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HomeMy WebLinkAbout06-22-09IN THE COURT OF COMMON PLEAS OF ~ ~ CUMBERLAND COUNTY, PENNSYLVANIA ~ . - ;:~ -~-3 ~::' . _ _ ~ r ~ ~ _ , ~ , ORPHANS' COURT DIVISION f ' ~ ,, _ <=? °~- _ ,, ,F:. _ _ ,; f ~ IN RE: WALTER PATTERSON O.C. No. ~~~~' - '~' - ~ - `~ , - ~~=, is -T' C3 PETITION FOR ACCOUNTING AND TURN OVER OF BENEFITS Petitioner, Perini Services/Southampton Manor Limited d/b/a Shippensburg Health Care Center ("Shippensburg HCC"), is a creditor of Walter Patterson ("Mr. Patterson"), and hereby respectfully represents that: 1. Mr. Patterson was admitted to Shippensburg HCC, a skilled nursing facility, located at 121 Walnut Bottom Road, Shippensburg, Pennsylvania 17257, on or about February 3, 2007. A copy of the Admission Agreement is attached hereto as Exhibit A. 2. Subsequent to his admission, Mr. Patterson's friend, Eddie L. Collins ("Mr. Collins"), claimed the role of agent through Power-of-Attorney for Mr. Patterson. A copy of the Power-of-Attorney document is attached hereto as Exhibit B. 3. Upon information and belief, at all times relevant hereto, Mr. Collins, as agent-in- fact for Mr. Patterson, has exercised control over Mr. Patterson's resources, including the proceeds from the sale of Mr. Patterson's home, the funds in Mr. Patterson's bank account and Mr. Patterson's monthly income. 4. Upon information and belief, Mr. Collins has received and/or used Mr. Patterson's resources for purposes other than paying for services provided to Mr. Patterson by Shippensburg HCC. See the PA-162 attached hereto as Exhibit C, which references the improper transfer(s) of Mr. Patterson's resources in the amount of $69,000. 5. Due to Mr. Collins failure to pay over Mr. Patterson's resources to Shippensburg HCC, Mr. Patterson's account with Shippensburg HCC has an outstanding balance of $97,556.68. A copy of the current account statement is attached hereto as Exhibit D. 6. Despite repeated requests from Shippensburg HCC, Mr. Collins has refused to pay over to Shippensburg HCC from Mr. Patterson's resources and bring the above-referenced account current. 7. Additionally, pursuant to the Admission Agreement and Medicaid regulations, at all times material hereto, Shippensburg HCC has had an immediate right to the possession of Mr. Patterson's resources and income. 8. If the above referenced resources are not turned over to Shippensburg HCC, Mr. Patterson will lose his Medicaid benefits, which will result in his discharge from Shippensburg HCC. WHEREFORE, Petitioner requests that this Honorable Court issue a Citation directed to Eddie L. Collins, 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 Mr. Patterson's resources, including the proceeds from the sale of Mr. Patterson's home, the disposition of the funds in Mr. Patterson's bank account and Mr. Patterson's monthly income from the time Mr. Collins was made Agent through Power-of-Attorney on or about June 29, 2007 to the present, and directing Eddie L. Collins to turn over to Shippensburg HCC said resources and income. Respectfully submitted, SCHUTJER BOGAR LLC Dated: (~~15 ~ ZUO q Livia F. L ngton PA. I.D. #91548 (412) 281-3710 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. LD. #83755 (717) 909-5920 417 Walnut Street, 4th Floor Harrisburg, PA 17101 Fax (717) 909-5925 Attorneys for Petitioner V~ li p ~~~~~ SEA LTFI CARS CB~iTER I21 Walnut Battotn Road Shippensbocg, Pennsylvstua 1'7257-90D5 Anlv~ssxox~~mo~v'r PAX (7]7) 5~0-8304 TTYI-S00-b54-5984 This reement' etareen Shippensburg Healfli Care Cerrter (the "Facility" or "we" and} ~~ C7~ (the "Kesiden~' or "you"} and, if you or the court have designated an individual to not on ~~~~ b,, or there is another individual tv act on your behal; or operation of law, ~:A~'~~`E ~ '1'T~(.JJ ~`yonr representative"), A checklist of the rights and responsibilities applicable to your representative is listed in Exiribit l and is incorporated into this Agreement. Faying_for Your Care If you are applying to this facility as a private^pay resident, you must provide all financial information requested by us. If we later find that the infoupation you or your representative provided was incomplete ar inac~uate; we will consider that as a breach of this Agreement which ~tves us the right to pursue all legal remedies against you or your representative. Who Can Be Required #o Pav for Yoax Care ' Only you and your insurer can be required to pay for your care. No other person. (i.e. a family member, .f=iend, neighbor, legal repre.~entatzve or guardian} can be required fo pay from their own funds for your care, aitbough he or she may knowingly and voluntarily agree to guarantee payme~.t for the cost of your care. We require the person responsible for making payu~ents on your behalf to pay for your came under the terrns of this contt'act in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third party payment plan, your representative agrees to make all .necessary payments from your funds. Your repTesentafiive could face a civil penalty for intentionally failing to pay required arr~ounts from your funds and could face a criminal penalty for abusing your fiuods. I'rivafe Pav Residents The items and services included in our daily rate is basaic room, boazd and general nursing care as required by yoatr medical condition. Payment for items and sea^vlces that are included in the daily rate is payable one month in advance and due on the first of each month. Items and services included in your daily rate are listed in Exla'bit 2.A. Yon w~l-be charged separately for additional. items and services not included in our daily rates such as special nursing care, special equipment, phaunacy charges, laboratory charges, xnedical transportation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers. Items and services for which you will be charged are listed in Exhibit Z.B. Payment for these additional itezus and services are due after you have requested the.na~, and; you havereceived and haze been billed for them. Within 3fl days of receiving an item or service, you have the right to ask us for an itemized financial statement that briefly but clearly describes each