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01-05222
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. ISABELLE DIFFENDERFER, Individually and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER HCR MANOR CARE No. Ol -5222 Action in: Civil-Law 548 2ND STREET CARLISLE, PA 17013 PRAECIPE FOR JUDGMENT ENTER JUDGMENT in the above case for failure to file, enter, an ANSWER TO THE COMPLAINT against Linda Amslev in favor of HCR Manor Care in the sum of $ 11.962.44 with interest AS ALLOWED BY STATUTE Total: $ 11,962.44 + COURT COSTS f~ Attorney for Plaintiff Daniel F. Wolfson, Esquire Q~-+s~~~,E2_ ~ ~ , 20 U/ ]udgment entered by the Prothonotary this day according to the tenor of the above statement. Prothonotary ~~~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-5222 Plaintiff vs. CIVIL ACTION -LAW ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendants NOTICE OF ORDER, DECREE OR JUDGMENT TO: ( )PLAINTIFF (X) DEFENDANT ( )GARNISHEE ( )ADDITIONAL DEFENDANT YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS BEEN ENTERED AGAINST YOU ON IN ACCORDANCE WITH THE PROVISIONS OF PA. R.C. P. 236 ( )DECREE NISI IN EQUITY ( )FINAL DECREE IN EQUITY (X) JUDGMENT OF () CONFESSION () VERDICT (X) DEFAULT () NON-SUIT () NON-PROS () ARBITRATION AWARD (X) JUDGMENT IS IN THE AMOUNT OF $11,962.44 PLUS COSTS $45.50 FOR A TOTAL OF $12,007.94. () DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF $ PLUS COSTS. () IF NOT SATISFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF TRANSPORTATION ROTHONOTARY BY IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE CONTACT: G~ NAME OF (ATTORNEY/FILING PARTY): WOLFSON & ASSOCIATES, P.C. ADDRESS: 267 EAST MARKET STREET YORK, PENNSYLVANIA 17403 TELEPHONE NUMBER: (717) 846-1252 OR 800-321-8467 NOTICE SENT TO: Linda Amsley 548 2nd Street Carlisle, PA 17013 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, . Defendants CERTIFICATION NO. 01-5222 CIVIL ACTION -LAW 1, Daniel F. Wolfson, Esquire, due hereby certify that on October 5, 2001, I caused a true and correct copy of the 10 Day Notice attached hereto to be served on the Defendant, Linda Amsley. Date: ~~~~~i~Gil~ Daniel F. Wolfson, Esquire WOLFSON $t ASSOCIATES, P.C. 267 East Market Street York, Pennsylvania 17403 Telephone No. (717) 846-1252 I.D. # 20617 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF ERIE COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. O l -5222 vs. ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendants CIVIL ACTION -LAW CERTIFICATE OF RESIDENCE I, Daniel F. Wolfson, Esquire, due hereby certify that the last known address of the above referenced Defendant is as follows: LINDA AMSLEY 548 2ND STREET CARLISLE, PA 17013 Date: I O Respectfully submitted, G ^' Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, P. . 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for HCR Manor Care IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. Ol -5222 Plaintiff vs. CIVIL ACTION -LAW ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, . Defendanu AFFIDAVIT OF NON-MILITARY SERVICE COMMONWEALTH OF PENNSYLVANIA COUNTY OF YORK I, Daniel F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my knowledge, information and belief, Linda Amsley, Defendant, above named; is over 21 years of age; is last known to reside at 548 2nd Street, Carlisle, PA 17013, 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. ~e Sworn and subsc ibe to bef this day of , 2001. Notary Public Daniel F. Wolfson, Esquire / ~ WOLFSON 8i ASSOCIATES, P.C. 267 East Market Street York, Pennsylvania 17403 Attorney I.D. #20617 Attorney for the Plaintiff Notariagl Seal Mich CIt MofMo kuPoik ~nlyPublic My Commission Expires Aug. 12.2002 Member Pe~sy~nlagssodaeonof Notat~ea ATTORNEYS Daniel F. Wolfson Amy F. Wolfson Philip C. Warholic Donald L. Hoage* COUNSEL Morrison B. Williams PARALEGALS Mazgazet L. Burg Michele M. McHugh ' Licensed to Practice in MaryWnd October 5; 2001 Linda Amsley 548 2nd Street Carlisle, PA 17013 267 East Market Street York, Pennsylvania 17403 (717) 846-1252 (800) 321-8467 FAX (717) 848-1146 e-mail: dfwolfson tadebtcoltection.net Re: HCR Manor Care vs Isabelle Diffenderfer, Et. AI. Docket No. 2001-05222(CP Cumberland County) Collection Matter Dear Ms. Amsley: 8 Manchester Street Glen Rock, PA ] 7327 (717)235-5074 PLEASE FORWARD ALL CORRESPONDENCETO THE YORK OFFICE We enclose a 10-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civil Procedure. Sincerely, WOLi FSON SL ASSOCIATES, P.C. ~~-'~~~~ Daniel F. Wolfson, Esquire DFW/cc WOLFSON & ASSOCIATES, P.C. Attorneys at Law enclosure IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-5222 Plaintiff vs, CIVIL ACTION -LAW ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendants TO: Linda Amsley 548 2nd Street Carlisle, PA i 70l 3 DATE OF NOTICE: October 5, 2001 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE; A }UDGMENT 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 A7 ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Court House , 1 Court House Square, 4`h Floor Carlisle, Pennsylvania 17013 (717) 240-6200 ~~~~ Daniel F. Wolfson, Esquire ~` WOLFSON St ASSOCIATES, P.C. 267 East Market Street York, Pennrylvania 17403-2000 Telephone: (717) 84b-1252 I.D. # 20617 Attorney for Plaintiff F~Piroffi-_'~na8~+" _kktl~tF:$.4n va4no,~:Et)u= ra+ Mrta dNiii!: 'fi _ ?-~~ v...~, .._ .- i~~vDNNUa~! i •'..• - „ ~ ~~ ~ O v ~~- CO ~ ~ C r~~r ._, \ t- V ~ ~ ~~~! _ K t~~ 'o __ ~, ~~ ,. SHERIFF'S RETURN - REGULAR CASE NO: 2001-05222 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS DIFFENDERFER ISABELLE ET AL SHAWN HARRISON Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon AMSLEY LINDA the DEFENDANT at 2016:00 HOURS, on the 14th day of September, 2001 at 548 2ND ST CARLISLE, PA 17013 by handing to AMSLEY a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 3.25 Affidavit .00 Surcharge 10.00 .00 19.25 Sworn and Subscribed to before me this ~~n/7 ~ day of ~n ~iyH.G.c..~ ~ ~ A . D . rothonotary '~' So Answers: ~s~~ R. Thomas Kline 09/17/2001 WOLFSON & ASSO I ES ` By: p t he iff ~. ~. ., ~„:. SHERIFF'S RETURN - NOT SERVED CASE NO: 2001-05222 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND HCR MANOR CARE VS DIFFENDERFER ISABELLE R. Thomas Kline Sheriff who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT to wit: DIFFENDERFER ISABELLE but was unable to locate Her in his bailiwick. He therefore returns the COMPLAINT & NOTICE NOT SERVED as to the within named DEFENDANT DIFFENDERFER ISABELLE ISABELLE DIFFENDERFER PASSED AWAY 1/16/01. Sheriff's Costs: So answers: > ~- Docketing 18.00 ~ ~~ ~i-~ Service 3.25 ~ -- y~ Affidavit .00 R. THOMAS KLINE Surcharge 10.00 SHERIFF OF CUMBERLAND COUNTY .00 31.25 WOLFSON & ASSOCIATES 09/17/2001 Sworn and subscribed to before me this ~'1 day of ,,.~..~ Pr t onotary ' __ . ..,. _ _ I .,. - / /~F ~i' f IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. ~~- $2a ~ Plaintiff vs. CIVIL ACTION -LAW ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendants NOTICE l.. l v c C,~~'2Ys-1 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 u"sed 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 queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades o otros derechos importantes 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 Association 2 Liberty Avenue Carlisle, Pennrylvania 17013 (717) 249-3166 TRUE-COPY FROM RECORD In Testimony whereof, I here unto set my hand and the seal of Bald Co at Carlisle, Pa. This da of ®, othonotary c ) ti 2 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. Plaintiff . vs. ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, . Defendanu CIVIL ACTION -LAW COMPLAINT AND NOW, this ~ day of ~/~J ~ , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire and the law firm of Wolfson 8t Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care 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, Isabelle Diffenderfer, is an adult individual with a current mailing address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, Linda Amsley, is an adult individual with a last known 2 > ~ a address of 548 2nd Street, Carlisle, Cumberland County, Pennsylvania, 17013. 4. That Defendant Linda Amsley represented herself to be the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer. Defendant Linda Amsley is the daughter of Defendant Isabelle Diffenderfer. 5. That on or about December 17, 1998, through the present, Defendant Isabelle Diffender was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and marked as Exhibit "A". 6. That on or about December 17, 1998, Defendant Linda Amsley executed an Admission Agreement, on behalf of Defendant Isabelle Diffenderfer, which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement including addendums is attached hereto, incorporated herein, and marked as Exhibit "B". 7. That by executing said Admission Agreement, Defendant Linda Amsley did.acknowledge that Plaintiff would be relying on the "Conditions", which are incorporated into the Admission Agreement in admitting the Patient, and that if Defendant Linda Amsley did not follow through with said Conditions, Plaintiff will have detrimentally relied upon said Conditions and Plaintiff would suffer financial 3 harm and loss. See Exhibit "B" as 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. 9. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Isabelle Diffenderfer's account as a result of said charges, for the period of the Defendant Isabelle Diffenderfer's stay with Plaintiff's facility before Medical Assistance was approved, is the sum of Eight Thousand Seven Hundred Sixty-Six and 55/100 Dollars ($8,766.55). See Exhibit "A" as previously identified and incorporated herein. 10. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Isabelle Diffenderfer's account balance, all to the damage and detriment of the Plaintiff. , 1 ] . Plaintiff has made numerous requests to Defendant Linda Amsley, as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer, demanding that the sums due and owing to Plaintiff be paid, and Defendant Linda Amsley, as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Isabelle Diffenderfer, for the period of Defendant Isabelle Diffenderfer's stay with Plaintiff's 4 facility prior to Medical Assistance approval. 12. That Defendant Linda Amsley violated her fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer by not utilizing Defendant Isabelle Diffenderfer's finances to pay Plaintiff when she knew or should have known there were outstanding medical care bills for Defendant Isabelle Diffenderfer, and therefore Plaintiff detrimentally relied on Defendant Linda Amsley following through with the aforementioned Conditions. 13. That the finances of Defendant Isabelle Diffenderfer should have been utilized to pay Plaintiff for her necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Isabelle Diffenderfer, but Defendant Linda Amsley failed to use Defendant Isabelle Diffenderfer's finances for that purpose, and therefore Plaintiff detrimentally relied on Defendant Linda Amsley following through with the aforementioned Conditions. 14. Plaintiff has retained the services of the law firm of Wolfson 8t Associates, P.C., in the collection of the amounts due from Defendanu. 15. Pursuant to Paragraph 8 of the' Fee Schedule, which is attached as part of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay all court costs, reasonable attorney's fees, and contractual interest if the account is referred to an attorney for collection. See Exhibit "B" as previously identified and- incorporated herein. 5 r a 16. As of the filing of this Complaint, Plaintiff has incurred reasonable attorneys fees from the law office of Wolfson si Associates, P.C., in the collection of the amounts due and owing by Defendants incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 17. The amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Two Thousand Six Hundred Twenty-Nine and 97/100 Dollars ($2,629.97). 18. As of the filing of this complaint, the amount of contractual interest which has accrued at a rate of eighteen percent 18%per year from March 28, 2001 is the sum of Five Hundred Sixty-Five and 92/100 Dollars ($565.92). 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. 6 x WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Isabelle Diffenderfer, Individually, and Linda Amsley, Individually and on behalf of Isabelle Diffenderfer, in the amount of Eight Thousand Seven Hundred Sixty-Six and 55/,100 Dollars ($8,766.55), plus reasonable attorney.fees in the amount of Two Thousand Six Hundred Twenty-Nine and 97/100 ($2,629.97), contractual interest in the amount of Five Hundred Sixty-Five and 92/100 Dollars ($565.92), the costs of this action and other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON 8i ASSOCIATE , P.C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff 7 VERIFICATION I, Michelle Thureson, Senior Financial Services Consultant for HCR Manor Care, verify that the statemenu made in the foregoing Complaint are true and correct to the best of my information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. DATE: ~Z`!' ~ f ~~ Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" 08/17/2001 02:47 7172490647 .`.. 