HomeMy WebLinkAbout01-6196 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
NO. C:)1, --
CIVIL ACTION - LAW
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 cone. Si used quaere defensas de esas demandas expuestas en las
paginas, sigulentes, used tiene viente (20) dias de plazo a[ partir de la fecha de lademanda y la notiflation. Used
debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus
defensas o sus objeciones a last demandas en contra de su persona. Sea avisado que si used no se defienda, la
corte tomara medidas y psedido entrar una orden contra used sin previo aviso o notificacion y por cualquier
queja o alivio que es pedido en la peticion de demanda. Used puede perrier dinero o sus propiedades o otros
derechos lmportantes para used.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO
O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O
LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA
ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar A~ociation
2 Liberty Avenue
Carlisle, Pennsylvania ! 701
(717) 249-3 ! 66
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR I~IANOR CARE,
Plaintiff
VS.
JANET CALAMAN, Individually and on Behalf:
of MAX CALAI~IAN, DECEDENT, :
Defendant ·
COMPLAINT
CIVIL ACTION - LAW
AND NOW, this _~_ d~ay of ~(~_ ,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 Complaint and in support avers as follows:
1. Plaintiff, HCR F'lanor 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 17013. 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
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,
200~, Hax 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 of the date of the 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
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.
! 2. Pursuant to Section !, Paragraph ! .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.
! 3. 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 O0 Dollars
($220.66).
1 a,. Plaintiff has retained the services of the law firm of Wolfson ~
Associates, P.C. in the collection of the 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
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 E 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 50/1OO Dollars ($2,275.50).
18. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
19. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court
enter judgment in favor of Plaintiff and against Defendant, Janet Calaman, Individually and on
behalf of Max Calaman, Decedent, in the amount of Seven Thousand Five Hundred Eighty-
Five and O0/1 O0 Dollars ($7,585.O0), contractual interest in the amount of Two Hundred
Twenty and 66/100 Dollars ($220.66), reasonable attorney's fees in the amount of Two
Thousand Two Hundred Seventy-Five and 50/100 Dollars ($2,275.50), the costs of this
action, and such other relief as the court deems proper and just.
Respectfully submitted,
267 East Market Street
York, PA ! 7403
(717) 846-1252
ID No. 20617
Attorney for Plaintiff
VERIFICATION
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 ! 8 Pa. C.S. Secrjon 4904, relating to unswom falsification
to authorities.
HCR Manor Care
DATE:
Michelle Thureson
Senior Financial Services Consultant
EXHIBIT "A"
Matior 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").
Center:
Resident:
Legal Representative:
Admission Date:
Term:
Deposit: S_
This Agreement shall begin on the day the Resident enters the Center and end on
the day the Resident is discharged.
L RIGHTS AND RESPONSIBILITIES OF TIlE 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 (10th) 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 &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).
.02 ~. The Resident further agrees to pay to the Center all charges for
additio I medical, therapeutic, or personal care servtces or supphes 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 off, ce 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~h) day of the month.
' a e Pa ment. Accounts not paid in full wit.bin thirty (30! days ofbilling shall be,
1.03 ~ , -- .,-- s.:~..est leoal rate of interest permitted by State law as set
subject to a service charge equa~ tu m~ ,.~,, o
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.
e end~. The Resident shall be directly responsible to independent
1.04 ~ . .~__ -~.:.a~.,,,, o,~.,,d n* nhvsician for any health or
provtders, including but not I maea to, mc r,~,u~,,, ....... ~ ,- ~ .
personal program in accordance with the terms ofthe program.
overnmental Pr°crams. If the Resident is eligible for coverage under any
1.05 p~oO~ - . . ' · · ' and
governmental ram, such as Medicare, Medicatd, or through the Veterans Administration,
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 pa)' 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 1.0~.
The Center participates in the following programs: e/Medicare, "'/Medicaid and/or ~'-~/,VA.
Medicare may pay for some or all of the Resident's ~are. 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.
Part',' Pa¥ors and Managed q;are Oraanizations. Ifa Resident is a participant
1.06 Third a third Party payor such as a Hea~th Maintenance Organization ("~MO"),
in a plan offered by
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 part>' payor, the Center
will bill the Resident's third party payor as a serwce, 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 Pas' 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 pr6mpt
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.
1.05 A~dmission 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
care coverage,
~ of' the Resident disenrollment, enrollment, change in health
failure to pay premium(s) or renewal of insurance coverage and any gancellations 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 A lication 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
are or rivate insurance program.. The Center shall be tinder no
party payor, manage.cl, c _ P _ .~.~. ,~.,,, ,~,, T t~ I enresentative and, when applicable, a
obligation to bill any tmrd party payor ou,;, ,, ........e,~a Rorlanization with which the Center ~s
governmental program third part)' payor or managed care
under contract.
1.10 Primary Resoonsibilit¥ for Pas'ment. 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 part)'. The Resident and/or
Legal Representative acknowledge that the insurance company, t-~O, PPO, PSO, PHC 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
Agreement serves as a ~ that the Center has notified the Resident and/or Legal
Representative that services provided at the Center may not be covered by a governmental payor,
third party payor or managed care organization. The Resident and/or Legal Representative agrees
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
al Ph sician. The Resident has the right to choose a personal physician,
1.11 ~erson.. V . - J · ....... ~,, ticensed and a~rees to abide by applicable law and
provided that the physictan setecteu ~s p~u~,,~, ~
the rules.~;d policies of the Center. At the time of admission, the Resident must supply the
Center wit the name ofhisfner personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notify the Center of
· · , f the physician chosen by the Resident fails to provide needed
the new physician s name. I
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.
c . The Resident and/or Legal Representative acknowledge the right to
oice, provided the pharmacy selected ts properly licensed, packages and
choose ar · 's
supplies pharmaceuticals in accordance with State law and agr.ees to abide by the Center policies
and procedures and the pharmacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distributi°n system.
II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE
. horit . The Legal Representative hereby represents that he/she has legal
2.01 ~ .......... d that the documents st~pporting such authority, ff
access to the Resident s income or res~ut~.~ a,~ ' '
any, have been delivered to the Center.
o Make Payments on Behalf of Residen, t. The Legal Represe.ntative
2.02 Agreement t .. , ........... u *:es and char~es for wh,ch the
agrees to pay promptly from the Restdents income or re~vu~,,~= ,~ .....
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 E~xhausfion of Resident's Funds, If the Resident's financial resources change such
that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must
notify the Center in writing when the application for Medicaid is made. If the Legal
Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and
proper manner, the Legal Representative shall be personally liable for all charges and fees not
covered by Medicaid which otherwise would have been covered had application been made in a
timely at~d proper manner.
'2.05 'Cooperation for Financial .As_sistane. e~ If the Resident is eligible for Medicaid, the ,
Legal Representative shall provide such mformatton 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.
