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HomeMy WebLinkAbout13-2012 Supreme Co nnsylvania Con leas For Prothonotary Use Only: �!{ C' I�' bv�eryS� Y Docket No: CU R NO I C ount y r� h 13 - 001 iu�l �►� The information collected on this form is used solely for court administration purposes. This fornt does not supplement or re lace the filing and ,service ofpleadings or other pap as required by late or rules of court. Commencement of Action: S [D Complaint ❑ Writ of Summons ❑ Petition Transfer from Another Jurisdiction ❑ Declaration of Taking E C Lead Plaintiffs Name: Lead Defendant's Name: GOLDEN LIVING CENTER CAMP HILL LEONA LINCOURT I Are money damages requested? Yes ❑ No Dollar Amount Requested: ❑X within arbitration limits Y g 9 (check one) ❑outside arbitration limits O N Is this a Class Action Suit? ❑ Yes ❑ No Is this an MDJAppeal? ❑ Yes El No A Name of Plaintiff /Appellant's Attorney: ASHLEY L. SWEENEY, ESQ. PA ID #313667 ❑ Check here if you have no attorney (are a Self - Represented Pro Sep Litigant) Nature of the Case Place an "X" to the left of the ONE case category that most accurately describes your PR /MARY CASE. If you are making more than one type of claim, check the one that you consider most important. TORT (do not include A•IassTort) CONTRACT (do not include Judgments) CIVIL APPEALS Intentional ❑ Buyer Plaintiff Administrative Agencies ❑ Malicious Prosecution ❑ Debt Collection: Credit Card ❑ Board of Assessment Motor Vehicle 0 Debt Collection: Other ❑ Board of Elections ❑ Nuisance HEALTHCARE SERVICES Dept. of Transportation ❑ Premises Liability Statutory Appeal: Other .S ❑i Product Liability (does not include mass tort) ❑Employment Dispute: E © Slander/Libel/ Defamation Discrimination ❑ Employment C ❑Other: Empl Dispute: Other ❑Zoning Board ❑ Other: , T ❑i Other: O MASS TORT Asbestos N [] Tobacco ❑ Toxic Tort - DES ❑ToxicTort - Implant REALPROPERTY MISCELLANEOUS ❑ Toxic Waste ❑ Ejectment ❑ Common Law /Statutory Arbitration Other: ❑ Eminent Domain/Condemnation ❑ Declaratory Judgment B ❑ Ground Rent Mandamus ❑ Landlord/fenant Dispute Non- Domestic Relations ❑ Mortgage Foreclosure: Residential Restraining Order PROFESSIONAL LIABILITY ❑, Mortgage Foreclosure: Commercial ❑ Quo Warranto ❑ Dental ❑ Partition ❑ Replevin ❑ Legal ❑ Quiet Title ❑ Other: ❑ Medical ❑ Other: Other Professional: I i l Updated 111/1011 21 co w z, 71 co rn �. WELTMAN, WEINBERG & REIS CO., L.P.A. = �:o = Attorney forPlaintiff(s) y cn o� BY: Ashley L. Sweeney, Esquire r T° I.D. No.313667 a� s 436 Seventh Avenue, Suite 1400 y = —c Pittsburgh, PA 15219 cz, Phone: 412.434.7955 -` Fax: 412.434.7959 File # 9854204 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION GOLDEN LIVING CENTER CAMP HILL Plaintiff /� vs. Civil Action No. 13 oivi Ierpi LEONA LINCOURT Defendant(s) COMPLAINT AND NOTICE TO DEFEND 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, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 (717) 249 -3166 (, S �ID3•'� P� I V+ - rN', CiF I I05033Y P -1 aBBI S9 COMPLAINT 1. Plaintiff is a corporation with offices at P.O. Box 180970, Fort Smith, AR 72918. 2. Defendant is an adult individual residing at 1540 Third St, Enola, PA 17025. 4. On or about October 19, 2011, Leona Lincourt was admitted as a resident of Golden Living Center Camp Hill. A true and correct copy of the Admissions Agreement is attached hereto and marked as Exhibit "I". 5. Pursuant to said Agreement, services were rendered to Leona Lincourt, for which there remains an outstanding balance due and owing of $2,848.60 as of October 16, 2012. A true and correct copy of Plaintiffs Statement of Account is attached hereto, marked as Exhibit "2 ", and made a part hereof. 6. Plaintiff claims interest at the statutory rate of 6.00% per annum from October 16, 2012. 7. Plaintiff avers that interest calculated at the aforesaid rate from October 16, 2012 to March 22, 2013 amounts to $178.41. 8. Although repeatedly requested to do so by Plaintiff, Defendant has willfully failed and/or refused to pay the aforementioned balance, or any part thereof to Plaintiff. WHEREFORE, Plaintiff demands Judgment in its favor and against Defendant, Leona Lincourt, in the amount of $3,027.01 (principal plus interest) with interest at the statutory rate of 6.00% per annum from March 22, 2013 and costs. THIS IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED SHALL BE USED FOR THAT PURPOSE. WELTMAN, WEINBERG & REIS, CO., L.P.A. As64 L Sw e ney, squire I.D. No. 313 67 436 Seventh Avenue, Suite 1400 Pittsburgh, PA 15219 Phone: 412.434.7955 Fax: 412.434.7959 File # 9854204 TABLE OF CONTENTS I. Preamble II. Parties to This Agreement III. Consent to Treatment IV. Financial Arrangements A. Charges for Self -Pay Residents B. Charges for Medicaid, Medicare and Insured Residents C. Billing and Payment i D. Payment of Refunds Due to You V. Transfers and Discharges VI. 