HomeMy WebLinkAbout11-3628PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2011- 3 6 ?-?- CIVIL TERM
CHARLOTTE DAVIS
DARREN DAVIS AND
MICHAEL DAVIS, AGENT FOR
CHARLOTTE DAVIS AND
INDIVIDUALLY,
Defendants
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 are
served, by entering a written appearance personally or by an attorney and filing in writing 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 for any other claim
or relief requested by the plaintiff. You may lose money or property or other rights 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 BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
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PERINI SERVICES/ :
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
CHARLOTTE DAVIS
DARREN DAVIS AND
MICHAEL DAVIS, AGENT FOR
CHARLOTTE DAVIS AND
INDIVIDUALLY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2011- 3 ( ,l„ ? CIVIL TERM
COMPLAINT
NOW, comes Perini Services/South Hampton Manor Limited Partnership d/b/a
Shippensburg Health Care Center ("Shippensburg Health"), by and through its attorneys, BARIC
SCHERER, and files the within Complaint and, in support thereof, sets forth the following:
1. Shippensburg Health is a Maryland limited partnership duly authorized to conduct
business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom
Road, Shippensburg, Cumberland County, Pennsylvania 17257.
2. Defendant, Charlotte Davis, is an adult individual with a residence address of 121
Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257.
3. Defendant, Darren Davis, is an adult individual with a residence address of 5925
Gabrielle Lane, Chambersburg, Franklin County, Pennsylvania 17202.
4. Defendant, Michael Davis, is an adult individual with a mailing address of P.O.
Box 3834, Ithaca, New York 14852.
5. Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
6. On or about January 8, 2010, Charlotte Davis sought to be admitted to the
Shippensburg Health facility.
7. On or about January 6, 2010, Charlotte Davis executed an Admission Agreement.
A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is
incorporated.
8. On or about January 8, 2010, Darren Davis executed the Admission Agreement as
the legal representative for Charlotte Davis.
9. Pursuant to the Admission Agreement, Charlotte Davis would be responsible to
pay any costs of care which were not covered by a third party payer.
10. On or about January 8, 2010, Charlotte Davis became a resident of the
Shippensburg Health facility and remains a resident to the date hereof.
11. Pursuant to the Admission Agreement, Darren Davis agreed, as the responsible
party for Charlotte Davis, to pay the costs of care provided from the income of Charlotte Davis.
12. As of March 22, 2011, Charlotte Davis owed Shippensburg Health the sum of
$13,472.99 for the costs of care provided by Shippensburg Health to her. A true and correct copy
of the Statement reflecting the balance due is attached hereto as Exhibit "B" and is incorporated.
13. Demand has been made upon Darren Davis to pay the amount due for the costs of
care provided to Charlotte Davis.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. CHARLOTTE DAVIS
AND DARREN DAVIS
14. Plaintiff incorporates by reference paragraphs one through thirteen as though set
forth at length.
15. Charlotte Davis has breached her obligation to pay for the costs of care as
provided by Shippensburg Health.
16. Darren Davis has breached his obligation to pay for the costs of care provided to
Charlotte Davis from the income and assets of Charlotte Davis.
17. As a consequence of that breach, Shippensburg Health is owed the sum of
$13,472.99 to March 22, 2011.
18. The accrued debt consists of the private pay obligation of Charlotte Davis. Darren
Davis has failed to pay the private pay obligation from the benefits he has received in the name
of Charlotte Davis.
19. The Admission Agreement bound Charlotte Davis to pay for the costs of her care
at the facility and bound Darren Davis to pay the costs of care from the assets and income of
Charlotte Davis.
20. The Admission Agreement provides for the recovery of a penalty for late
payments in the amount of 1.5% per month.
21. The Admission Agreement provides for the recovery of reasonable attorney fees
and costs incurred by Shippensburg Health to collect a debt due and owing to Shippensburg
Health.
WHEREFORE, Plaintiff requests judgment in its favor and against Charlotte Davis and
Darren Davis for the sum of $13,472.99 plus additional interest, costs and expenses and any
additional amount coming due to the date of award and attorney fees and costs.
COUNT II-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. MICHAEL DAVIS
22. Plaintiff incorporates by reference paragraphs one through twenty-one as though
set forth at length.
23. During the period of residence at the facility, Michael Davis has been receiving
social security and pension benefits of Charlotte Davis.
24. The proper use of those funds would have been to pay the costs of care accruing
for the care of Charlotte Davis at Shippensburg Health.
25. At the time of receipt of those funds, Michael Davis knew that these funds should
be paid over to Shippensburg Health for the costs of Charlotte Davis' care.
26. Michael Davis gave no consideration for the funds of Charlotte Davis he has
received.
27. Demand has been made upon Michael Davis to tender the funds of Charlotte
Davis to Shippensburg Health and he has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Michael Davis
requiring him to:
a) return the subject matter in specie;
b) pay over the value if Michael Davis has consumed the money in beneficial use;
C) pay its value if Michael Davis has disposed of the funds received; and
d) award costs, expenses and interest.
COUNT III-QUANTUM MERUIT
SHIPPENSBURG HEALTH v. CHARLOTTE DAVIS
28. Plaintiff incorporates paragraphs one through twenty-seven as though set forth at
length herein.
29. Despite demand therefore, Charlotte Davis has failed and refused to pay the costs
of her care accruing during her residency.
30. Charlotte Davis was unjustly enriched through her receipt of the care and services
provided without making payment therefore.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the
sum of $13,472.99, interest, costs and expenses and attorney fees.
Respectfully submitted,
ARIC SCH R
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David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/shcc/davis/complaint. pld
VERIFICATION
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they are true and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §
4904 relating to unsworn falsifications to authorities.
DATE
4
6
Allison Klimowicz
SHIPPENSBURG HEALTH CARE CENTER
ADMISSION AGREEMENT
A.D., by and between SHIPPENSBURG HEALTH CARE CENTER (hereafter
"SHIPPENSBURG") and (, 10 RE-
(hereafter "Resident"), previously residing at (Street Address and Post Office
Box) 5"0nb "BvrAows 4o,y !7 C ,
and 2) 1J 'D/y15 (hereafter
"Legal Representative"), residing at (Street Address and Post Office Box)
J I a 5 G ,rl(F 114 G As ?,,{ PA 17,111. The Legal
Representative's relationship with the Resident is that of 5or4
The staff of SHIPPENSBURG will take whatever time is necessary to answer
all of your questions. Please continue to ask questions
until you are sure that you understand.
1. PROVISION OF SERVICES
A, NURSING SERVICES: SHIPPENSBURG will provide the Resident with
routine nursing services; semi-private accommodations, three meals each day
(except as otherwise medically indicated), blankets, bed linens, towels and
wash cloths, laundering of blankets, linens, towels, and wash cloths,
housekeeping services, and activity programs and social services as
established by the facility, as identified on the Rate Schedule. The Rate
Schedule is attached to this Agreement and is incorporated herein as if set forth
in full. The Rate Schedule sets forth the list of supplies and services included in
SHIPPENSBURG's daily rates, those supplies and services which are not
covered by the daily rates for which the Resident will be separately charged,
EXHIBIT "A"
and those supplies and services covered by the Medicare and/or Medicaid
programs for enrolled Residents.
Federal and state laws and regulations change regularly and frequently
require changes related to the care and services SHIPPENSBURG provides.
Additionally, other financial factors may require SHIPPENSBURG to make
changes related to provision of Its care and services. On this basis, the Rate
Schedule may be changed, upon notice to the resident.
B. ANCILLARY SERVICES AND SUPPLIES: SHIPPENSBURG will also
provide ancillary services and supplies as set forth in the Rate Schedule, and
private accommodations upon the direction of the Resident's physician. The
ancillary services and supplies are subject to change from time to time at the
discretion of SHIPPENSBURG.
C. OUTSIDE FROWNERS AND NVN-t-AWLr i Y 7CKV1W:,:
SHIPPENSBURG makes available, from time to time, the services of outside
providers and non-facility services. These services will be available under
SHIPPENSBURG's policies and procedures, and at the Resident's sole
expense unless the charges for such services are covered by a third party
payer, Should the Resident arrange for the services of outside providers, the
providers must be properly licensed or registered under state and federal law,
and must comply with all SHIPPENSBURG policies and procedures, including,
but not limited to, providing SHIPPENSBURG with documented proof of their
legally required liability insurance coverage. All outside providers must be
approved in writing by SHIPPENSBURG before providing any services. At
SHIPPENSBURG's sole discretion, only providers deemed by
SHIPPENSBURG to fulfill all of the requirements set forth in federal and state
law, as well as SHIPPENSBURG's policies and procedures, may provide
services to Residents.
The Resident recognizes and agrees that all outside providers, including
those designated by SHIPPENSBURG, are independent contractors. The
Resident recognizes and agrees that such providers are not associates or
agents of SHIPPENSBURG, and that SHIPPENSBURG is not liable for any
outside provider's acts or omissions. The Resident shall be solely responsible
for payment of all charges of any provider who renders care to the Resident in
SHIPPENSBURG, unless the charges are covered by a third party payer.
Furthermore, the Resident agrees to confirm that any Resident initiated,
approved outside provider (i.e. private duty nurse, etc.) has worker's
compensation insurance coverage as required by law, as well as liability
Insurance. To the extent that the outside provider does not have the legally
required worker's compensation insurance coverage, the Resident will provide
and pay for such coverage.
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11. RgSIDENT`S RIGHT§
SHIPPENSBURG welcomes all persons in need of its services
and does not discriminate on the basis of age, disability, race, color,
national origin, ancestry, religion, or sex. Furthermore, SHIPPENSBURG does
not discriminate among persons based on their sources of payment.
A. Coneent for Treatment
1. SHIPPENISU,RG SERVICES: By signing this Agreement,
the Resident consents to SHIPPENSBURG providing routine nursing and other
health care services and administering all medication as directed by the
attending physician, or when the attending physician Is unavailable,
SHIPPENSSURG's Medical Director. SHIPPENSBURG is not obligated to
provide the Resident with any medications, treatments, special diets or
equipment without specific orders or directions from the Resident's physician or
SHIPPENSBURG's Medical Director. From time to time SHIPPENSBURG may
participate in training programs for persons seeking licensure or certification as
health care workers. In the course of this participation, care may be rendered
to the Resident by such trainees under supervision as required by law.
Consent to routine nursing care provided by SHIPPENSBURG shall include
consent for care by such trainees.
2. PHYSICIAN SERVICES: The Resident acknowledges that
he or she is under the medical care of a personal attending physician, and that
SHIPPENSBURG provides services based on the general and specific
instructions of that physician, or when unavailable, SHIPPENSBURG's Medical
Director. The Resident has a right to select his or her own attending physician.
If, however, the Resident does not select an attending physician, or is unable to
select an attending physician, an attending physician may be designated by
SHIPPENSBURG or in accordance with state law. All attending physicians
must meet and conform with all of SHIPPENSBURG's policies and procedures,
and are subject to the terms set forth in the Outside Providers and Non-facility
Services section of this Agreement.
3. RIGHT TO REFUSE TRgATMENT: The Resident has the
right to refuse treatment and to revoke consent for treatment. The Resident
also has the right to be informed of the medical consequences of such refusal
or revocation of consent, and to be informed of alternate treatments available.
Where, in the opinion of the attending physician or by judgment of a court of
law, the Resident is determined to be mentally incompetent to make a decision
regarding refusal of treatment, the decision to refuse treatment may be made by
a Legal Representative or other surrogate decision-maker, subject to state and
federal law.
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B. Resident's Personal Pr Rertv
SHIPPENSBURG strongly discourages the keeping of valuable jewelry,
papers, large sums of money, or other items considered of value in
SHIPPENSBURG. However, the Resident shall be permitted to retain and use
personal clothing and possessions as space permits, unless to do so would
infringe upon the right of other residents or unless determined medically
inadvisable as documented by the Resident's physician in the Resident's
medical record. SHIPPENSBURG shall make reasonable efforts to properly
handle and safeguard the Resident's personal property in SHIPPENSBURG.
The Resident agrees to Inform SHIPPENSBURG of all valuable property upon
admission. If, at any time during the Resident's stay, new items of value are
added to the Resident's possessions in SHIPPENSBURG, the Resident agrees
to so Inform SHIPPENSBURG's Administrator or designee.
The Resident Is responsible for obtaining at his or her own expense any
insurance coverage necessary to cover potential damage to or loss of any of
Resident's personal property. SHIPPENSBURG shall not be liable for damage
to or loss of any of Resident's personal property. Should the Resident lose his
or her property, or believe that his or her property has been otherwise removed
from his or her possession, the Resident agrees to follow SHIPPENSBURG's
procedure for filing reports of lost or stolen property.
In the event that Resident is transferred or discharged from
SHIPPENSBURG, or if the Resident expires, the Resident hereby authorizes
SHIPPENSBURG to transfer the Resident's personal property to the Resident's
Legal Representative, or to any duly authorized representative of Resident's
estate. If the Resident's personal property is not claimed or removed within
twenty-four (24) hours of the Resident's transfer or discharge, or expiration, the
Resident authorizes SHIPPENSBURG to place his personal property into
storage until claimed. Standard daily storage charges will continue while the
Resident's property remains in SHIPPENSBURG.
Should the Resident's property fail to be claimed within fourteen (14)
days of the Resident's transfer, discharge, or expiration, the Resident and
SHIPPENSBURG hereby agree to a storage and sale arrangement. Under this
arrangement, SHIPPENSBURG agrees to bear any and all costs of the storage
of the Resident's property, not including any insurance thereon. However, in
consideration of SHIPPENSBURG's storage of the Resident's property, should
the Resident's property fall to be claimed within thirty (30) days of placement by
SHIPPENSBURG Into storage, the Resident hereby agrees that
SHIPPENSBURG may dispose of the Resident's property with and at
SHIPPENSBURG's discretion, including retaining all proceeds from any sale
thereof.
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C. RMid-ent's Recor
9. CONFIDENTIALITY; Information included in the Resident's
medical records Is confidential. Unauthorized persons shall not be allowed to
review these records without the Resident's written consent, except as required
or permitted by law.
2. CONSENT TO RELEASE BY SHIPP€NSBURG: The Resident
authorizes SHIPPENSBURG to release all or any part of the Resident's medical
or financial records to any person or entity which has or may have a legal or
contractual obligation to provide the Resident with medical services, or to pay
all or a portion of the costs of care provided to the Resident, Including but not
limited to hospital or medical services companies, Insurance companies,
workers' compensation carriers, welfare funds, and/or the Resident's employer.
The Resident also authorizes release of information from medical or financial
records to any medical professional or institution responsible for the Resident's
medical or nursing care when the Resident is transferred or discharged from
SHIPPENSBURG. The Resident hereby releases SHIPPENSBURG from any
liability for damages or other loss suffered in or Incurred by the Resident and
arising out of or directly or Indirectly related to the reliance by the facility upon
the foregoing authorization.
3. PHOTOGRAPHS: The Resident authorizes SHIPPENSBURG to
photograph or videotape the Resident as a means of identification or for health
related purposes. The photographs or videotapes may also be used to help
locate the Resident in the event of an unauthorized absence from
SHIPPENSBURG, but shall otherwise be kept confidential. If SHIPPENSBURG
intends to use the photograph or videotape for purposes other than those noted
above, SHIPPENSBURG shall get written permission from the Resident in
advance of such use (SHIPPENSBURG sometimes requests Resident to permit
the use of their photograph and written impressions about SHIPPENSBURG in
marketing and other public Information materials). The Resident retains the
right to refuse the taking of a photograph at any particular time.
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D. RESIDENT'S RESPONSIBILITIES
1. RULESANQ_ REsGULATIONS: The Resident agrees that
SHIPPENSBURG may, to maintain orderly and economical operations, adopt
reasonable rules and regulations to govern the conduct and responsibilities of
the Resident. These rules and regulations include that SHIPPENSBURG is a
SMOKE FREE CAMPUS, with no smoking or use of smokeless tobacco
products permitted in all its buildings, grounds and parking areas, for new
residents, their visitors, staff, vendors, physicians, contractors, and volunteers.
The Resident agrees to follow those rules and regulations. It Is understood that
these rules and regulations may be amended from time to time as
SHIPPENSBURG may require. Any changes to the rules and regulations shall
be given to the Resident In writing. NOTE: Some residents admitted prior to the
effective date of the SMOKE FREE CAMPUS Policy will be allowed to continue
smoking In special designated areas as required by Federal regulations.
2. DIET: The Resident understands that his or her diet Is medically
prescribed and, therefore, must be monitored by SHIPPENSBURG. The
Resident agrees to consult with Nursing or Dietary staff when food or
beverages are brought into SHIPPENSBURG.
3. MEDICATIONS: No medications or drugs may be brought upon
SHIPPENSBURG premises unless the medications or drugs are labeled
according to the requirements of state and federal law. Packaging of
medications must be compatible with SHIPPENSBURG's medication
distribution system. No drugs or medications may be brought into
SHIPPENSBURG unless they are delivered directly to the nurses' station.
4. CARE OF SHIPPENSBURG'S PROPERTY: To preserve the
value of SHIPPENSBURG's property for future residents' use, the Resident
agrees to use due care to avoid damaging SHIPPENSBURG's property and
premises. The Resident shall be responsible for the costs of repair or
replacement of SHIPPENSBURG's property damaged or destroyed by the
Resident. However, the Resident shall not be responsible for such damage as
is to be expected from ordinary wear and tear.
5. CARE OF THE RESIDENT'S ROOM: SHIPPENSBURG
encourages the Resident to have a SHIPPENSBURG-like environment, and will
attempt to accommodate all reasonable requests to individualize resident
rooms. For safety reasons, SHIPPENSBURG must approve any addition or
rearrangement of furniture, hanging of pictures, posters, or other similar
activities.
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6. INDEMNIFICATION: The Resident hereby agrees to indemnify
and hold harmless SHIPPENSBURG, its officers, directors, agents, and
employees from and against any and all claims, demands or causes of action
for injury or death to person or damage to property, including all costs and
attorneys fees incurred in defending any claim, demand or cause of action
which Is caused by the Resident and which is not caused by any willful or
negligent action of SHIPPENSBURG. This indemnification includes, but is not
limited to, all claims, demands or causes of action stemming from the acts or
omissions of the Resident, Including but not limited to Resident's refusal of any
nursing care, medical or other treatment, or any other item or service deemed
necessary by SHIPPENSBURG or any other treating health professional.
Ill. POLICXREGARDIhiG TUE IMPLEMENTATION
OF THE PATIENT SELF-DETERMINAIION ACT
The following Information is being provided to the Resident as a result of
a federal law which requires certain health care institutions, including
SHIPPENSBURG, to disclose to the Resident his or her rights under federal
and state law to make decisions regarding his or her health care.
A. INTRODUCTION.
9. SHIPPENSBURG recognizes and appreciates the dignity and value
of each Resident's life, and the right of each Resident to make decisions
regarding his or her care.
2. SHIPPENSBURG recognizes the Resident's right to have these
decisions made on his/her behalf by a substitute decision-maker in accordance
with state law when the Resident is no longer able to make them.
3. SHIPPENSBURG recognizes the right of each Resident to utilize
those health care advance directives recognized under state law, and will honor
such advance directives developed and implemented in accordance with state
law and consistent with the level of care SHIPPENSBURG Is licensed to
provide. A health care advance directive is a written document that states
choices for health care and/or names or precludes those individuals who the
Resident wishes to make those choices. These choices may include the refusal
of certain types of care. A Living Will and a Durable Power of Attorney for
Health Care are examples of such advance directives.
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PENNSYLVANIA LAW PERMITS SHIPPENSBURG TO REFUSE TO
HONOR DECISIONS BY THE INDIVIDUAL YOU APPOINT AS YOUR
AGENT IN AN ADVANCE DIRECTIVE OR BY A "HEALTH CARE
REPRESENTATIVE" WHO SEEKS TO MAKE SUCH DECISIONS FOR
YOU UNDER PENNSYLVANIA LAW IF SHIPPENSBURG HAS A GOOD
FAITH BELIEF THAT THE INDIVIDUAL IS NOT REALLY AUTHORIZED
TO MAKE DECISIONS FOR YOU UNDER THE LAW OR THAT THE
DECISIONS BEING MADE ARE NOT CONSISTENT WITH THE RULES
FOR SUCH INDIVIDUALS TO MAKE DECISIONS ON YOUR BEHALF
ESTABLISHED BY PENNSYLVANIA LAW.
A health care advance
RECENT CHANGES IN PENNSYLVANIA LAW (discussed further below
in Subsection C) PROVIDE SOME ADDITIONAL REASONS TO
CONSIDER HAVING AN ADVANCE DIRECTIVE.
C. HEALTH CARE REPRESENTATIVE. PENNSYLVANIA LAW PERMITS
AN INDIVIDUAL QUALIFYING AS A "HEALTH CARE REPRESENTATIVE"
UNDER 20 PA. C.S. § 8461 TO MAKE HEALTH CARE DECISIONS FOR
INCAPACITATED PERSONS, WHO HAVE AN END-STAGE MEDICAL
CONDITION OR ARE PERMANENTLY UNCONSCIOUS, WITHOUT THAT
WHILE SHIPPENSBURG WILL REQUIRE A "HEALTH CARE
REPRESENATIVES" TO CERTIFY THAT THEY HAVE KNOWLEDGE
OF THE INCAPACITATED PERSON'S PREFERENCES, VALUES,
AND MORAL AND RELIGIOUS BELIEFS, THE LAW PERMITS THEM
TO MAKE SOME DECISIONS BASED ON THEIR OWN EVALUATION
OF THE INFORMATION ABOUT THE INCAPACITATED PERSON'S
CONDITION WHERE INSTRUCTIONS FROM THE INCAPACITATED
PERSON IS LACKING.
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authorized to follow the directiyQS therein.
AN ADVANCE DIRECTIVE CAN PROVIDE SPECIFIC INSTRUCTIONS
FOR AND ALSO LIMIT WHO CAN QUALIFY AS A "HEALTH CARE
REPRESENTATIVE" OR CAN PROVIDE THEM WITH ADDITIONAL
AUTHORITY TO ACT ON ONE'S BEHALF. IF A RESIDENT WISHES
TO PLACE SUCH LIMITS ON THE ABILITY OF OTHERS TO ACT AS
THEIR "HEALTH CARE REPRESENTATIVE" OR TO PROVIDE
ADDITIONAL INSTRUCTIONS FOR THEM, THE RESIDENT SHOULD
CONSIDER HAVING A WRITTEN ADVANCE DIRECTIVE THAT
STATES THEIR WISHES; AND, THE RESIDENT MAY WISH TO
CONSULT WITH THEIR FAMILY AND LEGAL COUNSEL ON THIS
QUESTION.
D. A S! TANCE AV ILABLE.
1. Questions about SHIPPENSBURG's policies regarding health care
decision-making and/or advance directives may be presented to
SHIPPENSBURG's Administrator.
2.
Resident's family. physician and attorney.
3. SAMPLE HEALTH CARE ADVANCE DIRECTIVE FORMS
4. Resident should consult with their family, physician, and
attorney before using any Advance Directive Forms.
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IV. CAPACITY OF RESIDENT AND GUARDIANSHIP
If the Resident Is or becomes unable to understand or communicate, and
is determined to be incapacitated by the Resident's physician, In the absence of
the Resident's prior designation of an authorized Legal Representative, or upon
the unwillingness or inability of the Legal Representative to act,
SHIPPENSBURG shall have the right to commence a legal proceeding to
adjudicate the Resident Incapacitated. As a result of such a legal proceeding
SHIPPENSBURG shall have a court appoint a legal guardian for the Resident.
SHIPPENSBURG also shall have the right to commence a legal proceeding to
have a court replace an authorized Legal Representative with a new one or with
a legal guardian when SHIPPENSBURG has a good faith belief that the Legal
Representative is not acting in the best- Interests of the Resident. The cost of
the legal proceedings, Including attorney's fees and costs, if not covered by the
Commonwealth, shall be paid promptly by the Resident or the Resident's
estate.
V, FINANCIAL ASPECTS OF THE AGREEMENT
A. Lena! Representative
1. SIMUS. While not legally required, if the Resident is unable to make
decisions for himself or herself, a Legal Representative should be available to
make certain .decisions on behalf of the Resident. For the purposes of this
Agreement, the Resident's Legal Representative is the person selected by the
Resident and defined under state and federal taw as the Resident's responsible
person, or as the person recognized under state law as having the authority to
make health care and/or financial decisions for the Resident. The Legal
Representative may or may not be court appointed, may be an attorney-in-fact
acting under a durable power of attorney for health care, guardian, conservator,
next-of-kin, or other person allowed to act for the Resident under state law. If
Legal Representative status has been conferred by a court of law or through
appointment by the- Resident, verification of such status must be provided to
SHIPPENSBURG at the time of Admission. Such verification includes providing
SHIPPENSBURG with a certified copy of any court order, or a validly executed
original Power of Attorney or other legal document.
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2. EUIREMENTS. For purposes of this Agreement, LEGAL
REPRESENTATIVES ARE REQUIRED TO SIGN THIS AGREEMENT FOR
ADMISSION, AND AGREE TO DISTRIBUTE TO SHIPPENSBURG, FROM
THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR
ITEMS/SERVICES PROVIDED TO THE RESIDENT. Legal Representative is
contractually bound by the terms of this Agreement and may become personally
liable for failure to perform their fiduciary duties under the Agreement. Legal
Representatives are also required to produce financial documentation as proof
of the Resident's ability to pay for charges when due. Wherever this
Agreement refers to the Resident's financial obligations under this
Agreement, the term "Resident" shall be construed to Include the
obligations of any Legal Representative to act on behalf of Resident.
B. Financial Arrangements
1. INCOME AND ASSETS/ CHANGES TO INCOME AND ASSETS; It
is essential that the Resident advise SHIPPENSBURG of the Resident's
income and assets, and to communicate changes In the Resident's income or
assets to SHIPPENSBURG as quickly as possible. The Resident hereby
agrees to notify SHIPPENSBURG ninety (90) days prior to the time when the
Resident has reason to believe that his income and assets will no longer be
sufficient to fulfill his financial obligations under the terms of this Agreement.
2. MEDICAL ASSISTANCE. Generally, when private funds are
depleted, residents apply for Medical Assistance benefits under Title XIX of the
Social Security Act and Article IV of the Pennsylvania Public Welfare Code.
The Medical Assistance application process can be complicated, and the
processing time can be lengthy. SHIPPENSBURG is experienced in the
Medical Assistance Application process, and can be of great assistance to the
Resident in this process. To be of assistance, SHIPPENSBURG must have
accurate record of the history and depletion of the Resident's income and
significant assets.
3. DISCLOSURE FORM, On this basis, please set forth the
Resident's income and assets below:
11
Income
Social Security:
Account Number: ? `r, ? / v 1??r..11
?
Monthly Income.
Payee:
Pension:
Account l
anc al Institution:
+ ? v v
Payee: -?"
Trusts:
Account Number(s):
Monthly Income:
N () N?
12
Pinanclal Institution(s):
Beneficlary(s):
Type of Trust(s):
other income (please describe :
Payee(s):
Assets
Residence/Real Estate:
Address:
13
Vehicles
Year, Make and Model:
State of Registration:
Bank Accounts:
Account Number(s):
Financial Institution(s):
insurance Policies:
Account Number(s):
Financial lnstitutlon(s):
dw I - N 4 - ?- ?
Beneficiary;
14
Other Slenificant Assets (please describe):
?L
Liabilities
Describe nature-and a to t:
Has a Will been completed?:
If yes, Executor's Name:
Executor's Address:
yes No
15
6. Regeipt of income/ Representative Pans. Many Residents find
security In appointing SHIPPENSBURG as the "Payee" or "Representative
Payee" of the Resident's Income, Including social security Income. By
appointing SHIPPENSBURG as the "payee" or the "Representative Payee", the
Resident directs that his or her income be directed to SHIPPENSBURG for the
purposes of paying for the Resident's care and services. Any excess funds
accumulated are refunded to the Resident or the Resident's Legal
Representative on or before the tenth (10) day of the month following the
receipt of the benefits. This Is not required. However, if the Resldent is
Administrator's designee.
arrangements.
making
6. PRIVATE RESIDENT: A Resident is considered private (or private pay)
when no state or federal program is paying for the Resident's room and board.
A private-pay Resident may have private insurance or another third party, which
pays all or some of his or her charges.
a.) Daily Rate. The Resident agrees to pay SHIPPENSBURG's private
pay per diem rate as described In the Rate Schedule. The Resident agrees to
pay SHIPPENSBURG in advance for one month's private daily rate. For each
additional month's stay, the Resident agrees to pay SHIPPENSBURG in
advance on or before the tenth (101h) day of the month. Any unuged advance
payment shall be refunded to the Resident ninety (90) days after the Resident's
discharge if the Resident becomes covered by Medicaid or Medicare, or leaves
SHIPPENSBURG before the end of the month.
b.) Rate Adjustments. SHIPPENSBURG may occasionally need to
increase the daily rate or optional service charges. If this happens, the
Resident shall receive thirty (30) days advance written notice of the rate
adjustment. SHIPPENSBURG shall provide notice to the Resident, and if
known, the Resident's Legal Representative, When a notice of a rate
adjustment Is received, the Resident can choose to end this Agreement by
providing written notice to the Administrator. If the Resident falls to leave
SHIPPENSBURG prior to the effective date of the rate adjustment, the Resident
shall be considered to have consented to the increase.
16
c.) Private insurance. Even when there is private insurance coverage,
the Resident remains nrimarfiv responsible for_pavinc all of SHIPPENSBURG's
charges. Where the Resident's private insurer is a managed care plan with
which SHIPPENSBURG has a contract, SHIPPENSBURG agrees to invoice the
managed care plan directly for the Resident's care and services. However, all
charges that are not covered by the managed care plan are the responsibility of
the Resident. These non-covered charges include but are not limited to any
coinsurance and/or deductible amounts which the managed care plan requires
the Resident to pay, to the extent allowed under federal and state laws. Where
the Resident's private insurer Is not a managed care plan with which
SHIPPENSBURG has a contract, SHIPPENSBURG will Invoice the Resident,
who is primarily responsible for payment of the Invoice.
7. MEDICAL ASSISTANCE (NEDI,CAiD) RESIDENTS: A Medicaid Resident is
one who receives benefits from the state Medicaid program for all or a majority
of his or her room and board charges. The services currently covered by
Medicaid are set forth in the attached Rate Schedule, which is subject to
change. SHIPPENSBURG makes no guarantee of any kind that the
Resident's care will be covered by Medicare, Medicaid, or any third party
insurance or other reimbursement source. SHIPPENSBURG, its agents
and associates are hereby released from any liability for the Resident's
potential claim for any failure to obtain such coverage.
With respect to applying for and receiving Medical Assistance through the
Medicaid Program, SHIPPENSBURG will assist the Resident in the application
process. The Resident agrees to the following:
a.) Qualifying for Medicaid Assistance. If the Resident elects coverage
under the Medicaid Program, the Resident agrees to act as quickly as possible
to establish and maintain eligibility for Medicaid. These actions must Include,
but are not limited to, taking any and .1II steps necessary to ensure that the
Resident's assets and income are within the required limits and that these
assets and income remain within allowable limits for Medicaid.
17
b.) Providing Application Information. The Resident agrees to provide
all financial and other Information required for completion of the Medicaid
application accurately and truthfully, as requested by applicable state/county
agencies. Additionally, the Resident agrees to provide this information in the
manner requested by the applicable agencies, and in compliance with any
deadlines set by the applicable agencies. Furthermore, the Resident agrees to
attend any and all interviews necessary for completion of the Medical
Assistance eligibility process, as requested by the applicable state/county
agencies. Failure to provide I financial and other information required for
completion and support of the Medicaid application accurately and truthfully, as
requested by applicable state/county agencies, may result in personal liability
for SHIPPENSBURG's charges.
c.) Keeping SHIPPENSBURG Informed. The Resident agrees to keep
SHIPPENSBURG Informed of the status and progress of the Medicaid
application. The Resident agrees to provide SHIPPENSBURG with copies of
any financial and other information related to the Medicaid application, Including
a copy of the completed application.
d.) Transferring Assets, If the Resident transfers assets, this transfer may
disqualify the Resident for Medicaid and/or cause a discontinuance of the
Resident's Medicaid benefits. The Resident acknowledges that this may result
in discharge of the Resident due to non-payment, and personal liability for
SHIPPENSBURG's charges.
e.) Legal Representative Controlling Resident's Funds. If the
Resident's Legal Representative has control of or access to the Resident's
Income and/or assets, the Legal Representative agrees to use these funds
solely for the Resident's welfare. This includes, but is not limited to, making
prompt payment for care and services provided to the Resident as specified
and required by the terms of this Agreement. Failure to use these funds solely
for the Resident's welfare may result in personal liability for SHIPPENSBURG's
charges.
f.) Providing Financial Information. The Resident certifies that any
financial information regarding the Resident's Income and assets required by
SHIPPENSBURG and provided by the Resident is complete and accurate.
g.) Daily Rate Payment. The Resident agrees to pay the costs or
SHiPPENSBURG's per diem rate as described in the Rate Schedule.
18
h.) Termination or Denial of Coverage. The Resident may remain in
SHIPPENSBURG for as long as he or she is certified eligible for Medicaid
coverage, or for as long as any share of cost owed by the Resident is paid as
due. A Resident who remains In SHIPPENSBURG after Medicaid coverage
has been denied and a final determination has been made must pay.
SHIPPENSBURG charges as a private resident. In this event, the Resident will
pay based on, the private rates, charges, and terms in effect at the time of
servlce. Where the Resident fails to pay the private rates and charges, the
Resident agrees to seek immediate placement at an alternate facility at the
earliest possible time. Residents who have not already been determined
1.) Resident's Share of Cost. The Medicaid program reviews the available
monthly income of all persons requesting Medicaid. Based on this review, the
Medicaid program requires most Medicaid residents to pay for a reasonable
share of the cost of their care. The amount of the Resident's share of the cost
of their care can change based upon the services the Resident chooses, and
the Medicaid program can adjust the amount of the Resident's share of the cost
of their care based upon changes in the Resident's income. Payment of that
share is the responsibility of the Resident.
J.) Appeal of Finding of Ineligibility. Where the Resident applies for
Medical Assistance benefits, the applicable state/county agency may deny or
limit benefits. While Resident retains all legal responsibility for obtaining his or
her benefits, Resident authorizes SHIPPENSBURG to assist Resident in
making any claims and to take all other actions necessary to secure the
Resident's benefits, including, but not limited to, assisting the Resident in
appealing any statelcounty agency determination and requesting Interim
Assistance benefits. The Resident agrees to provide SHIPPENSBURG with all
information related to obtaining benefits upon receipt, including, but not limited
to, notices of denial. This paragraph shall not create any responsibility on
behalf of SHIPPENSBURG to obtain benefits or any portion of benefits, nor any
liability for failure to obtain same. To facilitate this authorization, but not in lieu
thereof, the Resident agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION - MEDICAID statement attached to this Agreement.
19
Funds Allowance (the current amount is Iiste on ine aiiacnea Kew ouneaute.
8. MEDICARE RESIDENTS: A Medicare Resident is one who receives
benefits from the federal Medicare program for his or her SHIPPENSBURG
care. The services currently covered by Medicaid are set forth in the attached
Rate Schedule, which Is subject to change. Some additional items and services
may be also covered by Medicare. SHIPPENSBURG makes no guarantee of
any kind that the Resident's care will be covered by Medicare, Medicaid,
or any third party Insurance or other reimbursement, source.
SHIPPENSBURG, its agents and associates are hereby released from any
liability for the Resident's potential claim for any failure to obtain such coverage.
a.) Continuing Payment of SHIPPENSBURG3 Charges Pending
Eligibility. Where the Resident is not currently covered by Medicare,
the Resident agrees that white coverage is being pursued the Resident
shall pay the private pay rate as a private pay resident as described
within this Agreement. If the Resident Is unable to pay the private pay
rate, the Resident agrees to pay SHIPPENSBURG an amount that is at
least equal to the Resident's monthly income from all of the Resident's
income sources. This amount, minus any amount not covered by
Medicare, shall be refunded to the Resident within thirty (30) days of
payment by Medicare should the Resident be found eligible by Medicare.
Once the Resident is determined to be eligible for Medicare, the amount
of the Resident's share of cost not covered by Medicare shall be paid to
SHIPPENSBURG on or before the tenth (UP) day of each month.
Furthermore, the Resident shall immediately pay to SHIPPENSBURG any
amount the Resident is in arrears. If payment of any outstanding amount
cannot be. made immediately, the Resident shall immediately discuss same
with SHIPPENSBURG's Administrator or the Administrator's designee, and
shall make arrangements to bring his or her account Into balance within the
shortest possible time.
b.) Daily Rate Payment. The Resident agrees to pay the costs of
SHIPPENSBURG's per diem rate as described in the Rate Schedule for those
supplies and services not paid for by the Medicare program.
c.) Coinsurance and Deductibles. The Resident is responsible for
payment of any Medicare coinsurance and/or deductibles that are not paid to
SHIPPENSBURG by the Medicaid program or private insurance.
d.) Limited Coverage. The Resident understands that Medicare coverage
Is established by federal guidelines and not by SHIPPENSBURG. Medicare
coverage is limited In that only a specified level of care is covered for a
specified number of days (benefit period). If the Resident no longer meets
Medicare coverage criteria, coverage can be ended before the use of all allotted
days in the current benefit period.
20
e.) Expiration of Benefits. Prior to admission, the Resident must be able
to demonstrate the ability to pay SHIPPENSBURG (either privately or through
Medicaid) for services rendered after Medicare benefits expire. When Medicare
coverage expires, the Resident may remain in SHIPPENSBURG If private pay
or other payment arrangements have been made. If the Resident wishes to be
discharged from SHIPPENSBURG upon expiration of Medicare benefits, he or
she must so advise SHIPPENSBURG at the time of the Resident's admission,
If the Resident intends to become private pay when Medicare benefits expire,
the Resident agrees to pay in advance for one month's private daily rate when
the Resident changes to private pay status. No advance payment is required
from Medicare Residents who are eligible for Medicaid coverage.
f.) Appeals of Denials of Coverage. Where the Resident applies for
Medicare benefits, the applicable Intermediary, carrier or government agency
may deny the Resident these benefits or some portion of these benefits. Where
a denial occurs, the Resident retains all responsibility for obtaining his or her
benefits. However, the Resident authorizes SHIPPENSBURG to assist the
Resident In making all claims and to taking all other actions necessary to
secure his or her benefits, including, but not limited to, appealing any initial or
subsequent adverse determinations, including requests for Reconsideration.
The Resident agrees to provide SHIPPENSBURG with all information related to
obtaining benefits upon receipt, including, but not limited to, notices of denial.
This paragraph does not apply to benefits for which SHIPPENSBURG has
determined the Resident is not eligible, and does not affect the Resident's right
to have a Demand Bill filed. This paragraph shall not create any responsibility
on behalf of SHIPPENSBURG to obtain any portion of benefits, nor any liability
for failure to obtain same. To facilitate this authorization, but not in lieu thereof,
the Resident hereby agrees to properly execute the AUTHORIZATION FOR
REPRESENTATION - MEDICARE statement attached to this Agreement.
9. MANAGED CARE ORGANIZATIONS: Where the Resident enrolls in or
switches the Resident's enrollment to any managed care organization
(hereafter "MCO"), including MCOs that provide Medicare or Medicaid benefits,
the Resident agrees as follows:
a.) The Resident shall advise SHIPPENSBURG prior to enrolling in or
switching the Resident's enrollment to any MCO.
b.) The Resident acknowledges that SHIPPENSBURG Is not responsible
for and has made no representations regarding the actions or decisions of any
MCO with which SHIPPENSBURG is a participating provider, including
decisions relating to a denial of coverage.
21
c.) SHIPPENSBURG will accept payment from the MCO as payment In
full only for those services and supplies covered by the MCO. The Resident is
responsible for any co-payments or other costs assigned to the Resident under
the managed care plan, or not covered by the MCO under the terms of the
managed care plan. If the Resident utilizes services which the MCO refuses to
pre-authorize, the Resident shall pay SHIPPENSBURG for those services.
Further, the Resident shall pay SHIPPENSBURG for services for which the
MCO has denied payment because the Resident failed to supply information to
the MCO, or for services which are denied subsequently by the MCO.
d.) SHIPPENSBURG reserves the right to withdraw as a participating
provider in any MCO at any time and for any reason. In the event that
SHIPPENSBURG withdraws as a participating provider, the Resident may
convert his or her coverage to a health plan in which SHIPPENSBURG is a
participating provider. Effective the date of SHIPPENSBURG's withdrawal from
the Resident's MCO, the Resident is obligated to pay for services and supplies
provided to the Resident as a private pay resident. If possible,
SHIPPENSBURG will provide the Resident with advance written notice of its
withdrawal from the Resident's MCO thirty (30) days before SHIPPENSBURG's
withdrawal.
10. ASSIGNMENT OF THIRD PARTY PAYMENTS: The Resident irrevocably
authorizes SHIPPENSBURG to make claims and to take all other actions to
secure recelpt of third party payments to reimburse SHIPPENSBURG for its
charges. To the fullest extent permitted by law, and as security for payment of
SHIPPENSBURG's charges, the Resident hereby assigns to SHIPPENSBURG
all of the Resident's rights to any third party payments now or subsequently
payable to the extent of all charges due under this Agreement. Resident shall
promptly endorse and deliver to SHIPPENSBURG any payments received from
third parties to the extent necessary to satisfy the charges under this
Agreement. To facilitate this assignment, but not in lieu thereof, the Resident
hereby agrees to properly execute the ASSIGNMENT OF THIRD PARTY
PAYMENTS statement attached to this Agreement.
11. FINANCIAL POWER OF ATTORNEY: The Resident agrees that upon
admission the Resident, if able, will supply SHIPPENSBURG with a fully
executed and legally valid original Financial Power of Attorney appointing an
Individual chosen at the Resident's sole discretion to be his financial attorney-
in-fact should the Resident become medically incompetent. If not able, the
Resident agrees to work with SHIPPENSBURG to pursue guardianship. This
Power of Attorney need only become effective if the Resident becomes
medically incompetent. If, In the judgment of the Resident, no such Individual is
available, the Resident agrees to appoint such an individual when one becomes
available. Judgment of the Resident's incompetence shall not require a court
22
adjudication, but shall require the written order of Resident's physician plus
confirmation by a second examining physician. The Resident's financial
attorney-in-fact shall be granted the authority to make financial decisions for the
Resident, Including the unlimited power to pay SHIPPENSBURG`s charges and
invoices from the Resident's Income, and from the proceeds of the attorney-in-
fact's sale of the Resident's assets.
The selection of this attorney-in-fact serves at the complete discretion of
the Resident. However, should the Resident revoke the power of his or her
appointed attorney-in-fact, or should the Power of Attorney become inoperable
for any reason, the Resident hereby agrees to immediately appoint a successor
attorney-In fact for the financial purposes set forth herein, If such an individual Is
available. Upon receiving a duly executed copy or facsimile of this Agreement
noting the Resident's appointed financial attorney-in-fact, SHIPPENSBURG
may act hereunder. Revocation of the attorney-in-fact shall be ineffective as to
SHIPPENSBURG unless and until written or actual notice or knowledge of such
revocation Is received. The attorney-in-fact's power shall continue in full force
and effect and may be relied upon by SHIPPENSBURG despite purported
revocation until written notice of revocation is received by SHIPPENSBURG.
Residents should first consult with his or her family and attorney
before executing any Financial Power of Attorney form.
VI. PAYMENT INF=ORMATION
A. DUE DATES AND TFFE VbL1UAJIVN ur mylcLT PAiIYECiVI:
SHIPPENSBURG's charges for services provided shall be billed on a monthly
basis to the Resident. These charges are due and payable by the tenth (10`h)
day of each month. If payment is not received by the fifteenth (15t) day of each
month, the account balance is considered past due, and SHIPPENSBURG may
add late charges to the Resident's account. These late charges shall be
assessed on the monthly balance at the lesser of the monthly rate of 1.5% (one
and one-half percent) or the maximum amount permitted by law. This late
charge does not alter any obligations of SHIPPENSBURG or Resident under
this Agreement.
The Resident recognizes that SHIPPENSBURG does not offer credit or
accept installment payments. SHIPPENSBURG's acceptance of a partial
payment does not limit SHIPPENSBURG's rights under this Agreement to full
payment for the care and services provided.
23
B. BILLING ADDRESS: All of SHIPPENSBURG's invoices are to be mailed to
the following address for prompt payment (either Resident's address or Legal
Representative's address, when applicable):
C. F IA LURE TO PAY AND DEFAULT OF AGREEMENT: SHIPPENSBURG's
due date for its payments fails on the fifteenth (15th) day of each month.
Resident's failure to remit a required payment within twenty-one (21) days of
the due date constitutes DEFAULT of this Agreement, and SHIPPENSBURG
may require the Resident to vacate SHIPPENSBURG after appropriate
advance notice. If the Resident is required to vacate SHIPPENSBURG for
failure to pay, SHIPPENSBURG shall provide advance notice as set forth In
Termination section of this Agreement. SHIPPENSBURG retains the right
under federal law and social security regulations to request the regional social
security field office to change the name of Representative in the event of
DEFAULT of this Agreement or the Representative Payee is consistently late
with payments.
24
D. VENUE. It Is hereby agreed that this Admission Agreement is a
transaction entered Into and accepted by the parties herein at the offices
of SHIPPENSBURG, in Cumberland County, Pennsylvania. Resident
agrees that, in event of DEFAULT, SHIPPENSBURG may bring a civil
action in the Court of Common Pleas of Cumberland County,
Pennsylvania, to collect any amounts owed to SHIPPENSBURG under the
terms of this Agreement.
E. ATTORNEY'S _FEES ANQ CQSTS OF COLLECTION: In the event that
SHIPPENSBURG institutes and is a prevailing party in litigation In court against
any party to this Agreement arising from DEFAULT or other non-payment under
Agreement, SHIPPENSBURG shall be entitled to receive from the losing party
reasonable attorneys' fees and costs of collection.
F. FEE FOR RETURNED CHECKS: A service fee of $25.00 (twenty-five
dollars) or the actual fee charged by the bank, whichever is greater, will be
charged for any returned check.
G. OB IGATI,QNS OF RESIQENI'S ESTATE AND ASSIGNMENT OF
PRQPERTY: This Agreement shall operate as an assignment, transfer and
conveyance to SHIPPENSBURG of as much of the Resident's property as is
equal in value to the amount of any unpaid obligations under this Agreement,
and this assignment shall be an obligation of the Resident's estate and may be
enforced against the Resident's estate. The Resident's estate shall be liable to
and shall pay SHIPPENSBURG an amount equivalent to any unpaid obligations
of the Resident under this Agreement. This assignment shall apply whether or
not the Resident is residing in SHIPPENSBURG at the time of the Resident's
death.
25
Vil. BED HOLDS
A. NOTICE. The Resident may need to be absent from SHIPPENSBURG
temporarily for hospitalization or therapeutic leave. The Resident may request
that SHIPPENSBURG hold open the Resident's bed during this time. This is
known as a "bed hold." The Resident, and if known, the Resident's Legal
Representative shall be given notice of the bed hold option at the time of
hospitalization or therapeutic leave. A schedule of charges for bed holds is
located on the Rate Schedule attached to this Agreement.
B. MEDICAID RESIDENTS: If the Resident's care is paid under the
Medicaid Program, Medicaid currently pays for up to 15 consecutive bed hold
days for each hospitalization and for up to 30 bed hold days each year for
therapeutic leave. If the Medicaid Resident's _ hospitalization or therapeutic
leave exceeds the bed-hold period paid under the Medicaid program, the
Resident may request an additional bed hold period from SHIPPENSBURG by
agreeing to pay the daily additional bed hold amount listed in the attach6 Rate
Schedule. Otherwise, the Resident shall be readmitted upon the first availability
of a bed in a non-private room as long as the Resident requires the services
provided by SHIPPENSBURG and is eligible for Medicaid benefits.
C. PRIVATE AND MEDICARE RESIDENTS: Any Private or Medicare
Resident may request a bed hold from SHIPPENSBURG. The Resident's
private Insurance may or may not pay for bed holds. The Medicare program
does not pay for bed holds. However, if the Medicare Resident is also eligible
for Medicaid, and If proven to the satisfaction of SHIPPENSBURG, Medicaid
pays for 15 bed hold days, Otherwise, a Private or Medicare Resident
requesting a bed hold must pay SHIPPENSBURG's bed hold rate set forth in
the Rate Schedule for the bed being held during the bed hold period.
26
VIII. PERSONAL FUNDS
A. RgSIO NT FUND AUTHORIZATION. The Resident has a right to
manage his or her own personal funds. If the Resident wants assistance with
management of personal funds, and requests so in writing through a Resident
Fund Authorization form, SHIPPENSBURG will hold, safeguard, manage, and
account for these funds. A Resident Fund Authorization form can be obtained
from SHIPPENSBURG's Administrator or designee.
B. PROCEDURES. Resident personal funds deposited with
SHIPPENSBURG shall be handled as follows:
1. SHIPPENSBURG shall deposit funds In excess of fifty dollars ($50.00) in
an Interest-bearing account Insured by the Federal Deposit Insurance
Corporation (FDIC) that is separate from any SHIPPENSBURG operating
accounts. All interest earned on the Resident's funds shall be credited to his
or her account. SHIPPENSBURG shall have the option of depositing funds
of less than fifty dollars in a non-interest bearing account, an interest bearing
account, or a petty cash fund. SHIPPENSBURG shall Inform the Resident
as to how his or her funds are being held. SHIPPENSBURG's policy is to
maintain all resident funds in a separate account, except for a nominal
amount maintained In a petty cash fund for the Resident's convenience.
2, SHIPPENSBURG shall have a system that ensures a complete and
separate accounting, based on generally accepted accounting principles, of
the personal funds deposited with SHIPPENSBURG by each Resident or on
his or her behalf. This system shall also ensure that the Resident's funds
are not commingled with SHIPPENSBURG's funds or with any other funds
besides those of other residents. In addition to the required quarterly
accounting, SHIPPENSBURG shall provide individual financial records at
the written request of the Resident.
3. The personal fund balance a resident receiving Medicaid benefits must
remain within a certain dollar range for the Resident to continue to receive
benefits. SHIPPENSBURG shall notify a Medicaid resident if his or her
account balance is within two hundred dollars ($200.00) of the federal
Supplemental Security income (hereafter "SSI") limit. SHIPPENSBURG
shall also notify the Resident if the account balance, in addition to the
Resident's known non-exempt assets, reaches the SSI resource limit.
Furthermore, SHIPPENSBURG shall notify the Resident if the account
balance, in addition to the Resident's known non-exempt assets, reaches
the resource limits for Medicaid eligibility. A balance in excess of this limit
may cause the Resident to lose eligibility for Medicaid or SSI.
4. If a Resident who has personal funds deposited with SHIPPENSBURG
expires, SHIPPENSBURG shall refund the Resident's personal account
27
balance within thirty (30) days, and provide a full accounting of these funds
to the Individual, probate jurisdiction administering the Resident's estate, or
other entity as required by state law or regulation. However, any
outstanding balance owed to SHIPPENSBURG for the Resident's care and
services shall first be deducted from the Resident's personal account as
permitted by law.
5. SHIPPENSBURG shall ensure the security of all resident personal funds
deposited with SHIPPENSBURG, and shall not take money from a Medicare
and/or Medicaid resident's personal funds for any item or service for which
payment Is covered by Medicare and/or Medicaid.
IX. FUNERAL ARRANGEMENTS
SHIPPENSBURG assumes no financial responsibility for the funeral or
funeral related expenses associated with a Resident's passing.
SHIPPENSBURG recognizes the emotional hardship that such an event may
have on the Resident's family and loved-ones. To assist during this difficult
time, SHIPPENSBURG will convey the Resident's wishes, as expressed below,
concerning arrangements to a designated funeral director.
Funeral Arrangements:
Funeral Director:
Burial Fund:
Cemetery Lot Location:
Person Assuming
Responsibility for Burial:
28
X. TE MINATIO OF AGREEMENT
A. MIGHT TO T'ERMINAT : An explanation of the Resident's rights
concerning termination, transfer, and discharge Is contained In the Statement of
Resident Rights, which Is attached to but separate from this Agreement.
B. RESIDENT INITIATED: Notice of resident initiated termination is
required for proper discharge planning. Other than in the case of a medical
emergency or death, the Resident will provide SHIPPENSBURG with written
notice two (2) business days before the Resident's termination of this
Agreement.
C. RgF JU : If a Resident has personal funds deposited with
SHIPPENSBURG upon termination of this Agreement, SHIPPENSBURG shall
refund the Resident's personal account balance within thirty (30) days, and
provide the Resident or the Resident's estate with a full accounting of these
funds. However, any outstanding balance owed to SHIPPENSBURG for the
Resident's care and services shall first be deducted from the Resident's
personal account as permitted by law.
XI. RESIDENT GRIEVANCEI COMPLAINT RESOLUTION
A. RESIDf=NT GRIEVANCES:
1.) All Residents, family members, and Resident representatives are
urged to bring any grievances concerning SHIPPENSBURG to the
attention of the SHIPPENSBURG Administrator or the Administrator's
designee.
2.) In addition to bringing grievances to the attention of
SHIPPENSBURG Administrator or designee, residents may also contact
the outside representative of his or her choice. Outside representatives
include the Governor's Action Line at (800) 932-0784, the Department of
Health Hot Line at (800) 254-8154, the Long Term Care Ombudsman
located within the Local Area Agency on Aging, and the Legal Services
Program. The telephone number of the local Long Term Care
Ombudsman and the Legal Services Program is located within the
Resident's Bill of Rights accompanying this Agreement.
29
S.
(a) UNLESS OTHERWISE MUTUALLY AGREED UPON IN WRITING,
SHOULD GRIEVANCE PROCEDURES FAIL, THE RESIDENT AND
SHIPPENSBURG AGREE THAT ALL DISPUTES ARISING UNDER
THIS AGREEMENT, WITH THE EXCEPTION OF DISPUTES
CONCERNING DEFAULT (AS DEFINED ABOVE IN SECTION VI-C)
OR OTHER NON-PAYMENT FOR SERVICES RENDERED, SHALL BE
RESOLVED BY BINDING ARBITRATION BEFORE A NEUTRAL
ARBITRATOR, ASSIGNED TO THE MATTER IN ACCORDANCE WITH
THE AMERICAN HEALTH LAWYERS ASSOCIATION (AHLA)
ALTERNATIVE DISPUTE RESOLUTION SERVICE RULES OF
PROCEDURE FOR ARBITRATION,
(b) SUCH ARBITRATION SHALL TAKE PLACE AT SHIPPENSBURG
AT A MUTUALLY AGREED UPON TIME, ANY TIME A DISPUTE
ARISES, ANY PARTY MAY REQUEST THE APPOINTMENT OF AN
ARBITRATOR TO RESOLVE THE DISPUTE.
(c) THE REQUESTING PARTY SHALL NOTIFY THE OTHER PARTY
IN WRITING A MINIMUM OF SEVEN (7) BUSINESS DAYS PRIOR TO
REQUESTING THE APPOINTMENT OF THE ARBITRATOR.
('d) THE COSTS OF THE ARBITRATOR AND ALL COSTS
ASSOCIATED WITH THE ARBITRATION, INCLUDING ATTORNEY'S
FEES, COSTS, AND EXPENSES SHALL BE BORNE BY THE LOSING
PARTY.
(e) THE DECISION OF THE ARBITRATOR WILL BE FINAL AND
BINDING, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT
HAVING COMPETENT JURISDICTION.
30
XII. MISCELLANEOUS PROVISIONS
A. CLINICAU FINANCIAL INFORMATION: With and at
SHIPPENSBURG's discretion, the Resident hereby authorizes
SHIPPENSBURG to obtain all of the necessary clinical and/or financial
documentation from the Resident prior or transferring hospital or nursing facility.
B. SOLE AGREEMENT: This Agreement, along with any documents
attached or included by reference, is the only agreement between
SHIPPENSBURG and parties. Changes to this Agreement are valid only if
made in writing and signed by all parties. If changes in state or federal law
make any part of this Agreement invalid, the remaining terms remain valid and
enforceable,
C. bION ASSIGNABLE AGREEMENT: The Resident agrees that the right
of the Resident to reside at SHIPPENSBURG is personal and not assignable.
The Resident may not transfer his or her rights under this Agreement to any
other person.
D. GOVERNINGLA, ll: This Agreement shall be governed by and construed
by the laws of the Commonwealth of Pennsylvania, and shall be binding upon
and shall be for the benefit of each of the undersigned parties and their
respective heirs, personal representatives, successors and assigns.
E. S,EVERABILITY: The Resident and SHIPPENSBURG agree that each
separate obligation contained in this Agreement shall be deemed a separate
and independent agreement. If any term, condition, clause or provision of this
Agreement shall be determined or declared to be void or invalid in law or
otherwise, then only that term, condition, clause or provision shall be stricken
from this Agreement, and in all other respects this Agreement shall be valid and
continue in full force, effect and operation.
F. CAPTIONS: The captions used in this Agreement are inserted only for
the purpose of reference. Such captions shall not be deemed to govern, limit,
modify or in any manner affect the scope, meaning or intent of the provisions of
this Agreement. The captions shall be given no legal effect.
G. WAIVER: A waiver by either party at any time of any of the terms,
conditions, or covenants of this Agreement, or of any default or breach shall not
be deemed or taken as a waiver at any time thereafter of the same or any other
term, condition or covenant herein contained, nor of the strict and prompt
performance thereof.
31
H. MODIFICATIONS: SHIPPENSBURG reserves the right to unilaterally
modify this Agreement to the extent necessary to conform the Agreement with
subsequent changes in law or regulation, SHIPPENSBURG will notify the
Resident thirty days (30) before such modification, if possible.
XlII. ACKNOWLEDGMENTS
A. TA SCygQULE: The Resident and the Resident's Legal Representative
hereby acknowledge the receipt of a copy of the Rate Schedule and sufficient
opportunity to ask questions about the Rate Schedule to answer all of their
questions about SHIPPENSBURG's charges. The Resident and the Legal
Representative hereby acknowledge that SHIPPENSBURG can and will alter
the Rate Schedule from time to time, and that Resident will be subject to those
changes. The Resident and the Resident's Legal Representative hereby agree
to be subject to those changes as provided In this Agreement.
B. STATEMENT OF RESIDENT'S RIGHTS: The Resident and the Resident's
Legal Representative - hereby acknowledge being Informed orally and of
receiving a written copy of the Resident's Rights, as set forth in this Agreement,
and as further set forth in the accompanying SHIPPENSBURG's Statement of
Resident's Rights. Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Resident's rights and have received appropriate responses.
The Resident and the Resident's Legal Representative hereby acknowledge
that the accompanying Statement of Resident's Rights is subject to change
from time to time, and shall not be construed as imposing any contractual
obligations on SHIPPENSBURG or granting any contractual rights to the
Resident.
C. COMMONWEALTH'§S,ADMISSIONS NOTICE PACKET: The Resident and
the Resident's Legal Representative hereby acknowledge being informed orally
and of receiving a written copy of the Commonwealth's Admissions Notice
Packet, accompanying this Agreement. Furthermore, the Resident and the
Resident's Legal Representative hereby acknowledge having sufficient
opportunity to ask questions about the Resident's rights and have received
appropriate responses. The Resident and the Resident's Legal Representative
hereby acknowledge that the Commonwealth's Admissions Notice Packet is
subject to change from time to time, and shall not be construed as Imposing any
contractual obligations on SHIPPENSBURG or granting any contractual rights
to the Resident.
32
D. P IVACY ACT STATEMENT-!jHEALTH CARE RECORDS: The Resident
and the Resident's Legal Representative hereby acknowledge being Informed
orally of and receiving a written copy of the Privacy Act Statement - Health
Care Records, in compliance with the Privacy Act of 1974. Furthermore, the
Resident and the Resident's Legal Representative hereby acknowledge having
sufficient opportunity to ask questions about the Privacy Act Statement and
have received appropriate responses.
E. HEALTH CARE ADVANCE DIRECTIVES: The Resident and the Resident's
Legal Representative hereby acknowledge being informed orally and in writing
about health care advance directives, including receiving a copy of the
Commonwealth's Medical and Treatment Self-Directive Statement, and of
SHIPPENSBURG's policy concerning health care advance directives and
medical treatment decisions. Furthermore, the Resident and the Resident's
Legal Representative hereby acknowledge having sufficient opportunity to ask
questions about advance directives, the Commonwealth's Medical and
Treatment Self-Directive Statement, and SHIPPENSBURG's policy thereon,
and have received appropriate responses to all of their questions.
F. STATEMENT OF PRIVACY PRACTICES: The Resident and the Resident's
Legal Representative hereby acknowledge having been informed orally of and
receiving a written copy of SHIPPENSBURG's Statement of Privacy Practices,
in compliance with the Health Insurance Portability and Accountability Act of
1996 (HIPAA). Furthermore, the Resident and the Resident's Legal
Representative hereby acknowledge having sufficient opportunity to ask
questions about the Statement and have received appropriate responses.
G. AGRE€MENT: The Resident and the Resident's Legal Representative
hereby acknowledge that they have carefully read and understand the terms of
this Agreement, and that the terms have been explained to them by a
representative of SHiPPENSBURG. Furthermore, the Resident and the
Resident's Legal Representative hereby acknowledge having sufficient
opportunity to ask questions about the Agreement and have received
appropriate responses.
33
IN WITNESS WHEREOF, INTENDING TO BE LEGALLY BOUND, the
parties hereto have executed this Agreement the ?? day of
and same shall be
considered binding upon all parties, and shall remain in full force and effect
unless and until cancelled according to the terms of this Agreement.
l 1 ?
?es dent Date
-
Legai Representative
Date
SHIPPENS RG Representative
Witness
Witness
,-., } Q
Date
Date
Date
34
Shippensburg Health Care Center
121WALNUT BOTTOM ROAD
SHIPPENSBURC, PA 17257
(717)530-8300
CHARLOTTE DAVIS 01617
MICHAEL DAVIS
)?.0. BOX 3834
IT$ACA, NY 14852
09/01/10 Balance Forward
09/16/10 Payment
'08/01/10 CABLE
09/01/10 CABLE
CHARLOTTE DAVIS
01617
08/01/10
09/01/10
Balance Due: 13,472.99
Payments/
Charges Credits
----------- ----------
15,452.99 0.00
2,000.00
1 10.00
1 10.00
Please Remit: 13,472.99
EXHIBIT "B"
Rebuttal Statement Coversheet
Defendant:
Individual Making Statement Charlotte Davis
Mailing Address: 121 Walnut Bottom Road Ship ensburg PA 17257
Contact Number: 717-532-5317
Plaintiff:
Plaintiff: Perini Services/ South Hampton Manor L.P.
Case/Document #: 2011-3628
Attorney for Plaintiff: David A. Baric. Esquire I. D. #: 44853
Mailing Address: 19 West South Street. Carlisle PA 17013
Contact Number: 717-249-6873
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C} ern
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ry
Enclosed Documents:
? See Michael Davis Attachment # 23-1 thru 23-16 and 24-1 thru 24-3a
Personnel Receiving Statement:
Print Name:
Signature:
Date:
Time:
Rebuttal Statement
Individual Making Statement: Charlotte Davis
Mailing Address: 121 Walnut Bottom Road. Shippensburg PA 17257
Contact Number: 717-532-5317
I, Charlotte Davis, 121 Walnut Bottom Road, Shippensburg PA 17257, would like to submit this rebuttal
statement against the plaintiff: Perini Services/ South Hampton Manor, LP. Case/Document # 2011-
3628 as of the 18th of April 2011. This rebuttal statement is submitted in response to the information
stated in Case/Document # 2011-3628, COUNT I-Breach of Contract Shippensburg Health v. Charlotte
Davis, Paragraph 15. Listed below are the facts against the accusation made against the defendant
(Charlotte Davis). In ordnance with this section in Case/Document # 2011-3628, paragraph 15 states:
Paragraph IS- Charlotte Davis has breached her obligation to pay for the cost of care as provided by
Shippensburg Health.
Actual Facts against paragraph 15- With the exception of paying the exact amount requested, I
have made payments (Son-Michael Davis through access of my funds) to Shippensburg Health with
nearly my entire disability pension received. I acknowledge that I owe Shippensburg Health for the
charges accrued during the months of January 2010 thru June 2010 due to me making small payments.
Based on the amount of funds that I received from my disability pension, Michael Davis in the best
interest of me made payments to Shippensburg Health on my behalf.
While being a resident of Shippensburg Health, the only funds that I receive from any source of income
was my disability pension. Neither at this present time nor during my admission to Shippensburg Health
Care Nursing Home have I ever own property, or possessed any other source of income. My sole income
is my disability pension. Based on this income, on a monthly basis I receive a total of $1969.00 prior to
any deductions. There are only four deductions that are taken out of this amount prior to receiving my
net monthly payment. These deductions may vary in amount from month to month, but they are:
• Aetna Open Access High
• Basic Life Insurance Premiums
• Medicare Premium
C NeP
Initials: Page 1 of 2
Rebuttal Statement
• Federal Income Tax Withheld
At this present time (April 2011) after deducting all four items, the amount remaining which is deposited
to my account is what Michael Davis nearly pays Shippensburg Health on my behalf. On numerous
occasions my son (Michael Davis) has faxed my monthly annuity statements and my bank statements to
Debra Black (717-530-8300) and Shippensburg Health Corporate Office (Art Cosner- 301-745-8700).
Since I've been a residence of Shippensburg Health Care Nursing Home, these four deductions has
always been deducted from my disability pension. What I have available to pay Shippensburg on a
monthly basis equals the amount of money that I receive each month. Requiring me to pay above that
amount is simply impossible based on the total amount of income I receive each month.
Based on the facts provide above, I acknowledge that I owe Shippensburg Health for the charges
accrued during the months of January 2010 thru June 2010 due to me making small payments. Unsure
how I can pay this amount off if nearly of my entire disability pension is paid to Shippensburg Health.
Request that the Plaintiff award me financial credit for the amount that is being paid out in deductions
with the amount I receive. Request that this is effective January 2010 since my admission was in January
2010. Request an adjustment of what I am required to pay each month based on what I received from
my disability pension monthly. END OF STATEMENT
Print Name: Davis Charlotte n
Signature:
Date: _ /R A-AZ 20 I
Initials: v
Page 2 of 2
Rebuttal Statement Coversheet
Defendant:
Individual Making Statement: Michael Davis
Mailing Address: PO Box 3834. Ithaca NY 14852
Contact Number. 502-794-5538
Email Address: michael.a.davisl%9@9mail.com
Plaintiff:
Plaintiff: Perini Services/ South Hampton Manor, LP.
Case/Document #: 2011-3628
Attorney for Plaintiff: David A. Baric, Esquire 1. D. #: 44853
Mailing Address: 19 West South Street. Carlisle PA 17013
Contact Number: 717-249-6873
cam-
-
=
71 o r
-
C:
Enclosed Documents:
? Rebuttal Statement dated, initialed, and signed by Michael Davis (3 pages total)
? Charlotte Davis Annuity Statements (Jan 10 - Apr 11) Attachments #23-1 thru 23-16 (16 pages
total)
? Charlotte Davis Navy Federal Credit Union Bank Statement (Jul 10 and Sep 10) (2 pages total)
? Charlotte Davis Navy Federal Credit Union Bill Payment History (2 pages total)
Personnel Receiving Statement:
Print Name:
Signature:
Date:
Time:
Rebuttal Statement
Individual Maldng Statement: Michael Davis
Contact Number: 502-794-5538
Mailing Address: PO Box 3834. Ithaca NY 14852
Email Address: michael.a.davis 1969@gmaii.com
I, Michael A. Davis, PO Box 3834 Ithaca NY 14852, would like to submit this rebuttal statement against
the plaintiff: Perini Services/ South Hampton Manor, L.P. Case/Document # 2011-3628 as of the 18th of
April 2011. This rebuttal statement is submitted in response to the information stated in
Case/Document # 2011-3628, COUNT II-Money had and received Shippensburg Health v. Michael Davis,
Paragraph 23 through 27d. Listed below are the facts per paragraph against the accusation made against
the defendant (Michael Davis). In ordnance with this section in Case/Document # 2011-3628, paragraph
23 through 27b states:
Paragraph 23- During the period of resident at the facility, Michael Davis has been receiving social
security and pension benefits of Charlotte Davis.
Actual Facts against paragraph 23- Michael Davis does not physically receive any financial funds
(social security and pension benefits) on behalf of Charlotte Davis. Charlotte Davis as of this present
time and date 1118hrs 18th April 2011 has not nor has ever received social security financial benefits
during her residence of Shippensburg Health. The only financial benefit Charlotte Davis has received
during her residence was her disability pension. On numerous occasions Shippensburg Health and their
Business Office were faxed these annuity statements dating from January 2010 through the date
requested. Attachment #23-1 thru 23-16
Paragraph 24- The proper use of those funds would have been to pay the cost of care accruing for the
care of Charlotte Davis at Shippensburg Health.
Actual Facts against paragraph 24- All monies from February 2010 through this present date that
Michael Davis handle have been used only to pay Shippensburg Health. See Attachment #24-1 thru 24-
3a
Initials: M?/) Page 1 of 3
Rebuttal Statement
Paragraph 25- At the time of receipt of those funds, Michael Davis knew that these funds should be
paid over to Shippensburg Health for the costs of Charlotte Davis' care.
Actual Facts against paragraph 25- Upon all monies being deposited to Charlotte Davis Checking
Account, Michael Davis made arrangements with Shippensburg Health and/or Navy Federal Credit Union
to make the necessary payment to Shippensburg Health. See Attachment #24-1 thru 24-3a
Paragraph 26- Michael Davis gave no consideration for the funds of Charlotte Davis he has received.
Actual Facts against paragraph 26- Michael Davis through his actions paid Shippensburg Health
from February 2010 through the present date based on the amount of money available in Charlotte
Davis account. Once Michael Davis had access to Charlotte Davis Bank account and OPM account in July
2010, Michael Davis started paying Shippensburg Health directly on a monthly basis through Charlotte
Davis' bank account.
Paragraph 27- Demand has been made upon Michael Davis to tender the funds of Charlotte Davis to
Shippensburg Health and he has failed and refused to do so.
Actual Facts against paragraph 27- Michael Davis has made payments to Shippensburg Health.
Michael Davis on numerous occasions spoke with Debra Black (717-530-8300) and Shippensburg Health
Corporate Office (Art Cosner- 301-745-8700) discussing Charlotte Davis financial status. At no time did
Michael Davis ever refuse to pay any amount. Michael Davis paid Shippensburg Health based on funds
available in Charlotte Davis account. Example: Charlotte Davis received $820.70 deposited in her Navy
Federal Credit Union account during the month of March 2011. Michael Davis paid during this month
$820.00. The balance left in Charlotte Davis account after this payment was $2.29. See Attachment
#23-15.
Based on the facts provide above, request the Plaintiff remove all information from Case/Document #
2011-3628 that pertains to Michael Davis. At no time did Michael Davis ever sign any Admission
Agreement with Shippensburg Nursing Home. Michael Davis only acted on behalf of his mother
(Charlotte Davis) to ensure payments were made and to ensure if there was any financial issue, to
Initials: mh-) Page 2 of 3
Rebuttal Statement
resolve them in the best interest of Charlotte Davis interest. Continued pursuit of this judgment against
Michael Davis by the plaintiff will result in legal actions taken by Michael Davis. END OF STATEMENT
Print Name: Davis chael
Signature:
Date: Ile/`??2/ Ol/
Initials: M?) Page 3 of 3
Retivevilwnt Information and Services
Quality Benefits far the federal family
SrE n,l ces Online Privacv Ad I Seawav I Using Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
]N2 Aetna Open Access-High - 506.8
46 Basic Life Insurance
Premiums -17.88
20 Checking/Savings Allotment - 600.0
130 Medicare Premium - 110.5
$1969.00 31 Federal Income Tax Withheld -201.501 $532.27
This statement shows your 1/2/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
December 11, 2009.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.E
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel No agement 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:18 PM
b -
Z
Retheineint Information and Services ,.
Quality Benefift for Ow federal farnity
4
Services 01111,11e PriYaCY Act I Secnrilv I Usiao Senrium Online I Contact Us I life
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
20 Checking/Savings Allotment - 600.0
130 Medicare Premium -110.50
31 Federal Income Tax Withheld -201.501
$1969.00 20 Checkin /Savin s Allotment 1_60.00 $355.74
This statement shows your 2/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
January 15, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death,
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Offioe of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/2011 4:18 PM
Retir+erm" Information and Services.
Quality Benefits for the federal firmly
A-,
Services Online Privacy Act I Security I Using Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
]N2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
20 Checking/Savings Allotment - 600.0
130 Medicare Premium -110.50
31 Federal Income Tax Withheld -201.5
$1969.00 L 20 Checkin /Savin s Allotment - 170.0 $245.74
This statement shows your 3/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
February 19, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:18 PM
Retiroment Information and Services
Quality fte»efits for the / "kral fmnily
sE'rm ces Online Privacv Act I Securgv I Usina Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
]N2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
20 Checking/Savings Allotment - 600.0
130 Medicare Premium -110.50
31 Federal Income Tax Withheld -201.5
$1969.00 20 Checkin /Savin s Allotment -170.04 $245.74
This statement shows your 4/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
March 19, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.E
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:21 PM
'wF
Retirefm"it Information and Services .
Quality Benefits for the Aft*ral family
services 0111112P PrivacV Act I Security I Using Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
]N2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
20 Checking/Savings Allotment - 600.0
130 Medicare Premium - 110.5
31 Federal Income Tax Withheld - 201.5
$1969.00 20 Checkin /Savin s Allotment - 170.0 $245.74
This statement shows your 5/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
April 16, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:21 PM
Retiv osrm lEtt Information
Quality Benefits for the,F06-ral family
Services Online
"erG
and Services
Privacv Act I Securev I Usi a Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
PO BOX 47437
FORESTVILLE MD 20753
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
IN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
Checking/Savings Allotment - 600.0
Medicare Premium - 110.5
n Federal Income Tax Withheld - 201.5
$1969.00 2 Checkina/Savin-,
Allotment - 170.0 $245.74
This statement shows your 6/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
May 21, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The Commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilil
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:21 PM
Retirement Information and Services ?.
Quality Benefrts for the Federal family
Services Online PrivaCv Act I Securltv I Ushm Services Online I CoMad Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium - 110.5
$1969.00 31 Federal Income Tax Withheld - 201.5 $1015.74
This statement shows your 7/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
June 18, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and termination
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:21 PM
Retirrrrt information and Services,.
Quality Benefits for the Federal Family
Services 0111 ne Privacv Act I Securitv I Usi a Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium - 110.5
$1969.00 31 Federal Income Tax Withheld -201.50 $1015.74
This statement shows your 8/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
July 23, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilil
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:21 PM
Rotekein*nt Information and Services ,d.
Quality Benefifx for the Federal family
Services online Privacv Act I Secwxv I Using Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
IN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium -110.50
$1969.00 31 Federal Income Tax Withheld -_201.5 $1015.74
This statement shows your 9/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
August 20, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.S
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
4/18/20114:22 PM
Retireniont Information and Services LAC
Quality Benefrtx for the Federal Family
.S,Pri) [•e Onl ille Privacv Act I Securitv I Usia Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
]N2 Aetna Open Access-High -623.3
46 Basic Life Insurance
Premiums -17.88
Medicare Premium - 110.5
$1969.00 [f3l!? Federal Income Tax Withheld :221.A5 $1015.74
This statement shows your 10/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
September 17, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.E
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilil
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TrY (202) 606-2532
4/18/20114:22 PM
Rotirttrr lent Information and Services ..
Quality Benefits for the Fed"l Famgl ,
Services on l ll ie Privacv Act I Securltv I Using Services Online I Contact Us I He
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOUNT PAYMENT
ANNUITY
IN2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium - 110.5
$1969.00 31 Federal Income Tax Withheld - 201.5 $1015.74
This statement shows your 12/1/2010 annuity payment as of today, including the gross amount, up to
possible deductions or additions, and the net amount. However, changes can be made to this payment
November 19, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's death.
terminating events include waiver of annuity and are provided by law. Commencement and terminatioi
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5, U.E
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employee!
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title 50,
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disabilii
System (ORDS).
Important Links
U.S. Office of Personnel Management 1900 E Street NW, Washington, DC 20415 1 (202) 606-1800 1 TrY (202) 606-2532
4/18/20114:22 PM
Rir'tilirei?`1"1ent
Ot witty Belietits for the Federal Family
4094 1?
PdVSC l ACt I severity I Us'a Services o?i?e I Contact us
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOU PAYMENT
ANNUITY
]N2 Aetna Open Access-High - 623.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium -115.40
$1969.00 31 Federal Income Tax Withheld - 201.5 $1010.84
This statement shows your 1/2/2011 annuity payment as of today, including the gross amount, up
possible deductions or additions, and the net amount. However, changes can be made to this pay"
December 10, 2010.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's de
terminating events include waiver of annuity and are provided by law. Commencement and termini
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5,
Section 8345 (c), et seq. The t and termination of benefits under the Federal Empio)
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disa
System (ORDS).
NS. OQloa of Pwamaai flaaagonm* 1900 E Street NW, WashkVton, DC 20415 1 (202) 606-1800 1 TTY (202) 606-2532
i'
3/2MOI 15:11 PM
Retirement }.S.1 ,..
Quality Benefits for the federal family
Se 't ¢! f_ 't". Pftaicv Act 1 SeaarRv 1 Using Services on¦ne i Contact us
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION AMOt! PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 781.3
46 Basic Life Insurance
Premiums - 17.8
130 Medicare Premium -115.40
$1969.00 31 Federal Income Tax Withheld - 233.7 $820.70
This statement shows your 2/1/2011 annuity payment as of today, including the gross amount, up
possible deductions or additions, and the net amount. However, changes can be made to this pays
January 14, 2011.
This annuity payment Is paid on a monthly basis and will generally continue until the recipient's de
terminating events include waiver of annuity and are provided by law. Commencement and termini
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5,
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employ
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disa
System (ORDS).
U.S. ollbs of PeraorrnN Managunent 1900 E Street NW, Wast*%gton, DC 20415 (202) 606-1800 ( TTY (202) 606-2532
3/22/20115:11 PM
Retirement -"YCiV1`1f-2S
Quality Oedefas for the Federal Family
ra ?'
1 1 / 11 M) Privacl Act i Sea vkv 1 U*w Swvlms Oniro I Caefta Us
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
1THACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION A PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 781.3
46 Basic Life Insurance
Premiums - 17.8
130 Medicare Premium -115.40
$1969.00 31 Federal Inaome Tax Withheld -233.701 $820.70
This statement shows your 3/1/2011 annuity payment as of today, including the gross amount, up
possible deductions or additions, and the net amount. However, changes can be made to this payme
February 18, 2011.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's de
terminating events include waiver of annuity and are provided by law. Commencement and termini
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by tide 5,
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Emplol
Retirement System (FERS) and FERS Special is governed by tide 5, U.S. Code, Section 8464. Tide
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disa
System (ORDS).
U.S. Ofte of Peraon?al Nanageam R 1900 E Street NW, Wastdrgtan, DC 20415 i (202) 606-1800 TTY (202) 606-2532
3/22/20115: 10 PM
If I I t ; ' ?S`I _ Ira '_ , : fa: E_,. ..
(
Retirement
4uai+ty SaTefits for the Federal Family t
Privacy ACt I Sewrlty I Usino Serrioes Onire I Contact Us
Annuity Statement
CLAIM
NUMBER NAME AND ADDRESS
A40913370 CHARLOTTE A DAVIS
P. O. BOX 3834
ITHACA NY 14852
GROSS DEDUCTIONS OR ADDITIONS NET MONTHLY
MONTHLY CODE DESCRIPTION A PAYMENT
ANNUITY
JN2 Aetna Open Access-High - 781.3
46 Basic Life Insurance
Premiums -17.88
130 Medicare Premium -115.40
$1969.00 31 Federal Income Tax Withheld - 233.7 $820.70
This statement shows your 4/1/2011 annuity payment as of today, including the gross amount, up
possible deductions or additions, and the net amount. However, changes can be made to this paymi
March 18, 2011.
Please note any Insurance Benefits changes (Federal Employees Health Benefit (FEHB), Federal Err
Group Life Insurance (FEGLI), Federal Employees Dental and Vision Insurance Program (FEDVIP) o
Long Term Care Insurance Program (FLTCIP)) made before April 15, 2011 will not be reflected unti
02, 2011 annuity statement.
This annuity payment is paid on a monthly basis and will generally continue until the recipient's de
terminating events include waiver of annuity and are provided by law. Commencement and termini
for benefits to retirees, under the Civil Service Retirement System (CSRS), are provided by title 5,
Section 8345 (c), et seq. The commencement and termination of benefits under the Federal Employ
Retirement System (FERS) and FERS Special is governed by title 5, U.S. Code, Section 8464. Title
Code, Section 2093 governs the termination of benefits for the Organizational Retirement and Disa
System (ORDS).
U.S. ONiae of Peesorr--a Managawent 1900 E Street NW, Wastd gbon, DC 20415 i (202) 606-1800 1 Try (202) 606-2532
3/22/20115:10 PM
NAVY 0
FEDERAL,
Credit Union
#BWNLLSV
#000000P3W3QPQ5A8#000AMU002
CHARLOTTE DAVIS
PO BOX 3834
ITHACA NY 14852-3834
Summary of your deposit accounts
Previous
Balance
STATEMENT OF ACCOUNT
AT14Cf ?-M
, J q--!
ACCESS NUMBER
03731015
STATEMENT PERIOD
07/09/10 - 08/08/10
ACCOUNT NUMBER
Deposits/ Withdrawals/ Ending YTD
Credits Debits Balance Dividends
EveryDay Checking
2808903708 $989.31 $1,015.79 $1,983.50 $21.60 $0.25
Membership Savings
2808903005 $5.01 $0.00 $0.00 $5.01 $0.00
Totals $994.32 $1,015.79 $1,983.50 $26.61 $0.25
Checking
EveryDay Checking - 2808903708
Joint Owner(s): None
Date Transaction Detail Amount ($) Balance($)
07-09 Beginning Balance 989.31
07-09 POS Debit Visa Check Card 9779 07-07-10 Shippensburg Healt
Shippensburg PA 900.00- 89.31
07-26 ATM Fee - Withdrawal 07-25-10 Shippensburg Wa Shippensburg PA 1.00- 88.31
07-26 ATM Withdrawal 07-25-10 Shippensburg Wa Shippensburg PA 82.50- 5.81
07-30 Deposit - US Treasury 312 Civil Serv 073010 1,015.74 1,021.55
07-30 Dividend 0.05 1,021.60
08-05 POS Debit Visa Check Card 9779 08-03-10 Shippensburg Healt
Shippensburg PA 1,000.00- 21.60
08-08 Ending Balance 21.60
Average Daily Balance - Current Cycle: $250.24
Your account earned $0.05, with an annual percentage yield earned of 0.140%, for the dividend period
from 07-01-2010 through 07-31-2010
Items Paid
Cate Item Amount($) Date Item Amount($)
07-09 POS 900.00 07-26 ATMO 82.50
08-05 POS 1,000.00
Savings
Membership Savings - 2808903005
Joint Owner(s): None
Date Transaction Detail Amount($) Balance($)
4/18/2011 1:34 AM
NAW
Credit Union
A7--r-4c, 4m
?4? -
STATEMENT OF ACCOUNT
ACCESS NUMBER
0373 1015
STATEMENT PERIOD
09/09/10 - 10/08/10
ACCOUNT NUMBER
#BWNLLSV
#000000P3W3QPQ5A8#000OMC002
CHARLOTTE DAVIS
PO BOX 3834
ITHACA NY 14852-3834
Summary of your deposit accounts
Previous Deposits/ Withdrawals/ Ending YTD
Balance Credits Debits Balance Dividends
EveryDay Checking
2808903108 $1,037.36 $1,015.81 $1,000.00 $1,053.17 $0.34
Membership Savings
2808903005 $5.01 $0.00 $0.00 $5.01 $0.00
Totals $1,042.37 $1,015.81 $1,000.00 $1,058.18 $0.34
Checking
EveryDay Checking - 2808903708
Joint Owner(s): None
Date Transaction Detail Amount($) Balance($)
09-09 Beginning Balance 1,037.36
09-16 POS Debit Visa Check Card 9779 09-14-10 Shippensburg Healt
Shippensburg PA 1,000.00- 37.36
09-30 Deposit - US Treasury 312 Civil Serv 093010 1,015.74 1,053.10
09-30 Dividend 0.07 1,053.17
10-08 Ending Balance 1,053.17
Average Daily Balance - Current Cycle: $575.43
Your account earned $0.07, with an annual percentage yield earned of 0.1508, for the dividend period
from 09-01-2010 through 09-30-2010
Items Paid
Date Item Amount($)
09-16 POS 1,000.00
Savings
Membership Savings - 2808903005
Joint Owner(s): None
Date Transaction Detail
Amount($) Balance($!
09-09 Beginning Balance
10-08 Ending Balance
5.01
No Transactions This Period
5.01
4/18/2011 1:37 AM I
A,rTA(- - 4 M eo r :A-
Bill History 24-3
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box to show a list for specific settings.
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Payments 1 - 11 of 11« First < Prev 1 Next > Last >>
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Biller Name AccouotAmount Pay Date
Category
Sbippensburg Health Care Center *03708 $820.00 04/21/2011
Uncategorized
*0161.7
Shippensbuig Health Care Center *03708 $1000.00
Uncategorized
*01617
Sbippensburg Health Care Center *03708 $820.00
Uncategorized
*01617
Shippensburg Health Care Center *03708 $1000.00
Uncategorized
*01617
Sbippensburg Health Care Center *03708 $915.00
Uncategorized
*01617
SHIPPENSBURG HEALTH CARE CENTER *03708 $1000.00
*01617
Shippensburg Health Care Center *03708 $1000.00
Uncategorized
*01617
Statu Action
Pending View Detail
Chance Cancel
04/04/2011 Canceled View Detail
03/28/2011 Paid View Detail
03/04/2011 Canceled View Detail
02/18/2011 Paid View Detail
02/04/2011 Canceled View Detail
01/04/2011 Paid View Detail
4/18/2011 1:27 AM
Sbippensburg Health Care Center *03708 $1000.00 12/20/2010 Paid View Detail
Uncategorized
*01617
ShippensburgHealth Care Center *03708 $1000.00 11/17/2010 Paid View Detail
Uncategorized
*01617
Shippensburg Health Care Center *03708 $1000.00 10/15/2010 Paid View Detail
Uncategorized
*01617
Shippensburg Health Care Center *03708 $1190.12 07/02/2010 Paid View Detail
Uncategorized
*01617
Total $7745.12 Includes Paid, Pending and Processing armunts only.
Payments 1 - 11 of 11« First <Prev 1 Next > Last >>
N i TA4 ---f - A EOT-
02 q- 3A
4/18/20111:27 AM
Rebuttal Statement
,=.2 61 l i - 262
Individual Making Statement: Michael Davis Mailing Address: PO Box 3834. Ithaca NY 14852
Contact Number: 502-794-5538 Email Address: michaeU davisl969@em ila com
1, Michael A. Davis, PO Box 3834 Ithaca NY 14852, would like to submit this rebuttal statement against
the notice that I received (Plaintiff: Perini Services/ South Hampton Manor, L.P. Case/Document #
2011-3628) dated the 8"' of June 2011. This rebuttal statement is submitted in response to this notice
stating that Charlotte Davis AND Michael Davis have failed to enter a written appearance personally or
by attorney and file in written with the court our defenses or objections to the claim.
The statement of "we (Charlotte Davis AND Michael Davis) have failed to enter a written appearance
personally or by attorney and file in written with the court our defense or an objection to the claim" is
totally incorrect. After my mother (Charlotte Davis) and I were served the initial notice dated the 13'h of
April 2011, within 6 days we both completed our rebuttal statements and had it filed with the courts on
the 19"' of April 2011. 1 personally turned in both statements to the court. I was told as the documents
were being stamped in as received; this was the only action I had to perform. At no time was I ever
informed that I had to submit a copy of both rebuttal statements to anybody else including the attorney
of the plaintiff (David A. Baric, Esquire). As a matter of fact, the initial notice stated that we had (20)
days after receiving the notice to enter a written appearance personally or by attorney and file in
written with the court our defenses or objections. Again on the 19'h of April 20111 did exactly that by,,
C: ?
submitting a rebuttal statement for myself and my mother filing it with the courthouse in Cj& in--
.C rn c
Pennsylvania.
r- v
Print `-Name. Davis, Micbge
_ c .'
*-:94 A ZZ) Signature:
c-n
Date
A r-°-
Initials: )
: IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
PERINI SERVICES
SOUTH HAMPTON MANOR, L.P. C' '1 11
Plaintiff NO.362,8 1V1 20 _
VS. rrj 03 C_
CHARLOTTE DAVIS, DARREN
DAVIS AND MICHAEL DAVIS, tnr" tV
AGENT FOR CHARLOTTE DAVIS
AND INDIVIDUALLY, Defendant <C'
>
-c+
RULE 1312-1 The Petition for Appointment of Arbitrators shall be substantiallgifrthec4
l
Following form: :a
-
-?
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, THE JUDGES OF SAID COURT:
_ M
David A. Baric, Esquire , counsel for the plaintiffs iKJOItXin the above
action (or actions), respectfully represents that:
is ( ) at issue.
1. The above-captioned action)(OU DM9
2. The claim of plaintiff in the action is $ 13,472.99
The counterclaim of the defendant in the action is NONE
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit
as arbitrators:
None.
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to
whom the case shall be submitted. ?ay.o0 pd 4
spectf y bmitte Ctlt 4k I ?OWS
?,?. a !o2-p? S
David A. Baric, Esquire
ORDER OF COURT
AND NOW,
petition,
Esq., and
200 , in consideration of the foregoing
Esq., and
Esq., are appointed arbitrators in the above
captioned action (or actions) as prayed for.
By the Court,
Kevin A. Hess, P.J.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
PERINI SERVICES /
SOUTH HAMPTON MANOR, L.P.
Plaintiff NO. "Z6 C1V11 20 11
n,,
C C=
CHARLOTTE VS.
DAVIS, DARREN r i 03 c.._
xrr
DAVIS AND MICHAEL DAVIS, cnr
'C
AGENT FOR CHARLOTTE DAVIS r
AND INDIVIDUALLY, Defendant
RULE 1312-1 The Petition for Appointment of Arbitrators shall be substantiallZiirther,)
Following form:
PETITION FOR APPOINTMENT OF ARBITRATORS
G^A '%6;4 .VW p a
spectf y bmitte Ck 44 180(pS
G?
David A. Baric, Esquire
ORDER OF COURT
TO THE HONORABLE, THE JUDGES OF SAID COURT:
David A. Baric, Esquire
rTZ?
rr,
j
counsel for the plaintiffk U2NdWiXin the above
action (or actions), respectfully represents that:
1. The above-captioned action)(OD X90 is ( ) at issue.
2. The claim of plaintiff in the action is $ 13,472.99
The counterclaim of the defendant in the action is NONE
The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit
as arbitrators:
None.
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to
whom the case shall be submitted. d
AND NOW, '41 1A, y 1209/ , i onsideration of the r^ego_in?g
petition, Esq., and G?fyl e`
n.?
Esq., and Esq., are appointe arbitrators in the ?ovd'!'_
captioned action (or actions) as prayed for. ?M "'n
c? 7)r"
By the Court, c 1A00-
_C r(a -
cz)
C u fJ. Kevin A. Hess, P.J. °-
ee+p;c'S nw. trey VI) N
2/" c
1q, v-t r,
.Ito A
C?IfP/OWE ,/V/? Plaintif
?IrrtiNvtf ffi 4A44/ Aioji,
Defendant`'
In The Court of Common Pleas of Cumberland
-
County, Pennsylvania No. 90/1
.Civil Action - Law.
t "Oafh
We do solemnly swear (or affirm) that we vyi?I iipport, obey and defend the :Co,,4At* ion of the United
States and the Constitution of fts Commonwealth and that we will discharge the duties of our office
with fidelity.
I AA
Signatu
Name ( irman)
?,? ? b??a?y eF
Aj.i
Law Fi
3 ??
-JOAO
Addres
cp fl
City, Zip
4??4, 12-e
Signature
Name ? 8 ?• ?`/I?` 1?ir
? Her ac??aL?ur?
Law Firm
v?
6640H
Address
iName
aw Firm ?/0',(?
Add ess
C,ac ld4B I WO:
Oity, City, Zip Zip J
Award /!7&5-
We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the
following award: (Note: If damages for delay are awarded, they shall be separately stated.)
Arbitrator, dissents. (Insert name if applicable.)
Date of Hearing: 1212,11,
1-1201?ee (44VA 4
Date of Award:
Notice of
Now, the day of 20 at /07 D?F, }' .M., the above award was
entered upon the docket and notice thereof given by mail to the parties or their attorneys.
Arbitrators' compensation to be paid upon appeal
By:
Deputy
"I'll(
DEC ?; 49
ALI C I Y
Of THE AROjH ? C
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PERINI SERVICES/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v. N0.2011- 3628 CIVIL TERM
CHARLOTTE DAMS c ~ `='
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DARKEN DAMS AND ~ ~ -.;, -+
MICHAEL DAMS, AGENT FOR ~° o ~-='
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CHARLOTTE DAMS AND ~~„ r -c r
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INDIVIDUALLY, -<r
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PRAECIPE TO ENTER JUDGMENT -,
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TO THE PROTHONOTARY:
Please enter judgment in the above-captioned matter in favor of Plaintiff, Perini
Services/South Hampton Manor, L.P. and against the Defendants, Charlotte Davis and Darren
Davis pursuant to the attached arbitration award in the amount of $6,970.00 together with interest
of $1,103.81. to November 8, 2012 with a per diem of $3.43 for a total of $8,073.81.
Respectfully submitted,
B RIC SCHERER LL
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David A. Baric, Esquire
Date: November 8, 2012 I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
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We do solemnly swear (or affirm) that we willsupport, obey and defend the Constitution of the United
States and the Constitution of this Comrnonwea~th and that we will discharge the duties of our office
with fidelity.
Si~natu Signature ignat re
~// ~~' ~' °' ~, . In The Court of Common Pleas of Cumberland
Li,~/,~r~p~~l• AL°lj Plaintif ,
/~ County, PennsylvaniaNo.~4/% -~ d~
Defendant' ~ Civil Action -Law.
Nalme ( u-man)
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Law Finn
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Name
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City, Zip City, Zip ~ Crty, Zip
Award // ®~~'" ~-
We; the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the
following award: (Note: If damages for delay are awarded, they shall be separately stated.)
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.Arbitrator, dissents. (Insert name if applicable.)
Date of Hearing:
Date of Award:
Notice of
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/~ (Chairman)
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Entry of Award
Now, the -~~ day of , 20 `~ , at /.~Z-Gy, ~' .M., the above award was
entered upon the docket and notice thereof given by mail to the parties or their attorneys.
Arbitrators' compensation to be paid upon appeal: ~ ~-~Q = ~~
sy:
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CERTIFICATE OF SERVICE
I hereby certify that on November 8, 2012, I, David A. Baric, Esquire of Baric Scherer LLC,
did serve a copy of the Praecipe Enter Judgment, by first class U.S. mail, postage prepaid, to the
parties listed below, as follows:
Darren Davis Michael Davis
5925 Gabrielle Lane 11753 Riverstone Drive
Chambersburg, Pennsylvania 17202 El Paso, Texas 79936
Charlotte Davis
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
David A. Baric, Esquire