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Home My WebLink About04-6232 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, P A 17013 Plaintiff, v. No. CJ.I-I..::J.J d....... C l 'u L~'ER.... """J DAVID ARMENTO 714 Range End Road Dillsburg, P A 17019 Defendant. CIVIL ACTION - LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by 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. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, P A 17013 (717) 249-3166 94156 AVISO USTED HA SIDO DEMAND ADO/ A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y A viso radicando personalmente 0 por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se Ie advierte de que si usted falla de tomar acci6n como se describe anteriormente, el caso puede proceder sin usted y un faIlo por cualquier suma de dinero reclamada en la demanda 0 cualquier otra reclamaci6n 0 remedio solicitado por el demand ante puede ser dicta do en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero 0 propiedad u otros derechos importantes para usted. USTED DEBE LLEV AR ESTE DOCUMENTO A SU ABOGADO INMEDIAT AMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VA Y A A LA SIGUIENTE OFICINA. EST A OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE P AGAR paR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE EST A OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, PA 17013 (717) 249-3166 94156 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, P A 17013 Plaintiff, v. No. {:)L.f - t.r.;<J~ C0~tr<i.JLVl DAVID ARMENTa 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW COMPLAINT AND NOW, COMES, Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center (" Claremont"), by and through its attorneys, Latsha Davis Y ohe & McKenna, P.C, and files the within Complaint against Defendant, David Armento, and in support thereof, provides as follows: 1. Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center (hereinafter "Claremont"), is a county residential long term skilled nursing care facility whose offices are located at 1000 Claremont Road, Carlisle, Pennsylvania 17013. 2. Plaintiff Claremont owns and operates a long term care facility, providing medically necessary nursing services to the citizens of the Commonwealth, located at 1000 Claremont Road, Carlisle, Pennsylvania 17013. 94156 3. Defendant, David Armento (hereinafter" Armento"), is an adult individual currently residing at 714 Range End Road, York County, Dillsburg, PA 17019. 4. Defendant Armento is the son, and was the attorney-in-fact and person responsible for the financial affairs of Rosalie Armento, deceased. 5. Rosalie Armento was admitted May 23, 2003 to Plaintiff Claremont's nursing care facility. 6. On or about May 23, 2003, Plaintiff Claremont and Rosalie Armento, by and through her attorney-in-fact Defendant Armento, entered into an Admission Agreement (" Agreement"), pursuant to which Plaintiff Claremont agreed to provide Rosalie Armento with nursing care in exchange for the payment of a specific monetary fee. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and made a part hereof. 7. Pursuant to the Agreement, Rosalie Armento, by and through her attorney-in-fact Defendant Armento, agreed to pay Plaintiff Claremont for the nursing care services which it rendered to her. 8. Defendant Armento, as Rosalie Armento's attorney-in-fact and person responsible for her financial affairs, agreed to perform Rosalie Armento's duties pursuant to the Agreement, namely to use Rosalie Armento's assets and/ or resources to compensate Plaintiff Claremont for the nursing care and services which it provided to Rosalie Armento. 