'Bed Holds" and Readmissions VII. Personal Property and Funds Vlll, Photographs IX. Confidentiality of Your Medical Information X. LivingCenter Rules and Grievance Procedure XI. Entire Agreement (and Signature Page) Alternative Dispute Resolution Agreement �C 1131' I I. Preamble This Admission Agreement is a legally binding contract that defines the rights and obligations of each person (or party) who signs it. Please read this Agreement carefully before you sign it. If you have any questions, please discuss them with LivingCenter staff before you sign the Agreement. You are encouraged to have this Agreement reviewed by your attorney, or by any other advisor of your choice, before you sign it. If you are able to do so, you must sign this Agreement in order to be admitted to this LivingCenter. If you are not able to sign this Agreement, your Legal Representative, who has been given authority by you to admit you to the LivingCenter, must sign it on your behalf. This Agreement will become effective on the day you are admitted to the LivingCenter regardless of the date you and/or your Legal Representative signs it. You are not required to sign any other document as a condition of admission to the LivingCenter. II. Parties to This Agreement DEFINITIONS To make this Agreement easier to understand, references to "we," "our," "us," "the LivingCenter" or "our LivingCenter" mean: (Type or print the name of the LivingCenter as it appears on its license) References to "you," "your," "Patient" or "Resident" mean the person who will be receiving care in this LivingCenter. This person is: (Type or print the Resident/Patient's name here) The Necessary Parties to this Agreement are the Resident, the LivingCenter and, if applicable, the Resident's Legal Representative, including anyone who has legal access to the Resident's income and/or resources to pay for the Resident's care. NOTE: Any person who has legal access to your funds or your other assets is your Legal Representative, and your Legal Representative must sign this Agreement as a Necessary Party to this Agreement. By signing this Agreement, your Legal Representative agrees to use your income and/or other resources to pay for your care. Your Legal Representative also agrees (a) to provide complete and accurate disclosure of all relevant information to the LivingCenter, (b) to cooperate fully in applying for all applicable private or governmental benefits to pay for your care, and (c) to fulfill all other fiduciary duties owed to you. By signing this Agreement, the Legal Representative confirms that he or she has legal access to your income or resources to pay for your care. Your Legal Representative also agrees to inform the LivingCenter's Executive Director immediately if he or she no longer has legal access to your income and/or resources. Any Legal Representative who signs this Agreement on your behalf assumes no PERSONAL financial liability for your care provided by the LivingCenter. Our LivingCenter does not require you to have anyone sponsor you or guarantee payment for your care by signing or co- signing this Agreement as a condition of admission, expedited admission or continued stay in the LivingCenter. However, as a Golden LivingCenmrs: Admission Agreement (rev. 12111) 3 Necessary Party.to this Agreement, your Legal Representative agrees to be contractuallybound:by the terms of this Agreement and maybe personally liable for failure to perform duties required by it. UL Consent to Treatment You consent to receive routine nursing care and other care and services provided directly, or under arrangement, by this'LivingCenter. Yon also consent to receive other healthcare services directed by your attending physician as well as necessary emergency care. If you are, or become, incapable of making' your own medical decisions, we will follow the direction of a person with legal authority under state law to make medical treatment decisions onryour behalf such as a:gtwdian; conservator, a person you designate in anadvance healthcare directive or,power of attorney for healthcare, or next of kin. IV. Financial.Arrangements Beginning on (date), we will provide routine nursingapd emergency care and other services to you in exenange forpayinenf. Your attending physician or other.pxactitioners who pTOVtde servtc6 to you.during your,stay in our I ivingCenter`are independent contractors anrl'npt ttre LiumgCenter' §'8gents or employee "s.'They m'ay bill and collect fortfreirservicess'eparateand apart 'from the LivingCenter's..b`ilting and`collections Our LivingCenter participates in the following government insurance programs: Medicare Medicaid Veterans Affairs Other W e.cannot guarantee your care will be covered by Medicare, Medicaid; third - party' insurance or other.reinibursement source. By signing this Agreement you agree to pay your aecount.:with the LivingCenter for.the`items and services provided to you. At the time of admission; you and:you - Le' Representafive prornuse to provide us with all infoirr'atioii. necessary to submit claims and obtain paymenit for your cafe. `We may disclose portions of your medical records to insurance companies, bealthcare service plans Medicare; Medicaid;.TRICARE or other' entities that 'may be liable for all orany portion of the L1vtngCenter's charges for your care in order to determine liability payment or to obtain reirnbursement. If, for any period of time during, which you receive care and services from us, your primary or secondary source of payment changes, you and your Legal Representative promise to give us the updated . information necessary'to submit claims and obtain payment including but not.lirmted to all information required by the State Medicaid.Agency to apply for Medicaid benefits. Your Share of the G'ost of Your Care. Medicaid Medicare or a private insurance plan may require that you pay a co- payment; coinsurance, deductible or