· pon termination of this Agreement as provided in
2.06 Acceptance UoonDischar~. U. of
the Resident Handbook, the Legal Representattve agrees to arrange and pay for the departure
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
· ' to accept the Resident
the Restdent condition permits, who shalt uncondmonally be obligated
and to pay promptly ali charges.
ditional Resoonslbilkies. The Legal Representative acknowledges the other
2.07 Ad ..... -~,- ,~--:~--; o-~ to the Center as set forth in this Agreement and
duties and responsln Ittes Ior me r..~Lu~-,
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 ~. The Center shall act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
it The Center hereby acknowledges receipt of the Deposit, if any, noted a.t
3.03 D~?.os.... ' "he Deposit shall be applied to the charges for the first monm
the beginning o~t~ts Agreement. ~
of the Resident's stay at the Center.
funds An refund owed to the Resident for advance payments shall be paid by
3.04 . ._R.e .. ' ,.,,,}Y.~ .... ~,.~ ,~;~,-h~oe or transfer or. within the time frame required by
the Center w~thm tmrty [~v) ua~ ,~ ..........
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 ~;onsent to Release of Information.. The Resident and/or Legal Representative
hereby consents to the release of his/her medical records to the following persons: Center
personnel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organization responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
r~wi~ws or i~ayment audits i~rformed by ouch, the personnel of ~ny hospi~ or oth~r h~l~h c~.
f~ilky or pmvld~r to whom or w~ch the ReaM,ne may be tr~nsfe~cd~ the C~n~r's liability
ins~cc ca.er; and ~y person authoriz~d by law to review the medical r~cords.
4.02 ~onsent to Treal. The Resident =n~or ~g~l Representlfive, by sigMng tMs
A~eement, h~r~y author~es the appropriate $ta~ o~ the Center to pe~orm such ~n~ions, care
~d se~c~ (h~einaRer "Trea~at") as are necesSa~ to ms,tala the well-being of the Resident,
in~udZg but not li~ted to, assistance with bating, hYDene, dressing, toil~t~, and daily
~ctMti¢$ ~nd general nursing ¢~e, the ad~Msttation of medications and treatments, and the
p~ffo~tn~e of ther~ples, ~ prescribed by the Rtsldent's personal physlci~ in the Resldent's
Pl~ of Care, or as required ~om time to time in the axe,else or good nursing judgment, subjc~ to
any rights provided to the Resident by federal an~or state law,
As applicable, 'the uMersigntd Legal Rcprcsentatlve hereby represents thee
bas the legal authority to make health care decisions on behalf of th~ Resident, that documents
suppo~Mg such ~utSority h~v¢ bee~ ddivered to the Center, and tMt such Legal Representauve
hereby consents on behalf of the Resident to the Treatment described tbove.
4.03 Consent to Photo,raoh. The Re~ident ~nd/or Legzl Representative ~grcc
consent to thc Center t~kin$ a photograph of Ae$ident for use in identi$'ins the ResMent, for
placeme~ oC the pEotograph in the ~edtcatson Ad. inserat on Record or other records and for
~ny other similar uses oCthe photo~aph for ~entcr and ata~to identi~ the Resident
4 0a ~p~licies ~d Additional Informatlon~ The Resident ~or
Legal ~p~eser. t~tlve acknowledge t~at the ~tems listed brow hav~ bcea cxpl~inea
received copies of the items or Folicles ~d procedures, if appllcable. The Resident nad/or
Representative acknowledge they Mve had the oppoaun~t} to ask questions and questions have
b~en answered s~tisfactorily.
Authorization for Release or Review of Medical Information.
Att,~tchment C.
Authofizadon for Payment ¢t' Benefits See Attachment D.
Social Security Administration Appointment. See Attachment E.
SNF Me'qcare Determination Notice. Rea Attachment F.
Medicare Secondao' Payor Questionnaire, See Attachmet, t O.
At the request of the Resident and/or Legal Representat!ve. the Center
shall maintain the Reaident's personal funds in compliance with the laws
ara regulations relating to the Center's management of such funds. A
description and/or policies and procedures of pro:action of resident funds
and the Personal Trust Fund Agreement, Resident Personal Funds
and the Personal Trust Fund Agreement, Resident Personal 'Funds'
Authorization and any other related documents. See Attachment H-1 and
The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
Social Service Agencies and Advocacy Groups addresses and p.hone
numbers. See Attachment I (Center Supplement).
Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
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 oI~ce, the state ombudsman program, the
protection and advocacy network and the Medicaid fraud control unit. See
Attachment I (Center Supplement).
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 certi~'tcafion agency concerning resident abuse,
neglect, mistreatment and misappropriation of p~roperty. See Attachment I
(Center Supplement).
The Resident Handbook. See Attachment J.
Resident/Patient Rights. See Attachment K.
Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
Receipt of in~'ormation on advance directives including a copy of"Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Cafe's
Limited Treatment Practices and "No Cardiopulmona~ Resuscitation
Orders" and a copy or' the State summa~ of its laws governing the
Resident's right to direct his/her medical treatment. See Attachment M-1
and M-2.
q. Privacy Act Notification. See Attachment N.
S.
t.
U.
V.
W.
×.
y.
Z.
Inventory sheet and/or policy of personal items. See Attachment O.
ASM Form. See attachment P.
See Attachment T.
See Attachment U.
See Attachment V.
See Attachment W.
4.05 Assignment of Benefits.. The Resident and/or Legal Representative' hereby
requests that payment of authorized government arid/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. Discharee 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 ~even. (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 ~unds, the Center will request that local, state and federal
authorities, as appropriate investigate, which may result in prosecution.
4.07 Indemnlfication.. The Resident shall defend, indemniS/ 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 propeay
8
of any person r entity (including the Center), except in the case of negligence of the Center's
employees and agents.
hQ c'h.n~,es in the ~ Any provision of the Agreem. ent that is,.fo, und.~o~ be invalid
.~.to~.,ll~*LL ~ ,,, .,,~ .~ -.~ ...... c..~..o~ I-w wdl not invmmate me remaining
or unenforceable as a result of a change in ~tate ut x~-,,, .,-
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 I~EAD 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.
