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Home My WebLink About01-4773ATTORNEYS AT LAW dARKET STREET YORK, PA 17403-2000 (717) 846-1252 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS, ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. t~/~/_7,' 7:73 CIVIL ACTION - LAW NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after ~his Complaint and Notice is served, by entering a written appearance, personally of by attorney, and filing in waiting with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la torte. Si usted quaere defensas de esas demandas expuestas en las paginas, siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Se avisado que si usted no se defienda, la corte tomara medidas y psedido entrar una orden contra used sin previo aviso o notification y por cualquier queja o alivio que es pedido en la peticion de demanda. Usted puede perder dinero o sus propiedades o otros derechos importantes para used. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVlCIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUlR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland Coun~ Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) ~'49-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff ; VS. : : ELWOOD GOWER, Individually, and : CRAIG GOWER, Individually, and on Behalf of: ELWOOD GOWER, : Defendants : COMPLAINT NO. : CIVIL ACTION - LAW AND NOW, this }3 day ofA,}~.i.O~L ,2001, comes the Plaintiff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson ~ Associates, P.C., and files the within Complaint and in support avers as follows: 1. Plaintiff, HCR Manor Care is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1700 Nlarket Street, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Defendant, EIwood Gower, is an adult individual with a current address of 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Defendant, Craig Gower, is an adult individual with a last known address of Rollo Court LT 88, Mechanicsburg, Cumberland County, Pennsylvania 17055. 4. That Defendant Craig Gower represented himself to be the Legal Representative and/or Responsible Party for Defendant Elwood Gower. Defendant Craig Gower is the son of Defendant Elwood Gower. 5. That on or about April 11, 2000, through the present, Defendant Elwood Gower was a health care resident of Plaintiff, where he did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein, and collectively marked as Exhibit "A". 6. That on or about April I I, 2000, Defendant Craig Gower executed an Admission Agreement on behalf of Defendant Elwood Gower, which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible Party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and marked as Exhibit "B". 7. By executing said Admission Agreement, Defendant Craig Gower did assume and accept responsibility for the debt to be incurred by Defendant Elwood Gower in the event of a breach of the duty to provide payment from the Defendant Elwood Gower's income or resources for the fees and charges provided for in the 2 Admission Agreement. See Exhibit "B" as previously identified and incorporated herein. 8. That Plaintiff submitted to Defendants a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. 9. That Defendants have not objected to the above-mentioned Statement of Account submitted by Plaintiff to Defendants. 10. Plaintiff has made numerous requests to Defendant Craig Gower, as the Legal Representative and/or Responsible Pan:y for Defendant Elwood Gower, demaning that he sums due and owing to Plaintiff be paid, and Defendant Craig Gower, as the Legal Representative and/or Responsible Par~y for Defendant Elwood Gower, has refused his fiduciary obligation to pay necessary and appropriate bills and obligations for his father, Defendant Elwood Gower. I 1. That Defendant Craig Gower submitted an application for medical assistance on behalf of his father, Elwood Gower, on or about November 27, 2000. 12. That pursuant to the above mentioned application, Defendant Craig Gower was notified of discontinued benefits due to excess of resources of Defendant Elwood Gower. A true and correct copy of the notice of discontinued benefits is attached hereto, incorporated herein, and marked as Exhibit "C'. 13. That pursuant to said discontinuation of benefits, Defendant Craig Gower filed an appeal with the Department of Public Welfare. See Exhibit "C' as previously identified and incorporated herein. ! 4. That the appeal hearing, which occurred on or about June 27, 2001 upheld the prior decision of the Department of Public Welfare that benefits were to be discontinued. 15. That pursuant to the appeal decision, Defendant Craig Gower failed to appropriately utilize the assets of his father, Defendant Elwood Gower, to pay for the residential health care services which were being provided to Defendant Elwood Gower. 16. That Plaintiff alleges, and therefore avers, that Defendant Craig Gower is receiving Defendant Elwood Gower's social security benefit checks and expending said funds for his own use instead of using said funds to pay Plaintiff for the amount due and owing on Defendant Elwood Gower's account balance with Plaintiff. 17. That Defendant Craig Gower violated his fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Elwood Gower by utilizing Defendant Elwood Gower's social security benefits for his own purposes when he know or should have known there were outstanding medical bills for his father, Defendant Elwood Gower. 18. That Defendant Craig Gower wrongfully converted the funds of his father's social security benefits, without authority or justification, into his own possession and for his own personal use to prevent said social security benefits from being applied to the necessary and medical needs of his father, Defendant Elwood Gower. 19. That the funds of said social security benefits rightfully belonged to Defendant Elwood Gower and Plaintiff for his necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Elwood Gower. 20. That recovery for unjust enrichment is proper if one party is enriched by another, and injustice would result if recovery for the enrichment is denied. 21. That Defendant Craig Gower was enriched by the use of the social security benefits, which rightfully belonged to Defendant Elwood Gower, and injustice would result if recovery for enrichment was denied as said benefits were to be used to pay Plaintiff for the medical services it rendered to Defendant Elwood Gower. 22. As of the date of filing of the Complaint, the balance due, owing, and unpaid on Defendant Elwood Gower's account as a result of said charges is the sum of Forty-Eight Thousand Two and 18/100 Dollars ($48,002.18). See Exhibit "A" as previously identified and incorporated herein. 23. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Elwood Gower's account balance, all to the damage and detriment of the Plaintiff. 24. Pursuant to Section 1, Paragraph 1.03, of the ^dmission ^greement, Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" as previously identified and incorporated herein. 25. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance is the sum of Two Thousand Six Hundred Thirteen and 06/100 Dollars ($2,613.06). 26. Plaintiff has retained the services of the law firm of Wolfson ~ A~ssociates, P.C., in the collection of the amounts due from Defendants. 27. Pursuant to Section 1, Paragraph 1.03, of the ^dmission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney fees and all court costs if the account is referred to an attorney for collection. See Exhibit "B" as previously identified and incorporated herein. 28. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 6~ Associates, P.C., in the collection of the amounts due and owing by Defendants incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance which is due and owing. 29. That the amount of attorney's fees which represents thrity percent (30%) of the principal amount due and owing is the sun of Fourteen Thousand Four Hundred and 65/100 Dollars ($14,400.65). 30. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 31. The amount in controversy exceeds the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, EIwood Gower, Individually, and Craig Gower, Individually, and on Behalf of Elwood Gower, in the amount of Forty-Eight Thousand Two and 18/100 Dollars ($48,002.18), contractual interest in the amount of Two Thousand Six Hundred Thirteen and 06/100 Dollars ($2,613.06), reasonable attorney's fees in the amount of Twelve Thousand Four Hundred Seventy-Four and 35/100 Dollars ($12,474.35), the costs of this action, and such other relief as the Court deems proper and just. Respectfully Submitted, Daniel F. Wolfson, Esquire / '~ WOLFSON ~ ASSOCIATES, P.C. 267 East Market Street York, PA 174-03 (717) 846q 252 I.D. No. 20617 Attorney for Plaintiff VERIFICATION I, Michelle Thureson, Senior Financial Services Consultant for HCR klanor Care, verify that the statements made in the foregoing Complaint are true and correct to the best of my information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4(204, relating to unsworn falsification to authorities. DATE: Michelle Thureson, Senior Financial Services Consultant EXHIBIT "A" HCR.Manor Statem,nt MANORCARE CAMP HILL 583 1700 MARKET STREET CAMP HILL, PA 17011 (717)-737-8551 CRAIG GOWER FOR ELWOOD COWER ROLLO CT LT 88 MECHANICSBURG, PA 17055 PRIVATE ROOM 224 -A Please Return This Portion With Your Payment COWER, ELWOOD C 45 04/11/00 02/28/01 DATE OF 02/01/01 BALANCE FORWARD 41,581 . 