other amount; all of which the LivingCenter considers to be your share of the cost of the care and services provided to you: Nonpayment, including failure to pay your share of the cost of your care; is grounds for involuntary discharge from our LivingCenter. If you do not know whether your care in our LivingCenter can be covered•by Medicaid or Medicare; we will help you get the information you need. 4 Golden LivingCentm: Ad ramion Agreement (rcv, 12/11) A. Charges for Self -Pay Residents The basic monthly rate for self -pay and privately insured residents is $ and includes payment for the services and supplies described in the Notices given to you upon admission. We will give you written notice in compliance with applicable state law before increasing the basic monthly rate. The prorated basic monthly rate will be charged for the day of admission, and we may charge for the day of discharge if you depart the LivingCenter after 1 I a.m. Charges for optional supplies and services that are not included in our basic monthly rate are also listed in the Notices given to you upon admission. We will only charge you for optional supplies and services that you specifically request, unless the supply or service is required in an emergency. We will give you written notice in compliance with applicable state law before implementing any increase in charges for optional supplies and services. If you become eligible for Medicaid at any time after your admission, the services and supplies included in the basic rate and the optional supplies and services may change. At the time Medicaid confirms it will pay for your stay in this LivingCenter, we will review and explain any changes in coverage to you. B. Charges for Medicaid, Medicare and Insured Residents If you are approved for Medicaid benefits after you are admitted to our LivingCenter as a self - pay or privately insured resident, you may be entitled to a refund. We will refund any payments made for services and supplies that are later paid for by Medicaid (less any co- payment, coinsurance, deductible or other amount that is your share of the cost of your care) when our LivingCenter receives payment from the Medicaid program. If you are entitled to benefits under Medicare, Medicaid or private insurance, and if we are a participating provider in that program or with that insurer, we agree to accept payment from them for your routine care. However, you are still responsible for paying all applicable deductibles, copayments and coinsurance amounts, as well as any charges not covered by Medicare, Medicaid or your insurance plan. The Notices given to you upon admission describe the services covered by the Medicaid daily rate, services that are covered by Medicaid but are not included in the daily rate, and services that are not covered by Medicaid but are available if you request them and wish to pay for them. The Notices given to you upon admission also describe the services covered by Medicare, and services that are not covered by Medicare but are available if you request them and wish to pay for them.. Medicaid and Medicare will pay for covered supplies and services only if they are considered medically necessary by the Medicare or Medicaid program. If Medicare or Medicaid determines that a supply or service is not medically necessary, or if we believe it is not covered by the rules of the program, we will ask whether you still want that supply or service and if you are willing to pay for it yourself. We will only charge you for optional supplies and services that you specifically request, unless that supply or service is required in an emergency. A detailed list of the charges for all supplies and services is maintained in the Business Office and is available upon request during normal business hours. Goldcn LivingCenters: Admission Agmement (Mv. 12/11) 5 C. Billing and Payment We will give you an itemized statement of charges that you must pay every month. You agree to pay the account monthly on the fifteenth (15th) day ofeach month in which the statement is received. We accept payments in cash, by check or by credit card. You also acknowledge that the charges for services provided under this Agreement remain due and payable until fully satisfied. If you are discharged for any reason, including death, this Agreement shall operate as an assignment, transfer and conveyance to the LivingCenter of the amount of your assets of sufficient value to satisfy all unpaid obligations under this Agreement. This assignment shall be an obligation of your estate and may be enforced against it to pay the LivingCenter an amount equivalent to your unpaid obligations under this Agreement. D. Payment of Refunds Due to You At the time of your discharge, you may be due a refund, such as unused advance payments you may have made for optional services not covered by the basic rate. Upon actual notice of final settlement of all third -patty claims, we will refund promptly any money due to you, after deducting any amounts owed by you to us. V. Transfers and Discharges Except in an emergency, we will give reasonable notice to you before transferring you to another room within our LivingCenter. We will not discharge you from our LivingCenter against your wishes without prior written notice, as required by law. Our written notice of transfer or discharge against your wishes will be provided 30 days in