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HomeMy WebLinkAbout07-4664IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/ b/ a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. CIVIL ACTION -EQUITY NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 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. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 (800) 990-9108 ORIGINgL EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, : Plaintiff, v. No. LOIS TRAVER, Defendant. CIVIL ACTION -EQUITY AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demands y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falls de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier sums de dinero reclamada en la demands o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes pars usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Services Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. No. 0 7- yG~ ~' ~( l..e.H-~ CIVIL ACTION -EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services -Camp Hill, ("Plaintiff ManorCare"), by and through its attorneys, SCHUT]ER BOGAR LLC, and files the within Complaint against Defendant Lois Traver ("Defendant Traver'), and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 1700 Market Street, Camp Hill, Pennsylvania 17011. 2. Defendant Traver is an adult individual who currently resides at Petitioner's skilled nursing facility. 5. On or about December 17, 2004, Defendant Traver made application on behalf of her husband, Robert Traver, ("husband") for admission to Plaintiff ManorCare's skilled nursing facility. 6. On or about December 17, 2004, Plaintiff ManorCare and Defendant Traver entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Traver's husband with skilled nursing care and services in exchange for her promise to pay a specific monetary fee from her husband's income and resources and to make timely and proper application for Medical Assistance benefits when her husband became eligible for such assistance and to pursue any subsequent appeals if that application were denied. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 8. After her husband's admission to Plaintiff ManorCare s skilled nursing care facility, Defendant Traver's husband apparently became insolvent. As a result, pursuant to the Agreement, Plaintiff ManorCare notified Defendant Traver of her contractual duty to make application for Medical Assistance benefits on her husband's behalf. 9. An application for Medical Assistance benefits was filed with the Cumberland County Assistance Office of the Department of Public Welfare. 10. The application for Medical Assistance benefits will be denied unless Defendant Traver provides the information needed by Cumberland County Assistance Office to determine her husband's eligibility for Medical Assistance benefits. 2 COUNTI BREACH OF CONTRACT/ SPECIFIC PERFORMANCE 11. The allegations contained in Paragraphs 1 through 10 are incorporated herein by reference as if fully set forth at length. 12. Defendant Traver breached the Agreement with Plaintiff ManorCare when she did not make complete and proper application for Medical Assistance benefits on behalf of her husband, and Defendant Traver continues to breach the Agreement with Plaintiff ManorCare by not participating in the Medical Assistance application process by producing the documentation necessary to qualify her husband for Medical Assistance benefits. 13. Defendant Traver s breach of the Agreement with Plaintiff ManorCare has caused and continues to cause irreparable harm to Plaintiff ManorCare. 14. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/ or protections promised under the Agreement. WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BOGAR LLC Dated:~~NO~ By ' Chad ick O. Bogar Attorney I.D. No. 201289 (71'7) 909-5922 305 North Front Street, Suite 401 Attorney I.D. No. 83755 (717) 909-5920 Mariclare L. Hayes Harrisburg, PA 17101 Fax No.: (717) 909-5925 4 VERIFICATION The updersigned hereby verifies that the statements of fact in the foregoing Complaint are true artid correct to the best of my knowledge, information and belief. I understand that any false statexx,ent.G thzrein are subject to dte penalties captained in 1$ Pa. C.SA. § X909, relating to unsworn falsification tv authorities. Dated:_~~~~ EXHIBIT "A" Rx,Date/Time JUL-27-2007(FRI) 10; 3d 7177372189 P.O11 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 11 HCR Manor C~7re pe~~,lyQn~ ADMISSION GREEMF.NT This Agreement is entered into by and among Nightingale Nursing Home, l;nc., d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible party, if any, 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 Center ("Center"). Center: MatiorCare Health Services, Camp Hill Resident: ~p'b8r ~ Tro`v-e.-~ Responsible Party: ~p~ S '~`,r-av~- Admission Date: 1 ~171b~ Deposit; $ a, (a0 Term: This Agreement begins on the day the Residem eaters the Center and ends on .the day •the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. L RIGiHTS AND RESPONSiBILI'x'IES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay rile applicable Room and Board Rate set forth on AttachrneNt 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 upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section, will 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 I.06). 1, 02 ~~ Chases. The Resident will pay to Cemer 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 flan 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. Su~~h "Ancillary Chazges" are described on Attachment B hereto, and a content ancillary charge list i,; maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding nrtonth, and are payable in fi~~'I, along with the Room and Board Rate upon receipt. Rx Oate/Time JUL-27-2007(FRI) 10: 3Q 7177372189 P. 012 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 12 1.03 ~llectio~ps/Late Payments. Payment is due in full. within thirty {30) days of billing. , Should the Reside~tt's account for any reason be turned over for collection; the Resident will pay the Center's coliec:tion costs, including attorney's fees. 1.04 independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program ::n accordance with the terms of the program. 