0 fgA1QORCAFE CARLI5LPv 372 940 idALNU°k' 30T7'OM ROAD CAFtJ.,ISL,E, PA 170k3 (7173=249-0$$5 ' LIAtAA AMBLEY FQg ISAEELLE DSFrr`ENI7PRF`~'Et 54$ 2ND STREET CARLISLE, PA 17013 ~~w MAN~RCARE CARLISLE :a'C=2ti!3C1'16114 PAGE 02 ~„ i . F ' 7KE~DICATD PRIVATE{ ROOM 110 -E PleasB Retum This Pottian With Your PBymant 1 ;' DIBS`Eh1DERE'~, ISAH&LLE -_.,.. ---'--wi96041 --- 12/17/98 -,_--` ----10!31/99 __. L.- ~E~v,~. E., CODE ~} SERVICE RENDERE4 I CRARQES ` OREDITS t ''r2ia1/~s sALAtdCE FORWARD s.e0 10/12/39 PAYMPt3T 5.@0 10/31!99 11.600 'CABLE RENTAL.,, ( QTY 1 3 5.00 10105!99 11100 BEAUTY AND'BARHEE2 ( QTY 2 } 32.00 10/0i-10!31/99' PRIVAT& PORTION 676.05 =' 1 i 101 /89 ADV PVT PQl3'.L`ION .% b7 ~ . 05 _ ®4/01799 ADJ ,PV'T PORTION 4/99• ~ ~...-' 676.05 05/01/99 ADS' FVT PORTIOAJ 5/ 39• 676.05 r 06.1@1/99 AD3. , P,VT PORT B/99 676.05 .' 07!@1/99 , ADJ PVT PC)RT 7/99 676.05,''' :.@8/04!99 ADJ pVT PORT 8'199 ~~-~ 676,@S' •.09701199 ADJ PVT PnRT 9/99, ~ ¢76.05 5,445.4¢ AP,fioUMT DUE r fi ~~ { i PRGE 03 MANpRCARE CARL'S3LE' 372 940 WALNUT BOTTOt4 ROAD CARLISLE, PA 17913 (717j-299-09$5 LINDA AMSLEY FDR ISA@ELLE flIFFENDERFER 598 2ND STREfiT . GARLISLtc, PA 1707..3 ~~ MEnxCRiO 15R IV ATE RpDM 110 -6 Please Return This Portion With Your PaymBnt DIFFENnERFEA, ISA$ELLE 960x1 1z/1719$ 1x/s9/99 t7ATE OP CCDff SERVICE RENDERED CHARGES ~ CREDITS 9ERV~CE xx10x/99,•`J $ALANCE FpRWARO 8,995.40 1x"11+5f99 PAYMENT ,~ s7.9e 11/3a1gs lxtie0••cAeLlw RENTAL C QTY 1 ) 5.00 ,</ " 12/01199 AdV.,,PV7 PORTEpN 678.05 ~~ ,~ ~ _, i, 08/17/ 47 7172490647 ° .a MANCRCARE CARLISLE 5tatemenfr Mr'ii~6RCARE CARLTSLF 372 X34@ tdAl,tdUT i3OTTOPI ftOAp CARLISLE, PA 17@13 (717}-249-@@85 LICIOA AM5LEY FOR ISABELLE pIFFENO'ERFER 848 2Np STREET CARLISLE. PA 1701'3 PAGE ~ 05 ~~ NEpICAaIp PRIVATE ,. R O Ci Pt 110 -- B please Return This Portion With Your Payment pIFFENpERFER, TSABELLE 98@41 12j17/9$ 04/31/@@ k DATE OF ~ CflpE I ~ SEfiVICE AENOERE47 ~ ~ CHARGES k CREDITS I SERVECE 01/@1/4@ BALANCE A'ORWA~tO 6.8@2.5@ @11@4J@s PA,YMEN7 750.1 @1/15/@@ PAYMENT 37 .' @1j31/@@ 116@@ CABLE RENTAL ( 4TY 1 ) 5.00 f @2/@Y/@@ AQV PVT PORTION 578.05;°' J// .. . ,. 8:680. AMOUNT DUE ~ ~ 4 I 08f17f200i 02:47 7172490647 MANORCARE CARLISLE PAGE 06 _ • R.~~ `,;, ;, h~APfORCARE CARtTSLE 372 ~'f ~3AQ WALhIUT BOTTOM ROAD ~:~ `~,• CARLISLEP PA 1703,3 *,R { 73.7) -243-0@85 SEt?tetrl~ttt M1:OICAIf3 LINDA aMSLEY _ PRIVATE FOR ISAk3ELtE DZFFcNQERFER ROOM 11~ -8 -'. 548 2ND 5TREET CARLISLE , ? A 17 019 Pieria Return Thia Portion ' ' nth Your Payment' ~^ ---- pIFFENDERFER, ISABELLE-----_-.._-----96041- 12/17/98 ----~@2/29/@0--- SERVICE CEDE SERVICE RENDEREp CHARC3E5 CREDlT6 02!01 00 BALANCE FORWARD 6,685.65 02%lA/S0 PAYMENT 02/29/00 11800 CABLE RENTAL 02/23f00 11100 EEAUTY AND' BARBER '03/01/'00 a0Y BvT PORTION ~'~ . a' 769.00 qTY 1 } 6.00 ( OTY 1 } 36.00 576.05 o-' ;} ~~ 6,63A.6C AhiOVi<lT pUE 08/17/2001 02:47 7172490647 MANDRCARE CARLISLE PAGE 07 ~...,. ~ Stalernrt7d ® ~~ ~ F ' ~ ~ •~ i f. n ; ,, 1~ANORCARt= CAR~.ISLE'372~' ~ r Jq@ tJALNUT 5'DTTCIM RCAD i~ ,~ ,. CRRLISLE; PA '; 17A13 {717}-zas~e$a6' ' ~ MEOZCAZ~ LINDA AMSLEY ` PRSVATE i FOR TSABELLE DIFFENDERFER ROODt 7.10 -B.. 548 2ND STREET CA R L T S L E. P A 17 $13 Please Return This Portion t ~ Wiih Your Payment ~ DTFFI;NDERFER". TSABELLE 96@A1 12f17j98 3J~ije@ . GATE Ot= SERVtGE I CODE ~ SERVICE RENDERER `- ~ CHARGS$ . j CR80iTS ~''°~ 03/®Sf00 BALANCE FORWARD 6:634.6$ ' $a %27 /$$ PAYNBNT ~ 759;,@@ '03(2i/®'$ BAYMENT ~ 41'00 ib3J31($0 1160$ CABLE REN1"RL; ( QTY 1 j' 5.4~ ,,, '$4,j01/0$ ADV PV7 PDRTSON 676:05'~"r .J; ~ + ~ l' ` ~ ;. i gnACUNT RUE i 5,5@5.65 MANORCARE CARLISLE PAGE 08 ;i~`c'ZC°nits5'91` P PtANOk:CARE CARLISLE 872 9\i0 IJALtdUT aOTTOM f20A0 CARLISLE PA 1707.3 t 717)-ZAa--9085 \' MEOSCAxn LSNDA'AMSLEY RRIVATE FORsISA6ELLE AIFFENAERFER R£9QN 17.@ ~$ SAS ZPiD 5TREET .°~..,, , C A F2 L S S L E, P A 1 7 913 Please Return Ttus Portlan ~ ~ ~"'~- ~.^~ ~~ ~ YYith Your Payment r '. ,wl:e.:' .rY :m•y.. .. ~'""''~~, ~IF;=EM6E R, ISABELLE 96941 12J17j . DAT2 OF COPE ~ SERVICE RENdERED OC.J\lll~C ,;;A@4 j01 j00 BALANCE ~'ORWARO ° g'4(,25/@@ PAYMENT. ';"'~Qf30j@@ 116@0 GApLE RENTAL ogj'~t0/00,,t111~@ HEAUTY ANGt BARBER 95f@100"~ AII'J PV7 PORTION •. A640tJNT DUE CREDITS f 77k.9t ~6,R4B.7 Y s l~ @4js@j@@ ,6,505.65.: ~ 4TY 1 ) 5.00. ( QTY 1 ) ~ 35.@0 676.@5 r` 08I17A2001 02:47 7172490647 b1ANORCARE CARLISLE :,-.,. ' i . Statt3menE • MANORGAR£ CARLISLE 872 4A® LJALtdUT,BCTTOM ROAD CARLISLE, PA 17013 ~717)~aAa-sass LXNDA AM5L£Y F4R ISAB£LLE DIFFENpERFcR 5A8 2ND STREET GARLXSLE, PA 17$13 ' MEpICAID PRIVATE R90M ],19 •,•8 Please Return Thie,Partion With Your.Payment _ -~.N.. .. DTF'FENLIERFER. ISABELL£ 96041 12(11{98 @5/31(@0 DATE OF ~ SERVICE CODE • SERVICE REN67EgED OHARGES ~ CREDITS - p~&(01(08. x . SALpNCE FCR~,IARD - S,AA8:70 ~, .•w," ~:0 8~ {35/23/$0 PAYMENT. . @Sf31/$0 11600 GABLE R£NTAL• ( QTY 1 ) 5:00 P~5J1@/04 ti110$ BEAUTY AND BARBER 4 QTY 1 ) 9..00 ....,f"~r ` - ' -- 98'/23 f @@ 1110@.,BEAUTY ANC7 BARBER C QTY 1 ) 9.0@~ r' 0b/@iJ@@ ADV PV7 PDRTTDN 67&.@6 .~ ~ , s/' , Atv{OWT. DUE ti. ... .:.::- ~ ' 08I17f2001 02:47 7172490647 MANDRCARE CARLISLE PAGE 10 s t .. :Sid'ie']I T tE}i G t rSAtdpRCARE CARLISLE 372 . B90 iJfsLNU:T BO'1'TpE3 ROAD CARLISLE, FA if'4719 :s~ ~ (74.77-2A3^^@085 ~ . r >f _. } MEDICAID LINDA, AMSL.EY PRI'/ATtr ','r FOR ISABELI..E OIFFE~IDERF'ER ~P.pOYt 114 -B': 598 2ND STREET • CARLISLE , P A 17 p ~2 3 Please Return This Portion '"„°+, yR _ ~ nth Your Payment ,; . .w.x•._.... ' .r:. F F ..-•_ . ____DIFFENpERFER` I`'P BELL~___ _ 86$91_.._ 12/17/SB_W^ $6/3@/$$ . 1 ' ~ 3ERV GE ~ CpDE ~ ~ ~ SERV3CE RENDERED ~ CHARGES ~ ~ CREDITS $8f.91/@@ $A LANCE t•ORWARD 5,337,75"`. ' $&J2s%$@ ., PAYMENT 784:'@0 " eejs$/$$ 116$© CABLE R ENTAL ( QTY 1, } 5.00'- $S/@8 j$$ 111@0 BEAUTY AND BARBER ( QTY 1 ) 17.5@ $8/21 j$0 111$4 BEAUTY At10 8AR6ER ( QTY 1 } B. $@ + , O$/29/'p$ 111@@ BEAUTY Atd0 9ARBER. ( QTY ]. } 9.@$ d7/$1/@$ ADV PVT AORTION 676.@5 11/3@/99, AD.] REV S1'aS PREM 11J99 45..54 ~--' 12j.31/99 ADQ REV INS PRENf iZJ99 9`~':5@ 01 j31 J$Q AD~7 REV IRtS PREM 1 f 00 9S . S@ ©2f21j,$0 AD.7 REV INS PREt•1'2/q0 g'S.S@ ' r39j31/$@ ADJ Rt;V SN3 PRa:Ai 8'/@p !+5'•5@ 6.A97.Bq AFhOUNT DUE 08f17f2001 02:47 7172490647 ..~^~'. >'~•_' .. °.~I". . ! F9AidDRCf~R'E CARi.S5LE 3T2 ' SJ4® LdALNUT ESpTTDM ROAD h CART ISLti",. PA 17@Z3 (71.71..~qu; .. to~~C _ , ~:. ~ MAN~RCARE CARLISLE rta#a++s6n4 PAGE 11 CC' ~~_. :~~ vrliM ~'L~l. 1~v14i C.LLc DJ: ~'. ,-,. v.:.,~?wW ;.: ~i C•~: '.„: --S 646 2id0 S"iREwT ~a:vo^sLISLEa PA 9.7@i3 ~ ~ -_ ,,r-;;:::.c~~r Thy-F..~r„-. f, ~tiIFFENDERFERa',ISAa3ELLl 96441 12J17j9,8 D7/uA/§4D 9EFVIpE f ZOJc~~_ :>4'~V1C;c P~:efJC>~WED !7/Qa.~@@ BALANCE Fo~WaRo !T.%z'6/oa PAYNEtdT 37/31)@9 116@@ CABLE' REPs'TAL 77/$1J9D 1199@ INS PREM PICA FAC PD(PA} !7 /@4/@@ 11].@D $EflUTY AtiD $ARBER 97 f 01 /'®59 ~ 'REV LAST MO PP 17j61S-07f31[aO.PRSVATE PDRTI4IV 4E;~91/@@ ADV PV"" pC°.TIO"t 41 %01 j@6 'ADJ REV PVT FORT 1/@D 91 j@1/9@. AD.] ' P.RIVAT3^ FDRT 3 f DD 42f9t/D@ `AQJ REV PVT PORT 2/@@ 42/@1/96 "ADJ PRIVATE ppRT'2jD6 ~a)@~/e@. .,AOJ azEV PVT FORT ~i@@ 93/9S,JDD ~ ADJ PRIVATE p©RT 3;/DD .~:- still TOTALS ( QTY Z ) { QTY 1--} ( QTY 1 ) C!'iA1~G'ES 8,497.$ 5.. @ $6.@@ 734.20 7J~'q~ . z 9 734.2D 73A.2@ 1@,2@4.8@ AMOUNT DUE 1~ cNeui•rs ~, 583.@@ E '~ 45.5@ }676.@S 676:95 • 678,@5 676.95 ,.. 8,632.70 CARRIED FWD J °, J t %1L e~y~~ f., ~~L~F~`,J~ - $iSiiilESlf ~ ~. MAhFr~RCARE' C4sRLT8LE 372 ' $7g4i tdALTf7JT F07'TOM, RgA0 CRRt.XSt,k?. t'.^ 17W7.£+ 2 PAGE 12 e pACt; . ~ ~ Pi L. 4! !. ~: ti i. L. FU;4 CSfte~E't~~c U;t;F't`ENG'i:;l{r{,i,• i~AGfl ].Sv --~7 5gs~,zrab s-r:3r:a~T , CAR LISLE r, A:,A 27413 ='~casc ~;~[. ~. J~„a l"o.YOn A-4 - ~ J ~V`il(r) YQ:!t P~jfilcll[ .. Y .i ~ ~ r. ~• C)T6FENDERS<ER;.'IZSABE.i~~.E ~,~; :~ 96.'691 ,~12J.37,J`98' .I 07J31/OQ 3LAV40E '~°~`°"- 1 •`~•'~~l $eRVlCE.flEMt~,c'"REO ,~ _~J~~' ~T- (:HAFGES ~ CRECRS" - ,r' FWq PRq,M P4tECE0~ZNG $TM'f ;' ;. 1@,2@9.8@ 3,682.74 04 f81 J@4; i~'~gDJ REV pVT ~R7'' 4 J4fi! /~' ~ •~'v ,/~ i/ 675. fly fl4J@1/@fl .' ADJ RPo2V!};~'E,lpORT. ~4~' '':' f'/..c'~ ,/ ,' 78A,2Pt 05/01/4@;.y 'ADJ RE~7~~'V? pORT~'64"QO.w•.'~• ~''' .rF"."~~ 576.05 @5/fl~AJb 0."; AOJ ~i7RIY1~lT'1: pgR~f~iy'd4 j 784.2@ @6~~3iD'; '. AbJ btE.~~:~`pVT .FOIt~,~f"~"'h;J09j` •` 676.45 481f~~/,86:;: /ibJ~!,pklT PORT, 6(:@© ~' 784.2@ ! , ' f~~M: ,. ' ~r ~ ~ ~' t r.~ . .` ~: "~ ./ i (. ril. ( i..:' ~ n •:.. 11 v1P ./' ., ', ia, ~ . 3 y ~. .. ~ ;; :' is ~ ~ ~.. .. ;~ l~ ..., 1. ~N `I, " 6,761.55 AAAOUN7 DUE '' ~~ .1J ° i7.t' ' ~ ~, i~SAhdGRGARc Cf)RLISLE'37M ~*i•~ WALhdU"l" 3DTT0"( ft4^,D ' Ca~RLISL'c, PA 1~©13 ('%1% j-~24~--4vc5 LSh1D+1 Ai%SLc~Y .. 'rGF 75FLtELL.'a: DIF'rL?Iti?!_i:i-i~F: 5^}8 2Pd0 S'fP,E~rM7 CARLZSLc, PAS' 1741.8 . CARLISLE Staterrlen: PAGE 13 ~i'~'`. ii'i'c iti :r iJ ii dl~~ -•Li Niitil Yo+a; Fa, rnu.ii DIFFENDERFEti,~ISABELLE 90041 12j17J9F 418/31(64 . ' I]ATE OF ~~.fipE ~~ ~~ SERVICE I~iENpEFtE© ~^- ~ I CHARGES CREO[FS SERVICE jdx/ae sALANCS FoRd~dA~n, - s,~si.ss ~,". /15f4St,,, PAYMENT s1m.6d1 /41f00 11604 CABL1w RENTAL ' /31f00 11904 INS PREP1 MCB FAC PD(PA) /24/00 11100 BEAUTY AND BARBER /23/0•b'11100 BEAUTY AND 1iAR$ER ~f34J00 -11100 '8`E•A,SJTY AND BARER /Oif60 ADV PVT,PQRTIO~t t I a i f ,. .~ f . ~ I i I~' f 6,862.25 r 4 ~. '6 ( QTY 1 ) 5.46 ~ ( QTY 1-} 964.545 C QTY 1 ) 8.40 C 41`Y 1 ) ~ 9.40 C QTY 1.) 9.00 i34.2G . ~. AMOUNT DUE ~~ _. 08!17/2001 02:47 7172490647 r d~.~° ~ • t IJ 52 i;Sr3dcLL'i: JS r'F~. P<L'i .. it ~~E'i' nd5' 2{•Jd Sift6'F-i CFiFtLISLEp PA 1747.5 P1Ai•tORCWR~: CARL$5LE 3~r+2 340 tlALfdUT BOTTOM RtlAD C1fRLY5LE. PA ].7t~13 (7:13..^n._r,:e3 MAN~RCARE CARLISLE . Statement iS~~~:;C~:;;u i~ ii 1. ~V i3'I ti . ,~.. ~, - i i~ ~ r DSFFENOERFER TSA3ELLE __ _960A1 ---. _12JiTJ98 09I36Jpp EEFiVIGE ` GOD1= _ - S"ERVI(.:E fiE~?1pEF7EC1 _ C>•IAli3cu GP.EUl75 , as/D1/®Q 6A LANCE FORWARD ~,6~z.zs ~J~fBn/~sd 11640 GABLE RENTAL { QTY l } 6. pp 39 /36 /pp i19d6 IN5 PRE) I~1CD FAC PRCFA) C Q7Y 1~) 48.60 a~Jl~fpd 1110@ BEAUTY RPdO BARBER ( Q'f"Y 1 } 9.dp 33/13/80 11180 HAIRNET C QTY 1 ) 1.00 as12010d 11104 BEAUTY ANO F7AR8ER ( QTY 1 } 36.08 1pJgyJ9p AOV PVT PORTIDAd 734.20 , 7'r R,O.F-: 96 AMOUNT OUE f 08!17!2001 02:47 7172490647 MANORCARE CARLISLE PAGE 15 ._ ti_ . . ... ... .. ~. '4w... '.L~1~'2+C7.~" nA~aaRCAft~ cpRLxsL~ 372 «e~a ~:ALnuT adTTO~ ~ar~D (}.A 7~.. h..r_. nn... .., ~+ J 14l :" Statemor+t ~(s ~, 7CC,RC'"_:~ 197r:'c r.lh°irycn ~n/?!.5 ~.yf: ... ~_~ ~;~>72 2PlD STRcE"f - +` ica~: RowRt TICp PG::i_:1 GhRLSSLE, Aa 17413 4';~ei'~:~;crr~y~nen: i ~~ .__nx~~~tan~g~~R~_ ss~a~~L~t~ ___-_____ __,.. G§~?~!a~,___?`~/.~?1~?~.___.._-___! ._?.~lax.L~v __-- U:.'i t Ur SFRYIG° GOOF ~ 5„RVICE riENpERED CHA9GE5 ~ CAE~RS f 4/41/b0 BALANCE FaRbJAftq 7.4b1.95, ., b/12)44 PFlYh1Ey{T ,. SQS.49 aJsl/4b 136fl4 GABLE RLOdTAL { QTY 1 } 6.44 @/31fiY0 11804 xN5 PR~t4 MCD. FAC PD{PA} ( QTY 1-•} 46,64 ©/Z6 /04 111Q0 8ERUTY A?JQ 8AR8ER { QTY 1 ) 9.40 SJ41fb© ADV PVT PgRTIaN 734.24 ~d .r-. 7 , 3'43.6 5 pMOUPIT DUE _.~ nr~r17l2001 02:47 7172498647 -.r~.. , t ~ ~~ ! ~ MAN~RCARE CARLISLE PAGE 16 ~S326tTf8PF'[ ~. EtANORCARE CARLI5LE,372 396 JJALNUT BDTTDM ROAD ~ CARLISLE. f'A 17913 (717}-249-6pe5 1 LINDA AM5LEY FOR ISABELLE DIFFENDERI~ER ' 6q8 2ND STREET ,;` CARLISLE, FA 17@1B 1 MEDSCAID RRI'JATJ: RODM 11@ -B Plea&e Retum This portion With Your papment I_--JDIFFENDERFER_^ISABELLE~-- - 96@41'--- 12f17/9&--y---~__--11/3@faD___ I ' SERVICE I COPE ~ ~ SERVICE REMDEREO ` L ~ Cl1ARGES ~ CREUTFS - 1kf01/.OQ BALANCE FDRLJARD 7.3.Q8.85 11(3010@ 11b00 CABLE REM7`Af. ( qTY 1 ) S.@@ , I < 11f02/9@ 111®p BEAUTY AP1D,6ARBER ( Q7Y 1 ) . 17.50 11f'08Jp4 111@0 BEAUTY AND .BARBER ( QTY 1 ) 9.r,@ i1J1sJ6@ 111©@ BEAUTY AND BARBER. ( RTY 1 ) 9.00x;+'~ 12/e1f6@ ADV PVT,FEIRTION 734.20 , 6,©7B.3°. AfvtOUNT DUE asrl7rzael 02:47 7172 MANORCARE CARLISLE ~F1At.6RCARE CARLLSLE 372 ~R0 1.ALPJUT 6D7'7'OFl ROAD CAf4LI8LE> pA 17tl13 4717)-2A9-0085 i PAGE 17 ' I~1Ei3ICATD LINDA AM3LEY PRIVATE FOR ISASELLE DIFfENDERFER ROOM 110 -8 5~8 ZND STREET. CARLISLE , P A 174913 Fleas® Return This Portion Wifh Yaur i}aymen[ DSfFE9i*DEF{FER, I5ABELtE 9S0R1 12/"17/98 ~12131/tl0 ------------- ----~--------------------------,--- ----~-------------ti-r--- cao~ SERVICE RENl7EREP 12/01/00 BALATdCE FORWARD 12/31/00 11fi00 CA6LE RENTAL 12f249/00 12100 6ERUTY AND BARBER 0x/01/tl1 ADV PVT PORTZDN -., .~ f 1 { QTY S ) ( qTY 1 ) CHARGES ! CflECITS s.497a.3s 5.00 9,ea 734.20 a,82fi.5 q!,tUUNT CUE 08/17/2001 02:47 7172490647 MANORCARE CARLISLE $4E4Zti1Wi1~ `' ~ ~ + MANO'RC.ARE CARLISLi.E 372 SAO WALNUT BOTTOtt ROAD CARL2SLE, pA 17013 f717)-249-0085 LINDA ANSLEY FQR ISABELLE IIIFFENDERFER S48 2Na STREET CARLISLE, PA 17013 t PAGE 16 ' igEIIICAID PRIVATE RDD11 11fl ~0 Please getum This Portion With Your Payment DIFFENIIERFER, ISABELLE s eal 12/17/98 01/16/01 01/31/ti1 DATE t)g CODE SEgVtCE gENDERED CHARRE3 CREDRS SEflVkCE 01 01 6~LAN FORWA D ~ 8,$28. S tl1101/01 11900 MC8 FREkfStJM f QTY l-) 50. ,' pAYtM1ENT DUE 0Y TN,k 10TH aF 1'tfE PID°tdTH 8,776. AMOUNT DUE ~~•Mc71201"(~l'~ MAtdORCARE CARLISLE 372 940 WALtdUT BOTTOMI ROAU CARLISLE, PA 17013 (717)-249-OOHS LIfdDA APiSLEY FUR ISABELLE DIFF'EFdDERFER 548 2ND STREET CARLISLE, PA 17013 Statement Rleasa ReC.:re This Portion yy:,h vuu Pc7ma'1I r I`IEDICAID PRIVATE Roort 11© -~b DIFFENDERFER, ISABELLE 9604'i 12/17/98 01/'16/01 0'[/28f01 _._ - -- ~ r - - - _ -- --- - - ._ . -- -- --------- SERVICE LODE bEHVIi;E RENDERE[i ~ CHARGES I CREDITS ---- -- ---L---~---------------------__..----------~---- ---- `~- - 02/O1/01 .BALANCE FORWARD 8,776.55 PAYMEtJT UUE BY 1-HE 10TH OF THE MOtdTFi 8.776.55 n64OU?