advance. However, we may provide less than 30 days notice: (a) if the reason for the transfer or discharge is to protect your health and safety or the health and safety of other individuals, or (b) if your improved health allows for a shorter notice, or (c) if you have been in our LivingCenter for less than 30 days. Our written notice will include the effective date of discharge, the location to which you will be transferred or discharged, and the reason the discharge is necessary. VI. "Bed Holds" and Readmissions If you will be temporarily absent from the LivingCenter for hospitalization or therapeutic leave, you may request the LivingCenter to hold your bed during this time (called a "bed hold "). The Medicare program and most private insurance companies do not cover costs related to holding your bed in these situations.,We will notify you and/or your Legal Representative of the option to pay the applicable daily rate for each day we hold your bed open. You and your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medicaid is paying for your care, the state Medicaid program may pay us to hold the bed for you for a limited time. If you are away from our LivingCenter due to hospitalization for a longer period of time, we will readmit you to the first available bed in a semi - private room if you wish to be readmitted and if the LivingCenter is able to provide the level of care you need and is otherwise able to meet your needs. VII. Personal Property and Funds We strongly discourage keeping valuable jewelry, papers, cash or other items of value with you in the LivingCenter. You agree to inform us of all valuable property you bring with you upon admission and at any time new items of value are added to (or removed from) your possession. We will make reasonable efforts to safeguard your belongings that you keep in your possession. 6 Golden LivingCcmers: Admission Agreement (rev. I2 )11) i i If our LivingCenter participates in Medicaid or Medicare and you give us your written authorization, we will agree to hold personal funds for you in a manner consistent with all federal and state laws and regulations. You are not required to allow us to hold your personal funds for you as a condition of admission or continued stay in our LivingCenter. Upon request, we will give you our policies, procedures and authorization forms related to our holding your personal funds for you. VIII. Photographs You agree that we may take photographs of you for identification, security and other purposes related to your care. We will not photograph you for any other purpose, unless you give us your prior written permission to do so. IX. Confidentiality of Your Medical Information You have a right to confidential treatment of your medical information. Your confidentiality rights are described in our Notice of Privacy Practices, which is given to you upon admission. You may authorize us to disclose medical information about you to a family member or other person by completing an i Authorization for Disclosure of Medical Information form that will be provided to you upon request. X. LivingCenter Rules and Grievance Procedure You agree to comply with our LivingCenter rules, policies and procedures. When you are admitted to the LivingCenter, we will give you a copy of our rules, policies and procedures. The LivingCenter grievance procedure for resolution of resident complaints is included in Notices given to you upon admission and also is available upon request. XI. Entire Agreement This Agreement and the Notices given to you upon admission constitute the entire Agreement between you and us for the purposes of your admission to our LivingCenter. There are no other agreements, understandings, restrictions, warranties or representations between you and us as a condition of your admission to our LivingCenter. This Agreement supersedes any prior admission contracts regarding your admission to our LivingCenter. However, if you execute, or have executed, an Alternative Dispute Resolution Agreement with us in connection with any admission to our LivingCenters, then that Agreement shall be, and remain, binding upon you, and upon us, in accordance with the terms that are set forth in that Agreement. If any provision of this Agreement becomes invalid, the remaining provisions shall remain in full force and effect. The LivingCenter's acceptance of a partial payment on any occasion does not constitute a continuing waiver of the payment requirements of this Agreement, or otherwise limit the LivingCenter's rights under this Agreement. This Agreement shall be construed according to the laws of the State of Other than as noted for a duly authorized Resident's Legal Representative, the Resident may not assign or otherwise transfer his or her interests in this Agreement. Golden LiviogCcmers: Admission Agmemem (rev. 12111) 7 Resident's Name: _L lmne. Admission Date: Record Number: By signing below, you, your Legal Representative and this LivingCenter agree to the terms of this Admission Agreement: n Representative he LivingCenter ° Date By my signature, I acknowledge that I have read this Admission Agreement or had it read to me, that 1 understand what I am signing, and that I accept its terms. I gnmure of Resident Da[c By my signature, l represent that t am a person duly authorized by Resident or by law to execute this Admission Agreement and that I accept its