94156 2 9. Defendant Armento has failed to use Rosalie Armento's assets and/ or resources to pay Plaintiff Claremont for the nursing care and services which Rosalie Armento received at Plaintiff Claremont's nursing care facility. 10. As a result of Defendant Armento's failure to pay Plaintiff Claremont for the nursing care and services which it rendered to Rosalie Armento, an outstanding balance accrued and became due and owing in the amount $27,664.13. A true and correct copy of the A/R Account Detail from May 23, 2003 through October 28,2004 is attached hereto as Exhibit NB" and made a part hereof. 11. As Rosalie Armento's attorney-in-fact and responsible party, Defendant Armento had a fiduciary duty to use Rosalie Armento's assets and/ or resources to insure that her account with Plaintiff Claremont was kept current. 12. Defendant Armento has failed to use Rosalie Armento's assets and/ or resources to keep current her account with Plaintiff Claremont, and, instead, upon information and belief, has converted and/ or transferred Rosalie Armento's assets and/ or resources to himself and/ or others. 13. At the time of her admission to the nursing facility, Rosalie Armento possessed in excess of $80,000.00 of assets and received monthly social security and pension income in the amount of approximately $760.00. A true and correct copy of Rosalie Armento's Admission Application containing her financial data is attached hereto as Exhibit "C" and made a part hereof. 94156 3 14. Upon information and belief, Defendant Armento received Rosalie Armento's monthly pension and social security checks. 15. Upon information and belief, Defendant Armento breached his fiduciary duties owed to Rosalie Armento, to which Plaintiff Claremont is a beneficial party, by converting and/ or fraudulently transferring Rosalie Armento's assets and/ or resources to himself and/ or others. 16. Upon information and belief, Defendant Armento converted and/ or fraudulently transferred to himself and/ or others Rosalie Armento's assets and/ or resources to hinder or delay their transfer to Plaintiff Claremont. 17. Rosalie Armento died on July 14, 2004, and to date, no estate has been opened on her behalf. 18. A balance in the amount of $27,664.13, plus interest is currently due and owing to Plaintiff Claremont for the nursing care and services that it provided to Rosalie Armento. COUNT I - BREACH OF CONTRACT - ADMISSION AGREEMENT 19. Paragraphs 1 through 18 above are incorporated herein by reference as if fully set forth at length. 20. Rosalie Armento, by and through her attorney-in-fact Defendant Armento, entered into an Admission Agreement with Plaintiff Claremont whereby Plaintiff Claremont agreed to accept Rosalie Armento as a resident at Plaintiff Claremont's nursing care facility and to provide her living accommodations, dietary 94156 4 services, medication/ pharmacy services, and general nursing and medical care, in exchange for Defendant Armento's promise to pay a specific sum to Plaintiff Claremont. See Exhibit" A", 21. From May 23, 2003 through October 29, 2003, Plaintiff Claremont provided nursing care and services to Rosalie Armento pursuant to the aforementioned Agreement. 22. From May 23, 2003 through the present, Rosalie Armento has carried an overdue balance in her account with Plaintiff Claremont. 