¢T DUE EXHIBIT "B" ADMISSION AGREEMENT ~~ ManorCare WEEN PATIENT/RESIDENT AND FACILITY l Health Services THI~ION AGREEM~T (the "Agreement") is entered into this `~~ 19 ,between MANORCARF. HEALTH SFR the "Patient/Resident"), and/or~ (the "Responsible ty"). A sed herein, the term "Patient/Resident" s Party, if any. The parties agree as follows: day of '). and 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Residert is responsible for payment of ail charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i} before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from ail 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: (7) an immediate transfer or ! discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; ar (3) the Patient/Resident has not resided in the Facility for thirty =.(30} days. Such notice shat( 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 6, as well as applicable co-insurance and deductible amounts and al expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities tc release all or any part of his/her medical/health records to the Facility. The Patient/Resident alsc 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 thin party payor, including, but not limited to, government and private insurers, or any other person entitle( or authorized to receive such information by law or by the Patient/Resident. MHC•OC82C (Fi9V. //9ti1 P9 Federal Resident Rights • Resident Responsibilities • Lnfe Sustaining Treatment Policy • Medical/Nursing Education • Dental, Vision and Hearing Services • Interdisciplinary Care Conference • Utilization Review Meetings (if applicable) • Personal Laundry Policy • Barber/Beauty Services • Mail Policy • Voting Materials • Photo/Media Events • Personal Fund Account Procedure • Tobacco Policy • Grievance Procedures • State Resident Rights (if applicable) 14, GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIQNS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENT'S 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 and year above written. uate this ~missi ~ , gree nt as of the day ~~sp~insible Party -Printed Name C /~ -/ ~ -9~ Date MNC-0p8•RO (R¢V. 4/96) p9 6 EXHIBIT A ° RESPONSIBLE PARTY APPOINTMENT The Patient/Resident's Responsible Party may be any person legally responsible for the Patient/ Resident. ,4 competent Patient/Resident shall not be required to designate a Resppnsible,Party. Please check one of the four following, whichever is most appropriate. Q 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). ^ "J~he Patient/Resident does not have a legally appointed representative and wishes to give the responsibility to someone else. I hereby appoint as m representative (the "Responsible Party") and hereby apthorize him/her o handle my financ~s, pay my expenses, receive my personal funds and, ~it ! am unabl ~ o execute the Admiss~o~Agreement on my behalf. Any signature of Patient/Resident o esponsible Party on the Admission Agreement and/or this or any other exhibit or doc ent attached thereto or reference therein sha(I be considered binding on both the tient/Resident and the Responsible Par .The undersigned hereby agrees to the Cond~i ns (as herein after set forth and defined). ~ /~ _, ,_ .,,~. y-aaenc/ nesioenc - rnn~na rvamaUG ,~~ -~~ ~ Date ^ The Patient/Resident is competen~fid es not have acourt-appointed guardian, conser- vator or power of attorney and had not appo' ted a Responsible Party, but alone shall execute the Agreement. In consideratio of his/her a fission to the Facility, the undersigned hereby agrees, warrants and repres nts to the Condition (as herein after set forth and defined). ^ The Patient/Resident is~mentally or physically incapa of executing this Agreement, handling his/her own affairs ~ appointing a Responsible Party a d does not have a guardian, conser- vator or durabie~p'ower of attorney. The Patient/Reside 's physician will certify in writing that the Patient%Resident is incapable of executing the Agre~ient and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on bek~alf of the Patient/Resident, to act anii`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). MNe-ooe-xo (Rev.4/961 pg 6 1 Of 2 Conditions (collectively referred to as'"Conditions") 1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the. facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated ~,~~„ ~-! `j , 199 ~_ ,and which is attached hereto and made part. of this Exhibit and of the Admission Agreement, is true and accurate as of this date and 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. 1f 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- coy nts and gree h~is are not complied with, the Facility will have detrimen r lied upory'th~m nd the''~acilit~j ill suffer'~financial harm and foss. ~/ -"'- !FiP.Snnn¢ihlo-Party - vteSpAnsiwe ra/ny - rnn~eo rvana I Date%_! ~ _ ~~ MRC•008•SO (Rev. 4/96) D9 ~ 2 Ot 2 1=XHIBIT B -FEE SCHEDULE 1. ,Daily Rate. The daily rate is $ !?y. ~1V .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 ino9udes: ° • Routine Nursing Care • Linens • Social Services • Meals (additional fees may appl ctivities • Housekeeping • Room (circle one): Private Semi-Privat Triple The following are paid by Medicare in to the items included in the daily rate: • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment The following are paid by Medicaid in addition to the items included in the daily rate (to the extent covered and paid for by the state program): • Approved Rehabilitative/Therapy Services • Approved Medications • Approved Nursing Supplies • Approved Equipment • Approved Routine Personal Hygiene Items/Services • Other approved services/items covered and paid for under the-state Medicaid program. 2. Supplemental Services & Supplies. The daily rate may not include the following items, which will be provided at request of Patient/Resident and/or by physician order at the rate set forth in the attached facility rate sheet and will be the responsibility of the Patient/Resident. ITEM • Private Room • Prescription &Non-Prescription Drugs • Nursing & Personal Care Supplies • Transportation • Nursing Care (Other than ordinary nursing care) • Physical, Occupational & Speech Therapies • Phone, Cable TV, Newspaper, Barber/Beauty • Special Equipment • Bed Hold Fees • Personal Laundry (Personal Clothing) • Nutritional Supplements • Alternative Nutrition (Tube Feeding, TPN, etc.) RATE Based on location & level of care As determined by pharmacy See business office for current prices As determined by transport company See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list See attached fee list 3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever aPatient/Resident leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law. 4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies which may be needed by and provided to-the Patient/Resident, all additional costs/charges may not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in level of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the 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. P9 iof2 r 6. Refunds. Refunds shall be paid within thirty (30) days after discharge or transfer. 7. ,Funding Sources. The Facility makes no assurances that the Patient/Residents 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. Ariy 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 taw 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 shalhpay, 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 al! charges, The Patient/Resident is responsible for payment for items covered by Medicare supple- mental insurance and for applying 1~or 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/Residents becoming eligible for the Medicaid coverage or their being unable to pay privately; OR 2) The Facility currently participates in the Medicaid program. If the Patient/Resident believes i he 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. oe a 2 of 2 EXHIBIT C -PHARMACY AGREEMENT The Facility has developed policies and procedures for drug therapy, distribution and control which provide fbr "a uniform medication distribution ,system. The Facility has selected a' ph2rrrtiacy (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 any reason after written notice of such intent has been given to the Patient/Resident. 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 a~o>e[~dg agree in writing that it will comply with the Facility's uniform medication dis ribut~on systbm, the Facility's policies and procedures and applicable law^~, ~ ~ ~ ~~~`~., nesyuy+s~uie ray ~y - n u ueu rvamc 1~ ~7-~~' Date MRC-008•sa IRev. 4/961 P9 ~~ 1 Of 1 ` MSP SCREENING QUESTIONNAIRE Patien{/Resident Name: Service Dates: /~/ - ~/ `~ Ask all four questions of each Medicare Patient/Resident. If the Patient/Resident responds "Yes" to any question, continue to page two asking all applicable questions. The Patient/Resident or repre- sentative should sign the form whenever possible. NOTE: It is important to ask all questions and document all answers regarding MSP. A provider may be held liable if an overpayment occurs and Medicare finds that the provider furnished erroneous information or failed to disclose facts it knew were relevant to payment. 1. Is the Patient/Resident covered by the Veterans Administration, the Black Lung Program or Workers Compensation? ( /) No: Proceed to question #2 , , ( ) Yes: Bill the other insurer prior to Medicare 2. Is the/illness or injury due to any type of accident? ( / ) No: Proceed to question #3 or #4 Yes: Complete next page and continue with questions below #3 IF 65 OR OVER #4 IF UNDER 65 3. Is the,Patient/Resident 65 or over and employed, or is the spouse employed at time of service? ( ,/) No: Retirement Date: Patient/Resident Spouse Continue: See Note Below ( ) Yes: Complete next page -Medicare may not be primary 4, Is the Patient/Resident under 65 and covered under any Employer Group Health Plan (EGHP) or ~~e Group Health Plan (EGHP)? ( ) No: See note ( ) Yes: Complete next page -Medicare may not be primary Nofe: If answer to all question If any response is "Yes' Patient/ Resident/ Representative Date ~~'~ ~- ~~ 1 of 3 MxCaCe-zC (Rev. 4/96) p9 13 Pafie~ Servi~ Chec 2. ~t/Resident Name: ~ ~d~x1~. Medicare No.: L~~-/O-O,~?'„~'( / :e~ Dates: /.~ - l 7 - y k the appropriate box and answer fhe questions. ILLNESS/INJURY CAUSED BY ACCIDENT A. ( )Motor Vehicle: Name of Patient's/Resident's Automobile Insurer B. ( ) Another p ty was responsible for accident. Name and address of L bility Insurer Name and address of attorney C. ( )Work Related: Name of Wo kman's Comp. surer D. ( )Other accident (Slip and fall, etc.), xplain where accident occurred: Has the Patient/Resident filed or inten to file a bility suit? ( ) No: Bill Medicare and send opies of all p tinent documentation ( ) Yes: Name and address Liability Insurer Attorney Bill other Insurer prior to edicare; submit documentation Medicare if conditional payment requested. EMPLOYER GROUP OVERAGE FOR THOSE 65 AND OVER A. ( )Patient esident employed at time of this service. Given a of Patient's/Resident's company/emplo er Does Employer employ 20 or more employees? ( )Yes ( ~. ) No Does the Patient/Resident have an Employer Group Health Plan (EGHP) by reason of his/her current employment? ( )Yes ( ) No If "No" give Date of Retirement If "Yes" give the name of the EGHP Bill EGHP prior to Medicare 2of3 rxc•ooe•zo IRev. 4/96) pg 14 B. ( )Patient's/Resident's spouse employed at the time of this service, Give name of spouse's company/employer Does the spouse's employer employ 20 or more employees Does the spouse have an EGHP by reason of current employment which ident? ( )Yes ( ) No ff No, give the date of retirement If Yes, give the name of EGHP Bill EGH~prior to Medicare 3. A. ( ) Patie~ and in the first 18 Kidney transplant: MM/YY P COVERAGE FOR THOSE YOUNGER T N 65 'Resident is entitled to Medicare solely due to End Stage Renal Disease nonths of Medicare entitlement. Date f first Dialysis treatment or date of have coverage ealth Plan? r~( ) Yes: Does the Patient/Residel~t guardian's Employer Group ( ) No: Medicare Prim, Give name EGHP Bitl EGHP prior to Medicare his/her, his/her spouse's, a parent's or name of the employer B. ( )The Patient/Resident is eked to Medicare solely because of disability (does not have/has not had ESRD). //~\ Does the Patient/Resident have c erage rough his/her, his/her spouse's, a parent's or a guardian's Employer Group Healt Pian? ( ) No: Medicare Primary ( ) Yes: Continue Does employer(s) employ 1 or more employees? ( ) No: Bill Medicare ( ) Yes: If yes, giv name of each insured whose policy c ers the resident: a. Give name of a. Give name b. employer: b. EGHP: b. Bill EGHP(s) prior to Medicare 3of3 Ye~ . , ~( ) No co rs the Patient/Res- WMC•00e•z0 (Aev. 4/96) 04 15 ~~ ' ~ ( EXHIBIT D -STATE LAW ADDENDUM. The~Admission Agreement is amended in the following manner, in order to co~np~yyv~;ith 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" MHC•ooe-so (Rev. 4/961 P911 - 1 Of 1 1 ~~ -. MEDICARE ACCEPTANCE POLICY ManorCare Health Services This is to confirm that ~~~(' ~4.~40 ~~ -~~ ~ j~ was reviewed at the time of admission and found to be eligible for Medicare benefits. Of course, the Medicare program may change coverage, eligibility or co-payments at any time. ', It is understood that as long as the Patient/resident meets the criteria for coverage, at present Medicare Part A will pay for Medicare Part A covered services for the first twenty {20~ days. Beginning on the 21st day, there is a co-payment of $.