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Home My WebLink About01-05931 .\I' . i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. <:)1 - StlJ t C;uJ...T~ vs. CIVIL ACTION - LAW MARGARET RINEHART, Individually, and JOHN RINEHART, Individually and on Behalf of MARGARET RINEHART, 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 corte. 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 0 en persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra used sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda. Used puede perder dinero 0 sus propiedades 0 otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFFlCIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFlClNA CUYA DIRECCION SE ENCUENTRA ESCRIT AABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASSIT ANCIA LEGAL. ;"! Lawyer Referral Service Cumberland County Bar Association 2 Uberty A venue Carlisle, Pennsylvania 1 701 3 (717) 249-3166 ;'Ji~." "H-."~:<:s\,etr,,,o;;,;~,,,_~t,','t~~,j~,,.- ",_,f" __",_;" -, . ,-, "." ,,- ..,,- ~ -j" - , . " 'r 1- , 1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 0/- ~93/ C~~L C /~ vs. CIVIL ACTION - LAW MARGARET RINEHART, Individually, and JOHN RINEHART, Individually and on Behalf of MARGARET RINEHART, Defendants COMPLAINT AND NOW, this IOi \~ay ~ 200 I, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson & Associates, P.C, and files the within 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 1 700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1 7011. 2. Defendant, Margaret Rinehart, is an adult individual with a current mailing address of Arden Courts, 2625 Ailanthus Lane, Harrisburg, Dauphin County, Pennsylvania 1 7110. 3. Defendant, John Rinehart, is an adult individual with a last known address of 905 Hawthoen Avenue, Mechanicsburg, Cumberland County, Pennsylvania 17055. 1 f:~-,-il!)f !'-:-'"~,"~""'i""-",:",~.-?;" -,""",'-"~,~.-,-" ~ ",' ,-, ,[_'-~ ,., .", " -. =~ ,'-,' -. 1"1 " , \- \ " 4. That Defendant John Rinehart represented himself to be the Legal Representative and/or Responsible Party for Defendant Margaret Rinehart. Defendant John Rinehart is the grandson of Defendant Margaret Rinehart. 5. That on or about November 11, 2000, through on or about April 6 2001, Defendant Margaret Rinehart was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and collectively marked as Exhibit nAn. 6. That on or about November 11, 2000, Defendant John Rinehart executed an Admission Agreement, on behalf of Defendant Margaret Rinehart, 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 collectively marked as Exhibit "B". 7. By executing said Admission Agreement, Defendant John Rinehart did assume and accept responsibility for the debt to be incurred by Defendant Margaret Rinehart in the event of a breach of the duty to provide payment from Defendant Margaret Rinehart's income or resources or for failure to comply with completing and submitting an application for Medicaid. See Exhibit n B n as previously identified and incorporated herein. 8. That Plaintiff submitted to Defendants a copy of the itemization of 2 :~\'!,~",~.-,~o__ ""''''^c\_' ~>,~"e"',";_' ''Yo '--~'''', -"'1-;7",;~""_',<' I,' ''":''= , I, services accurately showing all debits and credits for transactions with Plaintiff. 9. That Defendants did not object to the above mentioned Statement of Account supmitted by Plaintiff to Defendants. 10. As of the date of the within Complaint, the balance due, owing and unpaid on Defendant Margaret Rinehart's account as a result of said charges is the sum of Fourteen Thousand Four Hundred Sixty and 08/100 Dollars ($14,460.08). See Exhibit "A" as previously identified and incorporated herein by reference. 