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03-15-11
NOTICE OF CLAIM (Filed Pursuant to 20 Pa.C.S. § 3532) ._ , - - _ . _, _ _ COURT OF COMMON PLEAS OF - ~ _"' r CUMBERLAND COUNTY, PENNSYLVANIA ,' " ~ ~ ~~ ~ ~' _.. ORPHANS' COURT DIVISION r __, - ,.:~ _.. --~ ~ ; _.T. i ESTATE OF ROBERT VARRICCHIO __, DECEASED i No. 2010-~~ (Claimant) amount of $ 10,000.00 ,against the above entitled Estate. The Decedent, who resided at 1705 Susquehanna St., Harrisburg, PA 17102 To the Clerk of the Orphans' Court Division: Enter the claim of Kevin Scolaro in the (Street Address) died on March 10, 2010 .Written notice of (Date of Death) said claim was given to Nancy Varricchio, Personal Representative _ (Persona/ Representative or his/her cozrnsel) at 1705 Susquehanna St., Harrisburg, PA 17102 & to her local counsel, David Lanigan, Esquire, '10937N. on January 16, 2011 (Address) 56th St . , Tampa, FL 33617 (Date) Kevin Scolaro c/o Michael_LaBarbera, Esquire (Claimant) 1907 W. Kennedy Blvd. _ (Street Address) Tampa, FL 33606 (City. State, Zip) (Claimant's Counsel) (Supreme Court LD. No.) (Address) (Telephone) Suit by John Knox Village against Kevin Scolaro, agent and claimed responsible party for decedent (suit attached), for $8,058.43, plus interest, costs and attorney's fees. Form OC-07 rev. ! 0.13.06 IN THE COUNTY COURT OF THE THIRTEENTH JUDICIAL CIRCU[T IN AND FOR HILLSBOROUGH COUNTY, FLORIDA JOHN KNOX VILLAGE OF TAMPA BAY, [NC. d/b/a JOHN KNOX VILLAGE MED CENTER, Plaintiff, CASE NO.: I(, CC` -'1 ~~~~' vs. v`- ROBERT VARRICCHIO and 1 ~ ~ ~-_1:_;; ; __; KEVIN SCOLARO, _. ~ - Defendants. _- , This communication, from a debt collector, is an attempt to collect a debt and any information obtained will be used for that purpose. COMPLAINT Plaintiff, JOHN KNOX VILLAGE OF TAMPA BAY, INC. d/b/a JOHN KNOX VILLAGE MED CENTER ("JOHN KNOX VILLAGE") sues Defendants ROBERT VARRICCHIO and KEVIN SCOLARO, and states: COMMON ALLEGATIONS 1. This is an action for damages which exceed $5,000.00 but do not exceed $15,000.00. 2. Plaintiff is a Florida corporation authorized to conduct business in the State of Florida and 'was at all times material hereto conducting business as a nursing home in Hillsborough County, Florida. 3. Defendant, ROBERT VARRICCHIO, is a resident of Hillsborough County, Florida. At all times material hereto, Defendant ROBERT VARRICCHIO was a resident at .JOHN KNOX VILLAGE. ~. Defendant, KEVIN SCOLARO, is a resident of Hillsborough County, Florida. At all times material hereto, Defendant KEVIN SCOLARO was the "Legal Representative" for Defendant ROBERT VARRICCHIO, who is referred to in the preceding paragraph. COUNT I -ROBERT VARRICCHIO UNJUST ENRICHMENT ~. Plaintiff reaffirms and realleges paragraphs I , 2 and 3 above. 6. On or about February 19, 2009, Defendant ROBERT VARRICCHIO was admitted to JOHN KNOX VILLAGE as a resident. 7. JOHN KNOX VILLAGE provided to Defendant room and board and other services totaling $8,058.43 as set forth in the Statements attached hereto as composite Exhibit "A". 8. Defendant ROBERT VARRICCHIO has failed to pay Plaintiff for said services. 9. Plaintiff has no adequate remedy at law for recovery of said services. l0. But for the expectation of being paid for said services, Plaintiff would not have provided them to Defendant ROBERT VARRICCHIO. 11. Defendant ROBERT VARRICCHIO has been unjustly enriched by the receipt of said services without payment therefore. 12. Plaintiff has complied with all conditions precedent to the maintenance of this action, or those conditions have been waived. 13. Plaintiff has made demand of payment from Defendant, ROBERT VARRICCHIO, but Defendant has failed and refused to pay. WHEREFORE, Plaintiff, JOHN KNOX VILLAGE OF TAMPA BAY, INC. d/b/a JOHN KNOX VILLAGE MED CENTER, demands judgment against Defendant, ROBERT VARRICCHIO, for the damages set forth above, together with interest and court costs. COUNT II -KEVIN SCOLARO BREACH OF CONTRACT 14. Plaintiff reaffirms and realleges paragraphs 1, 2, and 4 through 13 above. l5. Defendant KEVIN SCOLARO executed a Facility Admission Agreement and Financial Agreement, acknowledging and agreeing to pay any costs incurred on behalf of Defendant ROBERT VARRICCHIO. Copies of the executed Admission Agreement and Financial Agreement are attached hereto as composite Exhibit "B". 16. JOHN KNOX VILLAGE has sustained damages as a result of Defendant KEVIN SCOLARO's breach of the contract, consisting of unpaid room and board and other contractual charges totaling $8,058.43 as set fo--th in the Statements attached hereto as composite Exhibit "A"'. 17. In addition to the principal sum set forth in the preceding paragraph, Defendant is responsible for interest, court costs and Plaintiff s attorney's fees as required in the Resident Admission Agreement and Financial Agreement. 18. Plaintiff has co-nplied with all conditions precedent to the maintenance of this action. 19. Plaintiff has retained the undersigned law fi-•m to represent it in this action and is obligated to pay said law firm a reasonable fee for its services. WHEREFORE, Plaintiff, JOHN KNOX VILLAGE OF TAMPA BAY, INC. d/b/a JOHN KNOX V[LLAGE MED CENTER, demands judgment against Defendant, KEVIN SCOLARO, for the damages set forth above, together with interest, court costs, and attorney's fees. WETHE GTO AMILTON & ARRISON, P.A. ~, SHAWN E. HARRISON, ES DIRE Florida Bar No. 861502 1 O l 0 North Florida Avenue Tampa, Florida 33602 Telephone (813) 225-1918 Facsimile (813) 225-2531 Attorneys for Plaintiff RESIDENT' STATEMENT from John Knox Village Med Center 4100 E. Fletcher Ave Tampa, FL 33613 813-632-2429 ROBERT VARRICCHIO C/0: NANCY VARRICCHIO 1705 SUSQUEHANNA STREET HARRISBURG, PA 17102 BILLING DATE DUE DATE ACCOUNT NUMBER 03/31/2009 Due by 20th 70888-01 • ~ = ~ ~ ~ $ 8,305.50 AMOUNT PAID ~ ~~,a~~.^~ Please make check or money order payable to John Knox Village Med Center ! John Knox Village Med Center 4100 E. Fletcher Ave Attn: MC Billing Tampa, FL 33613 Please detach and return this portion with your remittance to the address above. Notes FAMILY COUNCIL MEETING: You are not a{one. The Med Center Family Council meets at 7p.m. on the third Tuesday of each month in the Dining Room (doavnstairs across from the Therapy gym). All Family members welcomed. A for- rofit or not-for- rofit or ublic nursin home licensed b the State of Florida Beginning Balance $ 0.00 02/19/2009 02/19/2009 to 02/19/2009 Room Charge - 1 $ 202.00 $ 202.00 $ 202.00 010!3 02/28/2009 02/20/2009 to 02/28/2009 Room Charge - 9 $ 202.00 $ 1,828.00 $ 2,020.00 045/6 02/28/2009 02/28/2009 1006 - 1006 -MEDICAL 1 $ 23,50 $ 23.50 $ 2,043.50 SUPPLIES PVT 03/01/2009 03/01/2009 to 03/31/2009 PreBill Room 31 $ 202.00 $ 6,262.00 $ 8,305.50 Charge - 045/B Total Balance Due: l $ 8,305.50 c EXHIBI T i f a ~ FACILITY NAME RESIDENT NAME Sohn Knox Village Med Center ROBERT VARRICCHIO 4000tJNT # P-AGES 70888-01 I 1 I Days/ Charges/ _ _ Dates _ _ Description _; _ _ - Rate ;Payments:; _ _ Balance_ ~ _ - -- Units- _ (CreditsY - RESIDENT STATEMENT from BILLING DATE DUE DATE ACCOUNT NUMBER John Knox Village Med Center 04/30/2009 Due by ZOth 70888-01 4100 E. Fletcher Ave • = ' ~ $ 6,607.26 Tampa, FL 33613 813-632-2429 AMOUNT PAID ~ ~ ^~~^~ ~D~ Please make check or money order payable to John Knox village Med Center ROBERT VARRICCHIO l ' C/O: NANCY VARRICCHIO 1705 SUSQUEHANNA STREET ! Jvhn Knox Village Med Center HARRISBURG, PA 17102 ~ 4100 E. Fletcher Ave Attn: MC Billing Tampa, FL 33613 Please detach and return this portion with your remittance to the address above. Votes 'our account is over bOdays ofd please contact our office. AMILY COUNCIL MEETING: You are not alone. The Med Center Family Council meets at 7p. m. on the third Tuesday of each month in he Dining Room (downstairs across from the Therapy gym). Afl Family members welcomed. for- profit (or not-for-profit or aublic)nursing home licensed by the State of Florida ~ .- Beginning Balance $ 8,305.50 f :$ 8,305.50 03/01/2009 03/01/2009 to 03/31%2009 ADJUST - PreBifi (31 j $ 202.00 $ (6,262.00) :~ 2,x43.50 Room Charge - 045/8 03/20/2009 03/01/2009 to 03/20/2009 Room Charge - 20 $ 202.00 $ 4,040.00 I $ 6,083.50 045/8 03/31/2009 03/01/2009 1006 - 1006 -MEDICAL 2 $ 84.00 $ 84.00 $ 6,167.50 SUPPLIES PVT 03/31/2009 03/11/2009 TRANSFER From AL to Med Ctr 1 $ (7,857.24) $ (7,857.24) ~ (1,689.74) 03/31/2009 03/19/2009 500 - 500 -BEAUTY SHOP 1 $ 15.00 $ 15.00 $ (1,674.74) 03/31/2009 03/21/2009 to 03/31/2009 Hosp Bed Hold - 12 $ 202.00 ~ $ 2,222.00 Q> 547.26 Room Charge - 045/B 04/O1/Z009 04/01/2009 to 04/30/2009 PreBili Room 30 $ 202.00 $ 6,060.00 $ 6 607.26 Charge - 045/8 ~ , Total Balance Due: (~ I $ 6,b07.26 John Knox Vi{lage Med Center ROBERT VARRICCHIO 70888-01 iv` RESIDENT STATEMENT from BILLING DATE DUE DATE ACCOUNT NUMBER John Knox Village Med Center 06/30/2009 Due by 20th 7088-01 4100 E. Fletcher Ave ' = ' ~ $ 8,152.78 Tampa, FL 33613 813-632-2429 AMOUNT PAID ~ ~ ~ ~^a ~^~ Please make check or money order payable to John Knox Viffage Med Center ROBERT VARRICCHIO C/O: ROBERT VARRICCHiO ' ' 4725 COVE CIRCLE ~ John Knox Village Med Center #602 ~ 4100 E. Fletcher Ave ST. PETERSBURG, FL 33760 ~ Attn: MC Billing Tampa, FL 33633 Please detach and return this portion with your remittance to the address above. totes cur account is over 60days old please contact our office. 