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Home My WebLink About01-06196 "'iITrm'" . , " HCR. MANOR CARE IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA " f " vs NO. 01 -6196 CIVIL ~ JANET CAL~, Individually and on Behalf of ,:',c:~ CALAMAN, Decedent RULE 1312.1. The Petition for A!,pointment of Arbitrators shaH be substantially in the foHowing fonn: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Amy F. Wolfson, Esquire """,..."",,'1 C~. ,'.."" ~,~_:_'"_'_:Ct;'j,.t'':1'<:'c,7't,4'):j,..,~".;.,..,, ';':p. ",~""r"'" --'~~>';"'"'f (...,~ ~'f't' ) j ,..'"",~,~~.:'...~ ~~.. ,,,."~ J:'.'w"'_~dl., _~1.:::k~~-i?'..~'~ '...,h.. ~h._~'!_"' ';:,'''~..'_'. V...l ,~'" lons , respeclfuHy represents thaI: 1. The above-captioned action (or actions) is (are) at issue. 2. The claim of the plaintiff in the action is $7. 'iR'i plllH interest, costs and attorney's fees. The counterclaim of the defendant in the action is -0- The following attorneys are interested in the case(s) as counselor are otherwise disqualified to sit as arbitrators: WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. ~:;;?~ ORDER OF COURT AND NOW, fi#w/I/U~7 ,1'9"~considerationofthe '<>reg""',,,.;",,, ~ ""', ~ kft Esq., and !f,,,A _ _ _ ,Esq., are appointed arbitrators in the above captioned action (or actions) as prayed for. . . . P.J. """'"~T,'li~(tJI1JDJllfiirYi[!r""'t c' .,. ., --, ""' -, '-";".~-:', .. """'m~1MTuili 1.l<N'~TT:r'\l"W"1Xi ~~'itr ,-~ -, ., i \';~~~~~. .. " , " iAi'll",t:!_- ','_, ,A,~" ".J~",;~..~lt~:::J.~4.'~:':;'-:.h ,.~f'''< "",,~,p^7-',< '_' _',;n ~, ;"';"""~"<?>B%W"'''i<l~""IriI~''t-"k;f,~''''4''i,!~K%,i;1'imllj'M",ltll:1illti~~ ,-~", 1 '-"'~ em Iil'On :lllt ('If} ~ln\,' \)~" r:.'1,1 i ).,0:' <""'"r\ i",'v: '(',nT!,f)\! " -:-",I,'\nl" 'I ;\1, 9:::;! (I" J '. 'I ,- ,"'('l1l'l\rrV ~ul'JF::)::':'j;"i~:\' '..J~.,,,.J ~ [ I PENi<SllV;\Nlt\ ,_~',e_."_",_"",,~.-,,,I ~,"- ~~ i.iW' '--, , ...... "',~.-" '" C" '.., :" ',; ~ ,'1*" C.' -- ',1 . ~ . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01-6196 CIVIL TERM Plaintiff vs. CIVIL ACTION - LAW JANET CALAMAN, Individually and on Behalf : of MAX CALAMAN, DECEDENT, Defendant CERTIFICATE OF SERVICE AND NOW, this .f~ day of November, 2002, I, Amy F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Petition for Appointment of Arbitrators upon the Defendant's counsel of record by First Class Mail, postage pre-paid, and addressed as follows: Steven J. Hogg, Esquire 19 S. Hanover Street Suite 10 1 Carlisle, PA 17013 ,'~ 'tt _.~ 0, i~ I - < --'''4'' ".,~\;,-, '. ""iJ <~ "]j '~'j-t" :~rrn:'- '/-;-;-:i~ ':.:' -;~ >-"":.:'t"ftt1i 'ij('~'--f";'h'f~:"'2f <;'~;~j:~;,~;",~tj:'// li " &0 ~ ~ ~ ~ eN ~ h o () o C -..,,~ ~~f ~s~i ~~i~- ~~~ -~, " -, , ',wi i.....~, ,-'., <.. ~ "t'l F! ~ ~ (."' ~-r:::1 ~) :,.) C:) ;1:" .....~ ~, ~ "~!Im!.~l~1ff''*t!l&Fili~',~l~~!Wffl.~iU'#!!,!\W'0J:JN',''O;-t,)j?"Vth!'O~-N,..,;,,,,,,,' iY'~"';_>!' -""'->;!'~fiJ1i)-,;,j~"""'~':.!":",'H'/j\"'M'-;l1-!~Sjf!1''rf*1''!Ij!t''i'l\'''J%~1w.~"J!i':!~ij'i'f'~1,~m~!1.!j1I\ ~. _"" .__~ ~_Ii"~ u~~r_-IiHF,~mm ,:' \ . . .. . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCRMANOR CARE, Plaintiff CIYIL ACTION - LAW v. No. 01~6I96 Civil Term JANET CALAMAN, fudividually and on Behalf of MAX CALAMAN, DECEDENT, Defendant BLUE CROSS, BLUE SHIELD, and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants PRAECIPE TO DISCONTINUE Defendant, Janet Calaman, individually and on behalf of Max Calaman, decedent, hereby discontinues all claims brought in the New Matter in the above-captioned matter against Blue Cross, Blue Shield, Capital Blue Cross, Pennsylvania Blue Shield, and Highmark, fuc. Kindly mark the above-captioned matter dismissed as to additional defendants Capital Blue , Cross, Pennsylvania Blue Shield, Highmark, fuc., Blue cr91 ~1~~jfd. ,//.. "'~. 'JQ' - ,./ -' " '''.' ,,,,~ -' ',._'/./'"..".... .., . .' / . '. ,. / ,~,' ,.' ;/ .' Stephen 1. Hogg, Esquire j" 19 South Hanover Streljl/' Suite 101 I Carlisle, PA 17013 Attorney for Additional Defendant SL123367lvl!02109.068 :-~,'~-="'-"". ~.~~ '~", I . f - -,~, -- o~~' ,"~, , _ _ , .~~,J. ~~~, "J~'l'J.."!r1.tf!l':u-m~l\!~IlO~,~'~,'liRl!,~"" "",-4_~~r~~'.~!i'Will~I~.li1i'i~~z,..,~r,~#I\~';iM"-''l?'J5''-I ",",,",' "~^'"' w__=_;,,_ '''''-., . ,k~'-A"';di;'" "'1"" Jfljr~t""u"li' ?[J."~A'~~';\;;1 o c <"" -oF' ~~~ ~C) :>~ -,7l.J :'-'0 ?(~ Z :<! co N r_. ~,::H' ~"'" l'J -Tl :IJ I'v \.0 ~-T"l (:J "U ~.2C) -rj '~~~,8 ~ ..,' ,~ :oJ -< ;;? ,:,:, m fi ,', .,:;:,:"<:;<--9'n,",;,"~'Y;;;'--"1i'i'l'j'!'!""';",f"';-",J1#!,,"Y;,rY~1il~:';":>f:;i'~iT~~ik! IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01-6196 vs. CIVIL ACTION - LAW JANET CALAMAN, Individually and on Behalf : of MAX CALAMAN, DECEDENT, : Defendant and BLUE CROSS, BLUE SHIELD, and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants WPL Y TO NEW MATTER AND NOW, this ~ day of December, 2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson & Associates, P.c., and files the within Reply to New Matter and in support avers as follows: The allegations and averments contained within paragraphs One (1) through Nineteen (19) of the Plaintiff's Complaint are incorporated herein by reference as if set forth in full. 20. Paragraph 20 of Defendant's Answer and New Matter is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in Plaintiff's Complaint are incorporated herein by reference as if set forth in full. 21 . Admitted. "<'~,l,,< ,-., "'--"""-"-,-" - "I _e "" 22. Admitted. 23. Admitted. 24. Denied. It is specifically denied that the Defendant and Decedent were fully insured for medical expenses incurred from the services of Plaintiff by Blue Cross, Blue Shield and Medicare. By way of further answer, Decedent's Blue Cross/Blue Shield policy paid only for eleven (11) days in February of 2001, and made no payments on behalf of the Decedent in either December of 2000 or January of 2001 because Defendant and Decedent had not met the required deductibles until February 17,2001. 25. Admitted in part; denied in part. If Defendant can show that Plaintiff should be paid by either Blue Cross, Blue Shield or Medicare for medical treatment and services provided to Decedent, it is admitted that Blue Cross, Blue Shield and Medicare are indispensable parties to this matter. As to Defendant's assertion, at this point in the proceedings, that any expenses incurred by Decedent from Plaintiff should be necessarily covered by either Blue Cross, Blue Shield or Medicare, after reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 2 ''''<>1 r J;, '"f 1~,l> _'"J __ - -',~ _ , ~ v. , t , " " "--; ''<",lJ:'" _~'"' __ _, '_>__ _, ',_ _, WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Defendant's New Matter and enter judgment in favor of Plaintiff and against Defendant, along with the allowable costs of this action, and such further relief as the Court deems appropriate. Respectfully Submitted, Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATE ,P.c. 267 East Market Street York, PA 17403 (717) 846.1252 1.0. No. 20617 Attorney for Plaintiff 3 "_"V^~, 0 r' I ,_" "",.. ,--,--:r~'_T",~__,,< '~,'r--,'I '.. ,)J_," VERIFICATION Daniel F. Wolfson, Esquire, hereby states that he is the attorney for the Plaintiff, HCR Manor Care, and he is authorized to take this verification on behalf of said Plaintiff in the within action and verifies that the statements made in the foregoing Reply to New Matter are true and correct to the best of his knowledge, information, and belief, based upon information prOVided by the Plaintiff. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: I2-P;/o I ~ Da lei F. Wolfson, Esquire WOLFSON & ASSOCIATES 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 2061 7 Attorney for Plaintiff ,-, 'I rr . ~ ,~ '----\!ft~!~)c'J., __" "'< . . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO. 01-6196 vs. CIVIL ACTION - LAW JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant and BLUE CROSS, BLUE SHIELD, and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants CERTIFICATE OF SERVICE if AND NOW, this Z/ day of December, 2001, I, Daniel F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Reply to New Matter upon the counsel of record by regular mail, postage pre-paid and addressed as follows: Steven ). Hogg, Esquire 19 S. Hanover Street Suite 10 1 Carlisle, PA 17013 (Counsel for Defendant) U Daniel F. Wolfson, Esquire WOLFSON & ASSOCIA T 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff - ',~ ~- - - 1- , '..I -,-, . . _J - "-~ -, 1~"- ;""",, '""",-",---,' " "'~ 2 :t;~ rnO:; ;?fD ;2:-" v- 1:;,' :J ._~_~ ::<('" r.....