1.05 Go~rernmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, l1![edicaid, or through the Veterans Administration, and the Center particiF~ates in such program, the Center will accept payments under such program in accordance with tl~e terms of the program as set forth in the contract the Center has with. the program. The Re!:ident is 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 progams: x_Medicare, _x~Medicaid and/or VA. Medicare may pay for some or ail of the Resident's care- If Medicare agrees to pay for the Resident's care, th~:re is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, oc speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any requited co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for applying for Medicaid. if the Resident receives Medicaid, most of the Center charges such as R~~om 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 agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined attd periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Managed Care Or~igns. If a Resident is a participant in a plan offered b~- a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital thganizatiott ("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 is res~~onsible 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 R~c.Date/Time JUL-27-2007(FRI) 10: 3Q 7177372189 P. 013 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 13 ' will bill the Resident's third patty payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within .a reasonable period of time. 1.07 ~riv_ate Pay Resident. The Resident is responsible for paying the Center for items anal services provided during the stay at the Center and during which time.ihe Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the ftnancial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify tt~e Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully .in applying for Medicaid and in the eligibility detenmittation process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's itrtention to discharge the Resident for non-~~ayment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third parry payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice Mwithin five 5 da s of the Resident's disenr, ollment, enrollment, change in health care coverage, failure tc~ pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Ce;~ter relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such irtforttaation, the Resident may be responsible for any denied charges due to lack of authorization, ineligibiliRy, non-coverage or other costs associa~:ed with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Avolication for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program, The Center has no obligation to bill any third party payor other than the .Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under, contract. 1.10 PrimrW Responsibility for Payt~ent Except for payments for services covered under governmental. programs or other third party payor provider agreemetats, the Resident remains primarily li;tble for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medicati~ms, and other care and. services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a Rx,Date/Time JUL-27-2007(FRI) 10.34 7177372189 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL P. 014 PAGE 14 governmental payor, third party payor or managed care organiution. The Resident and/or Responsible Part~• will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the tight to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her ~~ersonai physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Parry 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 fail:; to abide by applicable laws and regulations, the Center will call another physician to attenc; to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pha-ma The Resident and/or Responsible Party has the right to choose a pharmacy of choiGS, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. 1lL RIGHTS ,A.ND RESPONS)<BII,,ITY OF THE RESPONSIBLE PARTX 2.01 Le~~l_Autho h+. The Responsible .Party represents that he/she has legal access to the Resident's in.coir<e or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 ~rextnent to Make Pavrnents on Behalf of Resident. The Responsible Party will pay promptly from ~rhe Resident's it~ome or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the al~eeme»t from the Resident's income or resources, 2.03 ~~e~ted Items, The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program, 2.04 Exhaustion of Residern's Funds If the Resident's financial resources change such that the Resident maybe eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing; and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for .Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a tirtxely Rx.Date/Time JUL-27-2007(FRI) 10:34 7177372189 P.O15 67/27/2067 11:33 7177372189 MANORCARE,CAMPHILL PAGE 15 and proper mann.~r, the Responsible .Party will be personally liable for all charges and fees not covered by Medi~:aid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cooperation for Financial Assistance If the Resident is eligible for 1Vledicaid, the Responsible Pally must provide such information about the Resident's -finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to arty lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid pa~-ments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acceptance n Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the: Center. If after notice, the Resident is not removed ~ as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's corxdition permits, who shall unconditionally be obligated to accept the Resident or immediately n3ake medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise iiiegally transfers assets for purposes of avoiding the Responsible P<<rty's obligation to make payments on behalf of the Resident under Section 2.02 or for purposes o1' qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Residem's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or. civil sanctions against the Responsible Party. iQI. RIGHTS E-NA RES1i'ONSIBQ,)[TIES OF' THE CENTER 3.01 Room and Standard Serviced As part of the Room and Boazd Rate, the Center will 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. 3.0~ Oth~:r Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. Rx. Date/Time JUL-27-2007(FRI) 10;34 7177372189 P. 016 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 16 3.03 AepQsit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this ,agreement. The Deposit will be applied to the charges for the first, month of the Resident's stay at the Center. 3.04 lZe: funds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time fzame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENIERAL PROVISIONS 4,01 Coi~ent to Release of Information- The Resident and/or Responsible Parry hereby consents to the r~:lease of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or paymer';t audits performed by such; the personmel of arty hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized bylaw to review the medical records. 