item and the amount charged for it. You will be given an updated listing of services and related charges, including any charges for services not covered under Medicare or by the facilities basicper diem charges, annually on or about 7amtary 1 of each year. Medicare Residents We participate in the Medicare )'rograna. Medicare may pay £or some or all of your nursing home care, Far irl£ormation on Medicare, see Exhibit 3. ~ you are eligible £or Medicare, you have the right to have claiuss for your nursing home care submitted to Medicare, IVledlcaid Residents . We participate is the Medicaid program. For infortnation on Medicaid, see Exhibit 3. You are not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If your private funds are used up during your stay here a~td you acre eligible for Medicaid; we will accept Medicaid payments although Medicaid may require you to pay some ameunt in addition to what Medicaid pays for your care. Tf you are planning on applying to Medzcal Assistance later, you may want to find out now i£your are "medically eligible" for nursing home payment by Medicaid. Yauare responsible for applying for axtd obtaining Medicaid benefits and we will assist you.. We may nat charge, ask for, accept yr receive airy gift, money, donation or consideration other than Medicaid reimbursement as a condition of your admission ox eontionied stay here except that Medicaid may require you to pay certain amounts from your private funds. If you receive Medicaid, most of your nursing home charges such as roam, board, and general nursing care are covered. For a list of services covered by Medicaid, see Exh~it 4.A. The loco[ B card of Assistance will tell you whether you have to pay part of the charge for your care and, if so, how much. Same of the items and services that we offer are not covered by Medicaid. If you want any items ar services, which are not covered by Medicaid, you ox your representative will have to pay fox them. A list of the items and services oat covered by lvledicaid and the charges for hem are in Exhibit 4~. Payment for items and services that are not coveted by lvladicaid is due after you have requested them, and; have received and have been billed far them. Within 30 days of receiving the item or service, you have the right to ask us for an itemized statement Yhat briefly but clearly describes each item and the amount charged for it. Increases in Charges and Fees Any time we increase a fee ar charge far item ox service-or add a new item or service; we will provide you and your representative with 30 days advance written notice. Penalties - We may not charge you interest' you pay pour bill for tinn.e. Your payment is on time if it is made within 45 days of the date the bill is post marked, or 30 days after the end of the billing period, whichever is later. The penalty we charge is S% of the amount due, calculated on a per day basis. - If you or your represeiztative do not pay the money you owe us and we hire a collection agency - arattorney, you agree to be Liable for their fees and coux-t costs. P~.~ivafeDu Nurses GeixafricAides Lf you want a private duty parse or a private duty geriatric aide, you are responsible for selecting a person licensed and/or certified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for Letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she .must meet oar standards and follow onr palicies and procedures. Employees of the Fac~ity map not sezve as private duty nurses or private'duty geriatric aides. - . FloIdin~ Your Bed ff Yon Leave the FaciliEy I£ you are hospitalized or on leave from the Facility, ire Rill hold your bed for you as follows:- A. Tf you axe private-pay resident, or are receiving inpatient care reimbursed under Medicare }?rogram (and you are not covered under Medicaid}, unless you notify us athertvise, wa will hold your bed far as Long as you pay for it at the daily rate you are currently being charged. B_ If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximuw; nmxnber of days required by this state, cun.~ently 15 days. If you leave for any other reason, we will hold your bed. for up to the maximum number of days required by this state, currerrtly I $ days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are liable as determined by the Medicaid Program. C. If you have applied :for 1bledicaid, your bed will be reserved in accordance with Paragraph B. However, if you are found to be ineligible for Medicaid, than you are required to pay for the bed as a private pay resident as described in Pazagraph A. D . Other thud party payers may or play not have a bed hold policy. We will discuss this if it applies to you. As a nursing home resident you have many rights acco~.riing to State and Federal law These are described in detail inBshibit 6, which is attached. and is part of Phis Contract. You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility. You will not be harassed or discriminated against for making a coauplaint or suggesting a change in a policy or service. You play present your complaints to the facility, ntanagemerit company or to one ofthe following S#ate agencies: Lin Tierson, NHA Administrator Shippensburgxealth care center ]Zl Walnut Bottom Road Shippensburg, PA 17257 717-530'8300 Ombudsman Office of Aging I6 West High Street Carlisle, PA 1?013 717 2~0-6]10 71?