< :fc - 0 :go !i ~ .C' 'lrirh"i~~ C;:) -. o -r-, . ,:::, r'') (J f\.> cr. J:>, ~ ~-,,, ~~-- , ;l,F7;} }~~.' {:.)::!J <0 orn '-/ ,:c. .:D ''<;" - - !\;) r\.) e ()Ii ~_ ,.1 ,~ T,"_'_ ~, ~ _ 11 _nfP~r~i!lR~ _ ~~~_'."f:;j~""';>';'fl'~';;-''l'flW:"\""c'"i'i{'''P)O;''''~-';;'<Qip.~~''<!<!'''fi!l'-><:ifl"i'~jlo"f'i-I'1'r,-l""''Tt*,-,,,'''':lc'-''''j~m-,jW!i;;f!ft'i1'~*~ s, LAW OFFICES OF STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE. PA 17013 ;; IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, vs. NO. 01-6196 CIVIL TERM JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and CIVIL ACTION - LAW BLUE CROSS, BLUE SHIELD, and: HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. NOTICE TO DEFEND 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 are served, by entering a written appearance personally or by attorney and filing in writing 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 for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. 'c_ ,>-,,"..,.,.-. c_ _'~____', '" " , _" "'_",~ ,;:i 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 BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PENNSYLVANIA 17013 LAW OFFICES OF STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE, PA 17013 ;;,:NI,,~ ,1l1~ LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 1"_' '-', - <,,"~',- '_,"_W,"_ '. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, VS. NO. 01-6196 CIVIL TERM JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and CIVIL ACTION - LAW BLUE CROSS, BLUE SHIELD, and: HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. ANSWER WITH NEW MATTER ANSWER AND NOW, this November, 2001, Defendant, Janet Calaman, through her attorney, Stephen J. Hogg, files this Answer With New Matter to the Plaintiff's Complaint and avers the following: 1. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 2. Admitted. 3. Admitted. 4. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 5. It is admitted that Defendant and Decedent were married at the time Decedent became a resident at Plaintiff's facility. 6. Admitted. 7. It is specifically denied that the Plaintiff submitted to Defendant an accurate itemization of debts and credits for Decedent's transactions with Plaintiff. 8. It is denied that Defendant did not object to the Statement of Account submitted by Plaintiff to Defendant. 9. It is denied that the balance due, owing and unpaid on Decedent's account is $7,585.00. Defendant has no knowledge of any other amount due and owing to Plaintiff and proof thereof is demanded at trial. 10. It is denied that Defendant has failed, refused or continues to refuse to cause to pay any sum due and owing on Decedent's account balance. 11. It is denied that Defendant has failed, refused or continues to refuse to cause to pay any sum due and owing on Decedent's account balance. 12. Denied. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 13. It is denied that Plaintiff is entitled to receive reasonable attorney's fees. LAW OFFICES OF STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE. PA 17013 14. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 15. Denied. I" "--',V_" -"""'c' ", ,""-'-." ,'--'!,:.-' :~_.I'" '-. -,. n-C'-~" -__~,'.5",,;',__~,~___~_" _,.r_c' ,,'~,_,' "," ,_-., ~. __~~_, ~_,~~ '~, ' 16. It is denied that thirty percent (30%) of the principal balance due is a reasonable attorney's fee and it is further denied that the Plaintiff is entitled to collect reasonable attorney's fees from Defendant. 17. It is admitted that thirty percent (30%) of the principal amount Plaintiff alleges is due and owing is $2,275.50. It is denied that this amount is a reasonable attorney fee or is thirty percent (30%) of the actual amount due and owing. 18. Defendant has no knowledge of the allegations raised in this paragraph and demands proof thereof at trial. 19. Admitted. Wherefore, Defendant demands judgment in her favor and against Plaintiff. NEW MATTER 20. Defendant asserts the defenses raised in Paragraphs 1 through 19 as iffully set forth herein. 21. Defendant Blue Cross is a medical services insurance provider doing business at 2500 Elmerton Avenue, Harrisburg, Dauphin County, Pennsylvania. 22. Defendant Blue Shield is a medical services insurance provider doing bsuiness at 1800 Center Road, Camp Hill, Cumberland County, Pennsylvania. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 ''-''i~:l'_ , 0 '"',;,,'1.' ,,'~ _--; ^'~ .'_ ,~,;,__", gf' 23. Defendant Health Care Finance agency (Medicare) provides medicare insurance coverage for the elderly and has a domestic business address in care of Blue Cross and Blue Shield at the aforementioned addresses. 24. Defendant and Decedent were fully insured for medical expenses incurred from the services of Plaintiff by Blue Cross, Blue Shield and Medicare. 25. Defendant asserts that any expenses incurred by Decedent from Plaintiff are covered by either Blue Cross, Blue Shield or Medicare and therefore Blue Cross, Blue Shield and Medicare are indispensable parties to this matter. Wherefore, Defendant joins Blue Cross, Blue Shield and the Healthcare Finance Agency (Medicare) as additional defendants in this matter and, if there is any additional amount due to Plaintiff, it is to be paid by either Blue Cross, Blue Shield or the Healthcare Finance Agency (Medicare). Date: II / 30 / ~ I ( I Stephen J. H 19 S. Hano r treet Suite 101 Carlisle, PA 17013 (717)245-2698 Attorney for Defendant LAW OFFICES OF STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE. PA 17013 ">il':>-"".-,~c, oo-","r,.-,'_, ":1.'---J~1T" ".j " LAW OFFICES OF i: STEPHEN J. HOGG 19S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 '..,,0_.,._ ."~'h ~,'.' _' VERIFICATION I verify that the statements made in this Answer to the Court of Common Pleas of Cumberland County, Pennsylvania, are true and correct. I understand that false statements herein are made subject to the penalties of 19 Pa. Section 4904, relating to unsworn falsifications to authorities. ///g~~1 Date . ~j/ C~~(/ ET E. CALAMAN :"i-l LAW OFFICES OF STEPHENJ. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE. PA 17013 :''7 ,~ "' '. .' " , CERTIFICATE OF SERVICE I, Stephen J. Hogg, Esquire, Attorney for the Defendant, hereby certifies that I did on this day serve one true and correct copy of the attached Answer With New Matter by United States Mail, postage prepaid, from Carlisle, Pennsylvania, on the following: Date: Ij/"JtJ'/tf I / Daniel F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 "' / ,,// Stephen J. Hogg Attorney for Defe 19 S. Hanover Street Suite 101 Carlisle, PA 17013 (717) 245-2698 < ~.l ... .' )'--,", ,""'- "'''''1 '=" ,~, ";-';~'" . 'o'"'~.;; ~' '~Lj"' ,"- ';,-, ,; ~',.,....,~ ''''-,~ 'le ;,;,=""-','"",,..-...., "'~id:':1;I:r~A"rf'~--..- r '. -r, ;..'__ C!.~ j',-~: ".," ~5 ~~:~: ~,~C::7 i?i~ --j -< Q , ''''. I'-~: ,"::) ('j -;1 -- .-.~,,, '- "~GJ 16 "1 ~i,~ ""L"';' 5:J '" ,:..> <;:) S) '- . - -~,,".< - J~~,..- >~.-:-'~~if!;"'~~!}\:rr_wr~w'~~~~~~1 " , HCR MANOR CARE, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 0\ - blCfb Cu t'Lr~ vs. CIVIL ACTION - LAW JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant , 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 o SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VA Y A EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR ASSIT ANCIA LEGAL. lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 1 7013 (717) 249,3166 ,''''~~ -~',",,~', _,~'. _~IT".__ '-I 't _ ~" ~. iW.<r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff NO.OI-~I~ Gtut'te. vs. CIVIL ACTION - LAW )ANET CALAMAN, Individually and on Behalf : of MAX CALAMAN, DECEDENT, Defendant COMPLAINT ~~ AND NOW, this 11i day of f)dr\tJ ,2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law fimi 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 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Janet Calaman, is an adult individual with a last known address of 811 N. West Street, Carlisle, Cumberland County, Pennsylvania 1 701 3. Defendant is the wife of Max Calaman, Decedent. 