HomeMy WebLinkAbout03-10-09IN THE COURT OF COMMON PLEAS -CUMBERLAND COUNTY
ORPHANS' COURT DIVISION
O.C. No.
IN RE: GOLDIE M. HURLEY,
Deceased PETITION FOR ACCOUNTING
. AND TURN OVER OF BENEFITS
Filed on Behalf of:
Presbyterian Senior Living d/b/a Green
Ridge Village
Counsel of Record for This Party:
SCHUTJER BOGAR LLC
Nicole M. Kerns
PA. I.D. #206827
(412) 281-3511
Marijane E. Treacy
PA. I.D. #84070
(412) 281-3535
U.S. Steel Tower
600 Grant Street, Suite 3290
Pittsburgh, PA 15219
Fax (412) 281-0530
Chadwick O. Bogar
PA. I.D. #83755
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
(717) 909-5920
Fax (717) 909-5925 ~~
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IN THE COURT OF COMMON PLEAS -CUMBERLAND COUNTY
ORPHANS' COURT DIVISION
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IN RE: GOLDIE M. HURLEY, ~ ~.-~
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Deceased O.C. No. a~ ~ ~ d~~ -`= ~ ` ~ --'
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PETITION FOR ACCOUNTING AND TURN OVER OF BENEFITS
Petitioner, Presbyterian Senior Living d/b/a Green Ridge Village ("Green Ridge
Village"), is a creditor of Goldie M. Hurley ("Ms. Hurley"), and hereby respectfully represents
that:
1. Ms. Hurley was admitted as a resident of Green Ridge Village, a skilled nursing
facility, located at 210 Big Spring Road, Newville, Pennsylvania 17241, on or about April 24,
2007. A true and correct copy of the Admission Agreement (the "Agreement") is attached hereto
as Exhibit "A."
2. On or about February 9, 2009, Ms. Hurley passed away.
3. Daryl Hurley is Ms. Hurley's son and her Power of Attorney before she died. A
true and correct copy of the Power of Attorney is attached hereto as Exhibit "B."
4. Upon information and belief, at all times relevant hereto, Daryl Hurley exercised
control over Ms. Hurley's monthly pension, annuity, and social security benefits, as agent-in-fact
for her.
5. Presently, Ms. Hurley's account with Green Ridge Village has an outstanding
balance of twenty-nine thousand, two hundred one dollars and thirty-seven cents ($29,201.37).
This amount increased by approximately two thousand two hundred thirty-one dollars and one
cent ($2,231.01) each month before Ms. Hurley's death as Daryl Hurley failed to forward it to
Green Ridge Village. Said amount consisted of Ms. Hurley's monthly pension, annuity, and
social security benefits as directed by the Cumberland County Assistance Office as a condition
of her receipt of Medical Assistance benefits. A copy of the form PA 162 awarding Ms. Hurley
Medical Assistance benefits retroactive to August 5, 2007, and outlining her monthly patient pay
obligation is attached hereto as Exhibit "C."
6. Despite repeated requests, Ms. Hurley's agent-in-fact, Daryl Hurley, has refused
to bring the above-referenced account current by turning over Ms. Hurley's monthly income, as
required by the Medical Assistance Regulations.
7. Pursuant to the Admission Agreement, at all times material hereto, Green Ridge
Village has had an immediate right to the possession of Ms. Hurley's monthly income. See
Exhibit "A."
8. Upon information and belief, Daryl Hurley, Ms. Hurley's agent-in-fact, used Ms.
Hurley's income for purposes other than paying for services provided to his mother by Green
Ridge Village.
9. Daryl Hurley failed to use his mother's income for her support, which is a
violation of his fiduciary duties as her agent-in-fact, and is the basis for the imposition of a
surcharge against him. See In re: Paxson Trust I, 2006 Pa. Super 9, 893 A.2d 99 (2006); In re
Estate of Novosieleski, 2007 Pa.Super. 292, 937 A.2d 449 (2007).
WHEREFORE, Petitioner requests that this Honorable Court issue a citation directed to
Daryl Hurley to show cause, if any there be, why an Order should not be entered requiring him to
file a full and complete accounting of all transactions undertaken by him with respect to Ms.
Hurley's monthly income from the time she was admitted to Green Ridge Village until Ms.
Hurley's date of death on February 2, 2009, directing him to turn over to Green Ridge Village
said income to bring Ms. Hurley's account balance current, and surcharging him for breach of
his fiduciary duties as agent for Goldie Hurley.
Dated: ~-~~" Q 2 bU~l
Respectfully submitted,
SCHUTJER BOGAR LLC
By ~~Cc ~ e ~nJ
Nicole M. Kerns
PA. LD. #206827
(412) 281-3511
Marijane E. Treacy
PA. I.D. #84070
(412) 281-3535
U.S. Steel Tower
600 Grant Street, Suite 3290
Pittsburgh, PA 15219
Fax (412) 281-0530
Chadwick O. Bogar
PA. I.D. #83755
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
(717) 909-5920
Fax (717) 909-5925
Attorneys for Petitioner
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L®1`~G'TERIVI CARE ADIVIISSI~I~I AGREEI~ZEN~'
I. INTRODUCTION
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This A ~eement is betti~Jeen ~ ~~ ~`~ ` ~,~ u1~'~~
Resident, or ~ U ~ ,Resident's Representative (referred to as Resident
in the Agreement) and ,~ ~(~-~,~ Health Center, a licensed Long
Tenn Care Facility (refereed to as Health Center in this Agreement), for admission of Resident to
the Health Center on , 20 ~ .Date)
Resident requests occupancy of Room / , a room for occupancy of
residents at a Daily Rate of $~_• Resident may request a room change and the Health
Center will make every effort to honor such requests as soon as possible. However, a room
change may result in a change in the Daily Rate upon occupancy of the new room. In the event
of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any
change, thereby giving Resident sufficient time to request a room change (for example from a
private to asemi-private room) or to transfer to another nursing facility.
The Health Center agrees to accept payments from Medicare and other contracted third
party payers for Resident's stay if Resident meets all qualifications required by Medicare or other
third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by
Medicare or other third party payers.
If Resident qualifies for Medical Assistance ("MA"), the Health Center agrees to accept
the Patient Pay Liability (as defined below) as determined by the County Assistance Office with
the balance of the payment for covered services coming from the MA Program.
