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Home My WebLink About01-04092) HCR MANOR CFiRE , ) Plaintiff ) v. ) l.MELII~ B. SOBOTOR, :inc'aividuall~, MICHAEL SOBOTOR, individually, _ and on behalf of AMELIA B. SOBpTOR, Defendants OATH IJe do solemnly swear (or affirm) that we will support, obey and defend ~~ the Constitution of the United States and the Constituti,oa of this Comtton- wealth and that we will discharge the duties of fur office with fidelity. AWARD we, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) 1N ~iti d ~/I dF~O~ . applicable.) Date of Hearing: ,q/•igRNE 3, 2UUY Date of Award : /p/QiLGft +3 1(/p `~ In The Court of Cormton Pleas of Cumberland County, Pennsylvania vo. 2001 - 4092 tx~x Arbitrator, dissents NOTICE OF Eit (Insert name if Now, the 3 ~ day of ~2.~G~ I99 ~ l'X~ at 9 Sb 1~ ..5. , the above award was entered upon the docket aad notice thereof given by mail to the parties or their attoraeys. /~ Arbitrators` compensation to be ~i~.d.~; ~ a~ paid upon appeal: /~1 ' rothonotary $ 0240. Dy By: LJm.~c.~_ Q. ~2Pt. Deputy ~~~JS iN9lw.. E' UU'//.fS/~(//~/~ fit ~ s OOH 3a'~ ,rr~E~- y~ s - 2650 %a~a~ N.~%~ , ~ u~c Jeh,/ as2~usy~ow/G ~ fO~ S. h~/Of/fh ~JrtB~ Ceti/siF /~,~ ~ ~o, 3 t~ E-: o r il° ~ _..p IT, s:'_, ~ Rr ~y:-= ~ 'tf1T -C .:_ W C7 --T- e~_. _ ~`~l° ~~ _ iS? _.~ °~ O { t€7 f ~. 1~ l~ ~~{, ' ~" ~ 's ... ~ ~~' '4 _ _ _ _ ,_ ._ - Hde~t _. ~. kMFls!ut~l ., sut ,bH~~/ ~ r J'M~~ n Mss. ts~u~r .v¢ ;~.Ki€'fi`k~~fw. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ~--y~- HCR MANOR CARE, NO. U t - ~l~~~t U ~C, /frt.,., Plaintiff G vs. CIVIL ACTION -LAW AMELIA B. SOBOTOR, Individually,. MICHAEL SOBOTOR, Individually,,,, and on Behalf of AMELIA B. SOBOTOR, 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 twegty (20) days after this Complaint and Notice is served, by entering a written appearance, personSlly 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 againstyou by the Courtwithout further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la 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 torte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, la torte. tomara medidas y psedido entrar una Orden contra used sin previo aviso o notification y por cualquier,gtieja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades o otros derechos importances para used. LLEVE ESTA DEMANDA A U'N ~ABODOAGO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DIN6R0 SUFFICIENTE DE PAGARTAL SERVICIO VAYA EN PERSONA O LLAME POR 'fELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O,PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. 'fi~wyer Refer'ral' Service Cumberland Cduhty BarAssociatton 2 Liberty Avenue .Carlisle, Penhsylvania 17013 (717) E49-3166 R . m~e• } a IN THE COURT OF.COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, ""'' N0. O1- Y D 4 ~ Ce.o~ I _ew-- Plaintiff vs. CIVIL ACTION -LAW AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually;' and on Behalf of AMELIA B. SOBOTOR, Defendants COMPLAINT AND NOW, this ~ day of, 2001, comes the Plaintiff, HCR Manor Care, by and throug~ iu attorney, Daniel F. Wolfson, Esquire, and the law fine of Wolfson SL Associates; P.C:; and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care (hereinafter referred to as Plaintiff), is a health care provider qualified . ;to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Amelia''B. Sobotor, (hereinafter referred to as "Defendant Amelia"), is an adult individual with alast-known address of 940 Walnut Bottom Road, Carlisle, Cumberland Cdiinty, Pennsylvania 17013. 3. Defendant, Michael Sobotor, (hereinafter referred to as "Defendant Michael"), is an adult individual'.with alast known address of 19 Holly Estate Drive, y i Gardners, Adams County, Penhsylvania 17324. Defendant Michael is the son of Defendant Amelia. 4. That Defendant Tlichael represented himself to be Power of Attorney for Defendant Amelia. Atrue-and correct copy of the General Durable Power of Attorney dated October 22, 199b whereby Defendant Amelia designated Defendant Michael as her lawful Power of Attomey is attached hereto, incorporated herein, and collectively marked as Exhibit "A" 5. That on or about =]:uly ;16, 2000, through the present, Defendant Amelia is a health care residbnti'of Plaintiff, where she did receive and where she continues to receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein; and cbllectively marked as Exhibit "B". 6. That on or about July 16, 2000, Defendant Amelia executed an Admission Agreement which Agrpementoutlined various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and collectively marked as Exhibit'"C". 7. That Part 1 of the Admission Agreement, titled "Rights and Responsibilities of the Resident' ;did describe the various responsibilities of Defendant Amelia, which responsibilities did' include payment for the daily rate and charges for supplemental services, supplies not paid by any third party, as well as applicable co- 2 ~~ insurance and deductibles and all expenses of discharge or transfer. See Exhibit "C" previously identified and incorporated herein. 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 "B" and incorporated herein by reference. 9. That Defendants did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 10. As of the date of filing of this Complaint, the balance due, owing, and unpaid on Defendant Ameba's account as a result of said charges is the sum of Eleven Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See Exhibit "B" previously identified and incorporated herein. 1l. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused, and contJnue to refuse to pay all sums due and owing on the outstanding account balance, which accnaed due to residential health care services provided to Defendant Amelia, all to the damage and detriment of the Plaintiff. `~ ' 12. Plaintiff has made numerous requests to Defendant Michael, as Power of Attorney and Responsible Pariy for Defendant Amelia, demanding that the sums due and owing to Plaintiff be paid; and Defendant Michael has ignored his fiduciary obligation to pay necessary and appropriate bills and obligations for Defendant Amelia. ,..~. 13. Pursuant to Secfioh 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 "C" 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 Four Hundred Eighteen and 50/100 Dollars ($418.50). 15. Plaintiff has retained the services of the law firm of Wolfson 8t Associates, P.C., in the collecEion'of the amounts due from Defendants. 16. Pursuant to Section' 1, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive aiid'Defenda`hts have agreed to pay reasonable attorney's fees and all court costs if the account is referred to an attorney for collection. See Exhibit "C" 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 8L 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:''' 4 18. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Three Thousand Three Hundred Ninety-Five and 06/100 Dollars ($3,395.06). 19. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 20. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Amelia B. Sobotor, Individually, Ntichael Sobotor, Individually and on Behalf of Amelia B. Sobotor, in the amou'nt'of Eleven Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87);'contractual interest in the amount of Four Hundred Eighteen and 50/100 Dollars ($418.50), reasonable attorney's fees in 5 _~. the amount of Three Thousand Three Hundred Ninety-Five and 06/100 Dollars ($3,395.06), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON si ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717) 846-1252 LD. No. 20617 Attorney for Plaintiff 6 -~ EXHIBIT '°A" ,i °~iS +,i ,tyf~' - ars 4~ l~'4~ ~' i t i rt { ii'R,n ~-,~ i '.,~ S~f jl ~y l~r~ .iv y~{C,ns ~hF~l ~4~j .~it~~ i~~~~{~' ~G y~f~~ t~$ .F11 i~M1~1Y ~~1~F~I~ T' ~' ~l~' a~4Sd ~ ~ C ~.~{~~•~ I .~q ~l~'M ce,r..h ` ~~ gill.. .~"~a y.l>;~o`. i„w.)a..,. ~ ~,i)'1i.9~ . ~, a r y t ,'' a ~ tit~4A f~'~ tw,~a cn :~ ~ '. 411~yR ri+~,~ )~ R~ i; ~~2f pj]~pl'~' '' J "x~p ~t A~{~I~l N 4~J i r GENERAL DliRABLE POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, That I, AMELIA B. SOBOTOR, Manor Care, 940 Walnut Bottom Road, Carlisle, Cumberiand County, Pennsyivania 17013, do hereby appoint my son, MICHAEL P. SOBOTOR, 19 Hoiiy Estates Drive: Gardners, Cumberiand County, Pennsyivania 17324, as my agent ("my agent"), for me ar_d en my behalf, in my name or in 'r_is own name, to take a~~l actions and to perform all acts concerning my affairs as he may deem necessary or advisable, in his absolute discretion, as fully as I could do if personally present, including, without limiting the generality of the foregoing, for me and in my name anti on my behalf, as follows: 1. Inclusiveness. To receive and receipt for all sums of money or payments due or becoming due to me from any source; to enter my safe deposit boxes in any and all banking institutions, and to add to and to remove any of the contents thereof: to endorse all checks and other instruments payable to me and deposit and withdraw any and all moneys, checks and other instruments to which i may be at any time entitled in my name in any financial institutions; to pay any and ail claims and demands now or hereafter payable by me; to draw and sign checks, drafts and other orders for the payment of money upon my chec'.ting account or upon any other bank accounts or deposits now or hereafter belonging to me; to borrow money and to mortgage, pledge or hypothecate any property, real or personal, now or hereafter owned by me as security therefor; to sell, possess, insure, manage, maintain, improve, lease, mortgage, pledge, encumber, convey, and otherwise dispose of, or take any other action with respect to any property, real or personal, now or hereafter owned by me, on such terms and conditions as my agent considers appropriate, and ir_ the event of any sale of my real estate to execute the sales agreement and the deed in my name and to make settlement and receive the proceeds; to purchase, rent or otherwise acquire any aronerty, real or personal, for me and to pay for 'the same; to contract with and arrange for my entrance to any hospital, nursing home, health center, conval=scent home, or similar institution and to pay all bills in connection therewith; to arrange for and consent to or to withhold medical, therapeutical and surgical procedures for me, including the administration of drugs; to institute and to engage in and compromise any litigation on my behalf; for me and in my name and as my act to execute, endorse, acknowledge and deliver all documents; to prepare, execute and file any tax returns, governmental reports and other instruments of whatever kind; to engage and dismiss agents; and to manage, make and transact all and every kind of business of every nature. 2. General Authori'~v. To do ail other things wi:ich my agent she d deem necessary and prover in order to carry out t::e foregoing powers which shall be construed as broadly as possible, giving and granting unto my said agent full power and authority to do and perform all and every act, deed: matter, and thing whatsoever in and about my estate, property, and affairs as fully and effectually to all _tents and purposes as I might or could do in my own proper person if personally present, the abcve specially enumerated powers being il`n aid:.and exemplification o= the full, complete, and general power herein granted: and not in limitation or definition thereof; and hereby ratifying and confirming all that my said agent shall lawfully do or cause to be done by virtue of these presents. 3. Durability. This power of attorney shall not be affected by my s±:bsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and enure to my benefit and bind me and my successors in interest as if I were competent and not disabled. 4. Reliance on Power. This power may be accepted and relied upon by anyone to whom it is presented until such person either receives writter. notice of revocation by me or a guardian or similar fiduciary of my estate or has actual knowledge of my death. 5. Hold Harmless. Ail actions of my agent shall bind me and my heirs, distributees, legal representatives, successors and assigns, and for the p~LLrpose of inducing anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant and agree that if this power of attorney is terminated or amended for any reason, I and my heirs, distributees, legal representatives, successors and assigns will hold such party or parries harmless from any loss suffzred or liability incurred by s~,ch party or parties while acting in accordance with this acaer prior to that party's receipt of written notice of any swch termination or amendment. The following is the specimen signature of the person to whom this powi~'e/mar//Jof attorney ~i/s//~g,i~ven~ MICHAEL ~ SOBOTOR Page 2 of 3 pages d I have signed this power of attorney this zZ day of C7cf~ ~ 19 9 6 . R'., Witnesses: ~~""" ~~ AMELIA B. SOBOTOR Social Security No. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. On this ~2~day of 0~'~~'-' 1996, personally appeared before me, a Notary Public in and for the said county and state, the above-named AMELIA B. SOBOTOR, who acknowledged the foregoing power of attorney to be her act and deed and desires the power of attorney might be recorded according to law. I have signed my name and affixed my seal. Notary Public NOTARIAL SEAL WILLIAM S. DANIELS. Notary Publ'w Carlisle Boro, CumbeAand County M Commission Ex fires Oct 19, 20t1o ?age 3 of 3 pages ~ . EXHIBIT '°B" H~ •Mat10l'(~l~ MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 MIKE S080TOR FOR AMELIA SOB070R 19 HOLLY ESTATE DRZVE 6ARDP:ERS, PA 17324 Statement P9EDTCAID PRIVATE ROOP9 109 -A Please Return This Portion With Your Payment !r SOBOTOR, AMELIA B 96129 ~ 11J01/00 01/31J01 SERVCE I CODE SERVICE RENDERED J CHARGES I CREDITS 01 01 01 BALANCE FORWARD 10,366.52 01/01/01 11900 MCB PREMIUM { QTY 1-) 50.00 02(01J01 ADV PVT PORTION 1,000.35 PAYMENT DUE BY THE 10TH OF THE MONTH 11,316.87 AMOUNT DUE MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/03/96 05/10/01 10/31/96 7V CABLE 11/30/96 7V CABLE 11/30/96 INTEREST UNPAID 1.50%ON 5.00 12/18/96 PAYMENT -THANK YOU 12/18/96 PAYMENT -THANK YOU 1 213 1 /1 9 96 RESIDENT PORTION 1/1-1/31/97 RESIDENT PORTION 01 /21 /97 PAYMENT -THANK YOU 02/28/97 TV CABLE 2/1-2/28/97 RESIDENT PORTION 02/28/97 INTEREST UNPAID 1.50% ON 1326.98 03/04/97 PAYMENT -THANK YOU 03/04/97 PAYMENT -THANK YOU 03/04/97 PAYMENT -THANK YOU 03/12/97 PAYMENT -THANK YOU 03/12/97 PAYMENT -THANK YOU 03/14/97 PAYMENT -THANK YOU 3/1-3/31/97 RESIDENT PORTION $5.00 $5.00 $0.08 $784.45 $806.45 $5.00 $806.45 $19.90 $804.35 MEDICAID PRIVATE ROOM 125 - A 04/30/2001 ($5.00) ($5.00) ($220.00) ($784.53) ($564.45) ($784.45) ($5.00) ($806.45) ($5.00) $56.80 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 03/31/1997 BEGINNING BALANCE 03/31/97 TV CABLE 03/31/97 REVERSE INTEREST 2/28/97 04/1/97 TRANSFER MISAPPLIED PAYMENT 04/10/97 PAYMENT -THANK YOU 4/1-4/30/97 RESIDENT PORTION 05/12/97 PAYMENT -THANK YOU 05/31 /97 TV CABLE 5/1-5/31/97 RESIDENT PORTION 06/10/97 PAYMENT -THANK YOU 06/10/97 PAYMENT -THANK YOU 06/30/97 TV CABLE 6/1-6/30/97 RESIDENT PORTION 07/30/97 PAYMENT -THANK YOU 07/30/97 PAYMENT -THANK YOU 07/31 /97 TV CABLE 7/1-7/31/97 RESIDENT PORTION 08/13/97 PAYMENT -THANK YOU 06/30/97 MIS APPLIED PAYMENT 09/03/96 05/10/01 MEDICAID PRIVATE ROOM 125 - A 04/30/01 $56.80 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 ($19.90) ($100.00) ($811.45) ($701.53) ($4.92) ($806.53) ($4.92) ($806.53) ($601.45) ($210.00) ($773.03) ,.~„. MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/2001 96129 08/31/97 ADJ BEGINNING BALANCE 08/31/97 TV CABLE 08/31/97 RESIDENT PORTION 09/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09/30/97 TV CABLE 9/1-9/30/97 RESIDENT PORTION 10/31 /97 TV CABLE 1011-10/31/97 RESIDENT PORTION 11/07/97 PAYMENT -THANK YOU 11/07/97 PAYMENT -THANK YOU 11/30/97 TV CABLE 11/1-11/30/97 RESIDENT PORTION 12/19/97 PAYMENT -THANK YOU 12/19/97 PAYMENT -THANK YOU 12/19/97 PAYMENT -THANK YOU 12/31/97 TV CABLE 12/31/97 RESIDENT PORTION $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 ($773.03) ($4.92) ($806.45) ($0.08) ($5.00) ($806.45) ($4.92) ($811.53) ($806.45) $27.92 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 12/31/97 ADJ BEGINNING BALANCE 01/12/98 PAYMENT -THANK YOU 01/12/98 PAYMENT -THANK YOU 01/06/98 BEAUTY CHARGES 1/1-1/31/98 RESIDENT PORTION 0 1131 /1 9 9 8 INTEREST 02/09/98 PAYMENT -THANK YOU 02/09/98 PAYMENT -THANK YOU 02/28/98 TV CABLE 2/1-2/28/98 RESIDENT PORTION 03/12/98 PAYMENT -THANK YOU 03/12/98 PAYMENT -THANK YOU 03/31 /98 TV CABLE 311-3/31/98 RESIDENT PORTION 04/30/98 TV CABLE 4/1-4/30/98 RESIDENT PORTION 05/15/98 PAYMENT -THANK YOU 05/15/98 PAYMENT -THANK YOU 05/31 /98 TV CABLE $27.92 $32.00 $914.50 0.08 $5.00 $914.50 $5.00 $914.50 $5.00 $914.50 $5.00 ($4.92) ($806.53) ($32.00) ($806.53) ($4.92) ($806.53) ($4.92) ($806.61) $465.04 ,;,~ MANORCARF_ HEL4TH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 5/3198 ADJ BEGINNING BALANCE 5/1-5/31/98 RESIDENT PORTION 05/31 /1998 INTEREST 06/29/98 PAYMENT -THANK YOU 06/29/98 PAYMENT -THANK YOU 06/30/98 TV CABLE 6/1-6/30/98 RESIDENT PORTION 07/31/98 TV CABLE 7/1-7/31/98 RESIDENT PORTION 07/31/1998 INTEREST 08/17/98 PAYMENT -THANK YOU 08/17/98 PAYMENT -THANK YOU 08/17/98 PAYMENT -THANK YOU 08/31 /98 TV CABLE 8/1-8/31/98 RESIDENT PORTION 08/31 /1998 INTEREST 09/18!98 PAYMENT -THANK YOU 09/18/98 PAYMENT -THANK YOU 09/30/98 TV CABLE 9/1-9/30/98 RESIDENT PORTION 09/30/98 INTEREST MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/2001 $465.04 $914.50 $0.07 ($4.92) ($806.61) $5.00 $914.50 $5.00 $914.50 $12.25 ($4.91) ($811.45) ($183.64) $5.00 $914.50 $9.60 ($640.06) ($171.47) $5.00 $914.50 $9.74 $2,466.14 ,,~ MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 09/30/98 ADJ BEGINNING BALANCE 10/27/98 PAYMENT -THANK YOU 10/31/98 TV CABLE 10/29/98 BEAUTY CHARGES 10/1-10/31/98 RESIDENT PORTION 10/31!1998 INTEREST 11!30/98 TV CABLE 11/1-11/30/98 RESIDENT PORTION 11/30/1998 INTEREST 12/08/98 PAYMENT -THANK YOU 12/08/98 PAYMENT -THANK YOU 12/31/98 TV CABLE 12/1-12/31/98 RESIDENT PORTION 12!31!1998 INTEREST 01/07/99 PAYMENT -THANK YOU 01 /07/99 PAYMENT -THANK YOU 01/31/99 TV CABLE 01/01-01/31/99 RESIDENT PORTION 01 /31 /99 INTEREST $2,466.14 $5.00 $32.00 $914.50 $12.89 $5.00 $914.50 $25.73 $5.00 $914.50 30.04 $5.00 $933.76 $29.16 ($611.53) ($38.05) ($511.95) ($309.24) ($590.76) $4,231.69 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 01/31/99 ADJ BEGINNING BALANCE 02/24/99 PAYMENT -THANK YOU 02/24/99 PAYMENT -THANK YOU 02/28/99 TV CABLE 02/01-02/28/99 RESIDENT PORTION 02/28/99 INTEREST 03/31 /99 PAYMENT -THANK YOU 03/31 /99 PAYMENT -THANK YOU 03/31 /99 TV CABLE 03/01-03/31/99 RESIDENT PORTION 03/31 /99 INTEREST 04/30/99 TV CABLE 04/13/99 BEAUTY CHARGES 04/01-04/30/99 RESIDENT PORTION 04/30/99 INTEREST 05/31 /99 TV CABLE 05/01-05/31/99 RESIDENT PORTION 05/31 /99 INTEREST $4,231.69 $5.00 $933.76 $27.56 $5.00 $933.76 $33.43 $5.00 $32.00 $933.76 $48.01 $5.00 $933.76 $63.29 ($265.58) ($554.42) ($282.76) ($547.24) $6,541.02 .na MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 05/31/99 ADJ BEGINNING BALANCE 06/02/99 PAYMENT -THANK YOU 06/02/99 PAYMENT -THANK YOU 06/21/99 PAYMENT -THANK YOU 06/30/99 TV CABLE 06/01-06/30/99 RESIDENT PORTION 07/31/99 TV CABLE 07/01-07/31/99 RESIDENT PORTION 08/09/99 PAYMENT -THANK YOU 08/09/99 PAYMENT -THANK YOU 08/31 /99 TV CABLE 08/01-08/31/99 RESIDENT PORTION 09/20/99 PAYMENT -THANK YOU 09/20/99 PAYMENT -THANK YOU 09/30/99 TV CABLE 09!30/99 BEAUTY CHARGES 09/01-09/30/99 RESIDENT PORTION $6,541.02 $5.00 $933.76 $5.00 $933.76 $5.00 $933.76 $5.00 $32.00 $933.76 ($294.25) ($755.75) ($880.00) ($966.32) ($433.68) ($889.45) ($10.55) $6,098.06 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 09/30/99 ADJ BEGINNING BALANCE 10/31 /99 TV CABLE 10/01-10/31/99 RESIDENT PORTION 11 /30/99 TV CABLE 1 1101-1 1 /3 0/9 9 RESIDENT PORTION 12/31/99 TV CABLE 12/01-12/31/99 RESIDENT PORTION 01 /06/00 PAYMENT -THANK YOU 01/06/00 PAYMENT -THANK YOU 01 /31 /00 TV CABLE 01/01-01/31/00 RESIDENT PORTION 01/31/00 MCB PREMIUM 02/29/00 TV CABLE 02/01-02/29/00 RESIDENT PORTION 02/29/00 MCB PREMIUM 03/03/00 PAYMENT -THANK YOU 03/31 /00 TV CABLE 03/01-03/31/00 RESIDENT PORTION $6,098.06 $5.00 $933.76 $5.00 $933.76 $5.00 $933.76 $5.00 $1,000.35 $5.00 $1,000.35 $5.00 $1,000.35 ($1,930.26) ($269.74) ($45.50) ($750.00) ($45.50) $8,889.39 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 03/31/00 ADJ BEGINNING BALANCE 03/31/00 MCB PREMIUM 04/17/00 PAYMENT -THANK YOU 04/30/00 TV CABLE 04/01-04/30/00 RESIDENT PORTION 04/30/00 MCB PREMIUM 04/30/00 BEAUTY CHARGES 05/31/00 7V CABLE 05/11 /00 BEAUTY CHARGES 05/25/00 BEAUTY CHARGES 05/01-05/31/00 RESIDENT PORTION 05/31/00 MCB PREMIUM 06/30/00 TV CABLE 06/01-06/30/00 RESIDENT PORTION 06/30/00 MCB PREMIUM 07!03/00 PAYMENT -THANK YOU 07/31/00 TV CABLE 07/01-07/31/00 RESIDENT PORTION $8,889.39 $5.00 $1,000.35 $36.00 $5.00 $9.00 $9.00 $1,000.35 $5.00 $1,000.35 $5.00 $1,000.35 ($45.50) ($1,450.00) ($45.50) ($45.50) ($45.50) ($1,300.00) $10,032.79 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 07/31/00 ADJ BEGINNING BALANCE 07/31/2000 MCB PREMIUM 08/16/00 PAYMENT -THANK YOU 08/31/00 TV CABLE 08/01-08/31/00 RESIDENT PORTION 08/31/00 MCB PREMIUM 09/30/00 TV CABLE 09/01-09/30/00 RESIDENT PORTION 09/30/00 MCB PREMIUM 10/18/00 PAYMENT -THANK YOU 10/31/00 TV CABLE 11/30/00 TV CABLE 11/17/00 BEAUTY CHARGES 1 1 /01-1 1 /3 010 0 RESIDENT PORTION 11/30/00 MCB PREMIUM 12/22/00 PAYMENT -THANK YOU 12/31/00 TV CABLE 12/06/00 BEAUTY CHARGES $10,032.79 $5.00 $1,000.35 $5.00 $1,000.35 $5.00 $5.00 $36.00 $1,000.35 $5.00 $9.00 ($45.50) ($1,000.00) ($45.50) ($45.50) ($1,200.00) ($45.50) ($1,000.00) $9,721.84 .,„~, MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 12/31/00 ADJ BEGINNING BALANCE 12/20/2000 BEAUTY CHARGES 1 2/01-1 2/3 110 0 RESIDENT PORTION 12/31/00 MCB PREMIUM 01/31/01 TV CABLE 01/01-01/31/01 RESIDENT PORTION 01/31/01 MCB PREMIUM 02/28/01 TV CABLE 02/01-02/28/01 RESIDENT PORTION 02/28/01 MCB PREMIUM 03/19/01 PAYMENT -THANK YOU 03/31 /01 TV CABLE 03/01-03/31/01 RESIDENT PORTION 03/31/01 MCB PREMIUM 05/31/01 TV CABLE 05/01-05/31/01 RESIDENT PORTION 05/31/01 MCB PREMIUM 04/01/97 REVERSE TX MISAPPLIED PMT 06/01!97 REVERSE TX MISAPPLIED PMT MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 $9,721.84 $9.00 1000.35 $5.00 $1,031.85 $5.00 $1,D31.85 $5.00 $1,031.85 $5.00 1,031.85 $100.00 $210.00 ($45.50) ($50.00) ($50.00) ($1,000.00) ($50.00) ($50.00) $13,943.09 _~ EXHIBIT "C" 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 Care's Health Caze Center ("Center"). Center: ~RR °R jaw --'1 Legal Representative: Admission Date: ~ -° ~ (; ~ 0 ~ ~ Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIBII,TTIES OF THE RESIDENT _ ~ J 1.01 Room and, Boazd Rate. For the basic services provided for in Section 3.01, thy' 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 chazges for additional medical, therapeutic, or personal caze services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Caze. The Center reserves the right to charge for personal raze 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`") 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 personal program in accordance with the terms of the program. I.OS Governmental Pro rg ams. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medid'aid, or through the Veterans Administration, and the Center participates in such program, the Center shalt 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 apphcable 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: x Medicare, x Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the _,_ Resident's care, there is a required co-payment, whic:rMedicaze 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 chazges such as Room and Boazd and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Boazd 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 T 'rd Party Payors 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 chazges aze 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 Legat 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 longetr 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 parry 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_w,ith notice within five (51 des of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this 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 shalt 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 Legat 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 caze 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 caze 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 Residert and the fees chazged by such physician shall be borne by the Resident. 1.12 Pharmacv. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals inaccordance 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 chazges 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 chazges 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 aze 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 chazges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. a 2.05 ~gperation 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 cceptance Up9n Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. if after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition pernrits, who shall uncpnditionally 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 Standazd Services. As part of the Room and Board Rate, the Center shall famish 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 Gaze 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 9ther Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03. a sit. 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 Aedicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for caze 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 caze organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance ~:F~. 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 tlds Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the welt-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 arid 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 iry~the exercise of good nursing judgment, sub}ect 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 dotuments 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 Photoeraoh. 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 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). s' 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). 1 Procedures, name, address and phon¢srumber 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-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment 0. .-~ s. ASM Form. See attachment P. t. Consent to Photo¢raph 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 holder of mezlical 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 dischazge from the Center by providing the Center written notice of the Resident's desire to leave at least seve (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 e > of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Chances in the Law. Any provision of the Agreement that is found to be im~alid 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 fu1S11 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 QUESTIONSr~H`AVE BEEN ANSWQ ERED TO THEIIi SATISFACTION. /\ Signature of Resident: X ~)j/vh.~~ /a-~'w'~ti' Date: ~ " ~ ~ ~~ U Signature of Legal Representative, if signing on behalf of Resident: Date: -~-. -~ Signature of Legal Representative, signing on his/her own behalf: Date: Center Representative: ~ X/L~. I ~( /~'Y1~1 Gt Cam- Date: ~ ~' ~ l0' ~~ a ~ ~, ~ ~ (.~ ~ ~ ~' ~ _ ~~ u ~ !) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civil Term Plaintiff . vs. ELIA B. SOBOTOR, Individually, and ,HAEL SOBOTOR, Individually, on Behalf of AMELIA B. SOBOTOR, Defendants CIVIL ACTION -LAW PRAECIPE TO AMEND CAPTION THE PROTHONOTARY OF SAID COURT: Kindly amend the above caption to reFlect that Defendant, Amelia B. Sobotor, is now deceased, as follows: MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant Respectfully submitted, Daniel F. Wolfson, Esquire WOLFSON 8t ASSOC TES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff ~-, " ~+ + IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW :HAEL SOBOTOR, Individually, on Behalf of Amelia B. Sobotor, Deceased, Defendant CERTIFICATE OF SERVICE AND NOW, this 16`h day of September, 2002, I, Daniel F. Wolfson, Esquire, do certify that 1 have served a copy of the foregoing Second Amended Complaint the counsel of record by regular mail, postage pre-paid and addressed as follows: Douglas G. Miller, Esquire 1RWIN, McKNIGHT 8t HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 17013-3222 WOLFSON 8t ASSOCIAT S, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff } p.s l~ .a /~ ( t ^.. -1 ~: i `~{~ %`-~ 'Ti ~ ~-% y ~' vv"J '' ` ~' v 'v-. ._!, 5D K HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v, NO. 2001- 4092 CIVIL TERM AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Defendants. ORDER OF COURT AND NOW, this day of upon consideration of Defendants Preliminary Objections to Plaintiffs Complaint, it is hereby ORDERED that said objections are sustained and Plaintiff s Complaint is dismissed with prejudice. BY THE COURT, J. HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and: on Behalf of AMELIA B. SOBOTOR, Defendants. NO. -2001- 4092 CIVIL TERM CIVIL ACTION -LAW PRELIMINARY OBJECTIONS OF DEFENDANTS TO PLAINTIFF'S COMPLAINT AND NOW this 4`" day of September, 2001, comes the Defendants, AMELIA B. SOBOTOR and MICHAEL SOBOTOR, Individually and on Behalf of AMELIA B. SOBOTOR, by and through their attorneys, Irwin, McKnight & Hughes, and make the following Preliminary Objections to Plaintiffls Complaint, and in support thereof aver the following: L Preliminary Objection in the Nature of a Demurrer Pursuant to Pa. R.Civ. P. 1028(a)(41. 1. Plaintiff, HCR Manor Care, filed a civil complaint on or about July 2, 2001 against Defendants in the Court of Common Pleas of Cumberland County, Pennsylvania at Docket No. 2001 - 4092, alleging liability for health care costs incurred for the care of Defendant Amelia B. Sobotor. 2. Defendant Michael Sobotor is the son of Defendant Amelia B. Sobotor. 3. Plaintiffls Complaint alleges that Defendant Michael Sobotor is his mother's agent under a General Durable Power of Attorney dated October 22, 1996, and that Defendant 2 Michael Sobotor has a "fiduciary obligation to pay necessary and appropriate bills and obligations for Defendant Amelia." 4. Defendant Amelia Sobotor in fact has limited income and property and is currently receiving public assistance funds to help provide for her medical care costs. S. Pa.R.Civ.P. 1019(a) requires a claimant to plead all material facts on which its cause of action is based. 6. Plaintiff s Complaint fails to allege or aver that Defendant Michael Sobotor is a signatory of or is otherwise bound by the alleged Admission Agreement attached to Plaintiff's Complaint. 7. Plaintiff s Complaint fails to allege or aver any facts or cite to any legal authority to support the individual liability of Defendant Michael Sobotor for the medical care costs of his mother. $. Plaintiffs Complaint fails to allege or aver any facts or cite to any legal authority to support the liability of Defendant Michael Sobotor as agent under a General Durable Power of Attorney for the medical care costs of his mother. 9. Plaintiff s Complaint fails to state any cause of action against Defendant Michael Sobotor, upon which relief maybe granted for the medical care costs of his mother. WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss Plaintiffs Complaint. 3 II. Preliminary Objection Raising Insufficient Specificity of Plaintiff's Complaint Pursuant to Pa. R. Civ. P.1028(al(3). 10. Plaintiffs Complaint fails to allege with sufficient particularity alleged acts or agreements by Defendant Michael Sobotor to support his individual liability to Plaintiff for his mother's medical care costs. 11. Plaintiffs Complaint fails to allege with sufficient particularity alleged acts, agreements, or other signed documents by Defendant Michael Sobotor to support his liability to Plaintiff as an agent under his mother's General Durable Power of Attorney for her medical caze costs. 12. Plaintiffs Complaint lacks sufficient specificity to apprise Defendants of the issues to be litigated, or to allow them to adequately prepare and assert defenses to Plaintiffs allegations. WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss Plaintiff s Complaint, or in the alternative to grant their Preliminary Objection and order Plaintiff to more specifically plead the averments of its Complaint. HI. Preliminary Objection Raising Lack of Jurisdiction Pursuant to Pa. R. Civ. P. 1028(al(11. 13. Several causes of action are set forth or were attempted to be set forth against more than one Defendant in Plaintiff s Complaint. 4 14. Although the causes of action appear to be distinct causes of action, they are not set forth separately in the Complaint as required by Pa.R.Civ.P. 1020(a) or Pa.R.Civ.P. 1020(d)(1). 15. Plaintiffs Complaint includes allegations that Defendant Michael Sobotor is liable to Plaintiff by virtue of his being named as an agent for his mother under a General Durable Power of Attorney. 16. 20 Pa.C.S.A. § 711(22) provides that the Orphans' Court has mandatory jurisdiction over "all matters pertaining to the exercise of powers by agents acting under powers of attorney...." 17. Plaintiffls Complaint was not filed in the Cumberland County Orphans' Court which has mandatory jurisdiction over the claims raised by Plaintiff. WHEREFORE, Defendants respectfully requests this Honorable Court to dismiss Plaintiff s Complaint. Respectfully Submitted, IRWIN, McKNIGHT & HUGHES By. / < Douglas .Miller, Esq ire Supreme ourt ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717)249-2353 Dated: September 4, 2001 Attorney for Defendants 5 CERTIFICATE OF SERVICE I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy of the foregoing document upon the persons indicated below by first class United States mail, postage paid in Carlisle, Pennsylvania 17013, on the date set forth below: Amy F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Attorney for Plaintiff Date: September 4, 2001 IRWIN, McKDTIGHT & HUGHES Douglas G.er, Es'quir'e Supreme Co I.D. No. 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 (717)249-2353 Attorney for Defendants 6 .~' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 2001 - 40~. CIVIL TERM vs. MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant CIVIL ACTION -LAW RULE 1312-1. The Petition for Appointtnent of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Amy F. Wolfson, Esquire ,counsel for the 1_p aintiff/defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions) is (are) at issue. 2. The claim of the plaintiff in the action is $13,042.63 plus interest and court costs. The counterclaim of the defendant in the action is The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: Douelas G. Miller, Esquire WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respe ~dly su mitten ORDER OF COURT ~~03 AND NOW, ~ ,rte ~ f~ , ~ , in conyysideratrion of the - ~ j Foregoing petition, 1,~%/~~ ~~iLP~.~xP~.rJ Es ~idJ ~ /~G'G~Ca~/ /~-, Esq., and ~~ ~ (~ Esq., are appointed arbitrators in the above captioned action (or actions) as prayed for. By the Cour , P.J. 7U ~~ E/iNb'lllnr~IfV~d s 7.J ,i ~. ~ ir;~F ~iU ~C, ~ i r'";) ~~ ~ Per i1:9 ~',~ 1P~~i~_l it ;,~.} c G \~ 1= c~ r_ r Z} n L -A ~~ ~~ , w. 1, , ~:{; T/' [,_ ti { :.~; ',~ sJ (~. ^rn :~ d~ cF1 _,, 3-.: )r, .T{ ~e K J ~:1 j ~. -~.. K~ ~'. ~_, ~.~ ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civil Term Plaintiff' vs. CIVIL ACTION -LAW HAEL SOBOTOR, Individually, on Behalf of Amelia B. Sobotor, Deceased, Defendant NOTICE ~u have been sued in Court. If you wish to defend against the claims set forth in the following ges, you must take action within twenty (20) days after this Complaint and Notice is served, by tering a written appearance, personally of by attorney, and filing in waiting with the Court your fenses or objections to the claims set forth against you. You are warned that if you fail to do so, case may proceed without you and a judgment may be entered against you by the Court thout further notice for any money claimed in the Complaint, or document, or for any other im or relief requested by he Plaintiff. You may lose money or property or other right important you. )U SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH 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 p(azo al partir de la fecha de tademanda y la notifiation. Used debe presentar una apariencia escrita o en persona o por abogado y archivar en la torte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, (a 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 demands. Used puede perder dinero o sus propiedades o otros derechos importantes pars used. LLEVE ESTA DEMANDA A UN ABOGADO 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 ABAlO PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717)249-3166 ,~ IN THE COURT OF,COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW HAEL SOBOTOR, Individually, on Behalf of Amelia B. Sobotor, Deceased, Defendant SECOND AMENDED COMPLAINT AND NOW, this 16`h day of September, 2002, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson gt Associates, P.C., and files the within Amended Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Michael Sobotor, is an adult individual with a last known address of 19 Holly Estate Drive, Gardners, Adams County, Pennsylvania 17324. 3. That Plaintiff filed its original Complaint against Defendant and Amelia B. Sobotor on or about July 2, 2001 and it's first Amended Complaint against said Defendants on or about September 28, 2001. III 4. That Plaintiff is filing the within Second Amended Complaint in an attempt cure Preliminary Objections which were filed by Defendants in response to Plaintiff s Complaint on or about September 4, 2001. 5. That Amelia B. Sobotor, Deceased, executed a General Durable Power of appointing her son, Defendant, as her lawful Attorney-in-Fact, on October 22, 1996. A true and correct copy of said Power of Attorney is attached hereto, herein, and marked as Exhibit "A". 6. That pursuant to said Durable Power of Attorney executed by Decedent, the Defendant was given specific power, which included, but was not limited to, the ability to "contract with and arrange for my entrance to any hospital, nursing home, health center, convalescent home, or similar institution and to pay all bills in connection therewith". See Exhibit "A", Page 1, as previously identified and incorporated herein. 7. That Defendant inquired to Plaintiff s health care facility for the purpose of admitting Decedent as a resident on or about July 31, 1996. A true and correct copy of said Application for Residency is attached hereto, incorporated herein and marked as Exhibit "B". 8. That Defendant warranted and represented that the information he provided regarding the Decedent in the Application for Residency was complete and accurate and that the Plaintiff could rely on the information in admitting Decedent. See Exhibit "B", page 4, previously identified and incorporated herein. 2 9. That Defendant warranted and represented that the Decedent received social security and pension benefits in the amount Nine Hundred Twelve and 00 ($912.50) Dollars per month. See Exhibit "B", pages 3 and 4, as previously and incorporated herein. 10. That on or about August 9, 1996, Defendant executed an Admission on behalf of the Decedent, which Agreement outlined various terms of health care services to be provided by Plaintiff and the Responsible Party . A true and correct copy of the Admission Agreement is attached hereto, herein, and marked as Exhibit "C". 1 1. That on or about August 9, 1996, pursuant to the aforementioned Agreement, the Decedent was admitted as a health care resident of Plaintiff. 12. That from August 9, 1996 through July 2000, Decedent was a care resident of Plaintiff, where she did receive various necessary residential health services and health care treatment by Plaintiff. A true and correct copy of the of services is attached hereto, incorporated herein and marked as Exhibit "D". 13. That by executing said Admission Agreement, Defendant did acknowledge that Plaintiff would be relying on the "Conditions" of the Responsible Party Appointment, is part of the Admission Agreement, in admitting the Decedent, and that if Defendant did not follow through with said Conditions, Plaintiff will have detrimentally 3 ~f upon said Conditions and Plaintiff will suffer financial harm and loss. See Exhibit "C" previously identified and incorporated herein. 14. That Defendant agreed to remit payment to the Plaintiff from the assets of Decedent, for services provided by Plaintiff, and to have payment of any available or third parry payor benefits due and owing the Decedent assigned to the See Exhibit "C", specifically, the Admission Agreement's Condition No. l of the Party Appointment, as previously identified and incorporated herein by 15. That the Decedent incurred a debt in the amount of Ten Thousand Thirty- and 79/100 ($10,032.79) Dollars to Plaintiff while a Resident of Plaintiff's health facility for health care treatment and services provided pursuant to the Admission that was not compensated by a third party payor or government program, and is comprised of resident portion payments and small private balances as a result of and beauty treatment and cable charges. 16. That Plaintiff sent Defendant a copy of the itemization of services accurately all debits and credits for transactions with Plaintiff. 17. That Defendant did not object to the above mentioned itemization of services submitted by Plaintiff to Defendant. 18. As of the date of filing of this Complaint, the balance due, owing, and unpaid on Decedent's account as a result of said charges is the sum of Ten Thousand 4 Two and 79/100 Dollars ($10,032.79) Dollars. See Exhibit "D" as previously and incorporated herein by reference. 19. Despite Plaintiff's reasonable and repeated demands for payment, Defendant failed, refused, and continues to refuse to pay all sums due and owing on Decedent's balance, all to the damage and detriment of the Plaintiff. 20. Plaintiff has made numerous requests to Defendant, as Power of Attorney Legal Representative/Responsible Party for Decedent, demanding that the sums due owing to Plaintiff be paid, and Defendant, as Power of Attorney and Legal Party for Decedent, has ignored both his fiduciary obligation contractual obligation to pay necessary and appropriate bills and obligations for his mother, the Decedent. 21. That Defendant's willful failure to remit Decedent's monthly social security and pension benefits income to Plaintiff was a direct violation of the Admission Agreement Defendant executed with Plaintiff. See Exhibit "C" as previously identified and incorporated herein. 22. That at all times relevant thereto, said social security and pension benefits payments were not made to Plaintiff nor received by Plaintiff. 23. That the finances and income of the Decedent rightfully belonged to the Decedent for her necessary and appropriate medical services and treatment rendered by 5 Plaintiff to the Decedent, however Defendants failed to utilize Decedent's finances for that intended purpose. 24. That Defendant knowingly violated his fiduciary and contractual duties and as the Legal Representative/Responsible Party for Decedent, under the Agreement, by failing to utilize Decedent's financial resources to pay Plaintiff he knew or should have known there were outstanding medical bills for the care of Decedent. 25. Plaintiff has retained the services of the law firm of Wolfson Si Associates, P.C., in the collection of the amounts due from Defendant. 26. Pursuant to Paragraph 8 of the Fee Schedule, which was attached as part of the aforementioned Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay reasonable attorney's fees and all court costs if the account is referred to an attorney for collection. See Exhibit "B" as previously identified and incorporated herein. 27. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson St Associates, P.C. in the collection of the amounts due and owing by Defendant incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendant. 6 28, That the amount of attorney's fees which represents thirty percent (30%) of principal amount due and owing is the sum of Three Thousand Nine and 84/100 ;$3,009.84) Dollars. 29. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 30. The amount in controversy is within the jurisdictional amount requiring arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable enter judgment in favor of Plaintiff and against Defendant, Michael Sobotor, and on behalf of Amelia B. Sobotor, Deceased, in the amount of Ten Thirty-Two and 79/100 ($10,032.79) Dollars, reasonable attorney's fees in amount of Three Thousand Nine and 84/100 ($3,009.84) Dollars, the costs of this and such other relief as the Court deems proper and just. Respectfully submitted, ~a~uc~ ~. •~vuoaiu, uyuuc WOLFSON st ASSOCIATE .C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff 7 J VERIFICATION 1, Michelle Thureson, being the Senior financial Consultant for HCR Manor Care, verify that the statements made in the foregoing Amended Complaint are true and correct to the best of my knowledge, information and belief. 1 understand that false statements herein are made subject to the penalties of 18 Pa,. C.S. Section 4904, relating to unsworn falsification to authorities. HCR Manor Care DATE: 9l Plo'oZ- /~,~~ ~~~~a~ ichelle Thureson Senior Financial Services Consultant J EXHIBIT "A" yygq~•~ Ly waiY v~~irht . ~ o¢'~'~~a'',~tJ,.~l`IN t 3 yl. r la ~I PI ~lyfrr ~~ ~ 1 ~# ~ ~IJ~'~r-f s R F~Ii ~~I"` ~~I y` f~ T ~h~~ri ~~M~~j~1N1 ~~YJJ ~'Wlis ~j ~k l'~jI('ll ~ iI _._ M,. .fehi ___~.._ .3° .,1 .i...,i.w ~ In J ., f ~ ' '~ 13._t_.... i~_ GENERAL DuRABL~E POWER OF ATTORNEY iZNOW ALL MEN BY THESE PRESENTS, That I, AMELIA B. SOBOTOR, Manor Care, 940 Walnut Bottom Road, Carlisle, Cumberiand County, Pennsyivania 17013, do hereby appoint my son, MICHAEL P. SOBOTOR, 19 Hoiip Estates Drive, Gardners, Cumberiand County, Pennsyivania _7324, as my agent ("my agent"), for me and en my behalf, in my name or in 'r_is own name, to take a'_i ar_ticns and to perform all acts concerning my affairs as he may deem necessary or advisable, in his absolute discretion, as fully as I could do if personally present, including, without limiting the generality of the foregoing, for me and in my name anti on my behalf, as follows: 1. Inclusiveness. To receive and receipt for all sums of money or payments due or becoming due to me from any source; to enter my safe deposit boxes in any and ail banking institutions, and to add to and to remove any of the contents thereof; to endorse all checks and other instruments payable to me and deposit and withdraw any and all moneys, checks and other instruments to which I may be at any time entitled in my name ir. any financial institutions; to pay any and all claims and demands now o= hereafter payable by me; to draw and sign checks, drafts and other orders for the pa•rment of money upon my checking account or upon any other bank accounts or deposits now or hereafter belonging to me; to borrow money and to mortgage, aiedge o- hypothecate an_a property, real or personal, now or hereafter owned by me as security therefor; to sell, possess, insure, manage, maintain, improve, lease, mortgage, pledge, encumber, convey, and otherwise dispose of, or take any other action with respect to any property, rea'_ or personal, now or hereafter owned by me, on such terms and conditions as my agent considers appropriate, and ir_ the event of any sale of my real estate to execute the sales agreement and the deed in my name and to make settlement and receive the proceeds: to purchase, rent or otherwise acquire any aroperty, real or nersonai, for me and to pap for 'the same; to contract with and arrange for my entrance to any hospital, nursing home, health center, cor_valescent home, or similar institution and to pay all bills in connection therewith; to arrange for and consent to or to withhold medical, therapeutical and surgical procedures for me, including the administration of drugs; to institute and to engage in and compromise any litigation on my behalf; for me and in my name and as my act to execute, endorse, acknowledge and deliver ail documents; to prepare, execute and file any tax returns, governmental reports and other instruments of whatever kind; to engage and dismiss agents; and to manage, make and transact all and every kind of business of every nature. r mom,..,.., _., _.~,~ ...._.... ..... _,.... _..__.._._,.. ,,.,., .._ .~.. ,..,,,. ..~.,.. ~,x~..,_~,n,.......-~ 1 2. General Authority. To do ail other things which my agent snail deem necessary and groper in order to carry out the foregoing powers which shall be construed as broadly as possible, giving and granting unto my said agent full power and authority to do and perform all and every act, deed., mat''*_er, and thing whatsoever in and about my estate, property, and affairs as fully and effectually tD ail _r:tents and purposes as I might or could do in my own proper person if personally present, the abcve specially enumerated powers being in aid and exempii:ficatior. of the full, comp'_ete, and general power herein granted, and not in limitatign or definition thereof; and hereby ratifying and confirming all that my said agent shall lawfully do or cause to be done by virtue of these presents. 3. Durability. This power of attorney s'rall not be affected by my subsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and enure to my benefit and bind me and my successors in interest as if I were competent and not disabled. 4. Reliance on Power. This power may be accepted and relied upon by anyone co whom it is presented until such person either receives writter, notice of revocation by me or a guardian or similar fiduciary of my estate or has actual xnowledge of my death. 5. Hold Harmless. All actions of my agent shall bind me and my heirs, distributees, legal representatives, successors and assigns, and for the purpose of inducing anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant and agree that if this power of attorney is terminated or amended for any reason, I and my heirs, distributees, legal representatives, successors and assigns will hold such party or parries 'rarmless from any lOSS suffered or liabiilty inCi,irred by suCP. Party Or Partle5 Whlie acting In accordance W1~h this pDaer pr1Dr t0 that party's receipt of WYltten notice Of an4 such termination Or amendment. The following is the specimen signature of the person to whom this power~of attorn/e/`y//,/i/s//~gi~ven~: MICHAEL ?~. SOBOTOR Page 2 of 3 pages d I have signed this Bower of attorney this ~-Z day of C~c.1`G~-°~" 1996. Witnesses: /~/~~1~~ AMELIA B. SOBOTOR ~ ~ ~ J~O, ~~~ ~ Social Security No. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. On this ~ Z~ day of ~~'~~' 1996, personally apaeared before me, a Notary Public in and for the said county and state, the above-named AMELIA B. SOBOTOR, who acicnowiedged the foregoing power of attorney to be her act and deed and desires the power of attorney might be recorded according to law. I have signed my name and a/f'f/i~xeyd~my~ seal . \~ (/c!Z-tit-cc~m, ~ ",~ -L_ Notary Pllb1iC NOTARIAL SEAL WILLIAM S. DANIELS. Notary Public Carlisle Boro, Cumbadand County M Commission Ex fires Oct. 79, 2000 ?age 3 of 3 cages ~~ - , EXHIBIT "B" APPLICATION FOR RESIDENCY To apply for admission at our Nursirig Center, please complete the following questionnaire, sign, and return it to the Admissions Office. This application will become a part of the n Admission Agreement and should be completed in its entirety. All information will be held in .confidence. The complete medical history and physical examination results will be recorded on another form. Date: d~ 3 ~ lQ Name of Prospective //~~ II ~ I,, Resident: Hf'Y1211~(, $`~ ~0~ r Sex: ~ Age: Address: a ~ ~ ~ • ~~~~~~ Dr_ Telephone: No,: ~~1 ~,~3 ' ~~ ~ ~ Social Security No.: ~ ~~ -t~~5" 3' ~ 1 Date of Birth: Month ~ ~ Day ~ h Year J U Place of Birth: City State (County) Marital Status: Married Single Widowed Name of Inquirer: ~~elU ins ro,c~,~ Relationship: V~~ ld.)~~-r Address: ~a~m~rr~ ~ ~~ ` Telephone No.: ~lZ - y3y- ~3y~{ A'I [n arntit (~ i' 171 Other persons to contact (incase of emergency) Name Relationship Address Telephone No. `(lia.r~So~ar-- t~l~-- _ _--- ~-~~ 91a-y3S-5dt~~ 1. Personal Referral 6. Newspaper/Magazine 2. Hospital. 7. TelevisioNRadio 3. Physician 8. Yellow Pages 4. Other Nursing Home/ACLF 9. Mailing/Brochure 5. Health Dept. ~ FaiU:~~ ~ ~ ~~ HAVE YOU VISITED ANY OTHER NURSING CENTERS? YES NO How did you hear about ~.~C~.JLJ Nursing Center - _ :; , IF YES, WHICH ONES? SU/i MEDICAL/PERSONAL DATA ~,v~ ~u,~' ~ ~ a,Pte.~i G , ~n~- Resident's Current Physician:. Physician to Follow at Facility: 1. ~ Mentally Alert 2. Slightly Forgetful 3. Confused 4. Ambulatory 5. ~ Walks with Assistance -- - 6. equdes Bedrails 7. Bed Ridden 8. Requires Special Diet 9. Able to Eat Without `~ ssistance 10. ~ Requires Assistance with Eating 11. Incontinent 12. Continent Admission Desired On; ti51'f~ Resident No At:~~uNt~l ~~ Reason for Seeking Admission: ~ ~fih P~ ~~~ a `7 y0 ((f} l ~la~n.~ , 6E ~~~ ~7a I The Name(s) of the person(s), other than the resident, who will e`h'fia~eially~~ponsib e~ for the cost of care (the "guarantor"), if any. While a guarantor is not required for admission, the facility does require that a source of payment be identified to pay for the Resident's care. Name Address _ Home Telephone (Any person(s) whose names are listed here must also sign this application.) Has a trust account been established? Yes No ,. _ P Has a power of attorney conferred on the person(s) to be financially responsible? Yes No If yes, please provide a copy. pP a` - _ _ __ _ _ _ _ .. .. ~~ ~ ~ ~. -~ a To process your apphcatiori; he following .information is needed. The information supplied is confidential and allows us to assist you m your long-term planning. The financial data should be that of the'Resdent and/or the Guarantor. All `income and amounts listed, whether under the Resident or Guarantor section, must either be owned by the Resident or in fact be available, to the Resident to pay for the Resident's stay while at the facility. Your cooperation is appreciated in order to expedite admission. Please note that it is not mandated that a Resident have a Guarantor, only that an adequate source of payment be .identified. Thus, any person who agrees fo be a Guarantor is doing so voluntarily. MONTHLY INCOME Salary --Social Security - -_- Pensions/Annuities IRA Interest/Dividend Income Rental Income Trust Investments/Other TOTAL MONTHLY INCOME RESIDENT $~ ~ °I I ~ ~ GUARANTOR (if anv) ASSETS: Cash (Itemize by banWaccount #) $- Securities (Stocks/bonds) $ $ Trust ~ .i .. $ ` ~ $ ~~ , s Real Estate (DescriptioNlocation) Ex: 3 bdrm. hse., 3 Maple Ave., Anywhere, IL Other Assets: Cash Value of Life Insurance Vested Pension Benefits Business Interests Automobiles Other TOTAL ASSETS: - Liabilities: Home Mortgage Credit Cards/Charge Accounts Loans Other Debts Taxes Owed TOTAL LIABILITIES: RESIDENT GUARANTOR (if any) ~ °• ~ _ . ~ ~ i $ n (~ I -1 ~ NET WORTH (ASSETS - LIABILITiES): $ Please Sign Beiow: I hereby warrant and represent that the information provided is accurate and complete. I understand that the nursing facility will rely upon the accuracy and completeness of the above financial information in making an admission decision. I also understand that if any of the information is not accurate or not complete, the Facility will have detrimentally relied upon the above financial information and will suffer financial loss and harm.-The assets listed are in fact available to thflfle R^^ esident to pay for the Resident's-care, rftesiderit's or Responsible Party's Signature Date Guarantor's Signature. Reviewed by: Gila ~,~ ~ N Admissions Direct~r'~ Signature ' :~ ~ EXHIBIT "C" THIS ADMISSION AGRE~MENT (the "Agreement") is entered into this y~ day of 19 ~ ,between LEADER - CARLISLE (the'IFacility"), and Yi~- (the "Patient/Resident"), and/or .SObD~t2 (the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible Party, if any. The parties agree as follows: 1. Commencement. This Agreement shalt begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreemment, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) agaihst medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. However; the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patieht/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right to appeal a discharge decision with State authorities and the appeals process. If this Agreement is terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate the Patient/Resident's. discharge. 3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party appointment. 4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services and supplies not paid by any third party as described in the Fee Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also authorizes the release of records or information to any health care institution to which the Patient/ Resident may be transferred, any provider involved in the care of the Patient/Resident, any third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. Iv(ANOR HEALTHCARE MM'OPCiRE~LEiOkR~A6ffRlCA~'A~ WL'RSFAW.\5 Q'.~a Irv e~w~oa~uUeun~,f~f' MHPO08-ZO (Rev. 4/96) pg 3 1 of 3 .,.~~', 6. Refunds.i Refunds shall be paid within thirty (30) days after discharge or transfer. 7. Funding Sources. The Facility makes no assurances that the Patient/Resident's care will be covered by any third party payor. 8. Payment Policy. All amounts due shall be paid promptly within ten (10) days of billing. Failure to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in full shall be subject to a one and one-half percent (1'/z%) service charge on the past due balance each month until the balance due is paid in full. This amounts to eighteen percent (18%) annually on the unpaid balance. If the maximum annual service charge allowed by state law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall apply. Should the Patient/Resident's account be turned over for collection to an attorney or collection agency, or should the Facility seek to interpret or enforce any other provision of the Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees of the Facility if the Facility prevails. 9. Responsibilities. The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services/supplies not paid. by any third party, as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/ Resident is transferred to a different room or the level of care or payor status changes. The Patient/ Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility is released from all liability for harm which may result. Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for all charges. The Patient/Resident is responsible for payment for items covered by_Medicare supple- mental insurance and for applying for reimbursement from his/her insurer. Medicaid Beneficiaries: (circle correct number) 1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the Facility with at least four (4) months prior written notice of the Patient/Resident's becoming eligible for the Medicaid coverage or their being unable to pay privately; ~ OR 2 The Facility currently participates in the Medicaid pro ram. If the Patient/Resident believes e/she qualifies for Medicaid, he/she shall promptly complete and submit all documents required to apply for coverage, including pre-admission approval. If Medicaid coverage is denied, the Patient/ Resident will be liable for all charges from the admission date. When Medicaid pays for only a portion of the incurred charges, the Patient/Resident shall be responsible for paying his/her portion, as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay- ment of Facility's current charges for any requested non-Medicaid covered services/supplies. The Patient/Resident will provide financial information regarding monthly credits, increases/decreases in the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaid representatives. referred to as "fond The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the PatientlResident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the ihformation, including but not limited to that. contained on the attached Application for Residency, dated , 199 ,and which is attached hereto and made part of this Exhibit and of the- Admission Agreement, is true and accurate as of this date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. 4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other- wise transfer the Patient/Resident's assets and/or assets which are available for the Pat- ient/ Resident's care so as to prevent such assets from being used to pay for the care of the Patient/Resident while at the facility. 5. When the assets available to pay for the Patient/Resident's care at the Facility are not sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and other documents necessary or advisable to qualify him/her for all third party payor programs for which he/she may be eligible, including Medicaid. 6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/ Resident will provide financial information regarding monthly credits, increases and decreases in the Patient/Resident's bank account(s) and other assets to the Facility to enable the Facility to provide requested data to Medicaid representatives. 7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident will be utilized to pay extra charges not covered by the third party payor in a timely manner, and to notify the administrator of the Facility of any problem anticipated in paying such charges. The undersigned understands and acknowledges that the Facility is relying upon the above Conditions in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above warranties and representations are not true, or if the above covenants and agreements are not complied with, the Facility will have detrimentally relied upon them and the Facility will suffer financial harm and loss. ~ ~ ~ , ~ /1 ~1 (I .lt Responsible Party -Printed Name ~ t.tf 44 Q., I~~(.~ Date MxC•QOb.20 (Rev. 4/96) pg 7 `L Of 2 • Federal Resident Rights • Resident Responsibilities • Life Sustaining Treatment Policy • Medical/Nursing Education • Dental, Vision and Hearing Services • Interdisciplinary Care Conference • Utilization Review Meetings (if applicable) • Personal Laundry Policy • Barber/Beauty Services e Mail Policy • Voting Materials • Photo/Media Events e Personal Fund Account Procedure • Tobacco Policy • Grievance Procedures • State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS T0, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or default of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the entire agreement and any changes shall be in writing and signed by both parties. IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day and year above written. Cy~~~Cz ~~Si~/, ss.~ Facility Representative -Signature Facility Representative Printed Name & Title ~i(Q4~Tk_ ~, 1~~70 Date Responsiblea?arty -Signature ~~l ~ik ~)L'~L~-~cL~~ Responsible Party -Printed Name ~ il~~~ ~ , I a ~1 ~ Date r~~. The Patient/Resident's Responsible Party may be any person legally responsible for the Patient/ Resident. A competent Patient/Resident shall not be required to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. ^ -The undersigned has been legally appointed guardian, conservator and/or holder of a power of attorney to act on the behalf of the Patient/Resident and shall serve as Responsible Party for the Patient/Resident. The undersigned has delivered to the Facility copies of the legal documents designating him/her as the guardian, conservator and/or holder of a power of attorney of the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned, individually and personally, hereby warrants, represents; covenants and agrees to the Conditions (as herein after set forth and defined). The Patient/Resident does not have a legally appointed representative~an wi hes to give the responsibility to someone else. I hereby appoint /'Y] 1('/'rQ P/ c~C%~ O7~Z~ !~ as my representative (the "Responsible Party") and hereby authorize him/her to handle my finances, pay my expenses, receive my personal funds and, if I am unable, to execute the Admission Agreement on my behalf. Any signature of Patient/Resident or Responsible Party on the Admission Agreement and/or this or any other exhibit or document attached thereto or referenced therein shall be considered binding on both the Patient/Resident and the Responsible Party. The undersigned hereby agrees to the Conditions (as herein after set forth and defined). Facility Representative -Signature Facility Representative Printed Name & Title Date Patient/Resident -Signature -~r~,lia ~tx.~l.~;~ Patient/Resident -Printed Name -~! d~2~~~Q~ Date ^ The Patient/Resident is competent and does not have acourt-appointed guardian, conser- vator or power of attorney and has not appointed a Responsible Party, but alone shall execute the Agreement. In consideration of his/her admission to the Facility, the undersigned hereby agrees, warrants and represents to the Conditions (as herein after set forth and defined). ^ The Patient/Resident is mentaNy or physically incapable of executing this Agreement, handling his/her own affairs or appointing a Responsible Party and does not have a guardian, conser- vator or durable power of attorney. The Patient/Resident's physician will certify in writing that the Patient/Resident is incapable of executing the Agreement and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on behalf of the Patient/Resident, to act and serve as Responsible Party for the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned individually hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined). MHC-ooe•2o (Rev. 4/96) pg 6 ~ Of 2 F~~X~~BT~:g -•~`FEE ~C~E~U~E6~: 1. Daily Rate. The daily rate is $~ I (3 . D D .The monthly rate equals the daily rate multiplied by the number of days in the month. The daily rate is billed one month in advance and includes: • Routine Nursing Care • Linens • Social Services • Meals (additional fees may appl • ctivities • Housekeeping • Room (circle one): Private Semi-Private Triple The following are paid by Medicare in addition to the items included in the daily rate: • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment • Approved Routine Personal Hygiene Items/Services • Other approved services/items covered and paid for under the state Medicaid program. 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of. Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM • Private Room • Prescription &Non-Prescription Drugs • Nursing & Personal Care Supplies • Transportation • Nursing Care (Other than ordinary nursing care) • Physical, Occupational & Speech Therapies • Phone, Cable TV, Newspaper, Barber/Beauty • Special Equipment • Bed Hold Fees • Personal Laundry (Personal Clothing) • Nutritional Supplements • Alternative Nutrition (Tube Feeding, TPN, etc.) RATE Based on location & level of care As determined by pharmacy See business office for current prices As determined by transport company See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever aPatient/Resident leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law. 4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies which may be needed by and provided to the Patient/Resident, all additional costs/charges may not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in ievel of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the Facility no later than the day before the rate increase is effective. ThetFacility has developed policies and procedures for drug therapy, distribution and control which provide for a uniform medication distribution system. The Facility has selected a pharmacy (the "Designated Pharmacy") to provide medication under such distribution system. The Facility reserves the right to change the Designated Pharmacy at any time. The Patient/Resident is hereby notified that the Facility's parent corporation (i.e., Manor Healthcare Corp. or one of its affiliates) has a significant financial interest in Vitalink Pharmacy Services, Inc., which operates under the following names: Vitalink, Northern Nursing Home Pharmacy, West End Family Pharmacy, Propac Pharmacy, Apothecary Pharmacy Services, Parker's Pharmacy, Home Intravenous Care and Brentview Pharmacy. The Facility may have selected one of these entities as the Designated Pharmacy. The Patient/Resident has the right to use any pharmacy so long as that pharmacy will furnish the same medication distribution system noted above, and comply with the Facility policies and pro- cedures and all applicable laws and regulations. For Medicaid Patient/Residents, the Designated Pharmacy will file claims for payment directly with the Medicaid Program for any covered claims. If the Patient/Resident utilizes a different pharmacy, the Patient/Resident must make arrangements with such pharmacy for similar filing of claims for payment. All charges shall be billed to the Patient/Resident or the Patient{Resident's third party payor directly and shall be payable in full. The Designated Pharmacy reserves the right to terminate any account for ay~y reason after written notice of such intent has been given to the Patient/Resident. J The undersigned selects the Designated Pharmacy (as may be changed by the Facility from time to time) as the supplier of medications prescribed for the Patient/Resident while at the Facility. The undersigned selects as the supplier of medications prescribed for the Patient/Resident while at the .Facility. The undersigned understands-and agrees that such pharmacy must comply in all respects with the Facility's uniform medication distribution system, all Facility policies -and procedures and applicable law. If such pharmacy fails to do so, the undersigned shall be required to select another pharmacy. The above pharmacy shall acknowledge and agree in writing that it will comply with the Facility's uniform medication distribution system, the Facility's policies and procedures and applicable law. ~,~/~ ^ /~ (1 () 1 At..Kta L G """ Responsible Party -Signature i11~ J~~~~'~R Responsible Party -Printed Name ~~~~k~~i,1~1~1(~ to MXP0o8-20 (Rev. 4/96) pg 70 1 of 1 The Admission Agreement is amended in the following manner, in order to comply with state law and/or regulation: (Indicate additions to, and/or deletions from, the Admission Agreement required by state law. If no additions/deletions are necessary, indicate "NONE".) "NONE" m~~•uua-so lnev. w/yol P9 >> 1of1 r„~. EXHIBIT "D" s, MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 96129 09/03/96 05/10/01 $5.00 $5.00 $0.08 MEDICAID PRIVATE ROOM 125 - A SOBOTOR, AMELIA 10/31/96 11/30/96 11/30/96 12/18/96 12/18/96 12/31 /1996 1/1-1/31/97 01/21/97 02/28/97 211-2/28/97 02/28/97 03/04/97 03/04/97 03/04/97 03/12/97 03/12!97 03/14/97 3/1-3/31 /97 TV CABLE TV CABLE INTEREST UNPAID 1.50% ON 5.00 PAYMENT-THANKYOU PAYMENT -THANK YOU RESIDENT PORTION RESIDENT PORTION PAYMENT-THANKYOU TV CABLE RESIDENT PORTION INTEREST UNPAID 1.50% ON 1326.98 PAYMENT-THANKYOU PAYMENT-THANKYOU PAYMENT-THANKYOU PAYMENT-THANKYOU PAYMENT-THANKYOU PAYMENT -THANK YOU RESIDENT PORTION $784.45 $806.45 $5.00 $806.45 $19.90 $804.35 04/30/2001 ($5.00) ($5.00) ($220.00) ($784.53) ($564.45) ($784.45) ($5.00) ($806.45) ($5.00) $56.80 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 96129 09/03/96 05/10/01 $56.80 $5.00 MEDICAID PRIVATE ROOM 125 - A SOBOTOR, AMELIA 03/31 /1997 03/31 /97 03!31 /97 04/1 /97 04/10/97 4/1-4/30/97 05/12/97 05/31 /97 5/1-5/31/97 06/10/97 06/10/97 06/30/97 6/1-6/30/97 07/30/97 07/30/97 07/31/97 7/1-7/31/97 08/13/97 06/30/97 BEGINNING BALANCE TV CABLE REVERSE INTEREST 2/28/97 TRANSFER MISAPPLIED PAYMENT PAYMENT-THANKYOU RESIDENT PORTION PAYMENT -THANK YOU TV CABLE RESIDENT PORTION PAYMENT-THANKYOU PAYMENT -THANK YOU TV CABLE RESIDENT PORTION PAYMENT -THANK YOU PAYMENT-THANKYOU TV CABLE RESIDENT PORTION PAYMENT-THANK YOU MIS APPLIED PAYMENT $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 04/30/01 ($19.90) ($100.00) ($811.45) ($701.53) ($4.92) ($806.53) ($4.92) ($806.53) ($601.45) ($210.00) ($773.03) ,.~, MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR,. AMELIA 96129 08/31/97 ADJ BEGINNING BALANCE 08/31/97 TV CABLE 08/31/97 RESIDENT PORTION 09/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09/30/97 TV CABLE 9/1-9/30/97 RESIDENT PORTION 10/31 /97 TV CABLE 10/1-10/31/97 RESIDENT PORTION 11/07/97 PAYMENT - THANKYOU 11 /07/97 PAYMENT -THANK YOU 11 /30/97 TV CABLE 11/1-11/30/97 RESIDENT PORTION 12/19/97 PAYMENT -THANK YOU 12/19/97 PAYMENT -THANK YOU 12/19/97 PAYMENT -THANK YOU 12/31 /97 TV CABLE 12/31/97 RESIDENT PORTION $5.00 $804.35 09/03/96 05/10/01 04/30/2001 $5.00 $804.35 $5.00 $804.35 MEDICAID PRIVATE ROOM 125 - A ($773.03) ($4.92) ($806.45) ($0.08) ($5.00) ($806.45) $5.00 $804.35 ($4.92) ($811.53) ($806.45) $5.00 $804.35 $27.92 1 ' MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR,. AMELIA $27.92 12/31/97 ADJ BEGINNING BALANCE 01/12/98 PAYMENT -THANK YOU 01/12/98 PAYMENT - THANKYOU 01/06/98 BEAUTY CHARGES 1/1-1/31/98 RESIDENT PORTION 01/31/1998 INTEREST 02/09/98 PAYMENT -THANK YOU 02/09/98 PAYMENT -THANK YOU 02/28/98 TV CABLE 2/1-2/28/98 RESIDENT PORTION 03/12/98 PAYMENT -THANK YOU 03/12/98 PAYMENT -THANK YOU 03/31 /98 TV CABLE 3/1-3/31/98 RESIDENT PORTION 04/30/98 TV CABLE 4/1-4/30/95 RESIDENT PORTION 05/15/98 PAYMENT -THANK YOU 05/15/98 PAYMENT -THANK YOU 05/31/98 TV CABLE 96129 09/03/96 05/10/01 04/30/01 $32.00 $914.50 0.08 MEDICAID PRIVATE ROOM 125 - A ($4.92) ($806.53) ($32.00) ($806.53) ° $5.00 $914.50 ($4.92) ($806.53) $5.00 $914.50 $5.00 $914.50 ($4.92) ($806.61) $5.00 $465.04 ~'~ MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 MANORCARF_ H~I_ATH SF_RVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MEDICAID PRIVATE ROOM 125 - A SOBOTOR, AMELIA 96129 09/03/96 05/10/01 04/30/2001 5/3198 ADJ BEGINNING BALANCE $465.04 5/1-5/31/98 RESIDENT PORTION $914.50 0 5/3141 99 8 INTEREST $0.07 06/29/98 PAYMENT -THANK YOU ($4.92) 06/29/98 PAYMENT -THANK YOU ($806.61) 06/30/98 TV CABLE $5.00 6/1-6/30/98 RESIDENT PORTION $914.50 07/31/98 TV CABLE $5.00 7 /1-7 /3 119 8 RESIDENT PORTION $914.50 07/31 /1998 INTEREST $12.25 08/17/98 PAYMENT -THANK YOU ($4.91) 08/17/98 PAYMENT -THANK YOU ($811.45) 08/17/98 PAYMENT -THANK YOU ($183.64) 08/31 /98 TV CABLE $5.00 8/1-8/31/98 RESIDENT PORTION '$914.50 08/31/1998 INTEREST $9.60 09/18/98 PAYMENT -THANK YOU ($640.06) 09/18/98 PAYMENT -THANK YOU ($171.47) 09/30/98 TV CABLE $5.00 9/1-9/30/98 RESIDENT PORTION $914.50 09/30/98 INTEREST $9.74 $2,466.14 . { ~ lY~ MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR~ AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03/96 05/10/01 04/30/01 96129 09/30/98 ADJ BEGINNING BALANCE 10/27/98 PAYMENT -THANK YOU 10/31 /98 TV CABLE 10/29/98 BEAUTY CHARGES 10/1-10/31/98 RESIDENT PORTION 10/31 /1998 INTEREST 11 /30/98 TV CABLE 11/1-11/30/98 RESIDENT PORTION 11 /30/1998 INTEREST 12/08/98 PAYMENT -THANK YOU 12/08/98 PAYMENT -THANK YOU 12/31 /98 TV CABLE 1211-12/31/98 RESIDENT PORTION 12/31 /1998 INTEREST 01/07/99 PAYMENT -THANK YOU 01/07/99 PAYMENT -THANK YOU 01/31/99 TV CABLE 01/01-01/31/99 RESIDENT PORTION 01/31/99 INTEREST $2,466.14 $5.00 $32.00 $914.50 $12.89 $5.00 $914.50 " $25.73 $5.00 $914.50 30.04 $5.00 $933.76 $29.16 ($611.53) ($38.05) ($511.95) ($309.24) ($590.76) $4,231.69 ~, , MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 01/31/99 ADJ BEGINNING BALANCE 02/24/99 PAYMENT -THANK YOU 02/24/99 PAYMENT -THANK YOU 02/28/99 TV CABLE 02/01-02128/99 RESIDENT PORTION 02/28/99 INTEREST 03/31 /99 PAYMENT -THANK YOU 03131 /99 PAYMENT -THANK YOU 03/31/99 TV CABLE 03/01-03/31/99 RESIDENT PORTION 03/31/99 INTEREST 04/30/99 TV CABLE 04/13/99 BEAUTY CHARGES 04/01-04/30/99 RESIDENT PORTION 04/30/99 INTEREST 05/31/99 TV CABLE 05/01-05/31/99 RESIDENT PORTION 05/31 /99 INTEREST $4,231.69 09/03/96 05/10/01 04/30/01 $5.00 $933.76 $27.56 MEDICAID PRIVATE ROOM 125 - A ($265.58) ($554.42) ($282.76) ($547.24) $5.00 $933.76 $33.43 $5.00 $32.00 $933.76 $48.01 $5.00 $933.76 $63.29 $6,541.02 a1 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 MEDICAID PRIVATE ROOM 125 - A SOBOTOR,AMELIA 96129 09/03196 05/10/01 04/30/01 05/31/99 ADJ BEGINNING BALANCE $6,541.02 06/02/99 PAYMENT -THANK YOU ($294.25) 06/02/99 PAYMENT -THANK YOU ($755.75) 06/21/99 PAYMENT -THANK YOU ($880.00) 06/30/99 TV CABLE $5.00 06101-06/30/99 RESIDENT PORTION $933.76 07/31!99 TV CABLE $5.00 07/01-07/31/99 RESIDENT PORTION $933.76 08/09/99 PAYMENT -THANK YOU ($966.32) 08/09/99 PAYMENT -THANK YOU ($433.68) 08/31!99 TV CABLE $5.00 08/01-08/31/99 RESIDENT PORTION $933.76 09!20/99 PAYMENT -THANK YOU ($889.45) 09/20/99 PAYMENT -THANK YOU ($10.55) 09/30/99 TV CABLE $5.00 09/30/99 BEAUTY CHARGES $32.00 09/01-09/30/99 RESIDENT PORTION $933.76 $6,098.06 y ~ MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/30/99 ADJ BEGINNING BALANCE 10/31/99 TV CABLE 10/01-1b/31/99 RESIDENT PORTION 11/30/99 TV CABLE 11/01-11/30/99 RESIDENT PORTION 12/31 /99 TV CABLE 12/01-12/31/99 RESIDENT PORTION 01 /O6/00 PAYMENT -THANK YOU 01 /06/00 PAYMENT -THANK YOU 01/31/00 N CABLE 01/01-01/31/00 RESIDENT PORTION 01/31/00 MCB PREMIUM 02/29/00 N CABLE 02/01-02/29/00 RESIDENT PORTION 02/29/00 MCB PREMIUM 03/03/00 PAYMENT -THANK YOU 03/31 /00 N CABLE 03/01-03/31/00 RESIDENT PORTION $6,098.06 $5.00 $933.76 $5.00 $933.76 $5.00 $933.76 09/03/96 05/10/01 04/30/01 ($1,930.26) ($269.74) $5.00 $1,000.35 $5.00 $1,000.35 MEDICAID PRIVATE ROOM 125 - A ($45.50) ($45.50) ($750.00) $5.00 $1,000.35 $8,889.39 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 03/31/00 ADJ BEGINNING BALANCE 03/31/00 MCB PREMIUM 04/17/00 PAYMENT -THANK YOU 04/30/00 TV CABLE 04/01-04/30/00 RESIDENT PORTION 04!30100 MCB PREMIUM 04/30/00 BEAUTY CHARGES 05/31/00 TV CABLE 05/11 /00 BEAUTY CHARGES 05/25/00 BEAUTY CHARGES 05/01-05/31/00 RESIDENT PORTION 05/31!00 MCB PREMIUM 06/30/00 TV CABLE 06/01-06/30/00 RESIDENT PORTION 06/30/00 MCB PREMIUM 07/03/00 PAYMENT -THANK YOU 07/31/00 TV CABLE 07/01-07/31/00 RESIDENT PORTION $8,889.39 09/03/96 05/10/01 04/30/01 $5.00 $1,000.35 $36.00 $5.00 $9.00 $9.00 $1,000.35 $5.00 $1,000.35 MEDICAID PRIVATE ROOM 125 - A ($45.50) ($1,450.00) ($45.50) ($45.50) ($45.50) ($1,300.00) $5.00 $1,000.35 $10,032.79 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civii Term Plaintiff vs. CIVIL ACTION -LAW ;HAEL SOBOTOR, Individually, on Behalf of Amelia B. Sobotor, Deceased, Defendant CERTIFICATE OF SERVICE AND NOW, this 16`" day of September, 2002, 1, Daniel F. Wolfson, Equire, do certify that 1 have served a copy of the foregoing Second Amended Complaint the counsel of record by regular mail, postage pre-paid and addressed as follows: Douglas G. Miller, Esquire IRWIN, McKNIGHT at HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 17013-3222 Daniel F. Wolfson, Esquire '" WOLFSON 8i ASSOCIA , P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff n ~= c~ ~,. i - ~_' cn ~ ,~ <-'t: ~ _.. - : it ~ .,t/ _' r.- _;. v~ tl` -~: F. _.~cix~r~s~arsaW~. 'dM~ap~u-,^~,_ni .,o~:. s ,.. ,e+te~nts-reb a,ax.,,n~a .. ,..~~c s-a5~'d:. , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 2001-4092 CIVIL TERM Plaintiff . vs. CIVIL ACTION -LAW CHAEL SOBOTOR, Individually, and Behalf of Amelia B. Sobotor, Deceased, Defendant PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER TO PLAINTiFF'S SECOND AMENDED COMPLAINT AND NOW, this day of September, 2003, comes the Plaintiff, HCR Manor by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of Wolfson $t Associates, P.C., and files the following PlaintifYs Reply to Defendant's New Matter, and in support thereof avers as follows: The allegations and averments contained within paragraphs 1 through 30 of the Plaintiff s Second Amended Complaint are incorporated herein by reference as if set forth in full. 31. Paragraph 31 of Defendant's New Matter is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in PlaintifYs Second Amended Complaint, are incorporated herein by reference as if set forth in full. 32. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. By way of further while there were some sporadic payments made on the account balance of while Decedent was a resident of Plaintiff's facility, the total amount of monthly social security and/or pension income was not forwarded to Plaintiff Defendant as required by state and federal law. Therefore, it is denied that Plaintiff all of the compensation due to Plaintiff for the healthcare services and treatment to Decedent by Plaintiff. 33. Denied. After reasonable investigation, Plaintiff is without sufficient or knowledge to form a belief as to the truth or veracity of this allegation. same is denied and strict proof is demanded at trial. By way of further on or about August 9, 1996, Defendant knowingly, voluntarily and intelligently an Admission Agreement on behalf of the Decedent, which Agreement outlined terms of residential health care services to be provided by Plaintiff, including the costs associated therewith, and the Responsible Party therefor. By so executing said Admission Agreement, Defendant did acknowledge that Plaintiff would be relying on the "Conditions" of the Responsible Party Appointment, which is part of the Admission Agreement, in admitting the Decedent, and that if Defendant did not follow through with said Conditions, Plaintiff e•,ril[ have detrimentally relied upon said Conditions and Plaintiff will suffer financial harm and loss. By way of further response, pursuant to the terms of the aforementioned Admission Agreement, Defendant agreed to remit payment to the Plaintiff from the assets of the Decedent for services provided by Plaintiff that were not compensated by a third party payor or government program. Defendant violated the terms of said Admission Agreement as the total amount of Decedent's monthly social 2 and/or pension income was not forwarded to Plaintiff by Defendant as required by and federal law. 34. Denied. After reasonable investigation, Plaintiff is without sufficient or knowledge to form a belief as to the truth or veracity of this allegation. same is denied and strict proof is demanded at trial. By way of further on or about August 9, 1996, Defendant knowingly, voluntarily and intelligently an Admission Agreement on behalf of the Decedent, which Agreement outlined terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. By so executing said Admission Agreement, Defendant did that Plaintiff would be relying on the "Conditions" of the Responsible Party which is part of the Admission Agreement, in admitting the Decedent, and if Defendant did not follow through with said Conditions, Plaintiff will have relied upon said Conditions and Plaintiff will suffer financial harm and loss. By way of further response, pursuant to the terms of the aforementioned Admission Defendant agreed not to dissipate the assets of the Decedent, and to remit payment to the Plaintiff from the assets of the Decedent for services provided by Plaintiff that were not compensated by a third party payor or government program. Defendant violated the terms of said Admission Agreement as the total amount of Decedent's monthly social security and/or pension income was not forwarded to Plaintiff by Defendant as required by state and federal law. 35. Denied. The allegation contained in paragraph 35 of Defendant's New Matter is a conclusion of law to which no response is required. To the extent that Plaintiff 3 required to answer, Plaintiff specifically denies the allegation contained in this paragraph demands strict proof thereof. 36. Denied. The allegation contained in paragraph 36 of Defendant's New is a conclusion of law to which no response is required. To the extent that Plaintiff required to answer, Plaintiff specifically denies the allegation contained in this paragraph and demands strict proof thereof. 37. Denied. The allegation contained in paragraph 37 of Defendant's New Matter is a conclusion of law to which no response is required. To the extent that Plaintiff is required to answer, Plaintiff specifcally denies the allegation contained in this paragraph and demands strict proof thereof. 38. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 39. Denied. The allegation contained in paragraph 39 of Defendant's New Matter is a conclusion of law to which no response is required. To the extent that Plaintiff is required to answer, Plaintiff specifically denies the allegation contained in this paragraph and demands strict proof thereof. 4 WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Defendant's New Matter and enter judgment in favor of Plaintiff and against Defendant, ~e allowable costs of this action, and such further relief as the Court deems Respectfully submitted, Amy F. W¢Ifsc WOLFSON 8t York, PA 17403 (717)846-1252 I.D. No. 87062 Attorney for Plaintiff .TES, 5 267 East Market Street VERIFICATION Amy F. Wolfson, Esquire, hereby states that she is the attorney for the Plaintiff, HCR Manor Care, and she is authorized to take this verification on behalf of said Plaintiff in within action, and verifies that the statements made in the foregoing Reply to New Matter are true and correct to the best of her knowledge, information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: 9/8/03 WOLFSO'N si ASSO¢IATES, P.C. 267 East Market Street York, PA 17403 (717)846-1252 ID No. 87062 Attdrney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 2001-4092 CIVIL TERM Plaintiff vs. CIVIL ACTION -LAW ~HAEL SOBOTOR, Individually, and Behalf of Amelia B. Sobotor, Deceased, Defendant CERTIFICATE OF SERVICE AND NOW, this 8`h day of September, 2003, I, Amy F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Reply to New Matter upon the of record for the Defendant by Facsimile and First Class Mail -Postage Pre-paid, addressed as follows: VIA FAX: (717) 249-6354 Douglas G. Miller, Esquire IRWIN, McKNIGHT et HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 17013-3222 WOLFSON'ST ASSC~',l'ATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff T i'LL ~~~ __ G .:: __- ~ : i. ~.;" t _.... inc.:, ~ z, i , ~~ -, L~ ~-iavxr~._ ~w.z~~ v ~_.~ .~s~ss .x~._~R ..F-e ,=~~dF~& .. _ ~ HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. NOTICE TO PLEAD You are hereby notified to f ile a written response to t he e nclosed Ans wer w ith Ne w Matter within twenty (20) days from service hereof or a judgment maybe entered against you. IRWIN, McKNIGHT & HUGHES Douglas .Miller, Esquire Supreme ourt I.D. No. 83776 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717) 249-2353 Attorney for Defendant Date: July 31, 2003 HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. ANSWER WITH NEW MATTER TO PLAINTIFF'S SECOND AMENDED COMPLAINT AND NOW this 315` day of July, 2003, comes the Defendant, Michael Sobotor, by and through his attorneys, Irwin, McKnight & Hughes, and respectfully files this Answer with New Matter to the Plaintiffs Second Amended Complaint, and in support thereof aver as follows: 1. The averments of fact contained in paragraph one (1) of the Plaintiffs Second Amended Complaint are admitted. 2. The averments of fact contained in paragraph two (2) are admitted. 3. The auerments of fact contained in paragraph three (3) are admitted. 4. The averments contained in paragraph four (4) are conclusions of law to which no response is required. 5. The power of attorney referenced by Plaintiff in paragraph five (5) and identified as Exhibit "A" speaks for itself and therefore no response is required. 6. The power of attorney referenced by Plaintiff in paragraph six (6) and identified as Exhibit "A" speaks for itself and therefore no response is required. Byway of further answer, 20 Pa.C.S.A. § 711(22) provides that the Orphans' Court has mandatory jurisdiction over "all matters pertaining to the exercise of powers by agents acting under powers of attorney... ", but Plaintiffs Complaint was not filed in the Cumberland County Orphans' Court. 7. The averments of fact contained in paragraph seven (7) are admitted. 8. The averments contained in paragraph eight (8) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 9. The averments contained in paragraph nine (9) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 10. The agreement referenced by Plaintiff in paragraph ten (10) and identified as Exhibit "C" speaks for itself and therefore no response is required. By way of further answer, any implication that Defendant understood what he was signing or knew that he was not required by law to sign such an agreement is specifically denied and strict proof thereof demanded at trial. 11. The averments of fact contained in paragraph eleven (11) are admitted. 12. The averments of fact contained in paragraph twelve (12) are admitted in part and denied in part. It is admitted that Decedent was a health care resident of Plaintiff and that she 2 received certain services and treatment. The remaining averments in paragraph twelve (12) are specifically denied and strict proof thereof is demanded at trial. 