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01-05242
w IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. O I -,$'ac~~ Plaintiff vs. CIVIL ACTION • LAW GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, 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 Iademanda 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 nose defienda, la Corte 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 ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Refercal Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249.3166 I i r A ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff No. Ol - S'a~~ ~~ ~ ~L~~ vs. GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, Defendants CIVIL ACTION -LAW COMPLAINT AND NOW, this day of , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 8t Associates, P.C., and files the within Complaint and in support avers as follows: Plaintiff, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1701 1. 2. Defendant, Gladys Burns, is an adult individual with a last known address of 6130 15`" Avenue, Sacramento, California 95820. 3. Defendant, Sharon Daniels, is an adult individual with a last known address of 420 Reily Street, Harrisburg, Dauphin County, Pennsylvania 17102. 4. That Defendant Sharon Daniels represented himself to be the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns. Defendant Sharon Daniels is the daughter of Defendant k - - .aivc_a..~ _ ~ ~., C Gladys Burns. 5. That on or about April 21, 2000, through on or about November 13, 2000, Defendant Gladys Burns 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 April 21, 2000, Defendant Sharon Daniels executed an Admission Agreement, on behalf of Defendant Gladys Burns, 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 is attached hereto, incorporated herein, and marked as Exhibit "B". 7. By executing said Admission Agreement, Defendant Sharon Daniels did assume and accept responsibility for the debt to be incurred by Defendant Gladys Burns in the event of a breach of the duty to provide payment from Defendant Gladys Burns' income or resources or for failure to provide information about the finances of Defendant Gladys Burns requested by Medicaid which resulted in a denial of Medicaid benefits. 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. That Defendants did not object to the above mentioned 2 r R Statement of Account submitted by Plaintiff to Defendants. 10. On or about October 24, 2000, the Department of Public Welfare sent a notice to Defendants outlining additional information which was required to complete the Medicaid application. A true and correct copy of the relevant portion of this notice is attached hereto, incorporated herein, and marked as Exhibit "C". 1 1. On or about November 14, 2000, the Department of Public Welfare forwarded another notice to Defendants which reiterated prior requests made to Defendants to confirm the financial information of Defendant Gladys Burns. A true and correct copy of the notice dated November 14, 2000, is attached hereto, incorporated herein, and marked as Exhibit "D". 12. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Gladys Burns' account as a result of said charges is the sum of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/100 Dollars ($25,984.37). See Exhibit "A" as previously identified and incorporated herein by reference. 13. 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 Gladys Burns' account balance, all to the damage and detriment of the Plaintiff. 14. Plaintiff has made numerous requests to Defendant Sharon Daniels, as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns, demanding that the sums due and owing to Plaintiff 3 c be paid, and Defendant Sharon Daniels has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Gladys Burns. 15. That Defendant Sharon Daniels violated her duties and responsibilities as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns by not utilizing Defendant Gladys Burns' finances to pay Plaintiff when she knew or should have known there were outstanding medical care bills for Defendant Gladys Burns. 16. That the finances of Defendant Gladys Burns rightfully belonged to Defendant Gladys Burns for her necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Sharon Daniels's mother, Defendant Gladys Burns. 17. Plaintiff has retained the services of the law firm of Wolfson at Associates, P.C., in the collection of the amounts due from Defendants. 18. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay all court costs and reasonable attorney's fees if the account is turned over to an attorney for collection. See Exhibit "A". 19. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 8i 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 4 r proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 20. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Seven Thousand Seven Hundred Ninety-Five and 31/100 Dollars ($7,795.31). 21. Pursuant to Section 1, Paragragh 1.03 of the Admission Agreement, Plaintiff is entitled to receive and Defendants agreed to pay contractual interest at a rate of eighteen percent (18%) per year on balances not paid within thirty (30) days of billing. 22. The amount of interest which has accrued from September 4, 2000 is the sum of Four Thousand Five Hundred Twenty-One and 93/100 ($4,521.93). 23. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 24. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 Y WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gladys Burns, Individually, and Sharon Daniels, Individually and on behalf of Gladys Burns, in the amount of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/ 100 Dollars ($25,984.37), reasonable attorney fees in the amount of Seven Thousand Seven Hundred Ninety-Five and 31/100 Dollars ($7,795.31), contractual interest in the amount of Four Thousand Five Hundred Twenty-One and 93/100 Dollars ($4,521.93), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON 8L ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff T 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. 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: l ~~~~G~(A-fi{.C- Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" HCR•ManorC~e r . MANORCARE CAMP HILL 583 1700 MARKET STREET CAMP HILL, PA 17011 (717)-737-8551 GLADYS M. BURNS FOR GLADYS M. BURNS 326 EMERALD ST. HARRISBURG, PA 17110 Statement Please Return This Portion With Your Payment MEDICAID PRIVATE ROOM 204 -B BURNS, GLADYS M 49 06/10/00 11/13/00 02/28/01 ---------------------------------------------------------------------------- DATE OF CODE ~ SERVICE RENDERED CHARGES CREDITS SERVICE 02/01/01 BALANCE FORWARD 25,984.37 PAYMENT DUE BY THE 10TH 25,984.3? AMOUNT DUE 03129!01 B@SIDBNT LNDGBN AS OF DATE OF FINS! ACTIVITY PAGE 1 ~ARS6~ R86IDSNT RESIDENT R86IDENT GIL -- ACCOUHT6 R8C@IYABLB -- NUMBER TYP@ NANB DATS QTY ACCOUNT CBANGBS CREDITS BALANCB 49 NBDICAIO BURNS, GLADYS N 06/10(88 ADN CNTR RATE: 0.08 BOON 284 -B LEVEL 2 11!13108 DIS PRIV PORT: 1185.00 "PRIVATE - APR 00 11600 CABLE RENTAL 04121101 -- 04!30108 1 59158481120 5.00 "ENDING BALANCB 5,00 "INSURANCE -APR 81 29002 PBARNACY LEGEND 04121100 -- 04130100 1 54551201120 117.72 31082 PNABMACY NON LEGEND 841211/0 -- 0413/188 1 54951381121 91.54 14102 PHYSICAL TBBNAPY VISIT 04(24100 -- 04/28/80 15 52150207120 315.00 14412 PHYSICAL Tfl@RAPY BYAL 1412410/ 2 52151207121 50.88 11402 OCCUP TREBAPY EYAL 04/24!00 3 52550687128 15.00 I71B2 OCCUP THERAPY VISIT 84125100 -- 04128!00 10 52558601121 250,01 BOON CHARGE AT 219.00 04121100 -- 04130/08 10 51350001120 2191.00 "ENDING BALANCE 3208.36 "NCN CO INS - APN 00 10208 PT B CO-INS LAB-GLUCOSE N 04121100 2 1.15 18208 Pf B CO-IN8 LAB-GLUCOSE N 04122!08 2 1.15 10208 PT B CO-INS LAB-GLUCOSE M 04123100 2 1.75 10208 PT B CO-IN8 LAB-GL00088 M 04!24!00 2 1.15 10208 PT B CO-INS LRB-GLUCOSE N 04125100 1 .87 10208 PT B CO-IN8 LAB-GLUCOSE M 04!26!80 2 1.15 10208 PT B CO-INS LAB-GLUCOSE N 04128100 2 1.75 88V GL00088 D8000CT 04!30/80 14411058888 11,36 "ENDING BALANCE .01 "NBDICRRB B - APR 00 10208 LAB-GLUCOSE MONITORING 84121100 2 56151911120 8.74 10208 PT B CO-INS LAB-GL00088 N 04!21100 2 1.15 10208 LAB-GL0006E MONITORING 04122100 2 56151911120 8.14 10208 PT B CO-IHB LA8-GLUCOSE N 04122100 2 1.15 10208 LAB-GLUCOSE MONITORING 04123188 2 56151911120 8.74 10288 PT B CO-INS LAB-GLUCOSE N 04123!00 2 1.15 10208 LAB-GLUCOSE NOHITORING 04124100 2 56151911120 8.74 10288 PY B CO-INS LAB-GLUCOSE N 04124100 2 1.15 10208 LAB-GL00068 NOHITORING 04125100 1 56151911120 4.37 11208 PT B CO-IN8 LAB-GL00088 N 04125!00 1 .81 10208 LAB-GL00068 NOHITORING 04126180 2 56151911120 8.74 10288 PT B CO-IHB LAB-GL00088 N 04126!00 2 1.15 10208 LAB-G100068 MONITORING 04128100 2 56151911120 8.19 10208 PT B CO-INS LAB-GL00088 N 04128100 2 1.15 R8Y GLUCOSE DBOCUCT 04130108 14411050000 11.36 "ENDING BALANCB 56.80 "PRIVATE - NAY 00 BAL FND -LN- -30- -60- -90- -110+- 5,00 5,01 PAYNBHT 05118100 11210002000 5.00 11601 CABLE RENTAL 05101111 - - 05131180 1 59158411120 5.00 "ENDING BALANCE 5.80 " INSURANCE -MAY 00 03!29/01 ~AR56~ RESIDENT LEDGER A6 0V DATB OF VINST ACTIVITY FAGS 2 NBSIDBNT RBSIDBNT N86IDBNT HUMBER TYPE NANB DATB QTY 49 MEDICAID BURNS, OLADYS M 06110100 ADN NOON 204 -B LBYBL 2 11113!08 DIS "INSUNANCB -MAY 80 (CONT~ SAL VND -LN- -30- -60- -90- 3288.36 29009 PAARNACY LEGEND 04121100 - - 05119108 29809 PHARMACY LEGEND 04/21100 -- 85119/00 14182 PNY8ICA6 THERAPY VISIT 05/01!00 -- 05131 /B0 17102 OCCUP THBRAPY VISIT 05!01100 -- 05116100 29009 PHARMACY L8G8ND 05181108 -- 05119100 30809 PHARMACY NONLNGBND 05116100 -- 05(14108 NOON CHARGE AT 219.08 05101108 -- 05131108 *'ENDING BALANCB "NCR CO INS -NAY 00 BAL VND -LM- -30- -60- -90- .01 10206 PT 8 CO-IN6 LAB-GL00086 M 85!01!08 18208 PT 8 CO-IN8 LAB-GLUC088 N 05183108 18208 PT 8 CO-IN8 LAB-GL00086 N 05185100 18208 PT B CO-INS LRB-GL0008B N 05108100 18208 PT 8 CO-INS LAB-GLUCOSE N 05!18!00 10288 PT 8 CO-INS LAB-GLUCOSB N 05112100 10108 PT 8 CO-INS LAB-G1000S6 M 0Sl15f88 10208 PT 8 CO-IN8 LAB-GL00088 N 05111100 10208 PT 8 CO-INS LAB-GL00088 N 0S119f00 10200 PT 8 CO-INS LAB-GLUCOSE M 05122188 10288 PT 8 CO-IN8 LAB-GLUC08H N BS124100 10208 PT B CO-INS LAB-GL00088 N 05/26180 10208 PT 8 CO-IN8 LAB-GL00088 N 85(29108 18288 PT 8 CO-INS LAB-GL00086 N 05!31108 RBV 200 GLUC DEDUCT 0S/31i08 "ENDING BALANCB "MEDICARE B - NAY 80 BAL VND -LM- -30- -68- -90- 56.80 10208 LAB-GL00088 MONITORING 85!01100 10208 PT S CO-INS LAB-GL00088 N 0SI0118B 10200 LAB-GLUCOSE MONITONING 05103188 10288 PT B CO-IN8 LAB-GL0008E N 05!83108 10200 LAB-GLUCOSE MONITONING 05105100 10288 PT 8 CO-IHS LAB-GLUCOSE N 05/05100 10208 LAB-G1000S8 MONITONING 05108100 10288 FT B CO-INS LAB-GL00088 N 85100!00 18208 LAB-GLUCOSB MONITORING 05110100 10208 PT B CO-INS LAB-GL00058 N 05!10108 10208 LAB-GL000SB MONITORING 05112100 18208 PT B CO-INS LAB-GLUCOSE N 85!12100 18208 LAB-GLUCOSB NONITDRING 05115100 GIL -- ACCOUNTS RBCBIVABLB -- A000UNT CHARGES CREDITS BALANCB CNTB RATE: 0.00 PRIV PORTS 1185.80 -120+- 3200.36 54551201120 109.81 54551287120 52150207120 2800.00 52550601120 925.08 54551201120 109.81 54951387128 45.64 51350881120 6109,08 1 1 80 31 1 1 31 109.01 13151.01 -120+- Z 2 2 14411850800 .01 1.15 1,75 1.75 1.15 1.15 . B7 1.75 1.15 1.15 1.15 .87 1.15 1.15 1.15 -120+- 56.88 56151911120 0.74 56151911128 8.14 56151911128 0.74 56151911120 8.74 56151911120 8.74 56151911120 4.37 56151911120 0.74 22.12 .03 1.15 1,75 1.15 1,15 1.75 .81 03!29(01 fl8SID8NT LBDGBfl AB OF DATE OR PIdST ACTIVITY PAGE 3 ~AR56) RESIDENT RESIDENT RESIDENT GIL -- ACCOUNTS RECEIVABLE -- NUN88R TYPE NANB DATE QTY ACCOUNT CflARGB$ CREDITS BALANCE 49 NBDICAID BURNS, GLADYS N BOON 204 -B L8V8L 2 "MEDICARE B -NAY 88 (CONT~ 18200 PT B CO-IRS LAB-GLUCOSE N 05!15100 10200 LAB-GLUCOSE MONITORING 05111!88 10280 PT B CO-INS LAB-GLUCO68 N 05/17100 10200 LAB-GLUCOSE MONITORING 05119108 18200 PT B CO-IN8 LAB-GL0006E M 05119!08 10200 LAB-GLUCOSE MONITORING 05122180 10280 PT B CO-INS LAB-GLUCOSE M 05122100 18200 LAB-GLUCOSE NONITOBING 85124100 10280 PT B CO-IN6 LAB-GLUCOSE N 0S/24/08 10208 LAB-GLUCOSE MONITORING 85126/08 10200 PT B CO-INS LAB-GLUCO6B N 05126100 10288 LAB-GL00088 MONITORING BS129100 10208 PT B CO-INS LAB-GLUCOSE N 85129108 10208 LAB-GLUCOSE MONITORING 85131180 1A288 PT B CO-IN8 LAB-GLUCOSE M 05/31!08 R8V 204 CLUC DEDUCT 05/31/08 "BNDING BALANCE "PRIVATE - JUN 00 BAL RND -LN- -38- -60- -98- 5.08 FAYNENT 06114180 10208 BL000 GLUC088 TBBf 06112100 10280 BLOOD GLUCOSN PBST 06!14180 18208 BLOOD GL00088 PBSP 06116100 1028$ BLOOD GLUCOSE TEST 06114100 10288 BLOOD GLUCOSS TEST 86121188 10208 BLOOD GLUCOSE TEST 86(23108 iB20A BL00D GLUCO$8 TEST 86126/00 54101 CATS TRAY 06129108 BOON CBABGB AT 136.80 06110100 -- 06/13100 BOON CBABGB AT 142.00 06!14!00 -- 06138100 ADV BOON CRARGE RT 142.00 01181100 -- 07131l0A "ENDING BALRNCB "INSURANCE -JUN 00 BAL FWD -LN- -30- -60- -98- 9940.65 3208.36 14102 PBYSICAL TBBRAPY VISIT 06101100 -- 06109100 10202 BLOOD GLUC088 TEST 86182100 -- 06/09/00 30007 PBARMACY NON L8G8ND 86107100 ANCILLARY NBITB OFF 06130100 BOON CBABGB AT 219.00 06101100 -- 86!09!08 "BNDING BALANCE "NCB CO INS -JUN 8B BAL FWD -LN- -38- -68- -90- .02 .01 06118100 ADM 11113108 DIS CNTR RATBs 0.08 PRIM PORT: 1185.88 2 2 2 2 2 2 2 1 1 2 2 2 2 2 2 56151911120 0.74 56151911120 8.14 56151911128 8.14 56151911128 4.37 56151911120 0.14 56151911120 8.74 56151911128 0.74 14411058088 22.72 2 2 2 1 2 Z 2 1 4 11 -120+- 5.00 11218002088 56151901220 0.74 56151981208 8.74 56151981208 0.14 56151901208 4.37 5615198120@ 0.74 56151981200 0.74 56151901200 0.74 56154181200 10.04 51350001220 544.00 51350001200 2414.00 13211800800 4402.80 1.15 1.15 1.75 1.15 .01 1.15 1.75 1.15 170.40 5.08 7426.85 -120+- 13151,81 18 52150287120 4S8.8B 1 56151981120 30.59 1 54951387120 .90 51551501120 9 51350007120 1971.00 i 15600.60 -128+- 03 03129101 ~AR56~ RESIDENT RBSIDNNT RBSIDBNT NUMBER TYPE MANS 49 MEDICAID BURNS, GLADY6 M ROOK 204 -B LBVSL 2 "NCR CO IN6 -JUN 00 ~CONT~ 18288 PT B CO-INS LAB-GLUC06B N 10288 PT B CO-INS LAB-GLUCOSE H "ENDING BALANCE "MEDICARE B -JUN BB BAL FND -LN- -30- 113.60 56.88 18288 LAB-GL00068 MONITORING 18288 PT B CO-INS LAB-GLUCOSE M 1@288 LAB-GLllCOSE MONITORING 18288 PT B CO-IN8 LAB-GLUCOSE N "ENDING BALANCE 'rPRIVATE - JUL 00 BAL FWD -LM- -30- 1426.85 RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGH 4 -60- -60- GIL -- ACCOUNTS RBCBIYABLB -- OATS QTY ACCOUNT C8ARG8S CNNDITB BALANCE 06/10/00 ADN CDTR RATB~ 8.00 11113180 DI8 PRIU PORT: 110S.0B 06/28/80 2 1.75 06/30188 2 1.15 3.53 -90- -120+- 110.48 06128100 2 56151911208 8.14 06128100 2 1.75 86/30/00 2 56151911208 0.74 06130100 2 1.75 184.38 -98- 10281 BLOOD GLUCOSE f86T 86128108 -- 06130!08 10281 BLOOD GL00088 TEST 87103!00 -- 07731180 RBV LAST NO RC 81181108 BOON CNARGB AT 149.08 01101108 -- 07131180 ADV ROOK C8ARG8 88181100 -- 08/31100 "ENDING BALANCE "INSURANCE -JUL 00 BAL FWD -LN- -30- 2451.59 9948.65 10201 BLOOD GLUCOSE TEST 10201 BL000 GLUCOSE TBSY ANCILLANY WRIRB OFF "ENDING BALANCE "NCR CO IN8 - JUL 80 BAL FND -LN- -38- 3.58 .82 RBV PT B CO-IN6 RBY PT B CO-INS NSV PT B CO-IN6 rrENDING BALANCE "NBDICARB B -JUL 00 BAL FWD -LN- -30- 13,48 113.68 10208 LAB-GLUCOSE NONITONING 18208 LAB-GLUCOSE MONITORING 10208 LAB-GLUCOSE NONITOBING 182@8 LAB-GL00088 MONITORING 10288 LAB-GLUCOSE MONITORING 18208 LAB-GLUCOSE MONITORING 18288 LAB-GLUCOSE MONITORING 18280 LAB-GLUCOSE MONITORING -60- -98- -120+- 3288.36 15608.68 84121/80 -- 84128108 13 56151901200 56.81 05101!08 -- 85131108 26 56151987200 113.62 87131180 57557507208 110.43 12312.10 15608.68 -68- -90- -128+- .