18 02/28/01 51801 TOTAL INCONT-DLY FEE ( QTY 28 ) 84.00 02/28/01 99610 OXYGEN CONCENT RENTAL ( QTY 1 ) 504.00 02/28/01 11600 CABLE RENTAL ( QTY 1 ) 5.00 03/01-03/31/01 ADV ROOM CHARGE ~ 5,828.00 PAYMENT DUE BY THE 10TH AMOUNT DUE 48,002.15 93/29181 RESIDENT RESIDENT RESIDENT NUWDgR TYPH NRNg RREIDgNT LEDGER A80P DATE OP FIRHT ACTIVITY PAGE & G/L -- ACCOUNT8 RRCEIYABL8 -- DATA ~TY ACCOURT C8&RG88 CRHDITR BALARC8 45 PRIYATR GONER~ RLNOOD C ROOM 224 -R LEVEL 1 *'MEDICARE B - 3AR 61 (COAT) *SENDING BALANC8 **PRIVATE ' FEB 61 BAL F~ -LN- -36- -66- 11599.61 51861 TOTAL INOONT-DLY PAR 62/91/61 -- 62/28/81 99616 0X~S88 CORCGNT R8RTAL 92/91/91 -- 92/28/91 11666 CA8L8 RRRTAL 62/28/91 RHV LAST NO RC 02/91/61 ROOM CHARGE AT 828.68 82/91/61 -- 82/28/61 AHV ROOK CHARGE 93/61/61 -' 63/31/61 t'RWDING RALARCH **IRSURARCH ' FRS 6! ElL PWD -LN- "8WDIRG BALANCE "MCR CO IN8 - FEB 61 HAL FWD 'LM- 64/11/66 ADN CNTR RATE= 5828.66 DIM PRIV PORT= 9.98 -126+- 29981.5? i1591.18 28 56151801126 8i.66 1 55353691129 594,69 I 59158i61126 5.96 13211900969 28 51356661t26 5828.66 13211096669 5828.69 -38- -66- -98- -126+- 191,49- .89 -30- -68- -96- "ENDIRG BALARCE *'NEDICAR8 A - FEB 81 PAY~NT NCR'g/66 62/13/61 PAYMENT 62/13/61 'SRWDING BALANCR **MRDICARR B - FiB 61 BIL FWD -LM- -38- -66- -96- PAYMENT MCB-9186 92/13/61 S'ENDING BALANCE -126+- 288,05 286.95 11216062960 11219992999 522.99 -126+- 1144.24 1144.24 11219992666 5828,69 199,69 522,66 522,66 1144,24 {8602.18 198.69- 286.05 ,86 622.24 ~3~29~B1 lAN56} RWDIDRN? RRBIDENT RBBIDAN? NUMBER TYPE NAME RESlDERT LEDGER AB OF DATE OF FIRST ACTIVITY PAOR 1 G/L -- ACCOUNTS RECEIVABLE -- DATE QYY ACCOUNT CEARGEB CREDITS BALANCE PRIVATE ~WER, BLWOOD C ROOM 224 -A LEVEL 1 "PRIVATB - APR {B ll6BB CABLN RENTAL II18N BEAUTY AND BARBER "NNDING BALANCE "INSURANCE ' APR BB 290B2 PNANMACY LBGEWD 51582 WOUND TREATMENT 532E2 NTRTNL/RNTRL SRRV GRP 2 141BI PNYUICAL THERAPY VIBIY 144B1 PHYRICAL TNNRBPY RVAL 28182 SPEECH THERAPY VIHIY 2B4B2 SPEECH THERAPY EVAL 515E1 CAYRBTER TRAY ANCILLARY WRITE OFF N4/ll/BB ADM CNYR RATE~ 5828.BB DIE PRIV PORT~ 8.BE 841111BE -- E413BINE 1 591584Bl12B 5.BE H/28/EB I 591581BlI2B 18,88 H/ll/OB -- 141111BE -- 14/11/18 -- HI12/18 -- 14131lib 1 54551217121 252.59 14/15/NI 5 54151517121 48.88 B4/3B/IN 28 56153217121 41.Bt 14/15/Bt 1 529514B7121 25.1B 14/18/88 1 541§1587128 ILl8 14/15/18 -- 161.tN 15.ER ROOM CHARGE AT 23H.88 t4/11/18 -- **NNDIRG BALANCE 5427.59 "PRIVATE - MAY Ii BAL FWD -LM- -31- -6B- -91- -12B+- 15.N8 PAYMENT 06/22/BB ll2llli21Bi 25.Bi I1618 CABLE RNNYAL 85/il/NB -- B5/31/88 I 59158481128 5.88 *'ENDING BALANCE 5.1N- "INSURANCE - MAY iN BAL FWD -LM- -31- -61- -91- -121+- 5427.59 5427.59 29BB9 PRA~ACY LEGEND 15/BI/Bi -- 15/25/IE 1 5455121712i 384.55 532i2 RYRTNL/ENYRL 8BRV GRP 2 15/81/18 -- 15/31/il 112 56153217121 224.88 99611 OXYGEN CONCRNT RENTAL 15/El/Ii -- iS/31/ll 1 56353617121 558.1B ROOM CHARGE AY 236.11 ES/il/St -- 15/31/18 31 513581i712i 7316.1i '*ENDING BALANCE 1391B.14 '*PRIVATE ' 3UR ii RAL FWD -LM- -30- -60- -go- -128+- 5.08 Il,il- 5.88 11500 CABLE RENTAL i6/Ol/N! 1 59158481120 5.00 '*ENDING BALANCR **INSURANCE - 8UN NE BAL FWD -LM- -3t- -61- -gE- -121+- B482.55 5427.59 13918,14 532t2 RYRTNL/{NTRL HRRV GNP 2 i6/Ol/Oi -- i6/3O/lO 180 5615321712i 361.11 99618 OXYGEN CORCENY RENTAL 8S/il/18 -- 29117 PRBRMACY LEGEND B6/18/ll -~ 86/28/BB 1 545512B?12B 227.61 38887 PNA~ACY NON LEGBWD 86/08/81 -- 86189188 1 54951387128 29,84 ANCILLARY WRITE OFF B6/31/ll 6755751712i 256.65 ROOM CHANGN AY 236.88 16/81/88 -- 93129191 RR~IDRRT LIDGRR AB Of DATR O~ PIRNT ~C?IVIT¥ P~GR 2 RRSIDENT P~SIDINT RRSIDRNT G/L -- ACCOSTS RRCRIVASCi -- 8UMBIR YYPR NAM! DAYI OTY ACCOUNT CBARGIS CSRDIYB BAbANC! 45 PRIVAYR GONER, RLMOOD C ROOM 224 -A LIVtL 1 *'IRSURANCi - JUN ii [CORY) *'IWDING BBLANC! "PRIVAT! - JUL RAL FWD llIll BRAOYV AWD BB~BIR "BIDING "IRSORBRCR - JUL RAL FWD -LM- 7989.II 53212 NYR?NC/INYRL SRRV ORR 2 17192 OCCU~ TBIRAP¥ VISIT DIB PRIV PORT~ i. I9 21891.14 -3I- -6}- -91- 5.99 ii.ll- I7/96/99 I 59158191129 Il.I} 18.98 SOOM CBARO! "ENDING BALBRCR "PRIVATI - AUG }9 BBC FMD -LM- li.il 5,19 PAYMENT ROLL CREDIT ROLL CRIDIT ROLL CREDIT **INDINO B&CANCI **IN8ORANC! - BUG ii BBC ~WD -CM- 8434,89 2}112 SPRICR TSRRAPY VISIT 53212 NTRTIL/INTRL BERV GRP 2 99611 OXYGRN CONCENT RINTAC 17112 OCCDP TBRRAPY VISIT 29992 ~EB~4AC¥ CEGIND 29192 SPllCS TSIRAPY VISIT 2t412 SPIICH TSIRAPY IVAL -39- -6I- -96- -129+- 8482.55 5427,59 21899.14 IH}l/ii -- 17/31/11 186 56153217129 372.}1 97/il/99 -- 97/31/99 1 55353697129 558.19 97/15/tl -- 97/17/}} ] 54551217121 67.59 97/97/il 1 52559617121 25.Ii 97/ll/ll 1 52551617121 25.91 97/11/99 1 54951387129 21,21 97/31/I} 1 5295141712t 51.Al AT 236.99 97/91/19 -- 17/31/9t 31 51351197121 7316.99 -61- -96- -129+- 5.99 Il.il- 19.II 68/16/66 11216962199 Il.il 98/16/89 11219992691 1525.96 (BLIND} 07161/09 14411656966 li.6I (BLINB} 17/il/IN 1441115999I 5.19 (BLIWD) 97/61/96 14411659966 5.96 ROOM CHARG9 AT 236.99 88/91/98 -- 68/31/99 *'RNDIRG BALANCE '*PRIVATE - SiP 96 BAL FWD -LM- -36- -66- -99- 1525.99- 116}9 CABLS RIRTAL 19/Il/II -- 99/39/91 "RNDING BALANCl -66- -96- -126+- 8482.55 5427.59 39324.94 IN/Il/II -- I8/I3/il 3 5295}417121 169.66 68/61/66-- 98/31/66 186 56153297126 372,66 18/Il/II -- 18/31/69 1 55353697129 558.19 98/92/99 -- IE/15/il 9 52550667121 396.99 18/63/19 -- 18/28/11 1 54551217121 59.18 98/18/99 -- 96/31/89 ii 52959497129 525.99 98/18/16 1 52951467121 25.61 31 51359167126 7316.96 1525.99 5915846112t 5.99 36324.94 1525.99- 39586.12 1529.99- 03/29/01 [AN56} RNHIDNNY RNBIDRMT RNBIDEN? DUMBWD TYPE NAME RNBIDNNT LEDGER AD OF DAYE OF FIRHY AC?IVIYY PAGE 3 G/L -- ACCOUNYR RECEIVABLE -- DAYE QYY ACCOUHY CHANGEH CREOIYH BALANCE PRIVA?E OOMNR, NLWOOD C ROOM 224 -A LEVEL 1 "INBURANCE -RNP 00 BAL FWD -LM- -30- 9255.18 8434,8{ PAYMHNT CBC MAJ MHD 20102 RPEECH YHENAPY VIHIY 29HE2 PHARMACY LEGNWD 532{2 NYRYNL/ENYRL HXRV GRP 2 99610 OXYGEN CONCEN? RNNYAL N4/11/00 ADM CN?R RAYE, 5828.00 DID PRIV PORT~ 0.{0 ROOM CHARGE AT 236.0{ 0910110{ -- BR/)I/I! **ENDING BALANCE "PRIVATE - OCT ER BAL FWD -LM- -30- -60- -9E- 5.{{ 1525,0{- -60- -90- -120+- 7980,{{ 8482.55 5427.59 39580,12 09/05/0N 11210002000 {9/01/8E -- 09/21/88 14 529504{7120 775.0{ 09/E1/00 -- 09/15/00 1 54551207120 43.70 09/{1/{{ -- 89/30/00 188 56153287120 09/01/0N-- 09/30/00 1 55353607120 30 5135E{0712{ 7080,E{ -12E+- 16671.45 1528.00 290N2 PHARMACY LHGHWD 09/30/00 -- 10/23/00 1 54551201120 67.4E 99610 OXYGEN CONCNHY RENTAL 10/{I/0{ -- 1E/31/00 31 5535360112{ 558.00 30EE2 PHARMACY NON LEGHND 10/05/00 1 54951301120 21.21 IIiEE BEAUTY AND BARBER 10/24/E{ 1 5915810112E 515R1 HMALL OXYGEN TANK 1E/25/EO 1 54151501120 23.R0 11600 CABLE RENTAL 10/31/00 I 5915B401120 5.E0 ROOM CHARGE AT 828.00 10/01/00 -- 10/31/00 3t 5135EN{1120 5828.NN ADV ROOM CHARGH II/OIIH -- ll/3E/E{ 13211EE0000 "ENDING BALANCN '*INHURANCE ' OCY EO BAL FWD 'LM- '30' -6E- -RE- '120+- 879E,70 9255.18 8434.8{ B691,45- 13910.14 317E7.37 '*NWDING BALANCN "PRIVAYH ' NOV 00 BAL FWD -LM' -30- -60- 'RE- -120+' 1234E.61 5.{0 1525,E{' PAYMENT 11/21/00 1121E002000 4992.61 PAYMENT 11/211{0 1121E002000 60{7.39 30EN9 PHARMACY NONLHGHND 1E/05/00 1 54951301120 21.21 3liE9 PHARMACY HONLEGENR 10/05/00 1 54951301120 21,21 1160E CANLN RENYAL 11/N1/00 1 59158401120 5.RE 99610 OXYGEN CONCEHY RENYAL 11/{1/{{ -- Ii/3{/EE I 55353601120 REV LADY MO RC ll/O1/{E 132110BNOEN 5828.R0 ROOM CHARGE AT 828,0E ll/Ol/EE -- ll/30/E{ 30 5135EE{1120 5828.00 ADV ROOM CHARGE 12/Gl/NE -- 12/31/B0 1321100H000 5828.0E *'ENDING BALANCE "INBURANCN - NOV IN HAL {WD -LM- -3{- -60- -90- -120+- 8798,70 9255.18 8434.80 5218.69 31707,37 291E9 PHARMACY LNGNWD 09/Il/El 1 54551207120 17E.28 3lEE9 PNANMACY NONLEGHWD I0/05/E0 1 5495130712E 21.21 31707.37 10820.61 31707.37 6193.61 63/29/11 RRBIDRET LEDGBR AY OF DATE OF FIRB~ ACTIVITY PAGH 4 RBHIDRET REBIDRNT RNSIDBNT G~L -- ~CCODNTS RECNI~ABLR -- 45 PRIYATB GOWRR, ELM{OD C 64/31/66 ADH CNTR RATB~ 5828.66 ROOR 224 -A LBVHL I OtB PRI¥ PORT~ 6.66 **IRBURANCB - NOV 66 {COAT) **ERDIRG BALANCE 31515.88 *'PRIVRTR - DUC 66 BAL ~WD -LM- -36- -HH- -96- N193.B1 152~.~6 5.~6 1525.66- 61~3.61 PAYMANT MAJOR MNDICAL CK 69/H5/66 1121666266B 16671.45 PAYMENT 12/18/61 11216662161 365,61 PAYMENT 12/18/66 11216662666 7134.39 1161{ CABLH RENTAL 12/61/66 I 591584{I121 5.{6 51861 TOTAL INCONT-DLY FEE 12/11/66 -- 12/31/66 31 56151861126 31.66 99616 OXYGEN CONCERt RENTAL 12/11/16 -- 12/31/66 1 55353611126 558.66 REV LAHT MO RC 12/11/66 132116RE666 5828.66 ROOM CRARGH AY 82H.H{ 12/61/!t -- 12/31/{{ 31 51356611121 5828,{{ ADV ROOM CHARGE 61/61/61 -- 61/31/61 13211666666 5828.66 I68 YO PRIVATH 64/31/66 144116566{6 5427,55 INN TO PRIVA?R 65/31/66 14411656666 8462.55 INS TO PRIVAYB 66/36/6{ 144116561i6 7966.16 I#8 TO PRIVATE 07/31/06 14411856666 8434.66 IRS YO PR[¥AYH 66/31/66 56153217129 372,69 REV OXGYEN 68/31/66 57557569166 558.66 REV LEGEND 68/31/61 575575691{6 59.18 RMV R&B 68/31/66 51356667126 7316.66 REV LBGRED 89/15111 54551267128 43.76 REV RUTRI 69/36/16 56153267126 366.66 REV OXYGEN {9139166 575575691i6 546,96 REV B & B 69/36/66 51356667126 7666.66 CREDIT ROLL (BLIND} 1Z/61/66 1441165{666 1525.69 CREDIT ROLL (BLIND) 12/61/66 14411656666 5.66 CREDIT ROLL (BLIND) 12/11/66 14411656666 1526.66 **ENDING BALANCE 35697.18 "INHORANCH - DBC 66 BAL FWD -LM- -36- -66- -96- -126+- 191.49- 9798.76 9255.18 13653.49 31515.88 PAYMENT MAUOR MBDICAL CK 69/65/66 1121666266616671.45 INN YO PRIVATE 14/36/66 14411656166 5427,59 65/31/66 1441165RE66 8492.55 66/36/66 1441165966{ 7986.96 67/31/66 14411656666 8434.66 68/15/66 52559617121 319.69 68/33/66 56153267126 372.66 66/31/69 57557519169 558.96 68/31/66 57557569166 59.18 98/31/66 51351117129 7316.66 69/15/66 54551267126 43.76 99/21/99 52956467129 775.69 09/21/06 52956467126 656,66 INN ?0 PRIVATE INS TO PRIVATE IRS TO PRIVATE REV Ot INN YO PRIVATB REV OXGYHN REV LNGHRD REV R&B REV LBGNND REV 8P TO MAD B REV BP TO MUD B ~31291~1 (ARS6) ~BIDENT REBIDRNT RRRIDENT NUMBgR TYPg RARg RgBIDgNY LROGRi AB O~ DAYE O~ FIROI ACTIVITY PAGE 5 G/L -- ACCOURT8 RECRIYABLR -- DA~E O~¥ ACCOUNT CEARORO ORNDITB BALANCE 45 PRIVATE C. OWRR, RL#OOD C ROOM 224 -A LEVEL 1 **IRBUR~CR - DEC NB (CONT) R~V RUTMI REV OXYGEN REV B & B *'NNOING BALANCE**MCR CO INR - DEC NN CO INN OT CO INR PART B BP BP PART B "ENDING BALANCE **MEDICARE B - DEC NR MRD B OT CIA IRS BP PART B BP PART B CIA PART B RP PART B MRO B BPNECH C/A SPEECH **ENDING BALANCE *'PRIVATE - JAR il BAL FWD -LM- -3B- 5115.61 518R1 TOTAL INCOMT-DLY FEE 99H1{ OXYGEN CONCNNT RENTAL ll6BB CABLE RENTAL REV LABY MO RC ROOM CHARGE ADV ROOM CHARGE CREDIT ROLL CRROIY ROLL CREDIT ROLL CREDIT ROLL "ENDING BALANCE **INSURANCE ' JAR E1 BAL FWD -LM- *'ENDING BAL~CB **MCR CO INN - JAR El BAL FWD -LM- -6B- el/RI/B1 -- il/El/BI -- AT B2B.Re BI/RI/E1 -- 12/El/N1 -- {BLIND} }BLIND} (BLIND) {BLIND} R4/ll/ie ADM CNTR RATE: 5828.RB DIS PRIV PORT, N,NE eg/3i/ie 561532eT12e Egl3B/Ee 575575NglIN eR/3RIRB 5135RRBT12e EB/31/{I 5255NBll12e 56.39 EB/31/ll 529§N411121 99.16 BR/3{/NE 5295R41112B 13E.SB 36B.EB 54N,EE "NWDING BALANCE '*MEDICARE B - JAR il BAL FWD -LM- NR/31/RB 5255e61112B 225.58 eB/31/BI 5255EBll12e 18.e3 NB/31/eE 5255R61112N 1B.e3 IB/31/eN 5295141112E 396.66 BR/]I/~N 5295B41112B 154.1B IB/31/ll 57557511121 154.18 BR/3e/NN 5295B41112e 522.BB 19/31lee 5295141112B 122.51 ~9/3E/BB 5755751112B 122.5e -9)- -12B+- 299B1.§7 35197.t8 ~l/31/el 31 56151B)l12B R3.RB 11/31/il 1 55353611121 55B,EB {Il]l/N1 I 5915B4el]2~ 5.~B ~l/31/el 31 5135RRBl12B 5B28.RE B2/28111 13211EIB){I 5828,EI )1/)t/{1 14411{SRE{R 712.39 ~I/BI/EI 1441115)NEE 712.39 B1/)l/el 1441IRS)RRB 8642.75 Il/BI/il 144111511NB 8647.75 -3)- -6~- -9~- -12B+- 191.49- BTgB.71 E797.91- 19E.69 -Re- -12e+- 2B6.B) 286.15 -121+- 1144.24 1144.24 -6B- 19).$9- 286.N5 1144.24 41581.18 191.69- 286.e5 EXHIBIT "B" HCR Manor Care ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties w/th respect to the Resident's stay at this HCR Manor Cafe's Health Care Center ("Center"). Center: Resident: Admission Date: /~c/\ \ IC:x2D Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thLrty (30) days written notice. The Room and Board Rate set f6rth in Attachment A is payable in advance and is due by the tenth (10t~) day of each month. The Resident shall be respons~le for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the fight to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth ( 10th) day o f the mo nth. 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Proerams. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration,. and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ~' Medicare, /Medicaid and/or VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional [nformation. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Managed Care Organizations. Ifa Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organi?ation ("HMO"), Preferred Provider Organi?ation ("PPO"), Provider Sponsored Orga.ni?ation ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period o f time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of elig~ility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) days 6f the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be respons~le for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. It shall be the respons~ility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and ail charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the roles and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system II. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident The Legal Representative agrees to pay promptly fi.om the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment :from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Residem's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident fi.om the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. IH. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. ~ 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the fa'st month of the Rasident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time flame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organi?ation responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utili?ation review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinaRer "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required fi-om time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photo~rAp_h.h. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staffto identify the Resident. 4.04 Notice of Services, Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachment H-1 and H-2. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). Social Serv/ce Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state liceusure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone 'number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment J. n. Resident/Patient Rights. See Attachment K. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's fight to direct his/her medical treatment. See Attachment M-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 U. V. W. X. y. Z. ASM Form. See attachment P. See Attachment Q. See Attachment R. See Attachment S. See Attachment T. See Attachment U. See Attachment V. See Attachment W. 4.05 ~ent of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes th~ Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice tmless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a resuk ora change in State or Federal law will not invalidate the remalrfing provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION, Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: Signature of Legal Representative, signing on his/her own bel~lf: Date: Date: Center Representative: --[~ 4.c~ ,-& .~ ?z~_'~x ~ .,.~..- Date: 9 EXHIBIT "C" FROM : FAX NO. : ~fun. 21 2001 ~ ~ ~v~tEER~,~ C~bN~ ~i~TANC~ FOOD :~TAMP~ ~ .... $ GROSS MONTHLY DEPENDENT CARE r~ INCOME I. IMIT ~EGAL $E~VIC~S, iNC_ 8 IRVINE ROW 717-243-9480 7I 7-76&84.75 FROM : FAX NO. : Jum. 21 2001 04:4iAM P3 June 13, 2001 COMMO1N~WEAI,TH OF PENNSYLVANIA DEPARTlViENT OF PUBLIC VMELFARE Bureau of Hear/rigs and Appeals 1401 North Seventh Street, F/rst Floor Hsrrlsburg. Pe,~,~sylv~,~ia 17105-2675 Cas~ No_ 210/)89227-o01 NO~ICE OF SCItEDU L~.r~ Elwood Cower 1700 Market Str, Camp Hill, Pa 17011 Re: PA/FSI62 010116 Handwr/~en appeal 02/06/01 This notice acknowledges the receipt of your request for a £air hearing. Because you have chosen a telephone bearing, your hearing w~ll be conduce, ed by a hearing officer, who act~ as a~udge. The hea~ing ~Tcer w~ll call you at the telephone number you provided on your appeal notice at ~he ~ -' · ~d ~ime s~ ~low. Ple~e no~y ~e h~g o~cer im~ly ~e n~ber has c~ged or is in~t, ~r ~y~ wo~d l~e ~ t'h *~ your h~ ~oa fac~e h~ in H~burg. H~ ~: W~esday. J~e 27, 2001 ~me: 09:00 a.m. Yo~ ~ N,,~ (717) 766-9255 ~*~ ~ Phone ofWe~ H~ ~r 2: Fre~a M. ~unty, (717) 783-3950 · ACKNOWLEDOEME~T C~D~ROCIIU~: A ~lLad~essed, ~s~ge-p~d ~s~ard has boon includ~ ~ ~i~ no,ice. Please read the posted care~[ly, ch~k the appropriate box, and re~urn ~he c~d to ~e B~eau ofHe~in~ ~d Appeals a~ ~n ~ ~ible. A brochure ~s also been ~lud~ with ~s notice w~h p~des a starry of~e hea~ng proce~ and i~ormation reg~ding ~p~onal ~ ~ods. ifyouha~z~Yquestio~reg~dlngthecon~n~sno~ceorthe brochure, plea~ con~t ~he hea~g ~er_ The Bureau ofHea~gs ~d Appeals complie~ ~ the Americas ~th DisablHties Ac~_ We svill p~de re~o~ble accomm~ati~z u~n request, Please con~a~ the hearing offi~x at the ~ve ad.ess or telephone nu~ u~n receipt o~t~ ~e~nden~ ffyou ~e ~clal accommodations. Sincerely, cc: Cumberland CAO Craig ~q. Gower lkn tTreeda M. Prttnty, Welfare Hearing Officer 2 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOVVER, Defendants NO. 01-4773 CIVIL CIVIL ACTION - LAW PRELIMINARY OBJECTIONS TO PLAINTIFF'S COMPLAINT AND NOW, this ~,-c~ day of September, 2001, comes Craig Gower, individually and on behalf of EIwood Gower, through his attorney Michael D. Rentschler, Esquire, who files the within Preliminary Objections, as follows: Preliminary Obiections in the Form of A Motion to Strike Scandalous or Impertinent Matter Pursuant to Pa. Rule of Civil Procedure Rule 1028(a~(2~ 1. On or about August 13, 2001, HCR Manor Care, Plaintiff, filed a complaint against Elwood Gower, individually, and, his son, Craig Gower, individually, and on behalf of Elwood Gower. 2. The Complaint ostensibly is for the collection of amounts of money allegedly owed to Plaintiff by Defendant for alleged nursing home health care purportedly provided to Defendant Elwood Gower. 3. Paragraph 11 through 21, inclusive, contain allegations which are irrelevant, inappropriate, immaterial, scandalous, or impertinent. 4. Paragraphs 11 through 21, inclusive, of Plaintiff's complaint state as follows: 11. That Defendant Craig Gower submitted an application for medical assistance on behalf of his father, EIwood Gower, on or about November 27, 2000. 12. That pursuant to the above mentioned application, Defendant Craig Gower was notified of discontinued benefits due to excess of resources of Defendant Elwood Gower. A true and correct copy of the notice of discontinued benefits is attached hereto, incorporated herein, and marked as Exhibit "C". 13. That pursuant to said discontinuation of benefits, Defendant Craig Gower filed an appeal with the Department of Public Welfare. See Exhibit "C" as previously identified and incorporated herein. 14. That the appeal hearing, which occurred on or about June 27, 2001 upheld the prior decision of the Department of Public Welfare that benefits were to be discontinued. 15. That pursuant to the appeal decision, Defendant Craig Gower failed to appropriately utilize the assets of his father, Defendant Elwood Gower, to pay for the residential health care services which were being provided to Defendant Elwood Gower. 16. That Plaintiff alleges, and therefore avers, that Defendant Craig Gower is receiving Defendant Elwood Gower's social security benefit checks and expending said funds for his own use instead of using said funds to pay Plaintiff for the amount due and owing on Defendant Elwood Gower's account balance with Plaintiff. 17. That Defendant Craig Gower violated his fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Elwood Gower by utilizing Defendant Elwood Gower's social security benefits for his own purposes when he know or should have known there were outstanding medical bills for his father, Defendant Elwood Gower. 18. That Defendant Craig Gower wrongfully converted the funds of his father's social security benefits, without authority or justification, into his own possession and for his own personal use to prevent said social security benefits from being applied to the necessary and medical needs of his father, Defendant Elwood Gower. 19. That the funds of said social security benefits rightfully belonged to Defendant Elwood Gower and Plaintiff for his necessary and appropriate medical services and treatment rendered by Plaintiff to 2 Defendant Elwood Gower. 20. That recovery for unjust enrichment is proper if one party is enriched by another, and injustice would result if recovery for the enrichment is denied. 21. That Defendant Craig Gower was enriched by the use of the social security benefits, which rightfully belonged to Defendant Elwood Gower, and injustice would result if recovery for enrichment was denied as said benefits were to be used to pay Plaintiff for the medical services it rendered to Defendant Elwood Gower. 5. Since Paragraphs 11 through 21, inclusive, are immaterial, inappropriate, scandalous, or impertinent to the proof of the cause of action, it is respectfully requested that these paragraphs be stricken from the complaint. WHEREFORE, it is respectfully requested that this Honorable Court grant the within Preliminary Objections and, consequently, strike paragraphs 11 through 21, inclusive, from Plaintiff's complaint. Respectfully submitted, MICHAEL D. RENTSCHLER, ESQUIRE 1300 Market Street, Suite 200 Lemoyne, PA 17043 (717) 975-9129 Attorney for Defendant Craig Gower 3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANORCARE, Plaintiff NO. VS. ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, MICHAEL D. RENTSCHLER, ESQUIRE, do hereby certify that on this date I served a copy of the within document via first-class mail, postage pre-paid to the following recipient(s): Daniel F. Wolfson, Esquire 267 East Market Street York, PA 17403-2000 Date: WOLFSON & ASSOCIATES, P.C. ATFORNEYS AT LAW 267 EAST MARKET STREET YORK, PA 17403-2000 (717) 846-1252 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, : Plaintiff : VS. : : ELWOOD GOWER, Individually, and : CRAIG GOWER, Individually, and on Behalf of: ELWOOD GOWER, Individually and Jointly, : Defendants : NO. 01-4773 Civil CIVIL ACTION - LAW NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice is served, by entering a written appearance, personally of by attorney, and filing in waiting with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint, or document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la cone. Si usted quaere defensas de esas demandas expuestas en las paglnas, siguientes, usted tlene vlente (20) dlas de plazo al panlr de la fecha de lademanda y la notifiation. Usted debe presentar una aparlencia escrita o en persona o pot abogado y archivar en la corte en forma escrlta sus defensas o sus objeciones a last demandas en contra de su persona. Se avlsado que si usted no se defienda, la cone tomara medldas y psedldo entrar una orden contra used sin previo avlso o notiflcaclon y por cualquler queja o alMo que es pedldo en la peticlon de demanda. Usted puede perder dinero o sus propledades o otros derechos Imponantes para used. LLEVE ESTA DEMANDA A UN ABOGADO II*IMEDIATAI'4ENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 IN THE COURT OF COklI~ION PLEAS OF CUI~IBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, : NO. 01-4773 Civil Plaintiff : _. vs. : CIVIL ACTION - LAW : ELWOOD GOWER, Individually, and : CRAIG GOWER, Individually, and on Behalf of: ELWOOD GOWER, Individually and Jointly, : Defendants : AMENDED COMPLAINT AND NOW, this 27~h day of September, 2001, comes the PlaintJff, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson &: Associates, P.C., and files the wlthln Complaint and in support avers as follows: !. Plaintiff, HCR Manor Care is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business iituate at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1701 I. 2. Defendant, Elwood Gower, is an adult Individual wtth a current address of 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Defendant, Craig Gower, is an adult Individual with a last known address of ~ollo Court, Lot 88, Mechanicsburg, Cumberland County, Pennsylvania 17055. 