13. The averments contained in paragraph thirteen (13) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 14. The averments contained in paragraph fourteen (14) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 15. The averments contained in paragraph fifteen (15) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 16. The averments of fact contained in paragraph sixteen (16) are admitted in part and denied in part. It is admitted that a copy of the itemization of services was sent to Defendant. The remaining averments in paragraph sixteen (16) are specifically denied and strict proof thereof is demanded at trial. 17. The averments contained in paragraph seventeen (17) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 3 18. The auerments contained in paragraph eighteen (18) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 19. The averments contained in paragraph nineteen (19) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 20. The averments contained in paragraph twenty (20) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 21. The averments contained in paragraph twenty-one (21) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 22. The averments contained in paragraph twenty-two (22) are specifically denied and strict proof thereof is demanded at trial. 23. The averments contained in paragraph twenty-three (23) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 24. The averments contained in paragraph twenty-four (24) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 4 25. Upon information and belief, the averments contained in paragraph twenty-five (25) are admitted. 26. The averments contained in paragraph twenty-six (26) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 27. The averments contained in paragraph twenty-seven (27) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 28. The averments contained in paragraph twenty-eight (28) are conclusions of law to which no response is required. To the extent that a response is required, the averments are specifically denied and strict proof thereof is demanded at trial. 29. The averments contained in paragraph twenty-nine (29) are conclusions of law to which no response is required. To the extent that a response is required, the averments a re specifically denied and strict proof thereof is demanded at trial. 30. The averments contained in paragraph thirty (30) are admitted. WHEREFORE, Defendant Michael Sobotor, respectfully requests this Honorable Court to enter a judgment in his favor and against Plaintiff in this matter, together with reasonable costs and attorney fees, and such other and further relief as this Court deems just. 5 NEW MATTER 31. The averments of fact contained in the Answers to the Second Amended Complaint are hereby incorporated by reference and are made part of this New Matter to the Second Amended Complaint of the Plaintiff. 32. Plaintiff received adequate compensation for the services and treatment provided to Decedent while she was a resident in Plaintiff s facility. 33. Defendant was not aware of nor did he agree to be responsible for excess costs alleged to have been incurred by Plaintiff. 34. Defendant was not made aware of nor did he agree to be responsible for alleged private balances claimed to be owed to Plaintiff. 35. Plaintiff s Complaint fails to state claims or causes of action upon which relief can be granted. 36. Plaintiff's claims may be barred by the defense of the applicable statute of limitations. 37. Plaintiffs Complaint may barred by the defense of laches. 38. All or some of Plaintiffs claimed damages are attributable to persons and/or causes other than Defendant. 6 39. Plaintiff s claims maybe barred and/or limited by Plaintiff's failure to mitigate or to properly mitigate its damages. WHEREFORE, Defendant Michael Sobotor, respectfully requests this Honorable Court to enter a judgment in his favor and against Plaintiff in this matter, together with reasonable costs and attorney fees, and such other and further relief as this Court deems just. Dated: July 31, 2003 Respectfully Submitted, IRWIN, McKNIGHT & HUGHES By. Douglas Miller, Esquire Supreme Court ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717) 249-2353 Attorney for Defendant, Michael Sobotor VERIFICATION The foregoing Answer with New Matter on behalf of Defendant Michael Sobotor is based upon information which has been gathered by counsel for the Defendant in the preparation of this document. The statements made in this document are true and correct to the best of the counsel's lrnowledge, information and belief. The Defendant's verification cannot be obtained within the time allowed for filing the pleading. The undersigned is therefore verifying on behalf of the Defendant according to 42 Pa.C.S.A. § 1024(c)(2). The undersigned understands that false statements herein made are subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. r Douglas M' er, Es uire Date: July 31, 2003 CERTIFICATE OF SERVICE I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy of the foregoing document upon the persons indicated below by first class United States mail, postage paid in Carlisle, Pennsylvania 17013, on the date set forth below: Amy Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 (Attorney for Plaintiff] Date: July 31, 2003 IRWIN, McKNIGHT & HUGHES Douglas G 'ller, Esgi ' •e Supreme Court ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 (717)249-2353 Attorney for Defendant ~~ - :~._ -il :- .- ~ ~ . : ~,i.[ i .u :~ ' ^r: .i .- -{ HCR MANOR CARE v. Plaintiff MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants TO: Douglas C. Miller, Esquire 60 West Pomfret Street Carlisle, PA 17013 IN THE COURT O F COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-4092 CIVIL TERM CIVIL ACTION -LAW NOTICE OF HEARING Amy Wolfson, Esquire Wolfson & Associates, P. C. 267 East Market Street York, PA 17403 NOTICE IS HEREBY GIVEN that the undersigned Arbitrators appointed by the Court in the above-captioned matter will meet for the purpose of their appointment on Thursday, February 12, 2004, beginning at 9:30 o'clock a.m. in the Second Floor Hearing Room in the old Courthouse in Carlisle, Pennsylvania, at which time and place you may appear and be heard, together with your witnesses and counsel, if you so desire. Date: January 20, 2004 Keith O. Brenneman, Esquire, Chairman Tricia Naylor, Esquire Karen Koenigsburg, Esquire LAW OFFICES SNELBAKER, BRENNEMAN & SPARE CC: Court Administrator, Cumberland County HCR MANOR CARE, IN THE COURT OF COMMON PLEAS OF Plaintiff :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and :CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendant NOTICE OF HEARING TO: Douglas C. Miller, Esquire 60 West Pomfret Street Carlisle, PA 17013 Amy F. Wolfson, Esquire Wolfson & Associates, P. C. 267 East Market Street York, PA 17403 NOTICE IS HEREBY GIVEN that the undersigned Arbitrators appointed by the Court in the above-captioned matter will meet for the purpose of their appointment on Wednesday, March 3, 2004, beginning at 9:00 o'clock a.m. in the Second Floor Hearing Room in the old Courthouse in Carlisle, Pennsylvania, at which time and place you may appear and be heard, together with your witnesses and counsel, if you so desire. Date: February 12, 2004 Keith O. Brenneman, Esquire, Chairman Tricia Naylor, Esquire Karen Koenigsburg, Esquire LAW OFFICES SNELBAKER. BRENNEMAN & SPPRE CC: Court Administrator, Cumberland County IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW ELIA B. SOBOTOR, Individually, and ,HAEL SOBOTOR, Individually, on Behalf of AMELIA B. SOBOTOR, 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 without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la torte. Si used quaere defensas de eras demandas expuestas en las nas, siguientes, used tiene viente (20) dias de piazo al partir de la fecha de lademanda y la notifiation. d debe presentar una apariencia escrita o en persona o por abogado y archivar en la torte en forma ita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se ends, la torte tomara medidas y psedido entrar una Orden contra used sin previo aviso o notification y cualquier queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus ~iedades o otros derechos importances 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 PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Associatlon 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 Y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. AMELIA B. SOBOTOR, Individually, and MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Defendants NO. 01-4092 Civil Term CIVIL ACTION -LAW AMENDED COMPLAINT AND NOW, this 27`h day of September, 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson Associates, P.C., and files the within Amended Complaint and in support avers as 1. Plaintiff, HCR Manor Care, is a health care provider qualified to conduct in the Commonwealth of Pennsylvania with offices and/or a place of business at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Amelia B. Sobotor, (hereinafter "Defendant Amelia"), is an individual with a last known address of 940 Walnut Bottom Road, Carlisle, County, Pennsylvania 17013. 3. Defendant, Michael Sobotor, (hereinafter "Defendant Michael"), is an adult with a last known address of 19 Holly Estate Drive, Gardners, Adams County, Pennsylvania 17324. 4. That Plaintiff filed its original Complaint against Defendants on or about July 2, 2001. r 5. That Plaintiff is filing the within Amended Complaint in an attempt to cure Defendants' Preliminary Objections which were filed by Defendants in response to Plaintiff's Complaint on or about September 4, 2001. COUNTI HCR MANOR CARE vs. AMELIA SOBOTOR 6. Paragraphs One (1) through Five (5) of Plaintiff's Amended Complaint are incorporated herein by reference as if set forth in full. 7. That Defendant Amelia executed a General Durable Power of Attorney ("hereinaker Power of Attorney"), appointing her son, Defendant Michael, as her lawful on October 22, 1996. A true and correct copy of the said Power of is attached hereto, incorporated herein, and marked as Exhibit "A". 8. That on or about July 16, 2000, Defendant Amelia executed an Admission Agreement which Agreement outlined various terms of residential health care services to be provided by Plaintiff and her Responsible Party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit .. B.. 9. That on or about July 16, 2000, through the present, Defendant Amelia a health care resident of Plaintiff, where she did receive and where she continues to receive various necessary residential health care services and health care treatment by Plaintiff. 10. That Section 1 of the Admission Agreement, titled "Rights and Responsibilities of the Resident", describes the responsibilities of Defendant Amelia, which 2 r responsibilities did include payment for the daily rate and charges for supplemental supplies not paid by any third party, as well as applicable co-insurance and deductibles and all expenses of discharge or transfer. See Exhibit "B", Section 1 previously identified and incorporated herein. 11. That Plaintiff submitted to Defendant Amelia a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. A true and correct copy of the itemization of said services is attached hereto, incorporated herein, and collectively marked as Exhibit "C". 12. That Defendant Amelia did not object to the above mentioned Statement of Account submitted by Plaintiff. 13. That Defendant Amelia did not pay the Plaintiff for health care services pursuant to her Admission Agreement with the Plaintiff as identified in the Statement of Account. 14. That Plaintiff sent Defendant Michael a copy of the itemization of services showing all debits and credits for transactions with Plaintiff. 15. That Defendant Michael did not act on behalf of his mother, Defendant to pay her account balance with the Plaintiff. 16. As of the date of filing of this Complaint, the balance due, owing, and on Defendant Amelia's account as a result of said charges is the sum of Eleven Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See Exhibit "C" identified and incorporated herein. 3 r 17. Despite Plaintiff s reasonable and repeated demands for payment, Defendant has failed, refused, and continue to refuse to pay all sums due and owing on the outstanding account balance, which accrued due to residential health care services provided to Defendant Amelia, all to the damage and detriment of the Plaintiff. 18. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, Plaintiff is entitled to receive and Defendant Amelia has agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" previously identified and incorporated herein. 19. As of the date of the within Amended Complaint, the amount of interest has accrued on the past due balance is the sum of One Thousand Eighty-Eight and 10/100 Dollars ($1,088.10). 20. Plaintiff has retained the services of the law firm of Wolfson st Associates, '.C., in the collection of the amounts due from Defendant Amelia. 21. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, is entitled to receive and Defendant Amelia agreed to pay reasonable attorney's and all court costs if the account is referred to an attorney for collection. See Exhibit "B" as previously marked and incorporated herein. 22. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's from the law office of Wolfson St Associates, P.C., in the collection of the amounts and owing by Defendant Amelia, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the 4 r amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by Defendant Amelia. 23. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Three Thousand Three Hundred Ninety- Five and O6/100 Dollars ($3,395.06). 24. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 25. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Amelia B. Sobotor, Individually, Michael Sobotor, Individually and on Behalf of Amelia B. Sobotor, in the amount of Eleven Thousand Three Hundred Sixteen and 87/100 Dollars ($ l 1,316.87), contractual interest in the amount of One Thousand Eighty-Eight and 10/100 Dollars ($1,088.10), reasonable attomey's fees in the amount of Three Thousand Three Hundred Ninety-Five and 06/100 Dollars ($3,395.06), the costs of this action, and such other relief as the Court deems proper and just. COUNT II HCR MANOR CARE vs. MICHAEL SOBOTOR 26. Paragraphs One (1) through Twenty Five (25) of Plaintiff's Amended Complaint are incorporated herein by reference as if set forth in full. 5 27. That Defendant Michael knew or should have known his mother, Defendant was a resident of Plaintiff and was admitted pursuant to a written agreement. 28. That Defendant Michael represented himself to be the Attorney-in- Fact for his mother, Defendant Amelia, pursuant to her Power of Attorney. See Exhibit "A" previously identified and incorporated herein. 29. That Defendant Michael knew or should have known the Plaintiff's services being provided to the Plaintiff for a fee and thereby Defendant Amelia would incur with the Plaintiff for said services pursuant to their agreement. 30. That Defendant Michael knew or should have known he was authorized to on behalf of Defendant Amelia and to use her f-nancial resources to pay any bills with her agreement with the Plaintiff and that the Plaintiff was directed in the Power of Attorney, to accept and rely on it to bind her agent. See Exhibit "A" at page (2), Clauses 2 (two) and 4 (four). 31. That Defendant Michael unequivocally accepted fiduciary responsibility and as his mother's agent under the Power of Attorney as he signed it as the person whom the power of attorney was given. See Exhibit "A", page two (2). 32. That Defendant Michael knew or should have known that the Plaintiff to be paid for services provided to his mother pursuant to their agreement, by her, or by him as her agent under the Power of Attorney. 33. That pursuant to the Power of Attorney, Defendant Michael is the person appointed and authorized to act on behalf of Defendant Amelia and, among other things, "... to pay any and all claims and demands now or hereafter payable by me ...", and ". . 6 . to contract with and arrange for my entrance to any hospital, nursing home, health convalescent home, or similar institution and to pay all bills in connection therewith ...". See Exhibit "A" as previously marked and incorporated herein. 34. That Defendant Michael accepted the duty and responsibility to act on behalf of his mother in matters regarding and relevant to her medical treatment on or about 22, 1996, the date of execution of her Power of Attomey, well in advance of admission as a resident of the Plaintiff. See Exhibit "A" as previously marked and herein. 35. That Plaintiff submitted to Defendant Michael a copy of the itemization of accurately showing all debits and credits for his mother's transactions with Plaintiff. See Exhibit "B" previously identified and incorporated herein. 36. That Defendant Michael did not object to the above mentioned Statement of submitted by Plaintiff to Defendant Michael. 37. That Defendant Michael willingly failed to act on behalf of his mother, in of her responsibilities pursuant to her Admission Agreement with the Plaintiff, he did not timely pay the Plaintiff upon demand. 38. That Defendant Michael 's willful failure to act as agent, on his mother's pursuant to her Power of Attorney, was a breach of the fiduciary duties therein. 39. That Defendant Michael's breach of the Power of Attomey fiduciary duties in the Plaintiff not being paid for their services. 40. As of the date of filing of this Complaint, the balance due, owing, and on Defendant Amelia's account as a result of said charges is the sum of Eleven 7 Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87). See Exhibit "B" previously identified and incorporated herein. 41. Despite Plaintiff s reasonable and repeated demands for payment, Defendant has failed, refused, and continue to refuse to pay all sums due and owing on the account balance, which accrued due to residential health care services provided Defendant Amelia, all to the damage and detriment of the Plaintiff. 39. Plaintiff has made numerous requests to Defendant Michael, to pay the outstanding balance of his mother Defendant Amelia pursuant to his obligations under her Power of Attorney and Admission Agreement. 40. That Section 11, Paragraphs 2.01 and 2.02 of the Admission Agreement indicated that Defendant Amelia's Legal Representative was to promptly pay the Plaintiff for services provided under the Agreement. 41. That Plaintiff made repeated requests to Defendant Michael as Attorney-in- Fact for Defendant Amelia, demanding that the sums due and owing to Plaintiff be paid, Defendant Michael has ignored his fiduciary obligation, as the Attorney-in-Fact under mother's Power of Attorney, and therefore also as the Legal Representative and/or and Responsible Party for Defendant Amelia under the Admission Agreement, to pay necessary appropriate bills and obligations for Defendant Amelia as outlined in the Power of Attorney and Admission Agreement. See Exhibits "A" and "B" previously marked and incorporated herein. 42. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, July 16, 2000 by Defendant Amelia, Plaintiff is entitled to receive and 8 Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit "B". 43. As of the date of the within Amended Complaint, the amount of interest that has accrued on the past due balance is the sum of One Thousand Eighty-Eight and 10/100 Dollars ($1,088.10). 44. Plaintiff has retained the services of the law firm of Wolfson 8t Associates, '.C., in the collection of the amounts due from Defendants. 45. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, is entitled to receive and Defendants have agreed to pay reasonable attorney's fees all court costs if the account is referred to an attorney for collection. A true and copy of the Admission Agreement is attached hereto, incorporated herein, and vely marked as Exhibit "C". 46. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's from the law office of Wolfson 8i Associates, P.C., in the collection of the amounts and owing by Defendants, incident to the within action, and Plaintiff shall continue to such attomey'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. 47. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Three Thousand Three Hundred Ninety- Five and 06/100 Dollars ($3,395.06). 9 48. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 49. The amount in controversy is within the jurisdictional amount requiring 'i compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Amelia B. Sobotor, Individually, Michael Sobotor, Individually and on Behalf of Amelia B. Sobotor, in the amount of Eleven Thousand Three Hundred Sixteen and 87/100 Dollars ($11,316.87), contractual interest in the amount of One Thousand Eighty-Eight and 10/ 100 Dollars ($1,088.10), reasonable attorney's fees in the amount of Three Thousand Three Hundred Ninety-Five and 06/100 Dollars ($3,395.06), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esgi e WOLFSON Si ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney. for Plaintiff 10 VERIFICATION Daniel F. Wolfson, Esquire, hereby states that he is the attorney for the Plaintiff, HCR Manor Care, and he is authorized to take this verification on behalf of said Plaintiff in within action and verifies that the statements made in the foregoing Amended are true and correct to the best of his knowledge, information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: September 27, 2001 G%~~ ~/~ G Daniel F. Wolfson, quire WOLFSON 8t ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff EXHIBIT "A" kid ~~- I , E F~ 1 .r. +~1Fr[.xrv ... .i.,.. 1 g,¢ a ~: !~~{5 ~ iv.l ~, m931'4 yj;d oik etti d ~ k~ ~ a 14 a,;,4 N'F~I!~ ~11~{ f,W+G.y a~;2C~ay, C' 1 ty.~-..:M t ~ ~ ~ i~z ~ ~ v r pf~a ~~!I~a~t ~. ~u a 1 y~,4~~. t~ r,j_ v i i !