terms. t 4 &A , & � ib )9 /, mature of Resi cot's Legal Reprc n rive (if applicable) Date �i Dpi tr�S� Eh o� �a 1-7 as 7i7 Goa3SAYO \A css Phonc (VOTE: Copies of all documents verifying the status of the Legal Representative must be obtained at the time of admission. Examples of the required documents include but are not limited to the following: Power of Attorney, Durable Power of Attorney, Healthcare Proxy, Guardianship Appointment, Conservator Appointment and others conveying legal authority. A LEGAL REPRESENTATIVE, INCLUDING ANY PERSON OTHER THAN THE RESIDENT OR FINANCIALLY RESPONSIBLE SPOUSE, MAY NOT BE REQUIRED BY THE FACILITY TO ASSUME PERSONAL FINANCIAL LIABILITY FOR THE RESIDENTS CARE. By signing this Agreement and providing current credit card information, you authorize us to charge all charges under this Agreement to your credit card. If you plan to pay using a credit card, please provide the card information below. Discover` Account# Exp. MasterCard" Account # Exp. Visa" Account# Exp. % Oilokn LivingCcn@rsc Admi.eion Agreement frcv. IIV Ili J ALTERNATIVE DISPUTE RESOLUTION AGREEMENT THIS AGREEMENT IS NOT A CONDITION OF ADMISSION TO OR CONTINUED RESIDENCE IN THE FACILITY I. The Parties to This Agreement This Alternative Dispute Resolution ("ADR ") Agreement (hereinafter referred to as the "Agreement ") is entered into by ( "Facility"), and a Resident at the Facility ( "Resident "). The term "Facility" as used in this Agreement shall refer to the living center, its employees, agents, officers, directors, affiliates and any parent or subsidiary of Facility and its medical director acting in his or her capacity as medical director. The term "Resident" as used in this Agreement shall refer to the Resident, all persons whose claim is or may be derived through or on behalf of the Resident, including any next of kin, guardian, executor, administrator, legal representative, or heir of the Resident, and any person who has executed this Agreement on the Resident's behalf. As used in this Agreement, the term "Party" shall refer to the Facility or the Resident, and the term "Parties" shall refer to both of them. It is the intent of the Parties that this Agreement shall inure to the benefit of, bind, and survive them, their successors, and assigns. 11. Voluntary Agreement to Participate in ADR The Parties agree that any disputes covered by this Agreement ( "Covered Disputes ") that may arise between them shall be resolved exclusively by an ADR process that shall include mediation and, where mediation is not successful, binding arbitration. The parties to this Agreement acknowledge and agree that upon execution by Resident, this Agreement becomes part of the Admission Agreement, and that the Admission Agreement evidences a transaction in interstate commerce governed by the Federal Arbitration Act. The relief available to the Parties under this Agreement shall not exceed that which otherwise would be available to them in a court action based on the same facts and legal theories under the applicable federal, state or local law. THE PARTIES UNDERSTAND, ACKNOWLEDGE, AND AGREE THAT THEY ARE SELECTING A METHOD OF RESOLVING DISPUTES WITHOUT RESORTING TO LAWSUITS OR THE COURTS, AND THAT BY ENTERING INTO THIS AGREEMENT, THEY ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE THEIR DISPUTES DECIDED IN A COURT OF LAW BY A JUDGE OR JURY, THE OPPORTUNITY TO PRESENT THEIR CLAIMS AS A CLASS ACTION AND /OR TO APPEAL ANY DECISION II OR AWARD OF DAMAGES RESULTING FROM THE ADR PROCESS EXCEPT AS PROVIDED HEREIN. c Except as specifically provided in this Agreement, the Parties' resort to a court of law shall be limited to an action to enforce a binding arbitration decision entered in accordance with this Agreement or to vacate such a decision based on the grounds set forth in the Federal Arbitration Act, 9 U.S.C. sections I- 16, or the law of the state where Facility is located. The Parties agree that the speed, efficiency, and cost - effectiveness of the ADR process, together with their mutual undertaking to engage in that process, constitute good and sufficient consideration for the acceptance and enforcement of this Agreement. Golden LivingCenmrs: Alrema&e Dispute Resolution Agreement pev. 12/11) I 1 III. Covered Disputes This Agreement applies to any and all disputes arising out of or in any way relating to this Agreement or to the Resident's stay at the Facility or the Admissions Agreement between the Parties that would constitute a legally cognizable cause of action in a court of law sitting in the state where Facility is located. Covered Disputes include but are not limited to all claims in law or equity arising from one Party's failure to satisfy a financial obligation to the other Party; a violation of a right claimed to exist under federal, state, or local law or contractual agreement between the Parties; tort; breach of contract; consumer protection; fraud; misrepresentation; negligence; gross negligence; malpractice; and any alleged departure from any applicable federal, state, or local medical, health care, consumer, or safety standards. Nothing in this Agreement shall prevent the Resident from filing a grievance or complaint with the Facility or appropriate government agency, from requesting an inspection of the Facility from such agency, or from seeking a review under any applicable federal, state, or local law of any