Date:
Signature of Resident:
ture of. Legal Representative, !f signing on behalf of Resident:
Signature of Legal Representative, signing on his/her own behalf:
Date:__
Date:_
Center Representative:
Date~
EXHIBIT "B"
,~6/19/01
~ESIDE#T RESIDENT RESIDENT
9HBEH TYPE NA~E
RESIORNT LEOOER AS DF OATS OF FIRST ACTIVITY PA6E
OIL -- ACCOUNTS RECEIVABLE
DATE OTY ACCOUHT CHARGES CREOTTS BALANCE
/0lBO
HEDICARE A CALARAN, HAX A
ROOH 1SD -G LEVEl L
**PRIVATE - NOV De
10208 PT B CO-IHS LAS-GLUCOSE
1NDBG PT D CO-IHS LAB-GLUCOSE
10208 PT G CO-IHS LAD-GlUCOSE
1NDDG PT R CO-IHS LAB-GLUCOSE
1DODR PT B CO-IHS IAR-GIUCOSE
IQGBG PT S CO-INS LAB-GLUCOOE
1Q2BB PT R CO-IHS LAB-GlUCOSE
IllQB REAUTY AND DANGER
LQOB8 PT S CO-INS LAB-GLUCOSE H
"ENOING BALANCE
'*HEDICARE A - NOV Be
LAID1 PHYSICAl THERAPY VISIT
leA01 PHYSICAL THERAPY DUAL
2RBD1 PHARAACY LEGEHD
3NOB1 HHARNACY NOH LEGEND
17101 OCCUP THERARY VISIT
17ADI OCCUP THERAPY EVAl
DDiB1 SPEECH THERAPY VISIT
2AeB1 SPEECH THERAF¥ EVAL
ANCILLARY ~RITE OFF
121SS/BO ADH CNTR RATE: Q.BD
G21281NL VIS HRIV PORT: Q,BQ
ll123/OO 2 1.7S
Il/UA/Be 2 1.7R
a/ZS/DD L .87
tlI2GIBB L .B7
Il/us/oH i ,87
n/DB/OB ~ ,87
11129100 I SHiSB1BIIOQ S.5Q
ll/3Q/DO I .87
ROOH CHARGE AT 13G,Oe II/SD/AB -- llJ3Q/OB
ROOR ~RITE OFF ll/22/OJ ii~3B/OG
**ENOIHD DALAHCE
ll/22/AQ -- 11JOB/NB G S21DQ21Oi2B D7S.IJ
i1/22/QQ I S21S021012D 7$.BQ
ll/22/OJ ll/3Q/BO 1 5455121Q12Q SGA.91
11/22/RB 11/30/BA 1 GAgD1S1R1SR 43.77
ll/24/BD II/SQ/RB 4 S255N61Q12Q 275.OQ
ll/24/DD i SOSBB61R12D 2S.DR
11/28/BB 11/3D/Be 3 D2HSOAIQ12A iOQ.BQ
ilJ28/DD I 529SD41B12N 2D.BR
1113B/00 57DSlSIB12B
D D1SSiJlRIGR 1242.A~
9 S1SDTQlel2D liBG.7e
-HOV BO
HONITORIHO
LAS-GLUCOSE M
HONITORING
LAB-GLUCOSE
~ORITORIHD
LAN-GLUCOSE
~ONITORDNO
LAB-GLUCOSE
HONITORING
LAB-GLUCOSE
RONITORING
LAB-GLUCOSE
NONITORINU
LAB-GLUCOSE
HONITORIHG
'*NEDICARE
1GUDG LAB-GLUCOSE
1ODOR PT CO-INS
1B2D8 LAB-GLUCOSE
10208 PT CO-INS
1D288 LAD-GLUCOSE
1D2DR PT CO-IHS
ie2eA LAB-GLUCOSE
1GBD8 PT CO-INS
i028G LAB-GlUCOSE
1D288 PT CO-INS
iO2DR LAB-GLUCOSE
iA2D8 PT CO-iNS
IB208 LAB-GLUCOSE
1D2R8 PT CO-INS
1R2BR LAB-GLUCOSE
1DOG8 PT CO-INS LAB-GLUCOSE
**ENDING BALANCE
**PRIVATE -OEC DO
UAl FWO -L~- -00-
17.22
1Q208 PT B CO-INS LAB-GLUCOSE
11122/BQ 1 SD1S191112J 4.37
11/22/G0 1
ll/23/DD 2 SG1Slg111SQ 8.74
111R3/OB 2
11yUq/OJ 2 561S191112D B.74
11/DS/DD i 5615191112e 4.37
ll/2S/DO 1
ll/UG/~e L S615191112B e.37
iI/2G/QG 1
ll/281~e 1 SGIStglI1OQ 4.37
1LIUBI~G l
1CIDRIDB ~
II/SD/DQ 1 DGISiglI1RO 4.37
n/3J/oo ~
-DJ- -90- -12D+-
17.22
H 12/D2/QB 4 3,$Q
1383.S8
1.75
1.75
.87
.Bl
.87
.87
17.22
2428,24
34.98
ARG6~
RESID[flT LEDGE2 AS Of DATE OF FIRST ACTIVITY
P26E O
i~iSIDENT RESIDEOT
'URBER TYPE
RESIDE2T
RARE
OATE OTY
O/L -- ACC0UNTS RECEIVABLE --
ACCOUNT CHARGES CREOITS BALANCE
?~105 ~EDICARE A
"PRIVATE
102eD PT
10208 PT
1D20G PT
102D2 PT
10208 PT
iO2RD PT
1020B PT
10208 Pl
10268 PT
1R2A2 PT
10208 PT
1D208 PT
CALARAR, RAX A
ROOA 158 -8 LEVEL 1
DEC DR (CORT)
CO-t~$ LAB*GLUCOSE
CO-IRS LAG-GLUCOSE
CO-IRS LAD-GlUCOSE
CO-IRS LAB-GlUCOSE
CO-IRS lAB-GLUCOSE
CO-IRS LAB-GLUCOSE
CO-IRS lAB-GlUCOSE
CO-IRS LAB-GLUCOSE
CO-IRS LAB*GLUCOSE
CO-IRS LAB-GlUCOSE
CO-IRS LDO-GLUCOSE
CO-IRS LAO-BIUCOSE
1G2D8 PT CO-IRS LAB-GLUCOSE
1R2D8 PT CO-INS LAG-GLUCOSE
1Q2D8 PT CO-IRS lAG-GLUCOSE
CO-IRSURANCE AT 97.A0
CO-IRSURARCE AT 97,20
**ENDING BALANCE
**NEOICARI A - DEC DQ
2Al FWD -LN- -30- -Be- -9G-
2428.7(
1A1D1 PHYSICAL lHERAPY VISIT 12/O1/QR -- 12/DA/DO
171R10CCU~ THERAPY VISIT 12/01/20 12/DE/OD
G12R1 TOIAL IRCORT-DIY FEE 12/01/0R 12/21/DD
50201 NTRTRL/ERTRL SERV GRP 2 12/Q1/DQ 12/31/00
53201 NTRTRL/ERTRL SERV GRP D 12/R1/A) 12/31/00
101D1 PHYSICAL THERAPY VISIT 12~0D/RQ 12/2D/O0
17101 OCCUP THERAPY VISIT 12/NB/IR 12/2g/DO
17401 OCCUP THERAPY EVAL 12/28/D0
20401 SPEECH THERAPY EVAL
0010i SPEECH THERAPY VISIT
ARCILLARY WRITE OFF 12/31/0B
ROOR CHARGE AT 13D.DQ 12/01/D0 -- 12/D2/00
RGO~ WRITE OFF 12/D1/QO 12/D3/DO
ROOR CHARGE AT 138,DR 1D/OD/RD 12/ID/DO
ROOR ~RITE OFF 1D/DS/OD 12/iG/QR
DEDUCT CO-IRS AT 97,00
ROOR CHARGE AT 138.00 12/19/0D -- 12/31/DD
ROOR URITE OFF 12/19/D0 12/31/0D
OEOUCT CO-IRS AT 97.00
'*ERDING BALANCE
**OEOICARE D -OEC OD
OAL FWD -LR- -30- -60-
24,98
12/OS/OD ADE CNTR RATE: Q.OQ