-532-?28ti Ext. 6110 Mr. 7olut Perini President Magnolia Management, Ina 1710 Underpass ~Vay, Suite 201 Hagerstown, MD 21740 301-745-8700 Department of lIealth 1001dorth Camerae Street 2ud ~100r Tdaeisburg, PA 17XQ1 717-783-37911 Your Right to Make Decisions You have the right to make your own medical decisions and to manage your persoxia.l affairs. If you become disabled, it may be necessary for someone else to make decisions for you. For this reason, we recommend that you leave a living willand/or advance directive for medical decisions and a financial power of Attorney, but you ai~e not required to do so. See Exhibit 7 far a description ofyoux legal rights to decide about your futuramedi'cal treatment. ' Transfer, RclocaEiom_antl Dischar~ Yau have the right to remain here, and you may not be transferred, relocated or discharged against your wi11, except for ~e following reasons: (1} A medical reason (i.e. the facility cannot provide the kind of care that you need, your condition has iwpxoved so that you no longer need the care we provide, or a nnedical emergeecy arises; (2) your welfare or the welfare of other residents or staff; t;3) Nonpayment for a stay, or (4) fine Facility ceases to operate. If we decide that you should be frattsferxed or discharged, we will notify you, and an immediate family member or legal representative, by lettex 30 days ir- advance, if you axe transferred because of au emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective elate. The letter will also hell you haw you can appeal our decision to transfer or discharge yon. ff you are discharged Involuntarily, we will attempt to make other appropriate arrangements for your care. However, if outer arrangements are not available, your representative agrees to accept you into his or hex custody if it is rnedicaliy appropriate. Your Right to lend This Contract If you decide to end ffiis Contract and Leave the Facility, you must pay your bill before you Leave. You must give us ftve (5} days written notice to terminate this contract If you leave before fhe . end of that time, you must still pay fox each day of the required notice. ~ _ - ~. the event yotx die wh~.e ~ resident of the fncaity, your representative is respo:usible far naming the funeral arra~igemetds, rya wilt notify yrnu reprea~ntative ixana~_ Xf we ate unable to reach your representauve; we 'wt7l ~ the fiziieral l~oma of your ehoic~ to,fiaca~itate arta~ern~ents. .~:dilifianalDoctm~.eufs = . It is not poss~le fA cover ev~ytling That is important to your stay in our 7?ao~zty in ttie bony of t3~is Co~ract. Therefaxe~ ~ove bxve .eluded ad~orsal impoi~azzt rloeumerds as ~xl~ib. These • - E~ are part o$ ttZis .eoni~act. I'leasa'verify that you xeceitved tfie omits and fha:E the - erotts o~ the Exhibits were explained ~ you by ptaciug•your•init~ls on the ~e>ne~ to the descxiptior- a~`eachExh~it. Exiu7oit l._ ~2igbts and Obligafiions ofl~yresenfatives. - ~Ext~ibit2. Rot•Prz~fataPayR.esiclents: ~ . (a} Iteans and services covered by daily rate. - /y~ ~ (b} Itezn.4 a~d'services not covered by dat~y ram. ~-l~ ~'6it 3. Ua~ar to Apply For and Ube itrTedicare and Medicaid Be~elits. Exbx3it 4. (a) Ttems anal Services Covired. byMedica~d. f - (e} I-t~ns and Scxvices Not Caged bylvledicaid, Exi~ibtt 5. Physicians Who Practice at the Facibty. • • Bxbibit 6. Z,egat Rights of kennsylvazna to AeaideFuhue b~Iedical Treatbaent. ~Extubxt'1. Pvlic~ies andProcettures Coricer~ung'~'ourPeznoz~a.[Futids audYgur l'er~onal Property. . • Parhibifi 8. Services Pzovide~ by Outaide Cac'e Pz~oviders. Cha~n~es iu Taw , _ Ang Zsrovisiou of ti~is Contract-that is found to bs invalid or unenforceable as a resalt o£ d, change • in Stars or Fede,~cal taw wlll not uxvahdate the temaining provisions of this Cantract. Tf them are services wa have agreed to lmo~vide t~ are later found-to be impossible to r~de~ a.s•a.result o£ a. change in State or Federal hw, it is agreed thst to rho e~.tent possibl8, the Resident and the Fac~ity will continuato £~xifiil our respective obligaiious nndertlais Cor~tarart cQnsFStentwith the law. - ~cTNer~,r~ - IC3 S WSEREOF, the pa~des have cxecufied this Contract on this VrcJ, day o£ ~fU ~0~7 . with - I3y: 7~ W Scott Murray, Adrniuistt~atar . Shippens6urg health Care Center Witness Resident Ifthe resident has been adjudicated disabled ox the Resident's dc5ctiot deteimines tlSat the Resident is irieaQable o~understanding or exercising his ox her rights end responsibilities, the Faeilit~- may require the signature of atiother ~exson on this contract. The atheF person miay be: (11 An ap~inted healthcare agent raider at~d advance directive for medical care; (2) A guafdzan or Power of Attorney of the person; (3) A surrogate or fa+ni.lp member. t r~ - lY _-- Wi e5s - - _-- -- _ .. _ _ . _.. .. _ _. _ . - _ - . _ -- _ Res~onsibleParty (tNanne}-- - --..._... --- ---- - ------ l~ Tztle: Indicate w ether you are (1}, (2) or (3) ~~lo~srr x 12IG8'TS AND OSLTGATIONS Og REPRESENTATIVE The Representative shall have the r%ghf to be notified by the raciiity of any event or occurrence involving the Resident, which directly affects any obligation of the Representative under this Agreement. Representative agrees to assume independently, under Ibis Ageement; the following obligations and is entitled to the following nights, as indicated by Representatrve's initials accompanying anq of the followingpmvisions: Representative agrees to be responsible for ensuring flint any payment from the resident to ~asrhich the Facility is entitled pursuant to this Agreement shall be p aid to the Facility in a. , . timely manner. In the event the Resident is a beneficiary of lUfedieaxe, Medicaid or any other third~party payment plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covexed items and services, together with any late fees as described under this Agreernex-t; shall be paid from the Resident's fluids. Representative is subject to a civil penalty for willful violation of the agreement to distribute the Resident's funds to the facility. • (Unless the Representative vohmtarily agrees to act as guarantor), Representative shall be i~sponsible fox any payments required under this Agreement only to the extent of the Resident's funds. ' Resident is applying fax admission on pxivate pay basis, and Representative agrees fo assist the Resident in providing all financial inforrr-ation required by the Facility to determine the extent of the Resident's resources. If it is ever determined theRepxesentative participated in the disclosure of incomplete or inaccurate infarrnation, the znca:mplete or inaccurate disclosure shad be deemed a material breach of this Agreement and tlae Facilityreserves the right to pursue all available legal remedies against the Representative, ineludzng but na# limited to an action for breach of contract. Representative is signing thin Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for tins representation is attached to this Agzr~uent. ~ Representative is signing Ibis Agreement on Resident's