~_ per day for the next 80 days, a co-payment set by the federal agency which administers the Medicare program. But regardless of medical status, the maximum Medicare Part A benefit period is 100 days, which may include covered days at another facility. ~~~d 4,, ~ (,t,~p~, n- ~o( f~/i~' ,~~~`~L'~SS C Q Gt~c~ It is also understood that as long as the Patient/Resident meets the coverage criteria, at present Medicare Part B will pay 80% of the allowed rate for Medicare B covered services. There is a 20% co-payment for these services that is the responsibility of fhe beneficiary. Vitalink Infusion Services may be the supplier contracted to supply enteral/parentera! feeding products and is an affiliate of Manor Healthcare. At'the time Medicare coverage is denied or expires, a 30-day advance payment on the current Daily Rate will be required it the Patient/Resident is to remain at the Facility and it the care will not be paid by another approved third party payor. AUTHORIZATION OF PAYMENT OF MEDICARE BENEFITS TO PROVIDER J I certify that the information give4n by me in applying for payment of Medicare Part A or Part B benefits under Title XVIlI of the Social Security Act is correct. !authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or Carriers any information needed for this or a related Medicare claim. I further request that payment of authorized benefits be made on my behalf. I assign the benefits payable for the physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. For outpatient services, I request this authorization apply to the to ~ / Date Date iofi Facility R~epAresent^ativ~e'-Signature `~_iR'esponSible Party - '~~~~~- Facility Representative - Pr' fed Name & Title Re nsible Party - wdc-one-sn ~Hev. i/act pg in .~ AUTHORlZATlON TO PAY INSURANCE BENEFITS Man.orCare Health Services ~. Patient/Resident's Name Insured To (Insurance Company): N~~ I hereby authorize you to make direct payment to: Claim # Policy MANORCARE HEALTH SERVICES Facility Name herein after referred to as "Facility", otherwise payable to me. I understand that certain items/services, including but not limited to personal care items/services, are not covered by the third party payor named above. items/services including but not limited to beauty/barber services, lotion, laundry services, etc. are considered personal care items/services. I further understand that the Facility does not guarantee payment by the above third party for any items/services provided by the Facility. I agree that charges- for personal items/services, as well as any other charges denied or not paid in full by the above third party for any reason will be my responsibility. _ ~ "1 ,~ r ~ ~ `~ espo sible Party -Signature rsesNYnsiu~er rar ty - rnn~cu wank V ~~_ ~"/ 7-"9~ Date MNC•o0a-zo IFiev. 7/98) P9 20 • ,~ INSURANCE COVERAGE illanorCare r . y Health scr.itts t ~ , ManorCare Health Services wants to be sure that all possible sources of insurance to pay for [he resident/patient's care white staying with us are identified properly. Some insurance companies require precertification before they will pay for care provided. Please heap «s by listing all sources of insurance, and most important, by letting us know of any changes in the insurance company or types of coverage as soon as you become aware of the changes. Please state the correct order of the resident/patient's health insurance: 1. Primary Insurance: I~L~L'1iC~llJ~.r 2. Secondary Insurance: Is the resident/patient covered by Medicare? "Yes - No Is the resident/patient covered by a commercial Medicare HMO? -Yes t! No ,Does the resident/patient plan to change insurance carriers? _ Yes / No Has the resident/patient stayed at a hospital or skilled nursing facility within the past 60 days? /es " No The information you provide will be used to bill the proper insurance company. If we are not given the correct information, or not informed of changes, the insurance company or Medicare may not cover care we provide. The resident/patient or the guarantor (if any) will then be responsible for paying for that care. Thank you for your help. I ~ y[ / [ [ (~n ~ . ~ ~- (fir ~'6 Res' nt%Patien Date e onsi le Party Date (If Resident is unable to sign) MXC-001.128 (6/97) ~-~~~ yA.~TTHORIZATION TO RELEASE I MEDICAL RECORDS .x, CenTer Name Date MANORCARE HEALTH SERVICES Address Phone 940 WALNUT BOTTOM RD. CARLISLE PA 17013 717) 249-0085 Dear Doctor/Medical Record Administrator: The person named below was hospitalized in your hospital or was under your care in the past and is now a resident at our center. RESIDENT'S NAME BIRrHDATE SOCIAL SECURITY NUMBER It is necessary that the nursing center obtain copies of the following from you for the resident's chart in order for us to provide appropriate care for the Resident and comply with Medicare/Medicaid requirements for a Nursing Facility. CURRENT HISTORY AND PHYSICAL - A xerox copy is acceptable. a HOSPITAL DISCHARGE SUMMARY - As soon as possible. CURRENT CBC REPORT -Please include date. A xerox copy is acceptable. CURRENT UA REPORT -Please include date. A xerox copy is acceptable. CURRENT CHEST X-RAY -Report and date. (OTHER) Could you please forward to us the most current information that you have on file at your earliest convenience. Thank you. I hereby authorize all erso and/or entities to release all or any part of my medical/health records to the center. OF R E T/RES NSI L PARTY/ OwE F ATTORNEY i i DATE (//^i ~ T ~~ 1 of 1 MHC-OOS-16 .a.9-.~6 I .. Y if Y r ~ l ManorCare Health Services CONSENT TO PHOTOGRAPH As used below, the term "Photograph" includes video photography. COMPLETE ALL SECTIONS PUBLIC RELATIONS (check one) ,~ I do give my consenS for me/the Patient/Resident to be photographed, or to have my/the Patient's/Resident's voice recorded, by or on behalf of the Facility, for advertising or public display, or by the news media. I do not give my consent for mekhe Patient/Resident to be photographed, or to have my/the Patient's/Resident's voice recorded, by or on behalf of the Facility for advertising or public display, or by the news media. AD ~N/STRAT/VE (check one! _ I do cive my consen3 for me/the Patient/Resident to be photographed, by or on behalf of the Facility, for administrative purposes including but not limited to proper identification for drug administration and treatment, and all other purposes related to my/the Patient's/Resident's health, safety or admission to the Facility. _ I do not cive my consent for me/the patient/Resident to be photographed, by or on behalf of the Facility, for administrative purposes including but not limited to proper identification for drug administration and treatment, and all other purposes related to my/the Patient's/ Resident's health, safety or admission to the Facility. MED/CAL !Check One) I do cive my copse S for m'e/the Patient/Resident to be photographed, by the Facility, for medical monitoring and/or educational purposes, and/or reimbursement purposes, including, but not limited to wound and skin care, if necessary. Such photo aphs, ould not include identification except Patient/Resident medical record number I do not cive my consent for me/t a ' t/R slden to a pkiotogiaphed 'y t lily for medical monitoring and/or educatir n~ purpos~. ~~ I ~ i , ~ .1 to i iPatient/Resident or Responsible Party Signature Patient/Resident or espon ibla'P%r\arty Signature `J Dace 1 Resident's Name !last First, Mil ~ ~ Attending Physician ;.` ~ - RoomNumtier . PaLient/Residenf Number l/~l `/ and r , . `, ~~. .. -DEPARTMENT OF _ .. _ ....HEALTH:AND HUMAN SERVICES. - : ~, .., HEALTH CARE FINANCING ADMINISTRATION r ..~ , / ,. i ~_ rvnmc tr m[ ar rypel H.I. CLAIM NUMBER ~r~ /~ q ~ Secti I APPOINTMENT.AF REPRESENTATIVE I appoint this individual: (Print or type name and address of individual you want to represent you.) to act as my representative in connection with my claim or asserted right under Titles XI, or XVIII of the Social Security Act. I authorize this individual to make or give any request or notice; to present or to elicit evidence; to obtain information;~nd-x receive any notice in connection with my claim wholly in my stead. ~-. /. IG A RE (B ne(iciaryl ~ - ADD ~~~ ~ ~ ~ ~ / ~ F ~~ '-fELEP .ONE NUMBE R ATE ~ _ ~ ~J !] / / ~ - ° ~ / 9 ~I/'~_ / ~ - ~ - (Area Code) / OS 5 / / / / Section II `ACCEPTANCE O F APPOINTMENT I, ,hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration or the Health Care Financing Administration; that I am not, as a current or former officer or employee of the United States, disqualified from acting as the claimant's representative; and that I will not charge or receive any fee for the representation unless it has been authorized in accordance with the laws and regulations referred to on the reverse side hereof. In the event that I decide not to charge or collect a fee for the representation I will notify the Social Security Administration and the Health Care Financing Administration (completion of Section III (optional) satisfies this require- ment). lama/an ADMINISTRATOR, MANORCARE HEALTH SERVICES (Attorney, union representative, relative, law student, etc.) E ( epresenta' ) ADDRESS 940 WALNUT BOTTOM RD. ~ CARLISLE, PA 17013 TELEPHONE NUMBE DATE (Area code) (717) 249-0085 Section III WAIVER OF FEE OR DIRECT PAYMENT (Note to Representative: You may use this portion of the form to waive a fee or to waive direct payment of the fee from withheld past-due benefits.) I waive my right to charge and collect a fee for representing ~ "'~ '~ ~° ~O~ .~~ ~i1"a~~ ~"-X ~ before the Social Security Administration or Health Care Financing Administration. SIGNATURE DATE (See Important inlamation on reverse) Rr1RAA HCFA-1898-1Jd 110-841 i ..t i . MMC•ooa-zo (Rev.4/961 09 12 I ~ ~ , ManorCare ` ~ ~ l~eal~ Ser~•ices PATIENT SELF-DETERMINATION ACT ACKNOWLEDGEMENT To Our Residents: Pursuant to federal law, it is this Facility's policy to: (i) provide you with written information regarding your rights under state law to make decisions regarding your care, including the fight to refuse cart; and to make advance directives (living wills and durable powers of attorney:ifor health care); (2) provide you with the Facility's written policies regarding implementation of those rights; (3) document in your medical record whether you have an advance directive; (4) not to condition the provision of care or otherwise discriminate against you based on whether you have executed an advance directive; and (5) ensure compliance with state law regarding advance directives. To assist us in complying with these requirements, please complete, sign and date the following information: i 1. I, the undersigned Resident7Responsible Party (circle one) have received a copy of the Facility's Guidelines for "No Heroics' Requests, as well as a copy of state law information concerning medical care decision-making and advance directives. 2. The Residen't._does/does not (circle one) have an advance directive at this time. If the Resident has an advance directive, it is a living will/durable power of attorney for health care (circle one). A copy of the. advance directive is attached. -- .. _` ~~ ey: ~u - (Signature of Resident/Responsible Party) / ~ Print Name: Ilf Responsible Party, check here antl indicate relationship to Resident) Date: (If the Resident does not have an advance directive and wishes to make one, please contact your attorney or the local Ombudsman, State Department of Health or Office on Aging for valid forms) .. , . .~ w ~~ c pr ~w ~,-,~ ~~, ~1 O ~~ oy? ~~ _ „.~ ~~ ~~~ ~~, ~~,a ~~~ ~ ,;,~~~ ~=~ ~~ ~~ P °, 3:,t3~~ ..~, ~l ;• IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. Ql - S'~~,1 ~[Ut~,~1=~y~ Plaintiff l vs. CIVIL ACTION -LAW ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, 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 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 queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades o otros derechos importantes 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 ABA)O PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166i~ l IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff vs. ISABELLE DIFFENDERFER, Individually, and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendants NO. OI- 5~~~, CIVIL ACTION -LAW COMPLAINT ~ ~ ~I v ~~, AND NOW, this,~~ day of _~~~~~,~, 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney/, Daniel F. Wolfson, Equire and the law firm of Wolfson 8t Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care 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, Isabelle Diffenderfer, is an adult individual with a current mailing address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, Linda Amsley, is an adult individual with a last known 2 i ~ ~ T address of 548 2nd Street, Carlisle, Cumberland County, Pennsylvania, 17013. 4. That Defendant Linda Amsley represented herself to be the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer. Defendant Linda Amsley is the daughter of Defendant Isabelle Diffenderfer. 5. That on or about December 17, 1998, through the present, Defendant Isabelle Diffender was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and marked as Exhibit "A". 