4MILY COUNCIL MEETING: You are not alone. The Med Center Family Council meets at 7p.m. on the third Tuesday of each month in ~e Dining Room (downstairs across from the Therapy gym). All Family members welcomed. for- profit (or not-for-profit or public)nursin home licensed by the State of Florida Beginning Balance $ (1,6?4,74) $ (1 674.74) 06/30/2009 06/14/2009 1006 - 1006 -MEDICAL 1 $ 39.00 $ 39.00 $ (1 635.74) SUPPLIES PVT , 06/30/2009 06/14/2009 to 06/30/2009 Room Charge - 17 $ 202.00 $ 3,434.00 $ 2 798.26 04 S/B ; , 06/30/2009 06/25/2009 2ndary applied chgs to OOP. Pt 1 , $ 92.52 $ 92.52 $ 1 890 78 resp for March 09 coins , . 07/01/2009 07/01/2009 to 07/31/2009 PreBill Room 31 $ 202.00 $ 6,262.00 $ 8 152.78 Charge - 045/B , Total Balance Due: E f f I :$ 8,152.78 .-............. ,. rNUc John Knox Village Med Center ROBERT VARRICCHIO 70888-01 1 RESIDENT STATEMENT from John Knox Village Med Center 4100 E. Fletcher Ave Tampa, FL 33613 813-632-2429 ROBERT VARRICCHIO C/O: NANCY VARRICCHIO 1705 SUSQUEHANNA STREET HARRISBURG, PA 17102 BILLING DATE DUE DATE ACCOUNT NUMBER 07/31/2009 Due by 20th 70888-01 • ~ ~ ~ ~ ~ $ 8,058.43 AMOUNT PAID ~ ~ ~~^^~ ~~~ Please make check or money order payable to John Knox Village Med Center Sohn Knox Village Med Center 4100 E. Fletcher Ave Attn: MC Billing Tampa, FL 33613 Please detach and return this portion with your remittance to the address above. Notes (Thank you for keeping your account balance current. FAMILY COUNCIL MEETING: You are not alone. The Med Center Family Council meets at 7p.m. on the third Tuesday of each month in the Dining Room (downstairs across from the Therapy gym). All Family members welcomed. A for- profit (or not-far-profit, or public)nursing home licensed by the State of Florida Beginning Balance i 5 8,152.78 $ 8,152.78 07/01/2009 07/01/2009 to 07/31/2009 ADJUST - PreBill (31} $ 202.00 $ (6,262.00) $ 1,890.78 Room Charge - 045/8 07/28/2009 07/01/2009 to 07/28/2009 Room Charge - 28 $ 202.00 j $ 5,656.00 $ 7,546.78 045/8 07/31/2009 07/01/2009 1006 - 1006 -MEDICAL 1 $ 58.00 $ 58.00 $ 7,604.78 SUPPLIES PVT 07/31/2009 07/06/2009 700 - 700 -PHARMACY 1 $ 14.61 $ 14.61 $ 7,619.39 07/31/2009 07/08/2009 500 - 500 -BEAUTY SHOP 1 $ 15.00 $ 15.00 $ 7,634.39 07/31/2009 07/27/2009 coins for dos 5/1/09 1 $ 424.04 $ 424.04 $ 8,058:43.` ~ Total Balance Due: ~ ~' ~! ~ $ 8,058.43 ~ ~. F ~~~~~.; ~ -~Z C:v`y~ \ ~. ___ (;.;~ ~~C I John Knox Village Med Center f ROBERT VARRICCHIO 70888-01 1 .~ -C:~:~~ Days/ - Charges/ - - _ _, Dates Description - Units Rate_ (credits) ~ayrnents Ba{artee . -__ o~~i I~:.~ox =v~~ FA.CILIfiY ADN~SSIOI~UAGREENtENT Herein entered into this day of ~~~~~ ~ ~ ~,~ , 20 V~ between. #'~ ~ c ~~_ and John Knox Village Med Center ("Facility") on behalf of PatientlPatient Responsible Party Patient For the purpose of this Agreement, Responsible Party is defined as a person who manages, wes, directs or controls funds or assets which may be used to pay for the Resident's Facility charges, and/or who tends to make decisions for or otherwise acts on behalf of the Resident- The term is subject to the further definitions aid obligations of the Financial Agreement A Responsible Party may also be a surrogate, advocate, proxy, legally appointed power of attorney, guardian or representative of Resident The personal financial obligations of the Responsible Party are defined in the Financial Agreement. By executing this Agreement, Responsible Party agrees to ensure first priority distribution to the Facility on behalf of the Resident, from Resident's assets, to pay far services rendered to the Resident by Facility. The parties agree that Responsible Party shall be required to produce financial documentation to substantiate Resident's ability to pay for charges that will be due for services rendered to the Resident. If Facility does not timely receive payment in full from Responsible Party, Facility may require production by Responsible Party of evidence that Resident's assets were utilized only to prudently pay for Resident related expenses and that such spending gave first priority to the Facility's payments. Further, it is understood that should facility reasonably suspect that an inappropriate handling of Resident funds has occurred or is occurring, Facility may report same to appropriate authorities without liability to Resident and/or Responsible Party. This agreement and the accompanying Financial Agreement and Financial Disclosure Form represents all of the understanding between the parties and no condition, terms or provision shall govern this Agreement or the Financial Agreement which are not specifically contained or referred to in such documents. 'T'his agreement shall not be modified, altered of otherwise subject to any oral statements or representation not incorporated in writing this agreement. I hereby authorize the staff at John Knox village Med Center to perform upon resident/patientnnmed above such technical procedures, administer such drugs and render such medical care as may be directed by my physician unless otherwise refused by myself or by my lawfully designated surrogate or legal next of Idn should I be incapable or incompetent to act on my own behalf: CON)E''IDENT'IAZ.TTY: Information in the Resident's clinical record is confidential and disclosure to persons except as outlined below shall not be made without the Resident's or Representative's written consent, except as required or permitted by Iaw. Protected Health Information, as defined by HIPAA, will be utilized by the Facility for the provision of treatment, payment, or in Facility operations. CONSENT TO DISCI.oSURE BY FAC`IIrTTY: By signing this Admission agreement and Consent, you give us permission to use and disclose pratECted health information about you for treatment, payment, and healthcare operations except for any restrictions specified below to which we have agreed. Protected health information is individually identifiable information we create or receive, including demographic information, relating to your physical or menial health, to provision of healthcare services to you, and to the collection of payment for providing healthcare services to you. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you- You have the right to receive a copy of our Notice of Privacy practices before signing this EXHIBIT -~ Consent Farm. As provided in our Notice, the terms of the Notice of Privacy Practices may change. If we change our Notice, you may obtain a revised copy by contacting our Manager of Adm.issionlCase Management, Carole Davis at (813) 532-2354, who is also available to respond to any questions or receive any complaints you may have concerning your protected health information. You have the right to request that we re-trict how protected health information about you is used ar disclosed for treatment, payment, or healthcare operations. We are not required to agree to axy restrictions, bur f we do, we acre bound by our agreement. If you wish to make a restriction, please request a copy of our Form to Request Restrictions. If you do not sign this Admission ag~eementlconsent, we have the right to refuse you treatment unless a licensed healthcare professional has determined that you require emergency treatment or we aze required by law to treat you_ We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. Dale will offer you a copy of this documentation should you decide not to sign this consent. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. You may request to use our Authorization- for Release of Information Form for purposes of requesting your revocation, or you may simply send us a letter in writing. The Resident authorizes the facility to disclose all or any part of the Resident's clinical or financial records to any person or entity which is or may have legal or contrac{ual obligation to pay aII or a portion of the costs of care provided to the Resident, including but not limited to hospital or medical services companies, insurance companies, Worker's Compensation carriers, welfare funds or the Resident's employer. The Resident also authorizes release of information from medical or financial records when the Resident is transferred from the Facility to any medical professional ar institution which assurues responsibility for the medical or nursing care of the Resident_ CLIl~TIC.4L RECORD• RESIDENT ACCESS: The Resident/Representative shall be provided reasonable access, in accordance with applicable law to all medical records pertaining to himselfJherself (excluding weekends and holidays) of either oral or written request. After review of his/her records, the Resident may purchase photocopies of the records or any portion thereof upon request The Facility will charge the ResidentlRepresentative a reasonable amount not to exceed the community standard far the photocopies. The resident has certain rights to au--Zend the clinical record per HIPAA regulations. By signing this agreement you attest that you have received the HIPAA privacy informarion provided in tb,e admission packet ASSIGNMENT OF INSURANCE BENEFI'T'S: I hereby authorize, request and direct any and all assigned insurance companies to pay directly to John Knox Village Med Center the amount due and payable under my policy. I agree that should the amount be insufficient to cover the entire billing I will be responsible for payment of the difference and if responsibili~y for payment of the entire bill is refused by the iasurance carrier I will be responsible for payment in its entirety. RELEASE OF RESPONSLBIIaITY AND IIIABTLITY FOR PERSONAL VALUABLES: I understand and agree that Sohn Knox Village Med Center is not responsible for personal valuables or belongings brought into this facility or claim to have been brought into this facility by the named patient or his/her agent. Personal valuables or belongings include but are not limited to clothing, personal hygiene product,, toiletries, dentures, glasses, prosthetic devices such as hearioag aides, artificial limbs, }ewelry and money. I understand that personal funds may be deposited in a Resident Trust Account in the business office. Residents are strongly encouraged to send alE valuables home with family. THE FACILITY AGREES: To provide roam and board, including therapeutic diets, nursing care and related medical and rehabilitative services as ordered by the patient's attending physician(s) in accordance with accepted standards of practice. To assist in obtaining the services of provider's of the patient's choice so loag as such providers comply with the procedures of the facility and all Federal and State Reb lotions and Standards. Not to transfer or discharge the resident except if one of the following conditions applies and is attested to by the attending physician. • Your needs cannot be met by the facility. • Your health has improved sufficiently so that you no longer need the services provided by the facility. • The safety of other individuals is endangered. • The health of other individuals is endangered. • Your bill for services at the facility has not been paid after reasonable and appropriate notice. • The facility operation is ceasing. Facility agrees not to discharge Resident from the Facility soL°-lY as a result of the Resident changing their source of paying far services (i.e., private pay, Medicare, Medicaid, etc.) ar because of a change on the Resident's care needs, i.e., from l,ow Intensity to High Lntensity Care, from High Intensity to Law Intensity Care, from skdkled care to intermediate care or from intermediate care to skilled care, subject however to Facility's ability to provide the Gaze within its reasonable and customary provision of services. In consideration of this commitment on Facility's part, Resident does agree, at Facility's request, to transfer within the Facility, from time to time, to rooms that, in a Facility's opinion, best accommodate Resident's ability to qualify' for maximum thud party Payment (includin„ Medicare, etc.) and/or Resident's need for services (i.e., high or low intensity unit) and/or to reasonably accommodate the needs of another of Facility's residents or an individual seeking needed admission into the Facility. Resident recognizes and agrees that the Facility is configured with Certain areas being ~~ intensity designated, certain areas low intensity designated, certain areas that aze eligible for Medicare pragraYn participation. PHYSiCYAN SERVICES: The parties agree that Resident is and must at all times be under the medical care of their personal attending physician and that Facility will render its reasonable and customary nursing home services to the Resident under the general and specific instructions of said physician. By executing this Agreement the Resident and Representative certifies that Resident's attending physician has approved Resident's admission to the Facility and further consents to the Facility providing such services as Facility reasonably and customarily provides as directed by the attending physician. Should a physician presc~ ibe services beyond those reasonably and customarily provided by Facility, Facility may discharge Resident . Although Resident has the right to select an attending physician, if the Resident at anytime does nut timely select an attending physician or, for any reason, is unable to select an attending physician, depending on such physician availability, Facility on behalf of the Resident may select Resident's physician without any liability to Facility accruing for said selection. The parties agree that the Facility may require the use of an alternate licensed physician if the Facility is notified of the following (other reasons not listed below may also arise}: • The Resident's attending physicians does not practice in the Facility. • The Resident's attending physician refuses to provide care to the Resident in accordance will all applicable federal and state laws and regulations, including but not limited to, scheduled visits to the Facility. • The Resident's attending physician loses his or her license to practice or is banned from participation in the Medicaze or Medicaid Program. • Any emergency and/or urgent situation requires an immediate response to the Resident's medical needs. • Resident's attending physician continues to request services beyond those reasonably and customarily provided by Facility. Except in cases of medical emergency, the Facility will provide the Resident with notice prior to requiring the use of an alternate physician. The Resident and Representative recogniz° and agree that all attending physicians, including those physicians arranged for by the Facility, who are providing services to the Resident are not employed by the Facility nor are they agents of the Facility and that the Facility has no liability for acts or omissions by the Physician. The Resident shall be solely responsible for payment of all of physician's charges made for physician Services. PTiARi'YIACEUTICAL SERVICES: An independent pharmacy consultant supervises and monitors the overall pharmacy program to insure state and federal regulations are adhered to by the Facility. All prescription drugs used by Resident must be prescribed by Resident's attending physician and all Resident's prescriptions must be filled by a registered pharmacist Although any Resident has the right to use the pharmacy of his or her choice, the pharmacy chosen must follow the policies and procedures of the Facility's pharmacy program, to include, among other things, an approved unit dose system. Lf Resident chooses to utilize a pharmacy other than the Facility's contracted pharmacy, additional charges may result_ Prescription medications are an additional charge to a Resident and are not included within Facility's routine rate. if specific regulatory conditions are met, medications maybe eligible to be re-packaged(An explanation is included.in the admission packet). Under no circumstance w1I a resident be allowed to bring his/her o~vn medications for use in the Facility. Note: A resident may be permitted to self administer medications if certain conditions are met Permission to self administer medications is granted only after approval from the Facility Interdisciplinary team. NURSIl~IG SERVICES: Nursing -staff (licensed nurses and nurse aides) work in the Facility seven days a week, 24-hours a day. These staff are assigned to provide the reasonable and customary nursing home nursing and.persanal care. The services of the Nursing Departrnent are provided under the supervision of a D'uector of Nursing or his or her designee. Resident and Representative recognize and agree that the services purchased hereunder are not one-on-one, seven days per week, 24-hours per day services and further that their expectations shall be contingent upon this understanding. HOUSEKEEPING AND LAUNDRY SERVICES: The Facility maintains a Housekeeping and Laundry Services Department that provides housekeeping and laundry services. Personal clothing laundry service is available to the Resident at the following extra charge per month: $ .