3. That on or about November 17, 2000, Defendant executed an Admission Agreement, on behalf of Decedent, which Agreement outlined various terms of residential health care services to be provided by Plaintiff and which designated the 2 ~'?\~..~, '.-'" "".,~.', ",' -~--, -" I' , I '" ~,' '-,,' ~ v. r .., ~ " ,-, ;~ Responsible Party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit "A". 4. That on or about November 22, 2000 through on or about February 28, 2001, Max Calaman, Decedent (hereinafter referred to as "Decedent") was a health care resident of Plaintiff, where he 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 "B". 5. That the debt was incurred as part of the marital estate. 6. That 23 Pa.C.S.A. ~ 4102 provides that both spouses are liable for debts contracted for necessaries by either spouse, absent formal separation agreement or support order addressing the matter, and said obligation is imposed by law as an incident of the marital status. 7. That Plaintiff submitted to Defendant a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously identified as Exhibit "B" and is incorporated herein by reference. 8. That Defendant did not object to the above-mentioned Statement of Account submitted by Plaintiff to Defendant. 9. As ofthe date ofthe within Complaint, the balance due, owing and unpaid on Decedent's account as a result of said charges is the sum of Seven Thousand Five 3 "~",'\1!f"<W'1J!!'!~ ., ........., " , , 1 "'~""--'",,\;e;illl-.>t.-;<. ~ ~"".__~, ,.1'N~1 _ _ Hundred Eighty-Five and 00/100 Dollars ($7,585.00). 10. Despite Plaintiff's reasonable and repeated demands for payment, Defendant has failed, refused, and continues to refuse to pay all sums due and owing on Decedent's account balance, all to the damage and detriment of the Plaintiff. 11. Plaintiff has made numerous requests to Defendant demanding that the sums due and owing to Plaintiff be paid, and Defendant has refused her obligation to pay necessary and appropriate bills and obligations for Decedent as part of the marital estate. 12. Pursuant to Section 1, Paragraph 1.03 of the Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "A" as previously identified and incorporated herein. 13. As of the filing of this complaint, the amount of interest which has accrued on this account is the sum of Two Hundred Twenty and 66/1 00 Dollars ($220.66). 14. Plaintiff has retained the services of the law firm of Wolfson & Associates, P.c. in the collection ofthe amounts due from Defendant. 15. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay reasonable attorney's fees and all court costs if the account is referred to an attorney for collection. See Exhibit" A" 4 """"""'1 ~, '~~-I ~~ - ~ ,:e, , ".!j!<J~'o;,~",,,,,,1 , ''''~ previously identified and incorporated herein. 16. 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 Defendant, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendant. 17. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Two Thousand Two Hundred Seventy- Five and 50/100 Dollars ($2,275.50). 18. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 1 9. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. 5 , .'---r...,- "~~ : " 'I ~. , ~ 1 ;~~,~ WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendant, )anet Calaman, Individually and on behalf of Max Calaman, Decedent, in the amount of Seven Thousand Five Hundred Eighty- Five and 00/100 Dollars ($7,585.00), contractual interest in the amount ofTwo Hundred Twenty and 66 /1 00 Dollars ($220.66), reasonable attorney's fees in the amount of Two Thousand Two Hundred Seventy-Five and 50/1 00 Dollars ($2,275.50), the costs of this action, and such other relief as the court deems proper and just. Respectfully submitted, 7P~~ Daniel F. Wolfson, Esquire WOLFSON & ASSOCIATES, 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff 6 """~~"!i"'lli'[r 8_ , " ~ - ,'.~ ~~ , ,,,,,,,.~~ r~~ VERI FICA TION I, Michelle Thureson, being the Senior Financial Consultant for HCR Manor Care, verify that the statements made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Sec~ion 4904, relating to unsworn falsification to authorities. HCR Manor Care DATE: /D l~v \0 I ~~ Michelle Thureson "- Senior Financial Services Consultant ",i'","'4"'_""!f!<'\~ --,' .." 0.., r;- ',- ,~- ' I'!' I "" ,~ _ ,'oiIiJI EXHIBIT "A" "'i;1'~"", " ,C--'7""''''!'~''(;"n_.'''.",'' "r' .,.~_~ -"'1''''''_ 'I, ''', . .' ,,~,-,,~'":"*_tl HeR Mal/or 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"). C;1-I2-Ir.sk, /1J IJ-><- .4 &61-ff)~~ d-t9-rla....T G I j<J 1I1~ Center: /iU!,N.s - Resident: Legal Representntive: Admission Dnte: 11- 17-t'H) /J1(! - Deposit: S Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and 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 (loth) day of each month, The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge, This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06), 1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review, during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10th) day of the month. - ~.II -" ~~.., ...~._- .- ~~ 1.03 Late Pavments, Accounts not paid in' full within thirty (30) days of billing s~all 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 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: ,,/ Medicare, /'Medicaid and/or v 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 Part>. Pavors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 .l':"'''f!~,,"'~ H"", , - , [ ~,""- ~I ." 11I"I.1......,.. _~ '-'"-""'''\-'..'I~~~ will bill the Resident's third party payor as a service, but the Resident remains liable for charges ' not paid or covered by that third party payor including charges not paid within a reasonable period of time, 1.07 Private 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 Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) davs of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when appliC!!ble, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibilitv for Pavment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors, This 3 , , --I ~~ 0 "1 - Agreement serves as a written notice that the Certter 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 agr~es to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 Legal 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 t9 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 i\'ledicaid 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 -,,,,,,*,-,\>",-,~~~ ., ~""""7""P ' '" "r- " ~'1' - " - 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 Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services, As part of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. . 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or, within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30),days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident andlor 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 "~~Jj:->j"~') ."' --~'.I ," . "'~'"''''YY''e""g.!;" . review> or payment audits p4:rformed by such, the personnel of any hospital or other health cate facility or provider to whom or which the Resident may be transferred, the Center's liability insurance carrier; and ar:y person authori7.ed by law to review the medical recorcl5. 4.02 j:an~ent to Treat. The Resident andlor Legal Representative. by signing this Agreement. hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Trealr.icnl") 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 physicill/1 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 10 the Resident by federal and/or state law. As applicable, the undersigned legal Representative hereby represents that he/she bas the legal authority to make health care decisions on behalf of the Resident, that docume:1ts supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf ufthe Resident to the Treatment described above. 