II. DEFINITIONS
A. Daily Rate. The rate the Health Center charges a private pay resident for room
and board, general nursing care, housekeeping services, linen services, nutrition
management, limited in-room storage of Resident's personal belongs, and
recreational programs for each day a Resident is at the Health Center. Physician
sei-~~ices are not included in the Daily Rate.
B, Healtl~.care Sierrogate. .An adult who is appointed to malte healthcaT-e decisions
for Resident ~~~hen Resident becomes unable to make them for him/herself.
C, ~1ledical Director. The physician designated by the Health Center to be
responsible for resident care policies and the coordination of medical care in the
IIealth Center.
D. Clinical Records. All records (excluding financial recoi_ds) pertaining to a
particular Resident that are prepared and maintained by Health Center.
g. Patient Pay Liability. The amount of personal fields, as determined by the
Conmionwealth County Assistance Office, that a Resident who is receiving MA
must pay monthly to the Health Center in addition to the payment from the MA
program.
F. Personal Needs Ser-vices. Personal services such as telephone ser~~ice, laundry,
beauty and hair care (exclusive of routine assistance with grooming), and
newspaper delivery provided by the Health Center to Residents for their
convenience at Residents' expense.
G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of
the Health Center from his/her own resources (including private insurance and
Medicare Part B) and who is not covered by or has exhausted Medicare Part A
and MA coverage.
H. Resident Funds. Personal funds of a Resident that the Resident has authorized in
writing that the Health Center shall manage for the Resident.
I. Resident's Representative. A person who is responsible for malting decisions on
behalf of the Resident and has been so designated in witting by the Resident or a
court of competent jurisdiction. If a Guarantor Agreement is attached to this
Agreement, the Resident's Representati~~e is only obligated to make payment
from the Resident's personal funds. Reference in this Agreement to Resident
shall also include, as appropriate, the Resident's Representative or other person
authorized to act on Resident's behalf.
T, Skilled N~.crsing Care. Professionally supervised nursing care and related medical
and other health services provided to an individual not in need of hospitalization,
but whose needs are above the level of room and board and can only be rnet in a
long-tend care nursing facility on au inpatient basis because of a.ge, illness,
disease, injury, convalescence or physical or mental infinlzity.
K. Specialt~~ Care Ser-vr'ces. Medical services ordered by a physician for a Resident
that are not included in the Daily Rate. Medicare and Medicaid each include
certain Specialty Care Services in the per diem rates, but neither include all such
services.
L. Transfer acid discharge. Movement of a resident to a bed outside of the certified
facility or unit whether that bed is in the same physical plant or not: Transfer and
discharge do not refer to movement of a resident within the same certified facility.
III. HEALTH CENTER OBLIGATIONS:
The Health Center will:
A, provide, as part of the Daily Rate, room and board, general nursing care,
housekeeping services, linen services, nutrition management, limited in-room
storage of Resident's personal belongings, and recreational programs. General
nursing care does not include private duty nursing.
B. provide Specialty Care Services ordered by Resident's treating or attending
physician. Although additional fees for specialty services m.ay be covered by
third party payers, the Specialty Care Services identified on Exhibit A are not
included in the daily rate, and are billed at the rates set forth in Exhibit A. Any
items ordered by a physician, v~~hich are not identified on the Exhibit A will Ue
provided at charges identified by the Health Center prior to the delivery of the
service.
C. provide Personal Needs Services, at Resident's expense (at the rates set forth on
the Fee Schedule attached as Exhibit A) and at Resident's request, including but
not limited to:
1. Beauty/Barber Services
2. Neti~jspaper delivery and personal reading materials
3. Local and Long Distance Telephone Services
4. Cable Services, depending on cable provider
5. Personal laLUldry, dry cleaning and mending
6. Personal clothing.
D. provide safekeeping of Resident Funds, if authorized in writing by the Resident,
and make those funds available, at Resident's request, during normal business
hours.
1. Resident may manage his/her financial resources if (s)he wishes.
2. Residents may keep a limited amount of funds at the Health Center, the
maximum amount, which is specified from time to time by the Health
Center.
3. Requests for withdrawals in excess of $50.00 require advance notice to
assure availability of cash at the Health Center. Resident Funds shall be
retained in compliance with State and Federal regulations. Resident Funds
exceeding $50.00 shall be placed in an interest bearing account. A written
quarterly statement of these funds shall be provided to Resident. Resident
agrees to retuni signed copy to facility if required.
E. provide refunds of unused advance payments and Resident Funds within thirty
(30) days after deductions for payment of any outstanding bills or other amounts
due the Health Center after Resident's discharge or death. In the event of
Resident's death, refunds ti~~ill be made to the authorized representative of
Resident's estate.
F, assist Resident in applying for and obtaining p2-ivate insurance and/or public
benefits to cover the cost of the Resident's care.
G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of
the Health Center only for medical reasons, for Resident's welfare, because the
safety or health of individuals in the Health Center is endangered, because the
Resident has failed, after reasonable notice, to pay for a stay at the Health Center,
or with the voluntary consent of Resident. Except in emergency situations, at~
least 11112-~y (30) days' notice will be provided to Resident and Resident's
Representative to assure that the transfer is safe and orderly. The Health Center
reserves the right and discretion to move Resident to another morn or bed within
certified parts of the Health Center consistent with the safety, care and welfare
needs of the Resident.
H. arrange for Resident's transfer or discharge upon the order of Resident's personal
physician when he/she dee2ns it necessary to receive services the Health Center is
not qualified to provide or at Resident's request.
I. honor Resident's Rights as outlined in the Department of Public Welfare
Ad2nissions Notice Packet (MA 401).
J. to the extent permitted by law, hold Resident responsible to pay for any damages
or injuries caused by Resident to other persons, residents or staff. To the extent
pernitted by law, Resident shall indemnify and hold the Health Center harmless '
from any claims, actions or proceedings against the Health Center resulting from
Resident's actions or omissions. Health Center will be responsible for loss of or
damage to Resident's personal property by Health Centex staff.
K. provide Resident with a locked drawer or box for Resident's valuables or for
medications retained for self-administration. Resident may self-administer
medications only in certain circumstances and may not have medications in
his/her room z~~ithout physician authorization.