02128101 OIS PRIV PORT: D.OR
i~/DD/DU ~ ~.TS
12/04/B0 2 1.7G
i2/Q6/DC 2 1.75
12/07J00 G
12/D91DD ? 1.75
12/12/0D 1 .87
12/17/DU 1 ,BO
1B/10/O0 ! .87
12~2D/DD 1 ,87
10/21/0D I .87
I2/22/DD i
12/22/oD t .27
12/25/00 i .87
12/27/0D 1 .87
12/1~lH -- iG/1D/RD G
12/1N1DD 12/D1/OR 12 1261.0D
-12D+-
2428.14
2 5215D210120 IlS.RD
2 52550610120 5).00
21 DD151810120 31.01
62 S61GB21D120 12C,00
62 GG153210120 248.Q0
15 521S0210120 8AQ.20
13 D255061D1DQ gDO.R)
I S2SS061Q1Dg 20,0D
I G2BGOA1012D OS.DO
I 52950410120 52.00
STDG751D12D
3 5135DRID12R 410,D0
G GiG$7010120 395.58
i4 G13S0010120 I932.DR
10 5155701012) 27Gq.OB
6
13 D125001D12D 1790,0D
13 GIGS?01)120 2RD4,11
12
-120+-
34.98
2~78.DQ
582.00
1261.lO
1881.17
9929.$1
~6/1R/B1 RESIDENT LEUGEP AS OF SATE OF PIBST ACTIVITY PA6E U
ARBBI
~ESIDENT RESIDENT RESIDENT
;UMBER TYPE HAMS
G/l -* ACCOUNTS RECEIVABLE
SATE OTY ACCOUNT CHARGES CREDITS BALANCE
?BLUR
PEDICARE A CALARRN. ~AP A
RO0~ LBS -B LBVSL
**PEBICRRE - DEC RR
102SS CAS-GLUCOSE ~ONITORING
1RSQS PT CS-IHS lAB-GLUCOSE
1USSS iAS-~LUCOSE
1ABQB PT CO-IHS IAB-SIUCOSE
iRSRP tAB-SiUCOSE UOHITURING
leBRP PT CS-IRS IAB-GIUSOSE
1QSRB LAB-GlUCOSE NONITORING
1BSBB PT CO-IRS lAB-GLUCOSE
1QSSR lAB-GlUCOSE KONITOPIRB
i02SB PT CO-INS LAB-GLUCOSE
1RSSR IRB-GLUOOSE PONITORIHS
1QSRB PT CO-IHS LAB-GLUCOSE
lOSe8 LRB-S~USOSE NONITORINS
IQ2RB PT CS-INS lAB-GlUCOSE
iB2UR LAB-BtUSOSE NONITORINS
1BSSB PT CS*IHS LAB-GLUCOSE
LOSe8 lAB-GLUCOSE RONITORING
1RSRR PT CO-INS LAB-GLUCOSE
1USe8 LAP-GLUCOSE KOKITOPINS
1SSS8 PT CO-INS LAB-GLUCOSE
1R2Q8 IAB-SLUCOSE ROHITORIHB
iOSUS PT CO-IRS lAB-GLUCOSE
1RSQR lAB-GlUCOSE ROHITORIRS
1Q2SR PT CS-IRS LAB-GlUCOSE
iR2OH IAB-SIUCOSE NONITORIRG
1BSRB PT CO-~HS lAB-GLUCOSE
1RBeR LAP-SIUCOSE NONITORtNS
1QBRS PT CO-IHS tAB-GlUCOSE
ISBU~ LAS-SIUCOSE ~ORITORINS
1BSBB PT CS-I~S LAB-GLUCOSE
1RSBB LAB-GlUCOSE ~ORITORtNS
1RSRO PT CS-I~S lAB-GLUCOSE
**E~BERS BRIA~SE
*'PRIVATE - JA~ Ol
SAI F~S -lC-
18S8.9S
SO-INSURANCE AT
CO-I~SURANCE AT
CO-IPSURARCE AT
RVS PT B COINS 11-00
RVS COINS 12-OR
**ENSIHS BALANCE
**HBOICARE A - JAN Bi
PA~ F~U -l~- -SR-
/~8e.77 2428,74
12/RS/RS AO~ CRTR RATE: S.QR
BS/28/Bi SIS PRIV PORT:
121R2/RS 4 S61S1B1ZlBe il.tS
12/SS/OR 4 3.SN
12/R3/0~ 2 SS151Bli12~ 8.7~
12/BB/RO 2 1.75
12/RR/OU 2 5625191112B 8.74
12/B4/QO G 1.75
12/B6/OQ 2 S615191L12R 8.74
12/B6/SS 2 1.75
12/R7/OR 2 56151911120 8.74
12/B~/R8 2 1.?B
12/OR/OR 2 S615191112B 8.74
IB/BB/RB Z 1.75
12/12/US i B615191112B 4.37
~2~L2/SA i
12/17/BR 1 B6151911L20 4.37
12~17/R~ I .87
12/1B/RR i 5615191112U 4.37
12/19/SR I .B7
12/2S/00 I B615191112R 4.37
12/SB/BB I .BT
12/21/B0 1 U6EB1Olli2R (.S7
12/2i/osi
121BB/BSi B61B1BUl2S (.~7
12/SB/OS L B615191112e 4.37
12/23/B0 1 ,87
i2/24/00 I 561B191112~ 4.37
12/SA/RO 1 .BT
LB/Ss/ss i SB1Bi~lilse ~.37
12/27/OR 1 SBiBiBiilSe 4.37
12/27/§0 1 .87
118.~1
-30- -60- -BR- -12S+-
17.22 1881.17
Rl/QB/01 i121BRR2ORR
99.SR Oi/SllO1 -- B1/OU/Ri 3 2BI.UR
BP.OR R1]B~]Bi O1/IN]Q1 11 1ORR.OR
99.00 B1/1B/O1 B1/31/OI 17 1683.BR
ii/US/OR 34411UBRRRG
12/31/0S 14411RBROBR
-GB- "go- -12U+-
RBRB.S1
8.51
8.72
2R.95
4912.RR
.... RID, BESIDEI~T LEDGEB AS OF DATE OF FIRST A~,I~, PAGE
~ARGG)
RESIBERT RESIDENT
TYPE NR~R
G/L -- ACCOUNTS RECEIVHBLE --
GATE OTY ACCOURT CHARGES CREOITS BALANCE
~105 REOICARE A CALA~AR. MAX A 1BiBS/QB AO~ CI~TR RATE:
RO0~ !SO -B LEVEL 1 02/28/O1 DIS PRIV PORT:
"~EDICARE A - JAR RI ICORT)
PAYMERl 11-22-~i-OD-I-G-R Gl/lO/el 112~QOOBRRO
1RBOI LAB SERVICES RiJRI/OI 1 5615191Q12Q
10001 LAB SERVICES Qi/OI/G1 i 5615191012G
DRBO9 PHARAACY LEDERO Gl/GlIB1 -- Al/PO/Q1 I GRBG121B12Q
2RRBR PHRRNRCY LEGEND R1/Ri/B1 Gl/PO/D1 i B455121BI20
OROQR PHARMACY LEGEND RI/R1/BI QB/BO/RI 1 SRB512101PR
OOOOU PHARMACY NONLEGERG R1/O1/Ri Gl/DS/G1 i SRR5131OiBB
518B1 TOTAL INCORT-OIY FEE BI/RlJR1 $1/81/R1 31 GG15181R12Q
SSBRI RTRT~L/ENTRL SERV ORP 2 RlJRi/R1 B1/31/O1 62 5615321~120
53BB1 NTRTHL/EIiTRI SERV GRP 3 JlJJlJJl BlJOIJR1 62 SG15321012Q
B36R1 OXYGER CONGER RE~T PLY Gl/Il/Gl 01/31/0t 3I G$SSOG10120
14101 PHYSICAl THERARY VISIT Ol/lD/il BlJBB/QI A S21SBllR1BR
1B201 BLOOD OLUCOSE TESl Gl/lB/B1 R G61S1R1012R
171B1 OCCUP THERAPY VISIT Q1/RS/01 0 SBBSB61012Q
1QBQI BLOOD GLUCOSE TEST Gl/OR/Q1 3 SGiG191OIBR