4.03 Co~Sent to Phot02raoh. The Residem andlor Legal Represema:ive agree to consent to the Center taking II 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 end Additional Information, The Resident andlor Legal Representadve acknowledge that the items listed below ha~'e bcen explained lInd have received copies of the items or Folicies and procedures, if applicable, The Resident and/or Legal Representative acknowledse they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authoriution for Release or Review of Medical Information. See Attachment C b. Authorization for Payment of Benefits See Attachmer.t D. c Social Security Administration Appointment. See Altachment E. d, SNF Mdicare Determi:1ation Notice See Attachment F. e Medicare Secondary Payor Questionnaire. See Attachment G, f. At the request of the Resident 2.Ild/or Legal Reprcsentat:ve. 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 pro:eclion 0: residem Cunds and the Personal Trust Fund Agreement, Resident Personal Funds G -, r I 'l .<. - ~- -.~ ~'d"";'''<1-''''''''., .~""" -~-r-= and the Personal Trust Fund Agreement, Resident Personal 'Funds' Authorization and any other related documents. See Attachment H-l and H-2. g. The Center's policy and procedure on bedholds, election of bed holds and readmission, See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and p~one numbers, See Attachment I (Center Supplement). L Name, address and phone number of Ombudsman, See Attachment I (Center Supplement). J The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file 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. MedicareIMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HeR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-I and M-2. q. Privacy Act Notification. See Attachment N. 7 J . ,RI., "C~-~l "1 ~ ~'- ft~l~ r. Inventory sheet and/or policy of personal items. See Attachment O. s. ASM Form. See attachment P. rlu., rJd...rr In,-. ~ ~ r!~tLetJT I ~~ ~/=-S ~ I See Attachment Q. t. u. See Attachment R. v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. 4.05 . Assignment of Benefits. The Resident and/or Legal Representative' hereby requests that payment of authorized government aI).d/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized,units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice, If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 "'YO'-,,'___n~"Th~ 1,[[. _"_~ll , I ~I ",_C ~r- ~ of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND 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: 'r" ofL".1 Rope-".'. if ,igru"" " bob.f of R~ido'" [f4'q I 0 I 6 /' ~ P!A -rY'-1'I /1/\ / Date: /1/11/JIJ Signature of Legal Representative, signing on his/her own behalf: Date: Center Representative: Date: 9 ,'''''~'''~''''''. ~ "!' _e~"',.~n ,., "~. , "~-~ "--~ 1- 1~- ':r'.~ -~ _I' 1~.'C" ,. ,.;-' 'I -, EXHIBIT "B" '-I '.--7..,,,:,,,_ .,.,< ". , , c. '1'~ -C ,.. -"'" , ,~. . ',/19/01 RESI0ENT LEOGER AS Of OATE Qf fIRSf ACTIVITY PAGE AR5il 'ESIOENT RESIOENl RESIDENT G/l -- ACCOUNTS RECEIVABLE mER TYPE UAH om QIY ACCOUII! CHARGES C REO lT5 BALANCE 0105 !EOICARE A CAlA!AIi. r,AX A 12/05/00 AO', clm RATE: 0.00 ROOr, 15B ,B LEVEL 1 02/28/01 OIl PRIV PORT: 0.00 "PRIVATE ' IIOV 00 1020B PT 6 CO,INS lA6'GlUCOSE r, 11/22/00 1 .B7 m0B PT 6 CO, INS LA6,GLUCOSE N 11/23/00 2 1.75 1020B PT 6 CO-INS lA6,GLUCOSE r, 11/2./00 2 1.75 10206 PT 6 CQ'INS LA6,GLUCOSE N 11/25/00 1 .B7 10m PT BCD-INS LAB,GLUCOIE N H/26/00 1 .B7 1020B PT B CO'IN5 lA6-GlUCOS[ N 11{2B/00 1 .B7 10m PT B CO,INS lAB-GLUCOSE N 11{29/00 1 .B7 11100 BEAUTY ANO BARBEB 11/29/00 1 5915BI01120 8.50 10m PT B CO,INS LAB,GLUCOSE N 11/30/00 1 .B7 "ENOING BALANCE 17.22 "NEOICARE ~ ' NOV 0i Iml PHYSICAL THERAPY VISIT 11{22/00 -, 11/29/00 5 52150210120 215.00 lWl PHYSICAL THERAPV EVAl 11{22/00 1 52150210120 75.00 29001 PHARWY lEGEliO 11/22/00 -- 11/3i{00 1 54551210120 564091 30m PHARAACY NON LEGENO 11{22/00 -- 11/30}00 1 54951310120 43.77 17101 OCCUP THERAPY VISIT 11{24/00 " 11/30/00 4 52560610120 275.00 1740l OCCUP THERAPY.EVAL 11{24/00 1 52550610120 25.00 20101 SPEECR THERAPY VISIT 11/2B/00 -, 11/30/00 3 52950410120 100.00 20401 SPEECH THERAPY EVAl 11/2B/00 1 52950410120 25.00 ANCILLARY WRITE OfF 11/30{00 57557510120 13B3.6B ROOH CHARGE AT 136.00 11/22/00 -, 11/30/00 9 51350010120 1242.00 ROON WRITE OfF 11/22/00 -, 11/30{00 9 51557010120 l1B6.74 "ENDING BALANCE 242B.74 "IE 01 CARE B - NOV 00 1610B lAB,GLUCOSE r.ONITORIUG 11/22/00 1 56151911120 4,37 10208 PT 8 CO,INS lAB'GlUCOSE ! 11/22/00 1 .87 1020B LAB'GlUCOSE r,ONITORING 11/23/00 2 56151911120 B.7. lO20B PI B CO,INS IAB,GLUCOSE M 11/23{00 2 1.75 1020B LA8,GLUCOSE NONITORING 11/2'/00 2 56151911120 B.7. 10208 PT 8 CO,lNS lA8'GlUCOSE ! 11/24/00 2 1.75 10208 LAB'GlUCOSE r,ONITORING 11/25/00 1 56151911120 4,37 1020B PI B CO,INS LAB-GLUCOSE! 11/25/00 1 .B7 1020B lAB-GLUCOSE NONIIORING 11/26/00 1 56151911120 4,37 10208 PI 8 CO-INS lA8'GlUCOSE ! 11{26/00 1 .B7 lO20B lAB,GLUCOSE NONIIORING 11/2B)00 1 56151911120 4,37 1020B PI B CO-INS LA8,GLUCOSE ! 11/2B/00 1 .B7 1020B lAB,GLUCOSE AONIIORING 11/29/00 1 56151911120 4,37 1020B PI 8 CO, INS lA8'GlUCOSE N 11/29/00 1 .B7 li20B lAB-GLUCOSE r,ONIIORING 11/30/00 1 56151911120 4,37 li20B PI B CO,INS liB-GLUCOSE H 11/30/00 1 .B7 "ENOING 8ALANCE 3UB "PRIVATE ,OEC 00 8AL FWO ,LN, ,30- ,60- ,90- -120., 17.22 17.22 10208 PI 8 CO-INS LA8-GLUCOSE N 12/02/00 3.50 r;-"'l:"",,"l"'''',f~~~.4 .J _, "c ""1 ;'., - :':"''',,'''CP'' ~ - --. " /19/01 RESIDENT LEDGER AS Of DATE Of fIRST ACTIVITY PAGE ;AR56) 'ESIDENT RESIDENT RESIDEt:! G/l -- ACCOUNTS RECEIVABLE 'UlBER TYPE mE DATE QTY mOUtlT CHARSES CREDITS BALANCE ~'O 1 0 5 r.EDICARE R CAlAm, lAX A 12/05/00 A 0 ~ cm RATE: UO ROOR 158 ,B LEVEL 1 1212B/ll OIS PRIV POR1: UI "PRIVATE - DEe 10 [COII1) 10208 Pl 8 CG,IHS LA8,GLUCOSE ! 12/03/00 2 1.75 10m Pl 8 CO-INS LA8,OlUCOSE I 12/04/00 2 1.75 10208 Pl B CO,IHS lAB,GLUCOSE ! 12/06/00 , 1.75 , 10208 Pl 8 CO,INS LAB'GlUCOSE ! 12/07/00 1.75 10208 Pl 8 CO,IHS lA8,GLUCOSE ! 12/09100 1.75 am PT 8 CO,INS LA8'GlUCOSE I 12/12/00 .87 1im Pl 8 CO,INS lA8-GLUCOSE ! 12/17/00 1 .87 m08 PT 8 CO, INS LA8,GLUCOSE ! 12/19/00 1 .87 10m Pl 8 CO,INS lA8,GLUCOSE ! 12/20/00 1 .B7 10208 PT 8 CD-INS LA8-GLUCDSE R 12/21/00 1 .87 10208 Pl B CO-IHS lAB-GLUCOSE ! 12/22/00 1 .B7 10208 PT 8 CO,INS lA8-GLUCOSE R 12/23/00 1 .87 10m Pl 8 CO,INS lAB,OLUCD1I ! 1212\100 1 .87 am PT 8 CO,INS lAB-GLUCOSE I 12/25/00 1 .87 am PT 8 CO,IHS lA8-GLUCOSE ! 12/27/00 1 .87 CO,INSURANCE AT 97.00 12/13/00 " 12/18/00 6 682.00 CO-INSURAHCE AT 97.00 12/19/00 -- 12/31/00 13 126l.i0 "ENDING 8ALANCE 1B81.17 "HEDICARE A - DEC 00 8Al fWD 'll' ,30, ,60- -90, -120+- 2418.74 2418.74 14101 PHYSICAL THERAPY VISll 12/01/00 -, 12/04/00 2 52150210120 175.00 17101 OCCUP THERAPY VISIT 12/01/00 -, 12/04/00 2 52550610120 5UO 51801 101Al IHCO~T'OLY fEE 12/01/00 " 12/31/00 31 56151810120 31.00 53201 N1RT~L/ENTRl SERV GRP 2 12/01/00 -, 12/31/00 62 56153210120 124.00 53201 HTRTHl/EH1Rl SERV GRP 3 12/01/00 -, 12/31/00 62 56153210120 248.00 14101 PHYSICAL iHERAPY VISll 12106/10 -, 12129/00 16 52151210120 81UO 17101 OCCUP lHERAPY VISll 12/08/00 -, 12/29/00 13 52551610111 966.00 17401 OCCUP THERAPY EVAl 12/08/00 1 52551610120 2UI 20401 SPEECH THERAPY EVAl 12/18/11 1 52950410120 2UO 2i111 SPEECH THERAPY VISIT 12/21/0i 1 5295iH0120 5U0 ANCILLARY WRITE Off 12/31/00 57557510121 mU0 ROO! CHARGE AT 138.00 12/01/00 -- 11/03/00 3 51350010110 414.01 RDOH WRllE Off 12/01/00 -, 12/03/10 3 51557010120 395.58 ROOI CHARGE AT 138.00 11/05/00 " 12/18/00 i4 51350010120 1932.01 ROOI WRITE Off 12/05/10 ,- 12/18/01 14 51557010121 2754.08 DEOUCT CO'lN5 AT 97.01 6 5B2.10 RDO~ CHARBE AT 138.01 11/19/01 ,- 12/31/00 13 51350010121 1794.00 ROD! WRITE Off 12/19/10 " 12/31/00 13 51557010120 2034.11 OEDUCT CO,]lIS AT 9U0 13 1261.00 "ENOIN, 8ALANCE 9919.51 "IEDICARE 8 ' DEC 10 BAl fWD 'lH- ,31, -60, ,90- -120+, 34.9B 3U8 ''''-'''''''''_''"'1 -"'" , --1~ I ~~ c .