behalf, based upon a physician's certificate, a copy of which is attached to this Agreement, ceziifying that Resident does not p ossess thg capability to understand his or her rights and msponsibilities. Representative agrees that in the event of the Resident's death, Representative shall take responsi`631ity o£all burial azrangements for the Resident and for removal of all personal property fromthe Facility. (Exhibit 1, Continued} If it is the desire of the Resident of Representative to obtain the supplemental services of private duty nurses in accordance vritll the requirements described under this Agreement, Representative agrees to be respoasible far arranging independently for fhose services, including ensuring anypayment. Representative agrees that in the event the Resident's private funds are exhausted during the Resident's stay and the Resident is eligible to apply for benefiis under the Medicaid Program, the Representative shall assist the Resident and the Facility with any application for Medicaid b~iefits. Represezdutive further agrees to act, oA behalf of the Reside.n~ to faoiiitate any Medicare, Veterans Administration or otherthird-party b enefits which map be available to cover the cost of Resident's care at the Facility. • Iii the event the resident seeks ~ terminate this Agreement, the Representative agrees-to ensure that all notices required under this Agreement are provided to the Facility. Tn the eveirt of an involuntary termination of this Agree~neitt, if other arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the Resident into the Representative's custody, if medically appropriate. Representative has the right to copies of the following docume~ats and any amendment to them. Representative further acknowledges receipt of the fallowing documents, which map be amended fromE time-to-dine. 1_ A copy of this Admission Agreement. ~. A list of the Facility's rates, subject to amendment on thirty-(3a) days notice, and a description of charges for services not included, 3. A list of health care providers offering sen~ices at the facility. • Representative aclcttowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBYT 2.A. Private Pay Residents AAxLY ROOM RATES Total Daily Room Rates Effective January 1, 2flQ7 Special Care Program Px~iva#e Rooms ........................ $200.00 $204.00 Stani-Private Rooms ................. $190.00 $199.00 TriplefQuad Rooms .................. $1.85.00 $189.00 A. TI-e daily rate includes the following services: Room • Board • Social Services • Nursing Dare,including: • - v The administration of prescribed medications, treatments and diets o The provision of care to prevent sldn. breakdown, bedsores, and deformities. o The provision of care necessary to encourage the resident from accident, irc~ury and infection. o The provisions of care necessary to encourage; assist and train the resident in self-care and group activities. The daffy rate hoes I'+IOT include the following itemslservices: • Physician Services ~ Medications • Specializedand/or specially ozdered medical supplieslservieestequipment ' • Prescn'bed dietary supplement$ . Cable ($7.OD per month} • Telephone and telephone services • Beauty/Barher Shop Services • DisposableDiapers . • Items listed onAncillary Charge Sheet • Personal Laundry . i Payment: Payment is due in full and an the first day of each month. - Bill is done on a monthly basis. Each monthly payment shall also nich2de any additional fees and charges incurred in the proceeding month. - - .EXHIBIT 2.B ITEIV.IS AND. $ER'Y.CCES NOT COVERED BY THC DATI~Y RATE The following ifems and services are nat covered by the Faca7ity's basic daily rate: item ax Service P>~ysician Services Medications Prescribed Dietary Supplements Personal Dry Cleaniuga Personal Linens x'eleplione . Television Service BeautylBarber Svop Services Clatlung Sundry Pharmaceutical Ambulance Service, Medical Tran~spoYtation ~ IV Therapy X Ray Services 1~ledica)-Nursi~ag Supplies _ Dental, Podiatrist and Ophthalmology Services . Physical, Speech mad Occupatioxtal Therapy Services Oxygen 1Teurspaper, Periodicals Lab Services Specialized andlor specially ordered medical services/equiprneat Guest meals (Exlvbif 2.B, Continued) xT'GMS AND ~' VICP~ i~IQT COV'~D BY'I'HE DAII,Y RATE (refer to the Ancillary Charge List for additional costs) Item Telephone TelevisionlCableyer month BeantylSarber Shop S.esvices: Permanent I~Isircuts and Blow-d:ry Hair Sets Gait Only Dolor 1'.ersvnal Laundry Personal Dry Cleaning Physical Therapy Service OccupatiozxslfSpeech Therapy N Therapy Aerosol Therapy Cher¢e Direct bill from telephone company $ 7.OOpermonth $35.Od $10.25 8.25 $ 8.25 $30.00 $ 45.00 per moutb~ Saone as ISilled by cleaner Determned by level of care required Determined by level o£ care required Charge list will be provided by contract pharmacy prior to delivery of sexvices Determined by level of care required Shippensb~arg Health Care Centex cordially invites family members, guests and friends to jauz our Resident's at meal times. The prices for guest fxays, effective July i, 2001 are as follows: Breakfast A $4.00 Wilt. be served at 7:00 AM Breakfast B $4.00 ($3.77 + .23 state tax) served at 7:34 AM Lunch A $4.00 Will be sers-ed at 12;00 PM Lunch B $4.00 ($3.77 + .23 state tax) served at 12:30 PM Dinner A $4.00 Will he sewed at 5:00 PM " Dinner B $4.00 ($3.77 + .23 state tax) served at 5:30 PM The Resident's vrill 6e assigned their weal times upon admission. Meals can be paid fox at the Receptionists' desk. In order to prepare sufficient quantifies we require a 2 hoax notice to prepare guest tray, EXHIB~ 3 Thy following sutrmnaxizes the i4ledicare and Medicaid programs., It also ten's you who to call for snore detailed information. If you have questions, our staffwill also help you. V~Iiat's Cowered -Medicare 1. Cate in a hospital 2. IUO days of skilled care in anarsing home. Medicare provides fall coverage for the first 20 days. You must rtiake a co-payment after tip, The following services are examples of skilled care: a. Injections 8c feedings given through an ICI b. Tub a feedings c. Application of a dressing That involved prescription, n~edication d. Treatment of stage 3 ox 4 bedsores 3. 