6. That on or about December 17, 1998, Defendant Linda Amsley executed an Admission Agreement, on behalf of Defendant Isabelle Diffenderfer, which Agreement outlined .various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement including addendums is attached hereto, incorporated herein, and marked as Exhibit "B". 7. That by executing said Admission Agreement, Defendant Linda Amsley did acknowledge that Plaintiff would be relying on the "Conditions", which are incorporated into the Admission Agreement in admitting the Patient, and that if Defendant Linda Amsley did not follow through with said Conditions, Plaintiff will have detrimentally relied upon said Conditions and Plaintiff would suffer financial 3 a ~ A S harm and loss. See Exhibit "B" as 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. 9. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Isabelle Diffenderfer's account as a result of said charges, for the period of the Defendant Isabelle Diffenderfer's stay with Plaintiff's facility before Medical Assistance was approved, is the sum of Eight Thousand Seven Hundred Sixty-Six and 55/100 Dollars ($8,766.55). See Exhibit "A" as previously identified and incorporated herein. 10. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Isabelle Diffenderfer's account balance, all to the damage and detriment of the Plaintiff. 11. Plaintiff has made numerous requests to Defendant Linda Amsley, as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer, demanding that the sums due and owing to Plaintiff be paid, and Defendant Linda Amsley, as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Isabelle Diffenderfer, for the period of Defendant Isabelle Diffenderfer's stay with Plaintiff's 4 facility prior to Medical Assistance approval. 12. That Defendant Linda Amsley violated her fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Isabelle Diffenderfer by not utilizing Defendant Isabelle Diffenderfer's finances to pay Plaintiff when she knew or should have known there were outstanding medical care bills for Defendant Isabelle Diffenderfer, and therefore Plaintiff detrimentally relied on Defendant Linda Amsley following through with the aforementioned Conditions. 13. That the finances of Defendant Isabelle Diffenderfer should have been utilized to pay Plaintiff for her necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Isabelle Diffenderfer, but Defendant Linda Amsley failed to use Defendant Isabelle Diffenderfer's finances for that purpose, and therefore Plaintiff detrimentally relied on Defendant Linda Amsley following through with the aforementioned Conditions. 14. Plaintiff has retained the services of the law firm of Wolfson 8t Associates, P.C., in the collection of the amounu due from Defendants. 15. Pursuant to Paragraph 8 of the Fee Schedule, which is attached as part of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay all court costs, reasonable attorney's fees, and contractual interest if the account is referred to an attorney for collection. See Exhibit "B" as previously identified and incorporated herein. 5 16. As of the filing of this Complaint, Plaintiff has incurred reasonable attorneys fees from the law office of Wolfson si Associates, P.C., in the collection of the amounts due and owing by Defendants incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 17. The amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Two Thousand Six Hundred Twenty-Nine and 97/100 Dollars ($2,629.97). 18. As of the filing of this complaint, the amount of contractual interest which has accrued at a rate of eighteen percent 18%per year from March 28, 2001 is the sum of Five Hundred Sixty-Five and 92/100 Dollars ($565.92). 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. b s WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Isabelle Diffenderfer, Individually, and Linda Amsley, Individually and on behalf of Isabelle Diffenderfer, in the amount of Eight Thousand Seven Hundred Sixty-Six and 55/100 Dollars ($8,766.55), plus reasonable attorney fees in the amount of Two Thousand Six Hundred Twenty-Nine and 97/100 ($2,629.97), contractual interest in the amount of Five Hundred Sixty-Five and 92/100 Dollars ($565.92), the costs of this action and other relief as the Court deems proper and just. Respectfully Submitted, Y ~~v~% Daniel F. Wolfson, Esquire WOLFSON 8i ASSOCIATE , P.C. 267 East Market Street York, PA 17403 (717)846-1252 I.D. No. 20617 Attorney for Plaintiff 7 VERIFICATION I, Michelle Thureson, Senior Financial Services Consultant for HCR Manor Care, verify that the statements made in the foregoing Complaint are true and correct to the best of my information and belief. 1 understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. DATE: ---~~~v c,~,--~ ~' ~t/~-~ Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" 08/17/2001 02:47 7172490647 MANORCARE CARLISLE . j a4~isr~~~.liC a ~~'° I9AIr1OTtCAFE CARI,z$LPa 372 9g@ WALI~S[3°T' 3pTTOki RpAD CARLISL@, PA 17013 {717)249-@085 PAGE 02 ' ~ ~ MEDICAID ` LINAA AMSLEY PRIVATQ FOR T8A6ELLE DTF'~`ENAERE' ROOM 11@ -E 548 2ND STRffiL~T CARLISLE, PA 17 @13 Please Retum Tnis Portion With Yaur Paymarri 1 DIFPENDERPER, ISAHELLE .96041 12/17/98 20/31/99 DAFE OR .. .9EFiViC@' CODE SEAViGE RENDERED .. CHARGES CREDITS SALANCY~ FORWARD „~i0r®1199 5.0@. 10/12!99 PAYMENT 5.00 10!91!99 11600 'CABLE R~+1TAL ( QTY 1 } 5.00 10105/99 11100 BEAUTY AND BARBEE2 ', ( QTY 1 l 32.00 10!01-10!31/99' P1tIVAT14 PORTION 676.05 1it01/99 ADV PVT PORTION ~ b7 .05 04/01199 AD,J,PVT PORTION 4/99• ~ 676.05 , 05/01/99 ADJ' PV'T PORTI(32T 5/99• 676.05 - r 06.101199 AD,7 PVT POAT 6199 676.05 . @7/01J99 ADJ PVT PORT 7/99 87b.05,''' 08/01!99 ADw7 PVT PORT 8199' ~~; ~ 576.05 ..09/01199 AD,7 PVT SAT 9199, ¢7G.05 anaouNr our ,.; i 5,445.4¢ tfiANORCARE CARI.SSI_E'372 hop WALNUT F3Q7TCf4 ROAD GARLiSLB, PA 17913 (717)-249--9095 LiNOA AM5LEY FDR ISABELLE t]IFFENOl:RFtwR 548 2ND STREET GARLiSLE. PA 1701.5 • ~~ NEDICRID PRIVATE RODM 110 -B PleOSe Refum This AortiOn WYh Yatir Payment C1iFFENOERFEFi, iSABELLE 96041 22J17f98 11f30/99 {~ ogYE OF t~ ~ ~flE 5ERVICI= REfJDERED ~ CHAFtGE5 ~ I GREDIiS I 9ERVICP I 21f92/4s, '~ eALANCE FORwaRt~ 5,445.40 12/16f9y PAYMENT 57.90 11f30f98 12800 •G•ARLE RENTAL ( qTY 1 ) fi.00 ,°~~' 27.J01f99 AbV.,,PV7 PDR7IDN 676.05 . '•~,, - - ~; t i ! 11 i ., t __ 'y 6,089.45 AMOUNT DLiE 08{17/2001 02:47 7172490647 ~' - ~ s I 1 P',ANORCARE CARLI3lE'372 r X40 i-JALfd'JT Bg7'TdD1 RgAd f 1 CARLZSLE, 4~A 1701,3 r (717)--.2R9-0986 r ' } f.,. t ~ I LINDA AM5LEY fqR ISA6ELLE D7:FPENDERPER . 64$ 2Nq STREET CARLISLE, PA 17958 MANORCARE CARLISLE a t PAGE 04 MERICAIq PRIVATE RRRkS 110 u6 Please Rekum This PaFtidn With Your Paym®nt DIFFENDERFER, ISABELLE Q604]. 12/7.7/98 12/31/99 SERVICE I C"DQE ~ &ERVIGE RENDERED I G}1ARGES ~ CREDYTS . 7.2/01/99 BALANCC FgRWARD 6.0$.9.+45 12/31/99 11600 CABLE RENTAL, ( QTY 1 ) 6:00 12/1'4/99 17.100 t3l=AUT'Y ANq BARBER ( QTY 1 ) 32,m0 01/01/00 ADV PVT PgRTIgN B7£.OS v 6,602.60 AG40UN7 pUE 1 08!17!2001 02:47 7172490647 MANQRCARE CARLISLE PAGE 05 ~ °` ~°' ' r+1r'iiJORCARE CpRLS3LE 372 f340 EJAI,.NUT F3OTTOPl fi0A0 CpRLYSCE, PA 17013 (717)-349-ti055 tSNOp AMSLEY FOR SSpBELtE pIFFENC!'ERFER 648 2Np STREET CARLISLE, PA 17013 Statetn¢nt Please Return this POttIOn With Vour Payment NEDSCA°SO ARIVATE ROgPt 110 -E OIFFENpERF>rR. TSABELLE 36041 12)17/96 04/31/00 S~RV1~ GOaE SERVIGE RENOEREC - CHARGtTS CFtERITS - 01/01/00 BALANCE ~ORWARb 6,$02.5'0' 01/04/00 Pp,YMENT 760.E 01[18/00 PRYMENT 37,' 07(31/00 1160a CR9LE RENTAL ( QTY 1 } 5.00 ' 02/0YJ00 AOV PVT PORTItlN 67$.OStl 6,6E6. AMOUNT pUE a Ii , 08/17/2001 02:47 7172490647 MANORCARE CARLISLE PAGE 06 ._ ~ e i r `ti: .: PtANORCARE CARLISLE 372 ^ ~4~~ 9AD WALNiJT BOTTbM ROAD ti CARLISLE, pA 17013 '°a~ (727)-244-@@65 LINDA AMSLEY FOR ISAkiELLE DTFFENUcRFER - 648 2ND STREET CARLISLE. PA 17@13 ~ffltem@IiL r~EDICAID pRIVAT°H ROOM 110 -B Please Return This Portion ' With Youf Payment ~. AIFFEMDERFER, ISABELLE 4B@R1 12f17j98 02/29J@0 -... -.~ 4 ...-~ -a. .~-.--rr~ rw~n .. M-.~ ~. ... .~. r w~ -. -. OAT6 OF ~GCSDE SERVIGE RENDERED ~ CHAR4E$ CREDlTB SERVICE .. @2 @1 0@ 6ALANCE FORWARD 6,666.68 @2/lAfs@ PAYMENT @2/24/@0 1160@ CABLE RENTAL @2/23j@@ 117.0@ BEAUTY AND BARBER @3/@if@@ AOV AVT AORTZOM ~. 769.0@ ( qTY 1 } S.@@ ( pTY 1 } 36.00 678.05 a' j ; l 6,B34.6C ;i ~_ j A6~GUNT DUE J 00/1712001 02:47 7172490647 MANORCARE CARLISLE pq~ 67 ..~"~, I i /~ Staxel~nett3 , s ~~"P I t .~: A. 1',i j ~;, PIANORCARE CARLISLE 972i' r' S40 tdFLNUT BDTTGtM ROAC) ,~~ CARLISLE; PA 17013 (7173-249-0065 i ~ MEL7XCASD LINDA AM$LEY ' PRIVATE y' FGR ZSABELLE QIPFENfJERFER RQ4M 11Q -B_..' 549 2NQ STREET ~ " C A R L S S L E, P A 17 913 Please Rewrn This Porlton ' ~ ~ Wlth Your Payment r DIFFENDERITER: ISABELLE 960A1 127'17/99 3/1/00 . GATE OF SERVIGE CODE SERVICE RENDERED '- GHAR4E3 CREQIT$~;~"~~ 03/01/08 BALANCE EORWARq 8,,63A.60 03f27/0@ ' PAYMa"NT ' ~ 7189`.00 J00 03f27 PAYPFE NT 4100 03J31J0@ 11600 CABLE RENTAL; ( QTY 1 ) 5.0p „ 04,/01/00 AOV PVT PQRTION 876:05"" JI 1 s. ~ ~, E ~ ' ; 8,505.65 anFOUNr euE f P9ANOIiCARE GAREISLE 372 94k~ WALt~1U1° 80770M ftDAD CARLISLE, pA 1707,3 (717 ),2A9--9085 ' ~ MEDICAID f:ZNDA AMSLEY ~ RRSVATE ~ORISSABELLE UXFFENDERfER ROOM 119 ~,5 bA8 2ND STREET .--~..., , C A R L T 5 E E , P A 17 413 PleeSe Return TMs Ponlan * _ " ~~^~ ~" ' ~ With Your Payment ,~~:* ~ f' .,'°"^-~. E~7PFENDER R, SSABEELE 96441 12/17] 8 ~ 94J34J40 W GATE OF DDDE ~ SERVIGE RENDERED ~ GHAq?aES ~ CREDITS SERVICE _ _ .;;~,~4f01/00 9At.ANGE FORWARD 6,595.65 " 04(25(00 PAYMENT. ~ 774.Bt :"""~A'~/30/99 11600 GRBLE RENTAL DAf~O/00,,11100 BEAUTY ANfJ 8AR6ER 95}0100"y ADV PVT PORTION ( QTY 1 ) 5.99. ( QTY 1 ) 36.94 676.95. +` ~6,44$.7 Argpt~N7 our_ ~~ y. 09/17f2001 02:47 7172490647 htANORCARE CARLISLE p~ 09 i,: Statement a ~ ~ , MANORCARE CARLI6LE 872 4~+@ WALNUT,BDTTOM ROAD CARLISLE, PA 17010 (717}-2A9-00B5 LINDA AMSLEY FOR ISABELLE DIFFENpERFER 6A8 2NO STREET CARLISLE, PA 17013 ' MEl3ZGAICt PRIVATE ROOM 11@ -•B Pleas® Return TMS,Part3an Wfth Your.Payment ,e . 'DTFFEN OERFER, ISABELLE 96041 1Pj17{$8 @5f31j00 OAFE OF ~ SERY~CE CADE ~ SERVICE RENPEH,ED CHARGES ' GflED1T8 ,.!6/01/00, s BALANCE FORWARD T 6,44B:70 ~ ~"' @:':@ j2sj00 0 PAYMEN . ~ 05J31j00 11600 CABLE RENTAL ( QTY 1 } 6:00 ~5/10j04 11100 BEAUTY AND BARBER ( QTY 1 } 9.00 .ks"=- ~98j23j08 '111O0,BBAUTY ANO BARBER ( QTY 1 } .~ 8.00°;' 0bj01j00 ADV PV7 PORTION 696.05 A[viOUNT. DUE $e.~37.7 ~.. .. :, . . .... ~~ K ... ...,, F... 08f17f2001 02:47 7172490647 PIANORCARE CARLISLE PAGE 10 ` 4 K-o i•iAtdORCARE GARIISLE 372 . 540 l.IALPdUT f1QTTQt+1 RgAR CARLISLE, FR 17013 z~ ~ ( 717) -299-G5085 ~ . r { _ ' ~ MEDICAID LINDA, Ath5l..EY pRIVATir i FDR ISABEkIr.E DIFFENpERF'ER RD4ti xia -F3 i ~ 648 2ND STREET , f Please Return This Portion / C A R L I S L E, P A 17 @ yx 3 . , _ With Your payment ~ . .. ...: u.~..._. _. ... _ DIP°RENDERF>`R, I' BEILirv`~ 960Q1 ' 12Jx7/98 46/31D/@@ . ____.. _- ___..---__ f ..__-_.....-_- -, - - - ....._____ -____ .. ...-,_-_-..._-__......_- _..-- - - _ tiA . y DATE CF C9DE SERViGE RENDEflED SERWGE CHARGES W ~"l,RI;DIT6 45J@1/@4 BALANCE PQRWARD 6,337.75` ' 05f29/04 pAYMEMT 794. 0 . 06/30/44 1x60© CABLE RENTAL { QTY 1w ) 5.44'. 0sJ08j44 111.40 BEAUTY AtiD SARBER ( QTY 1 ) 27.64 @6/21/@0 11144 SEAUTY AtdD BARBER ( QTY 1 ) 9.@@ ~ . 9f44 xx144 BEAUTY. RtdD BARBER, ( 0S/2 QTY 1 ) 9.44 , 07/01/0@ ADV #VT PORTION 676.46 11/34199.. ADa REV ITdS pREM'x1/99 45..54 -~-'' i2j.31/99 A4J REV INS pRENf 12/99 4 •: 50 01[32/84 AOJ REV SN5 PREt4 1/aa 4.50 02/28/.@4 ADJ REV INS PRtet•1 2/09 ~}'S.S@ 43J31J04 AD,] REV SNS pREP1 3/4tl 45.7+4 6,497.80 At.AOIiNT DUE I . ,: _.. 06/17/2001 02:47 7172490647 MAhIDRCARE CARLISLE PAGE 11 { ~ .y.~. i, ^4. ' " ~ rieteill®t1t • B.P. i ' F9ANtlRCAR'E CARLISLE 372 " 94A WALNUT EtpTTDM RC~Al7 caRLxsLf=. PA a.7az:~ (79.~1~~n~..~,r~r,+c; .,_..r.cnxw~ : i iii a`I n~i a1 ~"i ' ~ . . . . . _ Y !. ... ~t~r, ibnr,cLLc. u~i-.,-~~v...,..'A:r. .?.;Gt. ., ,.. -. .:nnLISLE, Ak 9.7fii3 ' ~ `DTFFEPdDERF'ER, ISABE3.LE 9fi@41 12J17/9,6 Q7/?.A/6'i 49 C'aTE 0 ~ " SERVIGG L GCZJE~_ £EFS+JiLc,t:~ivCEFiEp ___ .. I G't'iJiRCiES !7/Q1~j0@ _ 6Al.AhCF. T_--.._ FORWARD . _.-.--- _ ___ 5,497 8 3T/2bj@@ PAYMEtdT 37/31)@@ 116@@ CA6LE RE fdTAL { QTY 1 ) 6<®@ 37/31/@@ 11900 INS PRF.M P1CD FAC PD(PA) ( QTY 1"-) !7/@4f@@ 111@@ $EAUTY A FdD 6AR$ER ( QTY 1 ) 35.@@ !T JQ1 /'@@ ~ ' REV LAST MO ~ PP lTjdl1--67f 31(@@ PRIVATE PnRTIOh' 73+7.2@ l~J~1J®Ju {~hli PV7" D()o^i"ION ~ ~~~. ~~e M 91/@1f@@ ~AOJ REV 'P VT PORT 1/@@ ~ flj@1/@©. ADJ P:RIVATi^ PDRT 1/@0 74.2@ !2f@i/@@ ADJ REV PVT PORT" 2/@@ laJe1J@@ "ADS PRIVATE PnRT 2/@@ 734.2@ )3]@~f@4 AD,7 . i2EV PVT PORT 3y@@ , 38JOl.J@@ . ~ Ap7 PRIVATE PORT 31@0 734.2@ "~ sus TnTALS 1@,2@9.a@ AMOUNT DUH _, ' GV9E~lfTS r 8&3.@@ 45. 5i! f °676.#35 '675:@5 676.@5 676.@5 ,. 3,632.70 GAfERIED'PWD A- f ~. t9Ah14RCflRE Cl~RLISLF 37? ~iAii tJFiLbIL+T E'L~TTbM ROFlC! C-''ARLZSLE'o f~.I3 1709.<'s ~ p (717J...2na.n"'"' f'pi4 :C :Sf§EiCfLItC (J;t;FFI„Nf:'i':I?Ff'.'rt 5ga,2rao s-r.~t:aT - CARLSSLE,.: Fi,A 1'7@18 ' x.. L ' i - `RIFF€NQERFEk,_`.ISABE.I~~.E ~'4"_ ._.._._r_. 46.'G,41 ~. 1 -f ,ry,.. _ ... .. 7 - - PAGE !-i t; b ~, ~ ; Fi is L' r~tx1/r1'f~~ rr"~ O G hl 9.10 ....~ r , j ~ S FlVlOE I. ~~ ~ ~ }'"°~~~~~~"~ ~~~ SrRV1CE f1ENtt{.6RED !- ~ C:HAFiGES ~ ~ CREDITS FWD PROM R.RECED,IPFG STM">r ;' i r ip,2p9.8p 3.632. 7p 04 f01 Jpe: '~'tM+!D.9 REV ~PV.T ~t~'6Rx ~ A JDO ~'~ / /' ~:' J .~Jr,. 675. fly 04 /@1 f 0@ .; ADJ FRIVATE,~PQRT. 4~'~ `i !! ed ,// 784 .2$ @5/0'1/00,•x, 'ADJ RSV /,F~7' ppRT,r•'Ei,~'00':''• rP" .'" 676.05 0S/ /'?3p."