~y ? i , I _.: ii. ~. u7~: e~- :~. ~ NU"('~' xpiY° ai!EdJ.;, ~i. GENERAL DliRABLE PGWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, i'rat i, AMELIA B. SOBOTOR, Manor Care, 940 Walnut 3ottom Road, Carlisle, Cumberiand County, Pennsyivania i70i3, do hereby appoint my son, MICHAEL P. SOBOTOR, 13 Hoiiy Estates Drive: Gardners, Cumberiand Ccunty, Pennsyivania 17324, as my agent ("my agent"l, for me and en my behalf, in my name or in his own name, to take a~!1 actions and to perform all acts concerning my affairs as he may deem ?ecessary or advisable, in his aDSOllite discretion, as fully as I could do if personally present, including, without limiting the generality of the foregoing, for me and in my name and on my behalf, as fcilows: 1. Inclusiveness. To receive and receipt for all sums of money or payments due or becoming due to me from any source; to enter my safe deposit boxes in any and ail banking institutions, and to add to and to remove any of the contents thereof; to endorse all checks and other instruments payable to me and deposit and withdraw any and a1i moneys, checks and other instruments to which i may be at any time entitled in my name in any financial institutions: to pay am and ail claims and demands aow or hereafter payable by me; to draw and sicn checks, drafts and other orders for tae payment of money upon my chea'.ting account or upon any ot'r.er bank accounts or deposits now or hereafter belonging to me; to borrow money and to mortgage, aiedge or Hypothecate any property, real or personal, now or hereafter owned by me as security therefor: to sell, possess, insure, manage, maintain, improve, lease, mortgage, pledge, encumber, convey, and otherwise dispose of, or take any other action with respect to any property, real or personal, now or Hereafter owned by me, on such terms and conditions as my agent considers appropriate, and ir. the event of any sale of my real estate to execute the sales agreement ar_d the deed in my name and to make settlement and receive the proceeds; to purchase, rent or et:;erwi5e acquire ar.p property. real or personal, for me and to pay for the same; to contract with and arrange for my entrance to any hospital, nursir_g home, health center, conval=scent Home, or similar institution and to pay all bills in connection therewith; to arrange far ar_d consent to or to withhold medical, theraaeutical and surgical procedures for me, including the administration of drugs; to institute and to engage in and compromise any litigation on my behalf; for me and in my name and as my act to execute, endorse, acknowledge and deliver ail documents; to prepare, execute and file any tax returns, governmental reports and other instruments cf w.^_atever ;rind; to engage and dismiss agents; and to manage, make and transact all aad every kind of business of every natur=_. =. li o__^.erai AuthO=i~=y. i0 d0 ail other thincs WniCa m_~ agent Snall deem necessary and aroner in order LO CdrrV Out the foregoing powers which shall be construed as broadly as possible, giving and granting unto my said agent full power and authority to do and perform all and every act: deed, matter, and thing whatscever in and about my estate, property, and affairs as fully and effectually to all _ntents and purposes as I might or could do in :ny owr. proper person if personally aresent, file above specially enumerated powers b=_ing utiz aid and e:temaiificatior. o`_ the full, complete, and general power hereiZ granted, and not in limitation or definition thereof; and hereby ratifying and confirming all that my said agent shall lawfully do or cause to be done by virtue of these presents. 3. Durability. This power of attorney shall not be affected by my s~.:bsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and enure to my benefit and bind me and my successors in interest as if I were competent and not disabled. 4. Reliance on Power. This power may be accepted and relied upon by anyone to whom it is presented until such person either receives written notice of revocation by me or a guardian or similar fiduciary of my estate or has actual knowledge of my death. 5. Hold Harmless. Aii actions of my agent shall bind me and my heirs, distributees, legal representatives, successors and assigns, and for the purpose of inducing anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant and agree that if this power of attorney is terminated or amended for any reason, I and my heirs, distributees, legal representatives, successors and assigns wil'_ hold such party or parries harmless from anv less suffered or liabi'_ity incurred by st:ch party or parties while ac'*_ing in accordance with this _cwer arior to that party's receipt of written notice of anyysuch termination or amendment. The following is the specimen signature of the person to whom this power of attcrney is giv~en~ MICHAEL ?'. SOBOTOR ?age 2 of 3 pages d I have signed this power of attorney t::^.is ZZ- day of ~~~~ 1996. Witnesses: 4/^~/'~!~" ~i~ AMELIA B. SOBOTOR Social Security No. COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this ~ Z~ day of ~~~~' 1996, personally apaeared before me, a Notary Public in and for the said county and state, the above-named AMELIA B. SOBOTOR, who acknowledged the foregoing power of attorney to be her act and deed and desires the power of attorney might be recorded according to law. I have signed my name and affi~xe~d/m~y seal. Notary PtibliC NOTARIAL SEAL - WILLIAM S. DANIELS Notary Public Carlisle Boro. Cumberland County M Commissbn Ez Tres Oct, t9, 2000 EXHIBIT "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 Caze Center ("Center"), Center ~ ~~('.~-v~~~ cR2°R 13~•~ Resident ~~ / r ' ~-t-°v~~- Legal Representative: rQ, _X/L Admission Date: ~ J ~ ~ ~ ~) ~ Deposit: $ _/C/ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT _~_ 1.01 Room and~Boazd 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 Ancillar~Chazges. 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 Caze. The Center reserves the right to charge for personal Gaze items of the Resident if necessazy for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary chazge 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 sh~j ~ 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 personal program in accordance with the terms of the program. 1.05 Governmental Pro rg ams. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medic+`aid, 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: x Medicare, x Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the _,_ Resident's care, there is a required co-payment, whichMedicare 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 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 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 z 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 reasortable 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 detemuned 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 Mediaaid 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 deternrination 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 dischazge 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 tJte Center_vv~th notice within five (5) dam of the Resident's disenrollment, enrollment, change in health raze coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this 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 raze 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 Ph, siLcian. 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. ff the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSlBILTTY 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 charges for which the Resident is liable under this Agreement. The Legal Representative shat] 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. ):f 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 Seances as Medicaid representative shall require for continued coverage of the Resident grid be personally responstble for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon temrination 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. IQ. 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,._a~nd 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 Srst 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 Dedicaid 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. N. 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 persoMel, attending physicians and consultants; and person, frrri, goverunent 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 s ~- 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 [he 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 grid 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 int~the exercise of good nursing judgment, subject io 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 Photoeraoh. 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 staffto identify the Resir~ent. -,_ 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. Medicaze 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 Croups addresses and phone numbers. See Attachment I (Center Supplement). i. Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). t' 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 phongstumber on how to fide 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. ResidenUPatient Rights. See Attachment K. o. Medicaze/Medicaid information and display of such information including how to apply for and use Medicaze 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 Cazdiopulmonary 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. ~1 f s. ASM Form. See attachment P. t. Consent to Photoeraoh See Attachment Q. u. v. w. See Attachment R. t' x. Y• z. See Attachment S. See Attachment T. See Attachment U. See Attachment V. 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 Legs! -rRepresentative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Caze 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 dischazge 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 s ~ •~ r 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 THAT THEY HAVE EACH READ AND UNDERSTOODR~ THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: ~~~~~ f~~ro'~v Date: ~ ` ~ ~ `~~ ~~ ~` Signature of Legal Representative, if signing on behalf of Resident: Date: -~- _~ Signature of Legal Representative, signing on his/her own behalf: Date: Center Representative: ~ XiLt~C. I_~( J ~i~V~ Gz ~ Date: ~ ~ !' l[7 ~ ~~ EXHIBIT "C" I~Cl~•1~IanorC~ar~e P•tANORCARE CARLISLE 372 940 WALtdUT 80TTOM ROAD CARLISLE, PA 17013 (717)-249-©©85 1 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 Statement ' MEDICAID PRIVATE ROOM 109 -A Please Rewrn TP~is Portion With Yow' Payment F~ S080TOR, AMELIA B 96129 ~ 1.1/01/00 ©1/31/01 ~~~'~``~~ I CODE I SERVICE RENDERED CHARGES ( CP.EDITS I J"ERVICE 1 O1 Q1 01 BALANCE FORWARD 1©,366.52 01/©1/491 1130© NCB PREMIUM 02/01/01 ADV PVT PORTIOPd PAYMENT DUE BY THE 10TH OF THE P10NTH ( QTY 1-) 1,0©0.35 50.00 11,316.87 At,AUUNT DUE MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 10/31 /96 TV CABLE 11/30/96 TV CABLE 11/30/96 INTEREST UNPAID 1,50% ON 5.00 12/18/96 PAYMENT -THANK YOU 12/18/96 PAYMENT -THANK YOU 12/31/1996 RESIDENT PORTION 1/1-1/31/97 RESIDENT PORTION 01 /21!97 PAYMENT -THANK YOU 02/28/97 TV CABLE 2/1-2/28/97 RESIDENT PORTION 02/28/97 INTEREST UNPAID 1.50% ON 1326.98 03/04/97 PAYMENT -THANK YOU 03/04/97 PAYMENT -THANK YOU 03/04/97 PAYMENT -THANK YOU 03/12/97 PAYMENT -THANK YOU 03712!97 PAYMENT -THANK YOU 03/14/97 PAYMENT -THANK YOU 3/1-3/31/97 RESIDENT PORTION 09/03/96 05/10/01 $5.00 $5.00 $0.08 $784.45 $806.45 $5.00 $806.45 $19.90 $804.35 MEDICAID PRIVATE ROOM 125 - A 04/30/2001 I ($5.00) ($5.00) ($220.00) ($784.53) ($564.45) ($784.45) ($5.00) ($806.45) ($5.00) $56.80 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR. GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 03/31/1997 BEGINNING BALANCE 03/31/97 TV CABLE 03/31/97 REVERSE INTEREST 2/28/97 04/1/97 TRANSFER MISAPPLIED PAYMENT 04/10/97 PAYMENT -THANK YOU 4l1-4/30/97 RESIDENT PORTION 05/12/97 PAYMENT -THANK YOU 05/31/97 TV CABLE 5/1-5/31/97 RESIDENT PORTION 06!10/97 PAYMENT -THANK YOU 06/10/97 PAYMENT -THANK YOU 06/30/97 TV CABLE 6/1-6/30/97 RESIDENT PORTION 07/30/97 PAYMENT -THANK YOU 07/30/97 PAYMENT -THANK YOU 07/31/97 TV CABLE 7/1-7/31/97 RESIDENT PORTION 08/13/97 PAYMENT -THANK YOU 06/30/97 MIS APPLIED PAYMENT 09!03/96 05/10/01 $56.80 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($19.90) ($100.00) ($811.45) ($701.53) ($4.92) {$806.53) ($4.92) ($806.53) ($601.45) ($210.00) ($773.03} MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) - 249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNER$, PA 17324 SOBOTOR, AMELIA 96129 09/03196 05/10/01 08/31/97 ADJ BEGINNING BALANCE 08/31/97 TV CABLE 08/31/97 RESIDENT PORTION D9/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09/16/97 PAYMENT -THANK YOU 09!30197 TV CABLE 9/1-9/30/97 RESIDENT PORTION 10/31/97 TV CABLE 10/1-10/31/97 RESIDENT PORTION 11/07/97 PAYMENT -THANK YOU 11 /07/97 PAYMENT -THANK YOU 11/30/97 TV CABLE 1 1 /1-1 113 0/9 7 RESIDENT PORTION 12/19/97 PAYMENT -THANK YOU 12/19/97 PAYMENT -THANK YOU 1 Z/19/97 PAYMENT -THANK YOU 12/31/97 TV CABLE 12/31/97 RESIDENT PORTION $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5.00 $804.35 $5,00 $804.35 MEDIGAID PRIVATE ROOM 125 - A 04/30/2001 ($773.03) ($4.92) ($806.45) ($0.08) ($5.00) ($806.45) ($4.92) ($811..53) ($806.45) $27.92 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARONERS, PA 17324 SOBOTOR, AMELIA 96129 09I03l96 05/10101 12/31/97 ADJ BEGINNING BALANCE 01/12/98 PAYMENT -THANK YOU 01/12/98 PAYMENT -THANK YOU 01/06/98 BEAUTY CHARGES 1/1-1/31/98 RESIDENTPORT{ON 01/31/1998 INTEREST 02!09/98 PAYMENT -THANK YOU 02/09/98 PAYMENT -THANK YOU 02/28!98 TV CABLE 2/1-2/28/98 RESIDENT PORTION 03/12/98 PAYMENT -THANK YOU 03/12/98 PAYMENT -THANK YOU 03/31!98 TV CABLE 3/1-3/31/98 RESIDENT PORTION 04/30/98 TV CABLE 4/1-4/3 019 8 RESIDENT PORTION 05/15/98 PAYMENT -THANK YOU 05!15/98 PAYMENT -THANK YOU 05/31/98 TV CABLE $27.92 $32.00 $914.50 0.08 $5.00 $914.50 $5.00 $914.50 $5.00 $914.50 $5.00 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($4.92) ($806.53) ($32.00) ($806.53) ($4.92) ($806.53) ($4.92) ($806.61} $465.04 MIKE SOBOTOR FOR AMELIA SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 5/3198 ADJ BEGINNING BALANCE 5/1-5/31/98 RESIDENT PORTION 05/31/1998 INTEREST 06/29/98 PAYMENT -THANK YOU 06/29/98 PAYMENT -THANK YOU 06/30/98 TV CABLE 6/1-6/30/98 RESIDENT PORTION 07/31 /98 TV CABLE 7/1-7/31/98 RESIDENT PORTION 07/31 /1998 INTEREST 08/17/98 PAYMENT -THANK YOU 08/17/98 PAYMENT -THANK YOU 08/17/98 PAYMENT -THANK YOU 08/31/98 TV CABLE 8/1-8/31/98 RESIDENT PORTION 08/31/1998 INTEREST 09/18/98 PAYMENT -THANK YOU 09/18/98 PAYMENT -THANK YOU 09/30/98 TV CABLE 9/1-9/30/98 RESIDENT PORTION 09/30!98 INTEREST 96129 09/03/96 05/10/01 $465.04 $914.50 $0.07 $5.00 $914.50 $5.00 $914.50 $12.25 $5.00 `$914.50 $9.60 $5.00 $914.50 $9.74 MEDICAID PRIVATE ROOM 125 - A 04/30/2001 I ($4.92) ($806.61) ($4.91 } ($811.45) ($183.64) ($640.06) ($171.47) $2,466.14 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA MEDICAID PRIVATE ROOM 125 - A 09/03!96 05!10/01 04/30/01 96129 09/30/98 ADJ BEGINNING BALANCE 10/27/98 PAYMENT - THAN K YOU 10/31!98 TV CABLE 10/29/98 BEAUTY CHARGES 10/1-10/31/98 RESIDENT PORTION 10/31!1998 INTEREST 11/30/98 TV CABLE 11/1-11/30/98 RESIDENT PORTION 11/30/1998 INTEREST 12/08/98 PAYMENT -THANK YOU 12/08/98 PAYMENT -THANK YOU 12/31/98 TV CABLE 12/1-12/31/98 RESIDENT PORTION 1 2/31 /1998 INTEREST 01/07/99 PAYMENT -THANK YOU 01 /07/99 PAYMENT -THANK YOU 01/31/99 TV CABLE 0110 1-01 731199 RESIDENT PORTION 01 /31 /99 INTEREST $2,466.14 $5.00 $32.00 $914.50 $12.89 $5.00 $914.50 $25.73 $5.00 $914.50 30.04 $5.00 $933.76 $29.16 ($611.53) ($38.05) ($511.95) ($309.24) ($590.76) $4,231.69 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBO70R, AMELIA 96129 09/03/96 05/10/01 01/31199 ADJ BEGINNING BALANCE 02/24/99 PAYMENT -THANK YOU 02/24/99 PAYMENT -THANK YOU 02/28/99 TV CABLE 02/01-02/28/99 RESIDENT PORTION 02!28!99 INTEREST 03!31 /99 PAYMENT -THANK YOU 03/31 /99 PAYMENT -THANK YOU 03/31/99 TV CABLE 03/01-03/31/99 RESIDENT PORTION 03/31 /99 INTEREST 04!30/99 TV CABLE 04!13/99 BEAUTY CHARGES 04/01-04/30/99 RESIDENT PORTION 04/30/99 INTEREST 05/31/99 TV CABLE OS/01-0 5/3 1 199 RESIDENT PORTION 05/31 /99 INTEREST $4,231.69 $5.00 $933.76 $27.56 $5.00 $933.76 $33.43 $5.00 $32.00 $933.76 $48.01 $5.00 $933.76 $63.29 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($265.58) ($554.42) ($282.76) ($547.24) $6,541.02 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/03/96 05/31/99 ADJ BEGINNING BALANCE 06/02/99 PAYMENT -THANK YOU 06/02/99 PAYMENT -THANK YOU 06/21 /99 PAYMENT -THANK YOU 06/30/99 TV CABLE 06/01-06/30!99 RESIDENT PORTION 07/31/99 TV CABLE 07/01-07/31/99 RESIDENT PORTION 08/09/99 PAYMENT -THANK YOU 08109/99 PAYMENT -THANK YOU 08/31/99 TV CABLE 08/01-08/31/99 RESIDENT PORTION 09/20/99 PAYMENT -THANK YOU 09/20/99 PAYMENT -THANK YOU 09/30/99 TV CABLE 09/30/99 BEAUTY CHARGES 09/01-09/30/99 RESIDENT PORTION 05/10/01 $6,541.02 $5.00 $933.76 $5.00 $933.76 $5.00 $933.76 $5.00 $32.00 $933.76 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($294.25) ($755.75) ($880.00) ($966.32) ($433.68) ($889.45) ($10.55) $6,098.06 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/03/96 09/30/99 ADJ BEGINNING BALANCE 10/31/99 TV CABLE 1 0101-1 013 1 /9 9 RESIDENT PORTION 11/30/99 TV CABLE 11/01-11/30/99 RESIDENT PORTION 12/31/99 TV CABLE 12/01-12/31/99 RESIDENT PORTION 01 /O6/00 PAYMENT -THANK YOU 01 /06/00 PAYMENT -THANK YOU 01/31/00 TV CABLE 0 1 /01-0113 1!00 RESIDENT PORTION 01/31/00 MCB PREMIUM 02/29/00 TV CABLE OZ/01-02/29/00 RESIDENT PORTION 02/29/00 MCB PREMIUM 03/03/00 PAYMENT -THANK YOU 03/31/00 TV CABLE 03/01-03/31/00 RESIDENT PORTION 05/10/01 $6,098.06 $5.00 $933.76 $5.00 $933.76 $5.00 $933.76 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($1,930.26) ($269.74) $5.00 $1,000.35 $5.00 $1,000.35 ($45.50) ($45.50) ($750.00) $5.00 $1,000.35 $8,889.39 -~ ,., . MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARpNERS, PA 17324 SOBOTOR, AMELIA 96129 09!03/96 03/31/00 ADJ BEGINNING BALANCE 03/31/00 MCB PREMIUM 04/17/00 PAYMENT -THANK YOU 04/30/00 TV CABLE 04!01-04/30/00 RESIDENT PORTION 04/30/00 MCB PREMIUM 04/30/00 BEAUTY CHARGES 05!31/00 TV CABLE 05!11 /00 BEAUTY CHARGES 05/25/00 BEAUTY CHARGES 05/01-05/31/00 RESIDENT PORTION 05!31/00 MCB PREMIUM 06/30/00 TV CABLE 06/01-06/30/00 RESIDENT PORTION 06/30/00 MCB PREMIUM 07/03!00 PAYMENT -THANK YOU 07/31 /00 TV CABLE 07/01-07131/00 RESIDENT PORTION 05(10!01 $8,889.39 $5.00 $1,000.35 $36.00 $5.00 $9.00 $9.00 $1,000.35 $5.00 $1,000.35 $5.00 $1,000.35 MEDICAID PRIVATE ROOM 125 - A 04l30I01 ($45.50) ($1,450.00) ($45.50) ($45.50) ($45.50) ($1,300.00) $10,032.79 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717) -249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/03/96 05/10/01 D7/31/00 ADJ BEGINNING BALANCE $10,032.79 07/31/2000 MCB PREMIUM 08/16/00 PAYMENT -THANK YOU 08/31 /DO TV CABLE $5.00 08/01-08!31/00 RESIDENT PORTION $1,000.35 08/31/00 MCB PREMIUM 09/30/00 TV CABLE $5.00 09/01-09/30/00 RESIDENT PORTION $1,000.35 09/30/00 MCB PREMIUM 10/18/00 PAYMENT -THANK YOU 10/31 /00 TV CABLE $5.00 11/30/00 TV CABLE $5.00 11 /17/00 BEAUTY CHARGES $36.00 11/01-11/30/00 RESIDENT PORTION $1,000.35 11/30/00 MCB PREMIUM 12/22/00 PAYMENT -THANK YOU 12/31!00 TV CABLE $5.00 12/06/00 BEAUTY CHARGES $9.00 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($45.50) ($1,000.00) ($45.50) ($45.50) ($1,200.00) ($45.50) ($1,000.00) $9,721.84 MANORCARE HELATH SERVICES 372 940 WALNUT BOTTOM RD CARLISLE, PA 17013 (717)-249-0085 MIKE SOBOTOR 19 HOLLY ESTATE DR GARDNERS, PA 17324 SOBOTOR, AMELIA 96129 09/03/96 12/31/00 ADJ BEGINNING BALANCE 12/20/2000 BEAUTYCHARGES 12/D1-12/31/00 RESIDENT PORTION 12/31/00 MCB PREMIUM 01/31/01 TV CABLE 01/01-01/31/01 RESIDENT PORTION 01/31/01 MCB PREMIUM 02/28/01 TV CABLE 02/01-02128/01 RESIDENT PORTION 02/28/01 MCB PREMIUM 03/19/01 PAYMENT -THANK YOU 03/31/01 TV CABLE 03/01-03/31!01 RESIDENT PORTION 03/31/01 MCB PREMIUM 05/31/01 TV CABLE 05/01-05/31/01 RESIDENT PORTION 05/31101 MCB PREMIUM 04/01/97 REVERSE TX MISAPPLIED PMT 06/01/97 REVERSE TX MISAPPLIED PMT Y ~ , r 05/10/01 $9,721.84 $9.00 1000.35 $5.00 $1,031.85 $5.00 $1,031.85 $5.00 $1,031.85 $5.00 1,031.85 $100.00 $210.00 MEDICAID PRIVATE ROOM 125 - A 04/30/01 ($45.50) ($50.00) ($50.00) ($1,000.00) ($50.00) ($50.00) $13,943.09 .., , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW ELIA B. SOBOTOR, Individually, and ,HAEL SOBOTOR, Individually, on Behalf of AMELIA B. SOBOTOR, Defendants CERTIFICATE OF SERVICE AND NOW, this 27'" day of September, 2001, 1, Daniel F. Wolfson, Esquire, do certify that I have served a copy of the foregoing Amended Complaint upon the of record by Regular Mail -Postage Pre-paid and addressed as follows: Douglas G. Miller, Esquire IRWIN, McKN-GHT 8t HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 17013-3222 (Counsel for Defendants) Gam` ~~ Daniel F. Wolfson, quire WOLFSON St ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717)846-1252 ID No. 20617 Attorney for Plaintiff ,. . -' - - Ct9 _ _.~ _I -~. i - :. J _` ~'il _ ~r ii K 6 O K. . --?rt.a54pYt~~leR3 ~'i+"fY-:tiY.!. _ ".-~'^ +'xi N" 'itlt .. .. ~_ ~. f ;~hi.Ak"~~ .. ~._.,~ <_ E ~*. ~ CASE N0: 2001-04092 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS SOBOTOR AMELIA B ET AL GERALD WORTHINGTON Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE SOBOTOR MICHAEL was served upon DEFENDANT the at 1905:00 HOURS, on the 3rd day of July 2001 at 19 HOLLY ESTATE DR GARDNERS, PA 17324 by handing to MICHAEL SOBOTOR a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 7.15 Affidavit .00 Surcharge 10.00 .00 23.15 Sworn and Subscribed to before menthi~s a~ day of l~~ oZotJJ -7, " A . D . ' Ae /(2./A~ 1.Q ~ othonotary 7 ~ So Answers: ~~~~~,~~ R. Thomas Kline 07/13/2001 WOLFSON & ASSOCIATES By . ~~ r./ .Deputy S iff SHERIFF'S RETURN - REGULAR `CASE NO: 2001-04092 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MANOR CARE VS SOBOTOR AMELIA B ET AL DOUGLAS DONSEN Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE AMELIA was served upon the DEFENDANT at 1040:00 HOURS, on the 12th day of July 2001 at 940 WALNUT BOTTOM RD SLE, PA 17013 by handing to AMELIA SOBOTOR a true and attested copy of COMPLAINT & NOTI together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 3.25 Affidavit .00 Surcharge 1G.00 .00 31.25 Sworn and Subscribed to before me th/i~s al3,rol day of ~,N.,/t,(//1cZbD ~ A . D . J16J/~~ ~A~/®AL~~ Pr t onb fi otary ~ So Answers: ~~~iett~ /~~ R. Thomas Kline 7 07/13/2001 WOLFSON & ASSOCIATES By . W~ ~-!