~~. - T ' , ~ "., ,~ ~ "'lIilil"T RESIDE II LEDGER IS Of OIIE QF FIRSi ICIIVIIY ,,6/18/01 IR56) ;ESIDEII RESIDE II ,umR TYPE PIGE RESIDElIT mE G/L -- ACCDUIITS RECEIVIBLE DIIE OTY ICCDUII CHIRGES CREDITS BAlINCE 11/05/01 10~ CITR RilE: 02/1B/010IS PRli PORI: 11/01/01 4 56151811110 11101/00 4 11/03/00 1 56151911110 11103/00 1 11104/00 1 56151911120 11/04100 1 11106/00 1 56151911110 11/06/00 1 11/07/00 1 56151911110 11/07/00 1 11/09/01 1 56151811120 11/08{00 1 11111/00 1 56151911110 11{11/01 I 11/17/00 1 56151911110 11/17/00 1 11{19/01 1 56151911120 11/18/00 1 11/10/00 11/10/10 11/11{00 11/11/01 11/11/00 11/11/00 11/13/01 11113/00 11/14110 11/14/00 12/15/01 11/15{00 11/17/00 11{27/01 '1105 !EDICIRE I CALIRII, ~IX I ROO~ 158 -, LEVEL I "REOICIRE , - OEC 00 (COil) 1010, ll"GlUCOSE !ORI10RING 10208 PT 8 CO-lIS ll"GLUCOSE M 1120, LI"GLUCOSE ~OIITORIIG 1010, PI B CO, liS LI"GLUCOSE R 1020, LI,-GlUCOSE M011TORING 10100 PI, CO,IRS LI"GLUCOSE R 10108 LI,-GLUCOSE !ONI10RING 10208 PT 8 CO-lIS LI"GLUC0SE R 1010, LI"GLUCOSE !OlIIDRING 1010, PI, CD,INS LI"GLUCOSE ! 1120, LI,-GlUCOSE NDNIIORINO 10108 PI 8 CO-IRS LI8,GLUCOSE R 10208 LI"GLUCOSE r.ONIIORING 10108 PT 8 CO, INS LI"GLUCOSE ! 10108 LIB-GLUCOSE !ONITDRIRG 11108 PI 8 CO,IIS llB,GLUCOSE ! 10108 LIB-GLUCOSE !ONITDRIIG 10108 PI B CO-IRS LIB-OLUCOSE R 10108 llB,6lUCOSE MDNITORIIG 10108 PI B CO, IRS LI8-GLUCOSE R 10108 lI8-GLUCOSE !OIITORIIG 10208 PT 8 CO,IRS LIB-GLUCOSE " 10108 llB,GlUCOSE RONIIORING 10108 PI B CO'lRl LI8-GLUCOSE R 1010B lAB,GLUCOSE MOlllORIIG 10108 PT 8 CO'1IS LIB'GlUCOSE " 10208 LIB-GLUCOSE !ORIIDRIIG 1010B PT B CO, liS LI8"lUCOSE ! 10108 lAB'GLUCOSr !D~1TORII, 10108 PI 1 CO-II5 lA8,GLUCOSE ! 10208 LAB-GLUCOSE !OlITOR1IG 10101 PI 1 CO'1II LIB'GlUCOSE " "EIOll6 BALANCE "PRIVAIE 'JAN ~1 BH FWD 'LM- ,30, 1863.85 17.11 PAYREI:T 01/09/01 CO,IISURINCE AI 98.00 01/01/01 -, 01/03101 3 CO'I~SURA~CE AT 99.00 01/04/01 "0111~101 11 CO,1ISURIRCE AT 89.00 01/1S/01 -- 01/31101 17 RVS PI B COilS 11-00 11130/00 RVS COlliS 12-00 11131/00 **[NOl~6 BALANCE "!EDICARE A ' JAI 01 BAl fWO -lM, -30- 7480.77 1418.74 ,61, ,90, ,60, ..90- "P"''''''''''''''''''''''.W: 1""""""'""- ,,'" 56151911110 1 1 56151911111 1 1 1 1 1 1 1 1 1 1 1 561S1911120 56151911110 50151911120 56151911120 56151911111 ,120+- 0.00 0.00 17.48 8.7~ 8.74 8.14 8.74 8.74 4,37 4,37 4,37 4,37 4,37 4,37 4,37 4,37 U7 U7 1881.17 11110001000 187.00 1089.00 1683.00 1'411050000 11111050000 ,110+, 9909.51 3.50 1.75 1.75 1.75 1.75 1. 75 .87 .87 .87 .Bl .87 .87 .87 .87 .87 .81 8.71 10.95 .. 118.91 8.S0 1911.00 '" T'--==__ %'W~it I'm li ~ , {(,/iSjCl RESIDE~T lEDGE, RS Of DRTE OF rIRs{ ~C~lVITY PRGE i AR56) rESIDENT RESIDENT RESIDENT GIL " ACCOUNTS RECEIVABLE ',UIBEA TYPE IIA~E DATE OTY ACCDUIIT eNRRGES CREDITS BAlANCE ~ ~ 105 mIeARE" CHAm. lAX A 11/15110 ADr. CIiTRRm: 1.10 RDD~, 158 ,8 LEVEl 1 11/18101DIS PRIV PORT: 0.01 "!EDICARE A - JA~ 11 ( CD~T) PAYIE~T 11-/2-11,31-1'6'1 11/16{11 11111111111 3111.57 11111 LAB SERVICES II/II/II 1 56151911111 37.15 11111 LAn SERVICES II/II/II 1 56151911W <6.10 19119 PHARNACY LEGEND II/II/II -- 11/13/11 1 54551111111 619.18 19m PHARWYLE6EIID 11/11111 -- 11113/11 1 54551111111 619.1 B 19m PHARIACYLE6EIID 11111{ll ,. 11/13/11 1 54551111111 581.73 31m PHAR!AC! NDNLEGEND 01111{ll " 11113{ll 1 54951311111 lU3 51811 TOTAL INCD~T'DLY FEE 11{ll111 .' 11/31/11 31 56151811111 93.11 53201 NTRTNL{E~TRI SERV GRP 1 11101{01 " 01/31/11 61 56153111111 114.11 53101 NTRTNl/ENTRL SERV GRP 3 11111/11 -- 11131{11 61 56153111110 W.01 53601 DXYGE~ CDNCE~ RENT DLY 11{11101 ., 11/31/11 31 55353610111 558.11 14111 PHYSICAL THERAPY VISIT 11101{ll ., 11115{ll 4 51151111110 115.11 11/11 BLOOD GLUCOSE TEST 11{13101 4 S6151911111 17.48 17111 DCCUP THERAPY VISIT 11/13/11 3 51S50611111 111.11 11/11 BLOOD GLUCOSE TEST 11114/11 3 56151911111 13.11 11/01 BLOOD GLUCOSE TEST 11/05/11 . 56151911111 11.48 mil 81000 GLUCOSE TEST 11/16111 A 56151911111 17.48 Wll BLOOD GLUCOSE TEST 11117/11 4 56151911111 17.48 11/01 8LDOD GLUCOSE TEST O1107{01 4 56151910120 17.48 10/01 8LODD GLUCOSE TEST 01/08/01 . 56151910110 17..8 H101 8LDDD GLUCOSE TEST 01109/01 A 56151910110 11.48 10001 lA8 SERVICES 01/10/01 1 56151910110 75.30 10/01 BLOOD GLUCOSE TEST 11/10101 4 56151910110 11.48 lOW 8lDOO GLUCOSE TEST 11/11/01 4 56151911110 17.48 10/01 8lDDD GLUCOSE TEST OI{12/01 4 56151910121 17.48 10/01 8LODD GLUCOSE TEST Ol111{01 4 56151910110 11.48 10201 BLOOD GLUCOSE TEST 01113/01 4 56151910120 17.48 11/01 8lDOD GLUCOSE TEST 01/14/01 4 56151910110 11.48 lOW 8LDDD GLUCOSE TEST Ol115{ll 4 56151910110 17.48 10/01 BLOOD GLUCOSE TEST 01/16/01 . 56151910110 17.48 lOW BLOOD GLUCOSE TEST 01/16111 4 56151910110 11.48 10m 8LODD GLUCOSE TEST 11/17/01 4 56151S10111 11.48 WOl 81000 GLUCOSE TEST 01/18101 4 56151910110 11.48 10/01 8LODD GLUCOSE TEST 11/19/01 4 56151910110 11.48 14101 PHYSICAL THERAPY VISIT 11{19101 " 11/31/01 7 51150110111 05.00 14401 PHYSICAL THERAPY EVAL Ol/19{OI " 01{31/01 1 51151111110 SUO 10/01 Bl0DD GLUCOSE TEST 01{10/ll 4 56151910120 17.48 10m 8LDDD GLUCOSE TEST Ol/11{OI 4 5615191111O 17.48 10/01 8L00D GLUCOSE TEST 01/11101 A 56151910110 17.48 11/01 8LOOD GLUCOSE TEST Ol/23{Ol 4 56151910110 11.48 lOW 81000 GLUCOSE TEST 01/1./01 4 56151910120 17.48 10111 BLOOD GLUCOSE TEST 01/15/01 4 56151910110 17.48 10/01 8LDOD GLUCOSE TEST 01115/01 . 56151910110 11.48 10/01 BLOOD GLUCOSE TEST Ol116{01 4 56151910110 17.48 51501 WOUND TREAT!Et:T 01/16101 ., 01/18101 3 54151510120 14.10 WOI 8LDDD GLUCOSE TEST 01117/01 4 56151910110 17.48 ~,~~:{~-- ,~ ~,. ". - '~~. -,., . " -" I"' ~~ 1 , , ~~, - , ~~ . '5119/01 RESIDENT LEDGER IS Of OITE OF FIRST ICTIVITY P!DE IR55) "SIDENT RESIDENT RESIDE/iT G{l u ICCOUNTS RECEIVIBLE "U!BER TYPE mE om DTY ICCOUIIT CHIRGES CREDITS 8!LINCE 'el0S r.EDICARE I CAlmN, !IX A 11/0S{00 !D! CNTRR!TE: UI ROO! 158 ,8 LEVEL 1 11/18/11 DIS PRIV PORT: 1.11 "!EDICIRE A - JIN II (COIIT) 11111 8LODD GLUCOSE TEST 11/17/01 , 56151910110 17.48 1&211 BLOOD GLUCOSE TEST 01117101 ; 56151910110 17.48 10101 BLOOG GLUCOSE TEST 01{19/01 , 5615191!W 17.48 10201 BLOOD GLUCOSE TEST 01131/U 4 56151910120 17.48 INCILIIRY WRITE OFF 01/31{01 57SS7510110 3338.16 10101 8LDOD GLUCOSE TEST 01/31/01 ; 56151910110 17.48 ROO! CHIRGE IT 138.00 01/01/01 -- 01/03/01 3 513S0010110 OLiO ROD! WRITE OFF 01/01/01 u 01/03/01 3 51557010120 46Ul DEDUCT CO-!I:S AT 9UO 3 197.01 ROD! CHARGE AT 138.00 01/04/01 " 01/1;/11 11 51350110110 1518.10 RDDr, WRITE OFF 0110'/01 -, 0111,'01 11 51557110120 1107.38 DEDue; CD,IiIS AT 9U0 11 1089.00 RDDr, CHRRGE AT 138.01 11{15/ll -- 01/31{01 17 51351011111 1346.10 RDOI WRITE OFF 01/15/01 -- 11{31/01 17 51SS7111110 981.i9 DEDUCT CO-INS AT 99.00 17 1683.01 GLUCOSE TEST 11,10 11130/00 56151910110 ;3.70 AIIC W,OFF 11-00 11{30/00 57SS7510110 43.70 PPSADJI1-01 11/30/00 51350011110 583.83 GLUCOSE 12-ii 11/31/01 56151911110 10U8 ANC WRITE IFF 12-00 11{31/00 57SS7510110 104.88 "ENDING 8ALANCE 11148.65 "IEDICARE 8 ' JAN 01 BAl FWD 'LI' ,30- -60, ,90, -110.' 83.93 3U8 118.91 PAY~ENT 11-11'11'31-00 1, 01/01{ll 11210101010 43.70 RVS GLUCOSE 11-01 11/30/00 56151911110 43.70 RVS PT B COINS 11-00 11/31{00 Wlli5000i B.72 RVS GLUCOSE 12,00 12{31/00 56151911110 10U8 RVS COlliS lHI 11/31{01 14411150101 10.95 "ENDING BALANCE 43.70' "PRIVATE ' FEB 11 BAl FWD -L~- ,30, -60- ,90- ,120., 3069.00 1834.10 8.51 4912.11 CO-IIiSURAiiCE AT 99.10 01/01/01 " 12/ll{ll 1 19B.00 CD-INSURANCE AT 99.00 01{03/01 -, 01/17/11 25 lm.01 "ENDING BALANCE 758UI "IEDICARE A ' FEB 01 BAl FWD -II, ,30- -60, ,90, -Ill.' 476 7.8 8 7;8U7 11148.65 PAY~ENT IEOICARE 01/06/01 11110001100 6961.11 PAYIENT IEDICARE 12/13/01 11110001001 713.19 PAYIENT !EDICARE 01/10111 1121i111110 4767.74 10011 LA8 SERVICES 02{ll/01 1 561619l!110 75.31 Jim lAB SERVICES 02/01{01 1 56151910120 9.00 ,,<j~,"".