~ ADJ RJtT~A'1'E POR,sT/~/5'/'00 J • 734,25 06,70~.0.+0'~~ ADJ RE.~7".'`PVT POR;7~-,i6/Opt' y 676.45 pfi~~i,9$~.. AbJ,~,PWT ~aRT 6/:@@ f 734.20 . s ~. l~'t , ,.r ~.. - ' 1 ~ ~~ ([f ~ it ~ ~ ' ~R `~ H.~ ~+ . ry~~.--'`".. ~; /,. .. AMOUNT DUE ° ~d„ ..J, ,y. J', •-,•-.J .j .. 0B/1712001 02:47 7172490647 MANORCARE CARLISLE PAGE 13 St~tOment ~ ~ ~ ~` r, ~aAr{aacAR~ Gf~RLISL£ 37M J4tl IJF~LttW7° ~30T1'D"" °0^7 . ' CARLYSL'c> PA 1~tl13 :7:i7 j-~i*i ~~^flv ~v^c5 i~'GR IzS A,OELI.'a, DI F~~: PIUI~'r:'i'"CF'E b~10 2P{0 S"fRE~cl' CARLSSLE', PF) 17+J18 . :'. ~:~ :' C f4 I ;`. ~. ill it I _' i5 : iJ I~i .: ,L ~i: ° p DIFFEPdO£RFER, SSAR£LLE ~abD91 12J17/SS 08/;31/@ts . ' SERV1aCE I~COOE ~ ~~ ~ Ri=RVICE RENDERED ~ -- ~ ` - CHARGES GREpfF6 j01j00 BALANCE FOR4IARD., 6;761.56 ~.,, /15J@Q, PAYMENT 810. 0c+ ., .. /@1f0® 11b0@ CABLE RENTAL ( QTY 1 ) 6.@@ /31/0i! 1180@ INS PREM MCD FAC PD(PA) ( QTY 1-) 95..50 ~ /10/00 11100 BEAUTY AN0 BARBER ( QTY 1 ) , , 9.@6 _ /23/011 'J.1100 BEAUTY AND BARBER C Q7Y ~ 1 ) 8•Q@ .f3@/00 11100 'fi'E~Al1TY AN^ BARB£R ( QTY 1.) 9.09 /01/@0 ADV PVT,PQRTIO~! 7:i4.2G . r Fi annaur{T Due ~. 6,562.25 r ~~~ ~y P1ArtORC/~WE CARL25L}: 3~?_ ., 340 tif?IDIUT 9PTTOM ROAC7 CA!;L~.SLE, r~F; ].7013 {7173,-'=~._,A.~,~ i`lJ f2 i; `J F3q i".L~.. %= ~~.f i'%. l'dti S_i1f1'.'i: :a4u „Yid SfRiw'E'E' CF~RLISLE, AA 17€~~.5 ~ .~ .~:rrt. vy.i~ .. .. f' r f p2FFENDERFFR, 25A8ELLE 96@41 12/17/96 09/36/00 ERV~G~ I _ CURE _ ~.J. ~..~... _ SFFiV fCE ti_~1DCliLp ! ~ _ ~- CHAfs~ie5~ CREDITS ~!j @9/wa/0@ BALANCE FORWARO 6,662.25 79/3@/00 11660 GABLE RENTAL { QTY 1 ) 8.00 79/30/@0 1a9@0 IN5 PREN AtCp FAC pp(FA) ( QTY 1•~} 45.60 79/13/@0 1110@ BEAUTY RPdD BARBER ( Q'E'Y 1 } 8,00 09/1/00 1a1@® wASRr~~T ( QTY 1 > 1.@@ 3~Jj20/D4 a~.1ed bEAI!'TY ANp BARBER ( QTY 1 } 36.00 L0f01/90 ADV PVT pQf2TI0Pd 734.20 7 , A,5l.Y= 9 6 AMOUNT dUE .. ~: 08!17/2001 02:47 7172490647 MANORCARE CARLISLE PAGE 15 _ ,,LL .. ~,>. Sfat®~nQnt MIANi1RCARE CFlRLISLE 372 ~~aa i:nLnuT r~oTTpr ROfip ~, •,,^y~n^, r~;+~.;~~ ~. ,~, cry y~~..~e. .r .: ..: ~: .. -/,?f' _T 5'F.3 ": .'..LE D7rccr.tn.-,^.r ~:~cr; ~nnr:i },it` _. c•. s~/-12 2PI0 STRcG"f vFi~4 ~~„'~;, :_., CI;RLaSLE, P.1 y,7aS3 L i~tib:~rrayi~rn: ~ ff. .__q_SFFEtaQ~R~Ett•,_ 75AL~Et~tE __-- „___t._ ?Srl~~Lc3.d? __-- O.a i e Oi= c~R~I1C~ GGD~ SERVICE RENpEpSp -T- .CHARGES I CREDITS f @/01/@Q sAI.ANCE FpRbJARO 7,atl2.95 flJx2j@@ PFlYMEPi7 3D.S.@9 p/sljcs@ 116fl0 Cfit3lt* RENTAL ( QTY 1 ) 6.©@ @/83,/tle 1190tl Ttd5 PR614 MCD, FfiC PO(PA) ( p7ti" 1-.) 45.64 @/26f@Q 113_ti@ S~AtfTY ASID BARBER ( QTY S ) 9.00 AJO1/tl4 AOV PVT PORTION 734.2fl ,* r- AMOUNT DUE 7 ~ B~D3 6 ~ 08!17!2001 02:47 7172490647 M19ANORCARE CARLISLE pA~ ~F • SSa25niarlt • 11ANDRCAE2Ic CAf~L25Lf:'372 9AD 4JALPdi;T 60TTOM RDA(7 ~ CARLISLE. PA 17D18 (717}-ZQ9-4D86 f MEgICAID LINDA AMSLEY PftiVATE ~Ok ISA6@LLE DIPFENOE'RFER RQfiM 1i0 -B B48 2ND STREET CARLISLE , P A 17 D i 3 please Retum this portion • With Your Payment DIFFENDERFER. ISABELLE 96441 12fS7J98 11/iii/0Q oaTE oF~ 'SERVICE CODE ~ SERVPCE RENI)E,REi7 ' ~ CFiAFiCzES ~ CREUtFS 1Zf41/.D4 BALRNCfs FtlftWaRD 7.3.43.56 11f30/D4 116D0 CA9LE R ENTAL ( QTY 1 } 6.D0 , `. ~ sifDZ/D4 1iiDq BEauTY arto,eaRS~R ( art 1 } 17.54 ! i1f'08/DO 111D0 BEAUTY AND BARBER ( aTY 1 l 9.Fi4 ~ i1f18/D4 1110® BEAUTY AN0 BARSffR. ( aTY 1 ) 9.00';~'' 12J01f44 ADV PVT .P4RTION 734.20 , 6,07 Ft. 3'. AfiR4UNT C7UE r 08/17/2001 02:47 7172490647 MANORCARE CARLISLE PAGE 17 . u~~:tiYC?ji',vfTi • ~ , _! P1AT;OR~ARE CARLISLE S72 94P t.lALPJUT B07"7'OM ROAD CARLT~LC. PA 17tl13 (717)-ak9-0086 • MEDICAID LINDA flMSLEY PRSVATS FOR SSABELLE QSFFENOERFER ROOM 110 -8 5,A9 2N0 STREET. C A R~ L 15 L E • P A 17 013 Plesso Return This Portion With Your Payment OSFFEN^DERFER, I5A8ELLE 9SDg1 1a/17/SS ~12131J00 ti, DATE OF ( COPE I SERVICE RENDERED I CNARCsES E GREDRS SERVICE la/D11eD eAt~ANCE FoRwARQ e.D~a.~s 12/31/D0 11800 CABkE RENTAL { QTY 1 ) 6.@D SaJ20/00 111.06 BEAUTY ANO $ARSER ( pTY 1 } 4.00 D1,/Di f 01 Ai?V PVT PORTSON •.. 734.20 `~' , 8.82E.5 A",IUUNT DUE 1 NANp'RC,ARE CARI.XSLI,E 37x 94@ WALNl1T BOTTOhf ROAD CARLISLE, PA 1T@28 (717)-243-@@85 LINgA ANSLEY FOR ISABELLE DxFFENDERFER 346 2ND STREET CARLISLE, PA 17©18 NEnicaxq PRIVATE ROOM 11@ -B Plea6a Ratum Tnie PordOn WitA Your Psymsnt tlTPFEt`dgERFER, SSABELLE S6@41 22/17J88 @7./16/@1 @1/31/@1 DATE O!= G6DE SBAVICE RENDERED CHAR6E3 QPIEDITS BEAVlCE @~. 07. @~. ~ALA~-F~RbJA D $,826. @2/@2J@2 119@@ NCB AREN?'t1N ( QTY 1-) PAYMt=NT DiJE 8Y THE 1®7H OF 1'HE P(ONTH 8@. 8,776. RNcOUNT DUE H~ •~OI~Cc1l"e MANORCARE CARLISLE 372 5740 WAItJUT BOTTOM; RORD CARLISLE, PA 17©13 (717)-249-©085 LIMDA APiSLEY FUR ISABELLE DIFFEtdDERFER 548 2ND STREET CARLISLE, PA 17©13 Statement Please R=tore This Portion ~fA;h `r our Fajment t1EDICAID PRIVATE ROOt'I 110 --5 DIFFEhDERFER, ZSABELLE 96©41 12/17/98 Di/16/D1 02/28/01 - - - r - - --- ---- - '\TE O- -` ~ COOt 1 SEHVI~E RENDERED -~HARGE-5 I CREDITS ERVII,E L D2/D1/D1 BALANCE FORWARD 8,776.55 PAYMEtJT DUE BY l"HE 1©TH OF THE MONTH 8,776.55 AMOU?.T DUE EXHIBIT "B" i ADMISSION AGREEMENT ManorCare CONTRACT BETWEEN PATIENT/RE$ID'ENT -AND FACILITY Heatth Services THIS DMISSION AGREEM NT (the "Agreement") is entered into this / 7~> day of '~~ 19 ~ ,between (th "Facil' y"), and the "Patient/Resident"), and/or (the "Responsible ty'"). A sed herein, the term "Patient/Resident" shall also mean the Res onsible Party, if any. The parties agree as follows: 1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of ail charges for five (5) days after notice is given, or until the Patient/Resident actually leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and hereby release the Facility, its employees and agents, from all liability connected with such departure. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat- ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi- duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The Patient/Resident acknowledges receipt from the Facility of materials as to the Pa#ient/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 tc release all or any part of his/her medical/health records to the Facility. The Patient/Resident alsc 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 thin party payor, including, but not limited to, government and private insurers, or any other person entitle; or authorized to receive such information by law or by the Patient/Resident. MHO-008.20 ~HBV.//atll P9 • Federal Resident Rights • Resident Responsibilities • Life Sustaining Treatment Policy • Medical/Nursing Education • Dental, Vision and Hearing Services • Interdisciplinary Care Conference • Utilization Review Meetings (if applicable) • Personal Laundry Policy • Barber/Beauty Services • Mail Policy • Voting Materials • Photo/Media Events • Personal Fund Account Procedure • Tobacco Policy . Grievance Procedures . State Resident Rights (if applicable) 14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH AMENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the 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 ~ missi - . gree nt as of the day and year above written. (° ~'1, -Resporisigl~ Party -Signature '~spfSnsible Party -Printed Name / Date MN0.poe-ao (Rev. 4/96) pg 5 EXHIBIT- A -- RESPONSIBLE PARTY APPOINTMENT The Patient/Resident's Responsible Party may be any person legally responsible for the Patient/ Resident. A competent Patient/Resident shall not be required to designate a Responsible Party. Please check one of the four following, whichever is most appropriate. 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. !n 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). ^ jhe Patient/Resident does not have a legally appointed representative and wishes to give the responsibility to someone else. I hereby appoint as rrt~epresentative (the "Responsible Party") and hereby apthorize him/her o handle my financ s, pay my expenses, receive my personal funds and, •if I am unabl ' o execute the Admissio~Agreement on my behalf. Any signature of Patient/Resident o esponsible Party on the Adm' sion Agreement and/or this or any other exhibit or doc ent attached thereto or reference therein shall be considered binding on both the tient/Resident and the Responsible Par .The undersigned hereby agrees to the Condit' ns (as herein after set forth and defined). ~ Farility Ranrr~wnfativw - Finnatu a PatieniLResident -Signature .. [ i- jGUeul, IICJNCIII - rnntcU wwnc//~ --~_~___-i ~- mil/ Date ^ The Patient/Resident is competent and es not have acourt-appointed guardian, conser- vator or power of attorney and h~ not appo' fed a Responsible Party, but alone shall execute the Agreement. In consideration of his/her a fission to the Facility, the undersigned hereby agrees, warrants and represents to the Condition (as herein after set forth and defined). ^ The Patient/Resident is~mentally or physically incapa of executing this Agreement, handling his/her own affairs appointing a Responsible Party a d does not have a guardian, conser- vator or durable,,power of attorney. The Patient/Reside 's physician will certify in writing that the Patient%Resident is incapable of executing the Agree ent and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on~k?alf of the Patient/Resident, to act and`serve as Responsible Party for the Patient/Resident. In cdnsideration 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). MNe•ooa-z0 (Rev. 4/961 P96 ~ Ot 2 _~ Cdnditions (collectively referred to as "Conditions") 1. The ~ assets of the Patient/Resident will be utilized to pay, when due, all costs jnGUrred by the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of personal clothing and care supplies as needed or desired by the Patient/Resident and as required by the Facility. 2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other property of the facility, other Patient/Residents or employees of the facility damaged by the Patient/Resident. 3. All of the information, including but not limited to that contained on the attached Application for Residency, dated _~~A-- ~,~, 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._a\bove-cov ants and gree tents are not complied with, the Facility will have detrimen relied upo~~thfim d the ac(lit ill suffer financial harm and loss. ' ., `lam, .. _. ~ n ; ~~ rotes Dnsioie ra/r[y ^ ran[ea rvame ~ p -! 7 - ~-r-~-- Date MNC•p08-Sp (Rev. 4/96( pg 7 `~ pf `2 ~u CEXHIBIT B -FEE SCHEDULE t. Daily Rate. The daily rate is $~. The morithly 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-Privat Triple The following are paid by Medicare in 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 fist 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 bil( will reflect associated charges and he/she agrees to pay them in accordance with the Agreement. ~ 5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior written notice, or, in case of emergency or change in level of care, with such prior notice as is reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the Facility no later than the day before the rate increase is effective. MNPOOa•2o fRev. 4/98) D9 B 7 Ot 2 ~~ 6., Refunds. Refunds shall be paid within thirty (30) days after discharge or transfer. f f 7. Funding Sources. The Facility makes no assurances that the Patient/Resident's Cara 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. Ariy 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 faw 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 ehforce 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 shalFpay, the daily Xate 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 program. If the Patient/Resident believes i he 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. MNP008.20 (Rev.4/98) D9 B 2 Of 2 EXHIBIT C -- PHARMACY AGREEMENT The Facilit~ lies developed policies and procedures for'drug therapy, distribution and controh- w-h h 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 any reason after written notice of such intent has been given to the Patient/Resident. ~t,~ 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 ac~ov~edye~agree in writing that it will comply with the Facility's uniform medicati n dis -i utt n syst m, the Facility's policies and procedures and applicable law--'~,, ~ ~ ~ ~~~`~., R2stfoyfsible Party -Printed Name ~ /7-,~ Date MNGOOe-zo IRev. 4/96) pg 10 t pf ~ •. wwwlal.. _ ..._.d...._. _., ._.. I I .~.,...-~,..~w~~.:~,o~ss.~., i.,~,..,x~ MSR SCREENING QUESTIONNAIRE Patient/Resident Name: Service Dates: /~ - "i "7 - No.: Ask all four questions of each Medicare Patient/Resident. if the Patient/Resident responds "Yes" to any question, continue to page two asking all applicable questions. The Patient/Resident or repre- sentative should sign the form whenever possible. NOTE: It is important to ask all questions and document all answers regarding MSP. A provider may be held liable if an overpayment occurs and Medicare finds that the provider furnished erroneous information or failed to disclose facts it knew were relevant to payment. 