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Margaret Rinehart's account balance, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant John Rinehart, as Legal Representative and/or Responsible Party for Defendant Margaret Rinehart, demanding that the sums due and owing to Plaintiff be paid, and Defendant John Rinehart has ignored his fiduciary obligation to pay necessary and appropriate bills and obligations for his grandmother, Defendant Margaret Rinehart. 13. That Defendant John Rinehart violated his duties and responsibilities as Legal Representative and/or Responsible Party for Defendant Margaret Rinehart by expending Defendant Margaret Rinehart's finances for other purposes when he knew or should have known there were outstanding medical care bills for Defendant Margaret. 3 ::';'-i-l'-"~,,,?",,,..,,,__,M,_,, '-""_'l",,',Y.' - c.,)"" e, ,,-1 "~_' ~'__':~""I , . . t 14. That the finances of Defendant Margaret Rinehart rightfully belonged to Plaintiff for the necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant John Rinehart's grandmother, Defendant Margaret Rinehart. 15. Plaintiff has retained the services of the law firm of Wolfson & Associates, P.C, in the collection of the amounts due from Defendants. 16. 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 reasonable attorney's fees and contractual interest if the account is referred to an attorney for collection. See Exhibit "A" as previously identified and incorporated herein. 1 7. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson & Associates, P.C, in the collection of the amounts due and owing by Defendants, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount ofthirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 18. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Four Thousand Three Hundred Thirty-Eight and 02/100 Dollars ($4,338.02). 4 ,~~,[ _ Y"_"-""~-~-' -, .,,",='( '" ,> ~1" ','- '1 , "~' , ~ ~ -, ; \--, ,-' - 1 " 19. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, Plaintiff if entitled to receive and Defendants have agreed to pay contractual interest at a rate of eighteen percent (18%) per year on all past due balances. 20. The amount of contractual interest which has accrued from April 1, 2001 is the sum of One Thousand Twelve and 46/1 00 Dollars ($1,012.46). 21 . Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 22. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 ',.~,~.-,''!' "!'-"~"--. ><~,.~c,-.~",- f-,,^- ?, _'C'-:' dT- > I . ~ -- ,,,-,-,,, .-' ,-~~- c -- . " , , WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Margaret Rinehart, Individually, and John Rinehart, Individually and on behalf of Margaret Rinehart, in the amount of Fourteen Thousand Four Hundred Sixty and 08/100 Dollars ($14,460.08), reasonable attorney fees in the amount of Four Thousand Three Hundred Thirty-Eight and 02/100 Dollars ($4,338.02), contractual interest in the amount of One Thousand Twelve and 46/100 Dollars ($ 1,012.46), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, ?ew~~ WOLFSON & ASSOCIATES, P.c. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff :;'~:1W;;;l!1fi!__~ '.f'~"r0P'~'1'''''-''''--''< ,_ ,';". " - e_" -1r"'- ,1,_," ~-- , " 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. DAT~~n~ThI \'1; 7(:[)\ I ~.~.. Michelle Thureson, Senior Financial Services Consultant 5~'Wl'r,'K/. ,~_ , "'~.,., ,_c-,;"" c'" , . ~" --. , , - "~ ;-~"[I!".~~ "=<!