4. That Plaintiff filed its original Complaint on or about August 13, 2001, and Defendants subsequendy flied Preliminary Objections to said Complaint on or about September 6, 2001. 5. That Plaintiff is filing the within Complaint as an attempt to cure Defendants' Preliminary Oblections. residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein, and collectively marked as Exhibit 14. That Defendant Craig Gower knew or should have known his father would !ncur expenses for health care services which the Plaintiff expected to be compensated. i 5. That Defendant Craig Gower knew or should have known charges for health care services incurred are not usually completely compensated by third party payor's or government programs and therefore his father would incur health care expenses in excess of any insurance and or kledical Assistance and that those expenses would be the personal responsibility of his father and or himself. 16. That at all times relevant thereto, Defendant Craig Gower, knew or should have known of his responsibility and or duty to pursue and secure Defendant Elwood 3ower's financial resources and any available benefits to pay for expenses incurred by his father. 1 7. That from the time Defendant Craig Gower executed the Admission the Plaintiff, on behalf of his father, he undertook the handling of the rights and responsibilities related to the health care services received by his father, and at all times thereafter, he was under and remained under obligation to the Plaintiff. 1 8. That by executing the Admission Agreement, Defendant Craig Gower agreed in writing to assume and accept responsibility for the debt to be incurred by Defendant Elwood Gower for the services to be provided by the Plaintiff and to provide payment from Defendant Elwood Gower's income or resources for the fees and charges In the Admission Agreement, and further, in the event of a breach of his duties and obligations and or his failure to provide the information required to submit and complete an application for Medical Assistance, he agreed to be personally liable to the Plaintiff. See Exhibit "B", SectiOn I, Paragraphs 1.05, 1.06, 1.07, 1. ! 0~ Section il, Paragraphs 2.01, 2.02, 2.04 and 2.05 previously identified and incorporated herein. 19. That Plaintiff submitted to Defendants a copy of the Itemization of services accurately showing all debits and credits for transactions with Plaintiff. 20. That Defendants have not objected to the above-mentioned Statement of Account submitted by Plaintiff to Defendants. 21. That Defendants have refused to pay the account balance identified in Exhibit 22. That Plaintiff has made numerous requests to Defendant Craig Gower, as the Legal Representative and/or Responsible Party for Defendant Elwood Gower, demanding ~hat the sums due and owing to Plaintiff be paid, and Defendant Craig Gower, as the Legal Representative and/or Responsible Party for Defendant Elwood Gower, has refused his obligation to pay necessary and appropriate bills on behalf of Defendant Elwood Gower, in direct violation of the Admission Agreement and his fiduciary duty as his father's legal representative. See Exhibit "A", Section 1, Paragraphs 1.07, 1.1 O; Section I1, Paragraph 2.02 previously identified and incorporated herein. 23. That Defendant Craig Gower submitted an application for Medical Assistance ~n behalf of his father, Defendant Elwood Gower, on or about November 27, 2000 as he 4 was required to do under the Admission Agreement. See Exhibit "A", Section 1, Paragraph ! .05 previously identified and Incorporated herein. 24. That pursuant to the above mentioned application, Defendant Craig Gower was notified his father's benefits were discontinued due to his father's excess resources in the amount of Twenty Three Thousand Eight Hundred One and 12/Dollars ($23, 801.12). A true and correct copy of the notice of discontinued benefits is attached hereto, incorporated herein, and marked as Exhibit "C". 25. That pursuant to said discontinuation of benefits, Defendant Craig Gower an appeal on behalf of his father, Defendant Elwood Gower, with the Department of Public Welfare. See Exhibit "C", previously Identified and incorporated herein. 26. That Defendants did not appear at the appeal hearing, which occurred on or 3bout June 27, 200 i, resulting In the dismissal of the appeal for failing to pursue It and thereby the prior decision of the Department of Public Welfare that benefits were to be discontinued was upheld. See Exhibit "C" previously identified and incorporated herein. 27. That Defendant Craig Gower's failure to appear was a direct violation of 11, Paragraph 2.05 of the Admission Agreement he signed with the Plaintiff in which he agreed to cooperate In the process of applying for and obtaining kledlcal benefits. 28. That Defendant Craig Gower knowing failure to cooperate with the Department of Welfare to obtain Medical Assistance benefits for his father constitutes a breach of the Admission Agreement and the fiduciary obligations owed to the Plaintiff. 29. Defendant Craig Gower has not pursued Medical Assistance benefits on ~ehalf of his father who continues to reside with Plaintiff and incur debt for health care services provided by Plaintiff. 30. That Defendant Craig Gower knew or should have known pursuant to the ~,dmlsslon Agreement he was personally responsible for cooperating with the Medicaid representative in attempting to qualify his father for benefits. 31. That Defendant Craig Gower knew or should have known his father was ¥ responsible for charges incurred while a resident with Plaintiff if benefits were and that any breach of his duty to provide payment to Plaintiff would result in his incurring personal liability on behalf of his father. See Exhibit "A" Section I, Paragraphs 1.07, !.09, !.01, !.02, 1.05, 1.10 and Section Ii, 2.02, 2.04 and 2.05. 32. That pursuant to the appeal decision and in direct violation of the Section Ii, 2.01 and 2.02 of the Admission Agreement he signed with the Plaintiff, Defendant Craig Gower willfully failed to appropriately utilize the assets of Defendant Elwood Gower, to pay for the residential health care services which were being provided to his father. 33. That Defendant Craig Gower unequivocally and willfully violated his agreement with the Plaintiff when he failed to follow through with the requirements of the Medical Assistance process. 34. That at all times relevant thereto, Defendant Craig Gower willfully, knowingly, and unequivocally violated his agreement with the Plaintiff when he failed to remit payment on behalf of his father. 35. That Plaintiff alleges, and therefore avers, that Defendant Craig Gower 'ecelving Defendant Elwood Gower's finances and expending said funds for his own use instead of using his father resources and funds to pay Plaintiff as he agreed for the amount due and owing on Defendant Elwood Gower's account balance with Plaintiff. 36. That Defendant Craig Gower violated his fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Elwood Gower by utilizing Defendant Elwood Gower's resources and finances for his own purposes when he knew or should have known there were outstanding medical bills for his father, Defendant Elwood Gower, which are currently due and owing to Plaintiff. 37. That the finances of Defendant Elwood Gower rightfully belonged to Defendant Elwood Gower and Plaintiff for the necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Elwood Gower. 38. As of the date of filing of the within Amended Complaint, the balance due, owing, and unpaid on Defendant Elwood Gower's account as a result of said charges is the ~um of Forty-Eight Thousand Two and 18/I O0 Dollars ($48,002.18). See Exhibit as previously identified and incorporated herein. 39. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Elwood Gower's account balance, all to the damage and detriment of the Plaintiff. 40. The damage to Plaintiff is the direct result of the failure to pay the Plaintiff for health care services provided to Defendant Elwood Gower, as a resident of Plaintiff, by both Defendant Elwood Gower and or his Responsible Party, Defendant Craig Gower. 4 I. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (! 8%) per year on past due balances. See Exhibit "B" as previously identified and Incorporated herein. 42. As of the date of the within Amended Complaint, the amount of Interest that has accrued on the past due balance is the sum of Three Thousand Seven Hundred Sixty-One and 62/100 Dollars ($3,761.62). 43. Plaintiff has retained the services of the law firm of Wolfson a: Associates, in the collection of the amounts due from Defendants. 44. Pursuant to Section !, Paragraph ! .03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney fees and all court costs if the account is referred to an attorney for collection. See Exhibit as previously identified and incorporated herein. 45. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 6: Associates, P.C., in the collection of the amounts due and owing by Defendants incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance which is due and owing. 46. That the amount of attorney's fees which represents thrity percent (30%) of the principal amount due and owing is the sun of Fourteen Thousand Four Hundred and 65/1 O0 Dollars ($ ! 4,400.65). 8 47. Any and all conditions precedent to the bringing of this action have been ~erformed by Plaintiff. 48. The amount In controversy exceeds the Jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Elwood Gower, Individually, and Craig Gower, Individually, and on Behalf of Elwood Gower, in the amount of Forty-Eight Thousand Two and 18/100 Dollars ($48,002.18), contractual interest in the amount of Three Thousand Seven Hundred Sixty-One and 62/1 O0 Dollars ($3,761.62), reasonable attorney's fees in the amount of Twelve Thousand Four Hundred Seventy-Four and 35/I 00 Dollars ($12,474.35), the costs of this action, and such other relief as the Court deems proper and Just. Respectfully submitted, WOLFSON 6t ASSOCIATES, P.C. 267 East Market Street York, PA ! 