1~Iedically necessary doctor's services, '1'Yhat's Covered-Medicaid i4ledicaid is a comprehensive program that will cover most of the casts of a nursing home stay See Bxhibit 4 for information about.covered and nan-covered items. Yaur Contribution -Medicare Medicare does not pay I OQ% ofthe cost of covered services. You will be required to pay pact of the charges. Your payment may be called a "ca-paynsen.Y', "deductible" ar "premiiun", depending on the type of care provided. If you receivel~Iedicaid,lrledicaid will pay for any payment that you are responsible for under Medicare, Your Contr~7intion -Medicaid Dependixzg on your income and assets, you may be req~zired to make a contribution toward the cost of your care, The amount of any contribution will be decided by the local Board of Assistance. 'UYho's Eligible-1Vfedicare People 65 years old or olderwho are eligible to collect old~gebenefits under Social Security are eligible, Persons who receive Sacial Secarity disability benefits for at least 24 months, ar have been found eligible for Medicare by the Social Security Administration because they have end stage renal disease xecluiring regular dialysis or ladney transplant are also eligible, VPI~o's Eligible-Medicaid Eligibility depends on whether your ineaYne and assets are below certain Ievels: 1. Tncame: You should consult the local Board of Assistance to fmd gut whether your income makes yon eligible, That phone number is listed on the next page, xf you gaalify, $30 per month of your income is protected for your personal use v~hile in the Facility. ~~ (Exhibit 3, Continued) 2. Assets: The Camberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualify. The following ate examples of things na counted as assets. a. Your house if your spouse lives there. b. Tiausehold goods. c. A certain amount of cash. d. Personal Pzoperty in pour possession in the Nursing home. e. A certain amount of money for hurler arrangements. Hover to Annly -Medicare Corrtact ~e local Social Security Office atthe following address: Saeial Security Office 401 L. Loather Stree# Carlisle, PA 1'7013 (800) 772-1213 (717) 243-0085 _ H_ oti~v #a ApUh--Medicaid Con#act the local County Board of Assistance at the following address: Board of Assistance 33 westminister 1}zive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 Whom #o Contact if you have a Question or Pi ablem -Medicare If Medicare denies a claim, youhave the right to appeal the denial 'You may appeal by writing to: Aetna 1vledicase Claim Administration SO1 Ofliee Centex Building Fort ~hTashing#on, PA 19034 (215) 643 7200 Whom to Contact if'vouhave aQuestion or]Problem - ~Iedieaid If year application for Medicaid is denied, your eovexage is terminated, or a service is not covered, you may appeal in writing to: Couarty Board of Assistance Office 33 Wesbniaister Drive P.O. Box 599 Carlisle, PA 17013 (717) 249 2929 (800) 269-0173 (F.xixibit 3, Continued). Wham bo Confect if you have Incurred 11'edical L~xnenses prior fo your MA Effective Date Medicare - Tot applicable Whom fo Conte ~t of you have Incurred 1Vtedicxl Exn eases urior to your MA Effective D ate -Medicaid Meclieal Mills that you received in the 3 months prior to receiving Medicaid may be covered by Medicaid. Contact: ~ ' County Board of Assistance Office 33 Westministet Dxive P.O. Box 599 Carlisle, PA 17013 (7I7) 249 2929 (800) 269-0173 F.~1~' 4.A ~. T#em~s and Se~-Qices Covered by the Medicaf~d Per Dient Rafe • Regular room, dietary services, social services and other services required to meet certification standards, rnedica! and surgical supplies, and the use of equipment and facilities. • General nursing services, including but not limited to, administration of oxygen and related medications, hand reeding, incontinency care, tray service and enemas. • BasisBeautpfBarber Services. The facditymustprovidB shampooing and hair care which is considered necessary for hygiene. The facility must infoun the resident of the types and frequency of the services provided. • Items fiixnished routinely and relatively uniformly to alt residents, such as water pitchers, basins, and bedpans. • Items flurushed, distributed, or used individually in small quantities such as alcohol, applicators, cotton balls, baud-aids, antacids, aspirin (and other non- legend drugs ordinarily kept on hand), suppositories, and tongue depressors. • Items used by individual xesidentg, but «rhidt are reusable and expected to be available such as ice bags, bed mils, canes, clutches, ~llters, wheelcbaus, tracfion equipm~t, and other durafile medical equipment, • Special dietary supplements used for tube feeding or oral feeding, such as eleanenial high nitrogen diets, even if written as a presrsipfion item by a physician. • Laandry services for other than personal clothing • Nora emergency medical transportation services. Other special medical services of a rehabilitative, n~storative, or maintenance nature, desigaed to zestoxe oa sustain the resident's physical and social capacities, • Personal care items including a patient gown, shampoo, skin. lotion, comb, brush, toothpaste, toothbrush, and denture cream. t EXHISXT 4.B B. x#eans and Services No# Covered by the Medicaid Per Diem Rate Medical expenses such as, but not Iimited to: + Health insurance px~emiwns. • Visits by a noirpartieipating physician other than approved by the nursing care facility. + lnn~rgency ambulance services, if tlZe ambulance company does not accept MA,. • Over the-eonnter medications, which are a particular brand not supplied by the nursing facility. Fox example, the nursing facility must provide aspirin, but the patient may regtuest and buy a specific brand of'pain aeliever, such as Excedrin PM, or Tylenol. Hearing aids and batteries. • Sp.ecializedBeautyBarbex Shop services. _ + Diapers, if the resident wants a style or brand which is not provided by the nursing ~~e ;Facility. + Personal care items of ~e resident's choice if prefen~ed instead of the items provided by the nursing came facility. This inelndes items such as brushes, combs, toothbrushes, cosmetics, etc. _ EXHIBIT S PHYSICIANS WHO PRACTICE AT THC FACI~I.T'Y Dz. Yogindra S. Balhara, M.D, Dr. Paul Orange, Mme. Dr, $axter Drew Wellmon, I[, D.O., P.C. 761 Fifth Avenue C~tambersburg, PA 172D1 (717) 261-2583 4225 Lincoln'@t~ay East Fayetteville,l~A 17222 (717) 352-3b16 127 Walnut Boftom Road Shippensbusg, PA 17257 (717} 532-3211 ~' EXIHBIT 6 LEGAL RIGH'T'S OF PENNSYLVAI~IIANS T4 DECIDE AEOIIT HEALTH CAR7+: You Have the Rinht to D eeide About Your Health.Care Adults generally have the right to deelde if they want na~edieal ta~eattnent, unless they are not competent. This rightincludes decisions abouttreatments that extend life, life-sugportzraachines, or feeding tubes. - $ ometinaes, as accident or illness takes away a p erson's ability to make health care choices. But the decislons still must be made. Yf you are unable to make them, others will. They will decide based as yaw wlshes or your hest interests if your wishes are unl~own. Pennsylvania la.