^, ,.'''" ',_," -,,...,.,..., " EXHIBIT "A" ~ .~~ 'HCR~ManorCare Statement " . MANORCARE CAMP HILL 583 17ee MARKET STREET CAMP HILL, PA 17ell ( 717 ) -737 -8551 PRIVATE JOHN R RINEHART FOR MARGARET RINEHART geS HAWTHORN AVENUE MECHANICSBURG, PA 17e55 ROOM 221 -B Please Return This Portion With Your Payment . . RINEHART, 'MARGARET E144 e2/19/l2Il e4/ras/el e5/311ral ! - --- -----------::---- ------------_._--.---- --;--- ------------------ -------- -----'---- DATE OF SERVICE eS/l2IlIe1 ; SERVICE RENDERED CHARGES CREDITS BALANCE FORWARD 14,4SI2I.ra8 PAYMENT DUE BY THE lraTH OF THE MONTH AMOUNT DUE "!, 14,4se.ea '",-",,-'i'~~ . - .~'-"-, ",'-,,','~"~'1'- ---0 ~,:"r~ ~1' -- F~',~ _ ~ " ~ ^, ^ , 16120181 RRSIDENT LRDGRR AS OF DArE OF FIRST ACTIVITY PAGR IAR561 RESIDRNT RRSIDiNT llKSIDENT GIL .- ACCOUNTS RECEIVABLE -- NUMBER TYPR NAMR DAn QTY ACCOUNT CHARGRS CRRDITS BALANCR l44 PRlVATR RINEHART, MARGARET E 021]910] ADM CNTR RATE. 5828.01 ROOM 22] -B LEVEL 1 W06101 DIS PRIV PORT, 0.00 "PRIVATR - NOV 00 60101 PT B CO-INS PT EVAL IP 11ll41ee 1 11.92 60109 PT B CO-INS PT THRRAPiUTI 11IWee 1 4,51 60120 PT B CO-INB PT THiRAPiUTI 111141 II 3 13,31 11110 BRAUTY AND BARBRR 11127180 1 59158101120 2U8 "iNDING BALANCR 50.74 "MRDICARi A - NOV II 29119 PHARMACY LEGEND 11111188 ] 5455]211121 81,39 14181 PHYSICAL THRRAPY VI8IT 11/13/00 -- 11/38/00 13 52150210120 658.00 ]4401 PHYSICAL THERAPY EVAL 11113100 1 52150210120 25.ee 17101 OCCUP THERAPY VISIT 11114108 -- 11127100 9 52550610120 680.00 11401 OCCUP THiRAPY RVAL 11114108 1 52558m128 25.ee 38189 PHARMACY NONLiGRND 11111118 1 54951318128 5.93 5150] WOUND TRIATRBNT 11111/00 1 541515]0120 B,ee 51501 WOUND TREATHiNT 11121101 1 54151510128 B.01 5150] WOUND TREATKBNT 11123100 ] 54]5]510]20 8.80 51511 WOUND TRIATMRNT 11/26180 1 54151510121 8,ee 51501 WOUND TRRATMENT 11129101 1 54151510120 8.01 ANCILLARY WRITI OFF 11130180 51551518128 1426.32 ROOM CHANGI AT 188.00 111]1100 -- ]1130100 20 5]3500]0]20 3760.00 ROOM WRm OFF 11111181 -- 11138108 20 51557110120 1411.60 "RNDING BALANCR 5161.60 "MIDICARR 8 - NOV 01 68101 PT RVAL IP 11114100 ] 52150211121 59,62 61111 PT B CO-INB PT RVAL IP 1111411I 1 11.92 61]19 PT THERAPIUTICIX IP 11114101 1 52150211121 22.56 68189 PT B,CO-INS PT THRRAPRUTI 11/1411I 1 4,51 61120 PT TBiRAPiUUC ACT IP 11114100 3 52150211128 66.57 68128 PT B CO-INS PT THRRAPRUTI 1111411I 3 13,31 "iNDING BALANCE 119.01 "PRIVATi - DRCl0 BAL FWD -LN- -30. -60- .90- -]20+- 50.74 58.14 11m BEAUTY AND BARBRR 12113100 1 59158111120 12,50 CO- INSURANCll AT 91.0012181110 -- 12118180 18 970.01 CO-INSURANCI AT 97,80 ]21]1100 -- ]2131100 21 2,137 .08 11114181 PT COIN RRV 11114180 14411058080 11.92 ]1/]4180 PT COIN RiV 11114100 14411050000 4.5] 11114100 PT COIN RRV 11/14180 144110511ee 13.31 "ENDING BALANCE 3040.50 "MRDICARR A - DRC 81 BAL FWD - LH- .30- -60- -90- -128+- 5161.60 5161.68 PAYMiNT KBDICARR A 1]110 12126100 11210002000 5161.60 14101 PHYSICAL THRRAPY VISIT 12181101 1 52150210128 25,88 '_ On"~ '':; :",M~ ;-O':''''''''A-'!!'t''1'*__"" -F""" .'&'7'W"-'~ , f'" ~'--'"'7"".-, -'=-,."".~",'",~'_",,,,,,,,",, '''".',",''' :;t<l"~"", _,..m '... -" 'I''''''-T''O''\ 0'0""""_0 . "'-",- ,- """~,"d'-'''''--;''''O_''''<'''%J',--I\ik'''''I~I'U"'-';:'RI ,,",'i',--;-'''"'''_('!'' -, _ =-,_", ~ '-r^"~" O~, "'1"'-' '1 . ..