23. A balance in the amount of $27,664.13, plus interest is currently due and owing to Plaintiff Claremont for the nursing care and services that it provided to Rosalie Armento. 24. Defendant Armento's failure to keep Rosalie Armento's account with Plaintiff Claremont current from Rosalie Armento's resources constitutes a breach of the Agreement. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in an amount in excess of $27,664.13 plus interest. COUNT II - QUANTUM MERUIT 25. Paragraphs 1 through 24 above are incorporated herein by reference as if fully set forth at length. 94156 5 26. Plaintiff Claremont has demanded payment in full for the nursing care and services which it provided to Rosalie Armento, and Defendant Armento has failed to pay. 27. Defendant Armento has been unjustly enriched and enhanced by the receipt of the care and services which have been rendered to Rosalie Armento by Plaintiff Claremont in an amount in excess of $27,664.13 plus interest. 28. Plaintiff Claremont is entitled to receive payment in full for the reasonable value of the nursing care and services provided to Rosalie Armento. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in an amount in excess of $27,664.13 plus interest. COUNT III - BREACH OF FIDUCIARY DUTY 29. Paragraphs 1 through 28 above are incorporated herein by reference as if fully set forth at length. 30. Defendant Armento, at all times material to this cause of action, represented himself to be Rosalie Armento's attorney-in-fact and person responsible for her financial affairs. 31. Defendant Armento, at all times material to this cause of action, acted as Rosalie Armento's attorney-in-fact and person responsible for her financial affairs in dealing with Plaintiff Claremont. 32. As Rosalie Armento's attorney-in-fact and person responsible for her financial affairs, Defendant Armento has a fiduciary duty to Rosalie Armento, to which 94156 6 Plaintiff Claremont is a beneficial party, to insure that Rosalie Armento's account with Plaintiff Claremont is kept current by using Rosalie Armenta's assets and/ or resources to pay Plaintiff Claremont for the nursing care and services that it rendered to Rosalie Armento. 33. Defendant Armento breached his fiduciary duties owed to Rosalie Armento, to which Plaintiff Claremont is a beneficial party, by failing to use Rosalie Armento's assets and/ or resources to keep Rosalie Armento's account with Plaintiff Claremont current, and, instead, converting and/ or fraudulently transferring Rosalie Armento's assets and/ or resources to himself or others. 34. As Rosalie Armento's primary care giver, entity responsible for her day- to-day care, and beneficiary of the power-of-attorney, Plaintiff Claremont, as a direct result of Defendant Armento's breach of his fiduciary duties owed to Rosalie Armento, has incurred damages in excess of $27,664.13 plus interest. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in an amount in excess of $27,664.13 plus interest. COUNT IV - CONVERSION 35. Paragraphs 1 through 34 above are incorporated herein by reference as if fully set forth at length. 36. Upon information and belief, Defendant Armento converted, misappropriated and deprived Rosalie Armento of her right in, use and/ or possession of her property as more fully set forth above. 94156 7 37. Upon information and belief, Defendant Armento's conversion, misappropriation and deprivation of Rosalie Armenta's right in, use and/ or possession of the aforementioned property has been beyond Defendant Armento's authority as Rosalie Armento's attorney-in-fact and for the purpose of hindering or delaying their transfer to Plaintiff Claremont. 38. As a result of the foregoing unlawful actions of Defendant Armento, Plaintiff Claremont has incurred damages in an amount in excess of $27,664.13 plus interest. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in an amount in excess of $27,664.13 plus interest. COUNT V - FRAUDULENT TRANSFER 39. Paragraphs 1 through 38 above are incorporated herein by reference as if fully set forth at length. 40. Upon information and belief, Rosalie Armento, by and through her attorney-in-fact Defendant Armento, transferred her assets and/ or resources without adequate consideration and for the purpose of hindering and delaying their transfer to Plaintiff Claremont. 41. Upon information and belief, Defendant Armento accepted the transfer(s) of Rosalie Armento's assets and/ or resources with full knowledge that the purpose of the transfer was to avoid paying Plaintiff Claremont for the nursing care and services that it has rendered to Rosalie Armento. 94156 8 WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento an amount in excess of $27,664.13 plus interest. COUNT VI - EQUITABLE SUPPORT 42. Paragraphs 1 through 41 above are incorporated herein by reference as if fully set forth at length. 43. Upon information and belief, Defendant Armento, as Rosalie Armento's attorney-in-fact, transferred Rosalie Armento's assets to himself or otherwise misappropriated said assets. 44. Upon information and belief, the above-referenced transfer and/ or misappropriation of assets rendered Rosalie Armento indigent and unable to pay the outstanding balance owed on her account. 45. Pursuant to 62 P.s. S 1973, the children of indigent parents have an obligation to support their parents. 46. Defendant Armento is Rosalie Armento's son. 47. As a result of Defendant Armento's transfer or misappropriation of his mother's assets, Defendant Armento had the ability to satisfy his mother's debt to Claremont. 48. By transferring or otherwise misappropriating his mother's assets and failing to pay for his mother's care, Defendant Armento violated 62 P.s. S 1973. 94156 9 WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento an amount in excess of $27,664.13 plus interest. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.c. Dated: /;l. /0. o..{ By: ~)J) - .- Kimber L. Latsha, Esq. Attorney I.D. No. 32934 Steven M. Montresor Attorney I.D. No. 74244 P.O. Box 825 Harrisburg, P A 17108-0825 (717) 761-1880 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing & Rehabilitation Center 94156 10 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILIT A TION CENTER, 1000 Claremont Road Carlisle, PA 17013 Plaintiff, v. No. DAVID ARMENTO 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW VERIFICATION I, Mary Kimmel, hereby verify that I am the Finance Manager for County of Cumberland, Claremont Nursing & Rehabilitation Center; that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. S 4904, relating to unsworn falsification to authorities. Dated: /~~(}~ /P~~ 7If,,,~,, / Mary~J[#"'('tl- 94156 O. -v1 t ~)'{Llr" . ~ I" :.Ji!/t .Q. ~ S- IV' 9' ~ ~ 1000 Claremont Drive Carlisle, PA 17013-8805 main (7171243.2031 fax (717) 240-1952 c.R...ehabilitation Center /) ~...(J{iilL Resident Name ADMISSION AGREEMENT (.1 /' - I .6'. t(.1/JrLi1[W As part of admission to Claremont Nursing and Rehabilitation Center, the Resident and the Responsible Pan,! assisting the resident acknowledge and agree to the following: 1. If Claremont Nursing and Rehabilitation Center determines that the Resident is net appropriate or does not qualify' for nursing home care, the .Resident will discharge from Claremont Nursing and Rehabilitation Center following a 30 day notification of the need to make alternate living arrangements. 2. If the Resident cannot qualify' for coverage under the Medical Assistance or Medicare programs, the Resident will pay daily rate for care at the nursing facility. 3. The Responsible Party (guarantor) assures that the Resident's bill will be paid from the Resident's assets/funds. If the Resident does not have personal funds or when personal funds are exhausted, the Responsible Party will make application to Medical Assistance on behalf of the Resident. If the Resident does not qualify' for Medical Assistance funding. the Responsible Party will arrange discharse for the Resident if the bill is not paid in aqmely manner. 4. Tne Resident author.zes Claremont Nursing and Rehabilitation Center to release information concerning their assets, real or personal, to the Cumber1and County Board of Assistance. 5. If the Resident is being covered by the Medical Assistance Program, the Resident and Responsible Party recognize that all income the Resident receives during the month of admission, must be paid to the Claremont Nursing and Rehabilitation Center, regardless of the day of admission, unless waived by the Cumberland County Board of Assistance. The Resident and Responsible Party acknowledge that all future income received by the Resident. while covered under the Medical Assistance Program, must be paid to Claremont Nursing and Rehabilitation Center. Income not applied to charges for care will be placed in the Resident Guest Fund or refunded. /j"(hiN1?/1?Jb 01 ~~~t Signature ~~r1< It;/l;C /)JHlr Vfttness ' J / (;'JcI.4~. /L<1'-; '2..~ J!e:, R~~iblt: I"arty S na /1/': - '~'1'/ . / ( /12 II. /'/ 1,I.f(..L' /) / . . . ~ v "" I __ ---r '- l '_ ~ Witness I J /)L: .92.02- V.J '_ .J .-J Date 05,,3j.oj Date 05.!}?;.()3 Date 05.33(>3 Date $'1 service agency of Cumberland County ., . ..:"'~~=:. .<t:-, .. Charges due and owing at December 31, 2003 May 2003 Medicare Co-Insurance June 2003 Medicare Co-Insurance June 2003 Private Pay Bill July 2003 Private Pay Bill August 2003 Private Pay Bill September 2003 Private Pay Bill October 2003 Private Pay Bill $925.75 $2,730.00 $780.00 $6,226.67 $6,095.82 $6,012.98 $4.892.91 $27,664.13 Total Due and owing at December 31,2003 06/22/2004 Resident Open A/R File [PA614] 4329 Rosalie SArmento G/L Due Fin Type Notes Fac State B111 date From Cl Level Chg. Balance ---------- ----------- PA 05/31/2003 PP MCA SNF COIN 925.75 PA 06/30/2003 PP MCA SNF COIN 2,730.00 PA 06/30/2003 PP PP SNF RB 780.00 PA 07/31/2003 PP PP SNF RB 6,045.00 PA 07/31/2003 PP PP SNF ANC 181.67 PA 08/31/2003 PP PP SNF RB 6,045.00 PA 08/31/2003 PP PP SNF ANC 50.82 PA 09/30/2003 PP PP SNF RB 5,850.00 PA 09/30/2003 PP PP SNF ANC 162.98 PA 10/31/2003 BC PP SNF ANC -0.01 PA 10/31/2003 PP PP SNF RB 4,875.00 1 PA 10/31/2003 PP PP SNF ANC 17.91 I~ ~laremon~ ur vel arl1sle' PA 1701: t 5 FEO. TAX NO. JeSTA~I~ '17covo.1 717\ /40-1q08 23-100::111 05/301 05310j 004 lENT NAME 13 PATIENT AOORESS rfT1F>nt () 1 Rs>~F 1 i A U 100~ C-T,ARF:MONT ROAn c-1Rr,rsT.F. PA 'l"THDATE ~15SEX 16 MS .1DA1( ~I" 1"II'E, 2D SAC 21 OHA 22STA423 MEDiCAL AECORONO. :M > 21 ~1 , .