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HomeMy WebLinkAbout08-0483IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, V. No. 0%- qT5 O'N i l Term 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 EN MEDIATAMENTE. 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, No. 0 8• 4 P 3 C,-? --r-.1-- 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 Petitioner's skilled nursing facility. 3. On or about January 25, 2006, Defendant Traver made application for admission to Plaintiff ManorCare's skilled nursing facility. 4. On or about January 25, 2006, Plaintiff ManorCare and Defendant Traver entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Traver 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 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 Thirteen Dollars and 17/100 ($50,213.17)1 plus current costs and attorney fees as provided for in the Agreement in the event of a breach. See Exhibit "A." 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 in accordance with the terms and conditions of the Agreement. 1 Because Lois Traver is a current resident, the outstanding amount owed will continue to increase each month by approximately $6,500.00. 2 9. Defendant Traver has failed to fully compensate Plaintiff ManorCare for the care and services that it has provided to her and continues to provide to her. 10. The breach of Defendant Traver has caused Plaintiff ManorCare to incur damages in the amount of Fifty Thousand Two Hundred Thirteen Dollars and 17/100 ($50,213.17) 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 Thirteen Dollars and 17/100 ($50,213.17) 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: By: Chadwick O. Bogar Attorney I.D. No. 83 55 (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 3 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 unsworn falsification to authorities. Dated: 4_r,%kx- Audry H Office Manager ManorCar ealth Services - Camp Hitt EXHIBIT "A" i UOLUIlime JUL-CI CUUIIr F 97/27/2007 11:33 7177372189 HCR Manor Cage f l f f](CI(,J MANORCARE,CAMPHILL AAMISSION AGRE M NT PAGE 02 Pennsylvania This Agreement is entered into by and among Nghtingale Nursing Home, Inc., d.b.a. HCR Manor Care f-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 dis HCR Maxtor Care's Center ("Center"). Center: ManorCare Health ervices Cam Hill Resident: m Responsible Party: 1 Admission Date: qnZJ A Deposit: Term: This Agreement begins on the day the Resident enters 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 RIGHTS AND RESPONSIBTI<,T US OF THE RESIDENT 1.01 Room and Board R?te. 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 Sectio;a 1.05) or by a third party payor or managed care organization (see Section 1.06). 1.02 AncillaU Charges. The Resident will pay to Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal -care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. 1 .11- .IUL-LI LUUitrrci) iu;ju 67/27/2897 11:33 7177372189 r.UU-1 MANORCARE,CAMPHILL PAGE 03 1.03 Col:.ectionsA.ate Payments. Payment is due in full within thirty Should the Resident's account for any reason be turned over for collection, a Resident will lpa the Center's collection costs, including attorney's fees. y 1'04;pendent 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 in accordance with the terms of the program. 1.05 CY0v=MMW prWams If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administr the Center participates in such program, the Center will accept payments ation, and under such at accordance with the terms of the program as set forth in the contract the Center has with mthe program. The Resi.dent 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 programs; _x_Medicaz _x-Medicaid Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there .is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident 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 covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate firom their monthly income. The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determin(A 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 P a ors and Mana ed Care Or anizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO" Preferred Provider Organization ("PPO"), provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 uu ?Cl . -,a JUL L I LUU I %I M& / I U. J4 - 97!27/2007 11:33 7177372189 I I 1 IJILIU7 r. UUU MANORCARE,CAMPHILL PAGE 04 will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or cover,?d by that third party payor including charges not paid within a reasonable period of time. I.07 Private Pay Rem, The Resident is 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 any governmental program or covered under any third party payor or managed :are organization plan. The Resident and/or Responsible Party notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make ;prompt application to Medicaid for. benefits. The Resident and/or Responsible Party will notify &!' Center in writing when application to Medicaid is made. The Resident and/or Responsible Parry 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 Add ..fission Information. The Resident and/or Responsible P Center and provide any needed information regarding all third Party PaYors Or ?Y will notify the coverages on admission and throughout the Resident's stay including copies of insurancercardss,, identification or verification of eligibility and coverage information. The :resident and/or Responsible party will provide the Center in writing with non-chin five 5 da of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associattbd with the failure to provide such notice in accordance with the terms and conditions of this Agreement- 1.09 Am i udion for Benefits. The Resident and/or Responsible Party ll apply coverage and to establish eligibility under any governmental, third party insurance prclgram. The Center has no obligation to bill an third ate' managewid care orfor the Responsible Patty and, when applicable, a governmental oam lthirdpaaor other than managed care organi;ation with which the Center is under contras party payor or I.10 Prima Resoonsibility for P___ av_ment Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third Ply. The Resident and/or Responsible Party acirnowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 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 uu - I -"p L I LUU I %I 111 / J4 III IJILIU7 1". UU7 07/27/2007 11:33 7177372189 MANORCAREICAMPHILL PAGE 05 governmental payor, third party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A pri Ii of se is is maintained at the Center's business Office and is available for review ce during St regular rv ce hours. business 1.11 Per;,onai Ph simian The Resident has the right 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 ??enter. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes admission, the Resident and/or Responsible P physicians at any time after physician's name. If the physician chosen by th Remust sident immediately ils to provide tneeded Center of cover e and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1-12 Pharr. The Resident -arid/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's poIiciea and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. IL RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY 2.01 .Legal Authority. The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, been delivered to the Center. if any, have 2.02 A,gre,;ment to Make Payments on Behalf of Resident. The Responsible Party will PRY promptly from tie 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 RKW, Ated m5 The Responsible Party will be personally liable for any services or products specificzlly requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhat, 'on of esiderrt'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 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 timely 4 UUIC/ I I".a JUL LI LUUI%I nl/ IU. Jµ I I t I J I L l U] t'. UUQ 97/27/2007 11:33 7177372189 MANORCARE,CAMPHILL PAGE 06 and proper manner, 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 Coa erati n for Financial Assistance If the Resident is eligible for Medicaid, the Responsible Party 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 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 Accr; tance U on ischar e. 