L. provide Resident with a choice of pharmacy if Resident does not wish to utilize
the pharmacy provider desib rated by the Health Center. ~~~ith this choice,
pharmacy must provide medications in compliance «~ith all applicable laws and
under a delivery s}stem that is consistent with the one used by the Health Center,
must provide a monthly ~~~ritten profile of all drugs provided to the IIealth
Center's consultant pharmacist, and must be delivered fiom the provider
pharmacy in tamper-proof containers, directly to the Health Center's licensed
nursing staff.
M. provide Resident with a choice of attending physician who will provide medical
care during the Resident's stay at the Health Center and who shall comply with
the Health Center's rules, regulations, policies and procedures and all applicable
laws and credentialling standards. Resident may also designate an alternate
attending physician in the event that the primary attending physician is
unavailable. In the event that Resident's attending physician(s) are unavailable,
the Resident authorizes Health Center's Medical Director or other physician
designated by the Health Center to issue appropriate orders.
IV. RESIDENT OBLIGATIONS
The Resident agrees to:
A. by signing this Agreement, Resident certifies that (s)he is competent, and has
never been adjudged incompetent, and is entering into this Agreement of his/her
own free will.
1. I11 the event Resident has been adjudged incompetent, Resident's
healthcare suizogate will attest, in a separate document that (s)he has the
legal authority to act on behalf of the Resident.
B. provide the Health Center with all information about Resident's health status and
financial resources. Failtu-e to accurate]y identify resources and income, or the
submission of false infonnatioil may amount to a violation of law and may result
in the termination of this Agreement by and at the option of the Health Center.
C, provide the Health Center wit11 a copy of all cun-ent insurance cards. Resident
will provide the Health Center with changes in insurance coverage or financial
status in a timely warmer, and will update the information provided to the Health
Center from time to till~e, as requested. Resident understands that making
incomplete or inaccurate disclosures will be considered a breach of this
Agreement.
D. authorize the Health Center to provide care and treatment to Resident consistent
with the terms of this Agreement and to carry out the orders of the Resident's
treating or attending physician or of the physician designated by the Health
Center. Resident also authorizes the Health Center to obtain all necessary clinical
and/or financial information from the hospital or nursing facility from which
Resident may be transfemng.
E. authorize the Health Center to make Resident's Clinical Records available to
Health Center staff and agents. Resident also authorizes the release of the
Resident's Clinical Records to any other health care provider from whom
Resident receives treatment, to third-party payors of health services, and to any
managed care organization (MCO) in which Resident maybe enrolled. Resident
also authorizes the release to the Health Center of records prepared and
maintained by any third-party payor of health care services pertaining to health
care ser-vices rendered to the Resident by the Health Center. Resident also
acknowledges receipt of the "Release for Electronic Transmission of Minimum
Data Set" ("MDS"), which explains the MDS system of records using Resident
data. Resident's Clinical Records will remain otherwise confidential, and shall
not be made available to anyone other than Resident or authorized agents of the
state or federal govennnents without the express written authorization of Resident
or without a subpoena or other judicial order.
F. cooperate firlly wrth the Health Center and any third party payer to secure
pa}~rllent. Resident authorizes the Health Center to collect any payments made by
third parties on Resident's behalf directly fi-om the third party payer. Resident
also authorizes the Health Center to make claims, file appeals or d ievances, and
take other actions necessary and appropriate to secure receipt of third-party
pa}~Inents to reimburse the Health Center for its charges for the stay and care of
Resident to the fullest extent permitted by law. Provided that Resident may, but
shall not be required to authorize the Health Center to pursue grievances or
appeals on Resident's behalf under Pemisylvania's Quality ~Iealth Care
Accountability arld Protection Act, to the fullest extent pernitted by law and as
security for payment of the Health Center's charges, Resident hereby assigns to
the Health Center all of Resident's rights to any third-party payments now or
subsequently payable for services rendered by or provided under arrangement
through the Health Center.
G. pay the Daily Rate established for the accommodation requested. Payment is due
30 days in advance, and Resident agrees to make full payment by the first of each
month. Collection procedures are initiated after thirty (30) days of unpaid
balances. Interest shall be charged on unpaid balances.
1. If the Health Center initiates any legal actions to collect payments due
from Resident under this Agreement, Resident shall be responsible to pay
all attorney's fees and costs incurred by the Health Center in enforcing
Resident's financial obligations under the•Agreement.
2. This Agreement shall serve as an assignment to the Health Center of as
much of Resident's property as equals the amount of any unpaid
obligations under this Agreement, and this assigriznent shall be an
obligation of Resident's estate that may be enforced against Resident's
estate. Resident's estate shall be liable to and shall pay to the Health
Center an amount equivalent to any unpaid obligations of Resident under
this Agreement. This liability shall apply whether or not Resident is
occup}ping the Health Center at the time of Resident's death.
H, pay for additional items, services and equipment not included in the Daily Rate as
identified by the Fee Schedules, attached as Exhibit A.
I, understand that Resident will Ue notified thirty (30) days in advance of changes in
the Daily Rate except when Resident requests room change, changes in charges
for Specialty Care Services or Personal Needs Services, or changes in billing
procedures, and agree that the changes will be effective upon the .date designated
by the Health Center.
J. understand that the Resident may continue to live at the Health Center as long as
Resident continues to pay the Daily Rate. Resident may be discharged for non-
payment of incurred charges or transferred for the benefit of the Resident or
others, as set forth in Section III(H) of this Agreement.
K. acknowledge that non-payment of the Daily Rate for a private room will result in
a room change.
L. acknowledge that the Health Center has the discretion, with thiri:y (30) days'
notice, to transfer Resident to another room or bed within the Health Center
consistent with the safety, care and welfare needs of Resident. The Health Center
also has the discretion, upon thirty (30) days' advance notice, to transfer or
change Resident's roommate, if any, at any trine consistent with the needs of the
Health Center.
M. terminate this Agreement upon written notice to the Health Center, but if Resident
leaves for any reason other than a medical emergency or death, Resident must
give reasonable advance written notice to the Health Center.
N. notify the Health Center at least tu~o months before the Resident has insufficient
resources, funds or income to meet his/her financial obligations and to apply for
MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not
eligible for MA, Resident ab -ees to vacate the Health Center.
p, pay co-payments and/or deductibles for services cohered by the Medicare
Program or other third party payer, and pay the Health Center within thirty (30)
days of receipt of services for those services not covered by the Medicare
Program or other third party payer.
p, pay for items and services requested by Resident and not covered by MA within
thirty days of receiving the non-covered service.