=-"","'S ,~ _. ~ _, " ~"_' ,,__ )'if ~ _ I~ "t-- . ,-. r" ", ~~ Y''''T'' c"" - ,~ . , ;'0/19/01 . . RESIDENT LEDGER AS OF DATE Of fIRST ACTIVITY PAGE 6 ,AR561 'ESIOENT RESIDENT RESIOEIiT 6/l -- ACCOUNTS RECEIVA8LE ',U!8ER TYPE IIA!E DATE QTY mourn CHARGES C REO ITS 8ALANCE 'C105 mmRE A CAlAm. !AX A 12/05/00AO! cm RATE: 0.00 ROO~ 158 -8 LEVEL 1 02/28/01 OIS PRIV PORT: 0.00 "MEDICARE A ' FEB 01 ICONT) 10m LA8 SERVICES 02/01/01 1 56151910120 86.81 10001 LAB SERVICES 02/01/01 1 56151910120 46.00 10m lA8 SERVICES 02/01/01 1 56151910120 37.25 51801 TOTAL INCONT-OLY fEE 02/01/01 -, 02/28/01 28 56151810120 84.00 53201 NTRTNl/ENTRl SERV GRP 2 02/01/01 -, 02/28/01 56 56153210120 112.00 53201 NTRTNL/EHTRl SERV 6RP 3 02/01/01 " 02/28/01 56 56153210120 224.00 53601 OXYGEN CONCEN RENT OlY 02/01/01 -, 02/28/01 28 55353610120 504.00 14101 PHYSICAL THERAPY VISIT 02/02/01 -- 02/23/01 9 5215021i120 525.i0 29001 PHARlACY lEGEND 02/09/01 ,- 02/19/01 1 54551210120 428.23 30001 PHAR!ACY NON LEGEND 02/12/01 -- 02/17/01 1 54951310120 37.44 51501 WOUND TREATMENT 02/26/11 -- 02/28/01 3 54151510120 24.00 ANCILLARY WRITE OfF 02/28/01 57557510120 2193.i3 ROO! CHARGE AT 138.00 02/01/01 -, 02/02/01 2 51350010120 276.01 ROO! WRITE OfF 02/01/01 " 02/02/01 2 51557010120 115.54 OEOUCT CO-JlIS AT 99.00 2 198.00 ROO! CHARGE AT 138.00 02/03/01 ,- 02/27/01 25 51350010120 3450.00 ROO! WRIH OfF 02/03/01 -, 02/27/01 25 51557010120 1950.75 OEOUCT CO,INS AT 99.00 25 247 5.0 0 "ENOIN6 8Al~NCE 2924.81 "IEOICARE 8 ' FEB 01 8Al fWD 'lr,- ,30- -60, ,90, -120', 43.70- 43.70 PAY!E~T !EOICARE 02/05/01 11210002000 43.70 "ENDING 8AlANCE .00 '*PRInn - r,AR 01 8AL fWD -L~- ,30, -60' '90- ,120., 2673.00 3069.00 1834.10 8.50 7585.00 "ENDI~G BAlRNCE 7585.00 "IEOICARE A ' ~AR 01 8At f~D -II, -30- -6i- '9i- -12i., 3119.29 713.05, 518.57 2924.81 "E~DIN6 8ALANCE 2924,81 "PRIVATE ' APR 01 8Al FWD 'l~- ,30, ,60, ,90, ,120.- 2673.00 3069.00 1834.10 8.50 7585.i0 "ENDING 8ALANCE 7585.00 "!EOICARE A ' APR 01 8Al FWD ,l!, ,30, ,60, ,90, ,120., 3119.29 713.05- 518.57 2924.81 PAmNTm 04/17/01 11210002000 3119.29 "ENOING 8AlANCE 194048, "PRIVATE ,m01 BAL fWD 'L ~- '30- '60, -90, -110., 2673.00 3069.00 1843.00 7585.00 "ENDING 8ALANCE ne 5.0 0 -~,lil!'il"l',,!. , ... ~--~, - -" .~~ ~- 1'-' "- -~-"~,~ HCR~ManorCare I ", :" :!~.~ I' .- MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD '. 1 CARLISLE, PA 17013 (717)-249-00B5 JANET CALAMAN FOR MAX CHAMAN 811. NORTH WEST STREET, CARLISLE, PA 17013 . 1 ) Statement . , MEDICARE A PRIVATE ROOM 158 -B Please Return This Portion With Your Payment CALAMAN, MAX A 20105 12/05/00 02/28/01 05/31/01 -------------------------------------------------------------------------. DATE OF SERVICE 05/01 (el SERVICE RENDERED BALAN~E!FORWARO ,'>0' PAYMENT DUE UPON RECEIPT .I ",',. l . 0_.,' ',,,-,""~'""f. ~,f!jJ _ ","' r~ "! CHARGES '7,585.00 AMOUNT DUE ~"~_41!1~ ~ ~.", "_ ~ CREDITS 7,5aS.Of ^o~ __c'~_ '.W ^"_.,_ ~,,<"~_~ '",,"",''''''_''' . "'. .. ... . ""-~'''-"'''"~'"~~I'C''~1'n'l1rr' . ,. .. , (J -'9- >"2 T'"< '-'I ~ ~ ~ " ~ ~'<.J G~_: :-) .frt C> I ~ 8 \),-:' ~ " ...... V) ,--' g ...... b' CY >v I ~ I :'-) , f! ~ 2 ~,? " ;~1 .... :;J -..j t]"\ :~ J 1W~ii~ ~~....JlIII!lil,_.". .!_~~__ ,>"iji~ ,~ ___lI"'l'~""!;R~.,,,,~~,.!,,,&~'~>:'~t.~~~., _[\i;l~i!",'ji!i"''-<''I-T;''''';' SHERIFF'S RETURN - REGULAR CASE NO: 2001-06196 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CALAMAN JANET IND/ON BEHALF OF GERALD WORTHINGTON , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon CALAMAN JANET INDIVIDUALLY AND ON BEHALF OF MAX CALAMAN the DEFENDANT , at 1531:00 HOURS, on the 30th day of October ,2001 at 811 NORTH WEST STREET CARLISLE, PA 17013 by handing to JANET CALAMAN 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 3.25 .00 10.00 .00 31. 25 r~~"~~ R. Thomas Kline n/Ol/2001 WOLFSON & ASSOC Sworn and Subscribed to before me this 9~ day of BY:-A~ fJniJ~ Deputy S iff 7'Ltxu MA'/u' / oMtJ / A. D . O~H~a ~ ~ rothonotary . ;-""""'.'--'''\'''''-"iI1"'''l'~ "~~ J:::~P:1... I~~'"' I ,. - - ~ .~ . . l~"I~ . SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-06196 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CALAMAN JANET INDloN BEHALF OF 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 ADD'L DEFENDANT, to wit: BLUE CROSS but was unable to locate Them in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On January 3rd , 2002 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Surcharge Dep Dauphin Co 18.00 9.00 10.00 35.25 .00 72 .25 01/03/2002 STEPHEN HOGG So answ~~~ 7 ~ R! Thomas Kllne Sheriff of Cumberland County Sworn and subscribed to before me /:L n this '7 - day of, /'f<(U'j' 2bo.2- A.D. C+r, > Q ?hdl,,-, AftUi Prothonotary ,'.,I*,{"",",,"-''''''''1''',",,::<, ~~ ,I:;.~~~ I' " - ,~, SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-06196 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CALAMAN JANET INDloN BEHALF OF 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 ADD'L DEFENDANT, to wit: HEALTH CARE FINANCE AGENCY MEDICARE but was unable to locate Them in his bailiwick. He therefore deputized the sheriff of DAUPHIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On January 3rd , 2002 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Surcharge So answers' ~7 ~ 6.00 .00 10.00 .00 .00 16.00 01/03/2002 STEPHEN HOGG R. Thomas Kline Sheriff of Cumberland County Sworn and subscribed to before me this 7 t;Y day oq.,,,,. 'f J-1rO:L A.D. n ", , Q IM<d/.. ~./ ')P1 prothonotary~ -' '~"".'I'l",",-i"~",\'W ,^ ~<. , -~ "I" SHERIFF'S RETURN - REGULAR CASE NO: 2001-06196 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CALAMAN JANET IND/ON BEHALF OF DAVID MCKINNEY , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon BLUE SHIELD the ADD'L DEFENDANT, at 1446:00 HOURS, on the 6th day of December, 2001 at 1800 CENTER STREET CAMP HILL, PA 17011 by handing to SALLY MCCOY, PARALEGAL 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 9.10 .00 10.00 .00 25.10 r~r.-~~ R. Thomas Kline 01/03/2002 STEPEHN HOGG Sworn and Subscribed to before ~ me this '7 ~ day of Gc;:;,;~ AD rothonotary ~ ...r By: ~ ~~.i eft/1- ~/f'I/II1-t 7- Deputy Sher~ff +'~-"'-;''''.'_'k!,'!",;?, !.t-\>Il<'lI~, U.Ln _". ""'"'" ". """J~ ~- -, "~ ~ SHERIFF'S RETURN - REGULAR CASE NO: 2001-06196 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CALAMAN JANET IND/ON BEHALF OF DAVID MCKINNEY , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon HEALTH CARE FINANCE AGENCY MEDICARE the ADD'L DEFENDANT, at 1446:00 HOURS, on the 6th day of December, 2001 at 1800 CENTER STREET CAMP HILL, PA 17011 by handing to SALLY MCCOY, PARALEGAL 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 01/03/2002 STEPHEN HOGG Sworn and Subscribed to before me this 1f:5.: day of CfWM1 .J-u:V A. D. ~r2.~/;'~.~~. rothonotary By: J}, j /}1fJ-~ ' ((./lr'U) . /Y)II/VVLVr- Deputy Sneriff ~,.~~"".",-",-""cp"'_.''''!1 ,1 J - ,) "1' ~ ~I~ .,.,..,$II! @tlitt of tfrc ~4triff William T. Tully Solicitor J. Daniel Basile Chief Deputy Mary Jane Suyder 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 Connty of Dauphin BLUE CROSS Sheriff's Return No. 3485-T - -2001 OTHER COUNTY NO. 01-6196 AND NOW:DElcember 11,2001 at 1:10PM served the within NOTICE & ANSWER upon BLUE CROSS by personally handing to SUSAN JOY, ADMINISTRATIVE ASSISTANT 1 true attested copy(ies) of the original NOTICE & ANSWER and making known to him/her the contents thereof at 2500 ELMERTON AVE. HARRISBURG, PA 00000-0000 ~. O;r\ECEMBER, 2001 l fJOIWnA) JR:#L Sworn and subscribed to efore me this 13TH day Sheriff of Dauphin County, Pa_ PROTHONOTARY ~tJ~ By Deputy Sheriff Sheriff's Costs: $35.25 PO 12/11/2001 RCPT NO 157677 T WONG !,'>"~'I'~,",~!'~'~,~ ~",. . ,; "I. ,^ , ~-~ .' T1 @iiitt of tlt~ ~4~:riff William T. Tully Solicitor J. Daniel Basile Chief Deputy Mary Jane Snyder Real Estate Deputy Michael W. Rinehart Assistant Chief Depnty 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 BLUE CROSS Sheriff's Return No. 3485-T - -2001 OTHER COUNTY NO. 01-6196 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 HEALTH CARE FINANCE AGENCY (MEDICARE) the DEFENDANT named in the within NOTICE & ANSWER and that I am unable to find him/her in the County of Dauphin, and therefore return same NOT FOUND, December 13, 2001 NO SUCH AGENCY AT 2500 ELMERTON AVE., HBG., PA NEED A BETTER ADDRESS. efore me this 13TH day ~DECEMBER, Q/~ I ~ r! (' ) . Jf1/YtVTL) '-/', + ~ I , , 2001 JfP Sworn and subscribed to Sheriff of Dauphin County, Pa. PROTHONOTARY By Deputy Sheriff Sheriff's Costs: $35.25 PD 12/11/2001 RCPT NO 157677 ._"",,,,,~~;m""-7"'~ 1< ,..~,.... , ~ ~" '.......,.~'~"^'C'~I'~ , ' . ,",~ " ~ =". ,....~ _"..."'_~ n_ In The Court of Common Pleas of Cumberland County, Pennsylvania HCR Manor Care VS Janet Calaman et al VS. Blue Cross et al SERVE : No. 01 6196 civil Blue Cross Now, December 4, 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 ofthe Plaintiff. ,"/'JR'- ~ ~~:-f'.:~ Sheriff of Cumberland County, PA Affidavit of Service Now, ,20_,at o'clock M. served the within upon at by handing to copy of the original a and made knovvn to the contents thereof So answers, Sheriff of County, PA 70 ,-- COSTS SERVICE MILEAGE AFFIDAVIT $ Sworn and subscribed before me this _ day of $ "1'~""''''''''~ ............', ~....'r . ' - '1 ' iF .', - In The Court of Common Pleas of Cumberland County, Pemnsylvania HCR Manor Care VS Janet Calaman et al VS. Blue Cross et al SERVE: Health Care Finance Agency (Medic~) 01 6196 civil Now, December 4, 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. ---.rJI"",/"J / /#, r ~./:.