IR2RI OLOOG GLUCOSE TEST Oi/RS/QD q GG1B191OlRO
IDB01 BLOOD GLUCOSE TEST Gl/RD/Bi R B61Blg1OLBO
1QBQI GLO00 GLUCOSE TEST GilD7/01 ( SG1S191QiOB
1BOOi BLOOD GLUCOSE TEST OB/BT/BI ( GGLSlg1R1DQ
1BBB1 GLO00 GLUCOSE TEST RI/QB/OL 4 SGiB1910120
1R2OS BLOOD GLUCOSE TEST Gl/DR/Bi A BGIG191B12R
iDB01 LAB SERVICES 01/1Q/01 1 56151910120
102BI BLOOD GLUCOSE TEST R1]10101 A B61B1910120
1ODD1 BLOOD GLUCOSE TEST Bl/11/OL 4 Bfi!G191012Q
1R201 BLOOD GLUCOSE TEST Bt/12101 ~ 5615191Ri20
10lO1 GLO00 GLUCOSE TEST Bl/12/01 4 Bfi1S191Q12~
1OPOI BLOOD GLUCOSE TEST Oi/1D/QL ( 561519iDL20
1BBB1 GLO00 GLUCOSE TEST RI/iR/BI ~ B615191G120
10201 BLOOD GLUCOSE TEST 01/15/0i ~ SfilSiRIO120
102BI BLOOD GLUCOSE TEST O1/lfi/D1 4 GfiID19101DQ
iO2Q1 BLOOD GLUCOSE TRST 01/16/Gi 4 561B191012~
IOD01 BLOOD GLUCOSE TEST B1/17/Q1 4 56151910120
102R1 BLOOD GLUCOSE TEST B1/181RI A 56t519i012B
1B2BI BLOOD GLUCOSE TEST 01/1g/01 4 SG1S19101PO
141Ri PRYSICRi TRERAPY VESIT OLI1R/BI -- OBI)L/GL 7 5215021GLBD
144B1 PHYSICAL THERAPY EVAL 01/1D/BI G1 SLID1 1 B21GB2101GO
10201 BLOOD GLUCOSE TEST RI/BO/BO A G615191R120
1BBB1 BLOOD GLUCOSE TEST Bi/tlJQI q 5615191Ot2B
1B201 BLOOD DIUCOSE TESI . BI~BP/BI 4 5615191Q12R
1QOQ1 BLOOD GLUCOSE TEST B1/2S/R1 A 561B191Q12D
18201 BLOOD GLUCOSE TEST R1/24/01 ( 561RlglDIO0
1QBR1 BLO00 GLUCOSE TEST 01/25J01 4 561B191RiBB
IQ201 BLOOD GLUCOSE TEST Gl/DS/Ri A B6151910120
1BBR1 BLOOR GLUCOSE TEST BLJ26/01 4 B615191D120
B1GB1 WOUHO TREATMEI~T 01/BG/Bi -- B1JBB/Q1 S BAiSiSIB12Q
1B201 BLOOD GLUCOSE TEST BI/)7/Q1 ( $615191R120
O.RR
O.ee
37.25
AD.go
619.18
582.73
lQ.gO
93.10
12(.BD
558.RB
2DS.DB
17.RD
13.11
17.48
Il.RD
17.48
17.4B
17.4B
17.(8
75.$O
i7.G8
i7.48
17.48
17.48
L7.AB
17.qB
17.AB
17.48
17.48
17.48
Il.AR
17.48
47S.00
GQ.QB
I7.48
1/.A8
17.48
17.48
17.48
17.48
17.4B
17.48
DA.DR
17.qB
3R12.$7
~G!ER/01
ARDG)
~ESDOERT REBIDEAT RESZDERT
RESIDEAT LEDGER AD OF DATE OF FERST ACTIVITY PAGE
6IL -- ACCOUATS RECEEVABLE --
DATE OTY ACCOUNT CHARGES CREDITS BOLA#CE
}~lOS
REDICARE A CALARAA, ROE
ROOk LSD -0 LEVEL L
"REDICARE A - 3AN Ol
[0201 BLDOD GLUCOSE TEST 01/27/H
tiROL BLO00 GLUCOSE TEST 0L/27/01 4
30201 BLOOD GLUCOSE TEST OL/DRtOi
1DBQ1 8LOOO GLUCOSE TEST Q1/BD/DI 4
ARCILL~R¥ WRITE OFT
1D/OS/DO AOR CATR RATE: O.RQ
Q2/DO/01 DIS PRIV ~ORT: D.RA
10201
BIOOO 6LUCOSE TEST 01/31/01
ROOR CHARGE AT L38.AD Gl/Q1/01 -- Di/DD/Q1
ROOm WRITE OFF D1/Rl/01 D1/OD/OL
BEUUCT CO-IRS AT RD,DO
ROON CHARGE AT L3D.AO RI1041O1 -- DL/[q/Q[ ll
ROOK WRITE OPE RllOA1Q1 O1/iAIDi 11
DEDUCT CO-INS AT RD.00
RO0~ CHARGE kT 138.OD D1/[S/DI -- 01/3L/e1 17
ROOm WRITE OFF O1/1S/D1 O1/3l/gl 17
DEDUCT CO-INS AT OD,gQ 17
GLUCOSE TEST il-gO
AND W-OFF ll-OO 11/30/00
PPG ADU H-Re 11130100
GLUCOSE 12-GD 12/31/D0
AAC WRITE OFF 12-DO 12/DL/O0
**ENDINA BALANCE
**~EDICARE D - JAN O1
9AL FWD -L~- -30- -DO- -9g-
83.93 34.98
RAY~ENT LI-22-LL-3g-Og 1- 01/02/DL
RVS GLUCOSE II-OD 11/30/00
RVS PT B COINS ii-QD ll/30/UO
RVS DLUCOSE 12-gA [2/31/08
RVS COIAS 12-00 12/31/RD
'*ENDING 8ALAACE
'*PRIVATE - FEB 01
BAL FWD -Lm- -30-
3869.88 1834.GD 8.60
CO-IASURANDE AT 99.0B D2/D1/A1 -- Q2/G2/01 2
CO-INSURANCE AT 9R.DQ U2/R3/Rt Q2/27/01 25
**EHDIAG 8ALAACE
*'HEDICARE A -FER
8AL FWD
4767.88 7480.17
RAYRENT ~EDICARE RD/D6/01
PAYAENT ~EDICARE O2/13/D1
PAYRENT ~EDICARE 02/OD/U1
lOGO1 LAD SERVICES DB/gl/Q1 1
1ODD1 LAD SERVICER QD/DI/O1 1
SG1G1910120 17.48
GG1S191D12D 17.48
56151910120 17,G8
SDIS191QIBO 17.48
S7S57SI012D
DGiG19IO12D 17.48
G13Dii1D120 RiA.GD
515S701R12R 469,41
G13GAOiOiDD 1518.0D
51667010120 2107.38
G13GDDIO1DR 234G.AO
S1USTgle1Og 982.09
5G15191D120 40.70
57GG7G1D120
Gl$SAOiG12Q Se3,83
66151910120 t04.88
57DSTSiO12Q
3338.26
297.0g
1D83.DD
IG83.DA
4D.7D
1D4.DR
-120+'
118.91
11210002DgO 43.7D
5615131112D 43.70
14411DDOROD 8.72
SG1519111~D 1B4.88
14411050RRD 20.9D
-12D+-
491D.OQ
198.DO
R47S.RA
-12D+-
12248.65
112108DDDBO 6RD2.20
l121QOODOOQ 713.19
ll21OOO2GDO 4767.74
GD15191812D 75.30
5615191012D g.gU
12248.65
43.70-
7S8S.OJ
;,~/iR/Hi ~ " RESIDENT ).EOGEH AS OF DATE OF FIRST ACTIVITY PACE
,ARS6)
~ESIOEHT RESIDENT RESIDENT
:fUHRER TYRE RARE DATE OTY
G/l -- ACCOUHTS RECEIVABLE
ACCOUNT CHARDES CREDITS BALANCE
:41e5 fEDICARE A CAtAMAR, flAX A 121851DD ADf
