HomeMy WebLinkAbout01-7188 FX
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO.Of - tmt COlt '---TiR..r""f\
vs.
CIVIL ACTION . LAW
RONALD GARDNER,
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 oth~r 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 usted quaere defensas de esas demandas expuestas en las
paginas, slguientes, usted tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Usted debe presentar una apariencia escrlta 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. Se
avisado que sl used no se defienda, la corte tomara medldas y psedido entrar una orden contra
used sin previo aviso 0 notificacion y por cualquler 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 ABQGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO
o SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA
o LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA
ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUlRASSITANCIA LEGAL.
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Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 1 7013
(717) 249.3166
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO. 0 t - "'lIP;?
Plaintiff
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vs.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
COMPLAINT
AND NOW, this ~ay of 'bel!f1l1.btf , 20 ~ comes the Plaintiff, HCR
Manor Care, by and through its attorney, Amy 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 place of business situate
at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013.
2. Defendant, Ronald Gardner, is an adult individual with a last known address
of 122 West North Street, Apartment A, Carlisle, Cumberland County, Pennsylvania
17013.
3. That on or about July 31, 2000, Defendant signed an Admission
Agreement, which Agreement outlined various terms of residential health care services to
be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the
Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit "A".
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4. That on or about July 31, 2000 through November 8, 2000, Defendant
was a health care resident of Plaintiff, where he received various necessary residential health
care services and treatment by Plaintiff. A true and correct copy of the itemization of said
services is attached hereto, incorporated herein, and marked as Exhibit "8".
5. That Defendant signed the Admission Agreement with Plaintiff in order to
gain admission as a Resident at Plaintiff's health care facility and in order to receive their
health care services.
6. That Defendant is identified as both the Resident and Responsible Party in
the Admission Agreement. See Exhibit "A" previously identified and incorporated herein
by reference.
7. That Defendant agreed to pursue and cooperate with the Department of
Welfare to determine if he was eligible for Medical Assistance benefits. See Exhibit "A",
Section I, Paragraphs 1.05, 1.06, 1.09 and 1.10.
8. That Defendant did not pursue nor secure Medical Assistance benefits, in
direct violation of the terms and conditions of the Admission Agreement entered into with
the Plaintiff.
9. That pursuant to the Admission Agreement, the Defendant agreed to be
personally liable for any debt incurred as a Resident of Plaintiff's health care facility not
compensable by a third party payor or government program. See Exhibit "A", Sections I
and II, previously identified and incorporated herein.
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1 O. That Defendant agreed to use his financial resources and income to pay the
Plaintiff for the debt incurred, if any, pursuant to the Admission Agreement. See Exhibit
nAn, Sections I and II, previously identified and incorporated herein by reference.
11. That Plaintiff reasonably relied on the representations of Defendant with
regard to the Admission Agreement which Defendant executed for the purpose of being
admitted to Plaintiff's facility on or about July 31, 2000.
12. That Plaintiff submitted to Defendant a copy of the itemization of services
accurately showing all debits and credits for transactions with the Plaintiff. Said Statement
of Account has been previously identified as Exhibit nRn and incorporated herein by
reference.
13. That Defendant did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendant.
14. That Defendant did not pay the Plaintiff for their health care services in
direct violation of the terms and conditions of the Admission Agreement entered into with
the Plaintiff.
15. That Defendant willfully and knowingly violated the Admission Agreement
when he failed to remit full payment to Plaintiff for the services he received as a resident at
Plaintiff's health care facility.
16. Defendant knew or reasonably should have known that he would incur health
care expenses while a resident at Plaintiff's facility and that such expenses would be his
personal debt obligation.
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1 7. Defendant knew or reasonably should have known that if he failed to pursue
and secure a third party payor or government program for financial assistance in paying his
health care expenses for services provided by Plaintiff's health care facility, that he would
remain personally liable for any debt incurred as a resident of Plaintiff's facility.
18. That Defendant did not identify nor represent to Plaintiff that another person
would be the Responsible Party under the Admission Agreement and therefore it was solely
incumbent on Defendant to act on his own behalf to secure financial assistance and to remit
payment from his income and financial resources. See Exhibit "A" previously identified
and incorporated herein by reference.
19. Defendant further violated his duties and responsibilities under the Admission
Agreement he signed with the Plaintiff by not utilizing his financial resources to pay the
Plaintiff when he knew or should have known that there were outstanding health care
charges due and owing to Plaintiff.
20. 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 Defendant's
account balance, all to the damage and detriment of Plaintiff.
21. As of the date of the within Complaint, the balance due and owing and
unpaid on Defendant's account as a result of said charges is the sum of SEVEN
THOUSAND SEVEN HUNDRED SEVENTY-THREE and SO/toO ($7,773.50) Dollars.
See Exhibit "B" previously identified and incorporated herein by reference.
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22. Plaintiff has retained the services of the law firm of Wolfson & Associates
,
P .c., in the collection of the amounts due from the Defendant.
23. 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 showing by Defendant, incident to the within action, and Plaintiff shall continue to
incur 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.
24. 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 THIRTY-TWO and
05/1 00 ($2,332.05) Dollars.
25. That pursuant to Paragraph 1, Section 1.03, of the Admission Agreement,
Plaintiff is entitled to receive, and Defendant has agreed to pay, contractual interest at a
rate of eighteen percent (18%) per year on past due balances. See Exhibit" A" as
previously identified and incorporated herein.
26. That the amount of contractual interest which has accrued on Defendant's
account balance, at a rate of eighteen percent ( 18%) from June 30, 2001, is the sum of
FIVE HUNDRED NINETY-SEVEN and 48/100 ($597.48) Dollars.
27. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
28. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
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WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter jUdgement in favor of Plaintiff and against Defendant, Ronald Gardner, in the
amount of SEVEN THOUSAND SEVEN HUNDRED SEVENTY-THREE and 50/1 00
($7,773.50) Dollars, with contractual interest in the amount of FIVE HUNDRED
NINETY-SEVEN and 48/100 ($597.48) Dollars, plus reasonable attorneys fees in the
. amount of TWO THOUSAND THREE HUNDRED THIRTY-TWO and 05/1 00
($2,332.05) Dollars, the costs of this action, and such other relief as the Court deems
proper and just.
Respectfully submitted,
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VERI FICA lION
I, Michelle Thureson, Senior Financial Services Consultant for HCR Manor Care, verify
that the statements made in the foregoing Complaint are true and correct to the best
of my information and belief. I understand that false statements herein are made
subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification
to authorities.