7403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff VERIFICATION Daniel F. Wolfson, Esquire, hereby states that he is the attorney for the PlainUff, HCR Manor Care, and he is authorized to take this verification on behalf of said Plaintiff in the within action and verifies that the statements made in the foregoing Amended Complaint are true and correct to the best of his knowledge, information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made sublect to the of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. September 27, 2001 WOLFSON 6: ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 206! 7 Attorney for Plaintiff EXHIBIT "A" · HCR Manor Care ADMISSION AGREEMENT This Agreement is entered into by and among ttCR Manor Care, thc Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Cafe's Health Care Center ("Center"). Center: Resident: Legal Representative: Admission Date: Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the as~c servmes provided for in Section 3.01, the b ' ' Resident agrees to pay the applicable Room and Board Rate set forth ~n Attachment A hereto. The Room and Board Rate/s subject to change upon thirty (30) days written notice. The Room and Board Rate set f6rth in Attachment A is payable in advance and is due by the tenth (10~) day of each month.' The Resident shall be respons~le for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Man~ged Care Organ;zation (see Section 1.06). 1.02 ~. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the fight to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Anci/lary Charges" are descn'bed on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (I0~h) day of the month. 1.03 ~. Accounts not paid in tull within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in fi~ll. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 ~. The Resident sh, all be directly responsible to independent providers, including but not limited to, the Resident s attendin_v ~h sician fi persona/program in accordance with the terms o£the program "' y or any health or 1.05 Governmental Pro ams. If the Resident is ellg~le for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration,. and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ~- Medicare, /Medicaid and/or _ VA. Medicare may pay for some or all of the Resident'-~care. If Mgdicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resideht also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Kate fi.om their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local depanment(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessaw' including requesting a court to order such payment. 1.06 Third Party Pavors and Manaeed Care Or~ani~ations. Ifa Resident is a participant in a plan offered by a th/rd Pan7 payor such as a Health Maintenance OrganiT-tion ("Ih-MO"), Preferred Provider Organization ("P,,P,O"), Provider Sponsored Organiv-tion ("PSO"), or Physician Hospital OrganiTation ("PHO), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by, the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, accord/rig to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center w~l/bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that th~'d party payor including charges not paid with.in a reasonable period of time. 1.07 Private Pav Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative ~ree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify, the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility, detennination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification.or verification of eligt'bility and coverage information. The Resident and/or Legal Representative agree to provide the Center with .notice ~ ~f the Resident's disenrolknent, enrollment, change in health care coverage, failure to pay premium(s) or renewal of/nsurance coverage and any cancellations in coverage as the Center relies on the information suppl/ed regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be respons~le for any denied charges due to lack of authorization, inelig~ility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 A lication for Bcncfrts. It shall be the respons~ility of the Residem and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a govemmentai program third party payor or managed care organi?ation with which the Center is under contract. 1.10 Primary Resnonsibility for Payment. Except for payments for services covered under govemmentai programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to biil a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This Agreement serves as a ~tten notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of serv/ces is always available at the business oflSce upon request. 1.11 ~ The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time ager adrn/ssion, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the fight to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Ph~_~..~_.~qy.. The Resident and/or Legal Representative acknowledge the right to _c.h..o_o,.se a ,pharmacy..of ,ch.oice, provided the pharmacy selected is properly licensed, packages and ~uppaes Pnarmaceuncars m accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distn'bution system similar to the Center's ancillary pharmacy's medication distribution system II. RIGHTS .,-SAND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE 2.01 ~. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, ff any, have been delivered to the Center. .02 Am'e~.rne~nt to Make Payments on Behalf of Reside,,~ The Le~, *'- - · - ,- ~- ~ .... ~,~,,,,~m ~ income or resources all fees and charges for which the a~'ees to pay nrommiv ~r,,-, ,t~ ~,~o:~_.,_, : ~,~x r~epresenratlve Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 ~ The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. · 2 04..Exhaustion ofResident's Fund~ If the Resi-~ ..... ' ' . =. uem s nnanc~ resources change such ttmt the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to :file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 2.05 .Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personal/y responsible for any charges defiled the Center due to any lack of cooperation. 2.06 .Acceptance Upon Discharee. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative ~agrees to arrange and pay for the departure of' the Resident fi.om the Center. If at, er notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditiomlly be obligated to accept the Resident and to pay promptly al/charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Stand~rd Services. As pan of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prelim-ed by the Resident's physician and the Center, w/th the Resident's consent~ for the health, safety and gener~l well-being of the Resident. 3.02 Other Services. The Center shal/act in accordance with the Resident Handbook, which is incorporated by reference in tl~ Agreement. 3.03 Deoosit. The Center hereby acknowledges receipt of the Deposit, i/any, noted at the beginnlng of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days at~er discharge or transfer or within the time fi.me required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days o f the Center's receipt of the final Medicaid payment for care o f the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organiyution responsible for all or any party of the payment or reimbursement of the Resident's charges, including an7 utili?~tion review or quality assurance reviews or payment audits Performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's 1/ability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinat~er "Treatment") as are necessary to maintain the well-being of the Resident, including but not l/m/ted to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the Performance of therapies, as prescribed by the Resident's personal physician in the Resident's ?lan o£Care, or as requirecI/rom tune to tune in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority Nave been delivered to the Center, and that such Legal Representative hereby consents on behalfo£the Resident to the Treatment described above. 4.03 Consent to Photo k The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Adm/n~ration Record or other records and for any other similar uses of the photograph for Center and staffto identify the Resident. 4.04 Notice of Sen, ices, Policies and Additional Information The Resident and/or Legal Representative:. acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, J/applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. f.. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachment H-I and It-2. The Center's pol/cy and procedure on bedholds, election of' bedholds and readmission. See Attachment I (Center Supplement). Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number of' Ombudsman. See Attachment I (Center Supplement). The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state Licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fi'aud control unit. See Attachment I (Center Supplement). The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Comer. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint w/th the state survey and certification agency concerning resident abuse, neglect, m/streatment and misappropriation of property. See Attachment I (Center Supplement). The Resident Handbook. See Attachment Resident/Patient Rights. See Attachment K. Medicare/Medicaid information and d/splay of' such information includiug how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulrnonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-I and M-2. Privacy Act Notification. See Attachment N. Inventory sheet and/or policy of personal items. See Attachment 0. ASM Form. See attachment p. See Attachment Q. See Attachment R. See Attachment S. See Attachment T. See Attachment U. See Attachment V. See Attachment W. 4.05 Assienrnent of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the' Cemer and any holder of meitical or other information to release such information to the Health Care Financing Admlnistration and its agents and to third party payors any infogmation needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terrain,ted as set forth below mad as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at le~t seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be respom~le for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident :md/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 ~ The Resident shall defend, indemnify and hold the Center harmless Rom any and all claims, demands, suit and actions made against the Center by any person resulting fi-om any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 ~ Any provision of the Agreement that is found to be invalid or unenforceable as a result ora change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOLNG AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Sigmture of Resident: Date: Sigmture of Legal Representative, i~signing on behalt'ofResident: Date: Sigmture of Legal Representative, signing on his/her own bel~..' Date: EXHIBIT "B" MANORCARE CAMP HILL 583 1700 MAI~KET STREET CAMP HILL, PA 17011 (717)-737-8551 CRAIG GOWER ~OR ELWOOD GOWER ROLLO CT LT 88 MECHANICSBURG, PA 17055 ROOM 224 -A Please Return his Potion With Your Payment GOWER, ELWOOD C ...................... 