Q. to the extent otherwise pemlitted by la~~,~, assume responsibility for any damages
or injtu-ies caused by acts or omissions of the Resident to other persons, residents
or staff' .
R. comply with reasonable rules, regulations, policies and procedures that the Health
Center establishes fiom time to time alld makes available to Residents, subject to
reasonable accommodation of Resident's individual needs and preferences. The
Health Center's rules, regulations, policies and procedures are for purposes of
internal management and shall not be construed as imposing contractual
obligations on the Health Center and are subject to change from time to time.
S. acknowledge receipt of the Resident Handbook, a document that provides
Residents with Health Center rules, regulations, policies and procedures.
T. acknowledge receipt of infomlation on Advance Directives in the absence of
providing the Health Center with an existing Advance Directive or Living Will.
U. provide the Health Center with a copy of any and all Durable Powers of Attorney,
Guardianships, and/or Advance Directives pertaining to the Resident.
V . aclaiowledge that (s)he has read and understands the teens of this Agreement, that
the teens have been explained to them by a representative of the Health Center,
and that (s)he has had an opportunity to ask questions about the Agreement.
V. MDDICARE AND A'IEDICAID
The Health Center is certified to participate in the Medicare and Medicaid Programs.
The Health Center's participation in these programs is subject to termination by either the Health
Center or the responsible government entity. The Pemzsylvania Departillent of Public Welfare
(DPW) is responsible for administering benefits under the Medicaid Program and the Centers for
Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program
tluough an intermediary. The Resident aclalowledges that the Health Center is not responsible
for and has made no representations regarding the actions or decisions of DPVd, CMS or the
Medicare intermediary in administering these programs.
A. Medicare
If Resident is eligible for benefits under the Medicare Program, Resident understands that
certain skilled nursing and related health care services maybe covered by Medicare. The Health
Center will bill Medicare Part A on behalf of the Resident for skilled nursing services and
payment will be made by Medicare Part A directly to the Health Center for services received by
Resident. When the Health Center notifies Resident that the nursing services being provided to
the Resident no longer qualify as a skilled service, the Resident may request that the Health
Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for
the charges incurred on the Medicare Part Anon-covered days.
The following describes coverage under the Medicare Part A Program:
1. Medicare Part A covers from one (1) to one hundred (100) days at the
Health Center. Coverage is not guaranteed and is limited to the unused
days in the Resident's benefit period. Conditions stipulated by Medicare
must be met for coverage to begin and remain in force.
2. The Medicare Part A Program pays for all covered charges from day one
(1) through day twenty (20) if the criteria for skilled service is met.
3. The Medicare Part A Program pays a portion Uut not all of the charges
from day twenty-one (21) through day one hundred (100). The Resident is
responsible for and shall pay any co-insurance or deductible amounts as
determined by the Medicare Part A program. Depending on the
circumstances, this payment may be made by personal health insurance,
MA, Or personal filllds.
4. The Medicare Part A Progu-am covers the following sen~ices: room alld
board, linens, meals, most prescription medications, therapy services, most
medical supplies, non-private duty nursing services, most recreational
sen~ices, most social services, and most personal hygiene items provided
by the Facility. (Note: only the t}~~e and brand of personal h}~giene items
provided bythe I-Iealth Center are included.)
5. Some items and sei~~ices not covered by the Medicare Pact A Program
include, but are not limited to: personal clothing, eyeglasses, hearing aids,
services of a beautician or barber, guest meals, special or altenla.tive meals
not required for therapeutic purposes or as a nutritional substitute, services
not deemed medically necessary, and personal telephone service. The Fee
Schedule for items and services provided to Medicare Part A eligible
Residents that are not covered by Medicare Part A is attached as Exhibit
A.
6. Bed hold days are not covered by the Medicare Part A Program. (See
Section VIL)
7. Residents covered by Medicare Part A should not go out on overnight
leave as this may disqualify them from further coverage by Medicare Part
A.
8. Residents may be covered for therapy and other ancillary services under
the Medicare Part B Program. The Health Center or provider approved by
Health Center will Uill Medicare Part B directly for these services. The
Residents are responsible for the annual deductible and the co-insurance
payment for Medicare Part B covered services.
9. Resident is responsible to pay the Health Center for services and supplies
not covered by the Medicare Program.
10. Ili the event that Medicare coverage is changed b}~ law, those changes v,Jill
control and take precedence over any contrary provision in this
Agreement.
B. Medicare AZaua~ed Care
The Health Center participates as a. provider of skilled nursing services under some, but
not all Medicare MCOs.
1. Requirements for eligibility for Medicare payments, deductibles and co-
insurance may be different from those discussed in Section V(A). Pre-
authorization of services is required by Medicare MCOs, and if the.,
Resident chooses to have services which the MCO refitses to pre-
autllorize, Resident shall pay the Health Center for those sen~ices. If t11e
MCO refuses coverage on the grounds that it does not consider an item or
service to be medically necessary, Health Center or MCO will provide an
Advance Beneficiary Notice of that determination. The Health Center will
communicate directly with .Resident's Medicare MCO to obtain
authorization for continued Medicare managed care coverage.
2. The Health Center will accept payment from the Medicare MCO as
payment in full only for those services and supplies covered by the
Medicare MCO. Resident is responsible for any copayments or other.
costs assigned to Resident or not covered by the MCO under the specific
teens of the managed care plan.
3. Resident aclnowledges that an MCO for which the Health Center is not an
authorized provider may not approve payment for services provided by the
Health Center, so that Resident maybe required to pay the Health Center
directly. Resident also acknowledges that the Health Center is not
responsible for and has made no representations regarding the actions or
decisions of any MCO for which the Health Center is an authorized
provider, including decisions relating to a deiual of coverage or refusal to
pay on behalf of the Resident.
4. The Health Center reserves the right to stop its participation in any MCO
at any time and in its sole discretion. To the extent practicable, the Health
Center will provide advance notice to Residents em-olled in a particular
managed care plan or insurance program of its decision to stop
participation in that managed care plan or insurance pro grain.
C. Medical Assistance Program
1. Residents who qualify for coverage under the MA Program must apply for
and be approved for these services at the County Assistance Office, It is
,Resident's responsibility to pursue MA coverage. Until approval of MA
coverage is obtained, the Health Center will consider Resident to be a
Private Pay Resident.
2. Resident will be required to use the Patient Pay Liability to pay the Health
Center for the Resident's stay in conjunction with the MA Program.
