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Home My WebLink About04-4395HCR MANORCARE, INC., Plaintiff, V. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. Q~- ~S CIVIL TERM CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice 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. PENNSYLVANIA LEGAL REFERRAL SERVICE 1 (800) 692-7375 PENNSYLVANIA ONLY (717) 238-6715 2 HCR MANORCARE, INC., Plaintiff, V. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. O't-439S CIVIL TERM CIVIL ACTION-LAW COMPLAINT NOW, comes HCR ManorCare, Inc., ("ManorCare"), by and through its attorneys, O'BRIEN, BARK & SCHERER, and fales the within Complaint and, in support thereof, sets forth the following: HCR ManorCare, Inc. is an Ohio corporation duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 1700 Market Street, Camp Hill Cumberland County, Pennsylvania. 2. Defendant, Roberta L. Saxton, is an adult individual with a residence address of 1700 Market Street, Camp Hill, Cumberland County, Pennsy]vania. 3. Defendant, William Saxton, is an adult individual with a residence address of 530 Third Street, West Fairview, Cumberland County, Pennsylvania. 4. At all times relevant hereto, Roberta Saxton and William Saxton have been husband and wife. ManorCare owns and operates a skilled nursing facility located at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania ("facility"). 6. On or about April 18, 2003, William Saxton and Roberta Saxton sought to have Roberta Saxton admitted to the ManorCare facility. On or about April 18, 2003, Roberta Saxton became a resident of the facility. 8. As of August 25, 2004, there remains an outstanding balance of $16,713.01 for the costs of care and services provided by ManorCaze to Roberta Saxton. A true and correct statement of the amount due and owing is attached hereto as Exhibit "A" and is incorporated by reference. 10. Demand has been made upon Roberta Saxton and William Saxton to pay the amount due and owing. 11. In connection with the admission of Roberta Saxton to the facility, William Saxton signed an Admission Agreement. A true and coned copy of the Admission Agreement is attached hereto as Exhibit "B" and is incorporated by reference. 12. William Saxton completed and signed an Application for Residency seeking to have Roberta Saxton admitted to the facility. A true and correct copy of the Application for Residency is attached hereto as Exhibit "C" and is incorporated by reference. 13. The Admission Agreement provides for the recovery of attorney fees incurred by ManorCare to collect amounts due and owing. 14. The services provided by ManorCare to Roberta Saxton are necessaries within 23 Pa.C.S.A. §4102. Roberta Saxton requires skilled nursing care because of her physical condition. COUNT I-BREACH OF CONTRACT HCR MANORCARE, INC. v. ROBERTA SAXTON and WILLIAM SAXTON 15. Plaintiff incorporates by reference paragraphs one through fourteen as though set forth at length. 16. ManorCare has and continues to provide skilled nursing caze to Roberta Saxton at its facility in Camp Hill. 17. All conditions precedent to recovery under the Admission Agreement have been fulfilled. 18. .Roberta Saxton has breached the Admission Agreement by failing to pay ManorCaze the amount due and owing. 19. Wiliam Saxton has breached the Admission Agreement by failing to pay ManorCaze the amount due and owing. 20. The Admission Agreement was a contract for necessaries for the support and maintenance of Roberta Saxton. WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the sum of $16,713.01, plus any additional amounts coming due to the date of award, plus interests, costs and attorney fees. COUNT II-QUANTUM MERUIT HCR MANORCARE, INC. v. ROBERTA SAXTON and WILLIAM SAXTON 21. Plaintiff incorporates by reference paragraphs one through twenty as though set forth at length. 22. Roberta Saxton has and continues to enjoy the benefit of the skilled nursing care being provided to her by ManorCaze. 23. Roberta Saxton has failed and refused to pay for the skilled nursing caze provided to her by ManorCare. 