~,., . , 06120181 RBSIDKNT LKDGKR AS OF DATK OF FIRST ACTIVITY PAGK 2 IAR561 RKSIDINT RRSIDKNT RKSIDKNT GIL -- ACCOUNTS RRCRIVABLK -- NUMBKR Tm NAMR DArB QrY ACCOUNT CHARGRS CRKDITB BALANCR 144 PRIVATI RINIHART, MARGARRT R 02/19101 ADM CNTR RATK. 5B28.08 ROOK 221 -8 UVKL 1 14116181 DIB PRIV PORT, UI "MlDICARK A - DKC 10 (CONTI 51801 TOTAL INCONT-DLY FKE 12101108 -- 12131108 31 56151B10128 31.80 53181 NTRTNLIRNTRL SRRV GRP 1 12111111 -- 12131101 62 56153111120 8UI 29819 PBARMACY LIGIRO 1211910& 1 54551210120 46,96 30119 PBARMACY NONLIGEND 12109/et 1 54951318121 2,29 51511 WOUND TRKATMKNT 12126/00-- 12/31/00 6 54151510128 48.&0 ANCILLARY WRITH OFF 12/31180 51551518121 233,85 ROOM CRARGK AT 1B8.80 12181110 -- 12118180 10 51358018121 1881,80 ROOM WRm OFF 12111118 -- 12111118 10 51551811128 111.81 DKDUCT CO-INS AT 91.08 18 918.&0 HOOM CB&HGH AT 188,11 12111111 -- 12131181 21 51351111128 394B.81 ROOM WHITR OFF 12111108 -- 12131181 21 51551818121 1388.51 DIDUCT CO. INS U 91.00 21 2831.88 "HIDING BALANCK 2213 . 29 "MKDICARR B - DRC II BAL rRO - LM- -38- -68- -98- -121+- 119.01 119.01 11114111 PT KVAL 11/14/00 52158211121 59,62 11114111 TRER RX 111l4/00 52151211121 22.56 11114118 TBRR ACT 11114108 52151211121 66,51 111141.1 PT COIN REV 111141.. 14411 Imu 11.92 11114101 PT COIN RHV 111141.. 14411051111 4,51 11114181 PT COIN RIV 11114/et 14411151181 13.31 "RNDING BALANCI .08 "PRIVATI . JAN 11 BAL FWD -LM- -31- -61- -90- -120+- 3119.58 21.88 3141,51 PAYKBNT MCR-12111 11123101 11211182111 2213,0B PAYMINT MCR-12111 11123111 11218112118 2213,88 111.. BHAUTYAND BlRBKR 11113/01 1 59158111120 11.11 11188 BHAUTY AND BARBRR 01121111 1 59158181121 11... CO-IRBURANCR AT 99.01 01111181 -- 11131111 31 3169. II "INDING BALANCR 6131.51 "MIDICARI A - JAN II BAL FWD - LM- -38- -61- -91- -121+- 2213.29 2213.29 PAYMlNT MCR-12181 11123111 11218102180 2213.0B 29189 PBAHKACY LKGHND 11181111 -- 01111111 1 54551210121 162.12 3.019 PBARMACY NONLRGKND 811111.1 -- 81118111 1 54951311120 21. 66 51511 WOUND TRIATMHNT 11111111 -- 11121111 21 54151518128 168.81 mil NTRTNLIRNTHL SIRV GRP 1 811111.1 -- 81131181 62 56153110121 81.68 51511 WOUND TRIATKHNT 11131111 1 54151518121 UI ANCILLARY WRITI OFr 81131/01 5155151012. 441.98 ROOM CBARGK AT 188,81 81111111 -- 01131111 31 51350111128 5B2B.II ROOM WRITK orF 11181181 -- 01131101. 31 51551818120 1931.61 , ""-''''~'--fJ'''!',--'',"_:'1''~-i'<\.'''f^':-ri'-''<'''-''_l''':''-" ~,"""" ~';-';1'-~-_ ..",""!>",,,,,,,'t"T',l;-C''''''O',''--''--,,,,,''-"'_P'P'' "_1,_-,,'__ .'''-'''+ ,"_"",,"- , . " ." '" ~ ",...,-,"",---" -:"~""~"-'""!%;;.'1'--''W>?''ffI'- "",,?,"t~'P!,;,_,,,, b''''--':~F~ . b' ~ <- "-^'. 06120/81 RKSIDINT LKDGKR AS OF DATK OF FIRST ACTIVITY PAGI 3 IAR561 RISIDKNT RISIDINT RISIDENT GIL -- ACCOURTS RBCKIVABLI -- NUMBKR mK Nm DAn QrY ACCOUNT CRARGKS CRIDITS BALANCK 144 PRIVATE RINERART I MARGARBT E 02/19101 ADM CNTR RATE. 5828,00 ROOM 221 -B LEYKL 1 84/06101 DIS PRIV PORT. 0.00 "MEDICARB A ~ JAN 01 ICONTI DEDUCT CO- INS At 99.00 31 3069.00 PPS ADJ 12f31/00 51557118188 .21 "INDING BALAHCK B21.39 "PRIVAn - FED 01 BAL FlID -LM- -30- -60- -90- -120+- 3191.00 3019.50 2U0 6131.50 11100 BEAUTY AND BARBER 02/19101 1 5915BI01120 11.00 53181 NTRTNLIINTRL SERV GRP 1 021191.1 -- 02128101 2. 5615311112. 26,11 CO-INSURANCE AT 99,0. 021.11.1 -- 021181&1 18 1182,00 ROOM CRARGR AT 828,00 02119101 -- 021281.1 II 5135...112. 2.81,48 ADV ROOM CRARGE &31&11&1 -- 03131/&1 13211.&&000 5828..& "KNOING BALANCE 15859.'98 "MEDICARE A - FED 01 BAL 'lID - LM- -30- -6.- -90- -120+- 821.39 821,39 PAYKlNT MeB-l/01 02120/tl 11211082000 82U8 53181 NTRTNLIENTRL SKRV GRP 1 02/01101 -- 021181.1 36 56153ml20 46.80 515&2 WOUND TREATMINT 02102/01 1 5415151112& 8.01 29m PRARMACY LKGIND 02/.6101 -- 02/01/01 I 54551210120 121 .64 30109 PRARMACY HONLRGIND 02101101 1 5495131012& 2.29 ANCILLARY WRITK OFF 02/2810l 5155151112. 