Periodic adjustments in the Patient Pay Liability are made by the County
Assistance Office and when issued, will supersede all previous
determinations. Resident shall arrange, if possible, for the designation of
the Health Center for direct deposit of any Social Security or related
benefits or any other income sources of the Resident in an amount not to
exceed the Patient Pay Liability.
3. MA program coverage includes the following: room and board,
prescrption and non-prescription medications, meals, linen service,
nursing services, incontinence care, social services, recreational activities,
personal laundry, a hair cut every six (6) weeks, a shampoo and set every
two (2) weeks, one permanent per year, and personal hygiene items
provided by the Health Center. (Note that only the type and brand of
personal hygiene items provided by the Health Center are included.) The
MA Program limits the fiequency of coverage for the purchase of
eyeglasses, hearing aids, and dentures.
4. The Health Center will not charge, solicit, accept or receive monies fi-om
or on behalf of Resident for bed hold days covered by MA Program,
except for the Patient Pay Liability, to cover the cost of Resident's stay or
as a condition of admitting a Resident under the MA Program.
5. Some items and services not covered by the MA Program include, but are
not limited to: personal telephone service, personal clothing, guest meals,
brand name personal hygiene items, and additional services provided by a
beautician other than those listed above. Resident is responsible for
charges incurred for these services at the rates listed on the Fee Schedule
attached as Exhibit A in addition to the patient pay liability amount.
6. Residents receiving MA coverage are permitted to keep the amount that
has been designated as the Resident's personal needs allowance for
personal spending. Personal funds maybe given to the Health Center for
safekeeping (see Health Center Obligations in Section III).
7. The MA Program provides for bed hold days for limited periods of time
during Resident's stay.
a) Up to fifteen days bed hold days are allowed when Resident is
transferred to a hospital.
b) Up to thirty days bed hold days are allowed annually for
intermittent therapeutic leave from the Health Center.
c) The bed hold days referenced above are based upon the law in
effect at this time, and may be subject to change if the governing
state law is changed.
8. The Health Center provides equal access to its services to all individuals,
regardless of payor source.
VI. TI3IRD-PARTY PAYMENTS
A. If Resident is or becomes eligible to receive financial assistance or reimbursement
from any third pasties (such as private insurance, employee benefit plans, MA,
Medicare, managed care coverage, supplemental medical or other health
insurance, supplemental security income insurance, or old-age survivors' or
disability insurance), the Health Center resen~es the right to collect such payments
directly from the third-party. Resident shall cooperate fully with the Health
Center and each third-party payor to secure payment, a11d Resident shall designate
the Health Center, to the extent permitted bylaw, as the recipient of direct deposit
for receipt of Federal Social Security benefits or any other Federal or State
govenunent assistance, reimbursement, or benefits to the extent of all amounts
due the Health Center.
B. Resident authorizes the Health Center to inalce claims and to take necessary
actions to secure receipt of third-party payments to reimburse the Health Center
for its charges for the stay and care of Resident. To the fiillest extent permitted by
law, as security for payment.of the Health Center's charges, Resident agrees to
assign to the Health Center Resident's rights to any third-party payments now or
subsequently payable to satisfy all charges. due under this Agreement. Resident
shall endorse and turn over to the Health Center any payments received from
third-party payor to the extent necessary to satisfy the charges under this
Agreement.
C. In the event of any denial of coverage by the Resident's insurance company,
Resident shall pay the facility for all non-covered services retroactive to the date
of the initial delivery of services.
VII. RT+~ADIVIISSION -BED HOLD POLICY
A. A Health Center representative shall corrununicate with Resident regarding
his/her desire to continue to occupy the Health Center bed during hospitalization
or therapeutic leave. Verbal consent shall be given to the Health Center
representative who shall document this consent in the clinical record. Written
consent shall Ue obtained following the verbal consent. See Fee Schedule (Exhibit
A) for bed-hold rates.
B. Bed holds- for Residents eru-olled in the MA Pro~-am are subject to the provisions
of Section 5(C)(7).
C. Resident's belongings shall be removed fiom the Health Center within 24 hours if
Resident does not execute a bed hold authorization. Belongings not removed in a
timely fashion play be packed and stored.
VIII. CIVIL RIGHTS COMPLIANCE
All Presb}~terian Homes, hic. facilities, including the Health Center, are open to all in
need of sei-~~ices and are not'restricted to members of the Presb}~terian Church. It is the policy of
PHI facilities to achi~it and to treat all residents without regard to race, color, national origin, age,
ancestry, sex, religious creed, handicap, limited English proficiency, or disability. The same
requirements for admission are applied to all; and residents are assigned without regard to race,
color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed,
handicap, limited English proficiency, or disability. There is no distinction in eligibility for, or
in the manner of providing, any service provided by or through the facility. All facilities -are
available without distinction to all residents and visitors, regardless of race, color, national
origin, age, ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited
English proficiency, or disability. Roommate preference requests, staff assigmnent to residents
and resident ancestry, sex, sexual orientation, marital status, religious creed, handicap, limited
English proficiency or disability. All persons and orgaiuzations that have occasion either to
make referrals for admission or reconunend a PHI facility are advised to do so without regard to
race, color, national origin, age, ancestry, sex, sexual orientation, marital status, religious creed,
handicap, limited English proficiency, or disability.
IX. REGULATION
The Health Center and Resident recognize that Health Center is licensed by the
Pennsylvania Department of Health and is regulated by the DPW. The Health Center and
Resident recognize that Health Center is also regulated by CMS of the United States Department
of Health and Human Services. Both pasties recognize that regulatory changes nlay alter the
conditions of this agreement.
~. G7E2IE~'ANCI+; PROCEDURE
If Resident believes that Resident is being mistreated in any way or Resident's riglrts
have been or are being violated by staff or another resident, on in any other way, Resident play
submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow
the Health Center's grievance procedure as described in the Resident Handbook. The Health
Center's grievance procedure does not preclude Residents from pursuing grievances with
appropriate regulatory agencies.
~I. ARBITRATION
Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or
concealing any rights arising thereunder or the breach thereof shall be settled e~:clusively by
arbitration, which shall be conducted at the Health Center in accordance «~ith the American
Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for
Arbitration. Judgment on the av~rard rendered by the arbitrator shall be binding on both parties
and may be entered in any court having jurisdiction thereof. Provided, however, that this
arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a
resident under the Medicare or MA programs or an applicable state law.