(Note: Charge is subject to change.) The Resident and Representative has the option of having the Facility process the personal clothing laundry or of having someone else, such as a family member, process this personal laundry. Whether the Facility processes the laundry or someone else, all personal items must be marked with the Resident's name in indelible ink or with sewn in nametags. 'Fhe parties agree hereto that Facility will not be responsible for Resident's damaged, lost or misplaced clothing. Further, the Resident and Representative understand that Facility's laundry utilizes high heat, strong crier icals, etc., in its launclr'y that mast likely will reduce cI©thing life. I`HERAPY SERVICES: Therapy Services including, but not limited to physical, speech/swallowing and occupational may be arranged through the Facility if the therapy is determined to be necessary by Resident's attending physician.. Therapy Services are billed in addition to routine services. SOCIAL SERVICES: A Social Services Director, shared by the entire Resident population, attempts to identify the social and emotional needs of each resident and to intervene where feasible. Services may be arranged to attempt to meet Residents' needs, either through staff at the Facility or by referral to appropriate prudent agencies or professionals. Some Social Services assistance offered may include: • Admissions and discharge coordination. Maintaining contact with family. • Resident ad}ustznent to the new environment DIETARY SERVICES: The Facility maintains a food service program monitored by a registered dietician. Regular meals, along with therapeutic diets and snacks prescribed by the Resident's attending physician, shall be provided by Facility. While unable to prepare a different menu for each Resident, Facility will use its reasonable best efforts to recognize individual preferences. A variety of ancillary supplies and services maybe utilized by the Resident during hislher stay in the Facility. Ancillary supplies and services include, but are not limited to, prescription drugs, certain medical supplies, intravenous therapy, radiology, laboratory, certain support surfaces, certain medical equipment and transportation. Thesa items, depending on circumstances, including the Resident's payer source, may he billed by Facility to Resident or by an independent professional or company to the Resident. You are advised that photographic pictures maybe taken for clinical record documentation. Any photos taken are considered part of the clinical record and subject to ail laws regulation of confidentiality in medical records. The facility reserves the right to increase or decrease the basic daily rate charge. A thirty (3d) day notice will be given in writing to the patientlpatient representative. .. The parties hereto agree that the services provided by Facility and others within Facility are not designed to somehow protect the Resident from the every-day, normal risks and responsibilities of living, including, but not limited to, such general accidents and situations such as falling, choking on food and weight loss and/or dehydration resulting from a Resident's failure to partake of food and drink. Additionally, the parties hereto understand that the services provided by the Facility do not include 24-hour, one-on-one, seven (7) days per week monitoring of its Residents. If a Resident or Representative desires service intended to protect against these inherent risks of daily living, the Facility's Social Services Department can assist Resident and Representative with procuring, at an additional charge, these services, in addition to those provided by Facility. REFUSAL OF SERVICES: Facility shall make good faith efforts to provide services to Resident, as are routinely provided, including those prescribed by Resident's attending physician. However, Facility shall not be responsible for outcomes associated with a Resident rcfusirg or refilSlIlg to comply with such services. Should a Resident refuse food, fluids, treatments, therapies, medications, groonurg, therapeu,`ic bathing, etc., andlar refuse to comply with physician's orders (i.e., Resident.is a diabetic with orders not to consume sugar, but Resident eats candy of own will, etc.), :Facility shall in no way be responsible for the outcomes associated with such Resident behavior. This shall apply to mentally competent and incompetent Residents. The Facility shall not be expected by Resident and Representative to intimidate or threaten a Resident into doing what the Facility and/or attending physician believe is best for the Resident Resident and Representative are strongly encouraged to participate in the planning of Resident's care both with the attending physician and facility. REASONABLE EXPECTATIONS: A "Setting Realistic Expectations" video is available through our admission's off.ce. Resident and Resident's Representative aclaiowledge that they have seen and clearly understand the content and message contained in the Resident Admission Video. The Resident and Representative agree and acknowledge that the Resident Admission Video cleazly state his or her acceptance of and commitment to a reasonable expectation of service and care to be provided by and received from the Facility with same to be paid for by the Resident The Facility believes that the optimal manner in which to deliver the care and services the Resident needs is to develop a partnership with the Resident and hislher responsible party towards reasonable, common, attainable, and realistic goals. --~z,.'~= _°r a9"'^'. ~ ".` r'`~"T~. ~- x r ~P~ .i~ =-~t-~,'r--'.., ~- ~`~..~" s; _~. ~ °r~'r'' ""~,°''9-~~`tfi a ~ =-.~ r..l ~-.,r'--.-~. ~ , ~ r.~~•e,.c~-r"-~-.z~- ~ ~' -+s ~-~ s1, ~ ~ ~ .c"~ ~ ~ ~ .~ ~ c ~ ~ ~ rs ~ °- 35-~ j _4.. -..... L 1tLYS~~_. L u~`. ~- =_~~.cL.iSf'w'IJL~ w ~..' ".~~ +. ~....trL;': ` ~ »rr~~ __ ~.a.LiR ..1 _a -a+1` This Facility, upon admission, has provided information to the Resident and Representative relative to Resident Rights pursuant to State and Federal rules and regulations. Privacy Act Notification: Resident information in the NII?S Assessment(Mini.mum Data Set) is transmitted to CIviS(Center for Medicare and Medicaid Services) via the Internet on a periodic basis. This transrnLSSion is confidential and not available to the public. HCFA requires this transmission for financial and regulatory purposes. UNDERST_41~TDING OF RYSKIBENEFTT: Chemical and/or physical restraints and protective devices are considered by the attending physician as a means to treat a behavioral or a medical symptomlcondition that endangers the physical safety of the Resident ar other Residents. If restraints and protective devices are deemed necessary by the physician, consent of the Resident or Representative will be obtained where and when reasonably passible. Shauld a Resident or Resident Representative refuse a restraint, Facility shall not be responsible for the outcome. Facility in no manner guarantees the success of a restraint device or methad_ Resident and Representative understand that there are inherent risks associated with restraint use and nonuse and the Facility shall not be held responsible for any outcome that is associated with the use of restraints (Reference: "Untie The Elderly" article in the admission packet) The potential risks involved when usin physical restraints maybe as follows: s decline in a resident's physical fimctioning(i.e. ability to ambulate and muscle condition) s COntI'a.CtUTCS development ofpressure sores • delirium • agitation • incontinence • increased incidence of falls and other accidents(i.e. strangulation) • loss of autonomy, dignity, and self respect The potential risks involved when not usirt~ physical restraints maybe as follows: • decline in a resident's physical func`aoning(i.e. ability to ambulate, independently turn self in bed, propel self in wheelchair: etc.) • increased incidence of falls and other accidents. WAIVER: Neither the failure nor any delay on the part of any party to exercise any right, remedy, power or privilege ("Right") under this Agreement shall operate as a waiver thereof, nor shall any single or partial exercise of any Right preclude any other or further exercise of the same or of any other Right, nor shall any waiver of any Right with respect to any occurrence be construed as a waiver of such Right with respect to any other occurrence. I~~o waiver shall be effective unless it is in writing and is signed by the party asserted to have granted such waiver. BL'~IDI'~ti G OBLIGATION: The Resident and Representative agree that the terms, conditions, restrictions and obligations of this Agreement also bind his ar her respective heirs, successor and self-designated representatives acting on behalf of the Resident including, but not limited to, family members, ombudsmen for the state or federal government, and any other private organization or advocacy