DATE: (:?!zo) or
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Michelle Thureson,
Senior Financial Services Consultant
EXHIBIT II A"
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HCR Manor Care
ADMISSION AyREEMENT
Resident:
, This Agre:ment is entered into by an.d . among HCR Manor Care, the Resident. and the
L~gal Representative, for the purpose of proVldmg for the rights and responsibilities of the .
With respect to the Resident's stay at this HCR Manor Care's Health ~are Center ("Center-res
Center: C
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Legal Representative:
Admission Date:,
Deposit: $ g----
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This Agreement shall begin on the day the Resident enters the Center and end on
. the day the Resident is discharged.
Term:
I. RIGHTS AND RESPONsmlLITIES OF THE RESIDENT
l.Ol Room and Board Rate.l For the basic services provided-forin'Section 3.01, the
Resident agrees to pay the applicable Room and Board Rate set forth on Attaclunent 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 Attaclunent A is payable in advance and is due by the tenth (10~ day
of each month. The Resident shall be responsible for the Room and Board Rate for the day of
admission as well as the day of discharge. This Section shall not apply if the Resident is covered
under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care
Organization (see Section 1.06).
1.02 Ancillary Charl1:es. 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 ofthe Resident. Such "Ancillary Charges" are described on Attaclunent B hereto, and
a current ancillary charge list is maintained at the Center's business office for review during
regular business hours. Ancillary Charges shall be included in the Resident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(10~ day of the month.
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. 1.03 L.ate Pavrnents. Accounts. not paid in full within thirty (30! days of billing shall be
subJe~t to a semce charge equal to the highest legal rate of interest penrutted by State law as set
forth In Attachment A on the past due balance each month until such time as the balance d .
pai~ in full. Should the Resident's account for anyreason be turned over for cOUection,u~u
ResIdent agrees to pay the Center's collection costs, including attorney's fees. e
. 1.0~ In~eDendent Provi~ers. The Resident shall be directly responsible to independent
proVIders, Includmg but not linuted 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
Residen! 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: .lLMedic;are, ~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 th~rapy 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
aC90rding 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 lImount as detennined 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.
l.06 Third Partv Pavors and Mana~ed 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 agreeme~.
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
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_ ,will b~ the Resident's third Par:>' payor as a se~ce, ~ut th~ Resident re~ains.liable for charges
not. pilld ~r covered by that third party payor mcludmg charges not pllld WIthin a reasonabl >
penod oftlme. e
1.07 P~vate Pay Resident. The Resident and/or Legal Representative acknowledge that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident has not been determined to be eligible for Medicaid.
!he R:side~t and/or Legal Representative agree to notify the Center promptly if there is
msu!ficl~nt mcome or assets to meet the financial obligations to the Center or to l'IIlIice prompt
appltcatlon to Medicaid for benefits. The Resident and/or Legal Representative agree to notifY
the Center. in writing when applicati:>n to Medicaid is made. The Resident and/or Legal
RepresentatIve agree to ,cooperate fully in applying for Medicaid and in the eligibility
detennination 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 arid/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 pf
insurance cards, identification or verification of eligibility and coverage information. .
_The-Resident and/or Legal Repfesentative agree to provide t)1e Center with ~
within five (5) days 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
Representativ~ 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 Vvith the terms and conditions of
this Agreement.
1.09 _ Application for Benefits. It shall be the 'responsibility of the Resident and/or Le~aI
Representative to' apply for coverage and to establish eligibility under any gov.ernmental, third
party payor, managed care or private insurance program. The Center shall be u?der no
obligation to bill any third party payor other than the Legal Representative and, when apphcable,.a
governmental program third party payor or managed care organization with which the Center IS
under contract. .
> 1.10 Primary Responsibility for Pavrnent. Except for payments for services .co".~
under governmental programs or provider agreements, the Resident shall remain primarrily Ii: e
for any and all charges for which the Center may agree to bill a third party. The Resident an or
Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, ~H? :.
managed care provider may not pay for non-covered services, supplies, .equipment, medlcall~
and other care and services which may be delivered by the Center (?r Its subcontractors.
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Agreement serves as a written notice that the Center haS notified the Resident andIo
R7presentative that services provided at the Center may not be covered by a govenunentaf Legal
third party pa~or or managed care organization. The Resident and/or Legal Representative payor,
to ?e responsible for non-covered services. A price list of services is always available :::
busmess office upon request.
I,ll Personal Phvsician... The Resident has the right to choose a personal physi .
provided. that the physician selected is properly licensed and agrees to abide by applicable law ~
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name of hislher personal physici,an. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Rep.resentative 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 shan have
the right to call another physician to attend the Resident and the fees charged by such physician
shall be borne by the Resident. .
I.l2 Pharmacy. 'The Resident and/or Legal Representative acknowledge the light to
choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and
supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies'"
and procedure'S and the pharmacy has a medication distribution system similar to the Center's
ancillary phanllacy's medication distribution system. '
n.
RIGHTS AND RESPONSmn..ITY OF THE LEGAL REPRESENTATIVE
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2.0l Lellal Authority. The Legal Representative hereby represents that he/she has legal
access to the Resident's income or resources and that the documents supporting such authority, if
any, have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Legal Represe~tative
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 Iiab~e for any
services or products specifically requested by the Legal Representative to be supphed 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 ch~ge such
that the Resident may be e~gible for MediCaid" th~ Resident an~~r I.:egal Representative ~
notify the Center in wri~lng when th~ apP!I~tlOn f~r MedlCatd IS ~ad~, , If:e 'and
Representative fails to notify the Center In wntlng or fails to file for Medlcatd In a Iy t
proper manner, the Legal Representative shall be personally liable for al! c~ges and f~~ ~~a
covered by Medicaid which otherwise would have been covered had application been ma .. ,
timely and proper manner.
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2.05 Coooeratioil for Financial Assistance. If the Resident is eligible for Medi 'd,
Legal Rep~esentative s~l provide .such infonnation about the Resident's finances as ~i ~
representative shall require for contmued coverage of the Resident and be personally res :d
for any charges denied the Center due to any lack of cooperation. POIlSl e
2.06 Acceptance UJlon Discharge. Upon termination of this Agreement as provided'
the Resident Handbook, the Legal Representative agrees to arrange and pay for the departur' ~
the Resi?ent from. the Center. If after notice the Resident is not removed as requested, then e~e
Center IS authonzed and empowered to remove- the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Represen~tive if
the Resident's condition pennits, who shall unconditionally be obligated to accept the Resid;Dt
and to pay promptly all charges.
2.07 Additional ResoonsibiIities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement and
Attachments. '
m. RIGHTS AND RESPONSmILITIES 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 assess~ent, 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 CeIiter, 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.