ROOf IS8 -B LEVEL 1 02/2R/BE DIS
*'NEDICARE A - FEB 01 (CONT)
IRBR1 LAD SERVICES B2/D1/B1 l
1ARDl LAB SERVICES Q2/D1/DI
1BBR1 LAB SERVICES ND/BI/R1
DIDO1 T0TAL IRDORT-OIY FEE BD/D1/B1 -- BO/OB/A1 28
532B1 NTRTNL/ENTRL SERV 6RP 2 B2/Bi/D1 D2J28/R1 SC
532R1 NTRTRL/ENTRL SERV 6RP 3 ADIRlJDL R2128/01 DC
D3CIi OXYCEfl CORDER RENT DIY D21Di/R1 O2/28/R1 28
lqlOl PHYSICAL THERAPY VISIT R2/AO/DI D2/231B1 R
OgOll PHARMACY IE6E~O BO/ON/Il OR/iN/B1 i
3DIAl PHARMACY NON LERENO g2/12lBl -- D2117/R1 1
SISAl WOUNO TREATHERT R21RD/R1 02/281QE
ANCILLARY WRITE OFF 02/28/Q1
ROOM CHAR6E AT 138.D0 D2/ll/B1 -- eD/D2/e! 2
ROOM WRITE OFF Q2/QI/BI 02/02/01 2
DEDUCT CO-IRS AT DH.DR 2
ROOR CHAR6E
ROOf WRITE OFF
OEDUCT CD-INS AT 99.DO
**ENDING BALANCE
**MEDICARE R - FEB Ol
HAL FWD -LN- -AB-
PAYMENT KEDICARE
**ENOIR6 RALANCE
'*PRIVATE - ~AR
BAL FWD
2673.00
**ENDING RALAHCE
**NEOICARE A - fAR el
BAL FWD
Sl19.29
**ENDING BALANCE
**PRIVATE - APR D1
8AI FWD
**EHOIN6 BALANCE
**NEOICARE A - APR Ol
BAI FWO
PAYRENT fCA
**ENOIN4 OALARCO
'*PRIVATE - fAY el
OAL FWD
CRTR RATE: D.Be
RRIV PORT: Q.00
56151RID120 86.8t
SD15191R128 4D.$B
BD15191DI2Q 37.25
SC15181R10R 84.DB
5C1532JR120 112.D0
DD15321B1RB 22R.DR
$5353C10120 5R4.BR
5215001812D
5455121Di2R 428.23
5495131A12B 37.44
54151510120 2R,RO
57557DiQ12Q
S135BRIR12R OTC.lB
CiDS7B1Q12R 115.54
AT 138.RD O2/O3/OL -- B2/27/01 25
RO/O3/BI 82/27/01 25
OS
**EROIND BALANCE
513DRBlOIDQ 34SO.HQ
5155701R12R 1950.75
-DO- ~go- -12Q+-
43.TO-
02/D6/41 i121QRO2QOD
-3D- -6Q- -RD- -12B+-
3NCR.DB iR34.SR 8.50
-3O- -60- -BO- -12O+-
713,e5- 5t8.57
-3D- -CO- -RD-
2673.DD 30DS.BO 1834.54 8.6R
-38- -OB- -OB- -1DD+-
3119.29 713,85- 518.57
84/I7/O1 11218002eOB
-30- -DB- -RD- -128+-
2673.BR 3D69.QO 1543,8Q
43.70
7585.RR
2824.81
7SOS,RD
2924.81
7585.00
2193.Q3
198.DR
2475.BB
43.78
3119.29
2924.8i
.QD
7S8B.BR
2R2A.R1
75DS.OR
194.48-
7585.BR
Statement
HCR, orCa
MANOr'ARE CARLISLE 372
94e NALNUT BOTTOM ROAD
'~CARLISLE, PA [7~13
(717)-249-e085
3ANET CALAMAN
FOR MAX CALAMAN
8ii,NORTH WEST STREET
CARLISLE,' PA ~7053
MEDICARE A
PRIVATE
ROOM ~58 -B
Ple~e Ream ~ls Potion Your Pa~ent
" 2eles 12/os/es ezl2S/ol os/si/el
CALAMAN! MAX A .............................................
~ SERVICE RENDERED CHARGES--~ CREDITS
e's/elTe! 8ALAN~E:'FORWARD 7,ses~ee "
pAYMENT DUE
UPON RECEIPT
AMOUNT DUE
7,585.e(
SHERIFF'S RETURN -
CASE NO: 2001-06196 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
CALAMAN JANET IND/ON BEHALF OF
REGULAR
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 CALA~AN
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 18.00
Service 3.25
Affidavit .00
Surcharge 10.00
.00
31.25
Sworn and Subscribed to before
me this ~-~ day of
l A.D.
~rothonotary '
So Answers:
R. Thomas Kline
11/01/2001
WOLFSON & ASSOC
- ' Dep6ty S~3~riff
STEP~-N $. I~OGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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
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.
STEPI-IF~ j. I-IOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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
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.
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 marded at
the time Decedent became a resident at Plaintiff's facility.
LAW OFFICES O~
STF~m~N J.
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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
Decadent'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 fl~e 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.
LAW OFFICES OF
S~ j. I-IOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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 tdal.
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 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.
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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: /I/'~6/b/
/Stephen J. H ~
19 S. Hanov~ 'eet
Suite 101
Carlisle, PA 17013
(717)245-2698
Attorney for Defendant
LAW OFFICEE OF
STEPHEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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 unswom falsifications
to authorities.