group. INCIDENTS BEYOND THE CONTROL OF FACILITY: Resident and Representative agree that Facility will not be liable for and agree to hold Facility harmless from any circumstances that are beyond the control of Facility including, but not limited to, acts of God, stag' shortages, strikes and changes in economic condirions that affect the nursing home's operation. Additionally, Resident and Representative agree that Facility will not be liable for and agree to hold Facility harmless from any changes in service; or service limits due to changes in payment levels received by the Facility from Resident and/or third party payers including but not limited to, Medicare and Medicaid. An advance deposit will be collected from all non-lifecare patients admitted or converting to a Private Pay basis. A deposit will not be collected from patients admitted under the Medicare program unless 1Vledicare entitlement ends and the patient remains in the facility. The facility will collect a deposit from a residentlpatient who may have a private HMO, and are responsible for a co-pay amount. When Medicare entitlement ends, the appropriate deposit ama~ant will be collected froze the patientlresponsible party on the first day of private pay states. Deposits will be applied to outstanding charges on the patient's bt71 upon discharge from the facility or in the event of the patient`s death. Deposits will not be applied upon a temporary discharge to the hospital or home if the patient is expected to return to the facility within a reasonable period of time. The following amounts will be collected by pay type: Lifecara - No Deposit Required • Limited Lifecare with Med Center Days remaining - No Deposit Required • Limited Lifecare with all days used - 30 days at prevailing rate for room occupied. • Sohn Knax Village Lease Resident - 30 days at prevailing rate far room occupied less deposit already on file with JKV for leased apartment. • Private Pay - 30 days at prevailing rate for room occupied ,. This facility welcomes all persons in need of its reasonable and customary nursing home services and does not discriminate on the basis of age, handicap, race, color, creed, ancestry, national origin, religion ar sex. While the Facility must receive payment for its services, the Facility does not discriminate among persons based on their source of that prompt and in-full payment. . r, All terms hereunder are subject to the definitions and obligations of the separate Financial Agreement ezecuted as a part of this Admission Agreement ^ PATIENT ACCEPTED AS SELF PA'S The Resident /Responsible Party agrees to pay all charges billed by the facility to the facility to the patient for services rendered. The services that are included in the basic rate of $ are indicated under "Coveted Services". ^ PATIENT A.CCEPTET.~ AS MEDICARE A COVERED The Resident/ResponsiblePotty agrees to pay the Medicare coinsurance of $ per day beginning on the twenty-first day of skilled nursing facility confinement, through and including the one-hundredth day. The maximum benefit period is one hundred (100) days of skilled nursing confinement. Medicare benefits are not guaranteed. If at any time the level of care no longer meets the requirements established by Medicare far a skii_led level of serv=ice, you will be notified in writing. Medicare pays for the reasonable and necessary physician ordered services including medical and pharmaceutical supplies, laboratory fees; physical, speech, and occupational therapy. Also covered are the basic items listed elsewhere in the Admission packet. ' ^ P ATIENT ACCEPTED AS MANAGED CARE The Resident/Responsible Party agrees to pay for services rendered, not authorized far reimbursement. During the authorized period we look to the insurance company for payrnent_ Your insurance company determines the services and treatments that meet criteria based an the terms of your contract. If at any time the level of care no longer meets the requirements for a skilled Ievel of care, you will be notified in writing by your company. Normally Managed Care pays for reasonable and necessary services including medical and pharmaceutical supplies, laboratory fees, and therapies based on the terms of the contract Services must be ordered by the Primary Care Physician and authorized by your insurance company. ^ PATIENT ACCEPTED AS MEDICAID The patientJpatient representative acting. as agent for the patient agrees to pay the amount of resident liability as determined by the Medicaid program. The facility will provide all services indicated in. "Covered Services". A separate billing will be rendered by the facility for any items not covered in the basic Medicaid service only if these items have been requested in writing by the patient pa~r~ 7 of 1 fl By my signature below, Y aclaaowledge that I have received information about the facility's policy on Advanced Directives. I understand that additional information on this subject is available upon request. I authorize St. Joseph's John Knox Village Med Center to protizde information necessary to the agency authorized by the Facility to perform customer satisfaction surveys. I understand that I will be asked to complete a written survey to provide feedback about my care. ,_ It is understood and agreed by the Facility and Resident, or ("Resident's Authorized Representative", hereinafter collectively the "Resident") that any legal dispute, controversy, demand or claim (hereinafter collectively referred to as "claim" or "claims") that arises out of or relates to the Resident Admission Agreement or any service or health care provided by the Facility to the Resident, shall be resolved exclusively by binding arbitration to be conducted at a place agreed upon by the parties, or in the absence of such agreement, at the Facility, in accordance with the American Health Lawyers Association ("AREA"} Alternative Dispute Resolution Service Rules ofProcedure for Arbitration which are hereby incorporated into this agreement, *and not by a lawsuit or resort to co~ut process except to the extent that applicable state or federal law provided for judicial review of arbitration proceedings or the judicial enforcement of arbitration awards. This agreement to arbitrate includes, but is not limited to, violations of any right granted to the Resident by law ar by the Resident Admission Agreement, breach of contract, fraud or misrepresentation, negligence, gross negligence, malpractice, or any other claim based on any departure from accepted standards of medical or health care safety whether sounding in tort or in contract However, this agreement to arbitrate shall not limit the Resident's right to ule a ~-ievar:ce or complaint, formal or informal, with the Facility or any appropriate state or federal agency. All disputes, claims and disagreements betGVeen facility and resident(or their respective successors, assigns, or representatives) arising out of the enforcement or interpretation of this agreement or related hereto or the services, care or treatment provided by the facility hereunder including, without liuzitation, allegations Fnade by resident(or any representative acting on behalf of the resident) of neglect, abuse, deprivation of resident rights, negligence or any other tortious conduct, whether made under the provisions of Chapter 400, et seq., Florida Statutes, or otherwise, which the resident and facility are unable to resolve between themselves shaIl be submitted to binding arbitration. 'This arbitration agreement excludes any action by the Facility to recover from the Resident/ Responsible Party any claim for payment far services and supplies rendered to the Resident by the Facility. The parties agree that damages awarded, if any, in an arbitration conducted pursuant to this Arbitration Agreement shall be determined in accordance with the provisions of the state or federal Iaw applicable to a comparable civil action, iszeluding any prerequisites to, credit against or limitations on, such damages. It is the intention of the parties to this Arbitration Agreement that it shall inure to the benefit of and bind the parties, their successors and assigns, including the agents, employees and servants of the Facility, and all persons who claim is derived through or on behalf of the Resident, including, that of any parent, spouse, child, guardian, executor, administrator, legal representative, or heir of the Resident. All claims based in whole or in part on the same incident, transaction, or related course of care or services provided by the Facility to the Resident, shall be arbitrated in one proceeding. A claim shall be waived and forever barred if it arose prior to the date open which notice of arbitration is given to the Facility or received by the Resident, and is not presented in the arbitration proceeding. The parties