NCB PREgIUq 19J31J00 33430400500 45.50
IN9 PREgiUq 10/31J40 334304095A0 70.00
LAB 10J31J90 56151901200 6.56
REV RX S1J30JAA S4S51201200 428,86
REV OTC 11/30/00 54951301200 11,54
REV OXYGEN lif3D(0D 54151001200 540.00
REV R G B 11J30J0A 5135000120A 3990,00
PRIVATE PORTION SiJ30(DD 14411050009 982, 6i
NCB PRENIUq 11/30/00 33430400300 45.50
INS PRENIUN 11J3AJOD 33430400500 70,00
AEV LAB 11/30J09 56151901200 39.67
REV GLUCOSE 11(39(00 Sb1519012A0 262,20
PRIVATE PORTION 12/31(AA 14411050000 962.61
NCB PREgIUN 12(31(00 33430400590 95,50
i INS PRENIUq 12(31(@0 33430400500 10.00
REV DXYGEN 12(31(60 541510A120A 558.00
REV OXYGEN 12J31JAA 64151001200 109.26
REV R G 8 32J3f/AA S135B001200 4123,OC
6J14J01 RESIDENT LEDGE P, AS Of GATE Of FIRST ACTIVITY PAGE b
ARSE)
ESIDENT RESIDENT RESIDENT GJL -- ACCOUWTS RECEIVABLE --
UMBEfl TYPE NANE DATE pTY ACCOUNT CHARGES CREDITS BALANCE
I
0018 PRIVATE BAKER, GEDR6IANNA J 02J19J6D ADM CNTR RATE: 9.DD
I ROOM 110 -A LEVfI 2 03JD1J01 OIS PRIV PORT: 930.D6
""PRIVATE - MRY 01 (CONT)
REV O%YGEN 41J31/01 54951301208 558.00
REV R 6 B 01J31J01 5135D001200 4123.00
PRIVATE PORTION OIJ31/01 19611050000 1018.11
' MC8 PREMIUM @iJ31J01 33430400500 SD.DD
REV PP 02J26/Oi 14411050040 930.00
PRIVATE PORTION. 02J26/D1 14411058009 1018.11
MCB PRENIUM 02/28JBi 33430600500 56.00
REV O%Y6EN 03J31J61 54151001200 18. DD
'*Eh'DIN6 BALANCE 31908.90
EXH[BIT "B"
HCR Manor Care
ADMISSION AGREEMENT
This 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 of the parties
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
Center:
Resident:
Legal Representative: - , ~~ ~'t , ', N/Ei~/~~r ~ ~ ~ , ~-rln ~~
Admission Date: ~U Deposit: $ .
Term: This Agreement shall begin on the day the Resident enters the Center and end on
the day the Resident is dischazged.
I. RIGHTS AND RESPONSIBILTTIES OP THE RESIDENT
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 (10`") 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
Organization (see Section 1.06).
1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for
additional medical, therapeutic, or personal caze services or supplies that may be requested by the
Resident, ordeced 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
(!0`s) day of the month.
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be
subject to a service charge equal to the highest legal rate of interest permitted by State law as set
forth in Attachment A on the past due balance each month until such time as the 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 limited to, the Resident's attending physician for any health or
persona] program in accordance with the terms of the program.
1.05 Governmental Pro re ams. 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 program, 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 all 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 following programs: 1riGledicare, Medicaid and/or ~A.
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay or 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 and/or 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 from 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 Managed Care Organizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity 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 Center
2
~. _.
wit[ bill the Resident's third party payor 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 far 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 far 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 responsibility of the Resident and/or Legal
Representative to notify the Center and to provide aay needed information regarding all third
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 davs 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 maybe 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 Agreement.
1.09 Application for 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, HMO, 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
3
Agreement serves as a written notice that the Center has notified the Resident and/or Legal
Representative that services provided at the Center may not be covered by a governmental payor,
third 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.
1.11 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 Lega] Representative acknowledge thb 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
and procedures and the pharmacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distribution system.
II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE
- 2.01 Legal Authority. The Legal Representative hereby represents thaf'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 from 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 from the
Resident's income or resources for the fees and charges provided for in this Agreement.
2.03 Requested Items. 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 Legal 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.
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such information about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally responsible
for any charges denied the Center due to any lack of cooperation.
2.06 Acceptance Upon Discharee. 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
3.01 Room and Standard Services. As part of the Room and Board Rate, 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 maybe required pursuant to the plan of care prepared by the Resident's physician and
the Center, with 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, if any, noted at
the beginning of this 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 frame required by
State law. In the case 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.
1V. GENERAL 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
5
reviews or payment audits performed by such; the personnel of any hospital or other health 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
Pian of Care, or as required from 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 Photo~raoh. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifying the Resident, for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to 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 opportunity to ask questions and questions have
been answered satisfactorily.
a. 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.
f. 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
6
Authorization and any other related documents. See Attachment H-1 and
H-2.
g. The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
h. Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
i. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
j. 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 fraud control:unit. See
Attachment I (Center Supplement).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phone number on how to file z. complaint
with the state survey and certification agency concerning, resident abuse,
neglect, mistreatment and misappropriation of property. See Attachment I
(Center Supplement).
m. The Resident Handbook. See Attachment J.
n. ResidentlPatient Rights. See Attachment K.
o. 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.
p. 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-1
and M-2.
q. Privacy Act Notification. See Attachment N.
r. Inventory sheet and/or policy of personal items. See Attachment 0.