@1 3.53 04138108 14411050000 .01 05131100 14411858880 .82 06130100 14411050081 3.50 -60- -98- -128+- 56,00 104.38 01103100 1 56151911200 4.31 @1183100 -- @7131108 23 56151911208 1@0.51 01105/88 2 56151911200 8.74 811@718@ 2 5615191120@ 0.14 81/10(00 2 56151911208 8.14 01112100 1 56151911200 4,31 01/14108 2 56151911200 8.14 01/11/00 2 56151911200 0.74 -128+- 1426.85 2 56151981208 8.14 23 5615190128@ 180.51 13211000080 4482.88 31 513580812@0 4619.00 13211000080 4619.08 03129101 RRSIDBNT L8DG8R AS OF DATS OF FINST ACTIVITY PAGR S ~ASS6( RRSI68NT RRSIDBNT R86IDRNT NUNBBS TYPE NANB DATE QTY 49 NNDICAI- BURNS, GLADYS N 06(101@8 ADN SOON 204 -B LBVBL 2 11113!00 DIS "NBDICARB B - JUL 08 (CONY( 18208 LAB'-GLUCOSE MONITORING 07(14100 18208 LAB-GLUCO88 MONITORING 87121180 10208 LAB-G1UCOSR MONITORING 01124180 18288 LAB-GL00088 NONIfORING 87126100 10208 LAB-GL00068 MONITORING 01128108 ANCILLARY NSITB ORF 07131/80 10208 LAB-GLUCO6B MONITORING 81!31(00 BRV PT B CO-INS 04130108 RSV GLUCOSB TEST 04130100 RBV PT B CO-INS BS131I00 R8Y GLUCOSE TBST 05/31108 S8V PT B CO-INS 86130100 SBY GLUCOBB T86T 06130/80 "BNDING BALANCS 'rPRIVATB - AUG 08 BAL FND -1N- -38- -60- -90- 9341.25 3024,85 RBV LAST NO BC 88!81108 280 CO-PAY 5100 85181108 'kBNDING BALANCE 'rNBDICAID -AUG 00 30081 PBASNACY NON LBGBND 08121180 ANCILLARY NRITB OFF 08131188 BOON CRARGB AT 149.08 08101108 -- 08131180 BOON NRITB OFF 88101100 -- 08131/80 '*BNDING BALANCS rrINSURANCB -AUG 08 BAL FND -LN- -30- -68- -90- 2451.59 9948.65 3208.36 PAYNBNT BC NAJ NRD 08104!88 PAYNBNT BLOB CROSS NAJ NB 08!84!80 RBV 208 CO-PAY 5100 05181180 "BNDING BALANCE 'rNBDICARB 8 - AUG 80 BAL RND -LH- -38- -60- -90- ,BI- "BNDING BALANCS '"PSIVATB - 88P B0 BAL FND -LN- -30- -60- -90- 216.29 4128.25 3824.85 11608 CABLE RENTAL 09/81180 -- 89138108 PSIUATB PORYION 09181180 -• 09130108 ADV PVT PORTION 18101/00 G!L -- ACCOUNRB RBCBIYABLB -- A000UNT CAARGBS CSBDITS BALANCS CNTS RATBt 0.00 PRIV POST; 1185.08 2 561519]1200 8.74 2 56151911280 8,14 2 56151911200 8.74 2 5615191120A 8.14 2 56151911200 8.14 S15S7511280 ,01 1 56151911208 4.31 14411050808 .01 56151911120 56.81 14411050880 .02 56151411120 113.62 14411858808 3,50 56151911280 17.48 01- -120+- 12312,10 13211008000 4619.88 14411058008 216.29 1469.34 ] 54951302288 .90 57551502200 .90 31 51350002200 4619.00 31 51551002280 1293.63 -120+- 3325.31 15608.68 11218002088 3288.36 11218802880 4132.36 14411050008 216.29 128+- 2451,59 01 01- -120+- 1969.39 1 59158401200 5.00 38 1185.88 13211000008 1785.88 83129101 (AR56( R88I08NT LEDGER AS OR DATB OR PI~ST ACTIVITY PAGE 6 RBSIDBNT RBSIDSNT R8SID8NT NUN88R TYPE NANB DATB QTY 49 MBDICAID BURNS, GLADYS H 06110100 ADN ROON 204 -B L8Y8L 2 11113/00 DIS '*PRIYATB - SBP 88 (CONY( *'BNDING BALANCB "MBDICAID -SBP 00 BAL RND -LN- -38- -68- -98- 3325.37 30001 PRARNACY NON LBGBND 09101!80 -- 09/23/08 51581 IRRIGATION PIBTON TRAY 89!06!00 ANCILLARY NRITB ORR 89130100 NOON CAARGB AT 149.00 09/81!00 -- 09!30/80 ROOK NRITB OFF 09101(00 -- 09!30/00 DEDUCT PYT PORT 09181700 -- 09130/00 `:BNDING BALANCB "INSURANCE -SBP 00 BAL RND -LN- -30- -60- -90- 2451.59 GIL -- ACCOUHT6 RBCBIYABLB -- ACCOUNT CAARGBS CR80ITS BALANCB CHTR RATE: 0.88 PRIY PORT: 1105.80 -120+- 3325.31 I 54951302208 64.19 1 54151502200 4.01 57551502200 30 51358002280 4418.00 30 51557082200 30 -120+- 2451.59 11544.39 14.00 1251.90 1785.80 4758.47 "BNDING BALANCB "MBDICARB 8 - 88P 00 BAL RND -LN- -38- -60- -98- -128+- ,01- .81 "BNDING BALANCB "PRIVATE - OCT 08 BAL RWD -LM- -30- -68- -90- -120+- 3515.08 216.29 4128.25 3024.05 11544.39 11600 CRBLB RENTAL IB131/OB 1 59158401208 5.00 R8Y LASP NO PP 10101108 13211000000 1705.00 PRIVATE PORTION 10101/00 -- 10131/80 31 1785.00 ADV PUS PORTION 11101188 13211000000 1185.00 RBV RN CRG 6100 06130/00 51350001220 544.00 R8V RM CAG 6100 06130100 51350081220 2414.80 RBV GLUCOSE T86P 06130100 56151901200 56.01 R6V CATS PRAY 86138/00 56154101208 18.04 BST PRIV PORTION 06130100 14411050000 1765.00 RBY GLUCOSE TST 01131100 56151981200 109.25 REV RN CBG 1108 81131108 51350801200 4619.00 88T PRI PORT 1180 01131180 14411058808 1185.00 BST PRI PORT 0108 08131100 14411050808 1185.00 "ENDING BALANCB "MBDICAID - OCT 80 BAL FND -LN- -30- -60- -90- -120+- 1433,10 3 325.31 4150,41 30001 PBARNACY NOH LEGEND 06!01100 -- 10/86188 1 54951302208 39.42 30802 PAARNACY NON L8G8N0 86101188 1 54451302200 .90 51501 CATR8T8R TRAY 10104/08 1 54151582208 18.08 ANCILLARY WRITE ORR 18131100 51551502208 48.52 ROOK CRARGE AT 149.00 10101100 -- 10!31100 31 51350802200 4619.88 2451.54 81- 18936.29 03/29!01 R8SID8NT L6DGBR A8 OF DATE OF FIRST ACTIVITY PAGE 1 ~AR56~ R66IDBNT RESIDENT R8SID8NT G1L -- ACCOUNTS RECEIVABLE -- NUNBBR TYPE NANB DATE QTY ACCOUNT C8ARG8S CR8DIT8 BALANCE 49 MEDICAID BURNS, GLADYS N 06110!00 ADN CNTR RATE: 0.08 ROOK 204 -B LBYEL 2 11/13(00 DI8 PRIY PORT: 1785,00 "MEDICAID - OCT 00 (CONf~ ROOK NRITE OFF 10101100 -- 10131100 31 51557082200 1181.61 DRDUCT PVT PORT 10181!00 -- 10131!08 31 1105.00 EST PRIY PORTION 86/30!00 14411050808 1105.80 SST PBI PORT 7(00 87!31180 14411850800 1105.08 SST PRI PORT 8188 88131100 14411058800 1785.08 "ENDING BALANCE 1044.86 "INSURANCE - OCT 08 BAL FND -LN- -30- -60- -98- -120+- 2451.59 2451,59 "ENDING BALANCE 2451.54 "MEDICARE B - OCT 00 BAL FWD -LM- -30- -60- -90- -128+- .01- .01 10208 LAB-GLUC086 MONITORING 10208 LAB-GLUCOSE MONITORING 10208 LAB-GLUC08B HONITORIHG 18208 LAB-GLUC088 MONITORING 10208 LAB-GLUC068 MONITORING 10208 LAB-GLUCOSE MONITORING 18208 LAB-GLUCOSE MONITORING 10288 LAB-GLUCOSE NONIYORING 10288 LAB-GLUCOBB MONITORING 10288 LAB-GLUC08E MONITORING 18208 LAB-GLUC08E MONITORING IB208 LAB-GLUC088 MONITORING 10208 LAB-GLUCOSE MONITORING 18208 LAB-GLUCOSE MONITORING 10208 LAB-GL000SE MONITORING 10208 LAB-GLUCOSE MONITORING 10288 LAB-GLOCOSB MONITORING ANCILLARY WRITE OFF MED BADS "ENDING BALANCR "PRIVATB - NOY 80 BAL FWD -LM- -38- 8930.80 1190.80 RBV LAST MO PP PRIYATB PORTION "ENDING BALANCE "MEDICAID - NOY 80 BAL FWD -LM- -30- 1646.39 1433.18 30009 PBARMACY NONL8G8N0 ANCILLARY WRITE OFF 10/02188 2 56151911200 0.14 10!04100 2 56151911208 0.14 18106100 2 56151911200 0.14 10109/00 2 56151911288 8,14 10130100 2 5fi151911200 8.14 10111!80 2 56151911200 0,74 18112!00 2 56151911208 8.74 10113100 2 56151911208 8.74 10114/00 2 56151911208 0.14 10/15100 2 56151911200 0.14 18(16/08 1 5615]911208 4.31 18110/00 2 56151911208 8.14 10120100 1 56151911200 4.37 10123180 2 56151911200 8.14 18!25100 1 56151911200 4.37 10127!00 1 56151911200 4.31 10/30/08 2 56151911200 8.14 10131108 57551511200 26.23 01101100 57551511200 .01 104.87 -68- -90- -120+- 216.29 10936.29 11101100 13211008000 1185.00 11101100 -- 11112108 12 1320.28 10479.51 -68- -90- -128+- 1540.31 1105,00• 1105.00• 1849.86 10106!00 1 54951302200 109.51 11130!88 57551502200 109.51 03129/81 R8SID8NT LEDGER AB OF DATE OR FIA6T ACTIVITY PAGE 0 ~AR56~ RSSIDBNT RS6ID8NT RESIDENT G/L -- ACCOUNTS RBCBIYABLB -- NUNBER TYPE NANE DATB QTY ACCOUNT CEARGBS CREDITS BALANCE 49 NBDICAID BURNS, GLADYS N 06/10100 ADN CNTR RATE: 0.80 BOON 204 -B LBVBL 2 11113100 DIS PRtV PORTS 1105.00 "NBDICAID - NOY 80 ~CONT~ ROON CHARGE AT 149.08 11/01/00 -- 11/12100 12 51350002280 1788.08 ROOK NRITE OFF 11!01/00 -- 11112f00 12 51551002200 454.72 DEDUCT PVT POHP 11101100 -- 11112/00 12 1328.20 RN CRG 06I3010B 51350802220 544.00 RN CHG 06/30100 51350002220 2414.88 RN W10 06130180 51557802228 120.24 RM NIO 06138100 51557002220 647.82 GL000H8 TEST 06130100 56151902200 56,01 CATS TRAY 06130180 56154102200 18.04 ANC WIO 86130100 57551502208 66.05 RH CBG 81131108 51350002200 4614.80 RN WIO 01!31100 51551002180 1293.63 GLUCOBS TEST 81!31!80 56151902208 109.25 ANC N/0 07131/08 57551582280 189.25 *'ENDING BALANCB 6551.97 "INSURANCE - NOY 08 BAL FWD -LH- -38- -68- -90- -128+- 2451.59 2451.59 "ENDING BALANCB 2451.59 "NBDICAR6 B - NOY 80 HAL RND -LN- -30- -68- -90- -120+- 104,81 104.07 "ENDING BALANCE 104.07 "PRIYAfB - DEC 08 BAL FND -LN- -30- -60- -90- -128+- 1320.20 1145.80 1198,88 216.29 1 0479,57 BC RBTRO TO PRIVATE 86/89100 52150201120 450.00 BC RETRO TO PHIVATB 06!09188 56151907120 38.59 06189/80 51350001120 1911.00 "ENDING BALANCB 12931.16 "MEDICAID - DEC 80 HAL FND -LM- -38- -fi0- -90- -120+- 1646,39 1433.10 1548.31 1930.11 6551.91 '*ENDING BALANCB 6551.91 "INSURANCE -DEC 80 BAL FND -LN- -30- -fi0- -90- -128+- 2451.59 2451.59 BC R8TR0 TO P@IYATE 06109100 52150207128 450.80 BC RETRO TO PRIVATE 06/89/00 56151907128 30.59 BC R8TR0 TO PRIVATE 86!89100 51350007120 1971.00 "ENDING BALANCB .00 "MEDICARE B - DBC 00 BAL FND -LN- -30- -60- -98- -120+- 104.87 104,87 "ENDING BALANCB 104.87 03/29/81 ~AR56~ BSSIDBNT RBSIDBNT RBSIDBNT NUNBBR TYPB NANB 49 NBDICAIO BURNS, GLADYS N BOON 204 -B L8Y8L 2 "PBIVATB - JAB 01 R88ID8NT LBDGBR A8 OV DATE OR RIBST ACTIVITY PAGB G/L -- ACCOUNTS RBCBIVABLB -- DAYS QTY ACCOUNT CAASGBS CHBDITS BALANCE 86110/80 ADN CNTR RATE: 8.00 11!13108 DIS PRIM PORT: 1185.80 BAL FWD -LN- -30- -60- -90- -120+- 1328.28 1145.08 1190.00 2661.88 1 2931,16 R8V RN CAARGB ADJ 06130100 51350001220 544.00 R8V RA CAARGB ADJ 06130!00 51358801220 2414.00 R8V CATS TNAY ADJ 06730/00 56154101208 18.84 B8Y PYT PORTION ADJ 06138/08 14411850000 1185.08 RBV RN CHG ADJ 87131/00 51350001280 4619.00 RBV PYf PORT ADJ 01131180 14411050080 1185,80 RBV PVT FORT ADJ 08131!00 14411850800 1185.00 BOON CAARGB 88131108 51358881208 4619.08 R8Y PVT PORTION 09130/00 14411858080 1185.08 IRRIGATIOA PISTON TR 04130/00 54151581288 4.81 ROOM CAARGB 09/30/00 51350001280 4619.00 CATflBTBfl PRAY 10131100 54151501200 10.00 ROOK CBANGB 10131180 51350881208 4619.00 RBV PYT PORTION 10131108 14411058808 1185.80 BBV PYT PORTION 11/30/88 14411050080 1328.28 ROOK CRABGB 11130180 S135B0B12B0 1841,64 '*BNDING BALAHCB "NBDICAID -JAN 81 BAL FWD -LN• -38- -60- -40- -120+- 1646.39 1433.10 3478.48 6551.97 RBY RN CHG ADJ 06/30/00 51350002220 544.00 RBV RW CRG ADJ 06138!80 51350002220 2414.88 R8Y RA WIO ADJ 06130100 51551882220 128.24 RBV RN WIO ADJ 06/38188 51551882220 647,82 R8V GLUCOSE ADJ 06130/00 56151902200 56.81 R8Y CATH TRAY ADJ 06130!80 56154102200 18.04 RBV AAC 810 ADJ 06138/08 51551502208 66,BS R8Y PVT PORTION ADJ 06/38/08 14411850880 1185,08 RBY PYT PORT ADJ 81/31108 14411850800 1185.88 B8V RN C8G ADJ 81131108 51350002208 4619.08 RBV RN X10 ADJ 07!31100 51557802208 1293.63 RBY GLUCOSE ADJ 01131180 56151902280 189.25 RBV ANC W/0 ADJ 01131100 57557502200 ]09.25 RBV FYT PORT ADJ 08131!00 14411050088 1185.08 RBV RN CBG 08131!00 51350882200 4619.00 RBY RN W10 88131108 51551082288 1293.63 RBV PYT PORTION 09138100 14411050000 1785.00 R8V IRRIG PISTON TRY 09138100 54151502288 4.81 R8V ANC WIO 09138108 51551582288 4.81 R8V ROOK CAARGB 09138108 51358802280 4418.88 R8Y RN W10 09/30100 51557002208 1251.90 B8Y CATA TRAY 18131180 54151582208 18.00 RBV ANC W/0 10(31100 51551582280 10.00 R8V RN CAG 10131(00 51358802200 4619,88 25984.31 03129!01 IAN561 BBSIOSNT ftBSIDBNT NUN88N TYPB RBSIOBNT NANB 49 NBDICAID BUNKS, GLADYS N NOON 284 -B LBVSL 2 "NBDICAID -JAN 01 (CONT) NNV NN W/0 N8Y PVT PONTION NBV PVT POBTION NBV NN CBANGB BBV NN WIO "NNDING BALANCS "NNDICANB B -JAN 01 BAL FWD -LN- -30- GLUCOSB TBST GLUCOSE TBST "SNDING BALANCB "PNIYATB - RBB 01 BAL FWD -LN- -30- "NNDING BALANCB "NBDICANB S - RNB 01 BAL FWD -LN- -30- "NNDING BALANCB NBSI08NT LSDGSS AS OR DATB 4F RIBST ACTIVITY PAGE 10 G!L -- ACCOUNTS RBCBIVABLN -- DATE QTY ACCOUNT CSASGSS CNBDITS BALANCS 86110100 ADN CNTS RATS: 0.80 11!13!08 DIS PNIY POftT: 1105.80 10131100 51551002288 1181.61 10!31!80 14411050888 1185.08 11130!00 ]4411850000 1328.28 11130/00 51350002200 1100.88 11130180 51551082280 459.12 80 -60- -98- -120+- 104.01 184.87 06138108 56151911228 5b.81 01131!80 5fi151911220 189.25 210.93 -68- -90- -128+- 1847.64 9989.80 14147,13 25984.31 25984.37 -68- -98- -120+- 104,87 166.06 218.93 278,43 ~~ EXHIBIT "B" HCR Manor Care ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Caze, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Caze's Health Caze Center ("Center"). Center: Resident: ~l~°r~~ys ~ ~YI'ls' Legal Representative: C~ (~.~r'~---~5~ Admission Date: ~l~l ~ ~~~~ Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIBH.ITIES OF THE RESIDENT 1.01 Room and Boazd Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10th) day of each month. The Resident shall be responsible for the Room and Boazd Rate for the day of admission as well as the day of dischazge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Caze Organization (see Section 1.06). 1.02 Ancillary Chazges. The Resident further agrees to pay to the Center all chazges for additional medical, therapeutic, or personal caze services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" aze described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and aze payable in full, along with the Room and Boazd Rate by the tenth (10`h) day of the month. 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be duectly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Proerams. If the Resident is eligible for coverage under any governmental program, such as Medicaze, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered chazges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reasan, the Resident will be chazged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs; /Medicaze, /Medicaid and/or _VA. Medicaze may pay for some or all of the Resident's Gaze. If Medicaze agrees to pay for the Resident's caze, there is a required co-payment, which Medicaze updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which aze not coveted by Medicaze Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center chazges such as Room and Boazd and nursing services aze covered, although Medicaid may require the Resident to pay a portion of the Room and Boazd Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Parry Payors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO'°), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered chazges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 will bill the Resident's third parry payor as a service, but the Resident remains Gable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they aze responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insu~cient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention io discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (51 dam of the Resident's disentollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied chazges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. It shaIl be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed Gaze organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily Gable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 ,. Agreement serves as a written notice that the Center has notified the Resident and/or Lega! Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed caze organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.1 t Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacv. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distnibution system similar to the Center's ancillary pharmacy's medication distribution system. R. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 LeaalAuthority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and changes provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products aze covered by a governmental program 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper marmer. 4 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition pemuts, who shall unconditionally be obligated to accept the Resident and to pay promptly all chazges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. IiI. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Boazd Rate, the Center shall fiunish basic room, boazd, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan' of care prepazed by the Residents physician and the Center, with the Resident's consent, for the. health, safety and general well-being of the Resident. ; 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the chazges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for caze of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consuhants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance 5 reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as aze necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Caze, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health caze decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record of other records and for any other similaz uses of the photograph for Center and staffto identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative' acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicaze Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds ~, .. -,.~~.. i _ . _. ~...I ... ~ ~ i i Authorization and any other related documents. See Attachment H-1 and H-2. g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). i. Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). j. The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical duector and other physicians who serve the Center. See Attachment I (Center Supplement). 1 Procedures, name, address and phone number on how to file a complaint with the state survey and. certification agency concerning resident abuse, ` neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m The Resident Handbook. See Attachment J. n. Resident/Patient Rights. See Attachment K o. Medicaze/Medicaid information and display of such information including how to apply for and use Medicaze and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which snmmari~es HCR Manor Care's Limited Treatment Practices and "No Cazdiopulmonary Resuscitation Orders" and a copy of the State summazy of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 a i ~ ~ s. ASM Foram See attachment P. t. See Attachment Q. u. See Attachment R. v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. . ~ 4.05 Assi~rmient of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service fiuYVShed by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Caze Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Dischazge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or deafly the Resident shall be responsible for all charges for the Room and Boazd Rate and for all services performed up to the end of the day that the Admission ends. Dischazge from the specialized units such as the Transitional Caze Unit or Subacute Unit may require less than seven (7) days notice. If dischazge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemrtification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property ~.,, ~, of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Chanp_es in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIIi SATISFACTION. Signature of Resident: Signature of Legal Representative, if signing on behalf of Resident: Date: Date: GI C ~ ~ ~ ~~ Signature of Legal Representative, signing on his/her own behalfi Date: ~~~ ~---Q Center Representative: ~ /Ttu'~r ~, Date: GI ~ ~-+ i I c'o i Yy i ' ~ ~ EXHIBIT "C" `~~'~ •~" ` NOTICE TO APPLICANT -=I DEPARTMENTOF PUBLIC WELFARE - __ CUMBERLAND COUNTYASSISTANCE OFFICE • • • • • - c - • ~ a • - - • • ~ , cv n.,m~,cn un PO BOX 599 - - ~ CARLISLE PA t70i3-0599 ~ P -. : _- BENEF{T eUClaua Euc°aT~c awolrvc - ` 1.500-269-0173 L71T) 9A0-2700 - ~ASSISTANCE~ -. - CHECK_ - ANer the Rrslrlteck which may be aspedal amount you wll receiva$ _ [~TvivAa Month ~OnceaMonth ~In Ufe Mail ~At the Bank - _ ~ - EDICAL ~ ~ ~ ASSISTANCE ~ you have a patlent AaY kab01N of $ ~~ - ~ ~ °~ t - - - -- - - - ~ - -- ~ (or the periotl beginning antl entling - ^ ERective Date - -" ~~~~ -- ~FOO1Y _ ST ~~ ~~ You w_ll receiva$- fwthe mDnth(s)Di 1Ten you will recetvefobd stamps In the amounf`ef$ ~"` smooth iMm to ~ ~Qln the Mad ~At the Benk URSING HOME CARS -~. Level of care auther~ed ~ ~ - "you are axpoctetl to pay $ ' a monm trnvarJ ~ ourcare, - ~r ii -T}IE FbL1.OWIN .P _._SA~1N~L ED - - _.. .. -: N NAME - HET P M ~ S C fJD NAME A P T ChE • • • • • • Regulation. _ _ fieason Csge _ Sinceyouur applic`a~t-i^o~n is over t e ay rocesa n_g t e co ,e_ a an___ t verification of JCLL7~. A~"1'GLF~+~'- ~ I I `71(70 - - . -- is -still - e to _- . be presented. We-are extending the application remember to provide all pending on the attached processing time to 45 days. notice as soon ,as possible or Please- th_e application DSTAMPS~ N`~tis_r, Yxerdgrl+3' []'ASSiSTA71CECHECiC_ -";_Nuritbef`a7PetagBa- - - Name S INWMY Name ~R J D N OMYY ~~ /. -._. _ - - _ ~11ame~ _. -.~-. ., ~- o y A NE IN OM - ,. _.. Name -_ . . - N I N ME J - -.. _ .. TOTAL GROSS MONTHLY YNCOME - ~ $ _ - TOTAL GROSS MONTHLY INCOME -- - - - $ - ~ ` _ GROSS MON'7ALY OEBENtlENT CdRE CO3T8 ~--` $ ~ -.--~. '-`"'- GROSS MONTHLY OEPENDENTCARE bOSTS- ~"° ` $ ~ --`~~ `-~'~°'~~' GROSS MEDICAL COSTS - - -~- $ ~ - - ~~ - - '-„?~ ;:'. rs :a Y~•`_ ~--'}' ~y„ ~:~~~.~'-~ ••. 7elephorta ~~--`-' ' ' Water)Sewage ~ `~--°~"' - ~. ME®ICAL ASSISTANCE 'i. ~. 71um°,~er o ` f~PersatF Electric - . GatbagelT2sh ~ Name UNOB N MINCAM~ Gas __ _ ~- '__ Utility Installation - ' - - - ~ _ ---- °' - - $ - ,~~ : GROSS UTIUTYC087S%U'fILITY STANDARD' ~~ - - - - $ ~ - ~~'~~-' ~ -_ -~~ - '° ~°" - ~- ' ~ ~ $ . REN7/MOg7GAGE _- ...:, <,.., s=,p..,. --. : $ _....,... .._, .. ...~:.-.-Name^`_ -.>:....: ..=: . N E ME -. _ ..::.: .. ..:_' TARE§. _. $ -: -:: ..-_ - ~ .~.__ ; .. ' :.~; ~ $ 77 ~/r - INSURANCE CO$TON HOME , - - _ ~ `~ . .- - _ - $ - - - ~ -- ° ~- ~ ~ ~ ~ ~"' ~ - ~~~' __ $ . ~ - TOTAL SNELYE73`CUSY _.: .: ° ' .' M $ _ ... _,_. _.~.., -. _ - s••N,_ E' - n'. - .. '. ~.._ $ /~L - "'"`4-'. - ^~' :~: '~N "-. r 'f~laj/ 3~i4'fCh ~6}i4T8$/J B ~ "~J18 hP - - ry COSJ3 ~ - 9 -' TOTAL GROSS M~i$THLY INCOME --~~ --~~ ~-~ - -'~~ $- ~- --~ i . 978A'dtlR7~. klUllty - sADwance §7 - iflB fllYle °Of ~r _ eapp77Caimn 877d On8 ~ NET MONTHLY INCOMElNET SEMIANNUAL INCOME - $ - -- - a1#?~,G1nA lYUliRQ gaCh fw6Ntl--Rid7tff7 PBdUd.. '' :'-,. - ,' :~. `.. ...: . INCOME LIMB - - - ~ ~ . - $ _- . CO RECORD NUMBER CAT - CTR DIO DI57 - - _ - zi - ~ynms- ~orct.Dn i0/Z~I ob_ /g002690! .2 - Workers Signature - - -' ~- 'Date 'Te e~phon®NUmber r - -.__ .. .~ -_ _. _: ~._ -1 --.-- .,.~¢N-FIELD .<'g,VAILA9)uEA`t`- ,.•' -" rn _ _ _ - LEGAL SERVICES, INC. - - - _ - ~~ ~~ ~ ^ _ ~ ~ _ ~ _ _ _ - 8 IRVINE ROW W t"WL~O~ CARLISLE PA 170133019 - - ..._-. 777.21&8400 Y77406.847b - CI_IFNT COPY + ~(f ~ K ~ ._ ij .~. i" f i i EXHIBIT "D" PP/FB,a2-aaa NOTICE TO APPLICANT - • • s ~ e • - • BENEFIT ,ELIGIBLE NOT PENDING ~ 1-. y ELIGIBLE DEPARTMENT OF P11611C WELFARE CUMBERLAND COUNTY ASSISTANCE OFFlCE - 33 WESTMINSTER DR K ~ r PO 80X 599 - ~ CARLISLE PA 17013-0599 1-800-2fi9.0173 (717)240.2700 - -- ^ A$$ISTA_NCE CHEC After [he frst check which may be a special amount you will receive $ _ ~ _ ^ iwiee a Month ^ Once a Month ^ In the Mail ^ At the Beek - - DICAL ASSISTANCE ^ You have a patient pay liability of § - - - - '" for the period beginning and ending ^ Effective Date - ^ FOOD STA S _ You will receive 5 For the month(s) of then you will receive food sC$mps in the ampbnt of § a month bom to ]] In the Mail - ~ A[ the Bank URSING HOME CARE Level of are autharizetl you are expected to pay $ a month toward your cara.~ ^ S VIU ^ 5 eci THE POLLOWiNG PERSON$ARB INCLUDED ~ ~_..., _, .•.. _ .- ~ ,_-:~,- - -_-_„_ _ __ _ __ ,_,,i * ` NO. NAME CH CK STAMPS ASS . SERVICE NO. NAME - CHECK STAMPS A ST. SERVIC 5 ccdx 1 1.1 ~ i•l s _ • • • • • Regulation .U4.Z Reason COtle O~Z ~~ _,vYL.fA~tv~9.- C7-/YLf~ ~OUrc2.~ ,e~ ~»~L.tc~..SZcRU ©f'~- ...... ~ ~.1 c~rLoC C7c. t zU . 2oo-a f1 ~ ~2 C~ccxLZ~~~iriLr~:~vE~~ J2DC~ ~cmoOcs rcxrq ~ n• v- c~~a rl ~12C3 ~7hcso ln'~r uxeo./vtg.c~• ~~ , are. oa v~ n.o~t. SZ ~-• _ - ° clo ~} --- C]_F0008TAMIPS - -- - Number,Rt Peret;~ _r ~-AS$ISTANCE.CHECK - - -- ~" -- Number of Pere~ng` , Name EARNED INCOME Name EARNED INCOME $ % $ Name UNEARNE~INCOM Name UNEARNED I NCpY $ ~ - $ $ _- $ TOTAL GROSS MONTHLY INCOME $ TOTAL GROSS MONTHLY INCOME - $ - GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MEDICAL COSTS $ ~ -- '~""-- _---`~-----' Telephone WaterlSewaga __ MEDICAL ASSISTANCE -- - -- Number Gt Persboe® EfeotdC -., GubagelTrash Name EARN D INCOMLE Gas Utility Installation _ $ Oil Other -- $ ~ GROSS UTILITY COSTSlUTILITY SYANOARO' - - $ $ RENT/MORTGAGE __ $ Name - UNEARNED I NCOME TAXES $ ~ - - _ -~ $ INSURANCE COST ON HOME $ , ~ $ TOTAL SHELTER COST $ - $ •ThB hO05BAOld may SWItCh befWBBd thB 8CfU8L UGTity 005(5 and the-~ TOTAL GROSS MONTHLY INCOME - $ $tallCft~l t_ UtlGtr ellOWdiICB dt 1}1B t%mB O/ fBBppf/CatlOtl eild ODe ~ NET MONTHLY INCOMEMET SEMI-ANNUAL INCOME $ al{dlftpr]-37 f(MB du}ittg B,3Ch tWe(VB~/iiOnjh perlOd. INCOME LIMIT $ - NU CTR DIG DIST 27 ~ ~ ~~ ~ Worker's Signature Date , Telephone Number r - ~°' rn.. ~,~., ~C )QJia~.,Cnti. CL. ~cam.c~,~ L J tf you do'Sr of urider~tadd aurdecfslon or have any questions confac; your WOrke{. rl IFr~T r^1ov LEGAL SERVICES, INC. 81RVINE ROW CARLISLE PA 1701&3019 717.293.9400 717.768-8475 A +~ of ~ ~ C'l r~_, ~ C-, ,~ ~ c - -~ r ~~' -~ ~; r ~ 0 .~ ~ ~ - i C ~ ~- ~t v ~ m h ~ _' .. "., :; ~~z:.. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-5242 Plaintiff vs. CIVIL ACTION -LAW GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, . Defendants CERTIFICATE OF SERVICE I hereby certify that I have served the foregoing "Court of Common Pleas Complaint" upon Defendant, Gladys Burns, via First Class United States mail and Certified mail receipt number 7099 3220 0008 3197 4309 as follows: Gladys Burns 6130 15`" Avenue Sacramento, CA 95820 Date• y~ ~ r Respectfully submitted, Daniel F. Wolfson, Esquire WOLFSON ~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717)846-1252 ID No. 20617 Attorney for HCR Manor Care e> <.~ - _..- _~; -;ii: r~ ~ ~ ,n =-n . ~' ~~ '' ' G3 ~5i: €.J: C ~ f'~". " :.4i ~'~ t .~.~ r'1 ;rtj rf' -~ 'S7 -~ i ~ +% ^!„ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01-5242 vs. GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, Defendants CIVIL ACTION • LAW PROOF OF SERVICE BY MAIL I, Daniel F. Wolfson, Esquire, do hereby certify that on or about September 4, 2001, a copy of the "Court of Common Pleas Complaint" filed in the above referenced matter was served upon defendant, Gladys Burns, via certified mail, return receipt 7099 3220 0008 3197 4309, requested as follows: GLADYS BURNS 6130 15T" AVENUE SACRAMENTO, CA 95820 Dated: U ~ ~ Daniel F. Wolfson, Esquire WOLFSON si ASSOCIATES, P.C. 267 East Market Street York, Pennsylvania 17403 Telephone No. (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff C ~ a ~ _~" ~ "tf"' ~ sv __, m <~~ ~ G; =~! =r ZC~ ~ >t7 ~~ =~ ~rn .\. ~ ~ ~/ m SENbER: I also wish to receive the p~ s Complete items 1 aridror2 For atlditlonal services. • Complete items, 4a, and 4b, follOWln services for an 9 a~ • Print your name and address on the reverse of this farm so that we can return this extra fee): - qrd ro you. • Attach this form to the front of the mailp'iece, or on the back if space does not 7 . ^ Addressee's Address ~l ~ permit. ~ Write 'Return Receipt Requested"on the mailpiece below the article number. Th R R i ill 2. ^ RBSidC[ed Delivery ~ . v e eturn ece pt w show to whom the article was de delivered. _ livered antl Ne date - Consult postmaster for tee. '$, ; 0 3. Article Addressed to: - ~ 4a. Article N umber i E 7099 3 220 0008 317 4309 ffi ~ GLADYS BURNS 4b. Service Type ~ $ 6130 15TH A[rENUE ^ Register e fXJ Certified ~ SACRAMENTO, CA 95820 ^ Expr i~g ~ ^ Insured ~ ^ Ret R i er ndi ^ COO ~ c 7. Dat of eli $ . ~ 5. Received By: (Aunt Name) 8. Add s 's if requested and tOS ~ 6. Sign : (Addres e o ant/ X ~ .., ,. _ [ii } = .i~t'... '~ ' ~ Ps Form 3811, December taea toasss-sa.e-oszv Domestic Return Receipt r ... . ._ ..._ L. ~.. I SHERIFF'S RETURN - OUT OF COUNTY CASE N0: 2001-05242 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS BURNS GLADYS R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: DANIELS SHARON but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On October 31st 2001 this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing 18.00 Out of County 9.00 Surcharge 10.00 Dep Dauphin Co 25.50 .00 62.50 10/31/2001 WOLFSON & ASSOC So answe R. Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this _~_ day of~'j•4t4._~,..,, a~b.~ ~ A. D . `~~ ~ ~.- Prothonotar Y/A~~ ~C` SHERIFF'S RETURN - OUT OF COUNTY CASE N0: 2001-05242 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS BURNS GLADYS ET AL R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: DANIELS SHARON ON BEHALF OF GLADYS BURNS but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On October 31st 2001 this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing 6.00 Out of County .00 Surcharge 10.00 .00 .00 16.00 10/31/2001 WOLFSON & ASSOC Sworn and subscribed to before me this ~~ day of `~`I.~~.a__. ~<~ So answe ~... R Thomas Kline Sheriff of Cumberland County ~.v?y( A.D. v n B. Prothonotary ~~~i~Q ~a~ e ~.~.ext,f~ Mazy Jane Snyder Real Estate Deputy William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255-2660 fax: (717)255-2889 Jack L.otwick Sheriff Commonwealth of Pennsylvania HCR MANOR CARE J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy vs County of Dauphin DANIELS SHARON ON BEHALF OF GLAYS BURN Sheriff's Return No. 2670-T - - -2001 OTHER COUNTY N0. 01-5242 I, Jack Lotwick, Sheriff of the County of Dauphin, State of ?Pennsylvania, do hereby certify and return, that I made diligent :search and inquiry for DANIELS SHARON, INDIVIDUALLY the DEFENDANT named in the within NOTICE & COMPLAINT and that I am unable to find him/her in the County of Dauphin, and therefore return same NOT FOUND, October 23, 2001 DEFENDANT MOVED FROM 420 REILY ST., HBG., PA 17102 TO 321 EMERALD ST., HBG., PA 17110. NOTICE & COMPLAINT EXPIRED. Sworn and subscribed to before me this 23RD day of OCTOBER, 2001 ~'- fj ( .PROTHONOTARY So Answers,~i~ ~~°i~~'` Sheriff of Dauphin County, Pa. By Deputy Sheriff Sheriff's Costs: $50.00 PD 09/21/2001 RCPT NO 154368 '~I 'yyyN~e. __ ... ..~ ..._L.a.:... ~ I Mazy Jane Snyder Real Pstate Deputy William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255-2660 fax: (717)255-2889 Jack Lotwick Sheriff Commonwealth of Pennsylvania HCR MANOR CARE J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy County of Dauphin Vs DANIELS SHARON ON BEHALF OF GLAYS BURN Sheriff's Return No. 2670-T - - -2001 OTHER COUNTY N0. 01-5242 I, Jack Lotwick, Sheriff of the County of Dauphin, State of Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for DANIELS SHARON ON BEHALF OF GLAYS BURNS the DEFENDANT named in the within NOTICE & COMPLAINT and that I am unable to find him/her in the County of Dauphin, and therefore return same NOT FOUND, October 23, 2001 NOTICE & COMPLAINT EXPIRED. DEFENDANT MOVED FROM 420 REILY ST., HBG., PA 17102 TO 321 EMERALD ST., HBG., PA 17110. Sworn and subscribed to before me this 23RD day of OCTOBER, 2001 ~. f ~ PROTHONOTARY So Answers, ~'~°i~~~ t~ (/ Sheriff of Dauphin County, Pa. By Deputy Sheriff Sheriff's Costs: $50.00 PD 09/21/2001 RCPT NO 154368 ~,,.~. ~~ ~~ Tiny C®u ~f Cam ~n Plus ®f Ca~~aberlaa~al C®~a~~y, Pennsylvanna HCR Manor Care vs. Gladlys Burns et al SERVE: Sharon Daniels, individually No. O1 5242 civil and on behalf of Gladys Burns Now, Septemberl0, X001 I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. ~' Sheriff of Cumberland County, PA Affidavit ®f Servace NOW, within upon at by handing to a and made known to So answers, the contents thereof. Sheriff of Sworn and subscribed befare 'ne this `day of , 20_ 20_, at o'clock M. served the .'copy of the original COSTS SERVICE _ MILEAGE _ AFFII3AVIT County, PA _ a, 1 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COIJNTY, PENNSYLVANIA HCR MANOR CARE, NO. Ol - .S"2Y~ ~ic~~C, (gjLy,,~ Plaintiff vs. CIVIL ACTION -LAW GLADYS BURNS, Individually, and 'SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, 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 nose defienda, la torte tomara medidas y psedido entrar una Orden contra used sin previo aviso o notification y por cualquier queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades o otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service ~~~~ ~®~~ ~~~ ~~~®~® stlroo~ whereof: 9 hmfr~ l Cumberland County Bar Assoc ~i ~ y 11$CB s~"t dtBy hand 2 Liberty Avenue and the seal of said tau at 1°~l:ri~wle, Pa. Carlisle, Pennsylvania 170I)~llg 7L day t _, (717) 249-3166 ®thonotary r '} t, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. vs. GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, Defendants CIVIL ACTION -LAW COMPLAINT AND NOW, this day of _ , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 8i Associates, P.C., and files the within Complaint and in support avers as follows: Plaintiff, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1701 1. 2. Defendant, Gladys Burns, is an adult individual with a last known address of 6130 15`h Avenue, Sacramento, California 95820. 3. Defendant, Sharon Daniels, is an adult individual with a last known address of 420 Reily Street, Harrisburg, Dauphin County, Pennsylvania 17102. 