45 04/11/00 ~ SERVICE RENDERED 02/01/01 BALANCE PORWARD 02/28/01 51801 TOTAL INCONT-DLY ~EE ( QTY 02/28/01 99610 OXYGEN CONCENT RENTAL ( QTY 02/28/01 11600 CABLE RENTAL 03/01-03/3!/01 ADV ROOM CHARGE ( QTY .. 02/28/01 41,581.18 28 ) 84.00 1 ) 504.00 i ) 5.00 ~ 5,828.00 PAYMENT DUE BY THE 10TH A,",1OUNT DUE 4B,002,ti 45 gONgL gL#OOD gOON 224 ~A 8AL YND 11599.6i **NCR CO IN8 - ~ge el BAL F~D -LM- -68- -98- 29981.57 41581.18 e21el/e] -- 82128161 28 58151881128 8~.88 82/ei/81 -- 82/28/ei 1 553536~i128 8212818! 1 59158481128 Lee 62/e1/81 13211eeele8 NOON CeANgg AT 828.ae ~2/e1/81 -- 82128181 28 51358881128 AD~ 800N CBAEGg 83/81/81 -- 83/31/E 13211eeeH! 5828.88 '*eNDING BAlANCe BAL ~WD .88 -38- -90- -128+- BAC YND -LM- -38- -60- -ge- -128+- 11(4.24 1144.24 PAENgNT NCB-9/e8 82/13/el I1218882888 5828.H 198.~9 522.88 1144.24 19L69- 286.85 622.24 BAng ~y ACCOU~ -- ACCOUNTS P~CgIYABLN -- O0#RN, ELNOOD C MOO! 22t -A LRIRL 1 116~ CABLE RRRTAL lllB~ NNAU~Y AND BARBER **MNDIRG BALARO! 14111 PRYNICAL TRRRAPY ~[NIT PMFSICAL TRMRAPY RYAL 2~452 SPRReN ?RRRAPY NYAL 51511 CA[N~[g~ [RAY A~CILLAR¥ #RI?g OFF ROOK CHARgg AT 236.91 i4/llll~ -- *'RNDING NALARCg **~RI~A~ ' KAY ~ NAL F~ -LM- -3R- '*gNDING BALANCg **IRRUNANCg ' FAY ~R RAL FMD -LM- -3R- 5A27.5~ 29R$9 PHARMACY LBGBND 9961~ ~t/ll/~ ANN CNTN Nl~g: 5828,ee DIR PNIV PORT: i.~! 59158191129 ii~Il~il -. 1413il11 ] 54551217121 252,59 It/il/il -- R4115111 5 541515~71~1 41.11 N4/lllll -- Ri/3tlIR Zl 56153217121 IR.Il R4/12/RI 2 52151217121 51.ii 14/lB/IR 1 54151597129 Ii,il R4/31/ll 57557517321 -61- -gl- iS/il/Il-- 15/31/ll i 59158411121 5.ti -61- -91- 5427,5B 15/il/il -- 15/25/li 1 54551217121 384,55 if/il/Ii -- 15/31/11 112 5HI53ZI?IZI 224.1~ **iMDIRG NALANC~ NAL F~D -LM- ll611 CABLE RENTAL BAL F~D -LM- 8482.55 5427.59 53212 N~RTNL/gN~RL R~NV GP~ 2 99~11 OXYGEN CONCENT RENTAL 29e17 PRAP~qACY LgGNND 3~e87 PBAN~ACY EON LgGgND OXYGEN CONCENY RENTAL 151~llil -- 15/31/ll 1 55353617121 558.11 ROOK CHANGE Af 236.11 15/il/{! -- 15/31/li 31 51351{~712~ 731H,ll -3~- -6~- -gi- ll.il- B6/el/ll i 591584~1121 ~6/18/lt -- IH/28/ll I IHliEl~i -- 16/19/11 I 1391~,14 56153217121 55353H~712~ §45512t7121 227.61 15,11 2~6.65 5427.59 13911.14 B3/29/B~ 45 **INSURANCE ' JUN Be '*ENDING BALANCE **P£IYAYE ' JUL BB 5,00 5.00 '*ENDING BALANCE BAL ~ 'LN- -39- 7989.00 6482.55 53262 NTRYNL/NNTRL 8gET OEP 2 29909 PHARMACY LEGXWD 17492 OCCUP THERAPY EVAL 17192 OCCUP THERAPY VIHIT 30009 PHARMACY NONLEGRND G/L -- ACCOUNTB RMCNIVABLE -- DATE OYY ACCOUHY CHARGER CRMDIYH BALANCE 04111106 ADM CNYR RATE~ 5828.60 DIH PRIV PORY~ 9.09 21890.14 -60- -BB- -126+- 19.00- .09 07106160 1 59158161129 10.00 19,09 20402 BPXNCE THERAPY EVAL E7/31/00 ROOM CHANGE AY 236.09 67/01/B9 -- 67/31/00 "ENDING BALANCE '*PRIVATE - AUG 09 BAL FWD -LA- -36- -60- 19.99 5.90 5.99 19,09- PAYMENT E8/16/60 ROLL CRMDIY {BLIND) 07161100 ROLL CRMDIY {BLIND) 97/91/00 ROLL CREDIT (BLIND} *'ENOIWD BALANCE '*INHURANCE ' AUG 60 BAL FWD 'LM- '39- '60- 8434,89 7990.99 8462.55 5427.59 20162 HPEECN THERAPY VIBIT 68/01/96 -- 68/03/00 3 53202 NTRYRL/RNTRL 8ERV GRP 2 08/91/90 -- 08/31/09 i96 R9610 OXYGEN CONCERT RENTAL 09/01/00 -- 68/31/00 1 17192 OCCUP THERAPY VIHIY BE/E2/09 -- 29092 PHARMACY LEGEND 08/03/00 -- 29192 BPEECB THERAPy VIBIY 08/18/09 -- 29492 HPEECH THERAPY EVAL ROOM CHARGE AY 22N.09 09/91/09 -- 08/31/09 31 *'ENDING BALANCE -30- -60- -60- -9O- -120+- 07/01/90 -- 67/31/00 186 56153207129 372.00 07/01/99-- 97/31/90 I 55353697129 558.09 07/05/09-- 67/17/60 1 54551207120 H7.59 07/07/90 I 52550607129 25,09 67/10106 ] 52550667129 25.00 97/11/06 1 54951307120 21.21 I 52956407129 59.09 31 51359997129 7316.90 "PRIVATE ' HEP 00 BAL FWD -LM- 1525,00- 11600 CABLE RENTAL ~'ENDING BALANCE 09101109 -- 09/30/00 -126+- 19,90 11210602000 10.00 1121909ZE99 1525,E0 14411056060 16.06 14411950909 5,00 14411050000 5.60 52950407129 100.00 56153207120 372,99 55353507120 52550597129 300.90 54551267126 59.18 52959497129 52956407129 25.00 51359907120 7316.90 -126+- 1525,09 1 59158401120 5.00 30324.94 1525.00- 1529.99- G/L -- ACCOVRTB ~ECEIYAHL~ -. Di~i ~y ACCO~H~ C~AHGE~ CREOI~ RALAWD~ 45 GOHEB, EL~0OO C HOO~ 224 -A LB~EL 1 '*INRUHANCE ' HHP RAL PWD 'LM- 9255.18 8434,9R PA~M~B~ CHC ~l~ ~WD 29~H2 PR~RMACY LEGBHD 996N 0XEBB COHCEN! RMBTAL ~91~llHH -~ HHISHIH~ ROOM C~ABGB '*P~IVA~ ' OC~ 90 HAL FWD 'LM' '39- -69- -90- 3~952 P~A~C~ NON ~EGEND Ci~l ~N~ R~! C~RMGg ~D~ ~OO~ '*gNDING PA~T PA~MERY 3~ PHARMACY NONLNGEND ADM CNTR RATE; 5828.9i DIS PRIV PORY~ 9,99 -69- -9H- 7989.69 9462.55 5427.59 39589.12 99/95/96 11219992999 99/81/99-- 89/21/99 14 52959487128 775.99 69191169 -- BH/1Sl~i 15~551297129 43.79 99/91/88 -- H9/39/99 189 56153287129 369.98 1 553H3697129 549.99 38 51359997129 7988,98 69/HH/69 -- 19/23/69 18/81/99 -- 18/31/99 19/95/09 18/2A/99 10125/90 19/31/99 AY 828.00 19/61/96 -- 10/31/OH 11/81/99 -- 11/38/68 -129+- I 545S129112H 67.46 31 55353691129 558,99 1 54951391129 21.21 1 591S918t129 19.99 1 54151591129 23.60 1 59159481128 5.98 32 5135H991128 5828.99 13211899898 5929.98 -39- -HH- -99- -129+- 9255.18 9434.88 9691,45- 13918.1A 31797.37 -39- -69- 5,90 1525,99- -96- -129+- 19829.61 11/21/99 1121H992999 4992.62 I1/21/99 11218882888 6897.39 ]9/B5/HH 1 54951391128 21.21 19/85/99 I 54951391128 21.21 11/91/66 1 S9158491129 5.99 11/39/88 1 55353691129 548.99 11/91/69 13211968999 5828.99 11/39/99 38 51359881129 5828,99 12/31/89 13211999899 5828.86 16671.45 OXYGEN COECEHY RMBYAL 11/91/99 -- REV LAH~ MO RC ROOM CHARGE Af 829.99 11/91/99 -- ADV ROOM CHARGE 32/91/89 -- '*INSURANCE - NOV 98 BAL FWD -LM- -39- -69- -99- -128+- 8799.79 9255,18 8434.68 §218.69 31797.37 39889 PHARMACY HOBLEGE~D 19/95/69 I 54951387128 21.21 31797.37 1529.98 19826.61 31767.37 6193.61 RBBI~RRT LEDGNB ~ OF DATB OF YlBBT ACTI~IT~ PAOB ~BIDEBT I~BI~BNT B~RIDNR~ G/L " ACCO~B~B RNCBIYABL8 -- OA~E Q~I ~CCOOBT CBABGgS ~RgDI?B BALABCB 45 PRIYATE GOW~R, ~LROOB C WDO~ 214 q LR~BL 1 "IRB~RANC! -NO¥ 66 ICORT) '*~NBIRG BALABCE 6193,61 1529,B9 PA~NT 11699 CABLE ~NT~L 51861. NTAL IBCON?-DLF FEE 99619 O~YGEN CONCEN~ RBB~AL ROOR CBABOB ~)V RO0~ CRARGB INB ~0 PRI~A~ INS TO PRIVATE IBB TO PBUATE lBS YO PRIVA?B REV OXOY~N REV R&B BEV LEGEND REV BUTRI REV B & B CREDIY ROLL CREDIT ROLL CBEDIF BOLL *'ENDING BALANCE **INBURANCE - DEC BAL FWD -LM- PAYMNNY MAJOR MWDICAL CK IBB ~0 PRIVAFE IEB ~0 PRIVATE INB fO PRZVAYE IRB YO PRIVA?E REV OY INB ~0 PRIVA?E REV REV L~EWD REV R&B REV LEGEND REV 8P ?0 MED B REV BP TO MED B 64111166 ADM CNTR RA?L 5828.69 DIS PRIV PORT: 9.99 -66- -99- -129+- 5,99 1525.96- 6183.6I 68/65/66 11216692666 16671.45 12/18/99 11219962669 365,61 12/18/96 11Z16B92666 7134.39 12/61/69 1 58158461129 5,69 12/61/B6 -- 12/31/66 31 58151891126 31.69 12/B1/96-- 12/31/66 1 55353861129 558.99 12/B1/66 13211666666 5828.69 B2B.B9 12/91/99-- 12/31/96 31 51356991129 5829,69 61/61/B1 -- 61/31/B1 13211666666 5928,96 64/36/96 14411651699 5427.59 65/31/BB 14411659666 8482.55 BH/36/99 14411656699 7989,96 67/31/66 14411650069 9434.66 68131169 56153297126 372.69 66/31/69 57557569166 558.66 96/31/89 5795?589196 59.16 09/31/66 51359667126 7316.60 98/15/90 54551297129 43,79 99/36/69 56153267126 366.66 99/35/99 575§7569165 549,99 99/36/99 51356667126 7689.99 {BLIND} 12/61/99 14411656899 1525.99 {BLIND] 12/61/66 144]1956969 5.99 {BLIND} 12/91/99 14411659999 1529.89 '66- -96- -126+- 8798.79 9255.18 13653,49 31515.88 69165196 1121666266616671.45 64/39/69 14411959666 5427,59 65131106 14411656960 8482.55 96/39/69 14411959999 7999.BB 67/31/69 14411650696 8434.66 68/15/89 52556697126 389.69 BB/3I/B6 56153297126 372.66 98/H/99 57557569106 558.66 69/31/66 57557509160 59.18 98/31/99 51359997129 7316.99 69/]5/99 54551297129 43.79 98/21/99 52959467129 775,69 69/21/66 52956467129 656.66 31515.88 35697.18 REBIDRRT RBNIONRT RNNIBNNT WDRRER TgP~ NANN PRIVATN GOWER, NLWOOD C ROON 224 'A LNVEL 1 "INSURANCE - DEC ON R~V NUTRI NNV OXYGEN RNVB&B **ENDING BALANCE "MCR CO INN -DNC Ne CO IWD OT CO INB PART B BP RP PBRT B 'RWDING BALANCE *'M~DICARN B - DEC Be MWD BOY C/A INK HP PART B HP PART B C/N PANf B NP PART B MED B NPEECR C/A NPNECE 'ENDING BALANCE *'PRIVATE ' 8AN BAL FWD -LM- 5115,61 5lHel ?OYAL INCONT-DLY CABLE RNHTAL RNV LAHT NO RC ROOM CHARGE ADV ROOM CHARGE CREDIT ROLL CRNDIT ROLL CREDIT ROLL CREDIT ROLL "NNDING BALANCE 'INBUBANCN - JAN BAL FWD 'ENDING BALANCE **MCR CO IWD - JAN BAL FWD "ENDING BALANCE **MEDICNRE H - JAN el BAL FED 'LM- G/L -- ACCOUNTS ~CNIVABLE -- ABM CRIR RA~E: 5828.~e DIS PBIV PORT~ Leg BB/31/Be 5255B61112E 56.3H 08/31/{~ 5255B6Il12e 225.58 BB/31/EE 5295~61112e IH.B2 88/21/B~ 5295041112e 154.18 eH/H1/ee 575§751112e 1§4,18 Bg/BB/OB 5755751112e 122.5e -EB- -~e- e2/e~/e2 -- elm/e~ el/el/el AT 828.ee el/el/el -. 81121181 e2/el/el -. 82/2e/el [BLIND) el/el/~l {HLINS} el/el/el {BLIND) el/el/el {BLIND} el/el/el -Be- -6e- -9B- 191.45- 879e.7e -12o+- 29981,57 35e97,le 31 561518el12E 93.Be 13211eeeeee 582e,ge 14411ese~ee 712.39 14411eseeee 8647.75 -12B+- 11~4.2~ 114~.24 28625 1144.2~ 41581.18 19L69- 2BE.eS EXHIBIT "C- Numbe~- LEGAL SERVICES. !NC. 8 IRYINE ROW C.~[JS[.E PA 717-24,.%J)400 FI~OM : J~me 15, 2001 FAX NO. : Jun. 21 2881 I~4:41¢¢I 0OM/~IOATW~AI,TH OF PENNS~,V~ DEP~~ OF P~LIO ~LF~ BUreau ofHe~n~ ~d Appe~ 1~1 ~h Sev~ 8~et, ~t ~r H~isburg' Pen"~Ylv""ia 17105-2675 Elw0ocl COwer 1700 Market Str, Camp Hill, Pa 17011 Re: PA/FSI62 010116 Handwritten appeal 07,/06/01 Dear Mr, Cower: This notice acknowledges the receipt of your requost for a fair hearing. Because you have chosen ~ inco~, or ~yo~ wo~d l~e ~ c~ your h~ ~ a fac~e h~ ~ H~: W~esday, J~e 27, ~001 Yo~ ~N~ (717) N~m~ ~g Phone ~W~ H~ ~ 2: Fre~a M. ~ty, (717) 783-39~0 *ACKHOWLEDGEMENT C~ROCHU~: A ~M~dresse~ ~s~-p~d ~s~ard has b~n inclu~ ~ ~ no,ce. Please rea~ the posted care~[)y, ch~k tSe appropriate box, and return the c~d to ~ B~eau ~e~in~s ~ Appe~s as ~on ~ ~ible. A brochure Ms also ~]ud~ ~th ~s no~e w~h ~des a S~ry of~e hea~ng pro~ and i~orma~on reg~g op~on~l ~g m~o~, If you ~v~ ~y ques~io~ reg~g ~he con~n~ ~s ~ce or ~e hrochur~ plea~ eon~t ~.he~g o~.