1. Is the Patient/Resident covered by the Veterans Administration, the Black Lung Program or Workers Compensation? ( /) No: Proceed to question #2 Yes: Bill the other insurer prior to Medicare 2. Is the illness or injury due to any type of accident? ( ~) No: Proceed to question #3 or #4 Yes: Complete next page and continue with questions below #3 IF 65 OR OVER #4 IF UNDER 65 3. Is the,Patient/Resident 65 or over and employed, or is the spouse employed at time of service? ( ,/) No: Retirement Date: Patient/Resident Spouse Continue: See Note Below Yes; Complete next page -Medicare may not be primary 4. Is the Patient/Resident under 65 and covered under any Employer Group Heaith Plan (EGHP) or ~~e Group Health Plan (EGHP)? ( ) No: See note ( ) Yes: Complete next page -Medicare may not be primary Note: If answer to all questior If any response is "Yes' Patient/Resident /Representative Date ~~'~ L ,~- 1 of 3 MNCOOa•ZO (Rev. 4/96) pg 13 Patier Servi< Chec' 2. it/Resident Name: Medicare No.: ur - O-o 7 ., t , _l ;e Dates: _ k the appropriate box and answer the questions. ILLNESS/INJURY CAUSED BY ACCIDENT A. ( )Motor Vehicle: Name of Patient's/Resident's Automobile Insurer B. ( ) Another p ty was responsible for accident. Name and address of L bility Insurer Name and address of attorney C. ( )Work Related: Name of Wo kman's Comp. surer D. ( )Other accident (Slip and fall, etc.). xplain where accident occurred: Has the Patient/Resident filed or inten to file a bility suit? ( ) No: Bill Medicare and send opies of all p tinent documentation ( ) Yes: Name and address ~f: Liability Insurer Attorney Bill other Insurer prior to edicare; submit documentation Medicare if conditional payment requested. EMPLOYER GROUP OVERAGE FOR THOSE 65 AND OVER A. ( )Patient esident employed at time of-this service. Given a of Patient's/Resident's company/emplo er Does Employer employ 20 or more employees? ( )Yes ( ~. ) No Does the Patient/Resident have an Employer Group Heaith Plan (EGHP) by reason of his/her current employment? ( )Yes ( ) No If "No" give Date of Retirement If "Yes" give the name of the EGHP Bill EGHP prior to Medicare 2of3 MNO-009-ZO IFev.a/96) pg to B. i( ; •, 1) Patient's/Resident's spouse employed at the time of this service. Give name of spouse's company/employer ~ ' Does the spouse's employer employ 20 or more employees ( ) Does the spouse have an EGHP by reason of current employment which c ident? ( )Yes ( ) No If No, give the date of retirement If Yes, give the name of EGHP Biif EGH~.prior to Medicare 3. A. ( ) Patie~ and in the first 1~ Kidney transplant: MM/YY Does the Patient/ResideY~t guardian's Employer Group { ) No: Medicare Prim Give name EGHP Bill EGHP prior to Medicare ( ) No the Patient/Res- have coverage ealth Plan? r ( ) Yes: his/her, his/her spouse's, a parent's or name of the employer B. ( }The Patient/Resident is e~ytled to Medicare sole) because of disability (does not have/has not had ESRD). //~\ Does the Patient/Resident have c erage rough his/her, his/her spouse's, a parent's or a guardian's Employer Group Healt Plan? ( ) No: Medicare Primary ( } Yes: Continue Does employer(s) employ 1 or more employees? ( } No: Bill Medicare ( ) Yes: If yes, giv, name of each insured whose policy c ers the resident: a. b Give name of corr sponding employer: a. b Give name o orresponding EGHP: a. b. Bill EGHP(s) prior to Medicare 3of3 Resident is entitled to Medicare solely due to End Stage Renal Disease nonths of Medicare entitlement. Date f first Dialysis treatment or date of NINGOOe•YO (Rev. 4/96) pg 75 EXHIBIT D -STATE LAW ADDENDUM 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" rnHC•ooa•zo (Rev. 4/96) v9 >> 1 Of 1 ,~ `' ~ ManorCare MEDICARE ACCEPTANCE POLICY 'Hegtth Services This is to confirm that ~~3.~f? ~ ~ -~~ ~cL~li~ was reviewed at the time of admission and found to be eligible for Medicare benefits. Of course, the Medicare program may change coverage, eligibility or co-payments at any time, It is understood that as long as the Patient/resident meets the criteria for coverage, at present Medicare Part A will pay for Medicare Part A covered services for the first twenty {20) days. Beginning on the 21st day, there is a co-payment of $~~~_ per day for the next 80 days, a co-payment set by the federal agency which administers the Medicare program. But regardless of medical status, the maximum Medicare Part A benefit period is 100 days, which may include covered days at another facility. ~r w~~ 4~ ~ ~P~ ~~ { ~~ ~ `~-~5 t;~,l/Q,SS C Gil c~ It is also understood that as long as the Patient/Resident meets the coverage criteria, at present Medicare Part B will pay 80% of the allowed rate for Medicare B covered services. There is a 20% co-payment for these services that is the responsibility of the beneficiary. Vitaiink infusion Services may be the supplier contracted to supply enteral/parenteral feeding products and is an affiliate of Manor Healthcare. At the time Medicare coverage is denied or expires, a 30-day advance payment on the current Daily Rate will be required if the Patient/Resident is to remain at the Facility and if the care will not be paid by another approved third party payor. AUTHORIZATION OF PAYMENT OF MEDICARE BENEFITS TO PROVIDER I certify that the information given by me in applying for payment of Medicare Part A or Part B benefits under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or Carriers any information needed for this or a related Medicare claim. I further request that payment of authorized benefits be made on my behalf. I assign the benefits payable for the physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. For outpatient services, I request this authorization apply to the perio~ -- to ;• ~~ Facility Representative -Signature ~,~-Respon ible Party -Signature L Facility Representative - Pr' ted Name & Title p nsible Party -Printed Name Date Date iofl 7/96) P9 _i ^ "~ • AUTHORIZATION TO PAY INSURANCE BENEFITS ManorCare f ~ kIeadhh Services Patient/Resident's Name Insured ` I To (Insurance Company): ~V~1~`~ Claim # Policy I hereby authorize you to make direct payment to: MANORCARE HEALTH SERVICES Facility Name 940 WALNUT BOTTOM RD. CARLISLE, PA 17013 Facility Address herein after referred to as "Facility", otherwise payable to me. I understand that certain items/services, including but not limited to personal care items/services, are not covered by the third party payor named above. Items/services including but not limited to beauty/barber services, lotion, laundry services,'etc. are considered personal care items/services. I further understand that the Facility does not guarantee payment by the above third party for any items/services provided by the Facility. I agree that charges for personal items/services, as well as any other charges denied or not paid in full by the above third party for any reason will be my responsibility. Facilit//y////R77epresentative -Signature ,/~~/ Facility Representative ~n ed Name & Title ~ %_ ~ 7 - 9~ ~ ~, Party -Signature Res~pgfisible Party -Printed Name (~ /off-/ 7-9~" Date MRC•ooe-so IRev. 7/98) p9 20 i ~ ~ ~i INSURANCE COVERAGE A7anorCare ' Health Services ManorCare Health Services wants to be sure that all possible sources of insurance to pay for the resident/patient's care while staying with us are identified properly. Some insurance companies require precertification before they will pay for care provided. Please help us by listing all sources of insurance, and most important, by letting us know of any changes in the insurance company or types of coverage as soon as you become aware of the changes. Please state the correct order of the resident/patient's health insurance: I. Primary Insurance: M~-~~'~~-'~1h2--~ 2. Secondary Insurance: ~- 6~'~--- Is the resident/patient covered by Medicare? 'Yes - No Is the resident/patient covered by a commercial Medicare HMO? ~ Yes V No Does the resident/patient plan to change insurance carriers? _ Yes / No Has the resident/patient stayed at a hospital or skilled nursing facility within the past 60 days? Yes - No The information you provide will be used to bill the proper insurance company. If we are not given the correct information, or not informed of changes, the insurance company or Medicare may not cover care we provide. The resident/patient or the guarantor (if any) will then be responsible for paying for that care. Thank you for your help. 1 r~ fx l f c Lcn ~ l 2- ~~ ~6 Res' ent);Patien Date e on ' le Party Date (If Resident is unable to sign) MHC•001.128 (6/87) .w `N'~s3d.. x.rcWGYSe'. AU'T'HORIZATION TO RE~,EASE MEDICAL RECORDS Center Name Date MANORCARE HEALTH SERVICES Address Phone 940 WALNUT BOTTOM RD. CARLISLE PA 17013 (717) 249-0085 Dear Doctor/Medical Record Administrator: The person named below was hospitalized in your hospital or was under your care in the past and is now a resident at our center. RESIDENT'S NAME BIRTHDATE SOCIAL SEC,IJRITY NUMBER It is necessary that the nursing center obtain copies of the following from you for the resident's chart in order for us to provide appropriate care for the Resident and comply with Medicare/Medicaid requirements for a Nursing Facility. CURRENT HISTORY AND PHYSICAL - A xerox copy is acceptable. a HOSPITAL DISCHARGE SUMMARY - As soon as possible. CURRENT CBC REPORT -Please include date. A xerox copy is acceptable. a CURRENT UA REPORT -Please include date. A xerox copy is acceptable. a CURRENT CHEST X-RAY -Report and date. (OTHER) Could you please forward to us the most current information that you have on file at your earliest convenience. Thank you. I hereby authorize all erson and/or entities to release all or any part of my medical/health records to the center. ~~ OF R E T/RES NSI L PARTY/ OWE F ATTORNEY i / ~ DATE 1 .,F 1 MHC-008-16 p59-Ah • , eir ManorCare Health Services CONSENT TO PHOTOGRAPH As used below, the term "Photograph" includes video photography. COMPLETE ALL SECTIONS PUBLIC RELATIONS (check one) I do give my consens for me/the Patient/Resident to be photographed, or to have my/the Patient's/Resident's voice recorded, by or on behalf of the Facility, for advertising or public display, or by the news media. _ I do not give my consent for me/the Patient/Resident to be photographed, or to have my/the Patient'slResident's voice recorded, by or on behalf of the Facility for advertising or public display, or by the news media. AD~N/STRATIVE loheck onel _ I do give my consent for me/the Patient/Resident to be photographed, by or on behalf of the Facility, for administrative purposes including but not limited to proper identification for drug administration and treatment, and all other purposes related to my/the Patient's/Resident's health, safety or admission to the Facility. _ I do not Dive my consent for me/the Patient/Resident to be photographed, by or on behalf of the Facility, for administrative purposes including but not limited to proper identification for drug administration and treatment, and all other purposes related to my/the Patient's/ Resident's health, safety or admission to the Facility. MEDICAL (Check one) ,,;~ I do rive my consent for me/the Patient/Resident to be photographed, by the Facility, for medical monitoring and/or educational purposes, and/or reimbursement purposes„including, but not limited to wound and skin care, if necessary. Such photo apps-would not include identification except Patient/Resident medical record number 1 _ 1 do not clue my consent for medical monitoring and/or ec or Aesponsible PatientlResident or espon ible Party Signature Date I for Resident's Name tl.ast First, Mil Attending Physician ; Room Number PatientlResident Number ~~ -~ G ~ sx;:tt ~ -axu..a ~ , M ~_ (~ I Fy 1 DEPARTMENT OF __. HEALTH AND HUMAN SERVICES- . ~HEALTH~CARE~FINANCI7dG ADMINISTRATION S H ~ i NAME (P int or Type) H.I. CLAIM NUMBER ~) /~ q (1 / '/~) Secti I ~_.- APPOINTMENT.,OF-REPRESENTATIVE I appoint this individual: (Print or type name and address of individual you want to represent you.) to act as my representative in connection with my claim or asserted right under Titles XI, or XVIII of the Social Security Act. I authorize this individual to make or give any request or notice; to present or to elicit evidence; to obtain information;end-# receive any notice in connection with my claim wholly in my stead. ~ IG A pE (6 neficiary) , _ ADD .~~~ ~ ~ p__ ) [?L.. r ~ / ~J ~ ~ ~~ ELEP ONE NUMBER ATE ~ ~J ~ - a~ / / (Area Code) OS Section II - `ACCEPTANCE O F APPOINTMENT I, ,hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration or the Health Care Financing Administration; that f am not, as a current or farmer officer or employee of the United States, disqualified from acting as the claimant's representative; and that I will not charge or receive any fee for the representation unless it has been authorized in accordance with the laws and regulations referred to on the reverse side hereof. In the event that I decide not to charge or collect a fee for the representation I will notify the Social Security Administration and the Health Care Financing Administration (completion of Section III (optional) satisfies this require- ment). lama/an ADMINISTRATOR, MANORCARE HEALTH SERVICES (Attorney, union representative, relative, law student, etc.) E ( epresenta' ) ADDRESS 940 WALNUT BOTTOM RD. CARLISLE, PA 17013 TELEPHONE NUMBE DATE (Area Code) (717) 249-0085 Section III VI/AIVER OF FEE OR DIRECT PAYMENT ' ' _ (Note to Representative: You may use this portion of the form to waive a fee or to waive direct payment of the fee from withheld past-due benefits.) I waive my right to charge and colleot a fee for representing t` O-~') ~O ~~0--~ ~~"""`="~¢'~~='f ~- before the Social Security Administration or Health Care Financing Administration. SIGNATURE DATE (See important information on reverse) FORM HCFA•1698-U4110-84) i of i MRC•OOa•ze (Rev. 4/96) pg 12 ~ ~ A f ~} + . ^ „ , ManorCare Health S@r~~fc@s PATIENT SELF-DETERMINATION ACT ACKNOWLEDGEMENT To Our Residents: Pursuant to federal law, it is this Facility's policy to: (1) provide you with written information regarding your rights under state law to make decisions regarding your care, including the right to refuse care and to make advance directives (living wills and durable powers of attorney for health care); (2) provide you with the Facility's written policies regarding implementation of those rights; (3) document in your medical record whether you have an advance directive; (4) not to condition the provision of care or otherwise discriminate against you based on whether you have executed an advance directive; and (5) ensure compliance with state law regarding advance directives. To assist us in complying with these requirements, please complete, sign and date the following information: t 1. I, the undersigned Resident/Responsible Party (circle one) have received a copy of the Facility's Guidelines for "No Heroics" Requests, as well as a copy of state law information concerning medical care decision-making and advance directives. 