decision to discharge or transfer the Resident. This Agreement also shall not prevent any Party from seeking interim equitable relief from a court of competent jurisdiction to prevent irreparable harm or to preserve the positions of the parties pending arbitration, or to seek appointment of an arbitrator. In addition, the parties are not precluded by this Agreement from seeking remedies in small claims court for disputes or claims within its jurisdiction. All claims based in whole or in part on the same incident, transaction, or related course of care or services provided by the Facility to the Resident shall be addressed in a single ADR process, which shall adjudicate solely the claims of the Parties named in this Agreement, and no others. A claim by the Party initiating the ADR process shall be waived and forever barred if it arose and was reasonably discoverable prior to the date upon which notice of arbitration is given to the Facility or the Resident and such claim is not presented in the arbitration proceeding. A claim that is not brought within the statute of limitations period that would apply to the same claim in a court of law sitting in the state where Facility is located also shall be waived and forever barred. IV. Administration and Process Covered Disputes, including the determination of the scope or applicability of this Agreement, shall be determined by arbitration in the federal judicial district in which Facility is located or the hometown of Resident, before one arbitrator. The arbitration shall be administered by JAMS pursuant to its Streamlined Arbitration Rules and Procedures in cases where no disputed claim or counterclaim exceeds $250,000, not including interest or attorneys' fees, and by its Comprehensive Arbitration Rules and Procedures in all other cases.I Judgment on the resulting arbitration award may be entered in any court having jurisdiction. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. Prior to the appointment of the arbitrator, and within 10 days from the date of commencement of the arbitration, the parties shall submit the dispute to JAMS for mediation. The parties will cooperate with JAMS and with one another in selecting a mediator from JAMS panel of neutrals, and in promptly scheduling the mediation proceedings. The parties covenant that they will participate in the mediation in good faith, and that they will share equally in its costs. All offers, promises, conduct and statements, whether oral or written, made in the course of the mediation by any of the parties, their agents, employees, experts and attorneys, and by the mediator or any JAMS employees, are confidential, The Parties may also agree in writing on another substantially similar method of administering ADR. If JAMS is used, the applicable rules arc available on the internet at huv://www .iamsadr.conilmim-download.mlc . In the event that JAMS is unable or unwilling to administer arbitration, a substitute arbitrator will be appointed pursuant to section 5 of the Federal Arbitration Act. 12 Golden LivingConters: Alternative Dispute Resolution Agreement (rev. (12 111) privileged and inadmissible for any purpose, including impeachment, in any arbitration or other proceeding involving the parties, provided that evidence that is otherwise admissible or discoverable shall not be rendered inadmissible or non - discoverable as a result of its use in the mediation. If the dispute is not resolved within 30 days from the date of the submission of the dispute to mediation (or such later date as the parties may mutually agree in writing), the administration of the arbitration shall proceed forthwith. The mediation may continue, if the parties so agree, after the appointment of the arbitrators. Unless otherwise agreed by the parties, the mediator shall be disqualified from serving as arbitrator in the case. The pendency of a mediation shall not preclude a party from seeking provisional remedies in aid of the arbitration from a court of appropriate jurisdiction, and the parties agree not to defend against any application for provisional relief on the ground that a mediation is pending. V. Costs and Fees Where Resident initiates arbitration against Facility, the only fee required to be paid by Resident is $250, which is approximately equivalent to a court filing fee; all other fees and costs, including any remaining JAMS case management fees and professional fees for the arbitrator's services, shall be paid by Facility. Where Facility initiates arbitration, Facility will pay all fees and costs associated with the arbitration other than Resident's attorney fees, if any. The Parties shall bear their own costs and attorney's fees except that the arbitrator may, in the Award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator and the reasonable attorneys' fees of the prevailing party. Notwithstanding this provision, in California the Resident may not be required to pay the fees and costs of Facility if the Resident does not prevail. VI. Governing Law Except as otherwise provided herein, this Agreement shall be governed by and interpreted under the Federal Arbitration Act, 9 U.S.C. §§ I et seq. VII. Severabillty If any provision of this Agreement is determined by a court of competent jurisdiction to be invalid or unenforceable in whole or in part the remainder of this Agreement, including all valid and enforceable parts