~r. The Bura~u o~Hea~ ~d Appeals complies ~ the Arabic.s ~lh D~ab/lt~ies Ac~. We ~I · ~lease ~n~ the he~ing o~ at the a~ve or telephone num~ u~n receip~ of~ co~es~nden~ ~you ~e m~al acco~olations, P3 Sincerely, cc: Cumberland CA0 Crag $. CoWer F'reeda M. Prtmty, Welfare He.rig Officer 2 ~ROM : FAX NO. ; COMMONWEALTH OF PENNSYLVANIA DEPARTMENT ~F PUBLIC WELFARE BUREAU OF HEARINGS AND APPEALS 1401 NORTH SEVENTH STREET, PO BOX 2675 HARRI,~BURG, PENNSYLVANIA 171015 CA~: 2100~9227~001 the C~B~RLAND COunty ~ard of Assis%ance. A he~ing ~aa ~;he~ule~ for June 2~, 2001 at 9;00 a.m. Before the hea=~ng ~h~ A~e11~ o=a11~ a~v~s~ ~he ~ureau of Hearing ~ Ap~als ~ha~ ~e o= she ~ul~ w~th~ra~ ~he ~e~l. T~e AD~ellant ~a6 in~truet~ to ~u~mit t~wit~zaw~l ~ wr~t~ ~ the Inasmuch as the appellant has fa/led to ~ursue the appeal, ~t le dismissed in aocordance with PA Code dismAsse~. Ei2her party to this P=oceeding has fifteen (15) ~ays from the date of this decision to request ReoOnslde;atiOn by the Secretary of the Depa=tment (In · oo4 Stamp =sass, OnZy the A$~gellant may seek Rec~si~e~ati~). TO seek This . action d~; ~ s~ the time wl2hin which an a~eal ~;t ~ files to C~n~alth Court. The appropriate Darty(ies), whets ~ermitte~, may take issue ~ith this Order an~ may appe&Z to the Commonwe&lt~ Coo£~ o~ ~enasylvani& within thtrb~ (30) the Clerk of ~nwe~I~h Court of ~e~lv~ia, P.O. ~x 11730, ~rri~hut~, ~A 1710~. FROM : FAX NO. : accordance with Pa R.A. 1~14. In this Ca~e, service must be made 2675, 1401 N. 7th St., 6th Floor, ~rrls~urg, Pe~s~lvania 17105-Z675, ~ Departmen~ Of Public Welfare, Of~i=e of Legal COunsel, R~m 309, F~nal Aamlnistrative Tho~s E. Cheffins, Ac~i~ & ~i!ing Da~e P~ FI~OM : FAX NO. : . , , ~ -TWI~ ,14~ L:~E~l 1~9:~;=~:~ P4 ,)I~PUCATION/PETTTION FOR Of you want R~,.ddendion, 'you mu~ complete thi~ form) Name: D~to of H~dng and Appeela Final Decision/FAA: If this application Is granted, the Secretary of Public Welfare will review your complete case fils and you will receive a decision from the Secretary. 1. Did the Bureau of Hea~ngs and Appeals' d~ision cor~ctly apply ~ate and federal poll~(l~), regulation(s}, and la~ ~ ~0 If your answer is ~o:' a. Identify, to t~e b~t of your ablii~/, policy(les), regulation(s), and law and explain how the Bureau of Hearings and Appeals applied them incorrect¥. b. TO the best of your abilities, give the specific pofi=y(lea), regulatlon(s), and law that should be appli~l and explain why they should be applied: FR[ ~ FAX NO. : HCR'~or~ ,,T~1,,14 :L:)~l ~9:56PM Pi Fax Cover Sheet 1700 Market Sb'eet Camp Hill, Pennsylvania 17011 Phone: 717-737-8,~1 .... To. '~ -~ ..... ' Fro~: ~ " ' ~ ..... ~.. ~-/~ ...._. ~ ~ - _ ' ; Re~ N~ber of P~: ~. Did you know... A,~.he~mer's ~r ~ated memc,.y tmpai~rrnents term respite stays IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. ELWOOD GOWER, Individually, and NO. 01-4773 Civil CIVIL ACTION - LAW CRAIG GOWER, Individually, and on Behalf of: ELWOOD GOWER, Individually and ]oindy, : Defendants : CERTIFICATE OF SERVICE AND NOW, this 27~ day of September, 2001, I, Daniel F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Amended Complaint upon the counsel of record by Regular Mall - Postage Pre-paid and addressed as follows: Michael D. Rentschler, Esquire 1300 Market Street, Suite200 Lemoyne, PA 17043 (Counsel for Defendants) WOLFSON &~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 IDNo. 20617 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff V$, ELWOOD GOVVER, Individually, and CRAIG GOVVER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. 01-4773 CIVIL CIVIL ACTION - LAW JURY TRIAL DEMANDED TO: HRC MANOR CARE NOTICETO PLEAD YOU AREHEREBY REQUIREDTO RESPONDTOTHE WITHIN NEW MATTER WlTHIN20DAYS OFSERVICEUPONYOU ORAJUDGMENT MAYBE ENTERED AGAINST YOU. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANORCARE, VS, Plaintiff ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. 01-4773 CIVIL CIVIL ACTION ~ LAW JURY TRIAL DEMANDED ANSWER AND NEW MATTER TO PLAINTIFF'S AMENDED COMPLAINT AND NOW, this .~ Z~day of October, 2001, comes Defendant Craig Gower, by and through his attorney, Michael D. Rentschler, Esquire, who files the within Answer and New Matter to Plaintiff's Amended Complaint, as follows: 1. Admitted, upon information and belief. 2. This allegation is addressed to a defendant other than client, so the same is denied. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 7 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 8. There is no paragraph 8 of plaintiff's amended complaint, so no response is 1 necessary. 9. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 9 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 10. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 10 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 11. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 11 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 12. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 12 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 13. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 13 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, it is denied that defendant Elwood Gower received necessary treatment and that the treatment was reasonable. 14. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 14 of the amended complaint, so the same is hereby denied and strict preof thereof is hereby demanded. 15. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 15 of the amended 2 complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 16. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 16 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 17. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 17 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 18. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 18 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, it is denied that defendant Craig Cower is personally liable for any purported debts of his father. 19. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 19 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 20. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 20 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 21. Admitted in part. Denied in part. It is admitted that defendant Craig Cower has not paid the amount requested by plaintiff. It is denied that the amounts requested are fair, accurate, and reasonable and that the amount alleged, is owed to plaintiff. 22. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 22 of the amended 3 complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 23. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 23 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 24. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 24 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 25. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 25 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 26. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 26 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 27. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 27 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 28. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 28 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 29. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 29 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 30. Denied. After reasonable investigation defendant is without knowledge as to 4 the truth or falsity of the allegations contained in paragraph 30 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 31. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 31 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 32. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 32 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 33. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 33 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 34. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 34 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 35. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 35 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 36. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 36 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 37. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 37 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 5 38. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 38 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 39. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 39 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 40. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 40 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 41. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 41 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 42. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 42 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 6 By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 43. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 43 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 44. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 44 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 45. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 45 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 46. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 46 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. By way of further answer, see defendant Craig Gower's New Matter which is incorporated herein by reference. 47. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 47 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. 7 48. Denied. After reasonable investigation defendant is without knowledge as to the truth or falsity of the allegations contained in paragraph 48 of the amended complaint, so the same is hereby denied and strict proof thereof is hereby demanded. NEW MATTER 49. Defendant Craig Gower incorporates by reference his responses to paragraphs 1-48 as if fully set forth herein. 50. Without admitting that defendant Craig Gower owes any money to plaintiff either individually or on behalf of his father defendant EIwood Gower, or jointly, plaintiff has failed to mitigate damages. 51. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, he is not liable for any legal fees of Wolfson & Associates, P.C. 52. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, defendant Craig Gower has not committed any acts which give rise to his liability for payment of legal fees. 53. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, the legal fees alleged to be owed are not reasonable and not owed by defendant Craig Gower. 54. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, defendant Craig Gower is not bound by any contract for legal representation by and 8 between plaintiff and Wolfson & Associates, P.C. 55. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, Exhibit "A" to plaintiff's amended complaint does not owe any money to plaintiff. 56. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, the plaintiff has filed to mitigate damages in that plaintiff permitted and continues to permit defendant Elwood Gower to reside at HRC Manor Care instead of discharging him from care at HRC Manor Care. 57. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant EIwood Gower, or jointly, defendant Craig Gower is not personally liable to plaintiff for any money allegedly owed to plaintiff. 58. Plaintiff's amended complaint fails to state a claim upon which relief can be granted against defendant Craig Gower, individually, or on behalf of defendant Elwood Gower. 