~v gives you -the xight to make many health care decisions in advance, are way to da this is by using a written advauee directive to Weans an agent to make your health care decisions if you cannot. A written advance directive can also state your treatment preferences, especially about ]ifs sustaining procedures. Nanaina a Health Care Agent 'You can name anyone to be your health care agent. The only exception is that, in general, someone wha works whexe you are receiving your care cannot be your agent. Your agerrt can be a family member ar a friend. You rho ose whets your agent can decide for you -right away, if you wax-t, or only alter two daetors agree that you are notable to decide for yourself. You also rho ass the kinds of decisions your agent can make fox you. For example, i£you want, you can give your agent very broad power to decide about life-sustaining treatment. Pick our health care agent very carefully. Make sure your agent knows what you want Your agent will then follow your wishes, even if your friends of faunily disagree, IIsin~ Advance Directives Tbezs are many ways to vse an advance directive..A living will is a type of written advance directive that states your wishes on life-sustaining ti-eatmenfs. $ usually comes into affect when a p erson will die very so on from an incurable condition. 1;t can also be used when a person is peixnaneaifly unconscious {in a vegetative state). You can tnalCe a babader written advance directive far other health care issues too. For example, you can decide whether yon want life,-sustaining treatment ifyou are in an end-stage condition. An end-stage condition is an advanced, progressive, and incurable condidonresulting in - complete dependency. What Happens If You do No# Make an Advance ©irectlye? No one can deny you health care because you do not have an advance dn~ective. $ut you should -know what happens legally if you do not. (Exhibit S, Continued) " Pennsylvania iavy allows a surrogate to make medical decisions for you, if you have notnamed a health care agent and are no longer able to decide treatment issues yourself. Then, pour closest relative would be asked to make health, care decisions for you. Your sponse, adult children, _ parents, or adult.brothers and sisters, in that order, are conside~~ed pour closest xelatives. If these relatives are not available, another relative or close friend can make decisions for you. A surrogate, though, might have less authority to decide againstlife-sustaining procedures than a health care agent. If there is no one to be a surrogate, a court might have to appoint a guardian to make your medical decisions. The guardian might be somebody who does mot know you personally. Hovc~Aa You Get tldore Iufarmation7 This snm~a~ary does not cover every issue. Tf you have legal questions about your rights, please speak to a lawyer. Also talk to your health care provider about the medical issues involved in your care. Tell those caring for you about ~rour decisions sad give them a copy of any advance directive. For a free copy of a Livioag`9PiD or Advance Directive form coxztact; State Representative Jeff Coy 39 West King Street Shippezzsburg, PA 17257 (7i7} 532-17Q? or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, PA 17013 (717) 532 728b Ext. b110 (717} 240-GI10 EXIi18Ifi 7 POLICIES AND PROCE14UR1CS~CONCERi~IIl~iG YOIIR PERS©NALTUL~tDS ' AND YOUR PERSONAL PROPERTY ..A.. Your Rights: 1. You have the right to keep and use yourpersonal pzoperfy,including some furnishings and clothing, so long as there is enough space and other residents are not inconvenienced. Xou also have the fight to security for your personal possessions. 2. -You have the right fo manage your financial affairs unless a court determines that you are incapacitated or tine Social Security Administration selects a repxes~tative to receive Social Secw.~ity funds for youruse $nd benefit. 3. W e cannot require you to deposit yoar personal fiends a2th as. Yoti may, however, choose any p erson to manage your funds, including the Facility, 4. Tf you decide to have us manage your personal funds, you may withdraw your money that we keep in the Fac~ity during the Facility's business hours. If we have deposited any of your foods in a bank, you cnay obtain those funds within three banking days, provided the funds have cleared. 5. If you need help to p erfonn your banking transactions, you rnag give the administrator of our Facility 1ega1 authority to access your account. 'This authority is called `~epreseaitative payee," To give the administrator this authority, you will need to complete a special form, b. Yon and your personal representative have the right, dung normal business hours, to inspect our lvi7tten records that eonc~n your personal funds. 7. You and your personal representative have a zfght to file a complaint if either of you believes tf-at your funds, valuables or other assets have been stolen or damaged. The agencies to contact in ardex to make a eornplaint are listed below: a, The Cumbearland County Of6.ce of Aging Attn: Ombudsman: Hwnan Services Building l6 Nest High Street - Carlisle, PA 17013 ('117) 532?286 Bxt. 6110 (717) 240-617 0 (Exhibit 7, Continued) b. ~ Cumberland County Board of Assistance 33 Westynznster Drive P.O. Box S99 Carlisle, PA 17013 (717) 249-2929 (800) 269-0].73 c. The Department of Health _ Division of Nursing Care Raeilities 100 North Camraron Street 2"~ Floor . Harrisburg, PA 17101 (7I7} 7S3 3794 _ B. Our Responsibilities: 1. We wiU provide a reasonable amount of secure space for you to keep your clothing and other personal property. We must investigate any damage to or loss of your personal property. 