7
s. ASM Form. See attachment P.
t. Consent to Photograph See Attachment Q.
u. See Attachment R.
v. See Attachment S.
w. See Attachment T.
x. See Attachment U.
y. See Attachment V.
z. See Attachment W. ~'
4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this 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 bolder 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 es ven (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 injury caused by the Resident to any person or the property
8
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 of a change in State or Federal law will not invalidate the remaining
provisions of this Agreement and, it is agreed that to the extent 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 T$AT 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 THEIIt SATISFACTION.
Signature of Resident:
Date:
Signature of Legal Representative, signing on his/her own behalf.
Center Representative: !/ (~ i~ ~-l 1 ~~
Date:
Date: ~ "
Signature of Legal Representative, if signing on behalf of Resident:
,;
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
NO. 01-3978
Plaintiff
vs.
CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
PRAECIPE FOR JUDGMENT
ENTER JUDGMENT in the above case for failure to file, enter, an
ANSWER TO THE COMPLAINT
against 11LL E. IANNEY
in favor of HCR MANOR CARE
in the sum of $49.481.67 with interest AS ALLOWED BY STATUTE
Total: $49.481.67 + COURT COSTS
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Attorney for Plaintiff
Daniel F. Wolfson, Esquire
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the Prothonotary this day according to the tenor of the above statement.
Prothonotary ~,1
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
vs.
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
CERTIFICATION
NO. 01-3978
CIVIL ACTION - LAW
I, Daniel F. Wolfson, Esquire, due hereby certify that on September
12, 2001, 1 caused a true and correct copy of the 10 Day Notice attached
hereto to be served on the Defendant, Jill E. Janney.
Daniel F. Wolfson, Esquire
WOLFSON 8t ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717) 846-1252
I.D. # 20617
Date: lr Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
NO. 01-3978
Plaintiff
vs.
CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
AFFIDAVIT OF NON-MILITARY SERVICE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
I, Daniel F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my
knowledge,.information and belief, Jill E. Janney, Defendant, above named; is over 21 years of
age; is last `'known to reside at 220 South Baltimore Street, Dillsburg, Cumberland County,
Pennsylvania, 17019, is not in the military service of the United States or its Allies, or otherwise
within the provisions of the Soldiers' and Sailors' Civil Relief Act of Congress of 1940 and its
Amendmenu.
Daniel F. Wolfson, Esquire
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Attorney I.D. # 20617
Attorney for the Plaintiff
Swom and subs ri ed to
befo5e me this day
of ~~(`t~~+? , 2001.
Notary Pu '
Notarial Seal
Michele M. McHugh, Notary Public
City of York, York County
My Commission Expires Aug. 12, 2002
Member, Pennsylvania AssoC4~don of Nohaltes
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO. 01-3978
Plaintiff
vs. CIVIL ACTION - LAW
GEORGIANNA BAKER, Individually, and
JILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
TO: JILL JANNEY
220 SOUTH BALTIMORE STREET
DILLSBURG, PA 17019
DATE OF NOTICE: Setember/Z, 2001
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU;:FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND
YOU lalAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO`TO OR TELEPHONE THE FOLLOWING
OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Court Administrator
Cumberland County Court House
1 Court House Square, 4`h Floor
Carlisle, Pennrylvania 17013
(717) 240-6200
BY: ~ -
Daniel F. Wolfson, Esquire
WOLFSON si ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403-2000
Telephone: (717) 846-1252
I.D. # 20617
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
vs.
GEORGIANNA BAKER, Individually, and
]ILL E. JANNEY, Individually and on Behalf
of GEORGIANNA BAKER,
Defendants
NO. 01-3978
CIVIL ACTION - LAW
NOTICE OF ORDER, DECREE OR JUDGMENT
TO: ( )PLAINTIFF (X) DEFENDANT ( )GARNISHEE ( )ADDITIONAL DEFENDANT
YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS
BEEN ENTERED AGAINST YOU ON
IN ACCORDANCE WITH THE PROVISIONS OF PA.R.C.P. 236
( )DECREE NISI IN EQUITY
( )FINAL DECREE IN EQUITY
(X) JUDGMENT OF () CONFESSION () VERDICT
(X) DEFAULT () NON-SUIT
() NON-PROS () ARBITRATION AWARD
(X) JUDGMENT IS IN THE AMOUNT OF $49,481.67 PLUS COSTS $185.62
FOR A TOTAL OF $49,667.29.
() DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF
$ PLUS COSTS.
() IF NOT SATISFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S
LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF
TRANSPORTATION
ROTHON TARY
BY
IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE CONTACT:
NAME OF (ATTORNEY/FILING PARTY): WOLFSON & ASSOCIATES, P.C.
ADDRESS: 267 EAST MARKET STREET
YORK, PENNSYLVANIA 17403
TELEPHONE NUMBER: (717) 846-1252 OR 800-321-8467
NOTICE SENT TO: JILL E. JANNEY
220 SOUTH BALTIMORE STREET
DILLSBURG, PA 17019