XII. GOVERNING LAW
This Agreement shall be governed by and construed in accordance with the laws of the
Commonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit
of each of the undersigned parties and their respective heirs, personal representatives, successors
and assigns.
XIII. SEVERABILITY
The various provisions of this Agreement shall be severable one from another. If any
provision of this Agreement is found by a court or administrative body of proper jurisdiction to
be invalid, the other provisions shall remain in full force and effect as if the invalid provision had
not been a part of this Agreement.
XIV. ENTIRE AGREEMENT
This Agreement represents the entire understanding between the parties, and supersedes
all previous representations, understandings or agreements, oral or «Tritten, between the parties.
~V. 1!'IODII'ICATIONS
The Health Center has the right to modify unilaterally the terms of this Agreement to the
extent necessary to confonll to subsequent changes in law or regulation. To the extent
practicable, the Health Center will give Resident and Resident's Representative thin}~ (30) days
advance written notice of any such modifications.
~~TI. WAIVER OE PROVISIONS
The Health Center Executive Director reserves the right to waive any obligation of
Resident under the provisions of this Agreement in its sole and absolute discretion. No tei~il,
provision or obligation of this Agreement shall be deemed to have been waived by the Health
Center unless and except to the extent that such waiver is in writing by the Health Center. Any
waiver by the Health Center shall not be deemed a waiver of any other term, provision or
obligation of this Agreement, and the other obligations of Resident and this Agreement shall
remain in full force and effect.
Signatures
This Agreement and any addenda to this A,~ -eeinent constitute the entire Agreement and
understanding between the Health Center and the Resident with respect to the subject matter of
this Agreement and supersede all prior Agreements and understandings. There are no
Agreements, understandings, restrictions, warranties, or representations bet«~een the Health
Center and the Resident other than those set Forth in this Ab-eement, or incorporated in this
Agreement by reference. This Agreement play be amended only by a document in writing
sib led by the Resident and the Admii>istrator or Executive Director, gild no act or omission of
any employee or agent of the Health Center shall alter, change or modify any of the provisions of
this Agreement.
~ ~-~.~
A 'nistrator or Executive Director Date
Resident Date
` I .(~~
~~ x / d~
Reside~:t Repre tative Date
~~~~~~ ~
Witness Dat
I, GOLDIE M. BURLEY; widow, of 2178 Newville Road; Carlisle; Pennsylvania, do
hereby nominate, constitute, and appoint my son, DARYI: L: $URLEF, of 466 Crossroad
School Road, Carlisle, Pennsylvania, my true and lawful attorney-in-fact, to aci in, manage, and
coirducE all my estate and all my affairs, for me and in my name, place, and. stead, and for my
bene£rt, and as my act and deed; to do and perform any that I miglrt legally perform through an
attorney-in-fact or that I myself might perform if I were present, including, but not limited to, the
following;
1. To buy, receive, lease, accept, or otherwise acgnire;. to sell, convey, mortgage,
hypothecate, ledge, gratclaim, or otherwise eneutnber or dispose of or to contract or agree for the
acquisition, disposal or encumbrance of; any property wltatsoeyer and wheresoever situated, be it
real, personal or mixed, or any custody, possession, interest, or right therein or pertaining thereto,
upon such taints as my said attorney shall tltinkproper,
real 2. To take, hold, possess, invest, lease, or Iet, or otherwise manage any or art of my
, Personal, or mixed property, or any inteaest therein; to create a trust for my benefit; to eject
remove, or relieve tenants or other persons from; and recover possession of, such property by all
lawful means; ar_d to maintain, protect, Preserve, insure, remove, store, transport, repair, rebuiid,
modify or improve the same or any part thereof;
3. To make, do, transact all and every kind of business of what nature or kind soever,
including the receipt, recovery, rgllecdon, payment, compromise, settlement, and adjustment of aII
accounts, legaaes, bequests, interest, dividends, annuities, demands, debts, taxes and obligations,
which may now or hereafter be due, owing, or payable by me or to me•,
4. To make, endorse, accept, receive, sign, seal, execute, aclmowledge, and deliver
deeds, assignments, agreements, certificates, hypothecations; checks, notes, bonds, vouchers,
receipts, and such other instruments in writing of whatever kind and nature°as may be necessary.
convenient, or propel in the Premises; •
S. To deposit and withdraw far the purposes hereof, in either my said attorney's name
or my name or jointly in both names, or in a trust far my benefit, is or firm any banking or other
institution, any funds, negotiable paper, or taoneys, either principal or income, which may come
into my said attorney's hands as such attorney or which I now or hereafer may have on depositor
be entitled to;
6. To institute, prosecute, defend, compromise, arbitrate, and dispose of Iegal, equitable
or administrative hearings, actions, suits, attachments, arrests, distresses or other proceedings or
otherwise engage in litigation in cormection with the premises;
7. To act as my attorney or proxy in respect to any stocks, shazes, bonds, or other
investments, right or interests, I may now or hereafter hold;
8, To engage and dismiss agents, counsel, and employees, and. to appoint and remove at
pleasure any substitute for, or agenYofmy said attorney. is respect to all or any of the matters or
things herein mentioned and upon such terms as nzy attorney shall ~~ fi~
9. To execute vouchers in my behalf for any and ~ allowances and reimbursements
properly payable to me by the United States including but not restricted to allowances and
reimbursements for trarrsportation of dependents or for shipment of household effects as
authoriud by law or armed forges regulations, and to receive, endorse, and collect the proceeds of
checks payable to the order of the undersigned drawn on the Trcasurerof the United States;
orts, a~ li ado amaze' execute' and file income and other tax returns, and other government
~ PP ns. requests, and documents;
1 I . To take possession, and order the nemovat and shiP~4 of an of m
any post, warehouse, depot, dock, or ether 1 Y Y Property from
pnvaie; and to execute and deliver an reI P a~ of storage or safe keeping, governmental or
other instrument necessary or convenient for pipo~' ~rpt' ~PPn°g ~~' cernficate, or
12. I direct my attorney not sell any of my household goods or furnishing unless it shall
be necessary in order to provide adequate funds to pay for my reasonable living and medical
expenses. I direct that my attorney shall retain all such household goods and fi2rttishings as my
attorney believes I may crnzently need or need in the future In the event my attorney decors it
necessary to dispose of any household goods or furnishings not needed to be sold to raise money
for my care and not deemed to be needed by me currently or in the future, then I direct that all such
household goods and furnishings be given ro the person or persons to whom I have provided that
they pass either specifically or as part of the residue of my estate in my most recently executed Last
Will and Testament and that none be sold.