2. If you want us to manage $50.00 or less of your personal foods, we will deposit this mauey in-anon-interest bearing account yr a petty cash fund. 3. If you want us to manage more than $50.00 of your personal foods, vve will deposit this money in an interest bearing account that is insured by the federal govemtent. This account will be separate fromi the accounts we use to operate the facility. Itz addition, we will credit you ti~~ith all interest earned on your money. 4. We will maintain a full, complete and separate acxounting of yom personal ftu-ds. We will also provide you with a quarterly statement of the activity of your accour-t. 5. If you receive Medicaid benefits, tive will notify you if your account balance becomes too high. zf you are tv remain eligible for Medicaid, your account balance must be and er a certain dollar limit that is established by the Federal government amd changes periodically. b. We may ~ use your personal funds to pay for an item or service that Medicare or Medicaid covers. 7. RTe will maintain adequate fire and theft coverage to protect your funds and personal property that aze kept at fire Facility. We shat! also obtain a surety bond or otherwise assure the security of yourpersonal fiords that are deposited with the Facility. (.~lsibxt 7, Continued) $. Ifyou are discharged, there are several things we must do; a. We will ensure the return of your personal funds in our possession, If we have deposited your personal fends in a bank account, we will ensure that this money is made available~to you or your authorized representative within 30 days. b. if we are your representative payee for Socia! Secnxity benefits, eve will promptly ask the Social Security Administration #n name a new representativepnyee and we will teansfex your money to that person, • 9. In the event of pour deatby (here are several things we must do: a. We wiQ convey your personal funds and a final accounting of those funds to the person in charge of administemng your estate within 3U days. We will iruinediately notify any • government agency that paid for all or past of your care in oux Facility. That agency shall have the right to assist us in detexmining what to do with your property. b. Yf a govexm~nt agency did not pay for your care, we will immediately .notify your representative or next of ldn to determine what to do with your • 1~P~y ~• c. If we have your funds, valuables or other assets in our possession, `ve will hold them untd the appointed personal representative of your estate presents a copy of the certi5ed Letters of Administration to us. All conveyance of personal funds wi[1 be by check made payable "To the Estate of...". d. 'We will make reasonable attempts to to cafe your personal xepresentutive and your heirs. If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we wiII write the State Office of the Comptroller for direction 10. If we are in possession of your fiends, valuables or other assets for more than one year fxom the da#e of your Transfer ar discharge, we wsll transfer your funds, any interest on your funds, and your~valuables or other assets to the State Office of the Comptroller's Office of any account(s) in your zAarne of which we have i:nowiedge. ~~ EiQ-IIB1T 8 SERVICES PROVIDED BY QUTSIDE HEALTH CARE PROVIDERS Some of the services avaiiable in the Facility, such as pharmacy services, are provided by outside health care providers. These services, and information about the providers, appear befoav, You are free to pick your own provider or to use one of those listed below: Whether we have ' Provider's Name, a firianaal Type of Service Address and Telephone Number interest in the provider Physiciian Dr. Yogindra Bathara 761 Fifth Avenue No Chambersburg, PA 17201 (717} 2646185 X-Ray Services Mobil X Ray Servlces The Chambersburg Hospital No 112 N. Seventh Street Chambersburg, PA 17201 (717) 267-7153 Lab Services Health Network Labs 1200 Walnut bottom Road No . Cariiste, PA 97413 (877) 402-4221 Pharmaceutical Millennium PharrtracySystems, Inc. '12454 Perry Highway, Suite 20fl No 41Vexford, PA 1509(3 (866 466-7779 Podiatrist Dr. Pinker ono[ D. Golec 47 Brookwood Avenue No Carlisle, PA 17fl13 (717) 243 2236 Hasgital Chambersbzarg Hospital No lnpatlent or Cariisle Hospital No Emergency 1±uElon Co, Medical Gen#er No Room Hershey Medcca! Center No Waynesboro Hospital No ' _' - s s: L =POWER ~ =ATTORIITEY . KNOW ALL MEN BY-THESE PRESENTS, that I, WALTER M. PATTERSON III, currently residing at 507 Muench Street, Iarrisburg, County of Dauphin, Pennsylvania, hereby revoke any general power of attorney that I have heretofore given to any person and do hereby appoint EDDIE L. COLLINS of 2234 Penn Street, Harrisburg, County of Dauphin, Pennsylvania, (hereinafter "my Agcnt") my true and lawful Agent for me and on my behalf to perform all such acts as my Agent in my Agent's absolute discretion may deem advisable, as fully as I could do if personally present. This Power of Attorney shall not be affected by my subsequent disability or incapacity. My Agent is hereby given the fullest possible powers to act on my behalf: to transact business, make, .execute and acknowledge all agreements, contracts, orders, deeds, writings, assurances, and instruments for any matter, with the same powers and for all purposes with the same validity as I could, if personally present. - - _ - oz's "'- ~~~~;1' 1 'Z.-~~'~ <~"Sr "• s...a iP.r '~?s: ~Cti,""~ ,d4ye _ _ , ~. - _ 't.'