/ - Deputy Sheriff HCR MANOR CARE, Plaintiff v. AMELIA B. SOBOTER, Individually, MICHAEL SOBOTER, Individually, and on Behalf of AMELIA B. SOBOTER, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 01-4092 CIVIL TERM CIVIL ACTION -LAW PRAECIPE TO ENTER APPEARANCE To .Curtis R. Long, Prothonotary: Please enter my appearance on behalf of the defendants, Amelia B. Soboter, Individually, Michael Soboter, Individually, and on behalf of Amerlia B. Soboter, in the above captioned case. Respectfully submitted, IRWIN, McKNIGHT & HUGHES By: Douglas Miller, Esquire 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717)249-2353 Supreme Ct. #83776 Attorney for defendants Date August 2, 2001 HCR MANOR CARE, Plaintiff v. AMELIA B. SOBOTER, Individually, MICHAEL SOBOTER, Individually, and on Behalf of AMELIA B. SOBOTER, Defendants NO.O1-4092 CIVIL TERM CIVIL ACTION -LAW CERTIFICATE OF SERVICE I, Douglas G. Miller, Esquire, hereby certify that a copy of attached Praecipe to Enter Appearance was served upon the following by depositing a true and correct copy of the same in the United States mail, First Class, postage prepaid in Carlisle, Pennsylvania, on the date referenced below and addressed as follows: Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P.C. 267 East Market Street York, PA 17403 IItWIN, McI{NIGHT & HUGHES By: Douglas G Miller, ~ sq. ' 60 West Pomfret Street Carlisle, PA 17013 (717)249-2353 Supreme Court I.D. No. 83776 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Date: August 2, 2001 ~ ` ~ l ~ m ~ °t - s ri ~:c~ .-5 i ,3 - z ~- ~ ` ' ; mss'- -c.- rv _ ~~ ,; _ c c; ~ `_, =, ~ ~z ~ .: ~~ e? ~Y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant NO. 01-4092 Civil Term CIVIL ACTION -LAW PRAECIPE F®R JUI)GMEN~ Enter Judgment in favor of Plaintiff and against Defendant, Michael Sobotor, for want of ANSWER TO 2"d AMENDED COMPLAINT. (X) Amount due $10,032.79 Attorney's Commission $ 3,009.84 TOTAL $13,042.63, plus interest and court costs (X) I certify that the foregoing assessment of damages is for specified amounts alleged to be due in the complaint and is calculable as a sum certain from the complaint. (X) Pursuant to Pa.R.C.P. 237 (Notice of Praecipe for final judgment or decree), I certify that a copy of this praecipe has been mailed to each other party who has appeared in the action or to his/her Attorney of Record. (X) Pursuant to Pa.R.C.P. 237.1, I certify that written notice of the intention to file this praecipe was mailed or delivered to the party against whom judgment is to be entered and to his/her Attorney of Record, if any, after the default occurred and at least ten days prior to the date of the filing of this praecipe and a copy of the notice is~ttached. DATE: Signature: Amy Wolfson, Esquire ID#: 062 Attorney for Plaintiff 267 East Market Street York, PA 17403 (717)846-1252 NOW, ~ , 20~_, JUDGMENT IS ENTERED AS ABOVE. Prothonotary/Clerk, Civil ' ~ sion ~~~~~~~~ Deputy PARALEGALS Margaret L. Burg Michele M. McHugh ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic Caprice Hicks Bunting James K. Reed* Gordon A. Lynn;^ 'Licensetl in Pennsylvania & Maryland ^ licensed in Maryland Only 4 December 2002 MICHAEL SOBOTOR - 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 (717) 846-1252 (800) 321-8467 FAX (717) 848-1146 e-mail dfwolfson @debtcollection.net a~E: jCR Manor Care vs ,~licnael Sobotor Docket No. O l -4092 Dear Mr. Sobotor: BRANCH OFFICE: 8 Manchester Street Glen Rock, PA 17327 (717) 235-5014 PLEASE FOR WARD ALL CORRESPONDENCE TO THE YORK OFFICE We enclose a 10-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civil procedure. Sincerely, WOL6SON 8t ASSOCIATES, P.C. ~:.~ ~! X11 Amy F. Wolfson, Es ire AFW\Iwe Enclosure WOLFSON & ASSOCIATES, P.C. Attorneys at Law 267 East Market Street York, Pennsylvania 17403 cc: HCR Manor Care -Carlisle (w/enc.) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant TO: MICHAEL SOBOTOR 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 DATE OF NOTICE: December 4, 2002 IMPORTANT NOTICE "~~u .-~~E IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (l0) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Court House 1 Court House Square, 4`" Floor Carlisle, Pennrylvania 1 7013 ' (717) 240-6200 BY: Amy F. Wol 'n, Esquir WOLFSON st ASSOCIATES, P.C. 2b7 East Market Street York, Pennsylvania 17403-2000 Telephone: (717) 846-1252 I.D. # 87062 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant AFFIDAVIT OF NON-MILITARY SERVICE COMMONWEALTH OF PENNSYLVANIA COUNTY OF YORK I, Amy F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am thc: Attorney for the Plaintiff in the above-captioned matter, and that to the best of my knowledge, information and belief Defendant, Michael Sobotor, above named, is over 21 years of age; is last know to reside at 19 Holly Estate Drive, Gardners, Adams County, Pennsylvania; 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 Amendments. Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 SWORN and SUBSCRIBED to befo//r~~e me this ~~ `~ day of Y~H~, 20 2~ N Notarial seal 3 Sweeney, Notary PuWio f York, York County Attorney ID# 87062 9~ ~~ T' ` W ~ '~ a ~ Ci G' t~; C w'' ci b -O ice' :' 7 .._ .':: J ': r c cs C `, ~r-- ,. ~ c,. 1 - a .si -` IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant NO. 01-4092 Civil Term CIVIL ACTION -LAW (x) Notice is hereby given that a DEFAULT JUDGMENT in the above-captioned matter has been entered against you in the/amount of $10,032.79, plus interest, reasonable attorney's fees and costs, on /~~~ ~ ~ _ ~ , 20~_. (x) A copy of all documents filed with the Prothonotary in support of the within judgment is/are enclosed. ~~ Prothonotary Civil Division If you have any questions regarding this Notice, please contact the filing party. Amy F. Wolfson, Esquire, Esquire 267 East Market Street York, PA 17403 (717) 846-1252 (This Notice is given in accordance with Pa.R.C.P. 236.) NOTICE SENT TO: MICHAEL SOBOTOR 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant AFFIDAVIT OF SERVICE Commonwealth of Pennsylvania County of York ss. AND NOW, TO WIT, this 3rd day of April, 2003, comes Amy F. Wolfson, Esquire, who being duly sworn according to law, deposes and says that she is the Attorney f~~ P~lai„ntiff in`t~he above-captioned action; that on September 16, 2003, she caused a true copy of th2~Complaint in the above-captioned action to be sent by regular mail, postage pre-paid, to the counsel of record ,Douglas G. Miller, Esquire, at IRWIN, McKNIGHT 8i HUGHES, West Pomfret Professional Building, 60 West Pomfret Street Carlisle, PA 17013-3222. SWORN and SUBSCRIBED to before me this .~l-G~day of {~prc,Q.- ao0.3 ~~~ ~a~ Melissa oee sweeney, ~~, Y+,bee+zz006 MemAer, aenr~sv ~50E'~0" pf.Nbares Amy F. olfson, Esquire I.D. N .87062 Attorney for Plaintiff i ~"'} ~ I C. :_J . r ~ fiiit" .~ s..t li ~; ~ ~ ~ r° -~- ' _ .. .. -f - ...5 .. M1M1 V ~' G b 4 G- r"' r HCR MANOR CARE, PLAINTIFF/RESPONDENT V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MICHAEL SOBOTOR, Individually and on behalf of AMELIA B. SOBOTOR, Deceased, DEFENDANTS/PETITIONERS 01-4092 CIVIL TERM ORDER OF COURT AND NOW, this 24th day of April, 2003, upon consideration of the foregoing petition, IT IS ORDERED: (1) A Rule is issued against respondent, HCR Manor Care, to show cause why the petition to strike off/open judgment should not be granted. (2) Respondent shall file an ahswer to the petition within fifteen (15) days of service. (3) The petition shall be decided under Pa. Rule of Civil Procedure 206.7. (4) Any depositions shall be completed within thirty-five (35) days of service. (5) Briefs shall be filed in chambers and argument shall be held on Monday, June 23, 2003, at 8:45 a.m., in Courtroom No. II of the Cumberland County Courthouse. (6) Notice of the entry of this order shall be provided to all parties by petitioner. (7) All proceedings shall stay pending further order of By ^~ ~ `~ ,~~` ~~ Edgar B. ~v ~~~ .6~ ~,a~ 0 ~;w .n '';s{ rG` ici~ r~ • ~.+ '- ~t3 I~~~ ~;Jlt.rC~.. Amy F. Wolfson, Esquire For Plaintiff/Respondent Douglas G. Miller, Esquire For Defendants/Petitioners :sal -2- HCR MANOR CARE, IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. DEFENDANTS' PETITION TO STRIKE OFF /OPEN DEFAULT JUDGMENT AND NOW this 21sT day of April, 2003, comes Defendants, MICHAEL SOBOTOR, Individually and on Behalf of AMELIA B. SOBOTOR, Deceased, by and through their attorneys, Irwin, McKnight & Hughes, and respectfully petition this Court to strike off or open the default judgment entered against Defendants on or about April 8, 2003, and in support thereof aver as follows: 1. Plaintiff commenced this action against Defendants on or about July 2, 2001 by Complaint that in summary alleges failure to pay for expenses by Plaintiff made on behalf of Amelia Sobotor prior to her decease. 2. On or about September 4, 2001, Defendants, by and through the undersigned counsel, timely filed Preliminary Objections to the original Complaint raising several defenses, including lack of capacity to sue. 3. On or about September 27, 2001, Plaintiff filed an Amended Complaint in response to the Preliminary Objections of Defendants. 4. Subsequently, several telephone conversations and correspondence took place between legal counsel for the respective parties, regarding among other issues, the lack of factual support in Plaintiffs complaints for a judgment against Mr. Sobotor individually. 5. Rather than file additional Preliminary Objections to the Amended Complaint, legal counsel for the parties agreed to extend the time in which to file a response. 6. Ultimately, Plaintiff filed a Second Amended Complaint on or about September 16, 2002, attaching additional documents purportedly in support of its allegations, as well as a Petition to Amend Caption to reflect the decease of Amelia Sobotor. 7. Additional telephone conversations and correspondence continued to take place between legal counsel for the respective parties in order to review and discuss the additional documents attached by Plaintiff to its Second Amended Complaint. 8. Additional extensions of time were granted by Plaintiff's legal counsel for these purposes. 9. On or about November 5, 2002, Plaintiff sent a ten (10) day notice to legal counsel for Defendants addressed "MICHAEL SOBOTOR; c/o Douglas G. Miller, Esquire." A true and correct copy of said notice is attached hereto and incorporated herein as Exhibit "A." 10. However, said notice attached as Exhibit "A" was not sent to the Defendants individually in accordance with Pa. R. Civ. P. No. 237.1(a)(2)(ii). 11. Apparently, on or about December 4, 2002, Plaintiff sent a subsequent ten (10) day notice only to Defendants individually. A copy of said notice as attached to Plaintiff's Praecipe for Judgment is attached hereto and incorporated herein as Exhibit "B." 12. Plaintiff did not send the notice attached as Exhibit "B" to Defendants' legal counsel of record in accordance with Pa. R. Civ. P. No. 237.1(a)(2)(ii). 13. Between December 16, 2002 and January 16, 2003, several correspondence was exchanged between legal counsel for the parties. These letters are collectively attached hereto and incorporated herein as Exhibit "C." 14. The understanding of Defendants and their legal counsel was that an initial extension to December 20, 2002, was by the subsequent correspondence and telephone conversations extended indefinitely to obtain additional documentation. 15. Plaintiff s letters attached as Exhibit "C" fail to specify the time within which the required action must be taken, and fail to sufficiently communicate the intention to take a default judgment upon the failure to plead. 16. Based on the above, it clearly appears from the record that Plaintiffs Praecipe for Judgment was not entered in conformity with the requirements of Pa. R. Civ. P. No. 237.1. 17. Accordingly, the default judgment against Defendants was entered improperly and must be stricken from the record. 18. The failure of Defendants to otherwise take additional steps to protect their interests was due to the failure of Plaintiff to properly communicate its intention to take a default judgment upon the failure to plead. 19. As the Cumberland County Courthouse was closed on Friday, April 18, 2003, this Petition is being filed within ten (10) days of the entry of default judgment on Aprfl 8, 2003. 20. Defendant possesses a meritorious defense to Plaintiffls Second Amended Complaint and the default judgment should therefore be opened. WHEREFORE, Defendants, MICHAEL SOBOTOR, Individually and on Behalf of AMELIA B. SOBOTOR, Deceased, respectfully request that this Honorable Court strike off and/or open the default judgment entered of record in the above captioned matter and allow Defendants to pursue their defense of this action, and that any and all execution proceedings upon the contested judgment be stayed pending resolution of the Petition to Strike Off /Open Judgment pending such determination. Respectfully Submitted, IRWIN, McKNIGHT & HUGHES By: Dou as er, ~ squire Supreme ourt ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717)249-2353 Dated: Apri121, 2003 Attorney for Defendants EXHIBIT "A" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant TO: MICHAEL SOBOTOR c%o Douglas G. Miller, Esquire IRWIN, McKNIGHT 8t HUGHES Wpst Pomfret Professional Building 60 West Pomfret Street Carlisle PA l 7013-3222 DATE OF NOTICE: November S, 2002 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Court House 1 Courr House Square, 4`h Floor Carlisle, Pennsylvania 17013 (717) 240-6200 BY: Amy WggI son, Esquire WOLFSOT~l 8i ASSOCI ES, P.C. 267 East Market Street York, Pennsylvania 17403-2000 Telephone: (717) 846-1252 I.D. # 87062 Attorney for Plaintiff EXHIBIT "B" WOLFSON & ASSOCIATES, P.C. ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic Caprice Hicks Bunting James K. ReedT Gordon A. Lynn ^` Attorneys at Law 4 PARALEGALS Nlazgare[ L. Burg Nlicheie NI. McHugh •Licensetl in PennrylvaNa & 4laryland ^ Itcensed in 3laryiantl Only 4 December 2002 MICHAEL SOBOTOR - 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 BRANCH OFFICE: 267 East Market Street 8 Manchester Street York, Pennsylvania 17403 Glen Rock, PA 17327 (717) 235-5014 (717) 846-1252 (800) 321-8467 PLEASE FORWARD ALL FAX (717) 848-1146 CORRESPONDENCE TO THE YORK OFFICE e-mail: dfwolfson ~debtcollection.ne[ ~: =-ii: i'~f:r,,r Care vs ;~licnael Sobotor Docket No. O 1-4092 Dear Mr. Sobotor: We enclose a ] 0-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civi! Procedure. Sincerely, WOLfaSON 8t ASSOCIATES, P.C. Amy F. Wolfson, Es~re AFW\lwe Enclosure cc: HCR Manor Care -Carlisle (w/enc.j 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-4092 Civil Term Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant TO: MICHAEL SOBOTOR 14 HOLLY ESTATE DRIVE GARDNERS, PA 17324 DATE OF NOTICE: December 4, 2002 IMPORTANT NOTICE ~. ,~~: IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF YOU IN THlS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, 'GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Court House 1 Court House Square, 4`" Floor G~iisle, Pennsylvania 1701: (717) 240-6200 BY: Amy F. Wol bn, Esquir WOLFSON 8i ASSOCIATES, P.C. 267 East Market Street York, Pennsylvania 17403-2000 Telephone: (717} 846-1252 LD. # 87062 Attorney for Plaintiff EXHIBIT "C" ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic James K. Reed* Gordon A. Lynn PARALEGALS Margaret L. Burg "vtichele M. McHugh Melissa D. Sweeney 'Licensed in Pennrylvania & Marylantl ^ licensed in Maryland Onty 16 January 2003 267 East Market Street York, Pennsylvania 17403 (717) 846-1252 (800) 321-8467 FAX (717) 848-1146 e-mail: dfwolfson@debtcollection.ne[ Douglas G. Miller, Esquire IRW1N, McKNIGHT SL HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 170.13-3222 RE: HCR Manor Care vs. Amelia and Michael Sobotor Cumberland County Docket No. 01-4092 Civil Term Dear Attorney Miller: 8 Manchester Street Glen Rock, PA 17327 (717) 235-5014 PLEASE FORWARD ALL CORRESPONDENCE TO THE YORK OFFICE ® ~ JA-N 17 P40~ IRWIN, McKNI~NT ~I~GN~S Upon receipt of this correspondence, kindly contact my office to advise whether or not you have received copies of the checks you requested from your client. We look forward to hearing from you in the near future. Sincerely; WOLFSON 8t ASSOCIATES, P.C. AFWOLfSON Amy F. Wolfson, Esquire AFW/Iwe WOLFSON & ASSOCIATES, P.C. Attorneys at Law pc: HCR Manor Care -Carlisle WOLFSON & ASSCICIATES, P.C. ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic Caprice Hicks Buntlng .lames K. Reed* Gordon A. Lynn PARALEGALS Margaret L. Burg Michele M. McHugh °Lici gsed in Pennryroania g Aaryland ^ licensed in Maryland Only 26 December 2002 Attorneys at Law BRANCH OFFICE: 267 East Market Street Yorlc, Pennsylvania 17403 (717) 846-1252 (800) 321-8467 FAX (717) 848-1146 e-mail: dfwolfsonCdeb[collection.net Douglas G. Miller, Esquire IRWIN, McKNIGHT st HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle; PA 1 70 1 3-3222 RE: HCR Manor Care vs. Amelia and Michael Sobotor Cumberland County Docket No. 01-4092 Civil Term Dear Attorney Miller: S Manchester Street Glen Rock, PA 17327 (717)235-5019 PLEASE FORWARD ALL CORRESPONDENCE TO THE YORK OFFICE i~ 1~~1 l DES 3l ~~~2 I have had an opportunity to discuss the invoice which was printed in error and forwarded to your client, pursuant to the above referenced matter. Kindly note that the credit balance which is reFlected on the billing is the result of adjustments for therapies which were done incorrectly. In the event that there is a credit balance after the adjustments are completed, and are confirmed to be correct, that credit balance would be credited towards the outstanding balance which we believe your client owes to HCR Manor Care. However, my client has indicated to me that they do not believe that there will be a credit balance pursuant to this account. In the event that you have any questions, or if you would like to discuss this matter in greater detail, please do not hesitate to contact the undersigned. Sincerely, WOLFSON St ASSOCIATES, P.C. AFv~ Amy F. Wolfson, Esquire AFW/Iwe .v.p„, ,~,1, ,..m __-___ ___-_- LAW OFFICES IRWIIV~ McK1VI BHT £~ HUGHES ROGER R. 1RWlN MARCUS A. McKVlGHT, !!I JAMES D. HUGHES REBECCA ft. HUGHES pOUGLAS G. MILLER WEST POMFRET PROFESSIONAL 8UlLDlNG 60 WEST POMFRET STREET CARL/SCE, PENNSYLVANIA 17013-3222 HAROLD S. lRWLV (/925-1977) HAROLD S !RW/N. JR. (1954-19NhJ IRWlN. lRWIN & fRW/N (1956-19N6) lRWIN, lRw7N & McKVIGH7 (19Nh-/994) fRWfN, McKNIGHT &HUGHES (1994- ) 1717/ 249-2353 FAX (717/ 249-6354 E-MA/L: IMHLAW@SUPERNE7. COM December 16, 2002 VIA FACSIMILE (717) 848-1146 and U.S. MAIL AMY F. WOLFSON, ESQUIRE WOLFSON & ASSOCIATES, P.C. 267 EAST MARKET STREET YORK, PA 17403 RE: HCR MANOR CARE v. SOBOTOR et al. No. 2001- 4092, Civil Term, Cumberland County Dear Attorney Wolfson: I had scheduled Friday; December 13, 2002, to follow up with you concerning the above- referenced matter. ,Unfortunately Mr. Sobotor had only received copies of the bank account information on December 6`h, and I did not receive them from him until the middle of.last week. Because of the bad weather and a recent illness, I have also not yet beeri able to review the information. Accordingly, I propose to contact you. on Friday, December 20, 2002, to discuss this matter once I have had the opportunity to review the account information. Please contact me immediately if this is not acceptable and I will file the appropriate response to your client's amended complaint. In addition, I am enclosing a copy of recent correspondence from HCR Manor Care to Mr. Sobotor. According to the envelope it was postmarked December 5, 2002. It is in part because of this type of correspondence that my client has concerns regarding the accuracy of the billing system. In the event that I do not hear from you earlier, I will assume that you are in agreement to delay this matter until Friday, December 20, 2002, as indicated above. Very truly yours, IRWIN, McKNIG~HT &HUGHES / V /~~ Dougl G. Miller DGM:tds Enclosure cc: Michael P. Sobotor VERIFICATION The foregoing Petition on behalf of the Defendants is based upon information which has been gathered by counsel for the Defendants in the preparation of this document. The statements made in this document are true and correct to the best of the counsel's knowledge, information and belief. The Defendants' verification cannot be obtained within the time allowed for filing the pleading. The undersigned is therefore verifying on behalf of the Defendants according to 42 Pa.C.S.A. § 1024(c)(2). The undersigned understands that false statements herein made are subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. ougl s G. er, Esquire Date: Apri121, 2003 CERTIFICATE OF SERVICE I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy of the foregoing document upon the persons indicated below by first class United States mail, postage paid in Carlisle, Pennsylvania 17013, on the date set forth below: Amy F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Attorney for Plaintiff Date: April 21, 2003 IRWIN, McKNIGHT & HUGHES ~ I vvVV '• Douglas G. er, Es ' •e Supreme Court ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 (717)249-2353 Attorney for Defendants 'l C7 i ri i ~i:- "il ~ .• J _J <%; -. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, Plaintiff N0.2001-4092 CIVIL TERM vs. CIVIL ACTION -LAW HAEL 5080TOR Individually and c~ ,~ o -~' , , Behalf of Amelia B. Sobotor, Deceased, 7i ;>; ~ i Defendant ~~' r t ,.,~, r--: -.- `' G1 ~ C7 t r,_j PRAECIPE TO VAC ATE JuD MEND w -~` - ;~ . -. TO THE PROTHONOTARY OF SAID COURT: Please vacate the above captioned judgment entered on April $, 2003. Respectfully submitted, WOLFSON ~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 [D No. 87062 Attorney for Plaintiff i M,..,~~.a. c_' o -x : ~ n ~~ ~ ' e . E.:::~:. ; ~I D~ ~c ° ,: c~ ( ~~ C7 d ~ ~~- > CJ :'f7; _• ~ 7V ~~ ~ s (y'' V ~ O ~ '~ Cn 4 J IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, Plaintiff NO. 2001-4092 CIVIL TERM vs. ~HAEL SOBOTOR, Individually, and Behalf of Amelia B. Sobotor, Deceased, Defendant THE PROTHONOTARY OF SAID COURT: 4) r*> ?