Dat~ /
,~qET I~. CALAMAN
LAW OFFICES OF
ST~PI-IEN J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
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:
Data:
Daniel F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
Stephen J..ogg
Attorney for DefendaM
19 S. Hanover Street
Suite 101
Carlisle, PA. 17013
(717) 245-2698
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
JANET CALAMAN, Individually and on Behalf
of MAX CALAI%6,N, DECEDENT,
Defendant
and
BLUE CROSS, BLUE SHIELD, and
HEALTH CARE FINANCE AGENCY
(MEDICARE),
Additional Defendants
NO. 01-6196
CIVIL ACTION - LAW
R. PLY 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
8~ Associates, P.C., and flies 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 ts 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.
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 kledicare. By way of further answer, Decedent's Blue Cross/Blue Shield policy
paid only for eleven (I I ) 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 kledicare are
indispensable parties to this matter. As to Defendant's assertion, at this point in the
proceedings, that any expenses Incurred by Decedent from PlaintJff should be necessarily
covered by either Blue Cross, Blue Shield or kledlcare, 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
WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss
Defendant's New Hatter and enter iudgment 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,
267 East klarket Street
York, PA 17403
(717) 846-12.52
I.D. No. 20617
Attorney for Plaintiff
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 Plaindff in
the within action and verifies that the statements made in the foregoing Reply to New
Matter are flue 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.
Da~:
267 East klarket Street
York, PA ! 7403
(717) 846-1252
ID No. 20617
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, : NO. 01-6196
Plaintiff :
vs. : CIVIL ACTION - LAW
:
JANET CALAMAN, Individually and on Behalf :
of MAX CALAIqAN, DECEDENT, :
Defendant :
and :
BLUE CROSS, BLUE SHIELD, and :
HEALTH CARE FINANCE AGENCY :
(IqEDICARE), :
Additional Defendants :
CERTIFICATE OF SERVICE
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 Hatter upon the
counsel of record by regular mail, postage pre-paid and addressed as follows:
Steven ]. Hogg, Esquire
19 S. Hanover Street
Suite 101
Carlisle, PA 1701:3
(Counsel for Defendant)
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 20617
Attorney for Plaintiff
SHERIFF'S RETURN - OUT OF COUNTY
~ASE NO: 2001-06196 p
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
CALAMAN JANET IND/ON BEHALF
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.
deputized the sheriff of DAUPHIN County,
serve the within COMPLAINT & NOTICE
He therefore
Pennsylvania,
to
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~r~:/~
R./ Thomas Kllne-
Sheriff of Cumberland County
Sworn and subscribed to before me
this 7 ~ day of ~
~0o ~_, A.D.
-~ t Prothonotary
SHERIFF'S RETURN -
CASE NO: 2001-06196 p
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
CAL~JW3~N JANET IND/ON BEHALF OF
OUT OF COUNTY
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.
deputized the sheriff of DAUPHIN County,
serve the within COMPLAINT & NOTICE
He therefore
Pennsylvania,
to
On Januar_z 3rd , 2002 this office was in receipt of the
attached return from DAUPHIN
Sheriff,s Costs:
Docketing 6.00
Out of County .00
Surcharge 10.00
.00
.00
16.00
01/03/2002
STEPHEN HOGG
Sworn and subscribed to before me
this _ 7~ day o~/~~
~L&u5 2~ A.D.
Prothonotar~ TF ;
Sheriff of Cumberland County
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,
at 1800 CENTER STREET
CAMP HILL, PA 17011
on the 6th day of December , 2001
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 6.00
Service 9.10
Affidavit .00
Surcharge 10.00
.00
25.10
Sworn and Subscribed to before
me this _ ,/~ day of
~-~ ~.2~ A.D.
So Answers:
R. Thomas Kline
01/03/2002
STEPEHN HOGG
By:
Deputy -Sher£ff' /
SHERIFF'S RETURN - REGULAR
CASE NO: 2001-06196 p
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CLrMBERLAND
HCR MANOR CARE
VS
CALA/~AN 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 MEDICAREthe
A]DD'L DEFEND~NT, at 1446:00 HOURS, on the 6th day of December , 2001
at 1800 CENTER STREET
CA/~P HILL, PA 17011
SALLY MCCOY, PAP~ALEGAL
by handing to
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff,s Costs:
Docketing 6.00
Service .00
Affidavit .00
Surcharge 10.00
.00
16.00
Sworn and Subscribed' to before
me this ~ day of
/~~. ~Z~ ~-~ A.D.
~ t~rothonotary --
So Answers:
R. Thomas Kline
01/03/2002
STEPHEN HOGG
Deputy' S~e~iff ' ~
Mary Jane Snyder
Real Estate Deputy
William T. Tully
Soliei~r
Dauphin County
Harrisburg, Pennsylvania 17101
ph: (717) 255~2660 fax: (717) 255-2889
Jack Lotwick
Sheriff
J. Daniel Basile
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
Commonwealth of Pennsylvania
County of Dauphin
: HCR MANOR CARE
vs
:
BLUE CROSS
Sheriff's Return
AND NOW:Decenfl~er 11,
NOTICE & ANSWER
BLUE CROSS
to SUSD2q JOY, ADMINISTRATIVE ASSISTANT
No. 3485-T - -2001
OTHER COUNTY NO. 01-6196
2001 at l:10PMserved the within
upon
by personally handing
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
Sworn and subscribed to
efore me this 13TH day o?~ECEMBER, 2001
PROTHONOTARY
So Answers,
Sheriff of Dauphin County, Pa.
Deputy Sheriff
Sheriff's Costs:S35.25 PD 12/11/2001
RCPT NO 157677
T WONG
Mary Jane Snyder
Real F. state Deputy
William T. Tully
Solicitor
Dauphin County
Harrisburg, Pennsylvania 17101
ph: (717) 255-2660 fax: (717) 255-2889
Jack Lotwick
Sheriff
J. Daniel Basile
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
Commonwealth of Pennsylvania
County of Dauphin
: HCRMANOR CARE
vs
:
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 & ~-NSWER
and that I am unable to find him/her in the County of Dauphin, and
therefore return same NOT FObl~D, December 13, 2001
NO SUCH AGENCY AT 2500 ELMERTON AVE., HBG., PA NEED A BETTER ADDRESS.
Sworn and subscribed to
efore me this 13TH day~f~DECEMBER,
PROTHONOTARY
2001
So Answers,
Sheriff of Dauphin County, Pa.
By
Deputy Sheriff
Sheriff's Costs: $35.25 PD 12/11/2001
RCPT NO 157677
· in The Court of Common Pleas of Cumberland County, Pennsylvania
BCR Manor Care VS Janet Calaman et al
VS.
Blue Cross et al
SERVE:
Blue Cross N0. 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, tkis
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cum berland County, PA
within
Affidav/t of Service
,20 , at
o'clock
M. served the
1/pon
by handing to
a
and made Imown to
copy of the original
So answers,
the contents thereof.
Sworn and subscribed before
me this day of
,2O
Sheriff of
COSTS
SERVICE
MILEAGE
County, PA
]n The Court of Common Pleas of Cumberland County, Pena~syivania
HCR Manor Care VS Janet Cal~an et al
VS.