184.13 ROOM CHARGE AT 188.00 02/01/&1 -- 02118/01 18 5135001012& 3384.00 ROOM WRInOFF 02101/01 -- 02/18/01 18 5l557110m 1121.58 DEDUCT CO-INS AT 99,'0 18 1182.01 "KNDING 8ALANCK 480.13 "PRIVATR -MAR .1 BAL 'lID - LM- -30- -6&- -90- -120+- 9128.48 309l.0. 3119,50 2l.00 15859,98 PAYMENT 03/19/01 llZU002m 2l.00 PAYHKNT .31191.1 1121mm0 2419.01 116et CABLI RINTAL '3/'1/01 -- '3/31/01 1 5915840112& 5.01 5ml NTRTNL/RNTRL SIRV GRP 1 031.11.1 -- 03126/'1 52 5615.3l1112. 61.6. 1110l BIAUTY AND BARBIR 03/14111 1 5915810112& 51.1. RKV LAST MO RC . 3IIl/ 01 1321111108. 5828.01 ROOM CRARGE AT 828.'0 '3/01/01 -- 03/31101 31 5135.001120 5828.00 ADV ROOM CRARGK 04101101 -- 04130101 1321100.... 5828." "INDING BALANCI 19311,58 "MKDICARK A - MAR .1 BAL 'lID - LM- -30- -60- -9'- -120+- 481.42 ,31 48',13 PAYMENT MCA-2/01 .3121101 112l0002m 488.24 "KNDINGBALANCK ,49 ": . "'-',>h"&~","i,;,","'""_'#;<<"'''W:''"'~'-''''-'',, ~,,[_;,:\-,;CCl'" ''''T'- {', " '-"" , ''''-~'''''-''II1"i'-<n--~''_f''''-V-fl''''_~'' ',-," - " "'-'"0" -"'"-''''''''''''''=>'<-~''I~l'-'''1''%'1'''''IW!:';"!(''')'>''''''' 06/21101 RESIDENT LiDGER AS OF DATE OF FIRST ACTIVITY PAGi 4 IAR561 RESIDENT RESIDENT RKSIDENT G/L -- ACCOUNTS RECIIVASLi -- NUNBIN Tm NAMI DATS QTY ACCOUNT CHARGKS CRlDITS BALANCK 144 PRIVATI RINIHART, MARGARIT I 02119181 ADM CNTR RATI. 5B2H,I0 ROOM 221 -S LEVKL I 0411611I DIS PHIV PORT, 8.81 "PRIVATI - APR n BAL FWD - LM- -ll- -60- -90- -120+- 11119.61 3918.48 ll9UI 541.51 I 9lI 1.58 11m CABLE RINTAL 041111B1 59158411121 5,11 RIV LAST 110 RC 04111111 13211 iBlBBI 582B,11 ROOK CHARGI AT 828,11 04/01/81 -- 14/15/01 5 51358811128 911.58 "INDING BALANCI 14461.B8 "MIDICARE A - APR II BAL FHD -LN- -l0- -60- -90- -120+- ,18 .31 .49 29019 PHARMACY LIGIND W161B1 I 54551211128 31.96 ANCILLARYHRITI OFF 14Il8fll 51551511121 31.96 "INDING BALANCI .49 "PNIVATR . NAY II BAL FWD -LM- -l8' -68- -90- -120+- 916,51 5951.60 3911.48 l19l.i1 541.51 IUGUB "INDING BALANCE 14460.08 "MEDICARI A - NAY II BAL FWD - LN- -l0- -60- -90- -120+- ,18 ,31 ,49 PPA ADJ III3I1B1 515518l0l20 .31 PPA ADJ 12128181 51551111121 .18 "INDING BALANCI ,.. ,', -- 'j ,..- "-,, "";"~i'!lf<,;g",-"",'", !Wr.-;;,~~,,: ,'I~\'.~i~~,'q"", ":>"~",,,,,,,",,-," c." r-' ,-- 'H,'" -, ~, ',,,, "_ ' - . -.--.-" - ""'-'-"~''';oj!F.--'''''1''';",fi:~W'W'-'''''!1,"l'I''"'''',~~M ",--,,, ,;' ,.,,--,, '1-- P'(', "I ",' -, >-,,,~!,ry;;"PT " j" r " EXHIBIT" B" - " ~ T "~ ~ --<=-1 _~',",l~ HCR l"lanor Care , , ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center"). Cen ter: HCR Manor Care Camp Hill Resident: mox~?-rek c. Q\~e.h:Lr"t Legal Representative: .J 0 h n C . Rille ha,vt Admission Date: -JJ..l i tI co Deposit: $ fJlA Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. T ., lliG}ITS A;';D RES.FG;:;nnLITIES Oi T:n~ M6.iiJ~i'iI 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 Goverrunental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident. ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident' s statement for the succeeding month. and are payable in full, along with the Room and Board Rate by the tenth (lOth) day of the month. ;-"-~''-~'1int~~=~...-:' , _ , ,'. ~ - ~ ~~-~ ~, 1".03 Late Pavment~. Acc<:luI1rs n6t paid in tull within thirty (30) days of billing shall be subject to a service charge equal to the highest lega(rate of interest permitted by State law as set tbrth 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 Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: X Medicare, X Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Partv Pavors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preterred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 "i<f"""'t-....""",, "'~~, --f' ,~" ,.