4.02 Con sent to Tneat. The Resident and/or ,Responsible Party consent to the use and disclosure of Itesidern's protected health information for the purposes of receiving treatment from the Center, obtainutg payment for healthcare services provided to Resident, and the Center's own healthcare operation needs, The Resident and/or Responsible Party, by signing this Agreement, authorizes the ap~~ropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as. are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she .has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to th.e Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 went to Phgtograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the 11~[edicatioa 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 Sery_ices. Policies and Additional Informations The Resident and/or Responsible Party 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 Responsible 6 Rx Date/Time JUL-27-2007(FRI) 10,34 717737218'9 P.O1~ 07/27/2607 11:33 7177372189 MANORCARE,CAMPHILL PAGE 17 Parry acknowied~;e they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of benefits. See Attachment C. b. SNF Medicare Aetermination Notice. See Attachment D. c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations .relating to the Center's management of such funds. A description andlor policies and procedures of protection of resident funds and the Personal Trust Fund Ageement, Resident Personal Funds Authorization and any other related documents. See Attachments F->, and F-2, e. Center Supplement: ~. Policy artd procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. Name, address and phone number of Ombudsman. 4. .Location in the Center where the names, addresses and telephone cumbers 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. S. The narge, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, Hanna, address and phone number on how to .file a complaint with the state survey aad certifteation agency concerting residenrt abuse, neglect, mistreatment and misappropriation of property. f The Resident Handbook. g. Resident/Patient Rights. h. Medicare/Medicaid information and display of such information including how to apply for and use Medicare anal Medicaid benefits, and how to receive refunds for previous payments. Rx.Date/Time JUL-27-2007(FRI) 10~3a 7177372189 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL P. 018 PAGE 18 i. Receipt of information on advance directives including a copy of"Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-1 and G-2. j. Privacy Act Notification. See Attachment H. k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and 1-2. 1. Ancillary Services Management Form. See Attachment J. 4.05 ~ssig~nent of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payer benefits as described in Sections 1.05 and 1.06, if ally, bps made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf #or any service furnished by or in the Center. The Resident and/or Responsible Party authorize tree Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payers any information needed to determine these benefits or benefits for related services, 4.06 Tenz~ination_ Discharge and Trait fer This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident andlor Responsible Party may tertninate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven ('~ 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 evens of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate acid for all services performed up to the end of the day that the admission ends. I~scharge from the specialized units such as the Ttansitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abusExl the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, wtuich may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from airy and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 8 ,~x,Date/Time JUL-27-2007(FRI) 10:34 7177372189 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL P. 019 PAGE 19 4.OS ~3n~es in the Law Any provision of this Agreement that is found to be invalid or unenforceable :ts a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will contirnce to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED CERTIk"Y AND ACKNOWLEDGE THAT THEX HAVE EACH READ A:ND UNDERSTOOD T1fIE FOREGOING AGREEII~ENT, AND THAT TAY ~-~ DAD AN OPPORTUNTI'X TO AS1K QUESTIONS AND THAT ,ANX QUESTIONS HAVE BEEN ANSWERED TO THET.Et SATISFACTION. Signature of Resident; - Date: Signature of Respo»sible P Q~ ~,,~~%~~~'U ~'• Aate; /~ -~~~ ° ~ Center Representative: Date: c~- ~~ d (-~ +..a -~- ' ~ Cj -..., ~ ~ _ ~' r ~ ---- ~ l '` rte.°° 4 3 Z ~1(_ ~ ` + W` i . - f -'7 ~ ~ E71 _ `~~\ r/ ~ r ~ ? ~ ~y l) t'-' W -_ ~ ~ ~ ~~ o .t.: O IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. CIVIL ACTION -EQUITY ACCEPTANCE OF SERVICE I accept service of the Complaint on behalf of Defendant, Lois Traver, and certify No. 07-4664 Civil Term that I am authorized to do so. Dated: 1, By: 'Lowell .Gates, Esquire Attor y I.D. No. 46779 GAT , HALBRUNER & HATCH PC 10 Mumma Road, Suite 100 Lemoyne, PA 17043 (717) 731-9600 Fax No. (717) 731-9627 Attorney for Defendant C~ ~ ~ _ ".'t- ~ ~ .~ ~- ~,} -=~i ~ ~? = C.. `~ `~! ~ '"„' ~~ .f' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. LOIS TRAVER, Defendant. No. 07-4664 CIVIL ACTION -EQUITY PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of the following ScxuZ7ER BoGAR LLC attorney as counsel of record in the above-captioned matter: Brandon Williams SCHUTJER BOGAR LLC 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Attorney I.D. No. 200713 (727) 909-5922 Dated: ~ By: Brandon Williams ORIGINAL .. `• CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Entry of Appearance was served via first-class, United States mail, postage prepaid, upon the following: Lowell R. Gates, Esquire GATES, HALBRUNER & HATCH, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Dated: 9 ~ '~ g By: William Keslar, Paralegal e•a ~~ ~ ~ ~~:~ ^~~ 1 ~-~; ~ ~ ~~ ; uro '~ __„# -c v "~ IN THE COURT OF COMMON PLEAS CUMBERLAND couNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/ b/ a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, ~. No. 07-4664 LOIS TRAVER, Defendant. CIVIL ACTION -EQUITY PRAECIPE TO WI1'HDRA~+V TO THE PROTHONOTARY: Kindly withdraw, without prejudice, our Complaint filed in the above captioned matter on August 6, 2007. Respectfully submitted, Dated: Scx[~7s~t Bocait LLC By: -~ Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 .-Brandon Williams Attorney I.D. No. 200713 (717) 909-5922 417 Walnut Street, 4~ Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for the Plaintiff ORIG;NAL j ,s CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw Complaint was served first-class, United States mail, postage prepaid, upon the following: Lowell R. Gates, Esquire GATE5, HALBRUNER & HATCH, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Dated: q ~ ~ 8 By: William Keslar, Paralegal ~, .~.. ~~ ~' .a