4. That Defendant Sharon Daniels represented himself to be the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns. Defendant Sharon Daniels is the daughter of Defendant ~ ~/ A Gladys Burns. 5. That on or about April 21, 2000, through on or about November 13, 2000, Defendant Gladys Burns 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 April 21, 2000, Defendant Sharon Daniels executed an Admission Agreement, on behalf of Defendant Gladys Burns, 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 is attached hereto, incorporated herein, and marked as Exhibit "B". 7. By executing said Admission Agreement, Defendant 3 Sharon Daniels did assume and accept responsibility for the debt to be incurred by Defendant Gladys Burns in the event of a breach of the duty to provide payment from Defendant Gladys Burns' income or resources or for failure to provide information about the finances of Defendant Gladys Burns requested by Medicaid which resulted in a denial of Medicaid benefits. 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. That Defendants did not abject to the above mentioned 2 Statement of Account submitted by Plaintiff to Defendants. A 10. On or about October 24, 2000, the Department of Public Welfare sent a notice to Defendants outlining additional information which was required to complete the Medicaid application. A true and correct copy of the relevant portion of this notice is attached hereto, incorporated herein, and marked as Exhibit "C". 1 1. On or about November 14, 2000, the Department of Public Welfare forwarded another notice to Defendants which reiterated prior requests made to Defendants to confirm the financial information of Defendant Gladys Burns. A true and correct copy of the notice dated November 14, 2000, is attached hereto, incorporated herein, and marked as Exhibit "D". 12. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Gladys Burns' account as a result of said charges is the sum of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/ 100 Dollars ($25,984.37). See Exhibit "A" as previously identified and incorporated herein by reference. 13. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay ali sums due and owing on Defendant Gladys Burns' account balance, all to the damage and detriment of the Plaintiff. 14. Plaintiff has made numerous requests to Defendant Sharon Daniels, as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns, demanding that the sums due and owing to Plaintiff 3 x be paid, and Defendant Sharon Daniels has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Gladys Burns. 15. That Defendant Sharon Daniels violated her duties and responsibilities as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party., for Defendant Gladys Burns by not utilizing Defendant Gladys Burns' finances to pay Plaintiff when she knew or should have known there were outstanding medical care bills for Defendant Gladys Burns. 16. That the finances of Defendant Gladys Burns rightfully belonged to Defendant Gladys Burns for her necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Sharon Daniels's mother, Defendant Gladys Burns. 17. Plaintiff has retained the services of the law firm of Wolfson 8t Associates, P.C., in the collection of the amounts due from Defendants. 18. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay all court costs and reasonable attorney's fees if the account is turned over to an attorney for collection. See Exhibit "A". 19. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 8L Associates, P.C., in the collection of the amounts due and owing by Defendants, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the 4 Y proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 20. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Seven Thousand Seven Hundred Ninety-Five and 31!100 Dollars ($7,795.31). 21. Pursuant to Section 1, Paragragh 1.03 of the Admission Agreement; Plaintiff is entitled to receive and Defendants agreed to pay contractual interest at a rate of eighteen percent (18%) per year on balances not paid within thirty (30) days of billing. 22. The amount of interest which has accrued from September 4, 2000 is the sum of Four Thousand Five Hundred Twenty-One and 93/100 ($4,521.93). 23. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 24. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 ~,~;; Y WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gladys Burns, Individually, and Sharon Daniels, Individually and on behalf of Gladys Burns, in the amount of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/100 Dollars ($25,984.37), reasonable attorney fees in the amount of Seven Thousand Seven Hundred Ninety-Five and 31/lOQ Dollars ($7,795.31), contractual interest in the amount of Four Thousand Five Hundred Twenty-One and 93/100 Dollars ($4,521.93), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON 8t ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717)846-1252 I.D. No. 20617 Attorney for Plaintiff Y VERIFICATION 1, 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. 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: . ~~~ -. Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" ~~~,, ~~•Mc~201"(~ MANORCARE CAMP HILL 583 1700 MARKET 5TREET CAMP HILL, PA 17011 (717)-737-8551 GLADYS M. BURNS FOR GLADYS M. BURNS 326 EMERALD ST. HARRISBURG, PA 17110 Statement Please Return This Portion With Your Payment MEDICAID PRIVATE ROOM 204 -B BURNS, GLADYS M 49 06/10/00 11/13/00 02/28/01 DATE OF. CODE SERVICE RENDERED CHARGES CREDITS SERVICE __ _ _ _ __ _ 02/01/01 BALANCE FORWARD 25,984.37 PAYMENT DUE BY THE 10TH 25,984.37 AMOUNT DUE . 03129!01 RBSIDRNT LEDGER AS OF DATE OF FIRST ACTIVITY. PAGE I (ARS6~ RE6IDBNT NBSIDBNT RESIDENT NUNBSS TYPE NAHE ORTE QTY 49 MEDICAID BURNS, GLADYS N 06110108 ADN NOON 204 -B LEVEL 2 I1 /13/00 DIS "PRIVATE - APR 00 11600 CABLE RENTAL 04121100 -- 04130100 "ENDING BALANCE "INSURANCE -APR 00 29002 PRARNACY LEGEND 04121180 -- 04!30100 30002 PHARMACY NON LEGEND 84121100 -- 84130/80 14102 PHYSICAL TBBRAPY VISIT 04/24100 -- 04128100 14482 PHYSICAL YEERAPY EVAL 04/24100 11402 OCCUP THERAPY EVAL 04124!00 11182 OCCUP THERAPY VISIT 04/Z5100 -- 04!28100 ROOH CHARGE AT 219,80 04121100 -- 04130/00 "ENDING BALANCE "NCR CO INS - APR 00 10200 PT B CO-IN6 1AB-GLUCDSE N 04121(00 IB20B PT B CO-IN8 LAB-GLUC088 N 04/22100 10265 PT B CO-IN8 LAB-GLUCOSE N 04123100 10288 PT B CO-IN6 LAB-GL0005E N 04124100 10200 PT B CO-INS LAB-GLUCOSE R 04125100 10208 PT B CO-IN8 LAB-GL0008E N 84/26108 10205 PT B CO-INS LAB-GLUCOSE N 04128!00 REV GLUCOSE DED000T 04130/00 "ENDING BALANCE "MEDICARE B - APR 80 10205 LAB-GLUCOSE MONITORING 04121100 10205 PT B CO-INS LAB-GLUCOSE M ~ 04I21100 10205 1AB-GLUCOSE NONIPORING 04/22/00 10205 PT B CO-IN8 LAB-GL000S8 M 04122180 10205 LAB-GLUCOSB MONITORING 04123100 10205 PT B CO-INS LAB-GLUCOSE H 04123100 10205 LAB-GLUCOSE MONITORING 04124100 10285 PT B CO-INS 1AB-GLUCOSE M 04124100 10205 LAB-GLUCOSE MONITORING 04/25/00 10205 PT B CO-IN8 LAB-GL0008E N 04125/08 10205 1AB-GL000SE MONITORING 04/26100 10205 PT B CO-IN8 1AB-GLUCOSE M 04!26/88 10205 LAB-GLUCOSE MONITORING 04128100 10208 PT B CO-INS 1AB-GLUCOSE M 84(28!00 RBV GLUCOSE DEDCUCT 04130100 "ENDING BALANCE "PRIVATE - NAY 00 BAL FND -LM- -30- -60- -90- S.aB PAYMENT 05/10/00 11600 CABLE RENTAL 05101188 -- 05131100 "ENDING BALANCE "INSURANCE -NAY 00 G!L -- ACCOUNTS RECEIVABLE -- AC000NT CBARGES CREDITS BALANCB CRTR RATE: 0.00 PBIV PORT: 1105,00 I 59150401120 5.00 1 54551207120 117.72 1 54951387128 90,64 15 52150207120 315.00 1 52150207120 50.00 3 52550601120 15.00 10 52558601120 250.00 10 51350001120 2148.08 2 1.15 2 1,15 2 1.15 2 1.15 1 .87 2 1.15 2 1.75 14411050080 11,36 ! 56151911120 8.74 ! 1,15 ! 56151911120 8.14 ! 1J5 ! 56151911128 0. T4 ! 1.15 ! 56151911120 8.74 ! 1.15 ! 56151911120 4.31 .B7 ! 56151911120 8.14 ! 1.15 ! 56151911120 8.19 ! 1,15 5,08 3208,36 .01 14411850000 11.36 56.80 -120+- 5.00 11210002000 5.00 1 59150481120 5,00 5.00 03129101 ~AR56~ R8SID8NT LEDGER AS OF OATH OF FIRST ACTIVITY PAG@ 2 RBSID@NT RESIDENT R86ID8NT NUHB@R PYPB NAHB DATE QTY 49 HEDICAID BURNS, GLADYS M 06!18/08 ADN BOON 204 -B LBVBL 2 11!13108 DIS "INSURANCE -NAY 00 ~CONT~ BAL FWD -LH- -30- -60- -90- 3208.36 29009 PBABNACY L8G8ND 04121108 - - 05119100 29009 PRARNACY LBGBND 04121100 - - 85/19/00 14102 PBYSICAL T@BRAPY VISIT 05/01180 - - 05131/00 17102 OCCUP T88RAPY VISIT 05101100 - - 05/16/80 29009 PBANHACY LBGBND 05!01!08 - - 05119188 30009 PNARNACY NONLEGBNU 05116/00 - - 05/19/88 NOON CHARGE AT Z19.B0 05101/00 - • 05!31!00 "ENDING BALANCE "NCR CO INS -NAY 00 BAL FWD -LH- -30- -60- -90- .01 10208 PT B CO-INS 1AB-GLUCOSE M 85(01!00 10208 PT B CO•IN8 LAB-GLUCOSE N 85/03180 1020@ PT B CO-INS LAB-GLUCOSB N 05105100 18288 PT B COINS 1AB-GL000SB N 05/08/88 10208 PT B CO-INS LAB-GLUCOSE H 05/10!80 10208 PT B CO-INS LAB-GL00058 N 05112100 .10200 PT B CO-IN8 1A8-GL0006E N 05!15/08 10288 PT B CO-INS 1AB-GLUCOSE H 05111/00 10288 PT B CO-INS LAB-GLUCOSB M 05119100 10200 PT B CO-IN8 LA8-GLUCOS@ H 85!22/00 10208 PT B CO-INS LAB-GLUCOSE N X05/24/00 10208 PT B CO-INS LA8-GLUCOSE M 05126!00 10208 PT B GO-INS LRB-GLUCOSB N 05129/00 10208 PT B CO•iN8 LAB-GL000SB H 85!31!80 REY 20~ GLUC DEDUCT 05131100 "BNDIHG BALANCE "NBDICARB B - NAY 80 BAL FND -LN- -30- -60- -90- 56.80 10288 LAB-GLUCOSE MONITORING 05101/00 10208 PT B CO-INS LAB-GLUCO$@ M 05(01100 10288 tA8-GLUCOSE MONITORING 05/83/00 10200 PT B CO-IN8 LAB-GLUCOSE N 05103100 10208 LAB-GLUCOSE MONITONING 05105180 10288 PT B CO-INS LAB-G10008@ M 85105180 18200 LAB-GLUCOSE MONITORING 05100100 10200 PT B CO•TNS LAB-GLUC08E M 05180100 10200 LAB-GL0008E MONITORING 05110/00 10208 PT B CO-INS LAB-GL00088 N 85118108 10208. LAB-GLUCOSE MONITORING 05112100 18200 PT B CO-IN5 LRB-GLUCOSE N 05112100 10208 LAB-GLUCOS@ MONITORING 05115100 GIL -- ACCOUNTS RECEIVABLE -- A000UNT CBASGSS CNBDITS BALANCE CNTR RATE: 0.00 PRIV P08T: 1105,00 -128+- 3200.36 1 54551201120 109.81 1 54551201120 189.01 80 52150201120 2080.00 31 51550601120 925.80 1 54551207120 109.01 1 54951381120 45.64 31 51358007128 6109.08 -120+- ,01 2 1.75 2 1.15 2 1.i5 2 1.15 2 1.15 1 .81 2 1.15 2 1.15 2 1.75 Z 1.15 1 .87 2 1.15 2 1.15 2 1.15 14411850808 -120+- 56.08 56151911120 0.14 56151911]20 0.74 56151911120 0.14 56151911128 6.74 2 56151911120 0.14 2 1 56151911120 4.37 1 2 56151911120 0.74 22.12 13151.81 .B3 t.15 1,15 1.15 1.75 1.15 .01 __ ~ _ - 03129101 R8SID8NT LEDGER AS OR DATE OR RIRST ACTIVITY PAGE 3 ~ARS6) RESIDENT RESIDENT RESIDENT GIL -- ACCOUNTS RBCEIYABLE -- NUMBER TYPE MANS DATE QTY ACCOUNT CHARGES CREDITS BALANCE 49 NBDICAID BURNS, GLADYS N 06110100 RDN CNTR RATE; 0.00 BOON 204 -B LBVBL 2 11113/00 DIS PRIV PORT; 1705,08 "MEDICARE B - NAY 00 ~CONT~ 10208 PT B CO-INS LAB-GLUCOSE M 85115100 2 1.15 18208 LAB-GLUCOSE NONITOftING 85111108 2 56151911120 0,14 10208 PT B CO-INS LAB-GLUCOSE N 85/17100 2 1.15 10288 LAB-GLUCOSE NONITOftING 05/19188 2 5fi151911120 0.14 10208 PT B CO-INS,LAB-GLUCOSE N 05!19(00 2 . 1.75 18208 LAB-GLUCOSt~NONITORING 05122108 2 56151911120 8.14 10208- PT B CO-INS LAB-GL00068 N 05/22/08 2 1,75 18200 LAB-GLUCOSE NONIT00ING 05124/08 1 56151911120 4.31 10208 PT B CO-INS LAB-GLUCOSE M 05/24/80 1 .87 10280 LAB-GLUCOSE MONITORING 05126108 2 56151911120 0.14 10208 PT B CO-INS LAB-GLUCOSB N 05/26100 2 1.15 10288 LAB-GLUCOSE MONITORING 8S/29/00 2 S61S1911120 0.74 10200 PT B CO-INS LAB-GLUCOSE N 05!29!00 2 1.75 18208 LAB-GLUCOSE MONITORING 85131188 2 5fi1S1411128 0.74 10200 PT S CO-INS LAB-GLUCOSE N 05/31(08 2 1.15 R8V 206 GLUC DEDUCT 05(31100 14411050888 22.12 "ENDING BALANCE 110.40 "PRIVATE . -JUN 00 BAL RWD -LM- -30- -60- -90- -120+- 5.88 5.00 PAYMENT 06114/80 112]8802008 5.00 10208 BLOOD GLUCOSE TEST 06/12100 2 56151981228 0.74 10208 BLOOD GLUCOSE TEST 06/14108 2 56151901200 8.14 10208 BLOOD CLllC0S8 TBSf ,86116188 2 S61S19B1200 8.14 10208 BLOOD GIUCOSB TEST 06119180 1 56151901288 4.37 10288 BLOOD GLUCOSE TEST 06121100 Z 56151901208 8.14 10208 SLOOD GLUCOSR TEST 06123!08 2 56151901200 8.14 18208 BLOOD GLUCOSE TEST 06126/00 2 56151901200 8.14 54101 CATR TRAY 86/29/00 1 56154101200 10.04 BOON CHARGE AT 136.00 06118/00 - - 06113100 4 51350801220 544.00 ROOK CHARGE AT 142.00 06114108 - - 06/30100 17 51350001200 2414.00 ADV BOON CRARGB AT 142.00 07101(00 - - 07131180 13211806800 4402.00 "ENDING BALANCE 1426.85 "INSURANCE -JUN 00 BAL FND -LN- -30- -60- -90- -120+- - 9948.65 3208.36 1 3151.01 14182 PHYSICAL TBERAPY VISIT 06101100 - - 06109100 18 52158201120 450.00 18202 BLOOD GLUCOSE TEST 86182188 - - 86104!88 1 561S19B1128 30.59 30007 PHARMACY NON LEGEND 06107100 1 54951301120 .90 ANCILLARY WRITR OFF 06138108 57551501128 .90 BOON CRARGB AT 219.00 06101100 - - 06/09/00 9 51350807120 1971.00 "ENDING BALANCH 15608.68 "NCR CO INS -JUN 00 BAL RiID -LM- -30- -60- -90- -120+- .02 .01 .83 03129101 ~AR56~ RESIDENT RESIDENT RESIDENT NUMBER TYPE NAWB 49 MEDICAID BURN6, GLADY6 N ROOK 204 -B LEVEL 2 "NCR CO INS - JUW 00 ~CONT) 10208 PT B CO-INS LAB-GLUCOSE N .10288 PT B CO-IN8 LAB-GLUCOSE N "BNDING BALANCE ''R80ICAR6 B -JUN B0 BAL FWD -LN- -30- 113.60 56.80 10208 LAB-GLUCOSE MONITORING 10288 PT B CO-INS LAB-GLUC088 M 10208 LAB-GLllC06E MONITORING 18288 PT B CO-tN8 LAB-GLUCOSB M "ENDING BALANCE "PRIVATE - JUL 00 BAL FWD -LM- -30- 142fi.85 RESIDENT LEDGER AS OF DATB OF FIRST ACTIVITY PAGE 4 -60- -60- G/L -- ACCOUNTS RBCBIYABLE -- DATE QTY ACCOUNT CAAHGBS CREDITS BALANCE 06110/00 ADR CNPR RATBi 0.08 11113!00 DIS PRIV PORT: 1105.00 06/28/00 2 1.15 86130!08 2 1.75 3.53 -90- -120+- 170,40 06120/00 2 56151911200 0.74 B6I2B/0B 2 1,75 06/30!08 2 56151911200 0,14 06130!00 2 1.75 184.38 90- 10201 B100D GLUC066 TEST 06128/00 -- 06!30/80 18201 BLOOD GLUCO$8 TEST 01103100 -- 01131!00 RBV LAST NO RC 07101/00 800W CBARGE AT 149.00 07!81180 -- 01131!00 ADV BOON CNARGB 08101/00 -- 08/31(00 "ENDING BALANCE "INSURANCE -JUL 00 BAL FWD -LM- -30- 2451.59 9948.65 10201 BLOOD GLUCOSE TEST 10201 BLOOD GL00086 TEST ANCI1LARY WRITS OFF "ENDING BALANCE "NCR CO INS -JUL 08 BAL FWD -LM- -38- 3.50 .02 REY PT B CO-INS R8Y PT B CO-INS RBV PT B CO-IN8 "ENDING BALANCE "MEDICARE B - JUL 00 BAL FWD -LM- •30- 13.98 113.68 10208 LAB-GLUCOSE MONITORING 18208 LAB-GL00088 MONITORING 10208 LAB-GLUCOSE MONITORING 18208 LAB-GLUCOSB MONITORING 10208 LAB-GL00088 MONITORING 10208 LAB-GL0008E MONITORING 10208 LAB-GLUCOSE MONITORING 10208 LAB-GLUCOSE MONITORING -68- -90- -120+- 3200.36 15688.60 04121100 --q 04128/00 13 56151907200 56.81 05181/00 -- 05131/08 26 56151987208 113.62 01131/00 57551501200 118.43 12372.10 15688.68 -68- -90- -120+- ,01 3,53 04130100 14411050000 .01 05!31!08 14411850088 .82 06130!00 14411850000 3.58 -60- -90- -120+- 56.00 184.38 07183!00 1 56151411200 4.37 07103!80 -- 01131/00 23 56151911200 100,51 01105!00 2 56151911200 0.14 07107108 2 56151911280 0.74 01110/08 2 56151911200 0.14 01112!00 1 56151911200 4.31 01114/08 2 56151911200 0.74 07111100 2 56151911200 0.74 -120+- 1426,85 2 56151901200 8.14 23 56151901200 108.51 13211000000 4402.88 31 51358801200 4619.00 13211800800 9619.00 1 03!29101 RESIDENT LRDGRR AS OF DATE OF FIRST ACTIVITY PAGR 5 )AR56) RESIDENT RESIDENT RESIDENT NUMBER TYPE MANE DAIS QTY 49 MEDICAID BURNS, GLADYS N 06110180 ADM ROOM 204 -B LEVEL 2 11113100 DIS '"MEDICARB 8 - JUL 00 )CONY) 10200 LAB-GLUCOSE MONITORING 01119100 10280 LAB-CL0006E MONITORING 07121188 10200 LAB-GLUCO6B MONITORING 01/24100 10288 LAB-GLUCOSE MONITORING 81/26/08 10208 LAB-GLUCOSE MONITORING 07128100 ANCILLARY 41RIT8 OFF 8.1131108 18208 1AB-GLUCOSE MONITORING 01!31!00 BBV PT B CO-INS 04138108 RBV GL000S8 TEST 04/30100 REV PT B CO-IN8 05131100 REV GLUCOSE TEST 05/31100 R8V PT B CO-INS 86/30180 REY GL00068 TBST 06130180 "ENDING BALANCE "PRIVATE - AUG 00 BAL FWD =LN- -30- -60- -90- 9341.25. 