Blue Cross et al
SERVE: Health Care Finance Agency (Medic~) 01 6196 civil
NOW, Dec~nber 4, 2001 , I, SHERIFF OF CUMBERLAND COUNty, PA, do
hereby deputize the Sheriff of Dauphin Col/nty to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cumberland County, PA
within
Affidav/t of Service
,20 ,at
o'clock __ M. served the
1/pon
at
by handing
a
and made lmown to
copy of the orig~inal
So answers,
the contents thereof.
Sworn and subscribed before
me this day of
,2O
Sheriff of
COSTS
SERVICE
IvlLLEAGE
AFFIDAVIT
County, PA
HCR MANOR CARE,
Plaintiff
JANET CALAMAN, Individually and on
Behalf of MAX CALAMAN, DECEDENT,
Defendant
BLUE CROSS, BLUE SHIELD, and
HEALTH CARE FINANCE AGENCY
(M~DICARE),
Additional Defendants
iN THE COURT OF COMMON pI.F~AS OF
CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION-LAW
:
NO. 01-6196 Civil Term
:
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: lannary 18, 2002
STEVENS.& LEE
Darnel B. Huyett [~
Attorney I.D. No. 21485
111 North Sixth Street
P. O. Box 6'/9
Re~din8, PA 19603
(610) 47S-2000
Attorneys for Defendants Capital Blue Cross
and Pennsylvania Blue Shield
SL1232018vl/02109.068
CERTIFICATE OF SERVICE
I, DANIEL B. HUYETT, ESQUIRE, certify that on this date, I served a ce~ified
true and correct copy of the foregoing Entry of Appearance upon the following counsel of
record, by depositing the same in the United States tmul, postage prepat , 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
Date: January 18, 2002
SL1232018vl/02109.068
C:t cz) CD
1N THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
JANET CALAMAN, Individually and on
Behalf of MAX CALAMAN,
DECEDENT,
Defendant
BLUE CROSS, BLUE SHIELD, and
ALT Fn ANC .
(M ICAtU ),
Additional Defendants
:
.-
:
..
:
:
CIVIL ACTION- LAW
No. 01-6196 Civil Term
PRAECI~E TO DISCONTINUE
Defendant, lanet Calanm~ individually and on behalf of Max Calaman, decedent,
hereby discontinues ail claims broul~ht in the New Matter in the above-captioned matter against
Blue Cross, Blue Shield, Capital Blue Cross, Pennsylvania Blue Shield, and Highmark, Inc.
Kindly mark the above-captioned matter dismissed as to additional defendants Capital Blue
Cross, Pennsylvania Blue Shield, Highmark, Inc., Blue Cro d,; Ig'd.
Step[~en I. Ho~ E~quire :///
19 South Hanover StreW."
Suite 101 /
Carlisle, PA 17013
Attorney for Additional Defendant
8LI 233671vl/O2109.0~g
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,
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
ClVIL 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: ?/'~ ~/~
Janet Calaman
WRIT TO JOINED AN ADDITIONAL DEFENDANT
HCR MANOR CARE
Plaintiff
Vs
JANET CALAMAN, INDIVIDUALLY
AND ON BEHALF OF MAX
CALAMAN, DECEDENT
Defendant
No. 01-6196
Civil Term
Cumberland County, ss:
The Commonwealth of Pennsylvania to EMPIRE BLUE SH/ELD AND EMP/RE 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
(SEAL)
Deputy
REQUESTING PARTY:
Name: STEPHEN J. HOGG, ESQUIRE
Address: 19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
Attorney for: Plaintiff
Telephone: 717-245-2698
LAW OFFICES OF
STEPI-IFJ~ J. HOGG
19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANORCARE,
Plaintiff,
ve.
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 THEPROTHONOTARY:
Please issue a Writ to join Empire Blue~~d'~ional
Defendant in this action.
'Stephen J. Hogg,
Attorney for Defendant
~/~?/~7~ Janet Calaman
Date: ~ ·
WRIT TO JOINED AN ADDITIONAL DEFENDANT
HCR MANOR CARE
Plaintiff
V$
JANET CALAMAN, INDIVIDUALLY
AND ON BEHALF OF MAX
CALAMAN, DECEDENT
Defendant
No. 01-6196
Civil Term
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
(SEAL)
Deputy
REQUESTING PARTY:
Name: STEPHEN J. HOGG, ESQUIRE
Address: 19 S. HANOVER STREET
SUITE 101
CARLISLE, PA 17013
Attorney for: Plaintiff
Telephone: 717-245-2698
HCRMANOR CARE
VS
JkWET CAL..AMAN, Individually and on Behalf
.... CALAMAN, Decedent
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 01 -6196 CIVIL
RULE L~12-1. The Petition for Appointment ~f Arbitrators shall be substantially in the following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Amy F. Wolfson, Esot .....
respectfully represents that: ........... ~ ......... .~.!~_ ~ ~ ~ .~ ~ ..: ~ ~: :cnons),
1. The above-captioned action (or actions) is (are} at issue.
2. The claim of the plaintiff in the action is $.]..~f~_5._pO. lm.~.~.~L~.~t, 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 counsel or 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.
Rfi~ecffully submitted,
ORDER OF COURT
AND NOW,
foregoing petition, ~7~O.-2t_~g/a~
Esq.,and .~.~
actions) ~ prayed for.
, t'9'~Tz2.a-~4n consideration of the
Esq., are appointed arbitrators in the above captioned action (or
By the Court,
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 :
NO. 01-6196 CIVIL
TERM
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
AND NOW, this Z/'~/~ 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 ]. Hogg, Esquire
19 S. Hanover Street
Suite 101
Carlisle, PA 17013
A~y (:. W,~lfson, Esqe
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
)
OA~
The Court of Common Pleas of
Cumberland County, Pennsylvania
We do solemnly swear (or affirm) :hat we will support, obey and defend
=he Constitution of =he Uni:ed S:ates and :he COns:i~ua~on of :his Common-
wealth and :ha: we will discharge :he duties of our office with fideli:y.
L Chairman
We, the undersi~aed arbttra:ors, having been duly appointed and sworn
(or affirmed), make =he following award:
(Note: If d~-m~es for delay are award, ed, they shall be
separately stated.)
· ArSiCracor, dissents. (Insert name if
applicable. )
DaUe °f Hear~g: '~-~0~
~, ~-2~,~ o~ ~~ , ~, ~ ~, ~.~.,
a~rd ~s entered upon :he doc~c and not!ca =hereof given by ~il
par:/es or =heir ac:o~eys.
IN THE COURT OF COMMON ['LEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
JANET CALAMAN, Individually and on Behalf
of MAX CALAI"IAN, DECEDENT,
Defendant
NO. 01-6196 CIVIL TERM
CIVIL ACTION - LAW
PRAECIPE TO SETTLE AND SATISFY
TO THE PROTHONOTARY:
( ) Please mark the above captioned action settlecl and
satisfied.
OR
( X ) Please mark the above captioned judgment or lien
settled and satisfied.
Respectfully submitted,
York, PA 17403/
(717) 846-1252
ID No. 87062
Attorney for
Dated: