HomeMy WebLinkAbout01-7188IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
RONALD GARDNER,
Defendant
:
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 hah demandado a used en la cone. Si usted quaere defensas de esas demandas expuestas en las
paginas, siguientes, usted dene viente (20) dias de plazo al pardr de la fecha de lademanda y la
notifiation. Usted debe presentar una apadencia escrita o en persona o pot 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 used no se defienda, ia cone tomara medidas y psedido entrar una orden contra
used sin previo aviso o notificacion y pot cualquier queja o alivio que es pedido en la pedcion de
demanda. Used 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 SERVICIO VAYA EN PERSONA
O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA
ABA]O PAPA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(7! 7) 249-3166
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
:
VS. :
:
RONALD GARDNER, :
Defendant :
NO.
CIVIL ACTION - LAW
COMPLAINT
AND NOW, this'~ay of ~F(I~/~ , 20_~j__, comes the Plaintiff, HCR
Manor Care, by and through its attorney, Amy F. Wolfson, Esquire, and the law firm of
Wolfson 8z 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 place of business situate
at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013.
2. Defendant, Ronald Gardner, is an adult individual with a last known address
of 122 West North Street, Apartment A, Carlisle, Cumberland County, Pennsylvania
17013.
3. That on or about July 31, 2000, Defendant signed an Admission
Agreement, 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 "A".
4. That on or about July 31, 2000 through November 8, 2000, Defendant
was a health care resident of Plaintiff, where he received various necessary residential health
care services and treatment by Plaintiff. A true and correct copy of the itemization of said
services is attached hereto, incorporated herein, and marked as Exhibit "B".
5. That Defendant signed the Admission Agreement with Plaindff in order to
gain admission as a Resident at Plaintiff's health care facility and in order to receive their
health care services.
6. That Defendant is identified as both the Resident and Responsible Party in
the Admission Agreement. See Exhibit "A" previously identified and incorporated herein
by reference.
7. That Defendant agreed to pursue and cooperate with the Department of
Welfare to determine if he was eligible for Medical Assistance benefits. See Exhibit "A",
Section i, Paragraphs 1.05, 1.06, 1.09 and 1.10.
8. That Defendant did not pursue nor secure Medical Assistance benefits, in
direct violation of the terms and conditions of the Admission Agreement entered into with
the Plaintiff.
9. That pursuant to the Admission Agreement, the Defendant agreed to be
personally liable for any debt incurred as a Resident of Plaintiff's health care facility not
compensable by a third party payor or government program. See Exhibit "A", Sections I
and II, previously identified and incorporated herein.
2
10. That Defendant agreed to use his financial resources and income to pay the
Plaintiff for the debt incurred, if any, pursuant to the Admission Agreement. See Exhibit
"A", Secdons I and !i, previously identified and incorporated herein by reference.
! 1. That Plaintiff reasonably relied on the representations of Defendant with
regard to the Admission Agreement which Defendant executed for the purpose of being
admitted to Plaintiff's facility on or about July 31, 2000.
12. That Plaindff submitted to Defendant a copy of the itemization of services
accurately showing all debits and credits for transactions with the Plaintiff. Said Statement
of Account has been previously identified as Exhibit "B" and incorporated herein by
reference.
! 3. That Defendant did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendant.
14. That Defendant did not pay the Plaintiff for their health care services in
direct violation of the terms and conditions of the Admission Agreement entered into with
the Plaintiff.
! 5. That Defendant willfully and knowingly violated the Admission Agreement
when he failed to remit full payment to Plaintiff for the services he received as a resident at
Plaintiff's health care facility.
16. Defendant knew or reasonably should have known that he would incur health
care expenses while a resident at PlaintJff's facility and that such expenses would be his
personal debt obligation.
! 7. Defendant knew or reasonably should have known that if he failed to pursue
~nd secure a third party payor or government program for financial assistance in paying his
health care expenses for services provided by Plaintiff's health care facility, that he would
remain personally liable for any debt incurred as a resident of Plaintiff's facility.
18. That Defendant did not identify nor represent to Plaintiff that another person
would be the Responsible Party under the Admission Agreement and therefore it was solely
incumbent on Defendant to act on his own behalf to secure financial assistance and to remit
payment from his income and financial resources. See Exhibit "A" previously identified
and incorporated herein by reference.
19. Defendant further violated his duties and responsibilities under the Admission
Agreement he signed with the Plaintiff by not utilizing his financial resources to pay the
Plaintiff when he knew or should have known that there were outstanding health care
charges due and owing to Plaintiff.
20. Despite Plaintiff's reasonable and repeated demands for payment, Defendant
has failed, refused, and continues to refuse to pay all sums due and owing on Defendant's
account balance, all to the damage and detriment of Plaintiff.
21. As of the date of the within Complaint, the balance due and owing and
unpaid on Defendant's account as a result of said charges is the sum of SEVEN
THOUSAND SEVEN HUNDRED SEVENTY-THREE and 50/100 ($7,773.50) Dollars.
See Exhibit "B" previously identified and incorporated herein by reference.
4
22. Plaintiff has retained the services of the law firm of Wolfson ~ Associates,
P.C., in the collection of the amounts due from the Defendant.
23. 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 showing by Defendant, incident to the within action, and Plaintiff shall continue to
incur attorney's fees throughout the conclusion of the proceedings in the amount of thirty
percent (30%) of the principal balance due and owing to the Plaintiff by the Defendant.
24. That the amount of attorney's fees which represents thirty percent (30%) of
the principal amount due and owing is the sum of TWO THOUSAND THIRTY-TWO and
05/1 O0 ($2,332.05) Dollars.
25. That pursuant to Paragraph 1, Section 1.03, of the Admission Agreement,
Plaindff is entided to receive, and Defendant has agreed to pay, contractual interest at a
rate of eighteen percent (18%) per year on past due balances. See Exhibit "A" as
previously identified and incorporated herein.
26. That the amount of contractual interest which has accrued on Defendant's
account balance, at a rate of eighteen percent (18%) from June 30, 2001, is the sum of
FIVE HUNDRED NINETY-SEVEN and 48/100 ($597.48) Dollars.
27. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
28. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
5
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable
Court enter judgement in favor of Plaintiff and against Defendant, Ronald Gardner, in the
amount of SEVEN THOUSAND SEVEN HUNDRED SEVENTY-THREE and 50/1 O0
($7,773.50) Dollars, with contractual Interest in the amount of FIVE HUNDRED
NINETY-SEVEN and 48/100 ($597.48) Dollars, plus reasonable attorneys fees in the
amount of TWO THOUSAND THREE HUNDRED THIRTY-TWO and 05/1 O0
($2,332.05) Dollars, the costs of this action, and such other relief as the Court deems
proper and just.
Respectfully submitted,
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
6
VERIFICATION
I, I~ichelle Thureson, Senior Financial Services Consultant for HCR Manor 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 4904, relating to unsworn falsification
to authorities.
DATE:
Michelle Thureson,
Senior Financial Services Consultant
EXHIBIT "A"
Manor Car~
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Care, the Resident, ami the
Legal Representative, for the purpose of providing for/he fights and respons~ilifies of the partie~
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
Resident:
Legal Representative:
AdmissiOn Date:-
Term:
Deposit:
Th/s 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 THF. RESIDENT
1.01 Room and Board Rate.~ For the basic services provided-f6r-in'Section 3.01, the
Resident agrees to pay the applicable Room and Board Rate set forth on Attacbanent A hereto.
The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room
and Board Rate set forth in Attachment A is payable in advance md is due by the tenth (10~) day
of each month. The Resident shall be responsible 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 ~kc~/_~ht~g~. The Resident further agrees to pay to the Center all charges for
additional medical, therapeuticl or personal care services or supplies that may be requested by the
Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The
Center reserves the right to charge for personal care items of the Resident if necessary for the
well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and
a current ancillary charge list is maintained at the Center's business office for review during
regular business hours. Ancillary Charges 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
(10~) day of the month.
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
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 Programs. 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 uhder 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 i:omply
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 privi~te pay
residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: x Medic. are, x 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, arid any non-covered services
ac.cording 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 Rate from thek monthly income.
The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this
Agreement, the contribution a~ount as determined and periodically adjusted by the State and/or
local department(s) handling Medicaid.-' If tM 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 Organization CI'IMO'),
Preferred Provider Organization ("PPO'), Provider Sponsored Organization ("PSO'), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which.the
Center has executed a provider agreement, the charges are governed by the applicable agreeme~,.
The Resident shall be responsible for any co-payments, deductibles or non-covered charges,
according to the ~ame 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
.will bill the Resident's third party payor as a service, but the Resident remains liable for chargem.
' not p~id or covered by that third party payor including charges not pald within a reasouable
period of 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 ~t the
Center and during which time the Resident has not been deterr~ned to be eligible for Medica]d.
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 f~lly in applying for Medicaid and in the eligibil~ty
detenrfination 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 hatentlon 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 a~d/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 eligibility and coverage information.
_The_Resident and/or Legal Representative agree to provide the Center with Inofice
within five (5) day, of the Resident's disenrollment, enrollment, change in health care coverage,
failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as
the Center relies on the information supplied regarding such coverage.- The Resident and/or Legal
Representative acknowledge that if they fail to provide such information, they may be responsible
for any denie~l 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'responsibility 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 insura,n, ce 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 ~s
under contract.
1.10 primary_ Resuonsibilitv for Payment. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall remain primarily ii.able
for any and all 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, ?SO, PHO or
managed care provider may not pay for non-covered services, supplies, equipment, medication-m,
and other care and services which may be delivered by the Center .,or its subcontractors- This
Agreement serves as a written notice that the Center has notified the Resident aM/or Le$al
Rel~resentative that services provided at the Center may not be covered by a governmental
'third party payor or managed care orga~i:,afion. The Resident and/or Legal Representative il~
to be responsible for non-covered services. A price Iisi of services is always available ~-g~
business office upon request.
1. I 1 Personal Physician.. The Resident has the fight to choose a personal physician,
provided that the physician selected is properly licensed and agrees to abide by applicable law md
the rules and Policies of the Center. At the time of admission, the Resident must supply the
Center with the name ofhisaer personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal ReEresentative must immediately notify the Center or
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 hav~
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 Pharmacy. 'The Resident and/or Legal Representative acknowledge the ~ight 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
ancill~zy pha~-uuacy's medication distribution system.
Il. RIGHTS AND RESPONSIBILrrY OF ~ 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 Agreerhent to Make Payments on Behalf of' Resident. The Legal Representative
agrees to pay promptly from 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
sen, ices 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 Resident'S Funds. Itthe 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. It the .Lp'gsI
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
timely ~d proper manner.
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such information about the Resident's finance~ as Medk~id
representative shall require for continued coverage of the Resident and be personally respon.fftfle
for any charges denied the Center due to any lack of cooperation.
2.06 Acceptance Upon Discharge. Upon termination of' this Agreement as provided ia
the Resident Handbook the Legal Representative agrees to arrange and pay for the departure of
the Resident from the Center. If after notice the Resident is not removed as requested, then the
Center is authorized and empowered to remove the Resident by reasonable .m~e~s 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.
RIGHTS AND RESPONSIBILIT~S OF THE CENTER
3.01 Room and Standard Services. As part ofthe Room and Board Rate, the Cer~ter
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 prep~d 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 beginni, ng 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 lidvanCe payments shall be paid by
the Center within thirty (30) days aRer discharge or transfer or within the time frame required by
State law. In the case of Medicaid Residents, any such retired shall, be paid within thirty (30) days -
of the Center's receipt of the final Medicaid payment for care of the Resident.
IV. GENER~I. PROVISIONS
4.01 CQnscnt to Release of' Information. The Resident and/or Legal Representative
hereby consents to the release of his/her medical records to the following persons: Ce.~er
personnel, attending physicians and consultants; and person, firm, government entity, thh'd pn-~y
payor or managed care organization resports~le for all or an~/ party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
' reviews or payment audits performed by such; the personnel of any hospital or other health
facility or provider to whom or which the Resident may be transferred; the Center's
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Treat. The Reside. nt and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of' the Center to perform such functions, care-
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
includin8 but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily
activities; and general nursing car. e, the administration of medications ahd treatments, and the
performance of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in the exercise of'good nursing judgment, ~ubject to
any fights 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 behaifofthe Resident to the Treatment described above.
4.03 Consent to Photograph. 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 staff'to 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.
a. Authorization for Release or Review of Medical Information. See
Attachment C.
Authorization fo~ Payment of Benefits. See Atta. chment D.
c. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Determination Notice. See Attachment F.
Medicare Secondary Payor Questionnaire. See Attachment G.
At the request Of the Resident and/or Legal Representative, the Ce.nter
shall maintain the Resident's personal funds in compliance with the ll,ws
and regulations relating to the Center's rnmaagement of such funds. A
description and/or policies and procedures 0f protection of resident funds
and the Personal Trust Fund Agreement, Resident Personal FundS
ho
po
Authorization and any. other related documents. See Attachment H-1 '~d
H-2.
The Center's policy and procedure on bedholds, election of bedholds
readmission. See Atta¢lunent I (Center Supplement).
Social Service Agencies and Advcicacy C~oups 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, medic~
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phonq 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).
The Resident Handbook. See Attachment I.
Resident/Patient Rights. See Attachment K.
Medicare/Medicaid infoimation 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 info,,ation on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Cafe'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.
Privacy Act Notification. See Attachment lq'.
Inventory sheet and/or policy of personal iten~. See Attachment O.
s. ASM Fo~iii. See attachment p.
t. Consent to Photo_~'at}h
See Attachment Q.
· See Attachment
See Attachment S.
See Attachment T.
See Attachment U.
See Attachment V.
z. See Attachment W. '-
4.05 Assignment 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, ~ 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 Center and any holder of medical or other info,,atlon 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 Temfination, 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 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 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 speci,llzed 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 Ceh~er
harmless from 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 t~ any person or the property
of any person or entity (including the Center), except in the case of negligence of the C~er's
employees and agents.
4.08 Changes in the Law. Any provision of' the Agreement that is found to I~ invalid
or unenforceable as a result of a change in State or Federal law will not invalidate'the remahfiag
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 ~q'~.REBY CERTn~ AND ACKNOWLEDGE THAT Tm~
HAVE EACH Iit~AD AND UNDERSTOOD ~ FOREGOING AGREEMENT, AND
THAT Ti~.Y HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND TI~'iT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THIn. IR SATISFACTION.
Signature' of Legal lRepreseltativ~, if signing on behalf of Resldent·
Date:
Signature of Legal Representative, signing on his/her own behalfi
Center Representative: ~-~L ~(-~ ~ ~
-Date:
Date:
9
EXHIBIT "B"
HCR .Manor
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717),~249-008S
ANGELA CARR
FOR RONALD GARDNER
122 W. NORTH STREET
CARLISLE, PA 17013
MEDICARE A
PRIVATE
ROOM 161 -A
Please Return This Poaion
With Your P~ment
GARDNER, RONALD E 20075 07/31/00 11/08/00 05/31/01
DATE Of
05/01/01 BALANCE FORWARO 7,773.50
PAYMENT DUE
UPON RECEIPT
AMOUNT DUE
7,773:5¢
OGI1RI81 RESIOENT LEOGER AS OF DATE OF FIRST ACTIVITY PAGE I
(ARGG)
RESIDENT RESIOENT RESIDENT
NUNBER TYPE NAME
G/L -- ACCOUNTS RECEIVABLE --
OATE QTY ACCOUNT CHARGES CREDITS BALANCE
)EOICARE.A DARONER, RONAIO E
% ROON 161 -A _LEVEL 1
**MEOICARE k- JUL 00
ROOK CHAR6E AT 142.00
RO0~ ~RITE OFF
**E~DIND BALANCE
"LAID CO-IN - AU6 08
07/31/0D
LL/08/00
AO~ CNTR RATE: 0.88
DIS PRIV PORT: 0,80
CO-INSURANCE
CO-INSURANCE
'*ENDING BALANCE
**NEOICARE A - AUG 00
BAL E~O -LH-
330.71
38081 PHARMACY NON LEGEND
30001 PHARNACY NON IEDENO
14181 PHYSICAL THERAPY VISIT
14401 PHYSICAL THERAPY EVAL
10101 X-RAY SERVICES
ANCILLARY NRITE OFF
RO0~ CHARGE
RO0) WRITE OFF
OEOUCT CO-INS
RO0~ CHARGE
RO0) WRITE OFF
DEDUCT CO-INS 'AT 97.00
**ENOI~G SALANCE
**NEOICARE 5 - AUD 80
10208 LAB-GLUCOSE ~ONITORI~G
87/31/00 i S1350010120 142.00
87/31/80 I 51557018120 188.71
AT 97.00 o812ot~o -- 08/28/88
AT 97.00 08129/00 -- 08/31/88
-30- -60- -98-
08101100 --
081811H --
8D/31/88
85/3L/00
0Rf31/88
88/03/o0
80/3L/DO
05/28/00
AT 149.88 08/01/88 --
OD/Ut/00 --
AT 97.00
AT 149.00 88/29/88 --
08/29/08 --
88/5L/00
9 873.80
3 291.08
-120+-
330.71
1 54951310128 685.80
1 54951318128 63.~5
62 52158210128 1550.08
1 S2150210120 180.00
I SG153A10120 88,25
57557518120
28 51350018120 4172.80
28 S1557810120 5087.88
3 51350010128 447.00
3 51557010120 424.44
3
10208 LAB-GLUCOSE NONITORING
10288 LAB-GLUCOSE NONITORIN6
10208 LAB-GLUCOSE NON~TORIN6
18288 lAB-GLUCOSE NONITORIN6
10208 LAB-GLUCOSE NONITORIN6
18288 LAB-GLUCOSE NONITORING
10288 LAB-GLUCOSE NONITORING~
18208 LAB-GlUCOSE MONITORIN6
18288 LAD-GLUCOSE NONITORIN6
10288 LAB-GLUCOSE MONITORIN6
10278 LA8-GLUCOSE NONITORIN6
10288 LAB-GLUCOSE ~ONITORIN6
ANCILLARY ~RITE OFF
**ENOING DALANCE
**LAID CO-I~ - SEP 80
DAL FWD -LN-
1164.00
CO-INSURANCE
08/1//D0 4 56151911128 17.48
08/18/00 4 56151911128 17.48
88/19/00 4 56151911128 17.48
08/20/80 4 56151911120 17,48
88/21/00 4 56151911120 17.48
08/DD/DO 4 56151911120 17.48
05/23/00 3 56151911120 13.11
88/24/00 3 56151911120 13.11
08/25/00 4 56151911120 17.48
88/26/00 2 56151911120 8.74
08/28/08 3 56151911120 13.11
88/29/00 1 56151911120 4.37
88/30/~0 1 56151911120 (.37
08/31/00 57557511120
-38- -~0- -90-
1154.80
AT 97.00 09/01/00 -- 09/28/00 28 2715.80
2488.81
873.08
291.00
35.85
330.71
1164.00
9298.83
143.32
06/19/01 RESIOENT LEOGER AS OF OATE OF FIRST ACTIVITY PAGE 2
(ARGG)
RESIDENT RESIOENT RESIOENT
NUMBER TYPE NANE
G/L -- ACCOUNTS RECEIVABLE --
OATE QTY ACCOUNT CHANGES CREOITS BALANCE
20DTG
NEDICAREA GARDNER, RONALD E 07/31/0~
~. ROOM 161 -A LEVEL 1 11/08/00
'*CAID CO-IN - SEP 00 {CONT)
CO-INSURANCE AT 97.BB 89/29/00 -- ~9/38/80
coin ~/o
**EHOIHG BALANCE
**MEDICARE A - SEP 08
AD~ C~TR RATE: 0.08
OIS PRIV PORT: 8.80
2 194.80
88J31J80 5855712588~ 1164.D8
8AL FWD -LN- -30- -68- -90- -120+-
8967.32 330.11
PAYMENT 09/12/88
17181 OCCUP THERAPY VISIT O8/01/88 -- 88/31/88
11401 OCCUP THERAPY EVAL 08/81/80
18201 81000 GLUCOSE TEST 89/81/10
14101 PHYSICAL THERAPY VISIT 89/81/00 -- 89/29/88
17101 OCCUP THERAPY VISIT 09/01/88 -- 09/29/81
29081 PHARNACY LEGENO 89/01/80 -- 09/30/00
29101 PHAR)ACY IV ORUGS 09/01/08
30801 PHARNACY NON LEGEND 09/81/88 -- 09/38/80
98270 PHARMACY IV PUNP 89/01/00
99590 I.V, THERAPY-SUPPLIES O9/81/80
18201 OLOOO GLUCOSE TEST 09/02/O0
10201 8L000 GLUCOSE TEST 09/03/80
18201 81000 GLUCOSE TEST 89/04/80
10281 BLOOD GLUCOSE TEST og/eG/8S
10201 ~LO00 GLUCOSE TEST 09/06/00
102Oi BLOOD GLUCOSE TEST 09/07/00
18281 81000 GLUCOSE TEST 69/08/88
10201 8LOOD GLUCOSE TEST 89/89/B0
10201 8LOOO GLUCOSE TESt 89/18/88
18281 BLOOD GLUCOSE TEST 89/11/B0
18201 ilO00 GLUCOSE TESF 09/12/88
10201 BLOOD GLUCOSE TEST 89/13/00
18201 8LOOO GLUCOSE TEST 09/IAJ08
18201 BLOOD GLUCOSE TEST 89/15/08
18281 GLO00 GLUCOSE TESf 89Jt6J88
10201 RLOOD GLUCOSE TEST 09/17/00
10281 81000 GLUCOSE TEST 09J10J88
182~1 81000 GLUCOSE TEST o9f191H
10201 BLOOD GLUCOSE TEST 89/21/80
10101 X-RAY SERVICES 09/22/00
10201 BLOOD GLUCOSE TEST 89/22/08
ANCILLARY WRITE OFF ~9J38J00
ROON CHARGE AT 149.88 89/H/88 -- 09/28/08
~OOH ~RITE OFF = 8~J81j08 -- 89/28/80
DEDUCT CO-INS AT 97.~0
ROON CHARGE AT 149.88 89J29J~B -- 09/30J00
ROON ~RITE OFF 09/29/80 -- 80/38/8~
DEDUCT CO-INS AT 97.88
9298.03
11210082OB0 330.72
21 825586181~8 175B.80
1 5~550618128 18.08
4 56151918120 11.48
20 52158218120 1675.80
28 52~58618128 1858.88
1 54581210128 92.88
I 54381410120 ~848.48
1 5~951310120 A,47
I R4353918128 2qB.GA
1 5435iA18128 54.74
4 56181910120 17.48
~ 56151918128 i/.48
2 56151910128 8.74
2 56151918120 8.74
L 56181910128 4.37
4 56151910120 17.48
2 56151910128 8.74
4 56151918120 12.48
4 56151910120 17.48
A 56151910120 12.48
2 86151910120 8.24
3 56151910120 13.11
B 58151918128 13.11-
2 56151910128 8.74
I 56151918120 4.31
! 56151910120 4.37
2 S6151918128 8.74
4 56181910128 11.48
2 56151918120 8.74.
1 56153410128 165.88-
1 56151918120 4.37-
57557510128 7215.85
28 S138081812~ 4172.08
28 $i557~1~120 3961.44
28 2/16.80
2 5135881H20 298.00
2 5155/818120 231.82
2 194.08
2910.00
BGI19101 RESIDENT LEOGER AS OF OATE OF FIRST ACTIVITY PAGE 3
(ARGG)
RESIDENT RESIDENT RESIOENT
NUN8ER TYPE ~A)E
6/L -- ACCOUNTS RECEIVABLE --
DATE QTY ACCOUNT CHARGES CREOITS BALANCE
~EOICARE'A GARDNER, RUNALD E
~ ROUN 161 -A LEVEL L
**NEOICARE A - SEP OD (CONT)
07/31/DD AO~ CHTR RATE: B.BB
LI/08/00 OIS PRIV PORT: D.IO
CONT ALLOWANCE 87/31/0D
**EHOIHG BALANCE
'*~EOICARE B - SEP 00
BAL EWO -LN- -30- -60- -90-
143.32
**ENDING BALANCE
**PRIVATE - OCT 00
11600 CABLE RENTAL 10/01/)B -- 10/31/00
11100 BEAUTY AND BARBER 10/12/04'
*'ENOING BALANCE
**CAIO CO-IN - OCT OG
BAI FWO -l~- -30- -GO- -OB:
CO-INSURANCE AT 97.0) 10/D1/OB -- 10/31/BO
~*E~OING BALANCE
**NEOICARE A - OCT 80
5155701D120 .01
-120+-
143.32
1 5~158401120 ).DO
1 591581DI12D B.BO
-120+-
BAL FWD -LN- -3D- -60- -98- -120+-
5753.26 8967.33 .01-
10001 LAB SERVICES 08/03/00 i 56151910120 i1.9G
100D1 LAB SERVICES 08/07/D) L 5615191012D 27.2)
1BDO1 LAB SERVICES 08/08/80 i 5615191D12D 71.30
10001 LAB SERVICES 08/12/08 1 5615191012) 81.30
18001 LAB SERVICES D8/16/O8 i 56151910120 45.38
18801 LA8 SERVICES 08/19/0D 1 5615191012D 45.3B
10DO1 LAB SERVICES 08/22/0D 1 SG15191D120 45.3)
10001 LA8 SERVICES 08/24/)0 ! 56151910120 45.3)
10061 LAB SERVICES D8/25/00 1 56151910120 ¢5.30
10001 LAB SERVICES 88/28/00 1 56151916128 81.3A
10001 LAB SERVICES 08/31/88 1 56151910120 31.65
10201 BLO00 GLUCOSE TEST 1D/D1/00 3 56151RL)120' 13.11
29601 PHARNACY LE6ENB 10/01/08 -- 10/31/08 1 5455121)120 40.27
~9101 'PHARNACY 'IV DRU6S 1B/B1/B) -- l)/3L/)l i 54351410120
3000! PHAR)ACY NON LE6ENO 10/B1/)) -- 10/31/00 1 5495131012) 4.47
99590 I.V. THErAPY-SUPPLIES LO/Al/t) -- LD/31/B) 1 sq3514L)120
10201 BLOOU GLUCOSE TEST 10/02/B0 4 5615191012D 1/.48
14101 PHYSICAL THERAPY VISIT 10/02/00 -- 10/31/00 22 52150210120 LOGO.BO
17101 OCCUP THERAPY VISIT 1D/O2/iO -- 10/25/0) ll S2SSOGlil2D'lGS).))
10201 BlO00 GLUCOSE TEST ~0/03/)) O SGIS1910120. 13.11
10201 BLO00 GLUCOSE TEST 10/D4/)) 3 SGIS1910120 iS.Ii
L)~OI BLO00 GLUCOSE TEST 10/)S/DO 3 5GIS191B120 LO.kl
102D1 BlO00 GLUCOSE TEST .
I0201 8LO00 GLUCOSE TEST 10/08/00 O S6151910120 13.L1
10201 BlO00 GLUCOSE TEST
1D201 BlO00 GLUCOSE TEST 10/10/00 3 S6151910120 13.11
10201 RLO00 GLUCOSE TEST 10/11/00 3 SGIS1910120 13,11
51.34
14720.58
103.32
13.5~
SRk7.H
DGIi~IOL RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PAGE 4
(ARS6)
RESIDENT RESIDENT RESIOENT
NUMBER TYPE HAME
6/L -- ACCOUNTS RECEIVABLE --
OATE QTY ACCOUNT CHARGES CREOITS BALANCE
280/5 MEDICAREA OAROHER, RONALD E
~ ROOM 181 -A LEVEL 1
**MEOICARE A - OCT 88 (CONT)
18201 BLOOD GLUCOSE TEST
10201 8LO00 GLUCOSE TEST
10281 81000 GLUCOSE TEST
10201 BLO00 GLUCOSE TEST
102D1 BIO00 GLUCOSE TEST
10201 81000 GLUCOSE TEST
1D281 BLO00 OLUCOSE TEST
IO201 8lO00 GLUCOSE TEST
10281 BIO00 GLUCOSE TEST
10201 8lO00 GLUCOSE TEST
1D201 BIO00 GLUCOSE TEST
1020L BLOOD GLUCOSE TEST
102D1 BLO00 GLUCOSE TEST
iO20L 8lO00 GLUCOSE TEST
10201 BIO00 GLUCOSE TEST
iDGDL
OEOUCT CO-INS
CONT ALLOWNACE
'*ENOING 8ALANCE
**MEDICARE B - OCT O0
BAL FUO -LN-
07/31/00 ADH CNTR RATE: O.OO
11/88/DD OIS PRIV PORT: A.08
IB[12/O0 3 S6181018120 13.11
LD/13/80 3 S615101D12D 13.11
10/14108 3 56151818120 13.11
10/iS/OR 3 SGLGlglB12D 13.11
10/16/8D 3 56151910120 13.11
IO]lT/88 3 GGiS1NIO12D 13.11
10/18/0B 3 SG15191D120 13.11
1O/l}/OO 3 5815191D128 13.11
- 18/20/0D 3 56151910128 13.11
IB/21/08 3 58151910120 13.11
10/22/00 3 56151910128 13.11
iO/GS/OD 2 GCiSiR18120 8.74
10/26/00 2 5615191O120 8.74
10/26/0D 2 $6151910120 '8.74
1D/27/O0 2 S615191812D 8.74
BLO00 GLUCOSE TEST 10/28/8D 2 $6151910120 8.7q
ANCILLARY WRITE OFE lO/S1/00 S7557510120 q295.19
ROOM CHARGE AT 158.00 ID/OB/GQ -- lO/SI/OD 31 S135001DiGD 4278.08
ROOM WRITE OFF 18/01/0D -- 10/B1/O0 31 SiSSTGiO1GO 4087.86
AT 97.00 3i 80DI.OD
07/31/00 SISS7010120 .01
-30- -68- -90- -i20+-
143.32 143.32
-38- -60- -90- -120+-
13.50
-38- -68- -R8- -128+-
291B.BR SN17,BB
AT 97.01 11/01/08 -- 11/87/0D 7 679.80
09/30/80 88GSTI2SG00 291B.60
18/311D0 SBSG/12SOil 3807.8D
' **ENOING BALANCE
**PRIVATE - NOV 00
8AI FWD -lM-
13.58
**ENOIN6 BALANCE
*'CAIO CO-IN - NOV OD
8AL FWD -lN-
30B7.88
CO-INSURANCE
COINS W/O
COINS ~/0
**ENOIN6 8ALANCE
**MEOICARE A -HOV OD
BAl F~O -LN- -38-
5358.66 5753.26
: PAYMENT
PAYMENT
PAYMENT
LAID1 PHYSICAL THERAPY VISIT
-68- -BO- -120+-
8967.33 28879.28
10/31/08 11210002060 8967.60
11/07/00 11210002000 5753.24
11/28/00 11210082800 5358.97
ll/01/00 -- 11/01/00 6 52150210128 375.00
20079.25
143.32
13.58
879.8J-
061191Ol RESIDENT LEDGER AS OF DATE OF FIRST ACTIVITY PA6E
RESIDENT RESIOENT RESIDENT
NUNBER TYPE NANE
20075
NEOICARE',A 6ARDNER, RONALD E
~ ROON 1~1 -A LEVEL 1
**MEDICARE A - NOV DO (CONT)
29001 PHARMACY LEGEND
3OOOL PHARMACY NON LEGEND
ANCILLARY WRITE OFF
ROON CRARGE
ROOM WRITE DEE
DEDUCT CO-INS
CONT ALLOWANCE
PT
ANC WRITE OFF
CONT ALLOWANCE
COflT ALLOWANCE
**ENOING BALANCE
**NEOICARE 8 - NOV DO
BAL FWO -LN-
REV PT
**ENDING BALANCE
**PRIVATE - DEC 06
8AL FWD -LM-
**ENDING BALANCE
**CAIO CO-IN -OEC DO
HAL FWO -LN-
679.00
**ENOING BALANCE
**MEDICARE A -OEC DO
6/L -- ACCOUNTS RECEIVABLE --
OATE QTY ACCOUNT CRARGES CREOITS BALANCE
DT/31/BD AON CNTR RATE: O.DD
11/08/00 DIS PRIV PORT: D.O0
ll/DI/DD -- 11108100 I 54551210120 4B.27
11/Bl/BQ -- 11108100 i 54951310126 4.47
11/30/D0 57557510120
AT 138.80 11/01/06 -- 11/67/88 7 5[350010128 966.OB
11/01/0Q -- 11/07/06 7 51557010120 923.62
AT 97.BB 7
08/31/0D 51557010120
08/31/00 $2150Z10120 143.32
08/31/00 57GG751012B
09/30/00 5155761D12R
IO/31/0B 51557010120 .31
-36- -60- -90- -128+-
143.32 L43.32
08/31/00 5215021112e
-30- -6O- -98- -120+-
13.50 13.5B
-3B- -60- -90- -12D+-
BIg. OD
HAL FWO -LN- -3B- -GO- -90- -120+-
1210.02 121D.02
11260 TRANSPORTATION SERVICES 08/07/00 1 5R15881D1 32.09
1120D TRANSPORTATION SERVICES 08/12/QD i SR1BBB1D1 32.00
11200 TRANSPORTATION SERVICES D8/14/60 1 591588151 32.60
I12DB TRANSPORTATION SERVICES 08/15/JD I SR16881i! 32.O0
l120D TRANSPORTATION SERVICES 08/23/00 I DglS881BI 32.H
I12gg TRANSPORTATION SERVICES 88/24/06 1 5915881B1 32.tB
11200 TRANSPORTATION SERVICES 09/08/06 1 591588101 32.60
11200 TRANSPORTATION SERVICES 09/12!DD 1 Bg15881Rl 32.0D
112D0 TRANSPORTATION SERVICES OR/13/1O 1 591S88101 32.B0
L1266 TRANSPORTATION SERVICES 10/9G~00 i 591588101 32,0D
ANCILLARY WRITE OFF 12/31/00 S75S75101
**ENOING BALANCE
**PRIVATE - JAN O1
HAL FWO -LN-
**ENOING RALANCE
CO-IH - JAN O1
-60- -OD- -120+-
13.50 13.50
419.74
B79.BB
143.32
.B2
143.32
320.00
1210.02
.OD
13.GB
G79.00
1210.02
13.50
05/19/01 RESIDENT LEDGER AS OF BATE OF FIRST ACTIVITY PAGE $
(ARSG)
RESIDENT RESIDENT RESIDENT GJL -- ACCOUNTS RECEIVABLE --
MU)DER TYPE NAME DATE QTY ACCOUNT CHARGES CBEOITS BALANCE
~EOICARE A GARONER, RONALO E 07/31/OO AO~ CNTR RATE: 0.00
~ ROOM 161 -A LEVEL X 11/08/01 OIS PRIV PORT: O.00
**CAIO CO-IN - JAN 01 {CONT)
RAL FWO -LM- -30- -68- -98- -120+-
**ENOING BALANCE
*'NEOICARE A - JAN 81
DAL FWD -LN- -38- -68- -98- -128+-
1218.82 121B.D2
PAYMENT 11-81-11-88-80 1- 01/82/01 11210002888
REC 8LO00 GLUCOSE 88/31/80 56151718120 179.17
REC ANC WRITE OF~ 08/31/88 57557510128
LAB 11/38/08 56151910128 68.R8
**ENOING BALANCE'
**MEOICARE B - JAN 01
RVS BLOOD GLUCOSE 88/31/00 56151911128
RVS ANC WRITE OFF 88/31/0D 57GSZG11120 35.85
RVS INCORRECT AOJ 08/31/00 $2150211128 1~3.32
**ENDING BALANCE
**PRIVATE - FEB 01
DAL F~O -LM- -30- -60- -90- -120+-
13.58 13.50
**ENDING BALANCE
*'CAIO CO-IN - FEB 01
BAL FWO -LN-
-38- -GO- -90- -120+-
679.88 679.00
**ENOIN6 BALANCE
*'MEDICARE A - FEB 81
8AI FWO
-3B- -60- -98- -120+-
.07-
*'ENDING BALANCE
*'PRIVATE - MAR 01
BAL FWO -LM- -30-
**ENOING BALANCE
**CAID CO-IN - MAR 01
8AL FWO -L~-
-60- -98- -120+-
13.S8 13.GA
**ENDING BALANCE
*~MEOICARE A - MAR 81
BAL FWO -LN-
-30- -60- -90- -120+-
679.08 6ZO.GD
-BO- -12B+-
.07-
**ENOIN6 BALANCE
'**PRIVATE - APR 01
BAL FWO -LN- -30- -60- -98- -120+-
13.58 13.58
AEC COINS 88/31/88 144118GlOBe 1164.80
AEC COINS 9/88 89/30/88 144110S$888 2918.8~
1210.09
179.17
68.08
179.17
.00
13.58
679.88
.87
.87-
13.50
679.08
.87-
05119/01 RESIOENT LEOGER AS OF DATE OF FIRST ACTIVITY PAGE 7
(ARB6)
RESIOE~T RESIDENT RESIOENT
NUNDER TYPE NA~E
20075
NEDICARE A 6ARDNER, RONALD E
~ ROON 161 -A LEVEL
**PRIVATE - APR 01 {CONT)
REC COINS 10/00
REC COINS 11/00
*'EHDIN6 BALANCE
**CAID CO-IN - APR 01
BAL FWD -LN- -30-
RVS COINS W-OFE
NOT APPROVED EOR ~A
RVS COIHS,W-OEF
RVS TO PRIVATE
RVS COINS W-OFF
NOT APPROVED TO PP
RVS COINS
**ENOING BALANCE
**NEOICARE A - APR 91
DAL FWD -LN-
-60-
PPG AOJ
PPG AOJ
**ENDIN6 BALANCE
**PRIVATE - ~AY Ol
8AL FWD -LN-
-30- -60-
**ENDING BALANCE
**NEDICARE A - NAY 01
BAI FWO -LM-
-30- -GO-
**ENDIN6 BALANCE
6/L -- ACCOUNTS RECEIVABLE --
OATE QTY ACCOUNT CHAR6ES CREOITS BALANCE
D7/~I/OB ADh CNTR RATE:
L1/B8/BB OIS PRIV PORT: 0.0B
IO/DL/O0 1ARl1050000 3007.90
11/30/00
-gl- -120+-
679.QQ G79.90
08/31/00 SBSS7L2SOAB 1184.00
08/31/00 14411050000 1164.00
09130100 SR$5712SOOi 29L0.00
09/30/00 1~Al1050009 2910,00
10/31/00 5855719S000 3007.00
10/31/00 14AIl~SODO0 3007.00
11/30/00 L4411050000 679.00
-OB- -120+- .
11/30/90 S1SS7018120 .O7
11/30/00 GIGS?DIAl20 .07
-90- -120+-
7773,50 7773.50
-30- -60- -90- -120+-
.07 '.Ol
.07
7773.50
.00
,O7
7773,S0
.07
SHERIFF'S RETURN - REGULAR
CASE NO: 2001-07188 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
GARDNER RONALD
DOUGLAS DONSEN , Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
GARDNER RONALD the
DEFENDANT
at 122 WEST NORTH STREET
, at 1510:00 HOURS, on the 2nd day of January
APT A
CARLISLE, PA 17013
by handing to
, 2002
RONALD GARDNER
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs:
Docketing 18.00
Service 3.25
Affidavit .00
Surcharge 10.00
.00
31.25
Sworn and Subscribed to before
me this ~ day of
~73 ~L A.D.
I I~rothonotary ' '
So Answers:
R. Thomas Kline
01/03/2002
WOLFSON & ASSOC.
By: ~~ _~~
Deputy Sheriff
IN THE COURT OF COlv~ON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
Plaintiff
VS.
RONALD GARDNER
Defendants
No. 2001-07188
Action in: Civil-Law
PRAECIPE FOR JUDGMENT
ENTER JUDGMENT in the above case for failure to file, enter, an
TO ENTER A DEFENSE
in the sum of $10,703.03
Total: $10,703.03
against RONALD GARDNER
in favor of HCR MANOR CARE
with Interest AS ALLOWED BY STATUTE
AND COURT COSTS
Attom~ for Plainti~
Amy P. Wolfson, Esquire
~ /~/a ' ,20 O.~ Judgment entered by
the Prothonotary this da ccord~ng to the tenor of the above statement.
Prothonotary
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
RONALD GARDNER,
Defendant
NO. 2001-07188
CIVIL ACTION - LAW
CERTIFICATION
I, Amy F. Wolfson, Esquire, due hereby certify that on February 1,
2002, I caused a true and correct copy of the 10 Day Notice attached
hereto to be served on the Defendant, Ronald Gardner.
Date:
Amy F.~lfson, Esqu~
WOLFS6N ~ ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717) 846-1252
I.D. # 87062
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
RONALD GARDNER,
Defendant
NO. 2001-07188
CIVIL ACTION - LAW
CERTIFICATE OF RESIDENCE
I, Amy F. Wolfson, Esquire, due hereby certify that the last known address of the above
referenced Defendant is as follows:
RONALD GARDNER
122 WEST NORTH STREET
CARLISLE, PA 17013
Date:
Respectfully submitted,
Amy F. v~r, blfson, Es,~ire
WOLFSON & ASS,~CIATES, P.C.
267 East Market Sl~reet
York, PA 17403
(717) 846-1252
ID No. 87062
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
VS.
RONALD GARDNER,
Defendant
NO. 2001-07188
CIVIL ACTION - LAW
AFFIDAVIT OF NON-MILITARY SERVICE
COMMONWEALTH OF PENNSYLVANIA :
:
COUNTY OF YORK :
I, Amy F. Wolfson, Esquire, being duly swom according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my
knowledge, information and belief, Ronald Gardner, Defendant, above named; is over 21 years
of age; is last known to reside at 122 West North Street, Apt A, Carlisle, Cumberland County,
Pennsylvania 17013, is not in the military service of the United States or its Allies, or otherwise
within the provisions of the Soldiers' and Sailors' Civil Relief Act of Congress of 1940 and its
Amendments.
267 East Market Street
York, Pennsylvania 17403
Attorney I.D. #87062
Attorney for the Plaintiff
Sworn and subscribed to
before rrte this /3'-/- day
of
"~N6tary Public
I'
Notarial Seal
Melissa Dee Sweeney, Notary Public
York, York County
My Commission Expires Sept. 12, 2002
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
RONALD GARDNER,
Defendant
NO. 2001-07188
CIVIL ACTION - LAW
TO:
Ronald Gardner
122 West North Street
Apt A
Carlisle, PA 17013
DATE OF NOTICE: February 1, 2002
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND
YOU NAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING
OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Court Administrator
Cumberland County Court House
1 Court House Square, 4~ Floor
Carlisle, Pennsylvania 17013
(717) 240-6200
Amy F. ~Vo~l'son, Esqt~e- p.~.
WOLFSON' 8~ ASSO{:iATES,
267 East Market Street
York, Pennsylvania 1 74.03-2000
Telephone: (71 7) 846-12.52
I.D. # 87062
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
:
VS. :
:
RONALD GARDN ER~ :
Defendant :
NO. 2001-07188
CIVIL ACTION - LAW
NOTICE OF ORDER, DECREE OR JUDGMENT
TO: ( ) PLAINTIFF (X) DEFENDANT ( ) GARNISHEE ( ) ADDITIONAL DEFENDANT
YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS
BEEN ENTERED AGAINST YOU ON
IN ACCORDANCE WITH THE ~PROVISION~--OF PA.R.C.P. 236
( ) DECREE NISI IN EQUITY
( ) FINAL DECREE IN EQUITY
(X) JUDGMENT OF ( )
CONFESSION ( ) VERDICT
(X) DEFAULT ( ) NON-SUIT
( ) NON-PROS ( ) ARBITRATION AWARD
(X) JUDGMENT IS IN THE AMOUNT OF $10,703.03 PLUS COSTS $76.75
FOR A TOTAL OF $10,779.78.
( ) DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF
$ PLUS COSTS.
( ) IF NOT SATISFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S
LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF
TRANSPORTATION
PROTHONOTARY ^ /~
IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE CONTACT:
NAME OF (ATTORNEY/FILING PARTY):
ADDRESS:
TELEPHONE NUMBER:
NOTICE SENT TO: RONALD GARDNER
WOLFSON & ASSOCIATES, P.C.
267 EAST MARKET STREET
YORK, PENNSYLVANIA 17403
(717) 846-1252 OR 800-321-8467
122 WEST NORTH STREET
CARLISLE, PA 17013
IN THE COURT OF COI~I1HON PLEAS OF
CUI~IBERLAND COUNTY, PENNSYLVANIA
HCR I~IANOR CARE,
Plaintiff
RONALD GARDNER,
Defendants
NO. 2001-07188
CIVIL ACTION - LAW
ENTRY OF APPEARANCE
Please Enter the Appearance of Amy F. Wolfson, Esquire, as the Attorney for the Plaintiff.
Date:
Respectfully Submitted,
267 E. Market Street
York, Pennsylvania 17403
Telephone No. (717) 846-1252
I.D. # 87062
Attorney for Plaintiff
PRAECIPE FOR WRIT OF EXECUTION (MONEY JUDGMENT)
P.R.C.P. 3101 to 3149
HCR MANOR CARE,
Plaintiff
VS.
RONALD GARDNER,
Defendant
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
JUDGMENT NO. 2001-07188
PRAECIPE FOR WRIT OF EXECUTION
(MONEY JUDGMENT)
To the Prothonotary: ISSUE WRIT OF EXECUTION IN THE ABOVE MATTER,
(1) Directed to the Sheriff of CUMBERLAND County, Pennsylvania;
(2) against, RONALD GARDNER, 49 EAST SOUTH ST, CARLISLE PA 17013, Defendant(s);
(3) and against, Waypoint Bank, 17 West High Street, Carlisle, PA 17013 Garnishee(s);
(4) and index this writ
(a) against, RONALD GARDNER, Defendant(s) and
(b) against, Waypoint Bank, Garnishee(s),
as a lis pendens against the read property of the Defendant(s) in the name of the Garnishee(s) as. follows:
(Specifically describe property) ****GARNISH ONLY***
You are directed to attach the property of the Defendant(s) not levied upon in the possession of
Waypoint Bank
17 West High Street
Carlisle, PA 17013
Garnishee(s)
All accounts including but not limited to all savings, checking and other accounts, certificates of deposit,
notes receivables, collateral, pledges, documents of title, securities, coupons and safe deposit boxes.
Amount due
Interest from March 14, 2002
At an interest rate of 6% per year
Dated July 1, 2003
$ $10,703.03
To Be Determined
Total $ $10,703.03 Plus costs & interest
Attorney ID ¢¢'87062
267 E. Market Street
York, PA 17403 /../
(717)846-1252
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA) NO 01-7188 Civil
COUNTY OF CUMBERLAND) CIVIL ACTION - LAW
TO THE SHERIFF OP CUMBERLAND COUNTY:
To satisfy the deb~, interest and costs due HCR MANOR CARE, Plaintiff (s)
From RONALD GARDNER, 49 EAST SOUTH ST., CARLISLE, PA 17013
(I) You are directed to levy upon the property of the defendant (s)and to sell
(2) Y~u are a~s~ directed t~ attach the pr~pcrty ~f the defendant(s) n~t ~evied up~n in the p~ssessi~n
of WAYPOINT BANK, 17 WEST HIGH STREET, CARLISLE, PA 17013, ALL ACCOUNTS
1NCLUD/NG BUT NOT LIMITED TO ALL SAVINGS CH~CKING AND OTHER ACCOUNTS,
CERTIFICATES OF DEPOSIT, NOTES RECEIVABLES, COLLATERAL PLEDGES,
DOCUMENTS OF TITLE, SECURITIES, COUPONS AND SAFE DEPOSIT BOXES.
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) Ifproperty of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due $10,703.03 L.L. $.50
Interest FROM MARCH 14, 2002 AT AN INTERST RATE OF 6% PER YEAR
Atty's Corem % Due Prothy $1.00
Arty Paid $103.75 Other Costs
PlaintiffPaid
Date: AUGUST 7, 2003
(Seal)
REQUESTING PARTY:
Name AMY F. WOLFSON, ESQUIRE
Address: 267 E. MARKET STREET
YORI~ PA 17403
Attorney for: PLAINTIFF
Telephone: 717-846-1252
Supreme Court 1D No. 87062
CURTIS R. LONG
Prothon~ry
Deputy
SHERIFF'S RETURN -
CASE NO: 2001-07188 P
COMMONWEALTH OF PENNSLYVANIA
COUNTY OF CUMBERLAND
GARNISHEE
HCR MANOR CARE
VS
GARDNER RONALD
And now J.M. ICKES
Cumberland County of Pennsylvania,
to law, at 0010:36 Hours, on the 20th day of August
as herein commanded all goods, chattels,
moneys of the within named DEFENDANT ,
GARDNER RONALD
hands,
,Sheriff or Deputy Sheriff of
who being duly sworn according
, 2003, attached
rights, debts, credits, and
possession, or control of the within named Garnishee
, in the
WAYPOINT BANK 17 WEST HIGH ST
CARLISLE, PA 17013
Cumberland County, Pennsylvania, by handing to
LINDA JULIAS (BRANCH MANAGER)
personally three copies of interogatories together with 3
and attested copies of the within COMPLAINT & NOTICE
the contents there of known to Her
true
and made
Sheriff's Costs:
Docketing .00
Service .00
Affidavit .00
Surcharge .00
.00
.00
So answers:
Sheriff of Cumberland County
Sworn and subscribed to before me
this 2 2~ day of~e~--
%.D.
~thonotary
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff,
VS.
RONALD GARDNER,
Defendant,
VS,
Waypoint Bank,
Garnishee,
NO. 2001-07188
CIVIL ACTION-LAW
PRAECIPE TO DISCONTINUE ATTACHMENT EXECUTION
TO THE PROTHONOTARY:
Kindly mark the attachment against the Garnishee, Waypoint Bank, discontinued, upon
payment of your costs only.
Respectfully submitted,
WOLFSON & ASSOCIATES, P.C.
Dated:
September 12, 2003
Amy ~. Wolfson~Esquire ,~
Attorney I.D. No. 87062 --
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717)846-1252
Attorney for Plaintiff
R. Thomas Kline, Sheriff, who being duly sworn according to law, states this
Writ is returned ABANDONED, no action taken in six months.
Sheriff's Costs:
Docketing 18.00
Poundage 1.64
Advertising
Law Library .50
Prothonotary 1.00
Mileage 3.45
Misc.
Surcharge 30.00
Levy 20.00
Post Pone Sale
Garnishee 9.00
TOTAL 83.59
Advance Costs: 150.00
Sheriff's Costs: 83.59
66.41
Refunded to Atty on 04/29/04
Sworn and Subscribed to before me
this /$___~ayof '~'7--
R. Thomas Kline, Sheriff