IV. GENERAL PROVISIONS
4.tH Consent to Release of Information. The Resident andlor Legal Represen~tive
hereby consents to the release of hislher medical records to the following pe~sons:. c~er
personnel attending physicians and consultants; and person, firm, government entity, third party
payor 0/ 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
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, reviews or payment audits performed by such; the personnel of any hospital or other health
~aci1ity or pr~vider to whom or whic~ the Resident ~y be trans~erred; the Center's ~
msurance camer; and any person authonzed by law to reVIew the medIcal records.
4.02 Consent to Treat. The Resid~nt and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perform such functions care
and se.rvices (hereinafter "Treatment") as are necessaI)' to maintain the well-being of the Resident,
inc~u~~ng but not limited .to, assistance wi~h. bat~ng, hygie~e, .dressing, toiletry, and daily
actIVIties; and general nursmg Care, the adnurustratlOn of medications and treatments, and the
performance of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in the exercise of good nursing judgment, Subject to
any rights provided to the Resident by federal and/or state law.
As applicable, the undersigned Legal Representative hereby represents that he/she
has the legal authority to make health eare decisions on beh,alf 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 toPhotol]:raph. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifying the Resident; for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph for Center and staff to identify the Resident.
4.04 Notice of Services. Policies and Additional Information. The Resident and/or
Legal Representative acknowledge that the items listed below have been explained and have
-received copies of the items or policies and procedures, if applicable. The Resident and/or Legal
Representative acknowledge they have had the opportunity to ask questions and questions have
been answered satisfactorily.
b.
d.
e.
f.
a.
Authorization for Release or Review of Medical Information. See
Attachment C.
c.
Authorization for Payment of Benefits. See Att~chment D.
Social Security Administration Appointment. See Attachment E.
SNF Medicare Determination Notice. See Attachment F.
Medicare SecondaI)' Payor Questionnaire. See Attachment G.
. . th Center
At the request of the Resident andlor Legal RepresentatIve, e ~
shall maintain the Resident's personal funds in compliance with the l~
and regulations relating to the Center's m~agement of such. funds. d
description and/or policies and procedures of protection of reSident fun ~
and the Personal Trust Fund Agreement, Resident Personal Fun
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Authorization and any other related documents. See Attachment H-1and
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 OmbudSnlan. 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).
I.
Procedures, name, address and phon~ 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).
The Resident Handbook. See Attachment J.
ResidentJPatient Rights. See Attachment K.
MedicarelMedicaid 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. ,
Receipt of information on advance directives including a copy of "Refu~ '
of Life Sustaining Treatment", which summarizes HeR Manor ~ax:e s
Limited Treatment Practices and "No Cardiopulmonary ReSUSCitation
Orders" and a copy of the State summary of its laws governing the
Resident's right to direct his/her medical treatment. See Attachment M-1
and M-2.
Privacy Act Notification. See Attachment N.
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r. ,Inventory sheet and/or policy of personal items. See Attachment O.
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4.05 Assi~rnnent of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, ifany, be made as setforth 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 infonnation needed to determine these benefits or benefits for related services.
4.06 Termination. Discharge and Transfer.. This Agreement may be tenninated 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
tills 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
perfonned 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 Cen~r
harmless from any and all claims, demands, suit and actions mad~ against the Center by any
person resulting from any damage or injury caused by the Resident to any person or the propertY
8
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of any person or entity (mcluding the Center), except in the case of negligence of the o-..ter'l
employees and agents.
4.08 Chan~es in the Law, Any provision of the Agreement that is found to be invalid
or u~~nforceabl~ as a result of a c~~e in State or Federal law will not invalidate'the ren...lnl,
proVlsloos'of this ~eement and, It IS agreed that to the extent possible, the :Resident and the
Center will continue to fu1.fil1 their respective obligations under this Agreement consistent with the
law.
THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THATTBEY
BA VE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND
THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND mAT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEm SATISFACfiON.
Signature ofResid~nt: ri?u ~ dJ!!- /~ -1. /!41A.--Date: I / S / / O~
I I.
Signature of Legal Representative, if signing on behalf of Resident:
Date:
I __
Signature ofLegal Representative, signing on his/her own behalf:
-Date:
Center Representative:
~ W tJYVl C. {~
Date: -( - (5 I -00
. \
9
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EXHIBIT "B"
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HCR-ManorCare
Statement
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE. PA 17013
(717 ),.,..249-0085
\
AN G EL A CAll R
FOR RONALD GARDNER
122 W. NORTH STREET
CARLISLE, PA 17013
MEDICARE A
PRIVATE
ROOM 161 -A
Please Return This Portion
With Your Payment
_____~~~~~~R~_~~~~~~!__________________~0~!~____~7j!~!~~__~lj~~!~~__~~~3~!~~__
DATE OF
SERVICE
05/01/01
SERVICE RENDERED
CHARGES
CREDITS
BALANCE FORWARD
7.773.50
PAYMENi DUE
UPON RECEIPT
7,773;5('
AMOUNT DUE
1
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6/19/01 RESIDENT LEOSER AS OF DATE OF FIRSi ACTIVITY PASE
AR56)
ESIOENT RESIDENT RESIDENT S/L ACCOUNTS RECEIVABLE
UHBER TYPE IIAlE DATE OTY ACCOUNT CHARSES CREDITS BALANCE
0075 MEDICARE A SARONER, RONALD E B7/31/00 ADM CmRm: ue
\ ROOl161 -A LEVEl 1 I11B8100 DIS PRIV PORT: 0.00
"HOlCARE ~ - JUl 00
ROO!CHARSE AT 142.00 07/31/00 1 51350010110 141.00
ROOl WRITE OFF 07/31/00 1 51557010120 188.71
"ENDING BALANCE 330.71
"CAIO CO-IN - AUG 00
CO,lIlSURANCE AT 97.00 0B}20/00 -- 08/18100 373.01
CO-lIISURA!CE AT 97.00 08/29/00 -- 0B/31/00 291.00
"ENDING BALANCE 1164.00
"NEDICARE A - AUG 00
BAl FIW -lM- -30- ,60- -90- -120+-
330.71 330.71
30001 PHARIACJ NOH lEGEND 08/01/00 -- 08/31/00 1 \49\1310110 6B\.80
30001 PHARMACJ NOH lESENO 08}01/00 -- 0B/31100 1 \4951310110 63 :96
14101 PHYSICAL THERAPY VISIT 0B/02/00 -- 08/31/00 62 511\0210120 15\0.00
14m PHJSICAl THERAPY EVAl 08/01/00 1 \1150210110 100.00
10101 HAY SERVICES 0B/03/00 1 561\3410120 BU5
ANCILLARY WRITE OFF 0B/31}00 575\7511120 24BU1
ROOM CHARGE AT 149.00 OB/01/00 -- OB/1B/00 18 \13\0010110 4171.00
ROOl WRITE OFF 08/01/10 -- OB/2B}11 2B 51557111121 5087.88
DEDUCT CO-IllS AT 97.00 9 B7UI
ROOl CHARGE AT 149.00 IB/29/00 -- 08131/00 3 513\O!lO110 40.00
RIOM WRITE OFF IB/29/00 -- OB/31100 3 \1557011121 414044
DEDUCT CO-INS AT 97.01 3 29UO
"ENDINS BALANCE 929 8.! 3
"IEOICARE B - AUG 01
1121B lAB-GLUCOSE MONITORING OBI17100 4 \6151911110 17.4B
1010B LAB-GLUCOSE MONITORING OB}IB}OO 4 56151911110 17.4B
1821B LAB-GLUCOSE 10NITORING OBI19100 4 56151911110 17.4B
1010B lAB-GLUCOSE 10NITORING 18/28/00 4 56151911110 17.48
10208 lAB-BlueOSE MONITORING OB/11/01 4 56151911120 17.4B
10208 lAB-GLUCOSE MONITORING IB/22/10 4 56151911110 17.4B
1010B lAB-GLUCOSE MONITORING OB/13/01 3 56151911110 13.11
1010B LAB-GLUCOSE IONITORING OB}14}00 3 \6151911120 13.11
1010B LAB-GLUCOSE MONITORING OB/15101 4 56151911120 17.4B
1010B lAB-GLUCOSE IONITORINS IB}26}01 1 56151911110 B.74
10208 LAB-GLUCOSE 10NITORING 08/1B/00 3 \6151911120 13.11
1010B lAB-GLUCOSE IONITORINS OB/19/00 1 56151911120 4.37
10108 lAB-GLUCOSE MONITORING OB/301.00 1 56151911120 4.37
ANCILLARY WRITE OFF OBI31111 \7557511120 3\.85
"ENOING BALANCE 143.31
"CAIO CO-IN - SEP 10
BAL FLJO -lM- -30- -~O- :90- ,120+-
116UO 116UO
CO-I1ISURANCE AT 97.01 09/81/00 -- 09/2B/OI 1B 1716.81
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6/19/01 RESIDENT LEDGER AS Of DATE Of fIRST'ACTIVITV PAGE
AR56) -
ESIOENT RESIDENT RESIOEIIT G/L -- ACCOUNTS RECEIVABLE u
UIBER mE 11m DATE QTV ACCOUIIT CHARGES CREDITS BALAIICE
0075 !EOICARE'A GARDNER, RONALD E 07/31/00 AOII cm RATE: 0.00
\, ROO! 161 -A LEVEl 1 11/0B/00 OIS PIIIV PORT: U0
"CAIO CO-III - SEP 00 (CONT)
CO-III SURA liCE AT 97.00 09/29/00 -- 09/30/00 194.00
CQIM,IIO 0BI31/01 5B557125000 1164.00
"EIIOIIIG BALANCE 2910.00
"!EOICARE A - SEP 00
BAL FWD -LII- -30- -60- -90- -120+-
B967.32 330.71 929 B.0 3
PAVIIENT 09/12/00 11210002000 330.72
17101 OCCUP T~ERAP1 VISIT 0B/~1/0~ -- 08131/~0 11 51550610110 1750.00
17401 OCCUP THERAPV EVAL 08/01/00 1 52550610120 75.00
10201 5LOOO GLUCOSE TEST 09/01/60 ; 56151910120 17.48
14101 PM1SICAL lMERAP1 VISll 09/01/00 -- 09/19/00 20 52150210110 1615.00
17101 DC CUP THERAPV VISll 09/01/00 -- 09/29/10 21 51550610120 105~.01
29001 PHARIIACV LEGEIIO 19/01/01 -- 09/30/11 54551211121 92.38
29101 PMAR!AC1 IV DRUGS 09/~1/00 1 54351410120 2048.41
30001 PHARNACV NON LEGEND 09/01/00 -- 09/30/00 54951310120 4,47
90270 PHAR!ACV IV PUlP 09/01/00 1 54353910120 240.00
99590 I.V. 1~ERAP1-SUPPLIES 09/01100 1 5mW0120 54.14
10201 BLOOD GLUCOSE TEST 09/02/00 4 56151910120 17.4B
10201 BLOOD GLUCOSE TEST 09/03/00 4 56151910120 17.4B
10201 BLOOD GLUCOSE lESl 09104/00 2 56151910120 8.7.
10201 BLOOD GLUCOSE TEST 09/05/00 2 56151910120 B.74
10201 BLOOD GLUCOSE TEST 09/06/00 1 56151!10120 4,3/
10201 BLOOD GLUCOSE TEST 09/07/00 4 56151910120 1/.48
10201 8LDOO GLUCOSE TEST 09/0B/00 2 56151910120 B./4
10201 BLDOO GLUCOSE TEST 09/09/00 4 56151510120 17.48
1020l BlDOO GLUCDS, TEST 09/10/00 l 56151910120 lUO
10201 BLOOD GLUCOSE TEST 09/11/00 4 56151910120 17.4B
10201 SLOOD GLUCOSE TESl 09/12/00 2 56151910120 8.74
10201 BLOOD GLUCOSE TEST 05/13/00 3 56151910110 13.11
10201 BLOOD GLUCOS, TEST 09/14/00 3 56151910120 13.11'
10201 BLOOD GLUCOSE TEST 09/15/00 2 56151910110 B.74
102i1 BLOOD GLUCOSE TES, 05/16/00 1 56151910120 4,37
10201 BLOOD GLUCOSE TEST 09/17/00 I 56151510120 4,37
10201 BLOOD GLUCOSE TEST 09/1B100 2 56151910120 B.74
10201 BLOOD GlUCOSE lEST OS/19!i0 4 56151510120 l1.4B
10101 BLOOD GLUCOSE TEST 09/21/00 2 56151910110 B.74,
lOU1 HAY SERVICES 09/11/00 1 56153410120 165.60'
10201 BlOOD GLUCOS, TEST 09/11/10 1 56151910110 4.3),
ANCILLARV WRITE OfF 09/30/00 57557510120 7115.5 5
ROD! CHARGE AT 149.11 09/01/11 -- 09/2BI00 1B 51351010110 ll/2.00
ROO! WRITE OFF 0~/01101 -- 0911BI00 18 515,J0l0110 3961.44
O,DUCT CO-IllS AT 97.01 2B 2716.00
ROaN C~ARGE AT 149.00 09/29/01 -- 09/30/00 2 51350010120 19B.01
ROO! WRITE OFf 09/19/00 ,- 05130/11 2 51557010121 231.81
OEDUCT CO-INS AT 57.00 2 194.00
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i/19/01 RESIDENT LEDGER AS Of DATE Of fIRST ,CTIVITY PAGE 3
IR56)
'SIOENT RE5IOENT RESIDENT G/L -- ACCOUNTS RECEIVABLE --
IIBER TYPE mE DATE QTY ACCOUIIT CHARGES C REO ITS BALANCE
1075 !EOICARE A GAROIIER, ROllAlO E 07/31/00 ROM cm RATE: 0.00
\ ROO! 161-A lEVEL 1 11/0B/00 OIS PRIV PORT: B.l0
"!EOICARE A - SEP 00 (CONT)
cOin AllOWANCE 07/31/00 51557010120 .11
"ENDING BALANCE 14720.5B
"!EOICARE B - SEP II
BAL fWD -L!- -30- -60, -90- -120t-
143.32 143.32
"ENDING BALANCE 143.32
"PRIVATE - OCT 10
11611 CABLE RENTAL 10/11/01 -- 10/31/10 1 5J15aqe1120 5.01
HIli BEAUTY AND B~RBER 111L2/1<< L 59158[01120 B.50
"ENDING BALANCE 13.50
"CAIO CO-IN - OCT 10
BAL fWD -lA- -30- -60- -90-- -120+-
2910.00 2910.00
CHliSUAANCE AT 97.10 11/01/00 -- 10/31/00 31 3007.00
"ENDING BALANCE 5917 .00
"MEDICARE A - OCT 00
BAL fWD -LA- -31- -60- -90- '121t-
5753.26 B967.33 .01, 1472UB
10001 lAB SERVICES 0B/03/00 56151910120 11.90
10001 LAB SERVICES 0B/07/00 56151910121 27.20
11m LAB SERVICES 0B/IB/00 1 56151910120 7!.30
10001 LAB SERVICES OB/12/00 1 56151910120 B1.30
10001 LAB SERVICES 0B/16/00 56151910120 45.30
10001 LAB SERVICES 08/19/00 1 56151910120 45.30
10m LAB SERVICES 0B/22/10 1 561\1910120 45.30
lIB01 LAB SERVIcES 08/24/00 1 56151910121 45.30
10001 LAB SERVICES 0B/25/00 1 56151911120 45.30
10m lAB SERVI~ES 0B12B/00 1 56151911lZ1 BUI
10001 lAB SERVICES OB/31/11 1 56151910120 31. 65
10211 BLOOD GLUCOSE TEST 10/il/11 3 56151910120' 13.11
29011 PNARAACY lEGEND II/II/Ii -- 11(31100 1 54551211120 40.27
29111 PHARAACY iV DRUGS 11/11/10 -- 11/31/00 1 54351411120 51. 34
31B11 PHARAACY NON LEGEND 11/01/10 -- 1i/31/01 1 54951310121 4.47
99590 LV. THER'APY-SUPPLlES 10/i1/10 -- 10/31/11 1 54351411121 21.11
10211 BLOOD GLUCOSE TEST 11/12/10 4 56151910120 11.4B
14101 PHYSICAL THERAPY VISIT 10/12/11 -- 10/31/00 22 521512101201B25.01
17101 OCCUP THERAPY VISIT 11/02/i0 -- 11/25/01 17 52550610120-1650.01
10201 BLOOD GLUCOSE TEST 10/03/01 3 56151910120. 13.11
10201 BLOOD GLUCOSE TEST 10/04/BI 3 56151910120 13.11
10201 BLOOD GLUCOSE TEST 10/05/00 3 56151910120 13.11
10201 BLOOD GlUtOSE TEST 10107/00 2 55151910120 6.74
11201 OLOOO GLUCOSE TEST 11/0B/00 3 56151910120 13.11
10201 BLOOD GLUCOSE TEST 10/09/00 2 56151910120 8.14
10201 BLOOD GLUCOSE TEST 10110111 1 50lSml120 lUI
10201 BLOOD GLUCOSE TEST 10/11/00 3 56151910120 13.11
, " ", ~ -,
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6{19/01
AR56)
RESIOENT LEOGER AS Of OATE Of fIRST'ACTIVITY
PAGE \
ESIOENT RESIOENT
Ul8ER TYPE
RESIom
mE
G/L -- ACCOUNTS RECEIVA8LE h
DATE OTY ACCOUNT CHARGES CREOITS 8ALANCE
0075 ![DIcm.A GARDNER, RONALD E 07 /ll /00 AON CIITRRATE: 0.00
\ ROO! 161-A LEVEL 1 11/08/000IS PRIV PORT: 0.00
"NEDICARE A - OCT 00 (CaNT)
10201 8LOOO GLUCOSE TEST 10/12/00 3 56151910120 13.11
10m 8LOOO GLUCOSE TEST 10/13/00 3 56151910120 13.11
10201 8LOOO GLUCOSE TEST 10/14/00 3 56151910120 13.11
10201 BlOOD GlUCOSE TEST 10/15/00 3 56151910120 13.11
10201 8LOOO GLUCOSE TEST 10/16/00 3 56151910120 13.11
10201 81000 OlUCOSE TEST 10/17/00 3 561\1910121 13.11
10201 8LOOO GLUCOSE TEST 10/18/00 3 56151910120 13.11
10m 81000 GLUCOSE TEST 10119101 3 50151910110 13.\1
10201 81000 GLUCOSE TEST 10/20/00 3 56151910120 13.11
102it 81000 GLUCOSE TEST 10{21{00 S 5615l910120 lUl
10m 81000 GLUCOSE TEST 10/22/00 3 56151910121 13.11
10201 8LOOO GLUCOSE TEST 10125/00 2 56151910120 8.74
10201 8LOOO GlUCaSE TEST 10/26/00 2 56151910120 8.74
10201 81000 GLUCOSE TEST 10/26{00 2 56151910120 8.7,
10m 8LOOO GLUCOSE TEST 10/27/00 2 56151910120 8.74
10201 81000 GLUCOSE 7EST 10/28/00 2 56151910120 8.74
ANCILLARY WRITE OfF 10/31/00 57557510120 4293.19
ROO,1 CHARGE AT 138.00 10/01/00 -- 10/31/00 31 51350010120 4278.00
ROOM WRITE Off 10/01/00 -- 10/31/00 31 515570101204087.66
muCT CO-InS AT 97.00 31 3007.00
COIIl AllOWllACE 07/31/00 5/557010120 .01
"ENDING 8ALANCE 20079.25
"MEDICARE 8 - OCT 00
80l FI<O -lM- -30- -\0, -90- -120+-
W.32 143.32
"ENDING 8ALANCE 143.32
"PRIVATE - NOV 30
8AL fWD -LN- -30- -60- -90- -120+-
13.50 13.5~
"ENDING 8ALANCE 13.50
"CAID (A-IN - N0V 30
8AL fWO -IN- -30- -60- -90- -120+-
30i 7.06 mUI 5917.10
CO-INSURANCE AT 97.00 11/01/00 -- 11/07100 679.00
com wlO 09/30/00 58557125010 291U0
COlliS W/O 10/31/00 58557125000 300 7.0 0
"ENDING 8ALANCE 679.01,
"!EOICARE A - NOV 00
8AL fWD -lM- -30- -60- -90- -120+-
5358.66 575 3.2 6 8967.33 21079.25
, PAYNENT 10/31100 11110002000 8967.60
PAVWIT 11/07/00 11210002006 5753.24
PAYWIT 11/28/00 11210002000 5358.97
1H01 PHYSICAL THERAPV VISIT Ll10l101 -- 11/07100 6 51150110120 375.00
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./19/01 RESIDENT lEDGER AS Of DATE Of fIRST 1CTIVITY PAGE
IR56)
,mEln RESIDENT RESIDENT GII. .. ACCOUNTS RECEIVAIlE ,-
INBER TlPE mE DATE DIY ACCOUNT CHARGES CREDITS IALANCE
1075 MEDICARE>.! GARDNER, RONALD E 07/31/00 AD! cm RATE: 0.11
\ ROON 161 -A LEVEL 1 11/18/00 DIS PRIV PORT: 0.10
"!EOICARE A - NDV II (CONI)
19101 PHmmlEGEllO 11111100 -- 11108100 1 5~mml1l \0.11
31111 PHARNACY NON lEGEND 11/11/00 -- 11/08/00 1 54951310110 4.47
ANCILLARY WRITE Off 11/30/00 57557511120 \19.74
RDON CHARGE AT 138.01 11/01/00 -- 11/07/10 51350010110 96UO
RDON WRITE Off 11/01/00 -- 11/07/00 51557010120 913.02
DEDUCT CD-INS AT 97.00 679.00
COII1 AllOWANCE 08/31/00 51557010110 .27
P; 03/31/00 51150110111 \;3.31
ANC WRITE OfF 08/31/00 57557510120 143.31
COil; AllOWANCE 09/30/00 51557010120 .01
COII1 AlLOI,ANCE 10/31/00 51557010120 .31
"ENDING 8AlANCE 121i.01
"NEDICARE B - NOV 00
3Al fWD -l!- -30- -60- -90- -120+-
143.31 143.31
REV PI 03/31/00 52150111120 143.31
"ENDING 3AlANCE .00
"PRIVATE - DEC 00
3AL fWD -l!- -30- -60- -90- ,120+-
13.50 13.50
"ENDING BALANCE 13.50
"CAIO CO-IN - DEC 00
BAl FWD -l!- -30- -60- -90- -120+-
679.10 679.00
"ENDING lAlANCE 619.00
, "NEOICARE A - OEC 00
3Al FWD -IN- -30- -60- -90- -120+-
1210.02 121U2
11m TRANSP0RTATI0N SERVICES 03/01/00 1 591\33101 32.00
11200 TRANSPORTATION SERVICES 0B/12/~0 I 591588101 32.00
11m TRANSPORTATION SERVICES 08/14/00 1 5915BI101 32.00
11200 TRANSPORTATION SERVICES 08/15/00 1 591588111 32.00
11200 TRANSPORTATION SERVICES 01/23/00 1 591588101 32.00
11210 TRANSPORTATION SERVICES 08/24/11 1 591581111 32.10
11200 TRANSPORTATION SERVICES 09/18/11 1 591588111 32.01
11aB TRANS?OR1ATION S1RVICES 1~1121U 1 5~1581111 32.01
11200 TRANSPORTATION SERVICES 09/13/10 1 591518101 32.01
11201 TRANSPOR1ATION SERVICES 10/06(00 1 591588111 32,01
ANCILLARY WRITE Off 12/31/00 575575101 320.01
"ENOING BALANCE 1210.02
, "PRIVATE - JAN Ql ' ,
8Al F~O -l!- -31- -61- -90- -120+-
13.\0 13 .\1
"ENDING BALANCE 13.50
"CAIO CO-IN - JAN 01
1< ','i,,_* ,-" ,.A;,~lI:..",.. ,," . '..' ~.. _,.Ji,'.."~.A--..Jik;;d;;,,,:1' '~ ,...:,~;A\:lL'" ;1>' '. K..A ,... ~ ,if.
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6/19/01 -
RESIDERT lEDGER AS OF DATE OF FIRST'ACTIVITY PAGE
AR56)
ESIDERT RESIDERT RESIDEllT G/l -- ACCOUNTS RECEIVABLE h
UmR TYPE mE DATE OTY ACCOUNT CHARGES CREDITS BRlANCE
-
0i75 WICARE A GARDNER, RONALD E 07/31/00 AD! cm RATE: 0.00
\ ROON 161-A LEVEl 1 11/0B/000IS PRIV PORT: 0.00
"CAIU to-IN - JAN Bl (CUNT)
BAl nlD -LN- -30- -6B- -90- -12B+-
619.00 679.00
"ENDING BAlANtE 679.0B
"AEOICARE A - JAN 01
BAl FWD -IB- -30- -60- -90- -120+-
1210.02 1210.01
PAYNENT 11-01-11-0B-00 1- 01/02/01 11210002000 121U9
BEt BLOOD GLUCOSE 0B/31/00 56151710120 179.17
REC AIIC WRITE OFFc 0B/31/00 57557510120 179.17
LAB 11/30/00 56151910120 68.00
AllCl W/O 11/30/00 57557510120 5B.00
"ENDING BALANCE' .07-
"NEOICARE B - JAN 01
RVS Bl00D GLUCOSE 0B/31/00 56151911120 179.17
RVS ANC WRITE OFF 0B/31/00 67557511120 35.B5
RVS INCORRECT ADJ 0B/31/00 52150211120 IJ3.32
"ENOING BALANCE ,00
"PRIVATE - FEB 01
BAL f~D -LN- -30- -60- -30- -110+-
13.50 13.50
"ENDING BALANCE 13.50
"CAID CU-IN - FEB 01
BAl FWD -IN- -30- -61- -90- -120+-
679.00 679.00
**ENOING BALANCE 679.00
"!EDICARE A - FEB 01
BAl FWD -IN- -30- -60- -90- -120+-
.07- .07
"ENDING BALANCE .07-
"PRIVATE - NAR 01
BAl FIW -IN- -30- -60- -90- -120+-
13.50 13.50
"ENDING BALANCE 13.50
"CAID CO-IN - NAR 01
BAl FWD -IN- -30- -60- -90- -120+-
679.00 619.00
"ENDING BALANCE 679.00
.'..mmRf A - MAR 01
BAl FWD -LN- -30- -60- -90- -120+-
.07- .07
"ENOING BALANCE .07-
'''PRIVATE - APR 01
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UNBER TYPE NAn DATE DIY moUIIT CHARGES CREDITS BALANCE
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RVS TO PRIVATE 09/30/11 lWI050010 2911.10
RVS COINS W-OFF 10/31/10 59557115000 3007.00
NOT APPROVED TO PP 10/31/00 14411050000 3007.00
RVS COINS 11/30/00 14411051000 679.00
"ENDING BALANCE .10
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SHERIFF'S RETURN - REGULAR
CASE NO: 2001-07188 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
GARDNER RONALD
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
GARDNER RONALD
the
DEFENDANT
, at 1510:00 HOURS, on the 2nd day of January ,2002
at 122 WEST NORTH STREET
APT A
CARLISLE, PA 17013
by handing to
RONALD GARDNER
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.00
3.25
.00
10.00
.00
31.25
r~~~
R. Thomas Kline
me this fte.