understand and agree that by entering this Arbitration Agreement they are giving up and waiviag their constitutional right to have any claim decided in a court of Iaw before a judge arzd a jury_ T _ .r,. ~ ,_ ~ 1 !1 The Resident understands that (1) helshe has the right to seek legal counsel concerning this agreement, (2) the execution of this Arbitration is not a precondition to the furnishing of services to the Resident by the Facility, and (3) this Arbitration Agreement may be rescinded by written notice to the Facility fron the Resident within 3 d days of signature. If not rescinded within 30 days, this Arbitration Agreement shall remain in effect for all care and services subsequently rendered at the Facility, even if such care and services are rendered following the Resident's discharge and readmission to the Facility. GOVERNING LAQV: This Agreement will be governed by, and construed and enforced in accordance with, the laws of the State in which Facility is located. A~SSIGl~Ii1'IDNT: The Resident and the Representative aclmowledges that the right of the Resident to reside at the Facility is personal and is not assignable. The Resident may not transfer hishier rights under this Agreement to any other peron or organization. The obligations of Resident to Facility under this Agreement, however, automatically transfer to Resident's estate and ail Representatives subsequently engaged by or represent Resident or Resident's estate. This a~eement will survive a merger or change of ownership of Facility. ACKNOWLEDGEMENT: By signing below, the Resident and Representative indicate that they have read, or had read to them, and completely understand Ibis Agreement in its entirety. Resident and Representative agree that they have had the opportunity to consult with an attorney regarding the execution of this Ageement and that the parties freely consent to be legally bound by all of the terms of this Agreement and its subsequent implementation by the Hiles regulations permitted hereunder. .,- ~ '~„ The bed-hold policy of John Knox Village complies with Federal guidelines and is as follows: MEDICAID RESIDENTS: "Medicaid will not pay for bed-hold when a resident goes to the hospital or on home leave if 20 percent or more of certified Medicaid beds are available. The percent occupancy of Medicaid beds is determined based an the nursing facilities occupancy rate far t'~e previous quarter of the year." • Maximum 8 day bed-hold for Medicaid residents. • Therapeutic Leave: Sixteen (16) days per calendar year. MEDICARR, VA, INSURANCE, PRIVATE-PAY RESIDENTS: Hospitalization and therapeutic Ieave: There are no federal or contractually mandated provisions for bed-hold for the above referenced payer types. Private-pay Residents: Bed-hold will apply for the number of days the resident and/or responsible party agrees to pay for the bed to beheld. A copy of the Bed-Hold Policy will be given to each resident andlor family member when a resident is transferred or discharged to the hospital. Abed will be held for each resident who has a paid bed-hold. A list of Medicaid residents whose hospitalization or therapeutic leave has exceeded the bed-hold period will be maintained by the Director of Social Services and the following procedure will be followed: a When the next available bed in semi-private rooms occur, it will be offered to the first most eligible person on the list. b. The offer will continue to be made until such time as the resident is eligible to return to the center, but declined to do so. . c. When a resident declines to return to the center, a notation will be made in the discharge summary of the medical record_ r_ __ n ~r i n FLU VACCINE/ PNEIIMOVAX VACCIl~E I understand this vaccine is given annually without further authorization uFiless I inform the facility otherwise in wntuzb• Vaccines will not be given witho~xt signed consents. Please initial the appropriate statements below that reflect your wishes: 1) I would like to receive the Pneumavax vaccine 2) ~,,~ I do not wish to receive the Pneumavax vaccine 3) ould like to receive the Flu vaccine 4} I do not wish to receive the FIu vaccine RESIDENT: Signatwe -Resident (or Mark -see below) FACILITY: St. Josevh's Sohn Knox Village Med Center Company Name ,. ' BY Date s' ed by Resi ~ Its: {{ n {~ Signature -Responsible Party Date: ~~`1 `I Date geed y Responsible Party One witness please if Resident is unable to sign and/or signs with only a mark, Signature -Witness ~vl ~-a~ Date Signed by Witness Pave i !1 of 1 f1 St Joseph's John I£nox Village Admission Consent Form (~I2~ `~(~ hereby consent to being admitted Resident's name to John Knox Village Medical Center. I request all ancillary services as prescribed by my physician as well as the services that are checked below. Beauty/Barber shop: as requested weekly bi-weekly monthly Laundry services I am aware that the medical center does not accept responsibility for personal items that are lost or stolen. I have been informed that all personal items brought into the facility must be marked with my {resident's} Last name and first initial. (Washable markers are available at each nurse's station}. x I give my permission for photographs to be taken of me, this includes those required for documentation of care. I have received a copy of the Nursing Home Ombudsman Pamphlet. I have received and reviewed the Patient's Obligations and Responsibilities. I have received and reviewed the Residents Bill of Rights. I have received a copy of the price list for ancillary services. - BeautyBarber shop services and for Laundry services. I have received the information sheet (VIS} on the risks and benefits of the Influenza-Vaccine-and-I give my permission to receive the Flu.~laccine annually. - I have received the information sheet (VIS) on the risks and benefts of the Pneumococcal vaccine. I give my permission for the Pneumovax (Pneumonia vaccine} to be adm.i.nistered to me. The current CDC (Center for Disease Control) recommends that all Nursing Home residents receive the vaccination on admission as well as every 5 years. If a history of vaccination cannot be established the guidelines are to administer the Pneumovax. I have previously received the Pneumovix in (year) I understand the following: 1. This facility uses PharmAmeri:ca as their pharmacy. Alternative pharmacies may be used if the state and federal regulations as well as this facili.ty's policies are followed. 2. All medication purchased for me in this facility will be at my expense ~~ith the only exception being - if I qualify for Medicare part A, Medicaid or some of the HMO insurance plans IF prescription coverage is included in your policy while you are in this facility. 3. If e medicine with at the time of discharge it will be at my expense. Date: ~/~/ v Re ' ent or Responsi Ie. arty signature 1 ~ Date: ~/~/ ~~ v Admission's coordinator signature S"f OSEPH'S ~ ~~ ~~o~ ~~~~~~~ t~~,. FINAI~ICrAt, AGREEMENT ~O~ ~£NOX VIY.LAGE MED CENTER PARTIES. Agreement made ~`(~' ~ "!` 1VIed Center (the =Facili ' k~_ , 2~ ~, bctwcen John Knox Village ty' ), th offices at 4)00 t,E. Fletcher Ave., Tampa, FI, 33 b 13, and and/or ~ ~ 1~ ~~ (the "Resident") (the Responsible Party"). PURPOSE OF AGREEMENT'. The Facility is in the business of providing Tong term health care services as specified in the Admission Agreement and all attachments and addenda thereto, whereas the Resident is in need of these Long terra care services. This Financial Agreement sets forth the terms and conditions of payment for those services. The Facility and the ResidentlResponsible Party hereby agree to be bound by the terms and conditions of the Admission Agreement, all attachments and addenda thereto, and perform their responsibilities as set forth below. Medicare; Residents admitted, whose stay is eligible for payment by Medicare Part A, have a Medicare Co-Insurance portion that is calculated on a cumulative basis beginning on the twenty frst day of Medicare Coverage. The maximum benefit period is one hundred (100) days of skilled nursing confinement within 30 days of a 3 night inpatient hospital stay. Medicare benefits are not guaranteed. If at any time the level of care no longer meets the requirements established by Medicare for a skilled level of service, resident or representative will ba notif ed in writing. The resident,'responsible party, subject to the terms below, agrees to pay the Medicare coinsurance of ~ per day beginning on the twenty-first day of skilled nursing facility confinement, throw and including the one-hundredth day. Resident, that have a l~iedicare supplement policy for Skilled Nursing Facility stays will usually have a portion of this co-payment paid by the supplemental policy. Medicare pays for the reasonable and necessary physician ordered services including medical and pharmaceutical