~ , Sheriff of Curnberland County, PA Mfidavit of Service Now, ,20_, at 0' 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 AFFIDAVIT $ $ ~__'S""~"","","'t. ^, '_""'''''''''''.0.,., " ~ "''''1 I ' ',-! I" - I ,,,,,,,," lAw OFFICES OF STEPlIEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 ;o::~~"''"~ ,. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HeR MANOR CARE, Plaintiff, vs. NO. 01-6196 CIVIL TERM JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and CIVIL ACTION - LAW BLUE CROSS, BLUE SHIELD, and: HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. NOTICE TO DEFEND 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 are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the clairns 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 for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. TRUE COpy FROM I:tEOORO ':1 T t.lJHmc[:iY \1J11'ere<:!, Illara Ullto sat my It.'ltl(l .J tliiJ ~O(;J GJ said Court at Carlisle. Pi. __ 1~;iS~~Y~~~4b~~~;e~ honotary ,.'-f'-"^I_ .,- '~~_"C' _',I "" '_""I . ~~~~~~ " ~ LAW OFFICES OF STEPHENJ. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 '.',,-'$~'~'1.- .", "_t-<___~,_",-c" "I,. .. 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 BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PENNSYLVANIA 17013 "'1,.' ~ I"' ". - ,'__' __'3, - " --~ ~- -, ~ l' ,~, ~,....,..."., "'1"......-, - LAw OFFICES OF STEPHEN J. HOGG 195. HANOVER STREET SUITE 101 CARLISLE. PA 17013 ';;~4'r~?"-,:" - i'~7~__' _', - " IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, vs. NO. 01-6196 CIVIL TERM JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and CIVIL ACTION - LAW BLUE CROSS, BLUE SHIELD, and: HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. ANSWER WITH NEW MATTER ANSWER AND NOW, this November, 2001, Defendant, Janet Calaman, through her attorney, Stephen J. Hogg, files this Answer With New Matter to the Plaintiff's Complaint and avers the following: 1. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 2. Admitted. 3. Admitted. 4. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 5. It is admitted that Defendant and Decedent were married at the time Decedent became a resident at Plaintiff's facility. ,~, I" -' ," "II'~ ,~ -~. .., '. -, ' ~ LAW OFFICES OF , STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 , ,'~r,--: _'-" '. -rye ,.~,,:.l ..,. __ ,."_,."."""_.....~~I~ ., 6. Admitted. 7. It is specifically denied that the Plaintiff submitted to Defendant an accurate itemization of debts and credits for Decedent's transactions with Plaintiff. 8. It is denied that Defendant did not object to the Statement of Account submitted by Plaintiff to Defendant. 9. It is denied that the balance due, owing and unpaid on Decedent's account is $7,585.00. Defendant has no knowledge of any other amount due and owing to Plaintiff and proof thereof is demanded at trial. 10. It is denied that Defendant has failed, refused or continues to refuse to cause to pay any sum due and owing on Decedent's account balance. 11. It is denied that Defendant has failed, refused or continues to refuse to cause to pay any sum due and owing on Decedent's account balance. 12. Denied. Defendant has'no knowledge ofthe allegations in this paragraph and demands proof thereof at trial. 13. It is denied that Plaintiff is entitled to receive reasonable attorney's fees. 14. Defendant has no knowledge of the allegations in this paragraph and demands proof thereof at trial. 15. Denied. ~. " ~. 16. It is denied that thirty percent (30%) of the principal balance due is a reasonable attorney's fee and it is further denied that the Plaintiff is entitled to collect reasonable attorney's fees from Defendant. 17. It is admitted that thirty percent (30%) of the principal amount Plaintiff alleges is due and owing is $2,275.50. It is denied that this amount is a reasonable attorney fee or is thirty percent (30%) of the actual amount due and owing. 18. Defendant has no knowledge of the allegations raised in this paragraph and demands proof thereof at trial. t: i: 19. Admitted. i ~ ' ,I i..-, LAW OFFICES OF "i !;i STEPHEN J. HOGG !i 19 S. HANOVER STREET SUITe 101 CAf:lLISLE. PA 17013 .,~._", ~ --, .,~ Wherefore, Defendant demands judgment in her favor and against Plaintiff. NEW MATTER 20. Defendant asserts the defenses raised in Paragraphs 1 through 19 as if fully set forth herein. 21. Defendant Blue Cross is a medical services insurance provider doing business at 2500 Elmerton Avenue, Harrisburg, Dauphin County, Pennsylvania. 22. Defendant Blue Shield is a medical services insurance provider doing bsuiness at 1800 Center Road, Camp Hill, Cumberland County, Pennsylvania. LAW OFFICES OF :-:,: i. STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE. PA 17013 ":J$~, ~,', "'~F"', .,"", ',~ ,. ,,_ ~" ~JL",__., . 23. Defendant Health Care Finance agency (Medicare) provides medicare insurance coverage for the elderly and has a domestic business address in care of Blue Cross and Blue Shield at the aforementioned addresses. 24. Defendant'and Decedent were fully insured for medical expenses incurred from the services of Plaintiff by Blue Cross, Blue Shield and Medicare. 25. Defendant asserts that any expenses incurred by Decedent from Plaintiff are covered by either Blue Cross, Blue Shield or Medicare and therefore Blue Cross, Blue Shield and Medicare are indispensable parties to this matter. Wherefore, Defendant joins Blue Cross, Blue Shield and the Healthcare Finance Agency (Medicare) as additional defendants in this matter and, if there is any additional amount due to Plaintiff, it is to be paid by either Blue Cross, Blue Shield or the Healthcare Finance Agency (Medicare). Date: 11/3tJ! tJl I I /Stephen J. H 19 S. Hano r treet Suite 101 Carlisle, PA 17013 (717)245-2698 Attorney for Defendant , , ~ :.. l " LAW OFFICI::S OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITe 101 CARLISLE. PA 17013 {~!~~__Ylti'll'1 , ^ , .. VERIFICATION I verify that the statements made in this Answer to the Court of Common Pleas of Cumberland County, Pennsylvania, are true and correct. I understand that false statements herein are made subject to the penalties of 19 Pa. Section 4904, relating to unsworn falsifications to authorities. //h~~/ Date . "" ,~. I,"'" ,.~_~ _", "e J:rj;- cf ~~(/ ET E. CALAMAN =.- ~ c R; I'; i~~ " ,-, I i~ ' t,e f i " I' i' I I' I l;: " J: I' i I' " LAW OFFICES Of: STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE, PA 17013 1': '~~"'''^'M.<l! ~~r " ., I, CERTIFICATE OF SERVICE I, Stephen J. Hogg, Esquire, Attorney for the Defendant, hereby certifies that I did on this day serve one true and correct copy of the attached Answer With New Matter by United States Mail, postage prepaid, from Carlisle, Pennsylvania, on the following: Date: I !7tJ' /0 I , / , ' vn''''n,. . Daniel F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Stephen J. Hogg Attorney for Defe 19 S. Hanover Street Suite 101 Carlisle, PA. 17013 (717) 245-2698 --. \'1[1111 n'.l~~~~I!m!~*;jW~~;!->''''H*,U;f-lf.t~~l'tll.Jjjii4 'I' . t:;:;~J.-:'--' ^(:,\i_:,:1f:., ,,-'\'~,~.::;!lf:~"(~., ^,,/9:','^~ "',-"n> ,,\. ")>.-'~' '~,',',~"."". T,'- ,.'- I ('" ._. i.IUJliii'&i!~!II-gf~ .~ .m:JItJ(lihWi.'~ '''IT ,., 'iiiioI; 01"1"1""0 "u "c F i v 1>18[;:[4 "~,Il SHERI'" Nor 30 '1" C1U/frV .,. 3 30/'if '0/ LA. F/ i ,'.'. PE10/",)L[ S'r'L VA.N/A. I' . " IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCRMANOR CARE, CIVIL ACTION-LAW Plaintiff NO. 01-6196 Civil Term v. JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant BLUE CROSS, BLUE SHIELD, and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants ENTRY OF APPEARANCE Kindly Enter the Appearance of Daniel B. Huyett and Stevens & Lee to represent defendants Capital Blue Cross and Pennsylvania Blue Shield, and kindly serve copies of all papers at the address identified below. Date: January 18, 2002 ::VENS~~ Dmri~ B. Hnydt l1f!; Attorney I.D. NO.2 85 111 North Sixth Street P. O. Box 679 Reading, PA 19603 (610) 478-2000 Attorneys for Defendants Capital Blue Cross and Pennsylvania Blue Shield SL1232018vl102109,068 o;;"'''',--J,''-''''~-'.""Pj''-''lI!