3024.85 REY LAST NO RC 88/01100 203 CO-PAY 5108 85101!88 "ENDING BALANCE '"MEDICAID -AUG 00 30001 PBARMACY NON LBGBND 88121100 ANCILLARY WRITS OFF 00131!80 ROOK CBARGE AT 149.00 00101/00 -- ,08131100 BOON WRITE OFF 00/01/00 -- 00131108 "ENDING BALANCE "INSURANCE -AUG 00 BAL FWD -LN- -30- -60- -98- 2451.59 9948.65 3208.36 PAYMENT BC MAJ NBD 0AI04100 PAYMENT BLUE CROSS NAJ NE 00184180 A8V 203 CO-PAY 5100 05101188 '"ENDING BALANCE ''MEDICARE B - AUG 00 BAL FWD -LM- -30- -60- -90- .01- "ENDING BALANCE '"PRTVATB - S8P 00 BAL FWD -LM- -30- -60- -90- 216.29 4720.25 3824.85 11600 CABLE RENTAL 09101100 -- 09138100 PRIVATE PORTION 89/81/08 -- 09130!08 ADV PYT PONTION 10/01180 G/L -- ACCOUNTS RECEIVABLE -- ACCOUNP C8ARG89 CREDITS BALANCE CNTR RATE: 0.00 PRIV PORT: 1105.80 Z 56151911200 0.74 2 56151911280 8,74 2 56151911200 8.14 2 56151911280 8.74 2 56151911200 0.14 57551511200 .B1 1 56151911208 4.37 14411050000 .01 56151911128 56.01 14411050880 .02 56151911120 113.62 14411850000 3.50 56151911208 11.40 .01- 120+- 12372.10 13211000000 4619.00 14411058808 216.29 1969.34 1 54951302200 .90 51557502200 .90 31 51350002280 4619.00 31 51551002208 1293.63 3325.37 -120+- 15608.60 11210002800 3280.36 11210082080 9132.36 14411050080 216.29 2451.59 120+- .01 .01- -128+- 7969.39 1 59150401200 5.00 38 1705.08 13211000008 1105.00 . 83129101 NBSIDBNT LBOGBR A8 OR DAPB OR RIRST ACTIVITY PAGE 6 (AR56~ RBSIDBNT RESIDENT RBSIDBNT NUNBBR TYPE NANB DATE QTY 49 NBDICAID BURNS, OLADYS N 06110/00 ADN ROOM 204 -B LBYBL 2 11113/00 DIS "PRIVATE - BBP 00 (CONT~ "ENDING BALANCB "NBDICAID -SBP 00 BAL FWD -LN- -30- -60- -90- •3325.31 30001 PHARMACY NON LBGRND 09!01/00 - - 09/23108 51501 IRRIGATION°PISTON.TRAY 09186(80 ANCILLARY'WRITB OFF 09138180 NOON CNARGB AT 149.00 09(01!00 - - 09/30100 BOON NRITB OFF 09/01!00 -- 89130180 DEDUCT PVT PORT 09101!00 - - 09138100 "ENDING BALANCB "INSURANCE -SBP 00 BAL FWD -LN- -30- -60- -90- 2451.59 "ENDING BALANCB "MEDICARE S - SBP 00 BAL FWD -LH- -38- -60- -90- .O1- "BNDING BALANCB "PRIVATE - OCT 00 BAL RWD -LM- -30- -60- -90- 3515.00 216.29 4720.25 3024.05 11600 CABLE RBNTAL 10131/00 RBY LAST NO PP ,10101100 PRIYATS PORTION 10101/00 -- 10131100 AOV PPT PORTION 11101!00 R8V RN CNG 6/00 06/30/80 R8V RM CNG 6100 06130/80 RBY GLUC086 TEST 06/30100 RBV CATB TRAY 06/30/08 BST PRIM PORTION 06/30!00 R8V GLUC058 TST 01131100 RBV RN CAG 1100 07131/00 i;ST PRI PORT 1/00 01131/00 RST PRI PORT 8/00 00/31100 "BNDINC BALANCB "NBDICAID - OCT 00 BAL FND -LM- -.30- -60- -98- 1433.IB 3325.31 30001 PBARNACY NON LEGEND 06101180 -- 10106100 30002 PHA@NRCY NON LNGBND 06181100 51501 CATHBTBR TRAY 10i04i00 ANCILLARY WRITN OFF 18!31180 ROOK CNARGB AT 149.00 10101100 -- 10131108 G/L -- ACCOUNTS RSCBIVABLB -- A000UNT CAARGBS CNBDITS BALANCE CNTR RATE: 0.00 PRIY PORT: 1185.00 -120+- 3325.37 1 549513@2200 64.19 1 5415I502200 4;01 51557582208 30 51350082200 4410.00 30 51551002200 30 120+- 120+- 2451.59 -120+- 11544.39 1 59150401200 5.00 13211000800 31 1185.00 13211000000 1185.00 51350001220 51350001220 56151901200 56154181200 14411050000 1185.00 56151901200 51350001200 14411058008 1105.88 14411050000 1105.80 11544.39 14.00 1251.98 1705.00 4758.41 2451.59 .81 .01- 1105.00 544.00 2414.00 56.81 10.04 189.25 4619.00 18936.29 -120+- 4150.41 1 54951302200 39.42 1 54951302280 1 54151502200 10.00 51557582208 31 51350082200 4619.00 90 48.52 ~w ~,_ . 03124/01 RESIDENT LEDGER AS O F DATE OF RIRST ACTIVITY PAGE 1 ~AR56~ RESIDENT RB8ID6NT RESIDENT G/L -- ACCOUNTS NBCEIVABLE -- NUNBER TYPE NAHB DATE QTY ACCOUNT CHARGES CREDITS BALANCE 49 MEDICAID BURNS, GLADYS N 06/10/00 ADN CNTR RATEo 0.00 ROOM 204 -B LEVEL 2 11/13/00 DI9 PSIV PORTS 1705.80 ''H6DICAID - OCT 00 ~CONT~ BOON WRITB OFF 10101/00 - - 10/31/00 31 51551002200 1101.61 D6000T PVT PORT 10!81100 - - 10131!00 3I 1705.00 8ST PRIV PORTION 06/30/00 14411050000 1785.00 EST PRI POST 1100 07731100 14411050800 1105.00 EST PRI PORT 0100 88/31/80 14411050800 1185.00 "ENDING BALANCE 1049.86 "INSURANCE - OCT 08 BAL FWD -LM- -30- -60- -90- -120+- 2451.59 245L54 '"BRDIHG BALANCE 2451.59 ""H6DICARE B - OCT 00 BA1 FWD -LN- -30- -60- -90- -128+- .01 - .01 10200 LAB-GLUCOSB MONITORING 10102100 2 56151411200 8.19 18200 LAB-GLUCOSE MONITORING 18104180 2 511151911200 0.14 10200 LAB-GL0008E MONITORING 10/06100 2 56151911200 8.14 10200 LAB-GLUCOSE MONITORING 10/09/80 2 56151911200 8.14 10200 LAB-GLiCOSB MONITORING 10/10/08 2 56151911280 8.74 10208 1AB-GLUCOSE NONITONING 10111108 2 56151911280 8.74 10208 LAB-GLUCO66 MONITORING 10112100 1 56151911280 0.14 18200 LAB-GLUCOSE MONITORING 10!13/80 2 56151911208 0.74 10200 LAB-GLUCOSE MONITORING 10/19/00 2 56151911208 0.74 10280 1AB-GLiCOSB MONITORING 10/15188 2 56151911200 0.74 10200 LAB-GLUCOSE MONITORING ,18/16100 1 56151911200 4.31 18208 LAB-GL000BE MONITORING 10118100 2 56151911200 0.14 10200 1AB-GIUCOSB MONITORING 10120100 1 56151911280 4.31 10288 LAB-GLUCOSE MONITORING 1Bf23100 2 56151911280 0.74 10208 LAB-GLUCOBB NONIPORING 10/15108 1 56151911200 4.31 10208 LAB-GLUCOSE MONITORING 18127108 1 56151911280 4.31 10280 1AB-GLUCOSE MONITORING 10!30!00 2 56151911200 0.14 ANCILLARY WRITB OFF 10131!00 51551511200 26.23 N8D B AD3 01I01I0A 57551511200 .01 "ENDING BALANCE 104.01 "PRIVATE - NOV 00 BAL FWD -LN- -30- -60- -90- -120+- 0938.08 1790.00 216.29 1 0936.29 REV LAST NO PP 11101/00 13211800000 1105.00 PRIVATE PORTION 11101!00 - - 11112/00 1Z 1320.20 "ENDING BALANCE 10479.51 "'MEDICRID - NOV 00 BAL FWD -1N- -30- -60- -90- -120+- 1646.39 1439,10 1540.31 1705.00 - 1105,00- 1849.86 30009 PBARNACY NON18G8ND 10/06100 1 59951302200 189.51 ANCILLARY WRITE OFF 11130!80 51551502200 109.51 03129101 RESIDENT LBDGBR AS OF DATE OF FIRST ACTIVITY PAGE 8 (AR56~ RBSIDRNT RRSIDENT RRSIDENT GIL -- ACCOUNTS RBCBIYABLB -- NUNBER TYPE NANB DATB QTY ACCOUNT CHARGES CRHDITS BALANCE 44 MEDICAID BURNS, GLADYS N 86/10108 ADN CNTR RAPS: 0.00 BOON 204 -B LBVEL 2 11113100 DIS P&IV PORT: 1185,80 *'MBDICAID - NOV 00 ~CONT~ ROON CNARGB AT 149.08 11101108 -- 11/12180 11 51358002208 1188.00 ROOK WRITE OFF 11181/00 -- 11112108 12 51551802280 459.12 DEDUCT PVT PORT 11101108 -- 11112100 12 1328.28 RN CBG. 06130108 51358882220 544.00 RN C8G 06130100 51350002228 2474.00 RM WIO 86138180 51551802220 128.24 RN WIO 06/30/00 51551002220 647.02 GLUCOSH TEST 06!30100 5fi151902280 56.81 CATH TRAY 0613010b 56154102200 10.44 ANC WIO 06/30100 51557582280 66.85 RH C8G 07131!00 51350002200 4619.00 RN WIO 07131/00 51551002208 1293.63 GLUCOSE T88T 01(31108 56151982208 104.25 ANC W10 01131180 51551582280 189.25 ''ENDING BALANCE 6551.91 ''INBURANCB - NOV 00 BAL FWD -LR- . -30- -60- •90- •120+- 2451.59 2451.59 "ENDING BA1ANCR 2451.59 **WBDICARE B - NOV 00 BAL FWD -LR- -30- -60- -90- -12~+- 104.81 104.81 "ENDING BALANCE 104.81 "PRIVATE - DEC 00 BAL FWD -LN- -30- -60- ` -90- -120+- 1320.28 7145.00 1198.00 216.29 10479.51 BC RBTRO TO PRIYATB 86/89100 52150201120 450.00 BC R6TR0 TO PRIVATE 06189180 56151907120 30.59 06/09100 51350001120 1971.00 "ENDING BALANCE 12931.16 "MEDICAID -DBC 00 BAL FWD -LN- -38- -60- -90- -120+- 1646.39 1433.10 1540.31 1938.11 6551.97 ""ENDING BALANCE **INSURANCB -DBC b0 BAL FND -LR- -30- BC R8TR0 TO PRIYATB BC RETRO TO PRIVATE BC RRTRO TO PRIVATE '"ENDING BALANCE "'HBDICARE B - OEC 08 BAL FWD -LW- -30- 104.81 **RNDING BALANCR -68- -90- 86109708 06/09100 06!04180 -60- -90- -120+- 2451.54 2451.59 52150201120 450.80 56151907128 30.59 51350001128 1911.00 -120+- 104.87 6557.91 .08 104.87 83/29101 (ARS6( R8SID8NT RBSIDRNT RBSIDRNT NUMBER fYPB NANB 49 NBDICAID "PRIYATB BAL BUNNS, GLADYS N NOON 204 -B 18V8L 2 - JAN 01 FWD -LN- -30- 1328.20 R8V RR CHARGR ADJ RBV RN CHARGE ADJ RBV CATA TRAY ADJ d8V PVT PORTION ADJ RRV RM CHG ADJ R8V PUT PORT ADJ R8V PVT PORT ADJ BOON CHARGB RBV PVT PORTION IRRIGATION PISTON TR BOON CAARGB CATHBTHR TRAY BOON CAARGB R8V PYT PORTION R8V PVT PORTION ROOM CNARGB "ENDING BALANCB "NBDICAID -JAN 01 BAL FND -LH= -38- R8V RH C8G ADJ RHV RM CAG ADJ R8Y RM WIO ADJ RBY RN WIO ADJ RHV GLUC088 ADJ RBV CATA TRAY AOJ R8V ANC WIO ADJ fl8V PVT PORTION ADJ RRY PYT PDRT ADJ R8V NN CAG ADJ R8V RW W/0 ADJ R8Y GL00088 ADJ R8Y ANC WIO ADJ R8V PYT PORT ADJ N8V RN CAG R8Y RN WIO RRV PYT PORTION N8U IRRIG PISTON TRY R8Y ANC WIO R8Y ROOM C9ARGB R8V RN WIO R8V CATH TRAY RBY ANC WIO &8V RN C8G RBSIDBNT LBDGBR AS OR DATE OR FIRBT ACTIVITY PAGR DATB QTY 06/10!00 ADM 11/13100 DI8 -60- -90- 1145,00 1198.08 06/30100 06130100 06/30!00 06138100 07/31/00 011311@0 08/31100 08131100 09/30100 09130/00 09/30100 10131(80 10!31100 10/31100 11130100 11130100 •60- -90- 1646.34 1433.18 06/30/00 X06138108 06!30100 86/30188 06/30/00 06130/00 06/30100 06/38100 01131100 07!31!00 01131/00 01/31188 81131100 00/31100 08131100 00131!80 09130100 09130100 09130100 09130188 09(30100 10131100 18131180 18131180 G/L -- ACCOUNTB RBCBIVABLB -- A000UNT CAARGBS CRBDIfB BALANCB CNTR RATRo 0.00 PRIM PORT: 1105.00 -120+- 2667.00 12931.16 51350001220 544.00 51350801228 2414.00 56154101200 10.04 14411050000 51350001200 4619.00 14411050000 14411050000 51358001200 4519.00 1441]050000 54151501200 4.01 51350001200 4619.00 54151501200 10,00 51350001200 4619.00 14411050080 14911050000 51350081280 1041,64 -lz@+- 3470.40 6551.47 51350002220 51350002220 51557802220 120.24 51551802220 641.02 56151902200 56154102200 51551502200 66.65 1441105000@ 1185.00 14411050000 1705.00 51350002280 51557002200 1293.63 56151902200 57557502200 109.25 19411050808 1105.00 51350002200 51551082200 1243.63 14411050000 1105.00 54151502288 57551502208 4.01 51350082280 51557002208 1251.90 541S15B2200 57551502200 18.00 5i350B02200 17B5.00 1105,80 1185.00 1185.00 1705.00 1320.20 25904.37 544.00 2414.ee 56.87 10.04 4619.00 109.25 4619.00 4.81 4478.08 10.80 4619.08 03129!01 RS8ID8NT LBDGBR AS OR DATE OR FIRBT ACTIVITY PAGE 10 (ARS6( R8SID8NT RESIDENT RBSIDBRT GIL -- ACCOUNTS RECEIYABLB -- NUNBBR TYPE NANB DAPB QTY ACCOUNT CBABGBS CREDITS BALANCB 49 NBDICAID BURNS, GLADYB N 06110100 ADN CNTR RATB ~ 0,00 ROOK 204 -B LEVEL 2 11!13100 DIS PRIV PORT S 1185.00 "RBDICAID - 1AN 01 (CONY( BEY RN WIO 10!31!00 51557002280 1101.61 R8V PYT PORTION 10!31!80 14411050000 1785.80 R8V PVT PORTION 11130!00 14411050000 1320.20 REV RN,C8AHG8 11!30100 51350002208 1188.00 REY RR Wt0 11!30100 51551002200 459.12 "ENDING BALANCB ,08 "MEDICARE B - JAN.01 " BAL RWD -LN- -30- -60- -90- -120+- - 184.07 104,87 GLUCOSB TE6T 06138/00 56151911220 56.81 GLUCOSE TEST 01(31!88 56151911228 109,25 "ENDING BALANCB 270.93 "PRIVATE - R8B 01 BAL RWD -LN- -30- -60- -40- -120+- - 1841.64 9909,00 14141.73 25904.31 *'BNDING BALRNCE 25904.37 "N80ICAR8 B - FEB B1 BAL RWD -LN- -30- -60- -98- -120+- 104,01 166.06 210.93 "ENDING BALRNCE 270.93 4 EXHIBIT "B" ~k~ HCR t~fanor Care ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Caze's Health Caze Center ("Center"). Center: Resident: ~lc~~vs ~`--t - ~ 15' Legal Representative: ~.~'7 (~-~i -~s~ .~i'l°~ Admission Date: ~+l~,i ~ ~ Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is dischazged. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and Board Rate: For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10`h) day of each month. The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Caze Organization (see Section 1.06).' 1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal caze items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary change list is maintained at the Center's business office fnr review during regulaz business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10th) day of the month. 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Proerams. If the Resident is eligible for coverage under any govenunental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center:participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered chazges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs; /Medicaze, /Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicaze agrees to pay for the Resident's care, there is a required co-payment, which Medicaze updates yeazly. If the Resident also participates in Medicaze Part B, fox physical, occupational, or speech therapy or other billable chazges (which are not covered by Medicaze Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center chazges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Boazd Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Pazry Payors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third parry payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the chazges aze governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 ~.~, will bill the Resident's third party payor as a service, but the Resident remains liable for chazges not paid or covered by that thud party payor including charges not paid within a reasonable period of tune. 1.07 Private P~ Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fiilly in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for caze at the Center and the Resident'is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all thud party payors or governmental coverages on admission and throughout the stay including copies of insurance cazds, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5~ da +ks of the Resident's disenrollment, enrollment, change in health caze coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Apnlication for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, thud party payor, managed care or private insurance program The Center shall be under no obligation to bill any third parry payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Prirnarv Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed caze provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 + J • a Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician: If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to .attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication dis[nbution system similaz to the Center's ancillary pharmacy's medication distribution system II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 Leal Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Maktir Payments on Behalf of Resident. The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and chazges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products aze covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is -made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. I M i l Y ~ i 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Canter as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standazd Services. As part of the Room and Boazd Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of caze prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for Gaze of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or. managed care organization responsible for all or any party of the payment or reimbursement of the Resident's chazges, including any utilization review or quality assurance w ~ K II Y , i reviews or payment audits performed by such; the personnel of any hospital or other health caze facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing caze, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Represemative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. . 4.03 Consent to Photoeranh. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similaz uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the hems listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of btedical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questiormaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the- Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds ~ A~ ' t e i Authorization and any other related documents. See Attachment H-1 and H-2. g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement}. i. Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). j. The location in the Centel where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the -state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). 1 Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, ` neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment J. n. Resident/Patient Rights. See Attachment K. o. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which snmmari~as HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 ~c a T t s. ASM Form See attachment P. t. See Attachment Q. u• See Attachment R. v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. 