supplies, laboratory fees, physical,. speech, and occupational therapy. Also covered are the basic items listed elsewhere in the Admission packet. Residents who request a private room will be billed the difference in the cost of a Private Room vs. a Semi-Private Room. Medicare only pays based on the semi-private room rate, Private Pay: Resident/Responsible Party, subject to the terms below, agrees to pay all charges billed b the facility to th ~cility to the patient for services rendered. The services that are included in the basic rate of $ are indicated under "Covered Services". The facility reserves the right to increase or decrease the basic dailp rate charge. A thirty (3Q) day notice will be given in writin to the patientlpatient representatve. g Billing will be made in advance for the basic daily rates. Other goods and services will be billed after they are provided. If a resident is admitted as Private Pay or becomes Private Pay during their stay, the Resident and/or Responsible Party will receive a bill by the 10~' of each month for services that include charges throw h the end of the month. This includes deductible and co-insurance amounts that are billable to Medicare Part B, and the room and board fee for the following month in advance. If a resident leaves the facility and has made payments in advance, the resident will be eligible for a refund of unused days. Managed Care; The residentJresponsible party agrees to pay for services rendered, not authorized for reimbursement, including but not limited to deductibles and copayments. During the authorized period we Iook to the insurance company for payment. Your insurance company determines the services and treatments that meet criteria based on the terms of your contract. If at any time the level of care no longer meets the requirements for a skilled level of care, you will be notified in writing by your company. The facility will assist the resident/respansible party with any managed care payment application and will provide assistance, it is ultimately the responsibility of the resident or responsible party to secure third party coverage for the facilities' services, and the resident/responsible party agrees to pay the facility for any charges not covered by managed care. Normally Managed Care pays for reasonable and necessary services including medical and~pharmaceutical supplies, laboratory fees, and therapies based on the terms of the contract. Services must be ordered by the Primary Care Physician and authorized by your Insurance campany. Medicaid: Resident/Responsible Party agrees to pay the amount of resident liability as determined by the Medicaid program. The facility will assist the residentlresponsible party with any Medicaid application and will provide assistance, however it is ultimately the responsibility of the resident and/or responsible party to secure third party coverage for the facilities' services, including Medicaid, and the resident/responsible party agrees to pay the facility for any charges not covered by Medicaid. The facility will provide all services indicated in "Covered Services". A separate billing will be rendered by the facility for any items not covered in the basic Medicaid service only if these items have been requested in writing by the patient. Private insurance coverage: Where Facility's charges for the Resident's services are eligible to be paid partially or in full by privately owned insurance, ResidentlResponsible Party shall remain responsible for making payments in full pursuant to this Agreement regardless of such insurance coverage, and shall be responsible for paying all charges not paid by any insurance policy, including any coinsurance or deductible amounts required by any insurance policy. While the Facility, as a courtesy, will file claims with most privately owned insurance companies, the Facility may, at its option, require the Resident and Responsible Party, in advance, to pay the Facility's charges while awaiting payment frorn the insurance company. The facility will assist the residentlresponsible party with any private insurance coverage issues, however it is ultimately the responsibility of the resident and/or responsible party to secure third party coverage for the facilities' services, including private insurance, and the resident/responsible party agrees to pay the facility for any charges not covered by insurance. LEVEL OF CARE CHANGE: State and Federal Medicaid/Medicare licensing regulations will be followed when a resident's condition necessitates a change in the level of care. The levels of care that are offered by the Health Center are skilled and non-skilled nursing care. Levels of care are subject to the eligibility criteria that are established by the state Medicaid program, Center for Medicare Services, or your private insurance provider. A change in condition may require a higher or Io~ver level of care. Following the evaluation confirming the change in the level of care, the physician will provide an order for the new Level of care. This change may also result in Ions of third party benefit coverage. BILLING. The daily room rate is charged for the day of admission but not for the day of discharge or death if it occurs by 11:00 a.m. If discharge occurs after 11:00 a.m., an additional fee equal to the daily roam rate will be added to -the bill. All private-pay and cost share charge, are billed in advance by the Facility and will be mailed to the ResidentlResponsible Party by the first (1st) of the month. All payments received after the tenth (10th) of the month will be considered late, and non-payment by this date will result in discharge of the Resident from the Facility. All accounts thirty (30) days overdue ~;~~ill be subject to interest at the highest rate allowed by law. RESPONSIBLE PARTY AGREEMENT. The Facility may not require a third party guarantee of payment to the Facility as a condition for admission, expedited admission or continued stay in the Facility. However, the Facility may require an individual who has legal access to a Resident's income or resources, to sign a contract to provide the Facility payment from the Resident's income or resources, without that individual incurring personal financial liability, except for a breach in his or her contractual obligations set forth herein. The Responsible Party must choose one of the following Responsible Party categories: A. VOLUNTARY GUARANTOR I agree to voluntarily guarantee payment to the Facility for services provided to the resident. I understand that I am not required, by law or by the Facility, to personally guarantee payment. I agree to be liable along with and in addition to the resident for ail charges incurred by the resident for items and services provided by the Facility as specified in the Admission Agreement, attachments, and this financial agreement. VOLUNTARY GUARANTOR'S INITIALS, IF APPLICABLE: B. LEGAL REPRESENTATIVE (REQUIRED IF NOT VOLUNTARY GUARA~'~ITOR). I do not wish to be a voluntary a grantor but aclmowledge that I have access to and/or authorized control over the resident's income and/or assets. I agree to use resident's income or assets to pay the Facility for goods and services provided to the resident. I am not assuming personal liability for any payment except up to the amount of the income or assets belonging to the resident over which I have authorized control, regardless of whether such control is joint with another person(s). Income and assets shall be defined as broadly as possible, and shall include but not be limited to cash, bank accounts, mutual funds, certificates of deposit, pension benefits, savings accounts, personal and real property. I further agree to comply with all terms set forth in the Admission Agreement, attachments and addenda thereto, and this Financial Agreement. LEGAL REPRESENTATNE' S INITIALS, IF APPLICABLE: RESIDENTlR.ESPONSIBLE PARTY'S DUTIES. The Resident, where applicable, and the Responsible Party, whether Voluntary Guarantor or Legal Representative, agrees as follows: 1. To initiate and maintain any proceedings in state court to appoint a Guardian, Conservator, or Power of Attomey for the Resident within t..hirty (30) days of a written request by the Facility to do so, or to pay for any legal charges related to proceedings to appoint a Guardian, Conservator or Power of Attorney for the Resident that are initiated by the facility, 2. To pay, monthly, in advance, the daily rate set forth above, as adjusted, in effect at the time the services are provided or to pay for items and services provided but not paid for by Medicare, Medicaid, insurance or any other third-party payor, 3. To cooperate fully with any application for government assistance such as Medicaid or Medicare, and to provide such information about the Resident's assets or finances as