~r.~,~.?1 J ~ ~'~ OCOJlRENCl:SPAH 37 I 0A1( ,,- I ~ DAn I ...., ',I I ca;v, 0;; 90l 0~0~ 39 VAlUE CODES ~ ~ I 4:,pg 8 N-C O. I 9 C-l ~'J 10 L-R O. 11 I 2] ..-'. .~ ~ : L:- 0~ 000 c d I ~ v. co. 4J OESCRIf'TlOH 4A HCPCSI RATES 45 SERVo DATE 46 SERVo UNITS 022 PPS ROOM AND BOARD CHARG RHC11 12Q R & B NURSING CARE - SEX 195.00 25G PHARMACY 30Q LABORATORY 3oJ5'J. 42G PHYSICAL THERP 42~ PHYS THERP/EVAL ~3G OCCUPATION THERP 43~ OCCUPATION THERP/EVAL ~4Q SPEECH PATHOL 44~ SPEECH PATHjEVAL 05270::. ~ ;: :;7)..} "i pt"tl r 17')). (, e OW~S i "4 ~ peA - l't.).$' ; 1;5 7~ '1JJl,." 00~ TOTAL CHARGES r~ ;:, 'n'- i' r ?,\!~. .,; .....J_ . - ~ :. ,; 'J.) , ...~ Cl~~.~ .<~-.1L~~-.o .......:.1 ,,~t \. ,'l"'[o'yr;, . .. .. ,-" ~ YER r~~~"1 , i I ' 'UJ=I~:{8JI~'~)jj~.~ . I59PREL 60 CERT.-SSN.HIC..tONO. 61 GROUPNAME 0':' 207071008A I 0:. 207074008 51 PROVIOER NO. ed:care Part t... rivate Pay 0395660 0395660 ;UPEO'S NAME rmento Rosalie S rmento Rosalie S 0>- ThlENT AlffiCA1ZATION CODES 64 ese 65 EMPlOYER NAME 66 EMP'. Oyr.1ol LOCATION 1~.;A;':'1;5719 r- ~';'~',~-~ V:7d I ,",..9. 80 PRINCIPAl PAOCEfjlJRE " 6~ COOE I OAre COOf l 1lA1( , --r. 1I J -'~"""r"I'''''i~ ~~s 390004 - 03/19/03 TO 03/22/03 95223 - 03/22/03 TO OS/22/03 95660 - OS/23/03 - ADMIT DAY 63 41 CODli VAlUE cooes N<<>>fI 47 TOTAl CHARGES 48 NON-COVEREO CHAAGES 49 ~ 9 1.00 17551.00 ~. 44 13~. 00 2 111' 1 4 641< 60 4471.53 671.57 21 71' 1 4 1 2 1~. 2 4 . ! ~ 1 2897[.66 55 EST. AMOUNT OUE 56 62 iNSURANCE GROUP NO. ,,~ I l76 AOM. OIAG. CD. I T7 E.cooE r _.1:.". -l r V454 82 ATTeONG PliYS. to In r~--''I'' E OATE C2777? HARM. Mn KF.NNF.TH R 83 OTHER PHYS. ID 01llEll PHYS. 10 -4CFAo-'''50 ",,",OVEDOMa NO. ~n 85 pt:NWl REPA~TlVE X ~~~ ilL .04'1< coPY, 06/17/2003 I CUlFf M CV<lW:AnoHSOH _ ~......' TO THIS IOU. """ __ 10 '_HEMOl'. _" ____ _ _.._"_ _~'_'____ _. _ _ __ ~ _____~_. ___ __"_ _ __ _"___ __"____ ____ ___ _J_.__ __'__'___ _..._----- . arl isle. PA-i"70;';"''i\ \ 5 FED. TAX NO. 18STA~T~ 17COVO.J 8~0. 717) 240-1908 23-600311~ 06010~ 06260~ 02~ lENT NAME ,\." 13 PATIENT ADDRESS rmento, Rosalie S ~ 1000 CLAREMONT ROAD CARLISLE PA 17013 ;~A;191 ~'5S; 16~ 05230~ ::'rmeli~ 21DHRI22~A~23 ~E;~l;ECORDNO. I 2< " ~~ m31 1~01~ ~ I 't~o.ci;:1~7e 0~~m03: ~ VAUJEX ~~~ll:{.)l"J.~' 4~ l!- 05 00~L7 3~.0~ ~ l b i c I d ! 4329 9 C-l2D~ 10 l-A D.' " 21: . V~ COOES AlICU~ --r- i ! ! V. co. 43 OESCRIPTlOH u2~ PPS ROOM AND BOARD ~2~ PPS ROOM AND BOARD ~2: PPS ROOM AND BOARD L20 R & B NURSING CARE 2 se PHARMACY 3100 LABORJI.TORY *2~ ~HYSICAL THERP !30 OCCUPATION THERP !4e SPEECH PATHOL 44 HCPCS f AA TES CHARC: RHCll CHARG RHC07 CP3\R(~ RMB02 - SEV 195.0e 4S SERVo DATE 46 SERVo UNiTS 05270~ 060503' 06210:7 47 TOTAl CHARGES 5" ~00 1 6 ~ 00 5 ~ 00 26 5070~00 139~94 51~82 840~03 734~80 72t38 6908197 46 NON-COVEREO CHARGES 49 ! t i )0: TOTAL CHARGES ,....... "~. "I.' ,....;;1>, ;::? J.- , ~ '"l t ;-.-:. J. .-'!!:-' co~.~ ")130.00 ~ . ~ '. rl : f"'.:l'1") ~~ ,! r.. J") L1\ :-..~..' :':.::\\~It(~~_ .~.: ;'.: ....,;.,. --n C;~ I!:"S.5~ . :.' _ __"':\__ -...J r 'ER :d:care Part A ~ivate Pay/" 51 PROVIDER NO. 0395660 0395660 '?!i!:- '!~y 54 PRIOR PAYMENTS X 'x 55 EST. AMOUNT CUE 66 ;REJ'S NAME :men:'o Hosa 11 e S 'mento Rosa 1 i e S I 'lIJ=t.;l'JI~I:l.:.tl/::tl'J~ .::.. 59 P.RR 60 CERT. - SSN - Hie. ' 10 NO. ~1 211n10/4\ljlt)oA 01 207074008 61 GROUP NAME 52 iNSURANCE GROUP NO. "i "'~ AlJTHQRIZA nON COOES 51 s: 65 EMPlOYER NAME 66 EMPlOYEtI lOCA nON ---1 .., "'" ':7:1 V'!,'r19 r 'J~'I~ v.