4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized govetvment and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service fiuvished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and a~ holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Reprdsentative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven ('~ days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property S ~t K T { of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Chanties in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIIt SATISFACTION. Signature of Resident: Signature of Legal Representative, if signing on behalf of Resident: Date: Date: G! (a, ~ ~ Oc~ Signature of Legal Representative, signing on his/her own behalf Center Date: Q Date: ~I ~ ~-+ ! ~ C~ 9 ~t . t» __. EXHIBIT "C" ._ PAlFSt62~B~ea NOTICE TO APPLICANT - ~ DEPARTMEM CF PUOLIC WELFARE _ CUMBERLAND COUNTY ASSISTANCEOFFICE - - ' • • - ' .. • . - - I • • PO BOX 599 V,~„~„ CARLISLE PA 17013-0599 R- c:,~ .-,BENEFIT ,-;: -.~ au¢IeLe auole~ P EN¢IN¢ 1.800-2&9-0173 (717) 240-2700 ^ ASSISTANCE,""- ~` CHECK ._ . Alter the foal check whzh may be a spedal amount you w9 raeeiva S ^Twkea Month ^ Oncea MOnlh ^ In the Mail ^ At the Bank - - EDICAL ASSI$TANCE ~ ^ You haves petlent pay liability oFS ------ -- - tar the pedotl be8innin and entling ^ ENective Date ^ FO00. 37AMPS You wll receive S for the monm(a) of then Y6u wgl receive fcod stamps in the amount of S amamhfrom to ^ In the Mall ^ At the Sank URGING HOME CARE Level of care authonzetl y«, are espected Io pay S - e month toward your care. 'hi LL~I ~ rs - .. . $ E N lu e _,~~.~.... 1r ~` _a7S M r~' ,xs': " ~ n -;1 ' ~~, >~~. ~~ ~~ x ~ ~-x;,'' , _.~v. ~d,i '~n+.+d,'xrt~~. mzv..e_. `.[." .f. :t:,nr .+ at 1~.8 sk. 414Y a ~t .:I f ': e'i5 ~; r .u °++t fi7 (. : NAME N ~ M aERVIC L NAME CH I $_ h. _ .I -- • • • • s • Ragulatlon_. Reaso n rioAB _ --- Since.your app ication a over t e ay roceasing time co e e verificatipn~,of.:~gy_ p-}-}-Qr..knt>~. - \~t ` ~ j ~~OC? an t e i6 still to be presented.' We are extending the applicatiott processing time to 45 days. P remember to provide all-pending on the attached notice as soon as possible or 1 lease the application ~w . • ~ s "u ' -""~;6 ~~:'4p FAR ui~ ~~ ~ :& ". ` "'"' _' • ~~ • 7~ei' ..- .. , •~ I. • :u . ~ eu• I. • • =: '._ s31S1'AlrfG G "~t'~Sst1~-,a3. Y~ ~~ L` C~....~ ~iF If» ~ .. ~ ':~`w I' , ~~' i~ .: .. -. - ` N~e INCOM - - Narita - GR ss of L - E - FNiNEO IN M / $ $ ///// $ $ /I///l ` - Name INC M ~ Nam9 RN _N LMF~ $ $ l~~l TOTAL GROSS MONTHLY INCOME - $ TOTAL GROSS MONTHLY INCOME - - $ " - ' GROSS MONTHLY OEPENDENT CARE COSTS .-.: $-~ -'-~. :'-°i-"--' ,GROSS MONTHLY DEPENDENT CARE COSTS " " $-- -= :r+%?=' GROSS MEDICAL COSTS - - ~ - ° - '" .;`X"t ?c ' y.~'i'F x ,: ~ "-M-'t34~ ~~N; )~:?T'' ~ Telephone' ~ .~:. ~ Water/Sewage - 1 9 is IVI '(71 11 la:"$3TdIV~,'~;~T"~~~'t~'' - ~ : C~~~i ,. : Ele~_ ~-...:- _,: :...., Garbage/Trash - -.- Name R NED N_COM ~ Gas - ~ - Utility Installation $ / / ~ ~~/ ~ . - -~7 ~ / / GROSS UTILITY COSTSAITILY TY STANDARD' $' ' $ J~/~~~ REN`fIf+YORi(3AOE'~'~~x. rr "S ,- ~... ` ` $ - ~ - - - Name ME -- RN I CO TAXES . a ~ y _ .,1,r„. ,t ~' $ ~ - $ j !~~// IN$UhANCE CbST ON i10ME ",; ' - ' .` $ - $ - l/ i '1'OYAC`$l1EL E `4t~$S .m.:n..? t r', t i5y.:r° $ -r,•..... -. ', _'. ::. pp //// // Il!l~~l. s ' -' ~ ~ r~eEe(f~ 9'A't" ~~-! ~ ~q~~5~ ~l( TOTAL GROSS MONTHLY INCOME -- - $ - - I _ %$, I ~ N 0.,, a NT~d~}I ~~~Y IUb{ln~t.~ a~f c J}I~s~ 9'.a.?.3;':. , t ah °t ^~'+~ tit. - - r ."~.'b"ptirpa!iJat'~ yx '... "' NET MONTHLY INCOMEINE7 SEMI-ANNUAL INCOME INCOME LIMB $ $ - - v=~:e .;,, .,u rer,~rox..-,... ~-,., .,.,. . ~. ~+.n :.:~. ,-...~.., ..1.w~K~ vyn ~+s .. ~m..Fi'mss_~ CO RECORD NUMBER CAT CTfl DIG DIST 21 2 ,: `~la S~J1~on. ~a.mulldo L l X~~n~-- ~!!41^C~(Jh l~~.Z'yOD ~Qb~4~~ Worker'c Signawre Date -Telephone Number LEGAL SERVICES, INC. 81RVINE ROW CARLISLE PA 170133019 717.243A400 717.766$475 J # ~-( ~ 111 rN EXHIBIT "D" PNFS 102.8~9a NOTICE TO APPLICANT DEPARTMEfJT OF PUBLIC WELFARE CUMBERLAND DOUNTY ASSISTANCE OFFICE • _ ~ , I r ] I ~ I ! •• Inmva~pn vn PO BOX 599 Y70'~059$. y BEN i1T ELIGIBLE noT EUGIeLE P ENpINn 7800.2690173 ~ ~ 24 -t76P , ~ ^ ASSISTANCE CHEC Alter [he first check which mny be a special amount you will receive 5 - - ^ Twice a Month ^ Once a Momh ^ In th¢ Meil ^ At the Benk DICAL ASSISTANCE ^ You have a patient pay liability of 5 _ - far the period be inning and endin -~ g g - ^ Ellectiv¢ Date ^ FOOD_ STA S You will receive $ for the month(s) of thenyou will receive food stamps in the amoum of $ _ a month from to ___ ^ In the Mail ^ At lh¢ Bank URSING HOME CARE Laval of care authorizetl you am especletl to pay S - ~ a month loviartl your care. ' ^ ERN E3 ^ adf ~ - ~ ~ ~ '- -- - ~ ~ ~ -- `' THE FOLLOWING PER$QNS ARE INCLUD ED ' - ` -~" ' -"' " '~"' ~ ~`' -" -" ~"_'-~ -•;_•=~-- °"" d" ~'' x '"~'6"' NO. NAME CHECK STAMPS SERVICE NO. NAME CH GK STAMP AS ~. SEF CICF 5 5 G c~a i 1. l ) J-- Q 1. i L' • • • • s • Regulation a y~ Reason Code Qr-I ~ - QQS~ ~clvrnq- Ovncl ,~pourc~ .-,~ 4~p ~»-w~ot- .f21-s+- 1.~,~aoC . On. ~Q~~ ~1 CvrLCX ~,c,~t 2.~1, ??AVa !1'C~~ .1Z~a~rtJ~ G2.cc.~ ~~d.u-cacL ~t-¢-~ooL~ rczo ~ -an- ~ .-~. 4 n.. ~C'yt.o , `7h.~o (in~rmi~~? uiQ+o..~-- ~c~, - ore-, az'nh.ot. C(oU ,.- Q KOOD ST ~~11PS:~:;- - • ,NumberYgt Persons- ~] ASSISTANCE CHECK _ F "' '-N~r~4er of P,§r`s,13 "' j Name EARNED INCOME NNne NED IN_~OME _ $ $ / $ $ !~ ' Name NEAR EO INC ME Name UN RNEO INCOM E T _ _ $ - $ /! TOTAL GROSS MONTHLY INCOME - $ TOTAL GROSS MONTHLY INCOME $ GflOS9 MONTHLY DEPENDENT CARE COSTS $ GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MEDICAL COSTS $ + - -• ~ ;;;:j'y„5 ., , ,,~,; ,, t.__ .:u ~rt sfin: Telephone - - WaterfSewage Q MEDICAL ASSISTANCE - ~~ ~ Number et Perseng Electric Garbagefirash Name EARNED INCOME Gas -- Utility Instaliatlon ~ ~ ~ ~ $ ///f Oil - Other - - - --- _- $ /ll/// GROSS UTILITY COS7SNTILITY 8TANDARD' $ - $ ///~ RENTlMORTGAGE $ Name UN NEDI_COM TAXES _. $ - _.. ~ 7~ $ / /I INSURANCE COST ON HOME $ ~ - - $ /~ TOTAL SHELTER COST ~ $ - $ ~1 'ThB hOUS9holoj may~SwitCh bgfween th@ actual Utility COSts acid the TOTAL GROSS MONTHLY INCOME $ - - standard . uhliry"allowance at the time o/. raappllCation and one NET MONTHLV INCOMEfNET SEMI-ANNUAL INCOME $ addlfloRal,t/me dur/ng each lwalJB-ii7ofifh pB1/oa: - -- - _- - INCOME LIMIT ~ $ CO O RD NU M BE REC R CAT CTR DIG DIST 21 / ^ ~ ~ y ~O ~Vb- Worker's Signature Date, Telephone Number r -I yc ~O.~lcvt.ax. Ct.,. ~lJc~,.u~.sas.. J li yrou-da not undersfand our decfslon or hays any Buest/ons, centact your worker AT " ' LEGAL SERVICES, ING B IRVINE ROW CARLISLE PA 1701&3019 717-243.9400 717-7fi6-8475 .-r ~ ~(?dtya if Jt ~~ r~ ,,~~1 ~4 ~ ~~~~ d3(~ ~1 ir'(--; J Bdlh~i, ~ yr~'74 %iid {1 t ,~ ~. ,. ~_ „~ ~~ uu y ~',pc,NIH, .~ 1Fii N~ h-r~r. flYC-1 }.ll'dI:UJ ivli.d~l'7G iJ'. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ~} HCRMANORCARE, NO.©l- S'.Z~/o~-~, 1..1c~,.C,~~ Plaintiff . vs. CIVIL ACTION -LAW GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, 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 hen demandado a used en la torte. Si used quaere defensas de esas demandas expuestas en las paginas, siguientes, used tiene viente (20) dies de plazo al partir de la fecha de lademanda y la notifiation. Used debe presenter una apariencia escrita o en persona o por abogado y archivar en Ia torte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used nose defienda, la torte tomara medidas y psedido entrar una Orden contra used sin previo aviso o notification y por cualquier queja o alivio que es pedido en la petition de demanda. Used puede perder dinero o sus propiedades o otros derechos importantes pare used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARR AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA.LEGAL. T~$UE G®PY FROM R~~OFi® Lawyer Referral Service in Tostan4ony Sher@tlt, I herb !~"lta Bft my hand Cumberland County Bar Assaiatiq~d the soa9 of said COUrt at Carliaio, Pa. 2 Liberty Avenue o~ Carlisle, Pennsylvania 17013 ThOS day t , (717) 249.3166 ~~"+ rothonotary i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. Plaintiff . vs. CIVIL ACTION -LAW GLADYS BURNS, Individually, and SHARON DANIELS, Individually and on Behalf of GLADYS BURNS, Defendanu COMPLAINT AND NOW, this day of , 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 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 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1701 l . 2. Defendant, Gladys Burns, is an adult individual with a last known address of 6130 15`h Avenue, Sacramento, California 95820. 3. Defendant, Sharon Daniels, is an adult individual with a last known address of 420 Reily Street; Harrisburg, Dauphin County, Pennsylvania 17102. 4. That Defendant Sharon Daniels represented himself to be the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns. Defendant Sharon Daniels is the daughter of Defendant Gladys Burns. 5. That on or about April 21, 2000, through on or about November 13, 2000, Defendant Gladys Burns was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plain~iff. An itemization of said services is attached hereto, incorporated herein and marked as Exhibit "A". 6. That on or about April 21, 2000, Defendant Sharon Daniels executed an Admission Agreement, on behalf of Defendant Gladys Burns, 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 is attached hereto, incorporated herein, and marked as Exhibit "B". 7. By executing said Admission Agreement, Defendant 4 Sharon Daniels did assume and accept responsibility for the debt to be incurred by Defendant Gladys Burns in the event of a breach of the duty to provide payment from Defendant Gladys Burns' income or resources or for failure to provide information about the finances of Defendant Gladys Burns requested by Medicaid which resulted in a denial of Medicaid benefits. See Exhibit "B" as previously identified and incorporated herein. 8. That Plaintiff submitted to Defendanu a copy of the itemization of services accurately showing all debiu and crediu for transactions with Plaintiff. 9. ThatDefendanu did not object to the above mentioned 2 A Statement of Account submitted by Plaintiff to Defendants. 10. On or about October 24, 2000, the Department of Public Welfare sent a notice to Defendants outlining additional information which was required to complete the Medicaid application. A true and correct copy of the relevant portion of this notice is attached hereto, incorporated herein, and marked as Exhibit "C". 1 1. On or about November 14, 2000, the Department of Public Welfare forwarded another notice to Defendants which reiterated prior requests made to Defendants to confirm the financial information of Defendant Gladys Burns. A true and correct copy of the notice dated November 14, 2000, is attached hereto, incorporated herein, and marked as Exhibit "D". 12. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Gladys Burns' account as a result of said charges is the sum of 0 Twenty-Five Thousand Nine Hundred Eighty-Four and 37/ 100 Dollars ($25,984.37). See Exhibit "A" as previously identified and incorporated herein by reference. 13. Despite Plaintiffs reasonable and repeated demands for payment, Defendants. have failed, refused and continue to refuse to pay all sums due and owing on Defendant Gladys Burns' account balance, all to the damage and detriment of the Plaintiff 14. Plaintiff has made numerous requests to Defendant Sharon Daniels, as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party, for Defendant Gladys Burns, demanding that the sums due and owing to Plaintiff 3 i be paid, and Defendant Sharon Daniels has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Gladys Burns. 15. That Defendant Sharon Daniels violated her duties and responsibilities as the Power of Attorney, and therefore the Legal Representative and/or Responsible Party., for Defendant Gladys Burns by not utilizing Defendant Gladys Burns' finances to pay Plaintiff when she knew or should have known there were outstanding medical care bills for Defendant Gladys Burns. 16. That the finances of Defendant Gladys Burns rightfully belonged to Defendant Gladys Burns for her necessary and appropriate medical serv'ces and treatment rendered by Plaintiff to Defendant Sharon Daniels's mother, Defendant Gladys Burns. 17. Plaintiff has retained the services of the law firm of Wolfson 8t 4 Associates, P.C., in the collection of the amounts due from Defendants. 18. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendanu have agreed to pay all court costs and reasonable attorney's fees if the account is turned over to an attorney for collection. See Exhibit "A". 19: As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 8t 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 4 proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 20. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Seven Thousand Seven Hundred Ninety-Five and 31/100 Dollars ($7,795.31). 21. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, Plaintiff is entitled to receive and Defendants agreed to pay contractual interest at a rate of eighteen percent (18%) per year on balances not paid within thirty (30) days of billing. 22. The amount of interest which has accrued from September 4, 2000 is the sum of Four Thousand Five Hundred Twenty-One and 93/100 ($4,521.93). 23. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 24. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 •_ WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gladys Burns, Individually, and Sharon Daniels, Individually and on behalf of Gladys Burns, in the amount of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/] 00 Dollars ($25,984.37), reasonable attorney fees in the amount of Seven Thousand Seven Hundred Ninety-Five and 31 /100 Dollars ($7,795.31), contractual interest in the amount of Four Thousand Five Hundred Twenty-One and 93/100 Dollars ($4,521.93), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON 8L ASSOCIATES, .C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff ___ ..~; \/ERIFICATION 1, 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:. l ~ l,LfidCt,G(,~.. ~d'G(~W~ Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" ~~ •Mid~201" MANORCARE CAMP HILL 583 1700 MARKET STREET CAMP HILL, PA 17011 (717)-737-8551 GLADYS M. BURNS FOR GLADYS M. HURNS 326 EMERALD ST. HARRISBURG, PA 17110 Statement Please Return This Portion With Your Payment MEDICAID PRIVATE ROOM 204 -B _____ BURNS, GLADYS_M_ ___ __ __ _ ___ 49 __06/10/00 11/13/00 02/26/01 DATE OF CODE SERVICE RENDERED CHARGES CREDITS SERVICE 02/01/01 BALANCE FORWARD 25,984.37 a PAYMENT DUE BY THE 10TH 25,984.3; AMOUNT DUE 83/29/01 JAR56J RESIDENT LBDGBR AA OP DATE OP FIRST ACTIVITY PAGE 1 RBSIDBNT RBSIDBNT RBSIDBNT NUMBBH TYPE NAME DATE QTY 49 NBDICAID BURNS, GLADYS N 06/10/00 ADM BOON 204 -B LBVBL 2 11!13/00 DIS "PRIVATE - APR 80 11600 CABLE RBNTAL 04121100 - - 04/30/00 "ENDING BALANCB "INSURANCE -APR 00 29002 PHARMACY LEGEND 04121100 - - 04/30/00 30082 PBARNACY NON L8G8ND 04121/08 - - 04/30/00 14102 PHYSICAL TASRAPY VISIT 04124100 - - 84120100 14402 PHYSICAL THERAPY BVAL 00124/00 11402 OCCUP THERAPY BVAL 04/24!00 11102 OCCUP THERAPY VISIT 04125108 - - 84!20/00 BOON CHARGE AT 219.00 04121/00 - - 04/30100 "ENDING BALANCB =:NCR CO INS - APN 00 10208 PT B CO-INS LAB-GLUCOSE M 04121100 18200 PT B CO-INS LAB-GLUC088 M 04122!88 10290 PT B CO-IN8 LAB-GLUCOSE M 04!23!00 10208 PT B CO-IRE LAB-GLUCOSE M 04(24100 18288 PT B CO-IN8 LAB-GLUCOSB H 04!25100 10200 PT B CO-INS LAB-GLUCOSE M 04126100 10200 PT B CO-INS LAB-GLUCOSB M 04/28100 BEV GLUCOSE DBDCUCT 04!30/80 "BNDIRG BALANCB "NBDICARB B -APR 08 10200 LAB-GLUCOSE MONITORING 04!21/00 IB288 PY B CO-INS LAO-GLUCOSE M X04121108 10200 LAB-GLUCOSE MONITORING 04122100 IB208 PY B CO-INS LAB-GLUCOSE M 04122/00 10280 LAB-GLUCOBB MONITORING 04123/00 10208 PY B CO-INS LAB-GL000S8 M 04123108 10200 LAB-GLllCOSB MONITORING 04/24100 18200 PT B CO-INS LAB-GLUCOSE M 04124108 10288 LAB-GLUCOSE MONITORING 84/25/08 -18200 PT B CO-INS LAB-GLUCOSE M 84/25180 10208 LAB-GLUCOSB MONITORING 04126/00 10288 PP B CO-INS LAB-GLUCOSE M 04!26/88 10200 LAB-GLUCOSE MONITORING 84/20100 10288 PT B CO-INS LAB-GLUCOSE M 04128/88 RBV GLUCOSE DBDCUCT 84/38100 "ENDING BALANCB "pRIYATE - NAY 00 BAL FWD -LN- -38- -68- -98- 5,88 G/L -- ACCOUNTS RECEIVABLE -- ACWUNS CflRRG85 CREDITS BALANCB CNTR RATE: 0.00 PRIV PORT: 1105,00 1 54150401120 5.08 1 54551201120 117,72 1 54951381120 90.64 15 52150201128 315.00 2 52150281128 50.08 3 52558601120 75.00 10 52550601120 250.80 10 51350001120 2190.00 2 1.75 Z I.7S 2 1.15 2 1.i5 1 .81 2 1.75 2 1.15 144118S00B0 11.36 ! 