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HomeMy WebLinkAbout08-0482 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, V. No. C)3- Ll %u, OiV i t Teem LOIS TRAVER, Defendant. : 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. 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 ORIGINAL 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 - LAW AVISO PARA DEFENDER 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 Demanda 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 falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda 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 para 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. No. 01'- t/PoZ t/ i..,- LOIS TRAVER, : Defendant. CIVIL ACTION - LAW COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/a ManorCare Health Services - Camp Hill, ("Plaintiff ManorCare"), by and through its attorneys, SCHUTJER 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 Plaintiff's skilled nursing facility. 3. On or about December 17, 2004, Defendant Traver made application for admission of her husband, Robert Traver, to Plaintiff ManorCare's skilled nursing facility. 4. 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. A true and correct copy of the Agreement is attached hereto as Exhibit "A." 5. Defendant Traver has failed to remit full payment to Plaintiff ManorCare for the care and services that it has provided to her husband in accordance with the Agreement. 6. Due to Defendant Traver's breach of the Admission Agreement, Plaintiff ManorCare has incurred damages in the amount of Fifty Thousand Two Hundred Forty-Five Dollars and 08/100 ($50,245.08)1 plus current costs and attorney fees as provided for in the Agreement in the event of a breach. See Exhibit "A." Because Robert Traver is a current resident, the outstanding amount owed will continue to increase each month by approximately $6,500.00. COUNTI BREACH OF CONTRACT - DAMAGES Plaintiff ManorCare v. Defendant Traver 7. The allegations contained in Paragraphs 1 through 6 are incorporated herein by reference as if fully set forth at length. 8. Plaintiff ManorCare has provided care and services to the Defendant's husband, Mr. Traver, in accordance with the terms and conditions of the Agreement. 9. Defendant Traver has failed to fully compensate Plaintiff ManorCare from her husband's resources for the care and services that it has provided to her husband. 10. The breach of Defendant Traver has caused Plaintiff ManorCare to incur damages in the amount of Fifty Thousand Two Hundred Forty-Five Dollars and 08/100 ($50,245.08) plus current costs and attorney fees as provided for in the Agreement in the event of a breach. See Exhibit "A." WHEREFORE, Plaintiff ManorCare demands judgment in its favor and against Defendant Traver in the amount of Fifty Thousand Two Hundred Forty- Five Dollars and 08/100 ($50,245.08) plus current costs and attorney fees as provided for in the Agreement in the event of a breach. See Exhibit "A." Respectfully submitted, SCHUTJER BOGAR LLC Dated: 4420M By: tBga wick O. Attorney I.D. 5 (717) 909-5920 Mariclare L. Hayes Attorney I.D. No. 201289 (717) 909-5922 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unworn falsification to authorities. Dated: 41 Mu oY Offlce ManaM ealth Services Camp Hill EXHIBIT "A° 07/27/2007 11:33 7177372189 r r? MANOR C. .... ... PAGE 11 HCR Manor Care Pennsylvania ADMLSS?ON ',RICE NT This Agreement is entered into by and among Nightingale Nursing Home, Inc., d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the R purpose of providing for the rights and responsibilities of the partiese with respect for the Resident's stay at this HCR Manor Care's Center ("Center"). Center: ? rCare health Services Cam Hill ,Resident: Pp'b_r+ -r1-0`V4_r-' Responsible Party: i of s 7' --o`ver Admission Date: )-a1/07I6q Deposit: S QD Term: This Agreement begins on the day the Resident enters the Center and ends ay the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. L RIGHTS AND RESPONS.IBI[,rMS OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will 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 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 1.06). 1.02 ,coat Wil es The Resident will pay to Center all charges r therapeutic; or personal care services or supplies that may be requested by the Resid additional en? 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 9. current 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 su and are payable in fui:l, along with the Room and Board Rate upon cceWing month, . v??Lr 11111C JVL L1 LVV1\111/ IVJ4 I I I J I L U 7 r . V I L 97/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 12 1.03 Cdecti sf to Pa ents. Payment is due in full within t Should the Reside:nt's account for ?y (30) days of billing... the Center' any reason be turned over for collection; the Resident will pay s coliec:tion costs, including attorney's fees. " 04 indepeKtdent 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,remmentai pro ams If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will acre a accordance with the terms of the program as set forth in thet cont actithe C such as with the program. The Resident is responsible for any eo-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 I.01 and 1.02. The Center participates in the following programs: x Medicar Medicare may pay for some or all of the Resident's cafe. If Medicare _x-Medicaid anto pay for d/or Vhe Resident's care, tlH:re is a required co-payment, which Medicare updates Yeearly. 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 agrees 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. The Resident and/or Responsible Party 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 cov require the Resident to a ?' although Medicaid may pay 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 and 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 Favors and Managed are O W tigns. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Or Preferred Provider Organization ("PPO"), Provider Sponsored Or ganrzn ( SHMOo Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed b the a licable The Resident is responsible for an co-payments Y Pp agreement. to the same terms and conditions applicable to, priva a deductibles has in y residents. veIff the charges, not executed a provider agreement with the Resident's third party as not pyor, the Center 2 %. UULC/I1111C JUL-LI-LUUIkr KlJ Iu;J4 1111JIC107 07/27/2007 11:33 7177372189 777 MANORCARE,CAMPHILL PAGE 13 will bill the Resident's third party payor as a service, but the Resident remains paid or covered by that third party payor includin liable for charges period of time. $ charges not paid within .a reasonable "" Private, Pay Resident. The lesident is responsible for paying the Center for items and services provided during the stay at the Center and during which timeshe Resident been determined to be eligible for any governmental program or covered under any asa of payor or managed care organization plan The Resident and/or Responsible Party will thirdnotify the Center promptly if there is insufficient income or assets to meet the Center or to make prompt application to Medicaid for benefits. The Refinancial o to the sidenand/or Res bligations nsible Party will notify the 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 determination 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 intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Adr.nission Information. The Resident I Responsible Party will notify the Center and provide any needed information regarding all third coverages on admission and throughout the Resident's stay includiParty ayors or nco piees of insurrancceelcards, identification or veification of eligibility and coverage information. notice The Resident and/or Responsible party will provide the Center in writing with within five (M-days of the Resident's disenr. ollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and coverage as the Cuter relies on the information supplied regarding sz Coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, inetigibil[ity, 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 AlMlication L&LBe-n-d-ts. The Resident and/or Responsible P will a 1 for coverage and to establish eligibility under ? app y private insurance any governmental, third party payor, managed care or program. The Center has no obligation to bill any third party payor other than the Responsible Pasty and, when applicable, a governmental program . urd party payor or managed care organization with which the Center is under contract t 1.10 PRmi Res onsi ill r Pa a t. Except for under governmental. Programs or other third ? payments for services covered remains primarily liable for PAY payor provider agreements, the Resident 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, )WO, PPO, PSO, PRO 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 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 .n.. UULC/ lank JUL LI LUU1%I 111/ IU•J4 1111Jicio3 r.u?u 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 14 g Responsible payor, third party payor or managed care organization. The Resident and/or overrimental Responsible Part, will be responsible for non-covered maintained at the Center's business office and isavailable services. hours. thew during regular b sc iness I.11 Personal Phvsic an The Resident has the ri provided that the physician selected is pro g perly licensed and to choose a personal Physician, and policies of the Center. At the time of admission, the Resident must supply Ilythlaw ent the rules name of his/her personal physician. If the Resident changes PP physicians er with the admission, the Resident and/or Responsible Party must immediately notify, he 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 attene: to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 - Phan, The Resident and/or Responsible Party has the right to choose a pharmacy of choir.; 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. IL RIGHTS AND RESPONSIBIOLITy OF THE RESPONSIBLE PARTY 2.01 L&ge sLAAh_0Mi . The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 A&emment to Make Payments on $ehalf of Resident. The Responsible Party will pay promptly from -the Resident's income 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 agreement from the Resident's income or resources, 2.03 RMLeggd_ 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 Exhau 'on of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writikg 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 timely 4 u u t. . l ..l l ... .. .... \ 1 11 1/ 1 u• j4 i i 1?1 L iuJ r. uij 07/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 15 and proper mann,. , the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cato era "on for Financial Assistance If the Resident is eligible fbr Medicaid, the Responsible Part y must provide such information about the Res dent's -finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. If the ,Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, 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 Ac nce n Disch . 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 condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 A,d.diti 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 mouse of Re ident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party'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 Resident'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. III. RIGHTS AND RESPONSIBELITIEs OF THE CENTER 3.01 Room and Standard Services As part of the Room and Board 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. 3.02 Oth-;r 'ces. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. . - , -'a 97/27/2997 11:33 7177372189 IIIJILIU7 MANORCARE,CAMPHILL r. uiv PAGE 16 3,03 DUO-it• 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 t Resident's stay at the Center, he 3,04 funds. Any refund owed to the Resident for advance payments the Center within thirty (30) days after discharge or transfer or within t e time fi.ame re ut edd by State law. In the case of Medicaid Residents, any such refund will be paid within thi q by rty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV_ GENERAL PROVISIONS 4.01 Con ent to ease o Information. The Resident and/or Responsible Parry hereby consents to the Mlease of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any Peron, 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 facility or provider to whom or which the Resident may personnel transferred; he or other Center's health care insurance carrier; and any person authorized bylaw to review the medical records. 