~ "'1 " ~ ~~'- - ~"'" ~ - will bill the Resident's third par\y payor as' a,ser'Vic~, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private 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 Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notifY the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notifY the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal no-ro<ontatl'vp tn n.nt;fV thP "'''''ntor aroi1 t(\ ,.....'"",:~o ........,. """'o.,.L"...:l :.....-C',,_~~:,,_ ___~_..1~__. _" ," ,1 t".,_:' , '---";.~ - '-"'", ..- \_'-....... ~-_._ r.- '__~ ......~.1 ~~~......"'.... uuvJ..lJ,J,......J.v.u. .......o"'-l......llJ.5 au LJ.illU party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) davs of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premiwn(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 Aoolication for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. l.l 0 PrimarY Responsibilitv for Pavrnent. 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, HNfO, 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 "W"'~.Of,"~ " ~ "F_.:' .. .. .. ~ .~7 r , --, --, e_ - Agreement serves as a written ndtice' that ,the, C.;nter 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 Phvsician. 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 hislher personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must mediately 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 onrl nr('lCC-!1I1T'C>'-'" -:l1"'lrt t'h.,. -n't-HH'T'I"P:lf""l! 'h"o:;: q "",",od;co::l+:""- ..-1;~......:'-""~:~_ hU"_,-'_' .' --.,-, ,',-. ,',',-.... ~....'.'L"'-." Q,., ~.__., -.')._ . ...~n___Hu_~ ~__.~ _ .l.....\,.- .L .....~..'-'.... ......o.,)4J..ll.l....4J........... .:J).)~...J..L... "LLlllia......... ... '-'.... "" ... ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTA TIVE 2.01 Legal Authoritv. 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 charges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 i'~Y,~~,:,rl[~ lWk_..,.._ ~_, - ~ ~ ~l~ ,if - 1.05 Cooperation for l'in<illcl<il A'ssistance. 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 Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3,01 'R00n! ann. St~:rri.~.l:'Q Se!""~~,:"s, A::;,?rt oftl:e ~~::;':::: ::.::;:! :SC~:: ~.:~~} ~l:..: C:":.u.~~i shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, ifany, 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 Medic aid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of hislher medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance 5 i :-"-,,..~-- ~_" ':,-~~""'!''1'!' ~ ~ ,,'~, - .,.,~ " ~ --- \ll'~~" - 3~ "'-tlf'"'''''mt>.':'~";<",,,,,,,,,-,, ., ~" ,~,~., reviews 'or payment audits perfonneu by sJchi tho p@rsonnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's 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 helshe 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 Photograph. The Resident and/or Legal Representative agree to ~-.;:'..ser..t ~~ ~:.e Ce::te: ~~~6 z.. ptv~vgrapl1 vi i\.C;~~UCHL .Lor use ill icientifying tne KeSldent, tor placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center arid staff to identifY the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds 6 . -'-';"l''!lt;or_~ T, ~ ~ _, ,'~ _ " . I ,-, ,~ , .~... p Autho~izaiion\~d ~y bther related documents. See Attachment H-l 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 pnyslclans who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment J. n. ResidentlPatient Rights. See Attachment K. o. MedicarelMedicaid infonnation and display of such infonnation including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment 1. p. Receipt of infonnation on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct hislher medical treatment. See Attachment M-I and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 _n~h u,.,.... _""''''"_~' , _1 . ,~- - I ~~- ~ .y,r<:,~.r ' >- \ {) r.. , "' . 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 andlor Legal Representative hereby requests tnat payment 01 autnonzed government anOlor tlllre! party payor benetits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident andlor Legal Representative hereby authorizes the Center and any holder of medical or other information to release such infonnation to the Health Care Financing Administration and its agents and to third party payors anyinfonnation needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident andlor 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 Ipdemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims. demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 ''';_ _e ~_, .- ~, . ," _ "~.,.. ""'"' ,.' .i' ,-_ . ill I. .' I: 4.' .. of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature ofLega! Representative, ifsigning on behalf of Resident: , ~('- ~' Signature oftegal Representative, signing on hislher oWn behalf: '" / ../' ./f Date: 1/ /~I/.2-t7 / Date: Center Representative: ~ (2,-"",-, f.I_ ~-c'~ Date: fI/22/00 9 r',",,! ""'c"7,~.__'" , ~ ~ 'J- T _, ~, - T I ,,, '--'~i-~ ~,-" _"'" '" """"""WIII','''w-'''!',iIlilTTil!!ifl I mnllll11lll1iiff{~ilJ!l"jtlli'" I \" , ... '>" '. () ~ "}:J 7i ~ ~ 0 /l .t- o a 1..-::) h D ~ --"1 8 ~LP ()1 D --::i ", -oCD n ..t: & 8, E;:!Ln -< t-~ J1 ~ .;..-. ~-'>--' ..... I zr-" - :~ (.n~ c;Ji '-~-' ~ V) -< / , \ ~CJ .::) ~ ~ il! ~\o -r, ~ ~O ~ >--'.'n .~ ~O 9? t~~;~ .,)J"C ~ '" :z -c ~ ~ :'1 :.t'. & -< :;n e:o -( ~",' .- _, ~p:r ..",_"~"~~ _1 l, "JU ."'-__""-''''-'''"~''''~'"''''~'''''''''''',,,, W;":""'""~''''i'''-,,,',!j'f,-17\'''':W;'fS'r''i!f'''N!,''''~i','-",,:,,,",c'""("""'''''fl,,,~,,,,,~,,,,,,,,,;.t''iI'''''i,,~q:''''li''mYmJ!;l~iP ... SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS RINEHART MARGARET 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: RINEHART MARGARET but was unable to locate Her deputized the sheriff of DAUPHIN in his bailiwick. He therefore County, Pennsylvania, to serve the within COMPLAINT & NOTICE On November 16th, 2001 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Surcharge Dep Dauphin Co 6.00 9.00 10.00 29.25 .00 54.25 11/16/2001 WOLFSON & ASSOC mas Kline ff of Cumberland County Sworn and subscribed to before me this elf.:::- day of7lh1~ :Jo-v ( A . D . ~ n.,ed, ~.~. Prothonotary '-"""",3-:"'''''''-'.1_ ," .~y- "- T<P ~> ~-".... ~f SHERIFF'S RETURN - REGULAR ~ CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS RINEHART MARGARET ET AL DOUGLAS DONSEN Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon RINEHART JOHN INDIVIDUALLY the DEFENDANT , at 2000:00 HOURS, on the 5th day of November, 2001 at 905 HAWTHORNE AVENUE MECHANICSBURG, PA 17055 by handing to CHERI RINEHART, WIFE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 18.00 7.15 .00 10.00 .00 35.15 rR~~:H-4~~ R. Thomas Kline 11/16/2001 WOLFSON & ASSOC Sworn and Subscribed to before By: QL O~ Deputy Sheriff me this :1..(. ~ day of ~ cJ.e.t,/ A.D. C)~ . t2 nu e~, ,./, ~ ~df othonotary l.>1'-~f~*"'~."!!!I'Il ,'~'~ - ~ ',- r ''r' -, :- ~-,~~ll_~ ~~__ ""l"'"-"~c,<...