56151911120 8.74 1.75 ! 56151911128 0.14 ! 1.15 ! 56151911128 0.14 >. 1J5 ! 56151911120 8.14 ! 1.75 56151911120 4.31 l .B1 ! 56151911120 8.74 ! 1.75 ! 56151911120 0.19 2 1.75. 14411050000 11.36 -120+- 5.00 PAYMENT 05/10/00 11210002008 5.00 11608 CABLE RBNYAL 05181188 -- 05131/00 1 59158401120 5.00 "ENDING BALANCB "INSURANCE -HAY 00 5,88 3208.36 .01 5fi.B0 5.00 83129/81 (AR56~ R8SID8NT LEDGER AS OF DATR OF FIRST ACTIVITY PAGE 2 RESIDENT RESIDENT RESIDENT NUN88R TYPE NANB OATS QTY 49 MEDICAID BURNS, GLADYS N 06/10/80 ADN BOON 204 -B LBVBL 2 11113100 DIS "INSURANCE -NAY 00 (CONT~ BAL FND -LN- -38- -60- -98- 3208.36 29089 PAABNACY LEGEND 04!21188 - - 85119!00 29009 PBANNACY LEGEND 04/21!00 - - 85/19/00 14102 PHYSICAL THERAPY VISIT 85/01/80 - - 85131188 17102 OCCUP THERAPY VISIT 05/01100 - - 05!16100 29089 PBARNACY L8G8ND 05101108 - - 05119(00 38809 PBARNACY NONLEGEND 85116188 - - 05!19188 BOON CBARGB AT 219,00 05101/08 - - 05131!00 "ENDING BALANCB "NCB CO INS • NAY 0B BAL FND -LN- -30- -68- -90- .01 10208 PT B CO-INS LAB-GLUCOSE N 85103(88 10288 PT B CO-INS LAB-GLUCOSE N 85183/08 10288 PT B CO-INS LAB-GLUCOSE N 05/05/00 10208 PT B CO-INS LAB-GLUCOSE N 05/08/00 10288 PT B CO-INS LAB-GLUCOSE N 05/10/00 10208 PT B CO-INS LAB-GLUCOSE N 85112!00 10288 PT B CO-INS LAB-GLUCOSE N 05/15/80 10288 PT B CO-INS LAB-GLUCOSE M 05111180 10208 PT B CO-INS LAB-GLUCOSE N 05119/08 18208 PT B CO-INS LAB-GLUCOSE N 05122180 10208 PT B CO-INS LAB-GLUCOSE M j05/24/00 18208 PT B CO-INS LAB-GLUCOSE N 05126!80 10208 PT B GO-INS LAB-GLUCOSE N 05129!00 10288 PT B CO-INS LAB-GL000S8 N 85131/80 REV 204 GLUC DEDUCT 05131/88 "ENDING BALANCE "MEDICARE B - NAY 08 BAL FMD -LN- -30- -60- -90- 56.88 10288 LAB-GL00088 MONITORING 85181100 IB208 PT B CO-INS LAB-GLUCOSE N 05181/88 10288 LAB-GLUCOSE NONITOBING 05/03100 10208 PT B CO-IN8 LAB-GLUCOSE N 85!83!00 10208 LAB-GLUCOSE MONITORING 05105/88 18208 PT B CO-INS LAB-GLUCOSE N 05105108 10208 LAB-GLUCOSE NORITORING 05108100 10208 PT B CO-INS LAB-GLUCOSE N 05188108 10208 LAB-GLUCOSE MONITORING 05/10188 18288 PT B CO-INS LAB-GLUCOSE N 85!18!08 10208 LAB-GLUCOSE NONITOBING 85112/08 18208 PT B CO-INS LAB-GL00088 N 85112188 10288 LAB-GLUCOSE MONITORING 05!15100 G!L -- ACCOUNTS RECBIVABLB -- A000UNT CAABGBS C880IT8 BALANCE CNTR RATE: 8.00 PRIV PORT: 1185.88 -120+- 3208.36 1 54551287128 189.01 1 54551207120 189.01 80 52158281120 2080.08 37 52550601120 925.08 1 54551207120 189.01 1 54951301120 45.64 31 51358001120 6789.00 13151.81 -120+- .01 2 1.15 2 1.15 2 1.T5 2 1.15 2 1.75 1 .81 2 1.15 2 1.75 2 1.15 2 1.15 1 .87 2 1.15 2 1.75 2 1.75 14411050000 22.12 83 -120+- 56:00 56151911120 0.14 ! 1.15 ! 56151911128 8.14 ! 1,15 ! 56151911120 8.14 ! 1.15 5fii51411120 8.14 >, 1.15 56151911128 8.14 1.15 ! 56151911128 4.37 l .81 56151911128 8.74 03129101 R8SID8NP LEOGBH AS OF DATE OF FIRST ACTIVITY PAGE 3 {AR56{ RESIDENT RESIDENT RESIDENT GIL -- ACCOUNTS RBCEIVABLE -- NUNBER TYPE NAME pATB QTY ACCOUNT CAARGBS CREDITS BALANCB 49 HBDICAID BURNS, GLADYS N 06110/00 ADM CNTR RATS: 0.00 BOON 204 -B LEVEL 2 11113/00 DI8 PHIV PORT: 1705,00 "MEDICARE B - MAY 00 {CONY{ 10208 PT B CO-INS 188-GLUCOSE N 85/15100 2 1.15 18200 LAB-GLUCOSE NONITOHING 05/17/80 2 56111411120 0,14 10288 PT B CO-INS LAB-GLUCOSE N 85/11/80 2 1.TS 10208 LAB-GLUC088 MONITORING 01119/08 2 56111911120 0.14 10280 PT B CO-TNS,LAB-GL00066 N 85119/08 Z 1.15 18288 LAB-GLUCOSE'NOAITORING 85/22108 2 56111911128 8.14 10288 PT B CO-INB LAB-GLUCOSE H 05/22!00 2 1.75 _ 18208 LAB-GLUC088 NONITOBING 05124/88 1 56151411120 4.31 10208 PT B CO-INB LAB-GLUCOSE M 05!24100 1 .81 10288 LAB-GLUCOSB NONITOHING 85126!80 2 56111911120 0.14 10208 PT B CO-INS LAB-GLUCOSE N 05/26100 2 1.11 18200 LAB-GLUCOSS HONITORING 85124108 2 56151411120 8.74 10208 PT B CO-INB 1AB-GLUCOSE N 05129/00- 2 1.71 18208 LAB-GL000SB MONITORING 85!31!80 2 56111911128 8.14 10288 PT B CO-INS LAB-GLUCOSB N 85/31100 2 1.75 HEV 208 GLUC DEDUCT 85131108 14411810888 22.12 ''BNDING BALANCB 110.40 "PRIVATE - JUN 80 BAL FWD -LM- -30- -60- -40- -120+- 5,88 5.88 PAYMENT 06114100 11210002008 5.00 18280 BLOOD GLUCOSE TEST 86112100 2 56111981220 0.14 10208 BLOOD GLUCOSE TEST 06/14100 2 56151901200 8.14 10280 BLOOD GLUCOSE YBST ,86!16108 2 56151981280 0.74 10208 BLOOD GLUCOSE TEST 86/19100 1 16151901208 4.37 18280 BLOOD GLUCOSE TEST 86121188 2 16151981288 8.74 10288 BLOOD GLUCOSE TBSS 86123/88 2 56151981200 8.14 18208 BLOOD GL00088 TEST 86126/88 2 56111981288 8.74 14101 CATS TRAY 06/24100 1 56154101188 10.04 NOON C8AHG8 AT 136.88 06118/00 - - 06113/80 4 51358881228 544.88 NOON CBARGB AT 142.80 06/14108 - - 06!30100 17 51350001200 2414.80 ADV ROOK CHARGE AT 142.80 01101108 - - 91131180 13211888880 4482.88 "BNDING BALANCB 1426.05 "IASURRNCB -JUN A0 BAG FYlD .-LH- -30- -6A- -90- -120+- _ 9948.65 3288,36 1 3151.81 14102 PHYSICAL P88RAPY VISIT 86/01100 - - 06/09108 18 52150201120 458.00 IB202 BLOOD GLUCOSE TEST 86/82!08 - - 86/84180 1 56151981128 38.19 38007 PHARMACY NOA LEGEND 06/01180 1 54411301120 .90 ANCILLARY NHITH OFF 06/38180 57511581120 .90 BOON CBARGE AT 219.80 06181100 - - 06189/00 9 51350087128 1471.00 "BNDING BALANCB 11688.60 "NCR CO INS - JUA 00 BAG FND -LN-. -30- -60- -40- -120+- .82 .01 .83 r ..... .:..:... ,_~,.:_ .. ,i _ _ -.~. 03129101 (ARS6( RESIDENT RESIDENT NUMBER TYPE R86IDENT NANB 49 NNDICAID BURNS, GLADYS M ROOK 204 -B LEVEL 2 "NCR CO INS - JUN 00 (CONT~ 10200 PT B CO-INS LAB-GLUCOSE N 10288 PT 8 CO-IN8 LAB-GLUCOSN N "ENDING BALANCB "MEDICARE B - JUN 0B BAL FND -LN- -30- 113'.60 56.00 10288 1AB-GLUCOSR MONITORING 10208 PT B CO-INS LAB-GLUCOSE N 10200 LAB-GLUCOSE MONITORING 10280 PT B CO-INS LA8-GL000SB H "BNBING BALANCB " PRIVATE - JUL 00 BAL FNO -LN- -30- 1426.85 RESIDENT LSDGBR AS OF DATE OF FIRST ACRIVITY 60- -60- PAGE 4 GIL -- ACCOUNTS RECEIVABLE -- DATE QTY ACCOUNT CHARGES CBEDIRS BALANCE 06110/00 ADN CNTR RATE: 0.00 11113!88 DIS PRIY PORT: 1105.00 06/28/00 2 1.75 06130!00 2 1.15 3.53 -90- -120+- 110.40 06128/00 2 56151911200 8.14 06/28!08 2 1.75 06/38/00 2 56151911280 0.74 06130180 2 1.15 104.30 98- ]0281 BLOOD GLUCOSB TB6T 06!28100 -- 06/30180 18201 BLOOD GLUCOSE TEST 81103!00 -- 01131108 SBY LAST NO RC 81101!08 SOON CBABGE AT 149.80 07!01!80 -- 01131!00 ADY NOON CBARGB 00101100 -- 00131/00 "ENDING BALANCE "INSURANCE -JUL 00 BAL FND -LN- -30- 2451.59 9448.65 10201 BLOOD G10006E TSST 18207 BLOOD GLUCOSE TESP ANCILLARY WRITS OFF "ENDING BALANCB "NCR CO INS - JUL 08 BAL FND -LN- -30- 3.50 .02 REY PT B CO-IN6 HEV PT B CO-INS REV PT B CO-INS' "ENDING BALANCE '*NEDICARE B - JUL 00 BAL FND -LM- -30- 13.98 113.68 18208 LAB-GLUCOSE MONITORING 18208 LAB-GL000S8 MONITORING 10208 LAB-GLUCOSE MONITORING 10208 LAB-GLUCOSE NONITO@ING 10208 LAB-GLUCOSE MONITORING 18208 LAB-GLUCOSE MONITO@ING 10208 LAB-GLUCOSE MONITORING 10208 LAB-GLUCOSE MONITORING -60- -40- -120+- 3288.36 15680.68 04/21/00 --004128/00 13 56151901200 56.81 05101108 -- 85131/80 26 56151907200. 113.62 Bi131/88 57557501200 110.43 12372.10 15680.60 -60- -40- -120+- .01 3.53 04130/00 14411050000- .01 05131!80 14411050000 .02 06138/00 14411050800 3.50 -60- -98- -120+- 56.00 104.30 81/03/00 1 56151911208 4.31 01!03180 -- 07131100 23 Sfi151911280 100.51 01105180 2 56151911200 0.74 07107108 2 56151411280 8,14 67/10!00 2 56151911208 0.14 01!12!00 1 56151911200 4.31 07/14!00 2 56151911208 0.74 01117100 2 56151911200 0.74 -120+- 1426.BS Z 56151901200 8.74 23 56151901200 IB0.51 13211800000 4402.08 31 51350001288 4614.08 13211000000 4619.00 03129101 ~AR56) RBSIDBHT LEDGER AS OF DATB OF FIRST ACTIVITY PAGE S RESIDENT RESIDENT RESIDENT NUNB@R TYPE NANB DATB QTY 49 NEDICAID BURNS, GLADYS N 06110100 ADN BOON 204 -B LBVBL 2 11113108 DIS 'PNEDICARB B - JUL 00 (CONT~ GiL -- ACCOUNT6 RECEIVABLE -- ACCOUNT CHA@G89 CREDITS BALANCB CNTR RATB~ 8.00 PRIV PORE; 1185.00 10208 LAB-GLUCO6S NONITORING 01119100 2 56151911200 8.14 10208 LAB-GLUCOSE NONITORING 01121/00 2 56151911200 8.14 10208 1AB-GLUCOSE NONITORING 01/24100 2 56151911200 8.14 10208 LAB-GLUCOSE NONIfORING 01!26!00 2 56151911280 8.14 10208 LAB-GLllC0S6 MONITORING 01/28100 2 56151911200 0.14 ANCILLA@Y°WRITB OFF 01131/00 S75S7511208 .01 18208 LAB-GLUCOSE NONITDRING 01/31100 1 56151911200 4.37 RBV PT B CO-INS 04!38100 14411858000 .81 RSV GLUCOSE TSST 09130100 56151911120 56.81 @SV PT B CO-INS 05131108 14411050880 .02 RSV GLUCOSR TEST 05131188 56151911120 113.62 RSV PT B CO-INS 06130188 14411050000 3.50 RBV GLUCOSR TSST 06/30100 56151911200 11.48 'PENDING BALANCB 'PPRIVATB - AUG 00 BAL FND -LN- -30- -60- -98- -120+- 9341.25 3824.85 12312.10 RSV LRST NO RC 08101/00 13211000000 4619.00 280 CO-PAY 5/88 85101100 14411050000 216.29 :"ENDING BALANCB "NBDICAIO -AUG 00 30001 PSARNACY NON LEGEND 08121100 1 54951302208 .90 ANCILLARY WRITS OFF 08!31100 57557502200 .90 ROOM CBARGB AT 149.00 08/01100 -- X08/31100 31 51350002200 4614.00 @OON WRITS OF@ 88181108 -- 08131!00 31 51551002200 1293.fi3 'PENDING BALANCB "INSURANCE -AUG 00 BAL FWD -LN- -30- -60- -98- -120+- 2451.59 9948.65 3208.36 15688.60 PAYMENT BC NAS NED 08(04100 11210002008 320fl.36 PAYMENT BLUE CR03S NAJ NB 08(04180 11210802000 9132.36 REV 200 CO-PAY 5100 05/01100 14411050000 216.29 'PENDING BALANCB P'NBDICARB B -AUG 08 BAL FWD -LN- -30- -60- -90- -128+- .81- .01 'PENDING BALANCE "PRIVATE - SBP 00 BAL FWD -LN- -30• -60- -90- •12A+- 216.29 4128.25 3024.85 1469.39 11600 CABLE RENTAL 09/01100 -- 09/30100 1 59158401200 5.00 PRIVATE PORTION 091B1I00 -- 09130100 30 1185.00 ADV PVT PORTION 10101(00 13211000800 1185.00 01- 1969.39 3325.37 24SI.S9 .01- . 83129181 RBSIDBNP L@DGBR AR OF DATE OF FIRST ACTIVITY PAGB 6 (AB56~ RBSIDBNT RBSIDBNT RBSIDBNT NUNBBR TYPB NANH DATE QTY 49 NBDICAID BURNS, GLADYS N 06110100 ADN ROOK 204 -B L@V8L 2 11/13188 DIS "PRIYRTB - SBP 00 (CONY) "BHDING BALANCB "NBDICAID -SBP 00 BAL VWD -LN- -30- -60- -90- 3325,31 30081 PBARHACY NON LRGBND 09/81100 - - 09!23/08 51501 IRRIGATION'PISTON TRRY 89186/80 ANCILLARY'WRITR OFF 09)30100 BOON CBABGO Af 144.80 09!01!00 - - 09138!80 BOON WRITR OFF 04/01/00 -- 09130100 D@DUCT PVT PORT 04101/00 -- 09130100 "BNDING BALANCB "INBURANC@ -SBP 00 BAL FND -LN- -30- -60- -90- 2451.59 ::BNDING BALANCB "NBDICARB B - S@P 80 BAL RWD -LN- -30- -60- -90- .81- "@NDING BALANCB "PRIVAT@ - OCT 00 - BAL YWD -LN- -30- -60- -90- 3515.00 216.29 4728.25 3024.85 11600 CABLB RBNTAL 18131/0B R8V LAST NO PP 410101/80 PRIVAPR PORTION 10101100 -- 10131100 ADY PVT PORTION 11101/08 flBY RN CHG 6100 06130100 R8Y 8N CAG 610@ 06130188 RBY GLUCOSR TBST 06130/00 H@Y CATA TRAY 86/38/08 BST PRIV PORTION 06130!00 RBV GLUCOSB TST 01!31180 RBY RN CAG 1/00 81131/00 @Sf PRI FONT 1100 81131/08 8ST PRI PORT 8100 00/31/08 "BNDING BALANCB "NBDICAID - OCT 00 BAL FWD -LN- -30- -60- -90- 1433.18 3325,31 38081 PRARNACY NON LRGBND 06101108 -- 10/06100 30082 PBARNACY NON LRGBND 06107100 51501 CATBRTBR T$AY 10/04(80 ANCILLARY WRITB OFF 10!31100 BOON CBARGB AT 149.08 10101/80 -- 10131100 G/L -- ACCOUNTS RBCBIVABLB -- ACWUNP CHAHGBS CHBDIPS BALANC@ CRTR RAT@: 0.00 PRIV PORT: 1185,00 11544.39 -120+- 3325.31 1 .54951302200 69.19 1 54151502280 4,81 51557502200 30 51350082200 4418,08 38 51551002200 30 120+- 120+- 2451.59 -120+- 11544.39 1 59158401200 5.00 13211000000 31 1185.00 13211800008 !185.80 51350001220 51350881228 56151401208 56154181208 14411050080 1785.08 56151981208 51350001280 14411858888 1185,00 14411050008 1155.80 74.00 1251.40 1185.08 4758.41 2451.59 .81 .01- 1785.88 544.80 2414.00 56.81 10,84 109,25 4619.00 18936,29 -120+- 4158.41 1 54451382208 39.42 1 54951302200 1 54151502208 10.00 51551582280 31 51350082200 4619.00 90 48.52 EXHIBIT "B" HCR Manor Care ADMISSION .AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Health Caze Center ("Center"). Center: Resident: ~LG~~V S ~ ~s Legal Representative: ~ (~e'~i~~s" Admission Date: ~l-la-,l ~ ~~~ ~ Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is dischazged. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and Boazd Rate. Far the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Boazd Rate set forth on Attachment A hereto. The Room and Boazd Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10`~ day of each month. The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Parry Payor or Managed Caze Organization (see Section 1.06). ` 1.02 Ancillary_Chazges. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" aze described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10th) day of the month. 1.03 Late Pavments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. I.OS Governmental Proerams. If the Resident is eligible for coverage under any governmental program, such as Medicaze, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: /Medicare, /Medicaid and/or VA. Medicaze may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicaze updates yearly. If the Resident also participates in Medicaze Part B, for physical, occupational, or speech therapy or other billable charges (which aze not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative .aze responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services aze covered, although Medicaid may require the Resident to pay a portion of the Room and Boazd Rate from their mornhly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and(or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Managed Care Oreanizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another sim~7ar entity with which the Center has executed a provider agreement, the chazges are governed by the applicable agreement.' The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 ., will bill the Resident's third party payor as a service, but the Resident remains Gable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pav Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Censer and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for caze at the Center and the Resident'is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cazds, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five ~fi) days bf the Resident's disenrolhnent, enrollment, change in health caze coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regazding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such infom~ation, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. It shall be the responsbility of the Resident andJor Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed caze organization with which the Center is under contract. 1.10 PriTM+aty_ Res~onsibih,~y for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident, shall remain primarily Gable for any and all chazges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed caze provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed caze organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician: If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, "provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distnbution system similar to the Center's ancillary pharmacy's medication distribution system II. RIGHTS AND RESPONSIBII,ITY OF THE LEGAL REPRESENTATIVE 2.01 Legai Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Makb Payments on Behalf of Resident. The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and chazges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and chazges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Ivfedicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a lonely and proper manner, the Legal Representative shall be personally liable for all chazges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper mariner. 2.05 Cooperation for Financial Assistance If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Dischaz~e. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all chazges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBII,ITIES OF THE CENTER 3.01 Room and Standazd Services. As part of the Room and Boazd Rate, the Center shall fiunish basic room, boazd, common facilities, housekeeping, laundered bed linens and bedding, general nursing Gaze, personal assessment, social services, and such other personal services as ttiay be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 DeQosit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the fast month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after dischazge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for caze of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third parry payor or. managed caze organization responsible for all or any party .of the payment or reimbursement of the Resident's chazges, including any utilization review or quality assurance 5 .. r. ~ ~'r q reviews or payment audits performed by such; the personnel of any hospital or other health caze facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment's as aze necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. ,As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photoeraoh. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. -See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Deternvnation Notice. See Attachment F. e. Medicaze Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds .r- : x ~ Authorization and any other related documents. See Attachment H-I and H-2. g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). i Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). j. The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). 1 Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect; mistreatment and misappropriation of property. See Attachment I (Center Supplement). m The Resident Handbook. See Attachment J. f n. Resident/Patient Rights. See Attachment K. o. Medicaze/Medicaid information and display of such information including how to apply for and use Medicaze and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Caze's Limited Treatment Practices and 'No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 ;: ~ w . s. ASM Form See attachment P. t• See Attachment Q. u• See Attachment R. v See Attachment S. w• See Attachment T. x• See Attachment U. y See Attachment V. z. See Attachment W. ~~~ 4.05 Assiemnent of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furtvshed by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Heahh Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer, This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may Terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Cetrter fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Boazd Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Caze Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's fiords, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the- Center by any person resulting from any damage or injury caused by the Resident to any person or the property _~ ~-,. ,. . +„~ , of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal Iaw will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIIt SATISFACTION. Signature of Resident: Signature of Legal Representative, if signing on behalf of Resident: Date: Date: ~ ~ ~+ i ~ ~~ Signature of legal Representative, signing on his/her own behalf Center Date: Q Date: ~l ~ ~ 1 ~ ~~ 11t- ,. • Y Y t .~. EXHIBIT "C" P"~a'°~-`°~ NOTICE TO APPLICANT DEPARTMENT OF PUBl1C WELFARE CUMBERLAND COUNTY ASSISTANCE OFFICE --. - • • - ~ • - a - - • ~ • • • • - vurmr~rm un PO BOX 599 9 17 ~~ r ,.,,,~ -BENEFIT - E4GIBlE Nor ELIGIBLE P ENDING - ~ 100-269-0173 (717)240. 2700 - ~ASSI3TANOE`' ~'-_° CHECK : -_ '- Auer Net'ust check whlM may b•aspecialamoum you wNrecelve$ - - - - ~ 7Wica a Month ~ Once a Month ~ In the MaT ~ At tha Bank ASSISTANC7= ^ you nave a patient pay Ilabillry of $ for the pedpd beginning and endin ^ EHecava Date FCCQ ~ - _ t37AMP8v~ You wdl recetve $ for the manth(a1 a ~ then Yoa will receive toad stamps in the arnourrt pF$ a month fmm to ^ In iha Maii ^ AL the Bank URSING_HOME CARS Level of enre authorizetl you are expected to payE - nmonth inward your care, Q EC ASE - ~ eci _ iTtiEFtSk~o4~1' iPR ~ M SAa'~ INCSUO€ g-u .. - -.. _... - :;._'y-_.-',~*:a ~>m-._~?~i w~a~, :.w -- r$r~~ _,~r~~ - _ .,. ~. ~_ _ ~T ~^~ s ~ ~ ~ N NAME CH AM A T ERVIC (~ME N C C ST M~ A$ RVI' • • • • • • Regula8on_ _ Reaso n Code - Siuce your application is over t e day rocessing time co e e an tie verification. of ~P-}~-~ r/hnU~. - I J rJj00 is -still to be presented.`- We..are extending the application processing time to 45 days. Please remember to"provide a1I pending on the attached notice as soon as possible or the application w e 1 nom. :+,r. g zit'fi"ri`+1`~Nuul6`$'r'~ ~~~~ 4?er's;~` :;~fkfiglSTA@1T~Ci'ILCK '',?~."®r~.;~i?--- _ . , .~ ... - - -Name M Name N IN M $ $ ' $ $ $ - $ --. Name NE IN Name ~- I N j --_ $ $_ $ $ ~I TOTAL GROSS MONTHLY INCOME $ TOTAL GROSS MONTHLY INCOME ~ - $ ~ "' ~ - ' - ' GROSS MONTHLY DEPENOENi~CARE COSTS - _.,-__ $ - - ~ ;GROSS MONTHLY bEPENDENT CARE COSTS-' -' $ - - -'~~?=~?f%:~'~?7- GROSS MEDICAL COSTS $ -; rv7ct"n, -~,:y:%x. -?- -:, c''.:r.. M'Li~> . 'i .,, 2'4^= ~ +?+.: ~-i. Telephone Wated5ewaga [,] ME[51~71t; A5$ SiANCffi :~ i ~Ium_- u Etec[ric ' _ Garbagei trash Name ~ M Gas ~ - Utility Installation $ OII -....- , t,. ,~'w.. s;.y, .,,- Other - ' :..n ._ .. . _: -. ,.. - $ . ,..: - GROSSUTILITY COSTSAITILITY STANDARD' - $ ~ ~- $ RENT/AAbRT'GAGE '""~'. ~"-}•Y .... .~..' - _ $- Name ~ .._ ._ - L . N r INSURANCE COST_ON iIOME . _ - _ $ ~ $ ~j -- , _ ~ TOTALS TE' C$§F -:-. „ -::._>~_ .~,,, - .. .-~:: - -_ ~ J* - ~ ~ 'T TOTAL GROSS MONTHLY INCOME $ - - - - F;,~, ~ ~ >ti '- {S~ ~ '1 7IIg~ UlYI6,t, Q# vy,(~jA% ~.BIII"j p~8~ ' NET MONTHLY INCOMEME78EM1-ANNUAL INCOME $ ~ ~~~~~ - ~ .o .-_ .. , . INCOME LIMB - $ ... -. ...~. v..:<.,:...~,...,~ s M.,.~;,:.,-. ... ..:. ~.:.::M ... n7 so .,T -.., ...: :.:,..-,.., - .~=wu .' <,..r-sav'<.u&--+:- CD RECORD NUMBER CAT CTR DIG DI5T Pf 2-.. r ~1 rn ~.~~ rnQ.,~c a~•L.~. ~1~ SOhca~.A~ ~a~.~ ~. Xi~Y.~_. ~L/Or~CZ(7/1 /fl/fi`r' OD J~rS~aZbROI~' Workers Signature Date -Telephone Number LECaLSeRVICES,INC. 81RVINE ROW CARU$LE PA 170133019 717-213.9900 717.766-8475 r ~. ~ ~:. •~~c e i._. ~~ ~ EXHIBIT "D" ~~~ ~ ~~ NOTICE TO APPLICANT ~ .- '- ' ' ' ' , ' ~ NoT • BENEFIT ELIGIBLE ELIGIBLE PENDING DEPARTMEM OF PUBLIC WELFARE CUMBERLAND COUNTY ASSISTANCE OFFICE - 33 WESTMINSTER DR PO BOX 599 -SOOU2 9E01731 7 713-02 9 9 ( ~ 40-2700°x^--+l~ ~ ^ ASSISTANCE OHECK - After the first check which may be a special amount you will rettiva $ ^ twice a Month ^ Once a Monty ^ In the Mail ^ At the Bank _ - DICAL ASSISTANCE ^ You fiava a patient pay IlabTity of $ - - for the pebotl beplnning and entling ^ Effective Date ^ FOOD 8TA S You will receive $ _ _ for the month(s) of ~ then yoU will receive food st'smpa in the amount of $ a month tram to ^ in tfie Mail ^ At the Bank ' URSING HOME CARE Level of wre aWhoraed you ere expected ro pay 5 ~- a month toward your care. ^ RVILE ^ 5 ecif - - - ~ ~ _ - -~ THE FOLLOWING PEFISO NS ARE INCLUD ED - -- '~~''-' "` _ - ,.r- - '' 1+'f .~° `""' ~ R~ - -,,. _ ~`~}q,~' ~ N NAME CH CI( STAM 5 ICE NO. NAME CH K STAMP AS5T. ERVIC ~i t-G.~.L f 1, j ~+ L. I s • • • a e Regulation V y2 Reason Code Q Z ~~' ~n~ntiu- aLm.cl /us3ourco.,~ ~ _/»-u~~.~..~~rt- y On- A.~'~' 2/. GLra.oC Cic-~ 2LJ , ?.ooa \#' rrlr p~2 nrr .,~tctrrL.iL G2.ccx%29~.t¢?n~rn~~~ ..~ ~t1+-~OOcs rca~o ~ ~ri)a~-Dn, tl- .ti. O r~. ~'t.O~a.2~`~, `7h,1~ f/~r wcn~o./r~c.E~. /,stCf.:.~.u-rtci, are, q~.rnot ~(oU . . . . . QFOQD,STAMPS --_'~ --'•.-Number-ofPeragn ~ . . . . . [~-ASSISTANCECNECK "'-° ~~NUm6erntPer$drigr Name g A E MINCO~ Name EARNE IN M - $ $ . -- r__ - $ - $ - Name - NEA NED L"Cl1! OME Narita UN N IN OME _ - $ $ TOTAL GROSS MONTHLY 2NCOME - $ TOTAL GROSS MONTHLY INCOME - $ GROSS MONTHLY DEPENDENT CARE COSTS $ GRO.S3 MONTHLY DEPENDENT CARE COSTS $ GROSS MEDICAL COSTS $ ~ ' - 'f-~~, ~..w -" x , J;~x~ g as.',..;w,+ Telephone - WaterlSewage Q MEDICAL ASSISTANCE -- - ~ Numtiet of_Persori5, Electric ~ GarbagerfraSh Name - EARNED IN ME bas Utility Installation ~ - - - $ Oil Other $ GR088 UTittiY COS7SlUTILITY STANDARD' $ - - $ RENT/MORTGAGE $ Name - UNEARNED M M TAXES $ _ - $ INSURANCE C057 ON HOME - $ ~ -' $ TOTAL SHELTER COST - $ - - - $ 'The housah0ld may SlvitCh hetween U7e aCtUE! ubhty OoatS YaJPd the TOTAL GROSS MONTHLY INCOME ~ - - $ Standard utility a!lowaRCe 8t the Yime of reapptlca2/on and one NET MONTHLY INCOMElNET SEMI-ANNUAL INCOME $ add~tfpnel,tlgie dudng each twelve-month peNao:.:-- ,:>: -.. -., -:- - INCOME uM1T - ~ ~ $ CO RECORD NVMBER CAT C7R DIG DIST 21 -g x.36 ~T~9 r ~lZar~~. rn- ~c.vLnka--- ~t~c~jvv..R-. u1~2~-0~. 1 i ~D lS0o~.6Rc Worker's Signature Date, 'telephone Numb -I LEGAL.HELP IS AVAILABLE A7 - %C ~~GtIL.Cn. Ct... ~Q~sas~ L `_J /f yov do not understand our decision or have any questions, contact your worker. rr tcr~T r+•^.cv LEGAL SERVICES, INC. B IRVINE ROW CARLISLE PA 17013.3019 717.243-9400 717-766-5475 .~., i- "` °d°W ~a'° -~.uM,. ,-3~ , a.-~~,neutta#et~tLaamex3~ .... ~. _.. X23 n IIA-sw t tcs o R t„~ . r. ;~ _ }f i''t,1J ~'' _i.j;! j~U . ~,., ~,'s .v., F ~~ 1i, J •. 7~;i1+ .~ d" ~ ~ lhfli' ~-'ri.: fi7G } JhJ 1C ~`dli !~~I~~wU 83/29101 R8SID8HT LBDGRR AS OF DATB OF FIRST ACTIVITY PAGB 1 (RB56) R86ID8NT R88ID8NT R8SID8NT NUMBBR TYPB NANB 49 NBDICAID BURNS, GLADXS M NOON 204 -B L8V8L 2 **NBDICAID - OCT 00 ICONT- BOON WRITS OFF DEDUCT PYT PORT 8ST PRIV PORTION SST PRI PO@T 1100 8ST PRI PORT 0/00 ''SNDING BALANCB _**INSURANCB - OCT'00 BAL FND -LN- -38- **SNDING BALABCB **MBDICA@8 B - OCP 80 BAL FWD -LN- -30- 10208 LAB-GLUCOSB MONITORING 18208 LAB-GLUCOSE MONITORING 10208 1AB-GLUCOSB MONITORING 18200 LAB-GL00088 MCNITORING 10200 LAB-GLUCOSE MONITORING 10208 108-GLUCOSE MONITORING 10208 LAB-GL00088 MONITORING 10208 LAB-GLUCOSR MONITORING 10208 LAB-GLUC06$ MONITORING 10200 LAB-GL00088 MONITORING 10280 LAB-GLUCOSE NONIPORING 18208 LAB-GLUCOSE NONIRORING 10280 1AB-GLUCOSE MONITORING 10288- LAB-GL00088 MONITO@ING 10208 LAB-GLUCOSE MONITORING IB288 LAB-GL00088 MONITORING 10288 1AB-GLUCOSE MONITORING ANCILLARY WRITE OFF N8D B ADJ **SNDING BALANCB *'PRIVAT& - NOV 00 BAL FWD -LM- -30- 8930.00 1790.00 RBV LAST MO PP PRIYATB PORTION **SNDING BALANCB *'N80ICAID - NOY 00 BAL FWD -LM- -30- 1646.39 1433.10 30889 PRARMACY NONLBGBND ANCILLARY WRITR OFF GIL -- ACCOUNTS RSCBIVABLB -- DATE QTY ACCOUNT CRARGBS CR8DIT8 BALANCB @6110100 ADM CNTR RATS: 0.00 11113/00 DIS PRIV PORT; 1705.80 10!81100 -- 10/31/00 31 51551002200 1101.61 10/01188 -- 10(31/08 31 1705.00 06/30100 14411050000 1705.00 07/31100 14411050080 1705.00 80/31100 14411050000 1-705.00 1849.86 -60- -90- -120+- 2451.59 68- -90- -120+- .01- 10/02100 2 56151411200 10/84/00 2 56191911200 10/06100 2 56151911200 10/09/00 2 56151911208 10110100 2 56151911200 10111100 Z 56151911288 10/12100 2 56151911200 10113100 2 56151911200 10/14/00 2 56151911200 10/19100 2 56191911280 ,10/16/08 1 56151911208 10118/00 2 56151911200 18120108 1 56151911280 10123108 2 56151911280 10125100 1 56151911208 10121!00 1 56191911288 10/30/00 2 56]51911200 10/31/80 51551511200 01/01100 57551511200 -60- -90- 216.29 11181100 11/01100 -- 11112!00 12 -58- -90- iS40.37 1185.00• 10/06188 11130/00 -120+- 2451.59 .01 2451.59 0.14 0.14 0.14 0.14 0.14 0.74 8.14 0.14 8.14 0.14 4.37 0.14 4.37 0.14 4.37 4.37 8.14 .81 2fi.23 184.81 1893fi.29 13211000000 1185.00 1328.20 10419.51 -128+- 1185.00- 1844.86 54951302208 109.51 51551502208 !09.51 1 03129101 SBSIDBNT LEDGER AS OF DATE OP FIRST ACTIVITY PAGE 0 ~AB56~ RESIDENT RBSIDENT RESIDENT G/L -- ACCOUNTS RECEIVABLE -- NUNBER TYPE NANE DATE QTY ACCOUNT CHARGES CREDITS BALANCE 49 NBDICAID BURNS, GLADYS N 86110100 ADN CNTR RATE: 0.00 NOON 204 -B LEVEL 2 11113108 DIS PRIV PORT: 1185,00 "MEDICAID - NOV 00 (COHT~ ROOM CRARGB AT 149.08 11101100 - - 11/12100 12 51350002100 1100,00 BOON WRITS OFF I1101100 - - 11!12180 12 51551002200 pEDUCT PVT PORK 11/01/08 - - 11112108 12 NN CBG. 86130100 51350002220 544.00 RN CBG 06130100 51350082220 2414.08 RN WIO 06!30/00 51557002220 RN W/0 06/38100 51551002220 GLUCOSE TEST 06!30100 56151902200 56.81 CATB TRAY 06/30100 56154102200 18.84 ANC WIO 06!30(00 51557502200 BN CAG 01!31/80 51350002288 4619.80 NN WIO 01!31180 51557002280 OLUCOBB TEST 01131180 56151902288 109.25 ANC W10 01!31!00 51551502208 "ENDING BALANCE '=INSURANCE - NOY 00 SAL FWD -LN- . -38- -60- -90- -120+- , 2451.59 2451.59 *'BNDING BALANCE "NEDICRRB B - NOY 80 BAL FWD -LN- -30- 184.81 "ENDING BA1ANCB "PRIVATE - DBC 00 BAL FND -LN- -30- 1328,28 7145.08 BC BBTBO TO PRIYATB BC BBTBO TO PRIVATE "ENDING BALANCE ='NEDICAID -DBC 00 BAL FWD -LN- -60- -90- -60- ~ -90- 179B.B8 216.29 86/09/80 86189/B8 86109700 -120+- 104.87 -128+- 10479.57 52150201128 450.08 56151901128 38.59 51350001120 1971.00 459.T2 1320.20 128.24 647.02 66.05 1293.63 184,25 6557.97 2451.59 104.81 -30- -60- -90- -120+- 1646,39 1433.10 1540.37 1930.11 6551.97 "ENDING BALANCE "INBURANCB -DEC 80 BAL FWD -LN- -30- BC RBT@0 TO PRIYATB BC RETRO TO PRIYATB BC RBTRO TO PRIYATB ='ENDING BALANCE "NEDICARE B - D8C BB BAL FWD -I;N- -30- 104.81 ==ENDING BALANCE -60- -90- 06/09/08 86/09/00 06109100 -60- -90- -120+- 2451.59 2451.59 52150281128 450,00 56151987128 30.59 51358807120 1971.80 -120+- 104.87 12931.16 6557.91 .00 184.81 03129101 (AR56( ~ . RESIDENT ABSIDBNT NUNBER fYPB HBSIOBNT NANB R8SID8NT L8DG8R AS OF DATE OF RIHST ACTIVITY DATE QTY 49 NBDICAI- BURNS, GLRDYS N BOOW 284 -B LBYBL 2 "PRIVATE - JAB 81 BAL FWD -LN- -30- -60- 1328.28 1145.00 RBY RN CAARGB ADJ R8Y RN CAARGB ADJ RBV CATH TkAY ADJ R8V PVT PORTION ADJ RBV RM CAG ADJ @BV PVT PORT RDJ H8V PYT PORT ADJ ROOW CHARGE RBV PVT PORTION IRRIGATION PISTON TR ROOK CHARGE CATABTBR TRAY BOON C8ARG8 RBV PVT PORTION R8Y PVT PORTION HOON CRARGE "ENDING BALANCE "NBDICAIO - JAN 01 BAL FWD -LN- -38- R8V RN CAG ADJ R8Y RN CAG ADJ REY RM WIO ADJ H8V RN WIO ADJ RSY GLUCOSE ADJ H8V CATS TRAY ADJ RBV ANC WIO ADJ H8V PVT POHPION ADJ R8V PVT PORT ADJ RBV RN CAG ADJ R8Y RN WIO ADJ R8Y GLUCOSE RDJ R8Y ANC W/O -ADJ @BV PVT PORT ADJ RRV RN CAG R8Y RN W10 flEV PVT PORTION H8V IRRIG PISTON TRY RSV ANC WIO @8V ROOM C8AHG8 REV RN WIO B8V CATS TRAY R8V ANC W10 H8V AM CAG 06110100 ADM 11113(00 DI5 -90- 1790.80 0fi/30/00 06138/00 86138/00 06!30!80 07/31/00 87/311@0 08131/00 BB/31 /0B 09/30100 89138!08 09130108 10!31100 10131108 15131108 11/30!00 11130100 -60- -90- 1646.39 1433.18 06/30180 ,86130100 86/30100 06138!00 86130!08 06!38/88 06130100 0fi130/00 01131 /B0 87!31108 01131100 01131100 81!31180 80131100 00/31100 00131100 09/30/00 09130108. 09130100 89138150 09130108 10!31108 10131180 18131/00 PAGE 9 GIL -- ACCOUNTS RBCBIVABLB -- A000UNT CBARGES CREDITS BALANCE CNTR RATE: 0.08 PRIY PORT: 1785.00 -120+- 2667.BB 12931.16 51350081220 544.00 51358001228 2414.00 56154101200 10.04 14411050000 51350001208 4619.08 14411050000 14411058000 5135A001208 4619.00 1441]050080 54151501280 4.81 51350001200 4619.00 54151501200 18.80 51350801200 4619.00 14411050088 14411050000 51358801200 1041.64 -125+- 3470.40 6557.91 51350002220 51350882220 51557882228 120.24 51551002220 647.82 56151902200 5615415ZZ00 51551502200 66.85 14411850000 1185.88 14411850008 1185.00 51350002288 51551082280 1293.63 56151902288 51551502200 109.25 14411050808 1185.00 51350002200 51551082208 1293.63 14411058000 1185.00 54151502200 5)55)502200 4.81 51358002280 51557882200 1251.90 54151582200 51551582208 10.00 51350801280 1705.00 1705.00 1185.00 1185.08 1785.80 1328.28 ZS984.31 544.00 2414.00 56.81 10.84 4619.08 104.25 4614.00 4.81 447e.50 18.88 4619.88 r r 03129/01 ~R05fi) NBSIDNNT RBSIDBNT RESIDENT NUA88R TYPE NANB 49 NBDICAID BURNS, GLADYS N SOON 204 -B LEVEL 2 "NBDICAID -JAN 01 (CONT~ SEV SN NIO R8V PVT PORTION R8Y PVT PORTION SEV RN,CHARGB REV RN WIO "ENDING BALANCE "NBDICARB B - JAN 01 - BAL FWD -LN- -30- GLUCOSE TEST GLUCOSE TESP "ENDING BALANCB "PRIVATE - R8B 01 BAL FWD -LN- -30- ::ENDING BALANCE "NEDICABS B - R8B 01 BAL FWD -LN- -30- "ENDING BALANCB @BSIDENT LRDGRR AS OF DATR OF FIRST ACPIVITY PAGE 10 GIL -- ACCOUNTS RECEIVABLE -- BATE QTY ACCOUNT CflASGBS CSBDITS BALANCB 06110100 ADM CRTR RATE: 0.00 11!13!00 DIS PRIV PORT: 1185.00 10131100 51557002200 1181.61 1@131108 14411050088 1185.00 11138100 14411050000 1328.28 11130108 51350002200 1188.00 11138/00 51551002288 459.12 08 -60- -90- -120+- 104.Bi 184.01 06130108 56151911220 56.81 01I311B0 56151911220 109.25 -60- -90- -120+- 1041.64 9409.08 14141.13 25984.31 -60- -90- -120+- 104.01 166.06 270.93 210.93 15984.31 270.93