day of
01/03/2002
WOLFSON &,ASSOC.
O~ut9~
By:
Sworn and Subscribed to before
.2.tnJ J..,
A.D.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
vs.
No. 2001-07188
Action in: Civil-Law
RONALD GARDNER
Defendants
PRAECIPE FOR JUDGMENT
ENTER JUDGMENT in the above case for failure to file, enter, an
TO ENTER A DEFENSE
against RONALD GARDNER
in favor of HCR MANOR CARE
in the sum of.$ 10.703.03 with interest AS ALLOWED BY STATUTE
Total: --310.703.03
AND COURT COSTS
/ 20 D:J Judgment entered by
the Prothonotary this da according to the tenor of the above statement.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-07188
vs.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
CERTIFICATION
I, Amy F. Wolfson, Esquire, due hereby certify that on February 1,
2002, I caused a true and correct copy of the 10 Day Notice attached
hereto to be served on the Defendant, Ronald Gardner.
Date: 63.ol,()~
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, NO. 2001-07188
Plaintiff
vs.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
CERTIFICATE OF RESIDENCE
I, Amy F. Wolfson, Esquire, due hereby certify that the last known address of the above
referenced Defendant is as follows:
RONALD GARDNER
122 WEST NORTH STREET
CARLISLE, PA 17013
Respectfully submitted,
Date: D3-0 I '<.JeT
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-07188
vs.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
AFFIDAVIT OF NON-MILITARY SERVICE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
I, Amy F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my
knowledge, information and belief, Ronald Gardner, Defendant, above named; is over 21 years
of age; is last known to reside at 122 West North Street, Apt A, Carlisle, Cumberland County,
Pennsylvania 17013, is not in the military service of the United States or its Allies, or othelWise
within the provisions of the Soldiers' and Sailors' Civil Relief Act of Congress of 1940 and its
Amendments.
Sworn and subscribed to
before me this / sf- day
of .qttMA... ,20ot.-
~i/.c,- 5fJ-~
N tary Public
Notarial Seal
Melissa Dee Sweeney, Notary Public
York, Vorl< County
My Commission Expires Sept. 12, 2002
MEmber,~ctNdBJies
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-07188
vs.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
TO: Ronald Gardner
122 West North Street
AptA
Carlisle, PA 17013
DATE OF NOTICE: February 1,2002
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (1 0) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND
YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING
OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Court Administrator
Cumberland County Court House
1 Court House Square, 4th Floor
Carlisle, Pennsylvania 1 70 1 3
(717) 240-6200
BY:
Amy F. Wo son, Esq e
WOLFSON & ASSO IATES, P.c.
267 East Market Street
York, Pennsylvania 17403-2000
Telephone: (717) 846-1252
I.D. # 87062
Attorney for Plaintiff
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-07188
VS.
CIVIL ACTION - LAW
RONALD GARDNER,
Defendant
NOTICE OF ORDER,DECREE OR JUDGMENT
TO: ( ) PLAINTIFF (X) DEFENDANT ( ) GARNISHEE ( ) ADDITIONAL DEFENDANT
YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS
BEEN ENTERED AGAINST YOU ON
fY2 'rl/J r t. 11f;.) O'J +
IN ACCORDANCE WITH THE;:'ROVISIONS OF PA.R.C.P. 236
( ) DECREE NISI IN EQUITY
( ) FINAL DECREE IN EQUITY
(X) JUDGMENT OF ()
(X)
( )
CONFESSION
DEFAULT
NON.PROS
( )
( )
( )
VERDICT
NON-SUIT
ARBITRATION AWARD
(X) JUDGMENT is IN THE AMOUNT OF $1 0,703.03 PLUS COSTS $76.75
FORA TOTAL OF $10,779.78.
( ) DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF
$ PLUS COSTS.
( ) IF NOT SATiSFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S
LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF
TRANSPORTATION
BY
IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE CONTACT:
NAME OF (ATTORNEY/FILING PARTY):
ADDRESS:
WOLFSON & ASSOCIATES, P.C.
267 EAST MARKET STREET
YORK, PENNSYLVANIA 17403
(717) 846-1252 OR 800-321-8467
TELEPHONE NUMBER:
NOTICE SENT TO: RONALD GARDNER
122 WEST NORTH STREET
CARLISLE, PA 17013
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
NO. 2001-07188
vs.
RONALD GARDNER,
Defendants
CIVIL ACTION - LAW
ENTRY OF APPEARANCE
Please Enter the Appearance of Amy F. Wolfson, Esquire, as the Attorney for the Plaintiff.
Respectfully Submitted,
Date: ()3'01- 0~
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PRAECIPE FOR WRIT OF EXECUTION (MONEY JUDGMENT)
P.R.C.P. 3101 to 3149
HCR MANOR CARE,
Plaintiff
vs.
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY. PENNSYLVANIA
JUDGMENT NO. 2001-07188
RONALD GARDNER,
Defendant
PRAECIPE FOR WRIT OF EXECUTION
(MONEY JUDGMENT)
To the Prothonotary: ISSUE WRIT OF EXECUTION IN THE ABOVE MATTER,
(1) Directed to the Sheriff of CUMBERLAND County, Pennsylvania;
(2) against, RONALD GARDNER, 49 EAST SOUTH ST, CARLISLE PA 17013, Defendant(s);
(3) and against, Waypoint Bank, 17 West High Street, Carlisle, PA 17013 Garnishee(s);
(4) and index this writ
(a) against, RONALD GARDNER, Defendant(s')and
(b) against, Waypoint Bank, Garnishee(s),
as a lis pendens against the real property. of the Defendimt(s) in the name of the Garnishee(s) as, follows:
(Specifically describe property) .****GARNISH aNt Y***
You are directed to attach the proper:lY of the Defendant(s) not levied upon in the possession of
Waypoint Bank
17 West High Street
Carlisle, PA 17013
Garnishee( s)
All accounts including but not limited to all savings, checking and other accounts, certificates of deposit,
notes receivables, collateral, pledges, documents of title, securities, coupons and safe deposit boxes.