13. To do or perform those ppooveers enumerated and authorized by Pennsylvania Statute
pursuant to the Probate, Estates and liditciaries Code (20 Pa.C.S.A. ~ 5601 et seq.), including:
a. To make gifts or limited gifts;
b. To create a trust for my benefit and to make additions to an existing oust for my
benefit;
c. To claim an elective share of the estate of my deceased spouse;
d. To disclaim any interest in property;
e. To renounce fiduciary positions;
f. To withdraw and receive the income or corpus of a trust,
g. To anthorize~my admission to a medical, nursing, residential or similar facility
and to enter into agreements for my care and to authorize medical and surgical
procedures.
GIVING' AND GRANTING unto my said attorney full power and authority ro do and
perform all and every act, deed, matter and thing whatsoever in and about my estate, property, and
~~ as fly and effectually to all intents and purposes as I might or could do in trry own proper
person if personally present, the above spxtally enumerated powers being in aid and
exem~liftt:ation of the full, let and general power herein granted and not in limitation or
definition theaeoi and here Y ratify ng all that my said attorney shall lawfully do or cause to be
done by virtue of these presents.
AND I hereby declare that any act or thing lawfully done hereunder by said attorney shall
be bindixg on myself, and my heirs, legal and personal representatives, and assigns whether the
same shall have been done before or after my death, or other revocation of this instnimenty unless
and until tellable intelligence or notice thereof shall have been received by my said attorney.
DURABLE POWER OF ATTORNEX: THIS POWER OF ATTORNEY SHALL
NOT BE AFFECTED BY MY SUBSEQUENT DISABILITY OR INCAPACITY.
ff ineompeteneY proceedings for my person or estate are instituted, I here nominate my
attorney-in-fact above namtd as guardian of my person and estate. ~
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 3rd day of
7une,1993.
WITNESS:
~~ ~_ ~-
~1_ ffff,~.~
GoIdie M. Hurley
Social Secunty No.: 202-20-6988
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CIIMBEItLAND
} ss
On this the 3rd day of June, 1993, before me, the undersigned officer, personally appeared
Goldie M. Hurley, widow, known to me to be the person whose name is subscribed to the within
instrument, and acknowledged that she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
tt0?AFJ.Rf. stu.
~^IISTA xr,:s. rzarAar Puauc
CAFW.StE. CUTSE~ERLdfiD COfIHTY, PA
11Y C017AfF55tON £XPbZF'S JtfiiE 27, 79@4
v IYIL/1 V/11/
P.o. sox V599" ELIGIBLE
33 'WESTMINSTER DRIVE
CARLISLE PA 17013-0599 NOTICE
CAO RETURN ADDRESS CSLD 0036
*09090000000*
SCHUTJER BOGAR LLC
ATTN: MARIE MARCUS-BRYAN
305 N.FRONT STREET STE 401
HARRISBURG PA 17101
~~v a~~.c iv aL /.~7t517
'CO ;-RECORD`. DLST-~. CAT'--.GG :P5-'"
21 0115019 0 TAN 5 00
WORKER: s PEIPER
TELEPHONE: (717) 240-2700
MAIL DATE: 04/18/2008
NOT: 985 OPT: J TYPE: E
rvu w ~rv/ unutKSlaNU OUR DECISION OR HAVE ANY
PUESTIONS, PLEASE CONTACT YOUR WORKER IMMEDIATELY.
PAGE 1 OF 1
You have been determined eligible for benefits effective 08/05/2007 to 08/31/2007.
You disposed of a total of $ 6684.71 in assets without receiving fair
market value. This transfer results in a period of ineligibility for payment
of Medicaid/Services in a Long Term Care (LTC) facility. You are not eligible
for payment towards the cost of Medicaid/Services in an LTC facility
beginning on 08/05/07 and ending on 09/02/07 During this period, you
will be responsible to pay the LTC facility for the LTC services you receive.
You are eligible for all other Medicaid benefits. You can request an undue
hardship waiver if the denial of payment of Medicaid/Services in an LTC
facility would deprive you of medical care which would endanger your health or
life or if the denial of payment of Medicaid/Services in an LTC facility would
deprive you of food, clothing, shelter, or other necessities of life.
Citations: Pub. L. 109-171, 6011 and 601678.104 (d)
Pub. L. 31, No_ 21 41.5 and 55 Pa. Code 178.104 (d)
It you disagree with our decision, you have the right to appeal. See attached form
for a complete expalnation of your right to appeal and to a fair hearing. If you are
currently receiving benefits and your oral request for a hearing is received in the
County Assistance Office or your written request is postmarked or received on or
before 05/01/2008 your assistance will continue pending the hearing decision,
except when the change is due to State or Federal law.
GOLDIE HURLEY
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241
• ~~
CUMBERLAND CAO
P.O. BOX 599
33 WESTMINSTER DRIVE
CARLISLE PA 17013-0599
MIDPENN LEGAL SERVICES
401-405 LOUTHER STREET
CARLISLE PA 17013
Notice ID: 82759819
C0.';" ", RECD.6D D45T C'qT, GG P5
21 0115019 0 TAN 5 00
WORKER: s PEIPER
APPEAL: 05/01/2008
TELEPHONE: (717) 240-2700
MAIL DATE: 04/18/2008
NOT: 985 OPT: J TYPE: E
!F YOU WISH TO APPAL, C~N[PLETE, THE BACK OFT ~. FORM AND RET~7RhF THE BOTTONf -
PpRTI ON TO CAC . ,
PA NIAts2A ..CONTINUED nN RFVFRC~ cin~ ....__. ___
P.O/uBOX ~599~V ~v~~vi~,r-~u
33 `WESTMINSTER DRIVE ELIGIBLE
CARLISLE PA 17013-0599 NOTICE
CAO RETURN ADDRESS CSLD 0036
*07090000000*
SCHUTJER BOGAR LLC
ATTN. MARIE MARCUS-BRYAN
305 N.FRONT STREET STE 401
HARRISBURG PA 17101
rvvucC w• 25L /5y /Sy
CO RECORD'.'- DIST ,: CAT Y'GG:,.PS
21 0115019 0 TAN 4 00
WORKER: s PEIPER
TELEPHONE: (717) 240-2700
MAIL DATE: 04/18/2008
NOT: 985 OPT: s TYPE: E
IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY
OllESTIDNS, PLEASE CONTACT YOUR WORKER IMMEDIATELY.