~ r-"Q~~- riF-' · .,:-0'. i"'\:"" -.... r- ~''lioi''~''')'''''''i'IIf , OTIiERPROCECURe __.-..I.\I';'.I:.;....,.,~ OT1EA~ COllE I DAre ...--.: ,_~.il:.." ".I I COllE ! CAre ~a ~~00J~ - 0~/1~/~~ 10 03/LL/0J 5223 - 03/22/03 TO OS/22/03 5660 - OS/23/03 - ADMIT DAY 63 /26/03 - DISCHARGE TO NON-CERT BED 1'COllE r-.t-..'1176~~.~I:.CD.1 n WlDE 1-78 S2 A TTENllfHG PHYs. 10 C 2 I 7 72 HARM, HU Kt;NNf;'1'H ~, 83 OTHER PHYS. 10 OlHe.q PHY5. 10 xl~1tl 811 D/lTE 07/21/2003 1=A-1450 _OVED 0'" NO._79 COPY! I csnrrlHlCllln'lCAl1OOOS 0II_1IE\ISl$I! -.. TO....IIIU. _ _ __ A '__. v v 'V. '-' ~ cu. cUlVlll. lJ1: 1 ve 4329 r- ',ar'lisle PA 17013 717) 243-2031 5 FED. TAX NO. J e srA19IENTCOVERSPeAlOO J 7 COVDJ , 2 s- 600311 ~ 0~0~ 0~~L=j 00'1 .nENT NAM€ 113 PAnoo ADDRESS .rmento, Rosa 1 i e S IATliDATE J15SEX 16~! '~Illlt. ~I" T'lPEtlD SAC 21 DHR 22srA~23 MEDICAL AECOAD NO. 909191l ~ 1 0b~/01 I I 3~ 4329 'I""'T IM~-r~ )~,t~./<"'!.. 8 N-C D. 9 (;.1\1'110 L-R D., 11 ~~M~ 1~1~~M31 37 A B OSALIE SARMENTO 'AVID P ARMENTO 14 RANGE END RD 'ILLSBURG, PA 17019 311 COOE VAUJE CODES .<llCUIT . ~. .1/. '... ':>:---41 ~COOE ! ! I 48 NON-a)VERED CHAAGES 49 . VAWE COOES AIICI.W1' a b c d EV. CD. 43 DESCRIPTlON 44 HCPCS/RATES 45 SERVo DATE 12~ a & ~ NUaSING CArtE - SE~ 135.0e 48 SERVo UNITS 47 TOTAl CHARGES 4, 78010~ 00: TOTAL CHARGES 4 I ,YEA ~.r.JA..;:" ?AY I "C'LAaZ:'-!ONT :....[pi; ~ ""''', ~"lII=1~:l'MI:l.:.;II:i{~" ..... 59 P REL 00 CERT.' SSN - HIC. -10 NO. 61 GRCtJP NAME . 01 207074008 55 EST AMOUNT DUE 56 ,URED'S NAME l-laell..o Ro::.alie 5 62 INSURANCE GROUP NO. -. E.\ moo AlITHOAIZ4 nON ceDES 61 ese 05 EMPlOYER NAME 66 EMPLOYER LOCA nON rs'tCDI 2~~ . 90 PRINCIPAL PRoceDURE COllE I OA rE OlliER PROCEDURE COllE , [lATE ! 82 ATTENDING PHYS.IO C27 772 I i..l\RN, 11D KI::JNI:TII a '" COOE r--.... '.-- r. cooe r-~-'J:''''.~ 176 ADM. OIAG. cD.ln E.cOOE I 24';3 I In 83 OTHER PHYS.IO \lAA~S OTHER PHYs. iO as PIlOVIOER ~...nVE x 8lI 0.\." 07/15/2003 -<<;FA-14SO AP~OVED OW8 NO 0008-027. COPY t I CPll'n TIll C!JITFlCA nooos 011_ AEVEIlSf:......y TO.....IIIU. /IMIJ ... __ . '_-.of'. -'- ~~~ ~laremont Drive . '. 0 5 "'" TO. NO J · STATBlENT CO\IEl'lS PERIOO' \7 ,.,.., D I ar 11 s 1 e P A .1 7 13 ",ov "^ . _ TIflOUGII: vv.. 717)' 243-2031 23-600311 07010j 073103 031 ,TtENT NAME 113 PATIENT ADDRESS r~entol RI~lie S ';;~TEl q 1 JS; 16M~ '7;; 0 r' r ~I i SAC 21 DHR 22STA~23 MEDICAL;ECORDNO. 0CCl.IlAENCE " . ..J ;~,~. ~ ClCC\.lRREIIa: ., .,~.. ~". 36 ~SPAN , I Mn ,.. .. '"1-1 Mn . " ... - """"" 311 _ ClllJ( VAlUE COOES ~ OSALIE SARMENTO AVID P ARMENTO 14 RANGE END RD TLTSRURG, PA 17019 ?-t. CD. 43 DESCRIP'TlON a b c d 44 HCPCS I RATES 45 SERVo DATE 46 SERV. UNITS 12Q R & B NURSING CARE - SE~ 2Se..PHARMACY 195.0~ 001 TOTAL CHARGES YEll I r~'~~"'1 I ! '1IJ=4ot;{'Mi:J:.l')::U1.... ~. i 59 p.Ra 60 CERT. ,SSN ' HIC. .10 NO. 61 GROUP NAME Sf oRQVIDER NO. :l::V.ll.TE PAY CLAREMONT ;UREDS NAME :omenta Rosalie S 01 207074008 "'" TMENT AVTOORtZA TION CODES 66 EMP\.OY~R VJCATlON 61 Ese 65 EMPLOYER NAME ~;:CO'I 2;~ ,"X", ~-, lQClllJ( r'&'~~~ClllJ( r~~'~':" ~ 80 PRINCIPAlPROCEOURE 61 OlliERPAOCEDuAl: -'" firll1' ~.t;,'".''''''' ~ coce I OAT< COOE I DAT< .- ..,~~ OTHEllPAOCEDURE ~"":!":L;.' .....;~. OlllER~E COOl! ! DATe ~-1--"--' '.-...... ClllJ( ! Do\Te " COOE l~ I 4329 9C40'I'OL.f40'1" 31 1 32 S K-C D. 37 A. B ,,",-- 'f-ia.II~.;:.''''~.' ~ .l."'~ ..'T'........." COO! i ! . i I i 41 TOTAl CHARGES . VAUJE cooes . .oMOOHT 46 NO~VEl\EO CHARGES 49 6045;00 181[67 55 EST. AMOUNT DUE 56 . i . I I ! r ~I" _ y.. '. XAt.4 176 ADM. DIAG. CD. I TT E.cooE 1 2449 Ij2 INSURANCE GROUP NO. 178 82 A lTENDlNG PIfYS. 