of the provision in question, shall remain valid, enforceable, and binding on the Parties. VIII. Proof of Agreement The Parties agree and stipulate that the original of this Agreement, including the signature page, may be scanned and stored in a computer database or similar device, and that any printout or other output readable by sight, the reproduction of which is shown accurately to reproduce the original of this document, may be used for any purpose just as if it were the original, including proof of the content of the original writing. This agreement shall be binding upon the Facility when signed by or on behalf of the Resident, regardless of whether this Agreement has been signed by a Facility representative. IX. Resident's Understanding The Resident understands that he or she has the right to seek advice of legal counsel concerning this Agreement; that his or her signing of this Agreement is not a condition of admission to or residence in the Facility; that he or she may revoke this Agreement by sending written notice to the Facility within thirty (30) days of signing it; and that this Agreement, if not revoked within that time frame, shall remain in effect for all care and services rendered to the Resident at or by the Facility regardless of whether the Resident is subsequently discharged and readmitted to the Facility without renewing, ratifying, or acknowledging this Agreement. Goldin LivingCentra: Almmntive Dispute Resolution Agreement (rev. 12/11) 13 THIS AGREEMENT GOVERNS IMPORTANT LEGAL RIGHTS. PLEASE READ IT CAREFULLY AND IN ITS ENTIRETY BEFORE SIGNING. Print Name of Resident Print Name and Nun bcr of LivingCenter f �- � � \ b cu gnutt[f'e��cs�i�en� Date By my signature, l acknowledge that 1 have read this Agreement or had it read to me, that 1 understand what 1 am signing, and that 1 accept its terms. Signature on behalf of LivingCenter. 1, 1 �yw�c ���(�c`����� (name of LivingCenter witness), sign this Agreement on ` e If of LivingCenter. By my signature, I attest that (1) before Resident and/or Resident's representative signed this document I offered the signer(s) the opportunity to read it in full, or to have it read to him/her in full; (2) 1 saw the signature of the resident, or of the person signing on behalf of the Resident, written on this document. 'S ignMure of Resident's Legal Repro tntive �'rt(t Name of Legal Represem ivc By my signature, I represent that I am a person duly authorized by Resident or by law to execute this Agreement and that I accept its terms. '14 cify Cupaci6iW Legal Repres: ( e.g., Power of Attorney. Agent, Next of Kin) AAA rces Phone Other acknowledgments: Printed Name and Signature ofother Representative or Next of Kin Date Printed Nam and Signature of Other Representative or Nest of Kin Date Printed Name and Signature of Other Repnscntative or Nest of Kin Date Golden Livin4O'oaets: Alternative Dip le ttesolun,. Agrectnou (rev. 01.t10i 1} d Golden Living Center a GGNSC Camp Hill III LP e� 46 Erford Rd Itemized Hill, PA 17011 Resident Statement Residem Name: Melling Address: RESIDENT ACCOUNT a: Leona Lincourt 112868 -03959 -93002 Leona Lincourt 1540 Third St DATE PREPARED: Enola, PA 17025 10/16112 DATE / PERIOD COVEREE DESCRIPTION DAYS/QTY CHARGES CREDITS Dec 2011 Television Service $11.50 Jan 28-31 2012 Medicaid Portion $752.48 Jan 2012 Television Service $11.50 Feb 1 -29 2012 Medicaid Portion $1,112.52 Feb 2012 Television Service $11.50 March 1 -5 2012 Medicaid Portion $940.60 March 2012 Television Service $11.50 April 2012 Pa ment $3.00 Discharge Date 03/06/2012 CHARGES CREDITS AMOUNT DUE $2,851.60 $3.00 $2,848.60 Page 1 oft EXHIBIT VERIFICATION The undersigned does hereby verify subject to the penalties of 18 PA. C.S. 4904 relating to unsworn falsifications to authorities, that he /she is (NAME) 6 of b A plaintiff (TITLE) (COMPANy) herein, that he /she is duly authorized to make this verification, and that the facts set forth in the foregoing Complaint in Civil Action are true and correct to the best of his /her knowledge, information and belief. G 0 7 h JUA WWR# 9854204 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff ut+w���fa r FILt0' F.F1CF' OF THE PRO x HONE TAR r Jody S Smith Chief Deputy 1 2 : Richard W Stewart Solicitor OF910EOrT�4r$4ER,rP CUMBERLAND COUNTY PENNSYLVANIA Golden Living Center Camp Hill Case Number vs. 2013-2012 Leona Lincourt SHERIFF'S RETURN OF SERVICE 0411812013 07:26 PM-Deputy Jason Kinsler, being duly sworn according to law, served the requested Complaint& Notice by"personally"handing a true copy to a person representing themselves to be the Defendant, to wit: Leona Lincourt at 540 Third Street, West Fairview/East Pennsboor�o, Enola, PA 17025. I - Jx+ /JASON KINSLER, DEPUTY SHERIFF COST: $44.50 SO ANSWERS, April 22, 2013 RONW R ANDERSON, SHERIFF (c)QountySub Shentt,Teleosoat,Inc. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION - : - GOLDEN LIVING CENTER CAMP HILL N v `.. uo Plaintiff vs. Civil Action No. 13-2012 CIVIL TERM 17 O 7'-*" � r, LEONA LINCOURT Defendant PRAECIPE FOR DEFAULT JUDGMENT TO THE PROTHONOTARY: Kindly enter Judgment against the Defendant,Leona Lincourt above named, in the default of an Answer, in the amount of$3,067.75 computed as follows: Amount claimed in Complaint $3,027.01 Interest from March 22, 2013 to June 17, 2013 at the rate of 6.00% per annum $40.74 TOTAL $3,067.75 I hereby certify that appropriate Notices of Default, as attached have been mailed in accordance with PA R.C.P.237.1 on the dates indicated on the Notices. WELTMAN, WEINBERG&REIS CO.,L.P.A. By: 1L William T. Molczan squire PA I.D.