4.02 Consent. to Treat, The Resident and/or Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by authorizes the appropriate staff of the Center to perform such funcctio?n?e and Agreement 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 cane, 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 the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above, 4.03 Q2%5ent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying photograph in the Medication Administration Record or er recd Resident, for any-other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of ices P 'eies d an Informati . 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 1 V 1 1 07/27/2607 11:337177372189 V J? MANORCARE,CAMPHILL PAGE 17 Party acknowledge they have had the Opportunity to answered satisfactorily ask questions and questions have been a. Assignment for Payment of $enefits. See Attachment C. b. SNF Medicare Detonation 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 mana Trust or and Fund policies and Agreement Bement of such 'funds. A description procedures of protection of resident funds and the Perother sonal s, Resident Personal Funds Authorization and any related documents. See Attachments F-I and F-2, e. Center Supplement; 1. Policy and procedure on bedholds, election of bedholds and z• readmission, 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 numbers of state client advoca 'addresses and telephone certification agency, the state liy groups, state survey and censure office, the state ombudsman; Program, the protection and advocacy network and the Medicaid fraud control unit. 5 The name, medical specialty and way of contacting the attending physician, director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mi?eatment and misappropriation of property. r The Resident Handbook. 9. Resident/patient Rights_ h. 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. 7 07/27/2007 11:33 r- 7177372189 I V +? J ' MANORCARE,CAMPHILL PAGE 18 Receipt of information on advance directives including a copy of" Refusal of Life Sustaining Treatment", which Limited summarises HCR Manor Care's 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- I 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. I Ancillary Services Management Form. See Attachment J. ' 4.05 Ass - !gMRent of Benefits. The Resident and/or Responsible Party request that Payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Resident's behalf fbr any service furnished by or in the Center. The cent either to Resident on Party authorize the Center and Resident and/or Responsible information to the Centers for Medicare nand Medicaid Services "CMS,-and is agents release such Pty Payors any information needed to determine these benefits or benefits for related Vices d 4.06 Ten ' ati Disch a and Tff?err. This my forth, below and as set forth in the Resident Handbook under the tn de?ated as set The Resident and/or Responsible Party may terminate this Agreement i ?schacnter written notice of the Resident's desire to leave at least seven Agreement by providing the Center departure. If the Resident leaves before the end of that time, the a d?v? illl payffor eaac s day of the required notice unless the Center fills the bed before the end of the notice h Except in the evert of an emergency or death, the Resident will be res' the Room and Board Rate and for all services Ponsible for all charges for admission ends. Discharge from the specialized Perfvrmed up to the end of the da units such as the Transitional Care Unit for Subacute Unit may require less than seven (7) days notice. I muse If discharge or transfer becomes necessary be someone else abuse:! the Resident's fund, the Center will erequest that local, stateban Party or authorities, as appropriate, investigate, which may result in prosecution. Pd arty 4.07 IndeDW on The Resident will defer from any d, indemnify and hold the Center harmless and all claims, demands, suit and actions made a resulting from any damage or injury caused against the Center by any person person or entity (including the Center), except in the Resident to the case of negligence of the the properly of any and agents. Center's employees s .•-..v ??r •IpG JVL LI LVVI\1 lll/ IV•Jr IIIIJILIV7 07/27/2007 11:33 7177372189 r.u17 MANORCARE,CAMPHILL PAGE 19 4.08 Ck-M&Mk the Law_ An or unenfo y Provision of this Agreement that is found to be invalid rcesble .Is a result of a change in state or federal law. will not invalidate the rem ' ' provisions of this Agreement and, it is a suur?g Center will continue to fulfill their weed that to the extent possible, the Resident and the law. respective obligations under this Agreement consistent with the THE UNDERSIGNED CERTI)H'Y AND A EACH READ AND UNDERSTOOD T CKNOWLEDGE THAT THEY HAVE THEY HAVE BAD AN OPPORTUMTY FOREGOING AGREEMENT, AND THAT ASK QUESTIONS HAVE BEEN ANSWERS oTTHEy R ATISFA ONS AND THAT ANY CTION. Signature of Resident: Date: Signature of Responsible Party: ea-G0? -e-l / Date: e? Center Representative: Date: of - l ?p ? -fp. -? ,-?? -,-. Q? ' ? i T 1" (?1- lyLJ V' o v ?y ?''' ? ?., ? _°? ??' ??? tir ??,? =< O X 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. 08482 Civil Term CIVIL ACTION - EQUITY PRAECIPE FOR ENTRY OF APPEARANCE TO THE PROTHONOTARY: Kindly enter the appearance of the following SCHUTJER BOGAR LLC attorney as counsel of record in the above-captioned matter: Brandon Williams SCHUTIER BOGAR LLC 417 Walnut Street, 4t Floor Harrisburg, PA 17101 Attorney I.D. No. 200713 (717) 909-5922 Dated: Z By: ?°- Brandon Williams ORIGINAL a 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, certified, return receipt requested, postage prepaid, upon the following: Sarah E. McCarroll, Esquire GATES, HALBRUNER & HATCH PC 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Attorney for Defendant Date: 0 William Keslar, Paralegal 2 t__, a7a C LL w C;1 David D. Bueff Prothonotary KirkS. Sohonage, ESQ, Solicitor 7759 2"d(Deputy prothonotary Office of the 1Trothonotary Cumberland County, Pennsylvania "7 04Z CIVIL TERM ORDER OF TERMINATION OF COURT CASES AND NOW THIS 25TH DAY OF OCTOBER, 2011, AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE -THE ABOVE CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R.C.P 230.2 BY THE COURT, W§nee X Simpson 1" Deputy prothonotary Z? 0 Irene E. Worrow DAVID D. BUELL PROTHONOTARY One Courthouse Square 9 Suite 100 • Carlisle, PA 17013 0 (717) 240-6195 • Fa.X (717 240-6573