- ''''. - -- ~--" - SHERIFF'S RETURN - REGULAR ," CASE NO: 2001-05931 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS RINEHART MARGARET ET AL DOUGLAS DONS EN , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon RINEHART JOHN ON BEHALF OF MARGARET RINEHART the DEFENDANT , at 2000:00 HOURS, on the 5th day of November, 2001 at 905 HAWTHORNE AVENUE MECHANICSBURG, PA 17055 by handing to CHERI RINEHART, WIFE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 6.00 .00 .00 10.00 .00 16.00 r~~~~ R. Thomas Kline "'" ,2(, ~ day of 11/16/2001 WOLFSON & ASSOC By: O~ Q~ Deputy Sheriff Sworn and Subscribed to before me this ~L./ :2fH)/ A.D. ~. 0 'tvt., il,., A ~~i P othonotary , \:"~~;-,- -" -- -~ T' - ,....,.,. "'~ r r ~ ~r_'" . ~ 1- 4~. ~..- @iiict of tlre ~4e:riff William T. Tully Solicitor J. Daniel Basile Chief Deputy Mary Jane Snyder Real Estate Deputy Michael W. Rinehart Assistaut Chief Deputy Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255,2660 fax: (717) 255-2889 Jack Lotwick Sheriff Commonwealth of Pennsylvania HCR MANOR CARE vs County of Dauphin RINEHART MARGARET Sheriff's Return No. 3127-T - -2001 OTHER COUNTY NO. 01-5931 AND NOW:November 9, 2001 at 9:15AM served the within .NOTICE & COMPLAINT upon RINEHART MARGARET by personally handing to CHERYL BUMGARDNER, DIRECTOR OF FINANCING 1 true attested copy(ies) of the original NOTICE & COMPLAINT and making known to him/her the contents thereof at 2625 AILANTHUS LANE HBG, PA 17110-0000 ~. A~) PROTHONOTARY So Answers, JR~ Sworn and subscribed to efore me this 9TH day of NOVEMBER, 2001 By Sheriff's Costs: $29.25 PD 11/01/2001 RCPT NO 156064 TORO :f';'",\~"._,___ " ::" ~. , - ,..., -~ --' , - - I ." ~ ,~, '~t!)1"n'~';~~MJ" ~..o' -,. - , --- - ,"-" ~ ,- " ~~ . in: The Court of Common Pleas of Cumberland County, Pennsylvania HCR Manor Care VS. Margaret Rinehart et al SERVE: same No. 01 5931 civil Now, . October 30, 2001 , 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. ,../7 ;oFP// ~ ~~ ..;::.e:;.,.4> Sheriff of Cumberland County, P A Affidavit of Service Now, , 20_, at o'clock M. served the within upon at by handing to a copy of the original and made known to the contents thereof. So answers, Sheriff of County, PA Sworn and subscribed before me this_day of ,20_ COSTS SERVICE MILEAGE AFFIDA VIT $ $ ,m,~,i 'J~..-"'"' ,0_. __" '. " ,0-. . . .=- __I ~ . ~. ,,' ~, "P ""~'.", ;"tr'Y'li'iIi"Ifi!ilLTilTi:l'lr 'liT i nITilll' E.5 R~ I UlRnnn\ll'" '",~' - 1i!!'I!llW M~_,!m~ij'~If('>11~~;;;~~i~~WlJi'l~R.!i!~fffl,~film~-~",_,:w",~:<",_jC""i'-'-'T'i'~-' "< 'f';" ,." """,':>""'~""':;>'"/.-'h'-"''' -_il"-"'r"^~'!"1!'";;'lHrc",,Hr1'l1:fi~~rn"-')'.~'J!'W:'~F ' L IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 2001-05931 vs. CIVIL ACTION - LAW MARGARET RINEHART, Individually, and JOHN RINEHART, Individually and on Behalf of MARGARET RINEHART, Defendants PRAECIPE TO WITHDRAW COMPLAINT Please withdraw the Complaint with prejudice in the above captioned matter. Respectfully submitted, WOLFSON & ASSOCIATES, P.c. my F. olfson, Esquir 267 st Market Stre York, Pennsylvania 17403 717/846-1252 I.D:#87062 Attorney for Plaintiff Dated: \t-\1J\b\ . "-"''{':;'"~~''''''i'''''''''''!l'.,:.\ "_~.." , , " ~ .,~,.,"- - \..,...... %,:~ __.J..J JT~ _ .." c~~ __w_ '~'''''' ~~~..,.,."",,,,~, ""~~"' =-;_..~_ ~_,.~~Il_ f J ,~.,.,-=,~~ !,"J.pM~,%,.qJ0-,;"c;.':';"f"V"''' - -- (') c: ~. "CO:; CPQ! ~~~: r.::;C: '- 'bo "'". :2:,:-'; :;0;;:: z :::: o o M M ~." I~ "-.j &; IlIlmJlill' r . 11Y r' ::/, . ~;:"'~ (,J '-0 ,-h. "';C) ~~rn _.~ .-<. r:? ",fl (::-; " T:":"';:~'~~""'-!!rB"'c;?fW-\'-\jo,[*,~'~wn['~,!~~~~'\"'