#47437 Weltman,Weinberg&Reis Co.,L.P.A. 1400 Koppers Bldg. 436 Seventh Avenue Pittsburgh,PA 15219 (412)434-7955 WWR#9854204 Plaintiff's address is: c/o Weltman, Weinberg&Reis Co.,L.P.A., 1400 Koppers Building,436 7th Avenue,Pittsburgh,PA 15219 And that the last known address of the Defendant is: 1540 THIRD ST,ENOLA,PA 17025 CM+ S 119 6A1 CX--0114/Rq(0 [2:*a CI e9t4 Sl, 14,().Ge ,Nl .1?J 9 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION GOLDEN LIVING CENTER CAMP HILL Plaintiff CASE#: 13-2012 CIVIL TERM LEONA LINCOURT Defendant IMPORTANT NOTICE TO: Leona Lincourt 1540 Third St Enola,Pa 17025 Date of Notice: 61 I i3 YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED 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 JUDGMENT 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, GO TO OR TELEPHONE THE FOLLOWING OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER,THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE,PA 17013 (717)249-3166 WELTMAN,WEINBERG&REIS CO.,L.P.A. By: Matthew D. Urban, Esquire P.A.I.D.#90963 436 Seventh Avenue, 1400 Koppers Building Pittsburgh, PA 15219 Phone: (412)434-7955 WWR#9854204 IN THE COMMON PLEAS COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION GOLDEN LIVING CENTER CAMP HILL Plaintiff Civil Action No. 13-2012 CIVIL TERM vs. NON-MILITARY AFFIDAVIT LEONA LINCOURT Defendant The undersigned is the duly authorized agent and/or attorney for the Plaintiff in the within matter and states as follows: Affiant states that the within Affidavit is made pursuant to and in accordance with the Servicemembers' Civil Relief Act (SCRA), 50 U.S.C. App. 521. Affiant further states that based upon investigation it is the affiant's belief that the Defendant, Leona Lincourt is not in the military service. Affiant further states that this belief is supported by the attached certificate from the Defense Manpower Data Center (DMDC), which states that the DMDC does not possess any information indicating that the below individual is in the military service: LEONA LINCOURT 1540 THIRD ST ENOLA, PA 17025 Affiant further states that the averments contained herein are true and correct to the best of Affiant's knowledge, information and belief and that these averments are made subject to the penalties of 18 Pa C.S.A. §4904 relating to unsworn falsification to authorities. 0,6114,41/ - Affiant Results as of:Jun-20-2013 07:32:48 Department of Defense Manpower Data Center SCRA 3.0 Status Report aAe � A ,;£ Pursuant to Servicernembers Civil Relief Act Last Name: LINCOURT First Name: LEONA Middle Name: Active Duty Status As Of: Jun-20-2013 On Active Duty On Active Duty Status Data Active Duty Start Date Active Duty End Data Status Service Component NA NA No. NA This response reflects the individuals'active duty status based on the Active Duty Status Date Left Active Duty Within 367 Days of Active Duty Status Date Active Duty Start Date Active Duty End Date Status Service Component NA NA No NA This response reflects where the individual left active duty status within 367 days preceding the Active Duty Status Date The Member or His/Her Unit Was Notified of a Future Call-Up to Active Duty on Active Duty Status Date Order Notification Start Date Order Notification End Date Status Service Component NA NA No NA This response reflects whether the Individual or his/her unit has received early notification to report for active duty Upon searching the data banks of the Department of Defense Manpower Data Center,based on the information that you provided,the above is the status of the individual on the active duty status date as to all branches of the Uniformed Services(Army,Navy,Marine Corps,Air Force,NOAA,Public Health,and Coast Guard). This status includes information on a Servicemember or his/her unit receiving notification of future orders to report for Active Duty. HOWEVER,WITHOUT A SOCIAL SECURITY NUMBER,THE DEPARTMENT OF DEFENSE MANPOWER DATA CENTER CANNOT AUTHORITATIVELY ASSERT THAT THIS IS THE SAME INDIVIDUAL THAT YOUR QUERY REFERS TO.NAME AND DATE OF BIRTH ALONE DO NOT UNIQUELY IDENTIFY AN INDIVIDUAL. Yhm,„ye Mary M.Snavely-Dixon,Director Department of Defense-Manpower Data Center 4800 Mark Center Drive,Suite 04E25 Arlington,VA 22350 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION GOLDEN LIVING CENTER CAMP HILL Plaintiff vs. Civil Action No. 13-2012 CIVIL TERM LEONA LINCOURT Defendant NOTICE OF JUDGMENT OR ORDER TO: ( )Plaintiff (xx)Defendant ( )Garnishee You are hereby notified that the following Order r J dg ent was entered against you on (xx) Assumpsit Judgment in the amount of$3,067.75 plus costs. ( ) Trespass Judgment in the amount of$ plus costs. ( ) If not satisfied within sixty(60)days,your motor vehicle operator's license and/or registration will be suspended by the Department of Transportation,Bureau of Traffic Safety,Harrisburg,PA. (xx) Entry of Judgment of ( ) Court Order ( ) Non-Pros ( ) Confession (xx) Default ( ) Verdict ( ) Arbitration Award 40,41) Prothonotary By: PROTH TARY(OR DEP TY) LEONA LINCOURT 1540 THIRD ST ENOLA,PA 17025 Plaintiff's address is: c/o Weltman, Weinberg&Reis Co.,L.P.A., 1400 Koppers Building,436 7th Avenue,Pittsburgh,PA 15219 1-888-434-0085