59. Plaintiff has not provided reasonable and necessary treatment to defendant Elwood Gower. 60. Without admitting that defendant Craig Gower owes any money to plaintiff, either individually or on behalf of his father defendant Elwood Gower, or jointly, plaintiff has acted in bad faith. 61. Defendant Craig Gower is not responsible for any payments to plaintiff on behalf of his father defendant Elwood Gower. 9 62. Plaintiffs action is barred in whole or in part by the applicable statute of limitations. WHEREFORE, it is respectfully requested that this Honorable Court find in favor of defendant Craig Gower and against plaintiff. Respectfully submitted, MICHAEL D. RENTSCHLER, ESQUIRE 1300 Market Street, Suite 200 Lemoyne, PA 17043 (717) 975-9129 Attorney for Defendant Craig Gower 10 VERIFICATION I, Craig Gower, verify that the statements made in the foregoing Answer and New Matter are true and correct to the best of my information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to authorities. Craig Gower, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, VS. Plaintiff ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. CIVIL ACTION - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVlCF I, MICHAEL D. RENTSCHLER, ESQUIRE, do hereby certify that on this date I served a copy of the within document via first-class mail, postage pre-paid to the following recipient(s): Daniel F. Wolfson, Esquire 267 East Market Street York, PA 17403-2000 Michael D. Rentschler, Esquire WOLFSON & ASSOCIATES, P.C. ATTORNEYS AT LAW 267 EAST MARKET STREET YORK, PA 17403-2000 (717) 846-1252 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. 01-4773 CIVIL ACTION - LAW PLAINTIFF'S REPLY TO DEFENDANT CRAIG GOWER'S NEW MATTER AND NOW, TO WIT, chis 15th day of November, 2001, comes the Plaintiff, HCR iManor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 6: Associates, P.C., and files the following Reply to New Matter and in support hereof avers as follows: The allegations and averments contained within paragraphs One (1) through Forty- -:ight (48) of the Plaintiff's Amended Complaint are Incorporated herein by reference as if set forth in full. 49. Paragraph 49 of Defendant's Answer and New Matter Is an incorporation )aragraph to which no response is required. To the extent chat a response ts necessary, me is denied and the allegations contained in Plaintiff's Complaint are incorporated herein by reference as if set forth in full. 50. Denied. It is specifically denied chat Plaintiff had failed to mitigate damages in this matter. To the contrary, Plaintiff has attempted to assist Defendant Craig Gower in obtaining Medical Assistance for his father, Defendant Eiwood Gower, but Defendant Craig Gower has refused and failed to cooperate with the proper procedures to obtain Hedical Assistance on behalf of his father. Accordingly, Plaintiff's attempts to mitigate damages have been thwarted by Defendant Craig Gower. 51. Denied. It is specifically denied that Defendant Craig Gower is not liable to Platndff for any attorney's fees as a result of this action. To the contrary, Defendant Craig Gower signed the Admission Agreement as Legal Representative on behalf of Defendant Elwood Gower, and in doing so, Defendant Craig Gower agreed to pay reasonable attorney fees and all court costs if the account Is referred to an attorney for collection. Strict proof is demanded at trial. The herein referenced Admission Agreement was attached to Plaintiff's Amended Complaint as Exhibit "B" and is incorporated herein. 52. Denied. It is specifically denied that Defendant Craig Gower, has not committed any acts which give rise to his liability for payment of legal fees. To the contrary, Defendant Craig Gower violated the terms of the Admission Agreement by failing to follow through with the requirements of the Hedical Assistance process and by utilizing Defendant Elwood Gower's resources and finances for his own purposes instead of utilizing said resources and finances to provide payment to Plaintiff. AS a direct result of said violadon of the Admission Agreement by Defendant Craig Gower, the Plaintiff was forced to refer the account of Defendant Elwood Gower to an attorney for collection due to non-payment, which therefore makes Defendant Craig Gower liable for the payment of Plaintiff's legal fees. Strict proof is demanded at trial. 2 53. Denied. It is specifically denied that the legal fees alleged to be due are not reasonable and not owed by Defendant Craig Gower. To the contrary, said legal fees are reasonable and due to Plaintiff as a result of the violation by Defendant Craig Gower, of the terms and conditions of the Admission Agreement. Strict proof is demanded at trial. 54. Denied. The allegations contained in paragraph 54 of Defendant Craig Gower's Answer and New Matter are conclusions of law to which no response is required. To the extent that a response Is necessary, same is denied and strict proof is demanded at trial. By way of further response, Defendant Craig Gower is responsible for reasonable legal fees as a result of his violation of the terms and conditions of the Admission Agreement. 55. Denied. The allegations contained in paragraph 55 of Defendant Craig Gower's Answer and New klatter are unclear and confusing. Accordingly, after reasonable investigation, Plaintiff Is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 56. Denied. It is specifically denied that involuntarily discharging Defendant Elwood Gower would be an appropriate or responsible method of mitigation for Plaintiff to utilize in this matter. By way of further response, there are a number of specific criteria which must be met in order for a nursing home care facility to involuntarily discharge a resident and said criteria would not be met as said criteria pertains to Defendant Elwood Gower as Defendant Elwood Gower requires medical care and treatment that Plalndff does not believe he would receive outside of Plaintiff's facility. Strict proof is demanded at trial. 57. Denied. It is specifically denied that Defendant Craig Gower is not personally liable to Plaintiff for money owed to Plaintiff as a result of the health care services provided to Defendant Elwood Gower. To the contrary, by executing the Admission Agreement, as Legal Representative on behalf of Defendant Elwood Gower, Defendant Craig Gower agreed that he would incur personal liability on behalf of Defendant Elwood Gower for a breach of the duty to provide payment to Plaintiff from Defendant Elwood Gower's income or resources for the medical services and treatment rendered to Defendant Elwood Gower and for failure to cooperate with Department of Public Welfare to obtain Hedical Assistance benefits for Defendant Elwood Gower. By way of further response and as previously stated herein, Defendant Craig Gower has breached both of the aforementioned duties and is, therefore, personally liable for the amount currendy due and owing to Plaintiff. Strict proof is demanded at trial. 58. Denied. The allegations contained in paragraph 58 of Defendant Craig Gower's Answer and New Hatter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. 59. Dented. It ts specifically denied that Plaintiff failed in any way to provide reasonable and necessary treatment to Defendant Elwood Gower at any time during which Defendant Elwood Gower has been a resident of Plaintiff's facility. By way of further response, any and all allegations or inferences that Plaintiff acted in bad faith or was negligent in any manner whatsoever, is hereby specifically denied and strict proof is demanded at Trial. 4 60. Denied. It is specifically denied that Plaintiff has acted In bad faith in any of its relations with Defendant Craig Gower. By way of further response, any and all allegations or inferences that Plaintiff acted in bad faith or was negligent in any manner whatsoever, Is hereby specifically denied and strict proof Is demanded at Trial. 6 i. Denied. It is specifically denied that Defendant Craig Gower is not responsible for any payments on behalf of Defendant Elwood Gower. To the contrary, by executing the Admission Agreement, Defendant Craig Gower acknowledged and accepted liability, individually and on behalf of Defendant Elwood Gower, for the account balance which Is currendy due and owing. By way of further response, Defendant Craig Gower violated his fiduciary duty and responsibilities as the Legal Representative and/or Responsible Party for Defendant Elwood Gower by not utilizing Defendant Elwood Gower's finances to pay Plaintiff when he knew or should have known there were outstanding medical care bills for Defendant Elwood Gower, in violation of the executed Admission Agreement. Further, the finances of Defendant Elwood Gower should have been utilized to pay Plaintiff for his necessary and appropriate medical services and treatment rendered by Plaintiff to Defendant Elwood Gower, but Defendant Craig Gower failed to use Defendant Elwood Gower's finances for that purpose, in violation of the executed Admission Agreement. Strict proof is demanded at trial. 62. Denied. The allegations contained in paragraph 62 of Defendant Craig Gower's Answer and New Matter are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. 5 WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Defendant Craig Gower's Answer and New flatter and enter judgment in favor of Plaintiff and against Defendants, along with the allowable costs of this action, and such further relief as the Court deems appropriate. Respectfully submitted, Daniel F. Wolfson, Esquire ,,~ ~ WOLFSON ~: ASSOCIATES~ P.C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff 6 VERIFICATION Daniel F. Wolfson, Esquire, hereby states that he is the attorney for the Plaintiff, HCR Hanor Care, and he is authorized to take this verification on behalf of said Plaintiff in the within action and verifies that the statements made in the foregoing Reply to New Hatter are true and correct to the best of his knowledge, Information, and belief, based upon information provided by the Plaintiff. The undersigned understands that false statements herein are made subject to the ~enalties of i 8 Pa.C.S. Section 4904, relating to unswom falsification to authorities. )ate: ~t\~\ ox Daniel F. Wolfson, Esquire . WOLFSON 6: ASSOCIATE~, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff ELWOOD GOWER, Individually, and CRAIG GOWER, Individually, and on Behalf of ELWOOD GOWER, Defendants NO. 01-4773 CIVIL ACTION - LAW CERTIFICATE OF SERVICE AND NOW, this 15~ day of November, 2001, I, Daniel F. Wolfson, Esquire, do hereby certify that I have served a copy of the foregoing Reply to New Matter upon counsel of record in the following manner and addressed as follows: REGULAR MAIL POSTAGE PRE-PAID Michael D. Rentschler, Esquire 1300 Market Street, Suite 200 Lemoyne, PA 17043 (Counsel for Defendant, Craig Gower) Danlel F. Wolfson, Esquire ~ WOLFSON 8~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Atmmey for Plaintiff