24. Roberta Saxton has been unjustly enriched by the use and enjoyment of the skilled nursing caze provided to her without having made payment therefor. WHEREFORE, Plaintiff requests judgment in its favor and against Roberta Saxton for the sum of $16,713.01 plus and additional amounts coming due to the date of award, costs and expenses and interest. Respectfully submitted, O'BRIEN, BARIC & SCHE David A. Baric, Esquire I.D#44953 19 West South Street Cazlisle, Pennsylvania 17013 (717) 249-6873 08/25/2004 15:01 7172495755 OBS PAGE 06 VERIFICATION The statements in the foregoing Complaint aze based upon information which has been assembled by my attorney in this litigation, The language of the statements is not ray own. I have zead the statements; and to the extent that they are based upon information which I have given my wunsel, they aze true and. correct to the best of my knowledge, information and belief. I understand that false statements herein aze made subject to the penalties of 18 Pa.C.S. §4904 relating to unswom falsifications to authorites. Date: ~ ~db-~`' RUG 25 2004 16 04 Helen Moloney Administrator 7172495755 PRGE.06 Iljl6j9A ,{ il,t6 6 ) RESIDENT 1E00ER AS OF pgTE OF FIRST ACTIVITY VASE RESIDENT AES[OE;IT RESIDENT fill -- RCCOUNTS RECEIVA3LE -- MUR3ER TYPE NAHE DATE QTY RCLO'J;I. C HARGES CREDITS BALANCE I3Aa MEOICRIO SRSTON, ROBERiA 07(13jd3 ADN ttITR RATE: 0.00 J ROJA 2l9 -9 LEVEL 1 OIS PRIV PORT: 18a9.94 "PRIvAiE - JUL a3 dAi. F'aD -lM- -39- -SA- -9A- - 122~- 64.ua 36.oa S9.aa 15a.0a PAYMENi CHECK ! t9a O1J16j97 tl?10902A09 36.0A PAYME;Ii CHECK # 29A 01j16J93 ll2tAaa20aa 64.90 PAYHEAT CNECK 0 290 01j16jD3 11210A020Jd 50.00 11190 BEAUTY RHO BRRAER 01j91j9D 1 S9lS81i1327 12.00 11600 CABLE RENTAL 01j01j73 1 S91S840i320 12.00 11107 BEAUTY AYO BARBER Olj10j03 1 5915819!329 24.99 1020A LAB-GLUCOSE MONITORING ~ 01j12j03 1 S61S19A132Z 3.23 !0299 LRB-GLUCOSE MONIT09[NG B1j13j03 1 561S19913C0 3.23 10208 LAB-GLUCOSE pONITORING 01(14(03 1 S61S190132a 3.23 l92'a3 LAB-GLUCOSE MONITORING 07j1SJ93 1 5615190!329 3.23 102A9 LAB-GLUCOSE MONIiORING 0!/16(03 1 5615190!327 3.23 10209 LRB-GLUCOSE MONITORING 01j11j93 t S61S198132A 3.23 10209 lAB-6L000SE gOUITORING 01j18j03 1 56151901327 3.23 10208 lR8-GLUCOSE MONITORING 01j19j03 1 66151901327 3.23 1A2A9 LRB-GLUCOSE pONITORINu 0/j20/03 1 56151901320 3.23 10208 lA8-GLUCOSE MONITORING Al(21j03 1 56151991329 3.23 10208 lA8-GLUCOSE MONITORING 01j21j03 1 56151901329 3.2? 10209 LAB-GLUCOSE NONIiORING 91j23j03 1 56151901320 3,23 11107 BEAUTY RND BARBER 01j23j03 1 59158101320 12.00 10298 lA8-GLUCOSE NOt1ITORINfi 01J24j03 1 56151901329 3.23 10209 lAB-OIUCOSE MONITOAIA6 01j2SJ03 1 56151901320 3.23 10208 LAB-GLUCOSE MONITORING 01j26j03 l 5615190!320 3.23 1020A LAB-GUICOSE N011I10RI11G:. Olj21J03 1 56151901320 3.23 19200 LAB-6L000SE MONITORING 91j28j0? 1 6615!90!329 7.23 10298 lA8-GLUCOSE MONITORING O7j29J93 1 56151901320 3.23 !1109 BEAUTY AND BARBER Blj29j93 1 59158101?29 12.00 10208 lR8-GLUCOSE NONITOAING 0J(30j03 1 56151901?20 3.23 10208 LRB-6lUtOSE M011ITORLYG 01/31(03 1 S6L51901320 3.23 "'ENUIIIG BALANCE 112.60 "DRIVAT E - RU r, 03 BAl FVIO -LM- -30- -67- -90- -ltA~- 62.60 50.97 112.69 11100 BEAUTY ANO d9A3ER A3f01/03 1 S91SAt01329 12.08 1119A BEAUTY ANO BARBER 08j14jA3 1 59158191320 24.0a 11S0a CRAIE RENTRL 03/31(A3 1 S915A401327 12.00 REV GLUCDGE A/j31fA3 561519a1329 64.59 "'EROIIIG BAlA11CE 12.0J '"PRIVRic - SEP 03 BRL f90 -lN- -30- -60- -90- -129.- 24.OA 2.00- 50.07 12.09 11190 BEAUTY A110 BRRBER A9jOlJ03 1 59158101120 12.00 11100 BEAUTY A8D BARBER 09j02j03 1 59158101129 12.09 t160a fRBIE RENTRL 09J30/03 1 59158401120 12.0A PRIVATE PORTION A9j01j93 -- 09j15j03 lS 1590.20 Exhibit "A" 11)16)04 RESIDENT 1E06ER AS OF DATE OF FIRST ACTIVITY PAuE 2 ,•~(1RS6) RESIDENT RESIDENT RESIDEI4T GJl -- RCtOUNTS RECEIVAaIE -- MUABER TYDE NAME 0.4TE QTY AiCOUNT CHAR6E5 CAEOITS BALANCE 1380 AEOICAIO SR%TON, RDBERTR JsJl3J03 AON tATR RATE: 0.00 RODN 2l9 -8 IEVE! l OIS PAIV PORT: 1899.94 "PRIVATE - SED 93 ([DNT) BEAUTY 0!10 BARBER O4J30J03 59!58101220 12.99 BEAOiY R90 9ARaER 0SJ31f93 53158101220 12.0) 7RIVRTE PORTIO'I 05)31)03 144110SOJ0J 1561.45 PRIVATE PORitON 76(30!03 144L1959400 1561.45 PRIVATE PORTIOtI OiJ.31J03 14411050000 1S 9d .20 INS PAEI 09)31)03 33439400500 58.10 PRIVATE PORTION O8J31J03 14411050000 1590.29 "ENDING 84LRBCE 1994.8) "PRIVATE - OCT 03 BAl FWD -LN- -30- -69- -99- -128+- 1602.20 1555.50 1588.20 IS6l.4S 1581.45 ]694.80 11908 INS PREN qtO F4t PO(PA) lOJO1J93 1 3343D901120 59.10 11900 PIS PREN pCD fAC PD(PAJ 10JO1J03 1 33930+01120 50.10 11109 BEAUTY R'ID BARBER 10)29)03 1 59158101120 52.08 11100 BERUTY ANO BARBER IOJ31J03 1 53LS910t120 12.09 11600 CABLE RENTAL 1OJ31J03 1 59158401120 12.00 PRIVATE PORiIOH 10)12)03 -- 10)31)03 20 1590.28 ROV PVT PORTION 11JOIJ03 13211000000 1590.20 "EAOINo BALRACE 11121.20 •'PRIVAT E - tIOV 03 BAl FWD -lA- -30- -60- -90- -120+- 3232.40 1602.20 1555.50 1588.20 3148.90 11121.20 11100 BEAUTY RIID BARBER 11)01)03 1 59159181120 12.0) 119D0 IIIS PREN NC9 FAC PO(PA) 11JO1J03 1 33430401120 56.10 11100 BERUTY RNO BARBER ~ 11)11)03 1 59158101120 29.00 REV LAST AO PP IlJ01J03 13211000000 1590.20 PRIVATE DOR1fOq 11JOIJ03 - - 11)30)0? 30 1590.20 ROV PVT PORTION 12)01)73 13211000000 1590.20 REV INS PREq 10)01)03 33430909500 56,10 CABLE CNRRGE 11)30)03 59158411220 12.00 '"ENDING BALRNCE 12620.0) '"PRIVATE - OEC 03 BAl fW0 -lN- -30- -60- -90- -120+- 3141.10 1683.50 1602.29 1555.50 4131,10 1262).00 PRYNEIIT CNEC% 0 243 12)11)0) it?1080200') 1SSO.SJ 11900 INS PREA NCO FAC PO(PA) 12J01fO3 1 33438401120 sa.Ya 11600 CABLE RENTRi. 12)31)03 1 59158401120 12.00 REV LRSi NO PP 12)01)03 132119999)0 1530.29 PRIVATE PORIIOA 12)01)03 - - 12(31/93 31 1590.20 AOV PVi PORTION 01)01)00 13211000000 1590.20 "ENDING B4lANCE 12513.08 "PRIVA TE - JA'I 04 8Al fWD -lN- -30- -69- -90- -120+- 3133.10 1551.50 1563.50 !602.20 1142.10 12613.00 11116!04 RESIOEBi 1E06E8 AS Of pATF Of FIRST ACTIVITY PAGE 3 ~•~(MA56) RESIDENT RES[OEGY RESIDENT 6Jl -- ACCOUNTS RECEIY931E -- NUNBEA TYPE MANE DRTE QTY ACCOUNT CNAdGES Ce.'.OITS BRIRNr,E 1380 NEOICRtO S4aON, ROdERTA 9iJL9J03 RON CATR RATE: 9.OJ ROON 2l9 -B LEVEL 1 OIS PRIV PORT: 1899.9! "PRIVRTE - JRN 04 (CORY) 11SJJ CR9lE RENTR! 98!08!!7 1 53iS840112J 12.0•) 1190) IeS PREN ACO fAC PO(PA) OIJOlJOJ 1 33139+01129 66.oJ 9EV LOST p0 PP 98!08!04 1328893!!!3 iS39.?9 PRIVATE PORTION 01f9IJJd -- 91!31!!4 31 1S9b.29 RO'J PVT PORiiO!i 02!98!04 13211000009 1590.29 IIIS PREN 99!30!03 3343b439Sd9 S3.1J "ENDING BAIRIICE 14089.98 "PRIVATE - FEB 04 BA1 fu0 -Lp- -30- -69- -90- -128+- 3125.80 1543.59 1651.50 1S83.S0 6295.60 U 969.9J PRYNENT thecR 9 394 a2Ja2Ja4 11210902803 12UJ.0b PRYNENT CHECK } 2JA8 02!19!04 11219382030 13db.0J 11603 CRdIE RENTR! 02!29!04 t 59156401128 12.99 11903 INS PREN NCO FRC PO(DA) 82J29J0a 1 33430401128 66.69 REV IRST NO PP 02!01!04 13?11000888 1593.20 PRIVRTE PORTIO!I 02!81(0! -- 92!29)94 29 1889.84 ADV PVT PORTION 03!91!04 13211009380 1889.84 "E80ING BALANCE 13124.19 "PRIVRTE - NAR 04 BRL Fu0 -LN- -38- -60- -99- -120+- 1225.08 1535.68 1S43.S0 1SS1.59 1869.10 1 3124 J9 PRYNENT CNECK ! 2009 93!19!04 ]1210092009 1225.03 PRYNEtIi CHECK } 2804 93!19!84 tLZ1B802009 114.92 11103 BERUTY ANO BARBER 93!25!04 1 59159101120 24.80 11189 BERUTY A110 BARBER 03J3tJ84 1 59158181128 12.89 11689 CR61E RENTAL 03!31!84 1 59158901120 12.00 11993 INS PREA NCO fAC PD(PA) 03!31!0! l 33438491120 66.60 REV LAST NO PP .83!01)04 13211080090 1689.84 PRIVATE PORTION 93!01!94 -- 031?1!04 31 1889.84 ROV PVT PORTION 94/91!94 13211080990 1989.84 REV PRIV PORT 91!31!04 14J11959b99 1593.29 REV PRiV PORT 0if31J94 14911959099 1989.84 REV PRIV PORT 92!29!0! 14411859999 1593.20 REV PAIV PORT 02!29!04 t941t0S9J08 1899.84 ROIi CREDIT (91189) 93!31!04 14411959090 365.12 R9ll CREDIT (dllNOj 03!31!94 1441105'4038 365.12 "ENO IIUi BAIRIICE 14111.39 "PRIVAT E - RPR 04 ' 9Rl fug -!N- -30- -69- -90- -t?p._ 214e.89 1663.32 IS47.59 9J?0.69 14111.33 11634 CRdIE REtRAL 04!39!04 L 691S949i129 L?.OO 11999 INS PREN NCO FAC PO(PR) 04!38!8! 1 33438!91120 66.69 REV IRST NO PP 04!01(04 132110980!0 1839.84 1]716784 RESIOEAi lEOGER AS OF DRTE OF fIRSi RiiIV1TY PAGE 4 ~•(AR56) RESIDENT RESIDERT pESIDENT GJl -- ACCOUAiS RECE1V.491E -- BUABER TYPE RRAE DRTE QTY RCCOURi CHRR6ES CREDITS BRIAAsE 1380 NEOICRIO SAXTOA, ROBERTR 8003 tl9 -8 IEVEI 1 "DRIVRiE - RPR 14 (COAT) PRIVaiE PORTION RDV PV1 PORT [OA "EtIOINS BaIAUCE "PRIVATE - AaY 9r BRl fW0 -lR- -30- 312s.03 251.04 PRYNENT POSTED TO IAC'PAY 11600 CaBIE RENTAI 11900 INS PREP OCD FRC PO(PA) REV IASi NO PP PRIVATE PORTION AD'0 PVT PDRTI0;4 "ENDING BALANCE "PRIVATE - JUN B4 PRIVATE PORTION AOV PVT PORTIO;4 BRL FWD -LO- -30- 3725,08 914,24 PAYAENi CHECK 1380 PAYRENT RTF CHECK-JUN PRV 11600 CABLE REAial 11900 !AS PREA RCO FAC PO(PA) REV IRSi NO PP '"ENO[i1G BAIA~VCE 04718/93 ADA CY,TA Ra1E: 1.18 DIS PAIV PORT: 1889.84 04J01JOu -- 84730/04 30 1883.84 OS(91J0J 1321100089a 1853.84 16606.54 -Sa- -9a- -120~- 1660.32 10364.12 1660o.S4 04723704 11210002002 861.00 85731704 t 59158491120 12.00 OSJ31J04 1 33430401120 66.60 OSJ0IJOV 13211099090 1899.84 9SJOlJa4 -- OSJ31JD4 31 1889.04 OSJOIJOu 13211099089 1083.84 17588.78 06701709 -- 06730704 30 1889,84 07J01(OV 132110090x0 1889.84 -60- -9J- -120~- 251.04 12624.42 11589.18 06(11(04 11210982000 06711704 11210002900 06730704 I 59158401127 12.00 0SJ?0784 1 33430471120 06f01J04 13211000009 921.81 891.80 66.60 1889.84 ll004.01 ,~ HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Ageement is entered into by and among HCR Manor Caare, d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if any,"for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: HCR Manor Care Resident: Roberta L.. Saxton Responsible Party: Wiliam Saxton Admission Date: OA-18-2003 'Deposit: $ Term: This Ageement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. I. RIGHTS AND RESPONSIBII.ITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 1.05) or by a third party payor or managed care organization (see Section 1.06). 1.02 Ancillary Charges. The Resident will pay to Center all charges for additional medical, therapeutic, or personal Gaze services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Caze. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Chazges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business bows. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. Exhibit "B" 1.03 CollectionslLate Payments. Payment is due in full within thirty (30) days of billing. ,•'< Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physiciaa for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comp]y with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01land 1.02. The Center participates in the following programs: ~/Medicare, edicaid andior _VA. Medicare may pay for some or all of the Resident's care. If Medicaze agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pa ~res~dents The Resrdent and/or Res~ok.,rtsible Party responsible foi• applying for Medicard Tf the Resrdent receives Medicaid,;most "of the Center. a:tunely,basis,,as set.forth,in.this,Agreeiuent;'the contn'bt as necessary, order'stich payment. 1.06 Third Party Payors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third pally payor such as a Health Maintenance Organization ("HMO"}, Preferred Provider Organization ("PPO"}, Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center z _ ~ will bill the Resident's third party payor as a service, but the Resident remains liable for charges .• ~ not paid or covered by that third party payor including chazges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident andlor Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident andlor Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident andlor Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident andlor Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreertient. 1.09 Application for Benefits, The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed caze provider may not pay for non-covered services, supplies, equipment, medications, and other caze and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may nat be covered by a 3 governmental payor, third party payor or managed care organization. The Resident and/or .•~~ Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. ].11 Personal Phvsician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacy. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIIiII.ITY OF THE RESPONSIBLE PARTY 2.01 Leaa] Authority. The Responsib]e Party represents that helshe has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur persona! financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident maybe eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely 4 and proper manner, the Responsible Party will be personally liable for all charges and fees not .•~ ` covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cooperation for Financial Assistance. If the Resident is eligihle for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.Ob. 2.06 Acceptance Upon Dischazge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreemem, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf of the Resident under Section 2.02 or for purposes of quali~yirrg the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency andfor the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. IIL RIGHTS AND RESPONSIBILITIES OF THE CENTER 3,01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit• The Center acknowledges receipt of the Deposit, if any, noted at the .•~` beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release of the,Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health Gaze facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized bylaw to review the medical records. 4.02 Consent to Treat. The Resident and/or Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Ageement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal andlor state law. As applicable, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Responsible 6 Party acknowledge they have had the opportunity to ask questions and questions have been ,•~~ answered satisfactorily. a. Assignment for Payment of Benefits. See Attachment C. b. SNF Medicare Determination Notice. See Attachment D. - c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-1 and F-2. e. Center Supplement: 1. Policy and procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5. The name, specialty and way of contacting the attending physician, ' medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. f. The Resident Handbook. g. Resident/Patient Rights. h. Medicare/Medicaid information and display of such information including haw to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. 7 i. Receipt of information on advance directives including a copy of "Refusal .~~~ of Life Sustaining Treatment", which summarizes HCR Manor Caze's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct hislher medical treatment. See Attachments G-1 and G-2. j. Privacy Act Notification. See Attachment H, k. Notice of Information Practices and Receipt of Notice of Information Practices. See Attachments I-1 and I-2. 1. Ancillary Services Management Form. See Attachment J. 4.05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident andJor Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Dischazge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible foc all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized. units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. s 4.08 Changes in the Law. Any provision of this Agreement that is found to be invalid -•~` or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Ageement consistent with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO T'HEIIt SATISFACTION. Signature of Resident: Date: Signature of Responsible Party~:c/%2Q= C. S~z-~ Date: N f ~8~03 Center Representative: ~/~/~~Q ,_ Date: 7/(~~~ .~~ HCR•ManorCare APPLICATION FOR RESIDENCY Torpply for admission to our Nursing Center, plcrse complete the follo+ring questionnaire, sign, and return it to the Admissions Office. This application mill become a part of the `Admission Agreement" and should be completed in its entirety. All information ~.•ill be held in confidence. The complete medical history and physical examination results kill be recorded on another document. Date: Name of Prospective R,es/idJentJPatient: ~r,~'~'("t ~ 1(~~ Date of Birth: 7 '~/-/9 S Sex: F 1<I Address: ~fi~i ~~ir~ ~'C~~ Telephone No.: (line 2) ~)~ ~QI V'U IC . Marital Status: Married Widowed Sinpgle C- L If Married or Widowed, Name of Spouse ,~.~ i I I~ wv , Xt~' 1 ~ Social Security No:l~oC~ t~~O.Sd QCO IVledicare No: HivlOllnsurance: Provider ID No: Group No: Insurance is: Primary• / Secondary Other Insurance: Provider ID No: Group No: Insurance is: Primary Secondary Name of Inquirer:;, ~ X~cTbh Address:.S.3D _~ r~5-4-. (line 2) ~t1pS't- ~=Ci+'tt~.eu5 ~1'n~~ Other persons to :contact in case of emergency: Name: ~, (,(U ~'?l ZlYY1fN~Yr{K1GlY~ Address: (line 2) Personal Referral Neyvspaper~Iagazine Hospital ~)}rn1l.I;,~,,;~hTelevision/Radio Physician Xellow Pages Other Professional Health Dept. Mailing/i3rochure Seminar/Event Other Nursing Ctr. Assisted Living Ctr. ~ awA Policy No. Co-insurance Policy No. Co-insurance Relationship: ~-t.tS~Qh~ Telephone No.: 7 ~,~-5~~~ Other Phone No.: Relationship: (~AJIA,q~F~ Telephone No: ~ y~ ~ ~1~ ~~) Other Phone No.: Now did you hear about ~n~~.~-,1` ~~•iry~r`~O(Z Nursing Center? Have you visited any other Nursing Centers or Assisted Living facilities' If yes, which ones? Exhibit "C" ;~~ PERSONAL/MEDICAL DATA Riother's btaiden Name; Father's Name: Place of Birth: City County State Church Preference (Optional): ~°~.~~5t'p ry.. Preferred Ambulance Company (Optional): N~me City Diagnosis: Current Primary Physician: Q{~~-,~,~~,~(~~i, 5 Telephone No.: Physician to follow at Facility: ~•a\ w.<!C~~){c~ Telephone No.: Tell us about the Resident/Patiertt: (please check all that apply) /Rlentally alert _Amb'ufatory -Confined to bed /Slightly forgetful :/~Yalls with assistance -Eats without assistance -Confused -Continent -Requires assistance with -Incontinent eating Admission desired on: ~- Resident/patient currently at: ~~~C~\-\-~'~ `7a1.~~~`~ If hospital: Date admitted Admitted from Where has the residentlpatient lir•ed in the last 60 days?: FINANCIAL INFORMATION The facilih requires that a source of pacment by identified to pay for the Resident/Patient's care. A person, other than the resident, mry a ish to be financially responsible for the cost of the care (°};uarrntor^). The facilih does not rcyuire a °guarantor". Name of the "Guarantor': Address: Telephone No.: Work No.; Other No.: (This person(s) must also complete the "Guarantor' information and sign the application.) Has a trust fund been established for the ResidentlPatient?: _l'es _/ o Has a Porver of Attorney been conferred on the person(s) to be financially responsible, or on the pers s) who will act on behalf of the resident (``Responsible Party"j?: Yes _No If yes, please provide a copy. Has a legal guardian been appointed by a court? `Yes `No If yes, please provide a copy. Has a Burial Trust been established?: ,Yes ~o If yes, with whom?: If no, who is the preferred funeral service for the ResidentlPatient's family?: ~i < To process .'our application, the Colloe•ing information is required. The information supplied is wnfidential rod allows us to assist you in your long-term planning. The financial data should be that of the Rcsident/prticnt and or the Guarantor. All income and amounts listed, whether listed under the Resident or Guarantor column, must either be or+'ned by the Resident or in tact be ar'ailable to the Resident to pry for the Resident's stay at the facilih•. Your cooperation is appreciated in order to expedite admission. Plcasc note that it is not mandrtcd that a Resident have a Guarantor, Dole that a source of pryment be identified. Thus, am pecson who agrees to be a Guarantor is doing so voluntarily. ASSETS: Cash Checking Savings Dloney-btarl:et Certificates oC Deposit ' Securities (Stocls/Bonds) Trust Annuities (if not yet paying (R.A monthly) NIONTNLY INCOME: Salary Social Security Pensions/Annuities (iC not above) IRA (if not above) interest/Dividend Income Rental Income Trust Investments/Other Long-Term Care Insutance REAL ESTATE S S GUARANTOR (if any) S 9~Z~' ~i~ /r~ r (descripNon/loca6on) Property: Name on Deed/Title Property: Name on Deed/Title OTHER ASSETS: Cash Value Life Insurance Vested Pension Benefits Business Interests Automobiles Other Total Assets: r NA 3 RESIDENT :< LIABILITIES: Home Mortgage Credit CardslCharge Accounts Loans Other Debts Tales Owed Total Liabilities: NET WORTH: (assets -liabilities} RESIDENT S S _ 3 , pUD` $ / GUARANTOR 5 PLEASE S[CN BELOW: I hereby warrant and represent that the information provided is accurate and complete. I understand that the nursing facility will rely upon the accuracy and completeness of the above financial information in making an admission decision. 1 also understaad that if anc of the information is not accurate or not complete, the Facility will Gave detrimentally relied upon the above financial information and will suffer financial loss and harm. The assets listed are in fact available to the Resident to pay for the Resident's care. ~~~~ t' _ 5;;.~ Resident's or Responsible Party's Signature t;uat antnr.'s Signature Reviewed bv: Admission's Director Signature ~~~ • ~ il~ Administrator's Si ature ?S A/~t o,3 Date Date y ~_s ~3 Date DS~~,~ .~ 4 n. ~~ ~~ o L~ T. ~~~ ~ T~ ~; '_~' ~' ~ ~' a t / `~ v <? ~ \ ' '< T) :.> t~ ~ ._ ~~ ~ 3 i v n HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COiJNTY, PENNSYLVANIA NO ~~y_~{3R; CIVIL TERM ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants. CIVIL ACTION-LAVJ PgAECIPE TO ATTACH NOTICE To: Curtis Long, Prothonotary Please attach the appended Notice to Defend to the complaint filed in this matter. Respectfully submitted, O'BRIEN, BARK & SCHERER. ~~ David A. Baric, Esquire Attorney for Plaintiff I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717)249-6873 HCR MANORCARE, INC., Plaintiff, V. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL TERM CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice 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 agaixist you. You aze 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 LAWS'ER AT ONCE. IF YOU DO OFO ICE SET FORTH BELOW TO FIND OUTO WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE, CARLISLE PENI\:SYLVANIA (717 -249-3166 n G` Q o wn ,_,, ~° a, ~ .y i.•..~ ~ r" !1 e:': ~ ' -[7 Z ~ 'Gi"+ c_ ~ m J '~ ~O HCR MANORCARE, INC., Plaintiff, V. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND CC~UNTY, PENNSYLVANIA NO.~~-y3Rs CIVIL TERM CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice aze 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 maybe 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 OO ICE SET FORTH BELOW ONFIND OUTO WHERE YOU CORN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE, CARLISLE PENNSYLVANIA (717 -249-3166 ra 0 e N O C s ~ ~ ~~r ~ ~ , c'a ~ in ~' W ~ u,: _. c "': :.~ ~~ - + ~ a ~ - ~'. SHERIFF'S RETURN - REGULAR CASE NO: 2004-04395 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS SAXTON ROBERTA L ET AL ROBERT BITNER Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SAXTON ROBERTA L the DEFENDANT at 1355:00 HOURS, on the 1st day of September, 2004 at 1700 MARKET STREET CAMP HILL, PA 17011 by handing to ROBERTA SAXTON a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs; Docketing 18.00 Service 11.10 Affidavit .00 Surcharge 10.00 .00 39.10 Sworn and Subscribed to before me {this iL ~ day of ' lyrotho ota/ r ~ So Answers: ~ ~~ ~~"J"az""ate'" ,,,~.-P R. Thomas Kline 09/01/2004 OBRIEN BARK SCHERER D putt' Sheriff SHERIFF'S RETURN - REGULAR CASE N0: 2004-04395 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS SAXTON ROBERTA L ET AL ROBERT BITNER Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SAXTON WILLIAM the DEFENDANT , at 1333:00 HOURS, on the 1st day of September, 2004 at 530 THIRD STREET WEST FAIRVIEW, PA 17025 by handing to WILLIAM SAXTON a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 11.84 Affidavit .00 Surcharge 10.00 .00 27.84 Sworn and Subscribed to before me this /~ ~ day of ~(o~~ca~ o2 UT7 `~ A.D. a DD.. , "7~ Prothonotary ~ So Answers: ~, .'~ ~•~ x t 4 R. Thomas Kline 09/01/2004 OBRIEN BARK SCHERER By: ~, ~ eputy Sheriff HCR MANORCARE, INC., Plaintiff v. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA N0.2004-4395 CIVIL TERM CIVIL ACTION-LAW PRAECIPE TO ENTER DEFAULT JUDGMENT PURSUANT TO Pa.RC.P. 103? TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, HCR ManorCaze, Inc. and against the Defendants, Roberta L. Saxton and William Saxton, for failure to file an answer to the Complaint of Plaintiff. True and correct copies of the returns of service from the Sheriff of County are appended hereto as Exhibit "A." True and correct copies of the Notices of Default aze appended hereto as Exhibit "B." True and con•ect copies of the Certificates of Mailing for the Notices of Default are appended hereto as Exhibit "C." I certify that the Notice of Default was given in accordance with Pa.R.C.P. 237.1. Plaintiff requests judgment in the amount of $16,713.01 as set forth in the Complaint. Respectfully submitted, O'BRIEN, B ~ SC R David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 SHERIFF'S RETURN - REGULAR CASE N0: 2004-04395 P COMMONWEALTH OF PENNSYLVANIA; COUNTY OF CUMBERLAND HCR MANORCARE INC VS SAXTON ROBERTA L ET AL ROBERT BITNER Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SAXTON ROBERTA L the DEFENDANT at 1355:00 HOURS, on the 1st day of September, 2004 at 1700 MARKET STREET CAMP HILL, PA 17011 by handing to ROBERTA SAXTON a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing .18.00 Service 11.10 Affidavit .00 Surcharge 10.00 .00 39.10 Sworn and Subscribed to before me this day of A.D. So Answers: Q_ i R. Thomas Kline 09/01/2004 OBRIEN BARIC SCHERER By ° ~~~- D putt' Sheriff Prothonotary LIITLL ~l7 ~~p SHERIFF'S RETURN - REGULAR CASE N0: 2004-04395 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS SAXTON ROBERTA L ET AL ROBERT BITNER Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SAXTON WILLIAM the DEFENDANT at 1333:00 HOURS, on the 1st day of September, 2004 at 530 THIRD STREET WEST FAIRVIEW, PA 17025 WILLIAM SAXTON by handing to a true and attested cagy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 11.84 Affidavit .00 Surcharge 10.00 .00 27.84 Sworn and Subscribed to before me this day of So Answers: R. Thomas Kline 09/01/2004 OBRIEN BARK SCHERER By: eputy Sheriff A.D. Prothonotary HCR MANORCARE, INC., Plaintiff v. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants ` TO: Roberta L. Saxton 1700 Market Street Camp Hill, Pennsylvania 17011 Date of Notice: September 22, 2004 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA N0.2004-4395 CIVIL TERM CNIL ACTION-LAW IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FA]I,ED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A NDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bat Association 32 South Bedford Street Cazlisle, Pennsylvania 17013 Telephone: (717) 249-3166 N, BARI ND SC R David A. Baric, Esquire 14 West South Street Cazlisle, PA 17013 (717)244-6873 dab. dir/mano rca re/sexton/roberta default. n tc HCR MANORCARE, INC., Plaintiff v. ROBERTA L. SAXTON and WILLIAM SAXTON, Defendants TO: William Saxton 530 Third Street West Fairview, Pennsylvania 17025 Date of Notice: September 22, 2004 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA N0.2004-4395 CIVIL TERM CIVIL ACTION-LAW IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAII.ED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS 5ET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 RIEN, BARIC D S R David A. Baric, Esquire 19 West South Street Carlisle, PA 17013 (717) 249-6873 dab.d it/ma norcarelsaxton/william d etault.ntc U.S. POSTAL SERVICE CERTIFICATE OF MAILING _ ~ MAV 9E USED FOR DOME TIC AND INTERNATIONAL MAI D N ''_~i4 ~~~ ~<. S PROVIDE FOR INSURANCE-POSTMASTER L, OES OT ^\: a '- ~"~ ~ tg'~~. Received From: 0' 6ri~ , &ric,~ Sch~x~r p ,d ~'y~~tr.-{~ ;' ~' SEF - ' R I `1 WF.s+ South Stmt- ~ 2'; CQrllsl~, P~1 I~pl3 1 2001 . // J `R'~` 7 Or'nn/\ehViec~e to'frLO/r{dinal1ry mail~ad(d~r~e(ssed(t~o: ~ 5 / , ~ ~~"~~~-.~- o m a ~ ~ r I 1\V V~/t IW F~ \Tw/b I'Y I ~DO larK~,+StY ~~.+ ~/~ NW oQ ~_NO DL -z-I ~WT~I~/1 a ' ~ ll t~, //~^ n ~ W~~ ~l ~Il ~ ~ I f~~l ~ v 9 m PS Form 3817, Mar. 1989 ~ .-\ U.S. POSTAL SERVICE CERTIFICATE OF MAILING ~ MAV 9E USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES ~N!~T a PROVIDE FOR INSURANCE-POSTMASTER ,r~'~"~1 ,~ \ ? 'Wt ~~ aa ~ R a ~ i Received From: D'Bri~, Boar, °+- Sch~x~r ;~' SfP I°I 11J~,s~-Sou-V~h Str~~' i !` X2009 Corllsl~, PIS I"IDI3 `~. ~~~,~.~~ One piece of ordinary mail addressed to: "~' m y ~ OO ONJ~D tl~illlum SaXt~n ^' a~ p " UNI ^ CNONr~V , v~ ~' WrrnWN '. 53o Third Strom /] ~a a a l1U~st FOIrUI~, PH I?Da5 m PS Form 3817, Mar. 1989 t/1lCl /J17 ~1~9 CERTIFICATE OF SERVICE I hereby certify that on October 5, 2004, I, David A. Bazic, Esquire, of O'Brien, Bazic & Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the parties listed below, as follows: William Saxton 530 Third Street West Fairview, Pennsylvania 17025 Roberta L. Saxton 1700 Market Street Camp Hill, Pennsylvania 17011 ~/~/~, David A. Baric, Esquire ~9 7U ~ `~ ~ ~ C ~~ ~., ~~, ~ ~ Q ~ ~~='~ ~.- ~~ ~ ~~