You have been determined eligible for benefits effective 09/01/2007 to 09/30/2007.
You disposed of a total of $ 6684.71 in assets without receiving fair
market value. This transfer results in a period of ineligibility for payment
of Medicaid/Services in a Long Term Care (LTC) facility. You are not eligible
for payment towards the cost of Medicaid/Services in an LTC facility
beginning on 08/05/07 and ending on 09/02/07 During this period, you
will be responsible to pay the LTC facility for the LTC services you receive.
You are eligible for all other Medicaid benefits. You can request an undue
hardship waiver if the denial of payment of Medicaid/Services in an LTC
facility would deprive you of medical care which would endanger your health or
life or if the denial of payment of Medicaid/Services in an LTC facility would
deprive you of food, clothing, shelter, or other necessities of life.
Citations: Pub. L. 109-171, 6011 and 601678.104 (d)
Pub. L. 31, No. 21 41.5 and 55 Pa. Code 178.104 (d)
If you disagree with our decision, you have the right to appeal.
fnr ~ rr....r.l..~.. ...... _~__..__
currently receiving benefits and "" ""' "' '°" "eann li you are
your oral request for a hearing is received in the
County Assistance Office or your written request is postmarked or received on or
before 05/01/2008 your assistance will continue pending the hearing decision,
except when the change is due to State or Federal law.
GOLDIE HURLEY
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241
•_~r~
CUMBERLAND CAO
P.O. BOX 599
33 WESTMINSTER DRIVE
CARLISLE PA 17013-0599
I .~ ; it y>•~u, WISH TO APP~AE, CQMPLETE THE: BACK, t~,` T}~i!
PO~tfiiON TO'~~AO.=..
MIDPENN LEGAL SERVICES
401-405 LOUTHER STREET
CARLISLE PA 17013
PAGE 1 OF 1
Notice ID: 82759719
~
CO RECORD _- -UIST -CAT - GG- PS ' ~~
21 0115019 0 TAN 4 00
~~
~
WORKER: s PEIPER c
~. ~
~~ ~
c
~ c
APPEAL: 05/01/2008 ~ a
TELEPHONE: ~~ c
~~ ''
(717) 240-2700 ~
MAIL DATE: ~~ ~
04/18/2008
NOT: 985 OPT: J TYPE: E ~~
)RI~I AND :RETURN. THE. B' TT' }VI -. ---
- -~ ----
.__
PAMA162A ~. _, , CONTIIIlI IFII nfu RCV~o~~ ~~.,~
719
• THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTIC
LINE FIRST
NAME ACCESS/INDIVIDUAL NUMBER E
O1' GOLDIE 430190141 1
• THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS
LONG TERM CARE (LTC)
. YOUR COST OF
Calculation of Gross Monthly Income Calculation of Contribution t
d
owar
Cost of Care
Begin Date 09/03/2007
-
- - - -- - Begin Date
Earned Income
~ _ -
~ 09/03/2007
- -
- ---- -- ---- ----- --.
Gross Monthl
I
_
--- - - - -
y
ncome
Wages. Salary 00 --- ---------------
. Total Earned Income . 0 0
Self Employment oo
. Total Unearned Income
2369.51
Rental Income o 0
Income available first month . 00
Other . 0 0 ---- -- --
Deductions
Total Earned _ -- _J
Income:
• 00 __ _ _ _ ___
Personal Needs Allowance 45.00
Unearned ~ - -
InCOme I Guardianship Fee
.00
Social Security 882 s0 Total Allowance for Spouse /
Dependant .oo
SSI . oo Home Maintenance
.oo
Veteran's Benefits .0o Contribution towards
Cost of Care: 2324. sl
Pension 1487 . oo The LTC facility will deduct the following medical expense from
your
contribution towards Cost of Care
Railroad Benefits 00
. Medicare Premium 93.50
Workmen's Comp o0
. Other Insurance Premium .00
Black Lung 00
The LTC facility may deduct additional medical bills
Annuity/Trust
Payment
• 00 including supplemental health insurance premiums,
provided they are verified.
Interest /Dividend . of
Other (Rental, etc.) . 0 0
Total Unearned
Income: 2369 - sl
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
•---- DETACH HERE
DETACH HERE ------•
Please check one of the boxes to show which type of hearin ^ I want a ^ 1 want a
g you want: telephone hearing. face-to-face hearing.
^ Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability:
^ Please check if you need an interpreter What language?
NOTE: If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-39s0
I WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS
TELEPHONE NO. DATE
PALTC162B
VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing document
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. § 4904, relating to
unsworn falsification to authorities.
Dated: ~ ~ Q
~~' \
t '~
Jeff Davis; CF~ \~,,%'
Presbyterian S nior Living d/b/a Green Ridge
Village
BOGAR
E mall: Isc isciani~sc h utjerbogar.com
Direct Dtal: (412) 281-0965
Fax (412) 281-0530
www.schutjerbogar.com
March 9, 2009
Va UPS OverniPht Delivery
Glenda Farner Strasbaugh
Register of Wills and Clerk
Of Orphans' Court
Cumberland County
1 Courthouse Square, Room 102
Carlisle, PA 17013
Re: Goldie M. Hurley, Deceased
Dear Ms. Strasbaugh:
Enclosed are the original and one copy of the Petition for Accounting and Turn Over of
Benefits for filing in the above-referenced matter. Please date stamp the copy and return it along
with a copy of the signed Order to me in the self-addressed, prepaid envelope provided herein.
An addressed, prepaid envelope for mailing the Preliminary Decree and/or CITATION to Mr.
Daryl Hurley, the deceased's Power of Attorney, is also provided herein.
In addition, enclosed is our firm check in the amount of $30.00 which represents the
$15.00 filing fee, and the $15.00 Automation and JCP fees.
Thank you for your assistance in this matter. Should you have any questions, or need
additional information, please do not hesitate to call me at the above-referenced telephone
number.
Very truly yours,
enclosures
SCHUTJER BOGAR LLC
`_~
Linda L. Scisciani ~--= o
,. ~,
Paralegal ~? ~~
~~. ~--
,,_
- --
.. ~~
_-~
-U
4 --i
..~
a~
0
-~
.~