~"'-"=s-i,.:. SPECIFIC POWERS INCLIIDED IN GENERAL POWER Without limiting the general powers hereby already conferred, my Agent shall have the following specific powers which are included in the foregoing general powers: (1) To create a trust for my benefit. (2) To make additions to an existing trust for my benefit. (3) To claim an elective share of the estate of my deceased spouse. (4) To disclaim any interest in property. (5) To renounce fiduciary positions. (6) To withdraw and receive the income or corpus of a trust. (7) To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care. (S) To authorise medical and surgical procedures. (9) To engage in real property transactions. (1 Q} To engage in tangible personal property transactions. (11) To engage in stock, bond and other securities transactions. - ~ _ - _<: (12) To engage in commodity and option transactions (13) To engage in banking and financial transactions, including checking and savings account(s), certificates of deposit, and savings bonds transactions. (14) To borrow money. (I 5) To enter safe deposit boxes. (16) To engage in insurance transactions. (17) To engage in retirement plan transactions. (18) To handle interests in estate and trusts. (19) To pursue claims and litigation. (20) To receive government benefits. (21) To pursue tax matters. DURATION OF POWER RELIEF FROM LIABILITY REVOCATION 1. This Power of Attorney shall not expire by reason of lapse of time. 2. I hereby ratify and confirm all that each Agent acting hereunder shall do or cause to be done under this General Power of Attorney. I specifically direct that such Agent shall not be subject to liability for such Agent's decisions, acts or failures to act. acting hereunder- written notification of the revocation, which notice shall not be considered binding unless actually received. HIPPA RELEASE AUTHORITY I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1966 (aka HIPPA), 42 USC 1320d and 45 CFR 160-164. I authorize: (a) .any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider any insurance company and the Medical Information Bureau Inc., or other health care clearuzghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services; (b) to give, disclose and release to my agent, without restriction all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse, i t. y.,~, ... _ "+~'+s"tc'. ~ _`S t,.7'-.~}':~~' "~.`sy~~~.,~ a ;,'".AMR~!~?t~Qt~EMS:'R:.fi.` , ,.s ~.:.r,,, --;~ 1': ',' ~'.:,~:-. .: The;authonty given' agent shall supersede any prior agreement that I may have .made with my health care .providers to restrict access to or disclose of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. IN WITNESS WHEREOF, and intending to be legally bound, I have hereunto set my hand and seal this ~ day of 2007. Signed, sealed, and delivered in the presence of ~~~ WALTER M. PATTERSON III COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the ~ day of , 2007, before me, A Notary Public personally appeared WALTER M. PATTERSON III, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. TAR PUBLIC COMMONWEALTH OF PENNSYLVANIA Notarial Seal Keay P. Roberts, Notary Pubac Paxtang eoro, Dauphht Cotnty My C.on-artissiott >~xpr~ Jan. 27, 2009 Member, Pannsyivania Association of Notafles c~ARTFC E. PETRIE A'CTOitI~Y AT LAW 3528 BRISBAN STR>rE3T HARRISBURC3, PENNSYLVANIA 1'7111 .___.~.. 717-561.1939 NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENTS BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUllE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa.C.S. Ch. 56. -~' ~ s~:f~ , cur IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT ,,. - UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. `.~ ~-~ WALTER M. PATTERSON III PRINCIPAL AGENT'8 ACHNOWLEDGEMENT I, EDDIE L. COLLINS, have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. AGENT DATE ~' „ - COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN . On this, the .~ day of , 2007, before me, A Notary Public, personally appeared EDDIE L. COLLINS, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and~official seal. Member, Pennsylvania Association et Notad~ P.o. sox s99 NOT ELIGIBLE 33 rWESTMZNSTER DRIVE NOTICE CARLISLE PA 17013-0599 CAO RETURN ADDRESS CgLp 0036 *01080000000* SHCC ATTN: DOROTHY ABBOTT 1710 UNDERPASS WAY STE 201 HAGERSTOWN MD 21740 'NCO,'. RE OAP ~ DI51:c CATt=~ GG~_c,,PS'~ _ 21 0116611 0 TJN 00 WORKER: s PEIPER TELEPHONE (eoo) 269-0173 MAIL DATE: lz/ls/zoos NOT: 9a5 OPT: J TYPE: N If YOiI ' DO NOT UNDERSTAND' ONR Dl~ISIAM Aft Nmrc euv WIESTIONS, PLEASE CONTACT YWR IlOrbfER IAOEDIATELY, PAGE 1 OF 1 You have been determined not eligible for benefits based on your application dated 12/11/2008. You disposed of a total of $ 69000.00 in assets without receiving fair market value. This transfer results in a pertod 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 05/01/08 and ending on 02/27/09 During this pertod, you wilt 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 faciltty would deprive you of food, clothing, shelter, or other necessfties 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. w~ a cvinuiniv n~cviarwuon yr VOUr rlgni W appeal ana [O a rair nearmg. 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 12/29/2009 your assistance will continue pending the hearing decision, except when the change is due to State or Federal law. ~ •~~- WALTER M PATTERSON SHIPPSNSHURG HEALTH CTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG PA 17257 ~~ ~~~~ CUMBERLAND CAo P.O. BOR 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPHNN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 (717) 243-9400 Notice ID: 69539711 'C0~ F~`CORD.~! DIST-,;_~~.CI.T._GG "'.-P$ .~ 21 0116611 0 TJN 00 WORKER: J PEIPER APPEAL- 1z/za/2ooa TELEPHONE: (aoo> 269-0173 MAIL DATE: 12/15/200a NOT: 985 -OPT: s TYPE: N PAMA162A CONTINUED ON REVERSE SIDE PA/MA 162 12103 717-530-8304 Shippensburg Health Car STATEMENT Q9: 56:56 21-05-2II09 5131 SHIPPENSBURG HEALTH CARE CTR Facility Phone: 717-530-8300 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Resident: WALTER M PATTERSON - Statement Date: 05/05/09 Ed Collins P.O. Box 2905 Harrisburg, PA 17105 Date Service Through Qty Description Amount Sub Totai as of 03/31/09 97,556.68 Total Amount Due 97,556.68 Payment due within 15 days_ Wa accept Visa and Mastercard. Page 1 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: (a J (J~ 0~ ~ ~'±~ / ~,,, Stephen Coetzee, Represe ative for Perini Services/Southampton Manor Limited d/b/a Shippensburg Health Care Center