the Facility or government representatives, shall require for continued coverage of the Resident. T'he Responsible Party, whether Legal Representative or Voluntary Guarantor, shall be personally liable to the Facility for any charges denied the facility due to such lack of cooperation, 4. To pay all invoices within l0 days of presentment and to pay interest on any invoices over 30 days past -due at the highest rate allowed by law in the state in which this agreement is signed, ~. To pay the Facility's costs of collection and reasonable attorney's fees for any legal. proceedings arising as a result of the Resident's stay at the facility, 6. Venue and jurisdiction for any legal proceedings arising as a result of the Reside.nt's stay at the Facility shall be in State Court i:n the county in which the Facility is located, ?. To waive any arbitration requirements, otherwise applicable for any legal proceedings, arising from resident's failure to pay for services provided by the Facility, 8. To assign, and does hereby assign, to the Facility any and all rights of the Resident to collect from Resident's insurance carrier or any other third party payor source for any benefits due to the resident or Facility related to resident's stay at the Facility, 9. To authorize the Facility to verify the accuracy of the information provided in resident's Financial Disclosure Addendum attached hereto and to review resident's eligibility for government assistance such as Medicaid prior to admission or at any time thereafter, including asset searches or credit reports, 10. To authorize the Facility to make application for third party assistance if the Resident or Responsible Party fails to do so, without relieving the Resident or Responsible Party of their obligation to initiate or assist in any such application process, 11. To notify the Facility of any change to Resident's financial status that will impact payment sources to the Facility and to be liable to the Facility for any non-covered charges for failure to do so, 12. To authorize the Facility to use the Resident's operating account to settle any outstanding balances awed to the Facility at the time of discharge or death. Any balance remaining in the Resident's operating account after settlement of the account will be paid within thirty (30) days after discharge or death to the Resident or Personal Representative of his estate. ASSIGNMENT OF BENEFITS: ResidentlResponsible Party hereby requests that payment of authorized Medicare, Medicaid, Social Security and other Insurance benefits as authorized l~elow be made directly to John Knox Village Medical Center. Resident further authorizes any holder of medical information about him/her to release to John Knox Village Medical Center, the Centers for Medicare and Medicaid Services, the Department of Medical Assistance and their agents any information needed to determine or confum my bene;fits under the Medicare or Medicaid programs. COVERED SERVICES: Room and board and general nursing care are charged on a daily basis. Ancillaries ordered by the physician are charged on a per item basis. Charges for professional services (such as physician) are separ--ate from Health Center charges and are handled u~u ough the off ce of th? professional providing the service. Residents covered by Medicare are charged for Part A and Part B deductibles, ca-insurance and for requested private roam rate difference. Medicaid residents are charged patient liability monthly as determined by their local Department of Social Services and for prescription drugs exceeding the allowable six {6} per month. A list of "Covered Services" included in the room rate charge is as follo`vs: • Dietary Services • Grooming • Home Health Consultation • Housekeeping • Hydrotherapy • Laundry • Pastoral Care • Professional Nursing • Recreational Activities • Resident Fund Management • Restorative ~tursing • Social Services • Therapeutic Diets SERVICES AT ADDT~IONAL COST: Personal care services and items (hair cuts and beauty services) are not included in Health Center room rate charges. A list of services available to residents at additional cost is as follows: • Audiology • Barber and Beauty (sets, perms, etc.) • Cable Television • Dental Services • Hospice • Medical Supplies • Medications • Occupational Therapy • Optometry • Physical Therapy • Podiatry • Prosthetic Devices • Private Telephone Service in Room • Psychiatric Consults • Respiratory Therapy • Speech Therapy • Transportation (non-emergency) The Resident may utilize a variety of ancillary supplies and services during his/her stay in the Facility. Ancillary supplies and services include, but are not limited to, prescription drugs, certain medical supplies, intravenous therapy, radiology, laboratory, certain support surfaces, certain medical equipment and transportation. These items, depending on circumstances, including the Resident's payer source, may be billed by Facility to Resident or by an independent professional or company to the Resident. DEPOSITS: A deposit will not be collected from patients admitted under the Medicare program unless Medicare entitlement ends and the patient remains in the facility. The facility will collect a deposit from a resident who may have a private IMO, and are responsible for a co-pay amount. A 30 day deposit is required for private pay resident. Lifecare residents will be responsible for their contracted rate.- When Medicare entitlement ends, the appropriate deposit amount will be collected from the patientJresponsibie parry on the rr5t day of private pay status. Deposi*.s ~.~~ill be applied to outstanding charges on the patient's bill upon discharge from the facility or in the event of the patient's death. Deposits will not be applied upon a temporary discharge to the hospital or home if the patient is expected to return to the facility within a reasonable period of time. RETURNED CHECKS: If a check is returned for insufficient funds, the Facility may charge its prevailing returned check charge and may require payment be made by certified check or money order. Expectations of Resident and/or Responsible Party l . To provide such personal clothing and effects as needed or desired by `she resident. 2. To provide such spending money as needed by the resident. 3. To be responsible for any transportation charges, except for services covered by Medicare, Medicaid or other Insurance.- ?. To be responsible for physicians' and dentists' fees, cost of medication, supplies, and other treatment or aids ordered by physician, except for services covered by Medicare, Medicaid or other Insurance. 5. To be responsible for the basic room rate and all additional charges, except for se;rvices covered by Medicare, Medicaid or other Insurance (if the resident receives benefits which are paid directly to the facility for such covered services) 6. To abide by the House Rules and Regulations as in effect and posted. Ln the event the resident is admitted to a hospital, another provider for treatment, or is absent from the facility far .longer than a 24-hour period, John Knox Village Med Center is required to discharge the resident from the facility You have the right to reserve the bed guarantying your readmission to the same room within the facility. Should you decide not to reserve the bed, the facility retains the right to fill the bed with the next appropriate resident and you will be responsible for removing your personal belongings within 24 hours of discharge. If you are unable to comply with this requirement, the facility reserves the right to remove your personal belongings and have them stored at your expense. Florida state Iaw does offer a degree of protection for returning to the facility by mandating the facility to offer "the next availab],e bed suitable for the resident's needs." John Knox Village Med Center requires advance payment to reserve the bed when a resident is absent from the facility. Payment should be made to the Patient Billing office located in the facility. You may contact the Billing Office at 813-632-2429. ACKNOWLEDGMENT This Agreement, together with the Facility's Admission Agreement and all addenda and attachments, constitute the entire Agreement between the parties, as of this date, and shall not be modifed except by a writing signed by all parties. This Agreement shall be governed by the laws of the State of :Florida and by all applicable federal health care regulations. By signing below, the Resident/Legal RepresentativeNoluntary Guarantor acknowledge that they have received the facility daily rates, covered and non-covered services and supplies, have read and understand this agreement, have teen given the opportunity to ask questions prior to the execution hereof, and agree to alt terms set forth herein. 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