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 Additional Res oasibilities. 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 ofReside t Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise ill ally Responsible Party's obligation to make transfers assets for purposes of avoiding or for purposes of cuaIi payments on behalf of the Resident under Section 2.02 t fying the resident for Medicaid eligibility, the Responsible P liable to the Medicaid agency and/or the Center for care that should have been paid for fr mythe 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. ELL RIGHTS AND RESPONS.IBILITItES OF T1FIE CENTER 3.01 Roorz: and Standard Services As Part of the Room and Board Rate, the Center will furnish basic T,?om, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other cM1ces. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. . UU1_c1 111110 JUL-L I -LUU I k I R 1/ I U. JtI 07/27/2007 11:33 7177372189 ?????????? r.UU1 MANORCARE,CAMPHILL PAGE 07 3,03 DPe >o9 The Center acknowledges receipt of the ,Deposit,' any, noted at the beginning of this A,greemnt The Deposit will be applied to the charges for the first month of the .Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance Payments the Center within thirty (30) days after discharge or transfer or within the t meframe required b State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) da s of the Center's receipt of the final Medicaid payment for care of the Resident. y n'- GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release 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 payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; ar.d any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Responsible P disclosure of Resident's protected health information for the purposes of `consent re the use and the Center, obtainin g payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, authorizes the appropriate staff of the Center to perform such function?care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathin hygiene, general nursing care, the administration off medicatio srandntreatments, and the daily activities; and therapies, as prescribed by the Resident's personal physician in the Resident's Platt f Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resilient 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 COMM to P oto ra h. 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 Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of ervices. Policies and addonal Information- The Resident and/or Responsible Party acknowledge that the items fisted below have been explained and have received copies of the items or policies and procedures, if applicable. The .Resident and/or Responsible 6 C UOLC/ I I IIIC JUL-L I -LUU I k I R1 / I U; 34 X77/27/2007 11:33 7177372189 r.uu0 MANORCARE,CAMPHILL PAGE 08 Party acknowledge 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 Determination 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 and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-1 and F-2. e. Center Supplement: 1. Policy and 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 numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman Program, the protection and advocacy network and the Medicaid fraud control un.it. 5. The name, specialty and way of contacting the attending physician, medical 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, mistreatment and misappropriation of property. f 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 N UULv ILINr JUL-LI-LUUIkr R1/ IU;)a F17I27/2087 11:33 7177372189 iiir3rciay r.UUIJ MANORCARE,CAMPHILL PAGE 09 Receipt of information on advance directives including a copy of ',Refusal of Life Sustaining Treatment" Limited , which summarizes HCR Manor Care's Treatment Practices and a copy of the governing the Resident's right to direct his/her medical treatment, Seems Attachments G-j. and G-2. l Privacy Act Notification. See Attachment H. k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and I-2. 1. Ancillary Services Management .Form. See Attachment J. 4.05 Assi:nment 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 Agreement Resident's behalf fer any service furnished by or in the Center. TThsident and/r Resident Responsible Party authorize the: 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 ply payors any information needed to determine these benefits or benefits for related services. 4.06 Tenrim .o D' har a and Transfer. This Agreement forth below and as set forth in the Resident Handbook under Section H terminated set The Resident and/or Responsible Party may terminate this Agreement raving "Discharge"' the Cent written. notice of the Resident's desire to leave at least sew ( days inadv nr a 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 will be responsible for all charges for the Room and Boar: d Rate and for all services performed t h admission ends. Discharge from the specialized units such as the Transitio the day that the Subacute Unit may require less than seven (7) days notice. Care Unit or If discharge or transfer becomes necessary because the Resident and/or Responsible P someone else abused the Resider's funds, the Center will request that local, state and fed al authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by an person resulting from any dEmage or injury caused by the Resident to any person or the property son person or entity (including the Center), except in the case of negligence of the Center's employees and agents. UULCI 1 1111C JUL-L I -LUU I %I F NI / I U. JLL rrrr?rLio? 17/27/2007 11:33 7177372189 r.uru MANORCARE,CAMPHILL PAGE 10 4.08 Changes in the Law. Any provision of this or unenforceable Es a result of a change in state or federal law ?l nothinvalxdatethe remainind provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligation law. s under this Agreement consistent with the THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUES77ONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: 4,vo-c-, Date: aw (f Signature of Responsible Party: Date: Center Representative: Date -JA-5 0 ?(o 00 r°1 Sli W 0 - te.-*? RJ f`J r C-J- IL %%. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, V. No. 08-483 Civil Term LOIS TRAVER, Defendant. CIVIL ACTION - EQ f= N) PRAECIPE FOR ENTRY OF APPEARANCE - TO THE PROTHONOTARY: Kindly enter the appearance of the following SCH"ER 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 (717) 909-5922 r Dated: ll?vlo a By: tit. 1, 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, 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: to William Keslar, Paralegal 2 (David D. Buell Prothonotary Kirk,S. Sohonage, ESQ Solicitor knee X Simpson 15` Deputy Prothonotary Irene E. Morrow 2" Deputy Prothonotary office of the 1tothonotary Cumberland County, Tennsylvania O e - '7 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, DAVID D. BUELL PROTHONOTARY One Courthouse Square • Suite 100 • CarCisCe, PA 17013 • (717 240-6195 0 fax (717 240-6573