~ "e' . ll!f "_I ___ ~ I. " ~,_. ~..- , -~ T'.;;"'~""" . ~~~~',"~,', ~ . .'l. CERTIFICATE OF SERVICE I, DANIEL B. HUYETT, ESQUIRE, certify that on this date, I served a certified true and correct copy of the foregoing Entry of Appearance upon the following counsel of record, by depositing the same in the United States mail, postage prepaid, addressed as follows: Daniel F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Stephen J. Hogg, Esquire 19 S. Hanover Street Suite 101 Carlisle, PA 17013 i; n.umB.J!A g,~ Date: January 18, 2002 i SL1232018vl/02109.068 -;,--",,,y,,-',,,,,,,,,",,,,\. '" "~,- ~"- I' ~c [' __ -.~ - . ~ l~~!~m~ . ~ ,'~ "'r--Ol--';'-~ 't<l" ,," "I!!I ~m_ _ "~~I~__,,, , ~~~~.~ili!iMli~'~~_~I""i;',"~"'''i!''1''Of';(''';'':-''.'''_~'''''.,' .--;~ '~'-->< o_."~ ,1,'->< 'I ".-.,'.''':h'.li'''irmr'- "'~ TI_~.'_~. ~'~.,~""'- '- "'~'-:'Ait~i( ::~'r'~ I. '" 0 0 r.. C N ...~.J .... -n -Om "- "'"1 :r""' CPf7'i :;J::': ~-~ ::::J ~~ N W J::'-, (~. <""......... ,j :J> ):~ ;.:I:::r: -7(") ::~ ~~f~ ""'0 9 J>e: Z 0-< ::::! '::. 55 {J1 -< ;',; ~" :~ I"~, :,:j :H i', ~': :., i;',' 'e LAW OFFICES OF ~i STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE. PA 17013 ';:~~-i"i'i' . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, vs. JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and BLUE CROSS, BLUE SHIELD and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. NO. 01-6196 CIVIL TERM CIVIL ACTION - LAW PRAECIPE FOR WRIT TO JOIN AN ADDITIONAL DEFENDANT TO THE PROTHONOTARY: Please issue a Writ to join Empire Blue Cross as an additional / Defendant in this action. //'/~' Date: / fi/CZ , , " tephen J. Hogg, Esq Attorney for Defenda Janet Calaman 4- f!n"J'~ ~~ ~~ rs e.n....,s/al. ~ ~~ r>l. d.cLiL...J~ A-J't' l09q() , , ." ,., ~, ,.. ""'''.--1'- , ,.' -",- _".C'_"''',' ___,.",~__.-,,__'''';,". ',- " ,.,-_''',- :"?'" ,",__~_,,,,_~ ,..0,..__ H' --'>;' ~" r ~ , ,~, ,,>-'," .- ,"','.,.., ,,~'~'^~''''L.", __'_',-"'.0 "~"" 0 JI~^ ,,_ ~.",~~ ,- ~ ~ -" << ,- '..<,--"",,~,.~," '"" ".,~'" ii" "~'h,{""'-' "Y;:~ii'~1f~:"lrtli\; ':'~'"-i'i.{ '. 't C. r t.~ ~ jf~ ~ ! ~~ f C) c ~ ~. N '-';~ ,- < -053 '""- --'! gJrT: :;::::.. ;].; -~ ,; _.J,' ...:~- '" i""':: Zl' N co -'. 'n c;; -.(,!'::;;-- c::b _c- r', ,'~ -r:: f-i ~~C'l ;;:CJ ':;' ,:5 c: \.Y c) IT') Z -., ~ -:,....) :3> ---' .II , 4' -< ~,'~"''':',__ ~.![~m ~:n~~l~\1>1it.>llfi"'*"'i'-~i''''''!l:l'i'*11'\'l''lfJ.~~.''(_~...."....",",~o,~~~W'' '<''';P,;'r~\.1'' '1 . .". WRIT TO JOINED AN ADDITIONAL DEFENDANT HCR MANOR CARE Plaintiff Vs No. 01-6196 Civil Term JANET CALAMAN, INDIVIDUALLY AND ON BEHALF OF MAX CALAMAN,DECEDENT Defendant Cumberland County, ss: The Commonwealth of Pennsylvania to EMPIRE BLUE SHlELD AND EMPIRE BLUE CROSS, 85 CRYSTAL RUN ROAD, MIDDLETON, N.Y. 10940 (Name of Additional Defendant) You are notified that JANET CALAMAN, lNDIVIDUALL Y AND ON BEHALF OF MAX CALAMAN, DECEDENT {Name (s) of Defendant (s)) has (have) joined you as an additional defendant in this action, which you are required to defend. Date JANUARY 29, 2002 CURTIS R. LONG Prothonotary ~ ~cv.J J ~.7f~ Deputy (SEAL) REQUESTING PARTY: Name: STEPHEN J. HOGG, ESQUIRE Address: 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 Attorney for: Plaintiff Telephone: 717-245-2698 .:'''i;'''~'tl'''',"h1''''',,,,,", ,0_," ,.", _ . ,. " , . ~I 1-- - , y. . . ~ ~~_ ,'f _~~I!l!l'li1\'1m"" , " i:'~ ,,, l:, I.; I',: c I' i;,~ ?" h , , i-' r:" , k I;: ~, , I r'; Ii r: I',: l' ! [" , i , ;.-, i-, r' Ii ~' ; r'i l'_ i i , f.-' " l: )", (':, i:'. , f" ii I vi STEPHEN J. HOGG 19 S, HANOVER STREET SUITE 101 CARLISLE, PA 17013 LAW OFFICES OF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff, va. JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant, and BLUE CROSS, BLUE SHIELD and HEALTH CARE FINANCE AGENCY (MEDICARE), Additional Defendants. NO. 01-6196 CIVIL TERM CIVIL ACTION - LAW PRAECIPE FOR WRIT TO JOIN AN ADDITIONAL DEFENDANT TO THE PROTHONOTARY: Defendant in this action. Date: ,I 47(02 d ,/ ,..e,;:-,,"~/ "..t'/~' '----",/ Stephen J. Hogg, Esq Attorney for Defendant Janet Calaman :k-rW)p"~ ~LI' E..- a,ElL .P5 Cf4!d~l (UA) ~ fll.Jtl.dl.doc..v..u /0. If. 109'10 I .n__ - ~< <~_J~ ,-L,- , .;"'..,,", ~!'" ~ '"~ili .--~' ~~"q ',,"~- '~.--. ',-,;;--'" "'.d .;.I;'hl~-~tiC'li'rti'f'rt-"1'~':"'<'?:'~ ',~5 '''i' "'- c~, F' ~ (J 1"- Jfr e,-~ ~F 0 0 0 C N un ~:: '- .---1 -0 CD ~ i'~~ mrr; ~ :z: I' ~.....) ZC u::> ~~.... ' )C r::G --0 ::-~~ -t, <- g~ ~O ::1.: ,"-, )>(:::, ~ .-"\ ~ ':.:> 5S .l"" -< ~~Im!-1'!l'if~iI;"i:~WI-'I%~<i!M';,>,:-,,=,,~,[m~;~~~~~~, .~_ '_,," r UJlL,,?' , WRIT TO JOINED AN ADDITIONAL DEFENDANT HCR MANOR CARE Plaintiff Vs No. 01-6196 Civil Term JANET CALAMAN, INDIVIDUALLY AND ON BEHALF OF MAX CALAMAN,DECEDENT Defendant Cumberland County, ss: The Commonwealth of Pennsylvania to EMPIRE BLUE SHIELD AND EMPIRE BLUE CROSS, 85 CRYSTAL RUN ROAD, MIDDLETON, N.Y. 10940 (Name of Additional Defendant) You are notified that JANET CALAMAN, INDIVIDUALLY AND ON BEHALF OF MAX CALAMAN, DECEDENT (Name (s) of Defendant (s)) has (have) joined you as an additional defendant in this action, which you are required to defend. Date JANUARY 29, 2002 CURTIS R. LONG Prothonotary ,-By 4o-.L. 2, 71z~ Deputy (SEAL) REQUESTING PARTY: Name: STEPHEN J. HOGG, ESQUIRE Address: 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 Attorney for: Plaintiff Telephone: 717-245-2698 ':"":'I'J~h?".'."-"""I"~~~. _"""","",,_ "-'1" ," !:>-.-, , . , ~~ ;><1"",.~--,". ~'''~=, ~~,' -- - MQR-24-e3 e4'48 PM sT~PHEH J HOGG ,- 245 .,9210 p.et r ! \ . i I I \ll THE COUlI.T OF COMMON PLEAS OF CUMBEIlI.ANP COUNTY, PENNSYLVANIA HeR MANOIl CAllE, NO. 01.6196 CIVil TtR1'l PlalRelff t' CIVIl. ^cnoN - \,^W YS. I 1 I I \ \ i I I ! , I lANET CAI.JlMAN. Individually and on Benal! of MAX CAt.AMAN, DECID!NT, Defendant ANI) NOW, th15 24" daY of Marth, 2003, come the partl. to ~11 aOlon, by and 1II1\'l11ah tilelr rlSpllCtlv! coun,~1 .lnd/aT Individually, and hel1!by stipulate and a",f!t as follOWS: ! I. On October 29, 200 1, P1alntlff flied a COmplaInt against Defendant aUeslng monIes dUll and owlnz. I. The IOlAl amount reqllfSted in Plaintiffs Complaint, lndudln.auom!)"s 'efS, It me sum ofTen ThousanHlghlY.Qne and 16/100 (S I 0,081. t 6) DoUars,pluSCClstS Int1Irnd In flIls action. I , I \ I 3. The part/I!) herecc, by and throullf1 theIr counsel, Ill'ee to the entrY of ]udpnent in the amount of Ellht Thousand Five Hundred Slaty and 50/100(58,560.50) DORaIS. plus CO$fJ Incurred In this action. \ t ~ I ':,0<~.",J - o__.__.;_J~_~I~__II!"". "~, -I ~', tTnO t~ t; to _l,' " , ' ,_~~ N^, gn MAR-24-es e4,4S PM STEPHEN ~ HCGG \ \ I I ;24~ 1!19;26 P~92 , ' 1 NOW, THEREFOli. the Uftdenlllled ~Qunsell1ereb)' request a Judgment b~ eIIwrel.'lln faVO\' of Plalntlll' and apllllt Defendant consisr.enc wlrh the terms of d1ls SdIlulatlon, I f t I I I ~ I I I r I I i i ~ f i , , I I , """',".'-..'~"",~~*,,,,,,,,,," , ,"nr.l' "". "'~ ,~ ,r~ -" "1 ,0 " I' ? " tH Ci'on ~O'\~CO ~ : ., ': ,~~~" !1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, NO. 01,6196 CIVIL TERM Plaintiff vs. CIVIL ACTION, LAW JANET CALAMAN, Individually and on Behalf of MAX CALAMAN, DECEDENT, Defendant PRAECIPE TO SETTLE AND SATISFY TO THE PROTHONOTARY: ( ) Please mark the above captioned action settled and satisfied. OR ( X) Please mark the above captioned judgment or lien settled and satisfied. Respectfully submitted, Dated: > ';~+~'-",M',;;:,--",,_ ~'___jl!l. . . - -- .Q,.. Ud.<l~IIl'__ , ~, 1 - ~ '-",',-~ '.". , "',;' ,":, " + ':'~'A';' F_(-: '''tan '<'';;'~~'~fj;~i'~t~::'''' {r~"f~'~uq.+'~"f'!3,J: 0 0 0 c '-0 'T1 s: :x :::! "'Om "'" . ".. _.~.. mrn -< 1.1:;:'::= Z:r::' N ::8C3 zc (j) ~~:- '.0 ':;~;(:) -<<, !<:c: --c ,Js3i ~Q ::lh '::-.' C) 5>1...-1 N ,:5:.:;rn c ::; ;2': ':n ?D =< --I -< 6:;. or\! __;&;""iW.-ll1,"1-"\1,,"~0!r'_,,~,.ii'.;-*W\-l--'i!,,""_kil"",'i!!lm_~~~!_~;MlIlIi'i!!li.~t~