2. The Residert_does/does not (circle one) have an advance directive at this time. If the Resident has ari advance directive, it is a living will/durable power of attorney for healtFi care (circle one). A copy of the advance directive is attached. i~ . ~,-~- -""~ By (5ignature~of Resident/Responsible Party) ( > Print Name: (If Responsible Party, check here and indicate relationship to Resident) Date: (If the Resident does not have an advance directive and wishes to make one, please contact your attorney or the local Ombudsman, State Department of Health or Office on Aging for valid forms.) .. o ' ~a ~~ ~ w ~ ~o ~~ ~~ T ~~~~ J ~% + ~~ 1 ~_, :n ;,; l1 (' 1. ~[ _ ` ~~ r lJ PRAECIPE FOR WRIT OF EXECUTION (MONEY JUDGMENT) P. R.C.P. 3101 to 3149 HCR MANOR CARE, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff vs. JUDGMENT NO. 01-5222 ~, d LINDA ANISLEY, I PRAECIPE FOR WRIT OF EXECUTION (MONEY JUDGMENT) Defendant(s) To the Prothonotary: ISSUE WRIT OF EXECUTION IN THE ABOVE MATTER, (1) Directed to the Sheriff of Cumberland County, Pennsylvania; .1F (2) against, Linda Amsley, i~x~ieHe-BifTt*nderfer, 548 2nd St., Carlisle, PA 17013 Defendant(s); (3) and against, M & T Bank, 1 W. High St., Carlisle, PA 17013 Garnishee(s); (4) and index this writ (a) against, I Linda Arnsley, Defendant(s) and (b~ against, M & T Bank, Garnishee(s), as a lis pendens against the real property of the Defendant(s) in the name of the Garnishee(s) as follows: (Specifically describe property)` ***ADDRESS*** 548 2nd Street, Carlisle, PA 17013 ALL PERSONAL PROPERTY OF ANY NATURE LOCATED WITHIN THE HOUSEHOLD OR IMMEDIATE VICINITY OF THE DEFENDANT(S) ADDRESS AND ALL OTHER PERSONAL PROPERTY WITHIN THE DOMINION AND CONTROL OF THE DEFENDANT(S) WHEREVER IT IS LOCATED SHALL BE SUBJECT TO THE LEVY. You are directed to attach the properly of the Defendant(s) not levied upon in the possession of M & T Bank 1 W. High St. Carlisle, Pa 17013 Garnishee(s) All accounts including but not limited to all savings, checking and other accounts, certificates of deposit, notes receivables, collateral, pledges, documents of title, securities, coupons and safe deposit boxes. Amount due $ 11.962.44 Interest from October 31, 2001 To Be Determined At an interest rate of 6% per year Total $ 11,962.44 Plus costs & interest Dated / ~2- G~~~ Daniel F. Wolfson, Esquire Attorney ID # 20617 267 E. Market Street York, PA 17403 (717)846-1252 ~~~ ~ ~~ _ r o ~~~ ~ ~~ N ~ r~ M (~ ^~ ~ ` c//~~ /~ ~ `F~- YC j~ '~ ~( w '60. ~ mrr, ~ ~~'~ " ,~ r ~ ^ ~ zx~ ~ ,- '" ~c~ ~ ~e z -.i ~ ~~~ ~. R. Thomas Kline, Sheriff, who being duly sworn according to law, states this writ is returned STAYED. Sheriff s Costs: Advance Costs: 150.00 Sheriff's Costs: 103.98 Docketing ~ 18.00 Poundage 2.03 Advertising Law Library . 50 Prothonotary 1.00 Refunded to Attyon 5/2/02 Mileage 3.4 5 Misc. Surcharge 30.00 Levy 40.00 Post Pone Sale Garnishee 9.00 103.98 Sworn and Subscribed to before me This ~,~,..( day of 2002 A.D. ~ rothonotary 0 u N So Ans ers• R. Tho as Kline, Sheriff r BY 1.~ ''P,t,~~ ,, ,~ -~`~d ~ ~~ t7 S1, ! ~~ r-a~'S tlu `~ Z g ~a~ c u L ~~ ~-"~ AlC;' ;~i0 ~?7 ~~ ~ J'0 C,123~a~,4 .` r.sav~rni.xwsaea~%& itS~a'~nx! ., _~ ..::-.. w.msueere~~ ime~n~a~aeeew¢~.3sxwea~w~:~u'.~;ae WRIT OF EXECUTION and/or ATTACHMENT COMMONWEALTH OF PENNSYLVANIA) COUNTY OF CUMBERLAND) NO 01-5222 Civil CIVIL ACTION -LAW TO THE SHERIFF OF CUMBERLAND COUNTY: To satisfy the debt, interest and costs due HCR MANOR CARE, Plaintiff (s) From LINDA AMSLEY, 548 END ST, CARLISLE, PA 17013 (1) You are duected to levy upon the property of the defendant (s)and to sell ALL PERSONAL PROPERTY OF ANY NATURE LOCATED WITHIN THE HOUSEHOLD OR IMMEDIATE VICINITY OF THE DEFENDANT(S) ADDRESS AND ALL OTHER PERSONAL PROPERTY WITHIN THE DOMINION AND CONTROL OF THE DEFENDANT(S) WHEREVER IT IS LOCATED SHALL BE SUBJECT TO THE LEVY . (2) You are also duetted to attach the property of the defendant(s) not levied upon in the possession of M & T BANK,1 W. HIGH ST., CARLISLE, PA 17013, ALL ACCOUNTS INCLUDING BUT NOT LIMITED TO ALL SAVINGS CHECKING AND OTHER ACCOUNTS CERTIFICATES OF DEPOSIT, NOTES RECEIVABLES, COLLATERAL, PLEDGES, DOCUMENTS OF TITLE, SECURITIES, COUPONS AND SAFE DEPOSIT BOXES. GARNISHEE(S) as follows: and to notify the gamishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant {s) or otherwise disposing thereof; (3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession of anyone other than a named garnishee, you aze duetted to notify him/her that he/she has been added as a garnishee and is enjoined as above stated. Amount Due $11,962.44 L.L. $.50 Interest FROM OCTOBER 31, 2001 AT AN INTEREST RATE OF 6% PER YEAR Atry's Comm % Due Prothy $1.00 Atty Paid $123.00 Other Costs Plaintiff Paid Date: APRIL 5, 2002 CURTIS R. LONG Prothonotary, Civil Division ~~ ~ ~~~~ REQUESTING PARTY: Name DANIEL F. WOLFSON, ESQUIRE Address: 267 E. MARKET STREET YORK, PA 17403 Attorney for: PLAINTIFF Telephone: 717-846-1252 Supreme Court ID No. 20617 v ,~ . . r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-5222 Plaintiff vs. ISABELLE DIFFENDERFER, Individually and LINDA AMSLEY, Individually and on Behalf of ISABELLE DIFFENDERFER, Defendant CIVIL ACTION-LAW INTERROGATORIES TO GARNISHEE IN AID OF EXECUTION TO: M & T Bank 1 W. High Street Carlisle, Pa 17013 PURSUANT TO RULE 3114 OF THE RULES OF CIVIL PROCEDURE, THE FOLLOWING INTERROGATORIES HAVE BEEN SERVED UPON YOUR INSTITUTION. GARNISHEE IS HEREBY REQUIRED TO ANSWER EACH OF THE FOLLOWING INTERROGATORIES SEPARATELY AND FULLY. PLEASE COMPLETE THE FOLLOWING INTERROGATORIES TO ASSIST THE CREDITOR'S EFFORTS TO SATISFY THE LAWFUL OBLIGATION OF THE ABOVE REFERENCED DEBTOR(S). IMPORTANT NOTICES AND INSTRUCTIONS TO GARNISHEE! A. You are required to file answers to the following interrogatories within twenty (20) days after service upon you. Failure to do so may result in judgment against you. B. The term "Defendant(s)" means the individual(s) or entity against whom the Writ of Execution was issued. C. "You" means the main office and all branch offices, representatives, employees, and agents of your organization. D. By service of the Writ of Execution upon you, all property of the Defendant(s) subject to attachment which is in your possession, custody or control is attached, including all property of the Defendant(s) which comes into your possession thereafter. E. These Interrogatories are considered to be continuing and therefore should be modified or supplemented as you receive further or additional information. F. Where exact information cannot be furnished, estimated information is to be supplied. When an estimate is to be used, it should be identified as such, and an explanation should be given as to the basis on which the estimate is made, and the reason the exact information cannot be furnished. G. Where knowledge or information in possession of a party is requested, such request includes knowledge of the party's agents, representatives, and attorneys. SS#175-03-3320- & 168-36-9058 PLAINTIFF'S INTERROGATORIES TO GARNISHEE DEFENDANT - tSABELLE DIFFENDERFER AND LINDA AMSLEY SS# ISABELLE 175-03-3320 8~ LINDA 168-36-9058 Ch~r~~n #~ // 3 585 ~~,~a~e~ ~~ 32 Lln~~ ~ ~~ / BAL!~hI!;ES PR©VIDED ^nAY IVOT PtEFLECT 'JN1='~STED i~FiANSACTIONS 1. DEPOSITORY ACCOUNTS: At the time you were served or at any subsequent time, state whether or not the Defendant(s) maintains any checking, savings, lines of credit, certificate of deposit's or other depository accounts with your institution. !f so, state the identification numbers of those accounts, and the amount or amounts the Defendant(s) has in each account. If the Defendant(s) maintains any of these jointly with any other person, or persons, give their name and address. 1A. DIRECT DEPOSIT ACCOUNTS: Are any of the accounts you have listed above direct deposit accounts? If yes, please state the identification numbers of those accounts. ~b 2. SAFE DEPOSIT BOXES: At the time you were served or at any subsequent time, state whether or not the Defendant(s) maintains any safe deposit box or boxes. If so, include the identification number or other designation of the box or boxes. Include a full description of the contents and also the amount of cash among those contents. If the Defendant(s) maintains any of these jointly with any other person or persons give their full name and address. ~(~ 3. PERSONAL PROPERTY: At the time you were served or at any subsequent-time, state whether or not Defendart(s) owns any personal property that was in your possession and/or control. If so, include a full description of all personal property giving full value and present location. State also whether or not there are any encumberances or liens holders, the present balance of the encumberance. State where and when the encumberances or liens was recorded. If the Defendant(s) owns any personal property jointly with any person or persons, give names and address. ~v ,. ,, 4. OTHER ASSETS: At the time you were served or at any subsequent time, did you know of the existence of any other asset(s) of the Defendant(s) which are not disclosed in the preceding Interrogatories. If so, please set forth all details concerning those asset. ~~ 5. PROPERTY: At the time you were served or at any subsequent time, was there in your possession, custody, or control or iri the joining possession, custody, or control of yourself and one or more other persons any property of any nature owned solely or in part by any Defendant(s)? If so, please describe for each Defendant each item of property including its value. ~~ 6. REAL PROPERTY: At the time you were served or at any subsequent time, did you hold legal, or equitable title to any property of any nature owned solely or in part by the Defendant{s) or in which and Defendant(s) held or claimed any interest? If so, describe for each Defendant each item of property including its value and the interest held by the Defendant(s). ~~ ,. .... .. , .., .~ .. ~-. I I _.. ~ ~_ ~,~~ o ~ w 7. PROPERTY HELD AS A FIDU subsequent time, did you hold as a fidu interest? If so, please describe for each value and the interest of Defendant(s). At the time you were served or at any ~perty in which any Defendant(s) had an s) the nature of the property including its i~~ 8. TRANSFER OF PROPERTY: At any time before or after you were served, did any Defendant(s) transfer or deliver any property to you or to any person or place pursuant to your direction or consent If so, for each Defendant(s) describe the property transferred or delivered including the dates of delivery or transfer and state the consideration paid. ~~ 9. FEES OUTSTANDING TO GARNISHEE: Are there any attorneys fees or processing fees charged by you against the Defendant(s) or account(s) of the Defendant(s) for the completion of this Answer. If yes, outline the exact amount of any fees due and owing to the garnishee or the attorney for the garnishee for the preparation of the Answer. Dated: ~ 2 ~~ WOLFSON & ASSOCIATES, P.C. BY: ~~~G~ Daniel F. Wolfson, Esquire Attorney I.D. # 20617 267 East Market Street York, PA 17403 (717) 846-1252 MANUFACTURERS AND TRADERS TRUST COMPANY By: Name: Nancy J o mson Title: Legat Docurent Analyst Legal Document Processing PO Box 844 Buffalo New York 14240 (716)635-0210 ~ ~-..' ` ~ ~'cail%sm~ ..:.v~ae-, oMnsx *~rt='~i3~2i~xe-axsswxs.,. ~~ . a .~ ..r.,==r ~ ~ trra::'~~ - ~ a G ~ b~ = -R 1 ^ , ~_~. ' v• ' ~7;. <.a'- ~~. f , ,~; ~ri ;~'3 ~~ , .. ~ ~~. r "" ,~~ 7` J ~ ~.~-^~~ AI.n~~ °-~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, v. NO. 01-5222 ISABELLE DIFFENDERFER, Individually and LINDA AMSLEY, Individually and on Belalf of ISABELLE DIFFENDERFER Defendant, v. M & T Bank Garnishee, CIVIL ACTION-LAW PRAECIPE TO ®ISCONTINUE ATTACHMENT EXECUTION TO THE PROTHONOTARY: Kindly mark the attachment against the Garnishee, M & T Bank discontinued, upon payment of costs only. Respectfully submitted, Dated: ~ Q~ WOLFSON & ASSOCIATES, P.C. By: ea s>~ Daniel F. Wolfson, Esquire Attorney for Plaintiff WOLFSON & ASSOCIATES, P.C. 267 East Market Street York, Pennsylvania 17403 Telephone No. (717)846-1252 Attorney I.D. No. 20617 0 ~ ~~ C', 1 ~ s""`~ i ~ ° G u y e> << ~ ~~ :: -, n =:;~ ~ : -~ ° _,.. ,. r _' .. `~ ~$ ~ ~ ~~ i ~~•1