Amount due $ $10.703.03
Interest from March 14, 2002 To Be Determined
At an interest rate of 6% per year
Total Plus costs & interest
Dated July 1, 2003
Amy F. Wolfs ,Esquire
Attorney ID 87062
267 E. Market Street
York, PA 17403
(717)846-1252
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WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
NO 01-7188 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due HCR MANOR CARE, Plaintiff (s)
From RONALD GARDNER, 49 EAST SOUTH ST., CARLISLE, PA 17013
(1 ) You are directed to levy upon the property of the defendant (s)and to sell
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of W AYPOINT BANK, 17 WEST IDGH STREET, CARLISLE, P A 17013, ALL ACCOUNTS
INCLUDING BUT NOT LIMITED TO ALL SAVINGS CHECKING AND OTHER ACCOUNTS,
CERTlFICATES OF DEPOSIT, NOTES RECEIVABLES, COLLATERAL PLEDGES,
DOCUMENTS OF TITLE, SECURITIES, COUPONS AND SAFE DEPOSIT BOXES.
GARNlSHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) Ifproperty of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due $10,703.03 L.L. $.50
Interest FROM MARCH 14,2002 AT AN INTERST RATE OF 6% PER YEAR
Atty's Co= % Due Prothy $1.00
AttyPaid $103.75 Other Costs
Plaintiff Paid
Date: AUGUST 7, 2003
CURTIS R. LONG
(Seal)
Proth~ E- Z2t
.......Bv: '/2;0, L . 'YJ/2/"~
Deputy
REQUESTING PARTY,
Name AMY F. WOLFSON, ESQUIRE
Address: 267 E. MARKET STREET
YORK, PA 17403
Attorney for: PLAINTIFF
Telephone: 717-846-1252
Supreme Court ill No. 87062
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SHERIFF'S RETURN - GARNISHEE
CASE NO: 2001-07188 P
COMMONWEALTH OF PENNSLYVANIA
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
GARDNER RONALD
And now J.M. ICKES
,Sheriff or Deputy Sheriff of
Cumberland County of Pennsylvania, who being duly sworn according
to law, at 0010:36 Hours, on the 20th day of August
, 2003, attached
as herein commanded all goods, chattels, rights, debts, credits, and
moneys of the within named DEFENDANT
GARDNER RONALD
, in the
hands, possession, or control of the within named Garnishee
WAYPOINT BANK 17 WEST HIGH ST
CARLISLE, PA 17013
Cumberland County, Pennsylvania, by handing to
LINDA JULIAS (BRANCH MANAGER)
personally three copies of interogatories together with 3
true
and attested copies of the within COMPLAINT & NOTICE
and made
..
the contents there of known to Her .
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
.00
.00
.00
.00
.00
.00
So answers:
~-~.~,~
R. Thomas Kline
Sheriff of Cumberland County
00/00/0000
Sworn and subscribed to before me
this 2. 2.~ day of r;'L~u.J-
:zocJ A.D. I
(~) '.L- t2 '71.uIJJ,) , 8~.
~thonotary I '1
By
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff,
vs.
NO. 2001-07188
RONALD GARDNER,
Defendant,
vs.
CIVIL ACTION-LAW
Waypoint Bank,
Garnishee,
PRAECIPE TO DISCONTINUE ATTACHMENT EXECUTION
TO THE PROTHONOTARY:
Kindly mark the attachment against the Garnishee, Waypoint Bank, discontinued, upon,.
payment of your costs only.
Respectfully submitted,
WOLFSON & ASSOCIATES, P,C.
~~YF~~
Attorney I.D. No. 87062
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717)846-1252
Attorney for Plaintiff
Dated: September 12, 2003
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,
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R. Thomas Kline, Sheriff, who being duly sworn according to law, states this
Writ is returned ABANDONED, no action taken in six months.
Sheriff s Costs:
Docketing
Poundage
Advertising
Law Library
Prothonotary
Mileage
Misc.
Surcharge
Levy
Post Pone Sale
Garnishee
TOTAL
l8.00
1.64
, Advance Costs: 150.00
Sheriffs Costs: 83.59
66.4l
.50
1.00
3.45
Refunded to Arty on 04/29/04
30.00
20.00
9.00
83.59
Sworn and Subscribed to before me
this / 3 ~ay of '?1117-
2004 A.D. ptJ!J.:'" ~
p thonotary ,
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. Thomas Kline, shifuff"""""'"
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WRIT OF EXECUTION 2nd/or ATTACHMENT
COMMONWEALTH OF PENNSYL VANTA)
COUNTY OF CUMBERLAND)
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due HCR MANOR CARE, Plaintiff (s)
NO 01-7188 Civil
CIVIL ACTION - LAW
From RONALD GARDNER, 49 EAST SOUTH ST., CARLISLE, PA 17013
(1) You are directed to levy upou the property of the defendant (s)and to sell
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of W AYPOINT BANK, 17 WEST IDGH STREET, CARLISLE, P A 17013, ALL ACCOUNTS
INCLUDING BUT NOT LIMITED TO ALL SAVINGS CHECKING AND OTHER ACCOUNTS,
CERTIFICATES OF DEPOSIT, NOTES RECEIVABLES, COLLATERAL PLEDGES,
DOCUMENTS OF TITLE, SECURITIES, COUPONS AND SAFE DEPOSIT BOXES.
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property ofthe defendant
(s) or otherwise disposing thereof;
(3) Ifproperty of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify himlher that he/she has been added as a
garnishee and is enjoined as above stated.
AmountDue $10,703.03
L.L. $.50
Interest FROM MARCH 14, 2002 AT AN INTERST RATE OF 6% PER YEAR
Arty's Comm %
Arty Paid $103.75
Plaintiff Paid
Date: AUGUST 7, 2003
Due Prothy $1.00
Other Costs
,., .
CURTIS R. LONG
(Seal)
Proth~ ~ ~
............BV:......L. ."F'
Deputy
REQUESTING PARTY:
Name AMY F. WOLFSON, ESQUIRE
Address: 267 E. MARKET STREET
YORK, PA 17403
Attorney for: PLAINTIFF
Telephone: 717-846-1252
Supreme Court ID No. 87062
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