- o ~ s ~~~~ ~ ,j _i -y ~: m T+- `- , r _ V o r-r ~, ~ ~ ~ -~, ~ ~'r, ~,- o c,, _ ~; n ; -~ ~, ~ :~ , Please vacate the above captioned judgment entered on April 8, 2003. Respectfully submitted, WOLFSON 8t ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff CIVIL ACTION -LAW ('J na r:. a, ° ~ °a, - _ „v 1 ~ ~~ == . . , ~ fir,`;:, s :~ , G ~-,:_ Cz;; ij ~ o V 4 (v I V \ V '~~' ° ~~ ~ ` `/ V~ ~~~ MAR 0 2 2004 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 2001-4092 CIVIL TERM Plaintiff, vs. CIVIL ACTION - IN LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant PRE-ARBITRATION MEMORANDUM AND NOW, TO WIT, this 27`h day of February, 2004, comes the Plaintiff, HCR Manor Care, by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of Wolpoff 8i Abramson, L.L.P., and files the following Pre-Arbitration Memorandum of which the following is a statement: A. SUMMARY OF FACTS: Defendant represented himself to be the Legal Representative and/or Responsible Party for Amelia B. Sobotor, Deceased (hereinafter referred to as "Decedent"). Defendant is the son of Defendant. From on or about August 9, 1996, through July 2000, Decedent was a healthcare resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. On or about July 31, 1996, Defendant inquired to Plaintiff's healthcare facility for the purpose of admitting Decedent as a resident. Defendant warranted and represented that the information he provided regarding Decedent in the Application for Residency was complete and accurate and that Plaintiff could rely on the information in admitting Decedent. Defendant warranted and represented that Decedent received monthly social security and pension benefits in the amount of Nine Hundred Twelve and 50/100 ($912.50) Dollars. On or about August 9, 1996, Defendant executed an Admission Agreement, as Legal Representative and/or Responsible Party for Decedent, which Agreement outlined various terms of residential healthcare services to be provided by Plaintiff and the Responsible Party therefor. That by executing said Admission Agreement, Defendant did acknowledge that Plaintiff would be relying on the "Conditions", which are incorporated into the Admission Agreement in admitting Decedent, and that if Defendant did not follow through with said Conditions, Plaintiff will have detrimentally relied upon said Conditions and Plaintiff would suffer financial harm and loss. As of the date of the within Pre-Arbitration Memorandum, the balance due, owing and unpaid on Decedent's account as a result of said charges is the sum of Ten Thousand Thirty-Two and 79/100 ($10,032.79) Dollars. Despite Plaintiff's reasonable and repeated demands for payment, Defendant has failed, refused, and has continued to refuse to pay all sums due and owing on Decedent's account balance, all to the damage and detriment of the Plaintiff. Plaintiff has made numerous requesu to Defendant, as Legal Representative and/or Responsible Party for Decedent, demanding that the sums due and owing to Plaintiff be paid, and Defendant, as the Legal Representative and/or Responsible Party for Decedent, has ignored his contractual and fiduciary obligations to pay necessary and appropriate bills and obligations for her Decedent. By executing the aforementioned Admission Agreement, Defendant agreed to remit payment to Plaintiff from the assets of Decedent, for services provided by Plaintiff, and to have payment of any available government or third party payor benefiu due and owing to Decedent assigned to Plaintiff. That Defendant violated his contractual and fiduciary duties and responsibilities as the Legal Representative and/or Responsible Party for Decedent by not utilizing Decedent's finances to pay Plaintiff when he knew or should have known there were ouutanding nursing home care charges for Decedent. The finances of Decedent should have been utilized to pay Plaintiff for her necessary and appropriate nursing home care services and treatment, but Decedent failed to utilize Decedent's finances for that intended purpose, in violation of DPW regulations. As of the date of the within Pre-Trial Conference Memorandum, the total charges by Plaintiff for services rendered to Decedent from August 9, 1996, through July 2000, remain unpaid. The principal value of said services is the sum of Ten Thousand Thirty-Two and 79/100 ($10,032.79) Dollars, and the attorney's fees that have amassed in this matter is the sum of Three Thousand Nine and 84/100 ($3,009.84) Dollars. 2 B. ADMISSIONS FROM THE PLEADINGS TO BE MADE PART OF THE RECORD: 1. Plaintiff, HCR Manor Care, is a healthcare provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carliile, Cumberlnad County, Pennsylvania 17013. 2. Defendant, Michael Sobotor, is an adult individual with a last known address of 19 Holly Estate Drive, Gardners, Adams County, Pennsylvania 17324. 3. Defendant inquired to Plaintiff's healthcare facility for the purpose of admitting Decedent as a resident on or about July 31, 1996. 4. That on or about August 9, 1996, Decedent was admitted as a healthcare resident of Plaintiff. 5. That Decedent was a healthcare resident of Plaintiff and that Decedent received various necessary residential healthcare services and healthcare treatment by Plaintiff. b. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. C, WITNESSES TO BE CALLED: 1. Kim Etzler, Business Office Manager HCR Manor Care -Carlisle 940 Walnut Bottom Road Carlisle, PA 17013 2. Any witnesses Defendants may call (as on cross-examination) D, EXHIBITS: 1. A true and correct copy of the Application of Residency. 2. A true and correct copy of the itemized bill pertaining to the charges and payments associated with the nursing home care services rendered to Decedent. 3 3. A true and correct copy of the Admission Agreement, which was executed by Defendant on or about August 9, 1996. E. STATEMENT OF LEGAL ISSUES INVOLVED AND LEGAL AUTHORITIES RELIED UPON OR EVIDENTIARY PROBLEMS TO BE ADDRESSED PRIOR TO TRIAL: 1. Breach of Contract 2. Detrimental Reliance 3. Damages BEST OFFER OF SETTLEMENT AUTHORIZED BY CLIENT: $10,000.00 G. ESTIMATED ARBITRATION TIME: Two (2) hours. 4 H. DAMAGES ManorCare Charges: Services rendered to Amelia B. Sobotor (8/9/96-7/00) $10,032.79 SUBTOTAL $10,032.79 Litigation Costs: Attorney's Fees $3,009.84 Costs + 143.90 SUBTOTAL $ 3,15 3.74 TOTAL $13,186.53 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 87062 Attorney for Plaintiff -"`1R Respectfully submitted, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 2001-4092 CIVIL TERM Plaintiff vs. CIVIL ACTION -LAW MICHAEL SOBOTOR, Individually, and on Behalf of Amelia B. Sobotor, Deceased, Defendant CERTIFICATE OF SERVICE AND NOW, this 27th day of February, 2004, I, Amy F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Pre-Arbitration Memorandum upon the counsel of record for the Defendant by First Class Mail -Postage Pre-paid, and addressed as follows: Douglas G. Miller, Esquire IRWIN, McKNIGHT 8t HUGHES West Pomfret Professional Building 60 West Pomfret Street Carlisle, PA 17013-3222 b J ~ "V Amy F. fson, Esquire WOLPO 8t ABRAMSON, 267 East Market Street York, PA 17403 (717)846-1252 ID No. 87062 Attorney for Plaintiff ;:~~. MAIN OFFICE rWOIRVINGTON CENTRE 702XING FRRM St VD. ROLXVILLE, MD 20H50 BRANCH OFFICES I VO05 !UDICIAL DR,BLOG. A-6. FAIRFAX, VA 22030 n~iN E MAIN ST., BTD IDn3. RICHMOND. VA 23216 it 22 GREE'JbVICH RD. VIRGMIA BEACH, VA 23162 t19N MARK ET ST, STE 1300. WILMINGTON, DE 19399 195J GREENSPRMG OR,. STE, 164 TIMONIUM, M021995 I VALLEY BANK BLDG. BOX tt26. CLARKSBURG,'NV "e6302 !6T [. MARKET ST„ YORK, PA 1"!403 NATIONAL COLLECTION ATTORNEY NETWORK 4FFILIATEO FIRM LOCATIONS INOT BRANCH OFFICES OF WOLPOFF & ABRAMSON. L-L.P.1' 31RM111NGHAM, ALABAh1A EDGPNOOD,COLORADO ANCHORAGE ALASHA FT. LAUDERDALE. FLORIDA cHOENI%. ARIZONA NORCROSS, GEORGIA ]f.BOi. ARKANSAS HONOLULU. HAVfAII TAN pIEGO, CALIFORNIA BOISE, IDAHO LAW OFFICES NATIONAL COLLEC WOLPOFF & AB RAMSON L L P AFFILIATED FIRM LI . - , . OFFICES OF WOLP( A(tomeys in (he Practice o/ Debt Collecfiort MERRILLVILLE. INDIAN, (A National Collection Attorney Network Firm) CHICAGO, ILLINOIS KANSAS CITY, KANSAS 267E MARKET STR'cET LEXINGTON. KENTUCK' YORK, PA 17403 METAIRIE, LOUISIANA (TOLL FREE) 1-600-758-0675 FACSIMILE (717)848-1146 PLEASE DIRECT ALL INQUIRIES i0 YORK CFFICE February 27, 2004 Cumberland County Pruthonotary's Office Cumber!;ut<i County Counhuuse One Courthouse Square Carlisle, PA 17013 RG: 1-ICR Manor C'arc ~s. Sobutur Docket No. 2001-4092 Cicil Tenn Ue;u- Clerl:: OKLAHOfdA JOE ISLAND i CAROLINA MINNEAPOLIS, MINNESOTA SANDY, UTAH ST. LOUIS, MISSOURI MILWAUKEE. WISCONSIN GREAT FALLS. MONTANA RAWLINS. WYOMING OMAHA, NEBRASKA LAS VEGAS, NEVADA -T~e National Collection M11ANCHESTER, NEW HAMPSHIRE Attorney Network is an a!(ilianon CEDAR KNOLLS, NE'N JERSEY of sevarate law firms. 5YOSSET, NEW YORK bvBA HO'J5 of Operal~pn, RALEIGH, NORTH CAROLINA Sa.m-I1pm.E5T A4F FARGO, NORTH DAKOTA Please find enclosed an original and one (I) copy of Plaintiff's Pre-Arbitration'MemormtdLmt pursuant to the ahoco-referenced matter. I:indly take the appropriate steps to file the original and return the time- stamped copy to our office in the enclosed self-addressed stamped envelope. Should you hate any yucstiuns or need additional inlorntation, please du not hesitate to contact the un<IersitneL1. Sincerely. ~~'olpol-f Abramson- L.L.P. Amy F. ~~'olfson, Esyuirc Ar~V: PCB'/ts Enclosures cc: Dou~_las G. Millrr, (?;yuire (~c%cnclusurc) HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA ~. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW A ~ 2DD4 on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. ORDER AND NOW, this ~ day of I YU~UTA./~~ 2004, upon presentation and consideration of the attached stipulation and agreement of the parties, it is hereby ordered and decreed that the attached Stipulation is made an Order of Court. BY E COU , r, G~~ 7. ma_c.ea1 ~~~ _Q ~~'t~1t~~~1,~tS~~"d~F~ !u`IS~~~ ~ f ~!, ~f~ £- PB~~ h~~l i HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. PETITION TO CONFIRM STH'ULATION AND NOW COME Defendants, by and through their attorneys, Irwin & McKnight, and in support of the Petition to Confirm Stipulation Defendants aver as follows: 1. The Default Judgment entered on or about April 8, 2003, shall be opened and removed without prejudice to the Defendants in the above-captioned matter. 2. The parties hereby waive any hearing with regard to the Petition to Strike Off / Open the Default Judgment filed by Defendants, so that the litigation may proceed in due course. 3. The Prothonotary is requested to amend the docket in accordance with this Stipulation. Respectfully Submitted, IRWIN, McI{NIGHT & HUGHES By: Douglas Miller, Esquire Supreme Court ID # 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013 (717) 249-2353 Dated: March 3, 2004 Attorney for Defendants HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS OF Plaintiff, :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2001- 4092 CIVIL TERM MICHAEL SOBOTOR, Individually, and: CIVIL ACTION -LAW on Behalf of AMELIA B. SOBOTOR, Deceased, Defendants. STIPULATION TO OPEN JUDGMENT TO THE PROTHONOTARY: THIS STIPULATION, made and entered into as of this day of !~ 2004, by and between counsel for respective parties in the above- captioned matter. WHEREAS, on or about April 8, 2003 a Default Judgment was entered by the Plaintiff in the above-referenced matter; and WHEREAS, on or about April 21, 2003, Defendants filed a Petition to Strike Off /Open the Default Judgment; and WHEREAS, prior to a hearing on Defendants' Petition the parties through their ."cSpi;CtCve legal eQU^sel agreed t^v cper: and remo:'e 4yha Tlrfa.,~,lt T„dgment In eXehange fnr Defendants filing an Answer to the Plaintiff s Second Amended Complaint; and WHEREAS, Defendants filed an Answer with New Matter on or about July 31, 2003, in accordance with the agreement of the parties. NOW, THEREFORE, intending to be legally bound hereby, the parties hereby agree as follows: 1. The Default Judgment entered on or about April 8, 2003, shall be opened and removed without prejudice to the Defendants in the above-captioned matter. 2. The parties hereby waive any hearing with regard to the Petition to Strike Off / Open the Default Judgment filed by Defendants, so that the litigation may proceed in due course. 3. The Prothonotary is requested to amend the docket in accordance with this Stipulation. Dated: `~ 02 QC Dated: ~~4 / •/~~ Douglas .Miller, Esquire Attorney or Defendants 2 CERTIFICATE OF SERVICE I, Douglas G. Miller, Esquire, do hereby certify that I have served a true and correct copy of the foregoing document upon the persons indicated below by fast class United States mail, postage paid in Carlisle, Pennsylvania 17013, on the date set forth below: Amy F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Attorney for Plaintiff Date: March 3, 2004 IRWIN & McKI`TIGHT Douglas G. AVIiller, Esquire Supreme Court I.D. No. 83776 West Pomfret Professional Building 60 West Pomfret Street Carlisle, Pennsylvania 17013-3222 (717)249-2353 Attorney for Defendants C? rs f~ ~ ~ !•~ C'i;+.w ' 1 'Tt~ !- ~ W =2i '"> "- 3a. T C, ~i (-. .:e.: CJ C, n 4a ~}rit ~ ~t _ ~ K ~' ~'-,~ _~ ~'~ ,~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANL9 HCR MANOR CARE No. 2001-4092 Plaintiff vs. AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Defendants PRAECIPE FOR JUDGMENT ID# 87062 Attorney for Plaintiff 267 East Market Street YORK, PA 17403 (717)846-1252 NOW, , 20~, JUDGMENT IS ENTERED AS OVE. Prothonota~ryn/C,lerk, Civil Divir~s~-i-oyy"yam,/, may' .~/~-V~n~ ~~i~~, Deputy Enter Judgment in favor of Plaintiff and against Defendant, MICHAEL SOBOTOR, pursuant to ARBITRATION AWARD. (X) Amount due $ 9,000.00 Interest from Mazch 15,2001 $ to be determined Filing Costs $ 128.90 TOTAL $ 9.128.90 alas costs & interest (X) I certify that the foregoing assessment of damages is for specified amounts alleged to be due in the complaint and is calculable as a sum certain from the complaint. (X) Pursuant to Pa.R.C.P. 237 (Notice of Praecipe for Final Judgment or Decree), I certify that a copy of this praecipe has been mailed to each other party who has appeared in the action or to his/her Attorney of Record. (X) Pursuant to Pa.R.C.P. 237.1, I certify that written notice of the intention to file this Praecipe was mailed or delivered to the party against whom judgment is to be entered and to his/her Attorney of Record, if any, after the default occurred and at least 10 days prior to the date of the filing of this Praecipe La~copy of the notice is attached. DATE: ~ / l ~ Signature: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE Plaintiff vs. AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Defendants No. 2001-4092 (X) Notice is hereby given that a JUDGMENT in the above-captioned matter has been entered against you pursuant to the Arbitration Awazd in the amount of $9,128.90 plus interest, reasonable attorney's fees and costs, on 20~~. (X) A copy of all documents filed with the Prothonotary in support of the within judgment is/are enclosed. Prothonotary Civil Division If you have any questions regazding this Notice, please contact the filing party. Amy F. Wolfson, Esquire 267 East Mazket Street YORK, PA 17403 (717) 846-1252 (This Notice is given in accordance with Pa.R.C.P. 236.) NOTICE SENT TO: MICHAEL SOBOTOR DOUGLAS G. MILLER, ESQUIRE 19 HOLLY ESTATE DRIVE IRWIN, MCKNIGHT and HUGHES GARDNERS, PA 17324 WEST POMFRET PROFESSIONAL BUILDING 60 W. POMFRET STREET CARLISLE, PA 17013-3222 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE No. 2001-4092 Plaintiff vs. AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Defendants AFFIDAVIT OF NON-MILITARY SERVICE COMMONWEALTH OF PENNSYLVANIA COUNTY OF YORK I, Amy F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am the Attomey for the Plaintiff in the above-captioned matter, and that to the best of my knowledge, information and belief, Defendant, MICHAEL SOBOTOR, above named, aze over 21 years of age; is last know to reside at 19 HOLLY ESTATE DR., GARDNER5, PA 17324, ADAMS County, Pennsylvania; 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 ~}ct of Congress of 1940 ~ttd its Amendments. ' j /"1 .e~•' Amy F. Wo~`f"son, Esgre,/ Attorney for the Plain p~ Attorney ID# 87062 Wolpoff & Abramson, L.L.P. 267 East Market Street York, PA 17403 SWORN and SUB~RIBED To before me this day Of~~.l` >20~. '~T f1 ~ ...._ f` f1 _ . --cal ~ _ Notary Public GOMfNONNlEA;_TN O~PE'N%iSYLVANIA Neiarial Seaf Tara A. Smitl•~, i~iutaD~ Public City Of York, York county My Cgmmissv,r_Expire;Duly 23, 2007 Member Penns)1vt:ni;, r€sc/'!etlcn Df IVOL~rie> ,~ IN THE COURT OF COMMON PLEAS OF Ci.JMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE No. 2001-4092 Plaintiff vs. AMELIA B. SOBOTOR, Individually, MICHAEL SOBOTOR, Individually, and on Behalf of AMELIA B. SOBOTOR, Defendants CERTIFICATE OF RESIDENCE I, Amy F. Wolfson, Esquire, due hereby certify that the last known address of the above referenced Defendant is as follows: MICHAELSOBOTOR 19 HOLLY ESTATE DRIVE GARDNERS, PA 17324 Respectfully submitted, Date: April 6, 2004 Amy F. W son, Es ue WOLPO & AB N, L.L.P. 267 East Market Street York, PA 17403 (717)846-1252 ID No. 87062 Attorney for Plaintiff :._ '~~t~~'~~5~ ) HCR MANOR CFiRE, ) Plaintiff ) v. ) e3MELiEi B. SOBUTOR, inciividuall~, M~CFIAEL SOBOTOR, individually, and on behalf of AMELI~i B. SOBpTOR, Defendants OATH In The Court of Coemmon Pleas of Gumberlaad County, Pennsylvania No. 2001 - 4092 We do solemnly swear (or affirm) that we will support, obey and defend j the Constitution of the United States and the Constitution of this Comtton- wealth and that we will discharge the duties of yur office with fidelity. AWARD We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages'for delay are awarded, they shall be separately stated.) 1N A.d~ ~i~ .~nhe ~R ,.. 7f e~eu.~,~-. ~ ~ 9_ dd~1.0o Qr./ Go~f~ dry ~'kii arfio./ . applicable.) Date of Hearing: ~qR~ 3, 2oU'! Date of Award: /~ll.Lt~ +~, Laa~ Arbitrator, dissents. (Insert name if NOTICE OF EIvxsx ~r awq Kll Now, the ~'.~+C day of ~ A,~-e.~v ~ ~~ ~; at 9: ~9 , A ~ •:i. , the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensation to be I-GL,-~~+ paid upon appeal: rothonotary $ X40• trU By: Q ~12c~0_, ' Deputy ~k. ~ : p c <:; c> `;F T ~ _~~ -~ S_r I'ilr _ ~ ~~ Q' ';..~ ~. 'mac ~ /~ - N , rri `` ~~ AJ~ _~ r - - ... ~ _ .~s ,.. _ __ ~nx;~rxu+~r,.--, ,. ,~.-s i,y=-yw ,.o-cm~m'u., _.,~e<~. ,-,. z~.,E _ ~C`'IQ ~ P pf~Y E ~2 n e_ Plaintiff -. ft M e-i Yq; /~ So ~JO ~ o f~ _vfi t..~Q- Defendant In The Court of Common Pleas of Cumberland County, Pennsylvania No. G ! - Y 6 3 ~ Civil Action -Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitutionaf this Commonwealth and that we will discharge the duties of our office with fidelity. Signature I~Gth (~. ~7rue.:e.MRv Name (Chairman) .Smn~~,a.!'er c IJRee/ac/wsa Law Firm A,co. (3ep 31fi 4 4 lu , fh ~ ~ ~~. Sty ~- Address UiIP,I'r`Slr lT"n )7e>3 City, ' Zip Signature ~, ,~~n.'{. ~ Ipu 06~' Name Je~N e. Ds~,us~w~Gz Law Firm °fD~i' S ~rvc~uer~zr-r' Address ~ /'~ ~~iS~ ~1 7013 ~/ao~v Signature A~ARe.,u h CU marf,v s //Name ~i(~6 ea/t/•r ems) Law F' ,2 & IVc~.~ti.. 3a ad •~. Adnndress l~A M~ ~~<-G(~ / 7o/i City, ' Zip Award ~ /~ 8 73 We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) . Arbitrator, dissents. (Insert name if applicable.) Date of Hearing: ,~el ~6 f~. FJx e.,~ ~v e rw.a~l ; ..,, , (Chairman) ;. ~. Date of Award: /lam; o;,o- /,}/~ N.fw~f~2 :.~..~..o., . Nofice of Entry of Award , Now, the ,j,n2C day of ,~. , 20 o y . , at R; yg fJ• .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensation to be paid upon appeal: $ ~9 0 •~ Prothonotary By: Aeputy ~, ti HCR Me'~NOR CFiRE, v. ZeMEL.iZi ' B. SOBUTO MiCIiAEL SOBOTOR, and on behalf of ) Plaintiff ) Et, :individually, individually, AMFLIA B. SOBOTOR, Defendants ~l~l~~~`i5~' In The Court of Conmon Pleas of Cumberland County, Pennsylvania No. 2001 - 4092 O'ATH Tde do solemnly swear (or affirm) that we will support, obey and defend ~~ the Coastitut~.on of the United States and the Cdnstitut~.oa of this Common- ' wealth and that we will discharge the duties of Sur office with fidelity. AWARD ode, the undersigned arbitrators, having been duly appointed and sworn (or .affirmed), make the following award: (Note: If damages°for delay are awarded, they shall be separatelAAy stated.) .1N 779dA.C Ol" /'~A'i~///~ Ow//.l d~B.lif/J¢ ~f~£/G~~~d~' ~/G~ d ~LiJ Q~io.T/ . applicable.) Date of Hearing: ~~ga~ 3, 2ao~/ Date of Award: 7!//2Ll~t +?, LOO' `tR,`c,A 0, n/Ayi<r Arbitrator, dissents. (Insert name i= NOTICE OF EN Now, the ~.~ day of ~~~ ~,ac~j ~ at 99: ~9 , A-•.1. , the above award was entered upon the docket and notice thereof given by mail to the parties or their attoraevs. Arbitrators' compensation to be ~ic.~~; ~ ~ " paid upon appeal: rothonotary $ X90. i,ZJ By: _ ~ ~yLc~O_, . Deputy Plaintiff ~ rv~~i (w ~3. So bo i-a r, ~~. Defendant In The Court of Common Pleas of Cumberland County, Pennsylvania No. 0l - ~ b S z° Civil Action -Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution. of this Commonwealth and that we will discharge the duties of our office with fidelity. Signature 1~e~tt, (7. ~rt .uemn~ Name (Chairman) Law Firm P,c~.f3op 318 Address l.:H lQ,t,'s Pr ltn 1'ZO/3 city, ' zip N ~'~ 5 b5~ Si~ahue ~~'n49- ~ dl- ~i~v Name Jd~. N e. ~s~us~rui cz Law Firm Iu~t 5 NA NCOU Cf ~EN Address l.A ft l rs ~.~ (1 a . ~ 703 City, Zip Award ~/S/Iignature // KARPN /h, CU M/fl lA/95 Name li(~6 C,v/~cs e~J ~IS /NaG!' °~ /SS/ Off/' Law F' /~ Address /~ CA ~e ~~G! IY l7a// City, ' Zip ~/~893 We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed}, make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) . Arbitrator, dissents. (Insert name if applicable.) Date of Hearing: ,~~t ~ ~ ('~, ~j - " _ -= R ~N ti e m.AuJ ,' ~;.,... ~~-,~. s Date of Award: /7Jiei'o~`,a ~ A/~av~~2 (Chaunran) .a . -- Ts~. Notice of Entry of Award "`'' Now, the .~>~ day of ~.r,~.~ , 20 0 , at ; v ~~ .M, the above award was ~- ~~ _ entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensat~n to be paid upon appeal: $ ~ 9 ~ ~~ By: Prothonotary Deputy ) BCR MAI+IOR CFjRE, ) Plaintiff ) v. ) [',MELi1~ B. SOBUTOR, individually, M~CBAEL SOBOTOR, individually, and on be7ialf of AMELIA B. SOBpTOR, Defendants O'ATH In The Court of Cotmion Pleas of Cumberland County, °ennsylvania Np. 2001 - 4092 We do solemnly swear (or affirm) that we will support, obey and defend j the Constitution of the United States and the Constituti.oa of this Common- ' wealth and that we will discharge the duties of yur office with fidelity. AWARD We, the undersigned arbitrators, having been duly appointed and sworn (or .affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) /h°iti 0 ~Lil Q(/7'rior~/ . . Arbitrator, di~s~sents. (Insert name if applicable.) f'S /"~ Date of Rearing: /~1aRUE 3, 2DU~/ ns Chairman Date of Award: /!~/~Ll~r ~, za~`~ '~ -1"!~ i ci %+ D Np y ro r ~ t~ 0.n J~.~:~Cle-P~a NOTICE OF ENTRY OF AWARD ~ ~~ ~ ~ •`~ Now, the ~.~Cdaq of /GLl.t-t.~ ~3,7ck~`f at 99: u9 , A•.:f., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensation to be 4'e,_~ ~ of paid upon appeal: ~7 rothonotary Deputy :~ ~ ._ n a, ~~Ltai o W~LA' {2Glctb..~ ~~ x ~j~ ~w obi B~ ~-C~