10 C27772 HARM, MD KENNETH R 53 cme PHYS.IO \ARKS OTHeR PHYS. 10 as PROVIOER AEPAESEHT ATIIIE x I f III Drill: I 08/18/2003 i , 'CfJm'"f7Hl! CSII1I'lCA11ONSOH7Hl! __ ","",-YY07NS 1lU___ AP__. :FA-14!O """ROVED 0... PoO. ~79 COPY! ~'" I ,-.-...u :ft1{:;,,~~ C1;;~~~OI~:' Crit/e ~ t'~~::\..J':..~:"!.:'~;'. :il::~ i::, -~S 2;' !.'{r313 5 FED. TAX NO. . ~6srA~COVERS~ ~7COVO.~ '-i-\ 74J-~031 23-60031'1 08010~ 08310 03 - ., - f ::~~::~M~, t. o. 2,".3 a ~ ~ p. s 113 PATIENT ADDRESS iRTHOATE 115SEXI'6MSI'7 DAre ~, 1Il'tP[, 20 SAC 21 OHR ,22STATl23 MEOlCALRECORO NO. ):"':~719:~~ ~ ~ tI)c:2!el~ I I 3~ 4329 OCCURRENCE ,~.w,.,.:, '.~ 3C OCCURRENCE \jc~.,...:,.;:-".".-c.*" 36 OCClJRRENCESPAH . I M' ,0=...''''....<,..... -, M' ~1".].','"'- - - - 3Il CODe VAUJE cooes AWOIIo'T ~.~5~~L:E SARMENTO a b c d 44 HCPCS I RATES 4S SERV. OA TE 5::;0{ 195. 0~) 46 SERVo UNITS ~.;::, '.j : D i? ,';...qNEN:.'O : 14 R.;"t.!(;Z SI'1D F.O ~:LLS2U~C. ?~ 1701? EV. co. 43 OESCRIPTlON ~. ;. ._ t"J ~. '.... ~~ l.}L7:~~3:~~G '^." n~ ................:".t:J - ~:.s0 ?H::.RMACI 0001. :rc'r.L\L C~i.~'":\CES 'AYER 51 PROVIOER NO. "~~;Jiii 54 PRIOR PAY!.lE~"_,,,:,::. t_ ,-.~..i:tf.:Vli.)r~'r . .,}IJ::J:i;C.M l;'{:'ill=~f (~~ 59P.RElI so CERT. ,SSN.HfC. ,10 NO. 161 GROUP NAME - ~ 0,' ~j .:"'9 .:.... ~ :.. /..., ..; ~SURED'S NAME ..~ ~. ~-::._Jl ~~: ~'. ,,) r"J- .:.: r... : ~ ~ .... ~/:. ~ L. '...~ t:/: ; '!'{j~;:::. 'PEATMENT AUTHORIZATION COOES 51 ESe 65 EMPLOYER NAME 66 EMPLOYER LOCATION ::'~i o~~~ Col :.? 0'j r .~- c so PRINCIPAL PROCEDUFlE ccce I CArl OtHER PAOCEllURE COllE f DAre i 8 N-C O. 4329 9 Cl 0'110 L-R 0'111 I ~s 131 2< I :0 "'-'1 28 n 3G 37 A B ~~.'Il ,\"~;h.-;d,,._. .1 . ............... ._.. .,I'l~ CCX1E VAUJE COOES AMO\M' 47 TOT AI. CHARGES 48 NON-COVEREO CHARGES 49 '<? -:.!o4~. ;jtt 5"-i 8? ,. - 60')5.82 55 EST. AMOI.JNT DUE 56 62 :NSURANCE GROUP NO. r="'Il.~fii>~CO'?fb 1. CODE r-.v... ,.,.....1 176 ADM. DIAG. CD. I T7 E-COOE ~..z..1: ': il2 A T:'ENOING PHYS. 10 [n r'..... 'wi al ,OtHERPROCEl).JP.E, ~~.... ..:.,...._,.::!\......~ COllE l OAre '~. '" ..... .. :.~, ~~.;-':"'l~;.. -",., '''':1.\ IM~, OTHER RE ~'""f~-:" ~~r-- .. '~I CClOE I DAre I....~-..l J\I COllE C-:II/~ 83 one PHYS. 10 ;SIAAFlKS OirIER PHYS. iO '85 PROVIDER REPAESEHTATIIIE 811 DATE 11/19/2003 x Z HCFA-14SO ,."PROVED 0"8 NO. ot38-027V COPY, .-!A.:<.M, 1"\0 !\.::.,Nl'I.c:..i:rl rt I CQIF( 1Ill CIllTI'ICATIOHSON _ _ AWl,y TO 1lIS.u. """ _ _A '_'-. c~; { .;;; ~~,v;~0~~ l"e ~~"::'}~3;'-1:~.1."'(8-~~~9~0'Cl~iCOVERS0J. ~93f"a..17 ~v3D.l 8 N~D. . ~' .1. -;) .2 '1 3 -;:;;} 3 1 ~ oJ V ~ \Ii $ ~ f 1U v \;i ~ 'fJ ~ ;~J:>j::~ ~ r;. :.-. '..:: S 2: 1 i e .., 113 PATIENT ADDRESS ;IPThDA~ ~ .115~116MS.I I7~TE ~llIlYI'I!l2DSIlC 21DHR22ST~TI23MED~RECORDNO. I Z4 ~ ~I - 21 n' 30 131 (.)90'.:~d' 1: .~ 00270~ I I ..J~ 4::129 I I I · i'iW ~l~~'?:~~_1 t",<~<;a'b ~....- : 39 VAI.lJECOOES ". ~'''''-'!';II.-,{.~ ,..,,~. 41 COOE oIloIlllMf ~~)..... ".: ~ COllE lGSALIE :.; ~.RHSNTO a JA'lID f A..8.ME:l-lTO b - 1 ~i RAl'JGE EN"D &0 c I ::LLSEURG, FA l7019 d ! Ev. CD. 43 DESCRIPTlON 44 HCPCS f RATES 4S SERV. DATE 46 SEflV. UNITS 47 TOTAl CHARGES 46 NON-COVEflEO CHARGES 49 ~l=e n & 3 ~lj~S:NG CARE SSM 195.00 3~ 5B5~.00 ":50 PP.ARMAC~ 161,98 ~1l(JO.:. TOTA.:. C~'iARGES 3:.. - )j Cl ~jJ'~ 9 C-l Q.!,0 L-R 0.\11 ~ I VAWECOOES .u.tOUNT R. _=.: T.....::;:, ~: ..Co...{ 5\ PROVIDER NO. e L.!"-..R.E:MONT "'f~'..r'~~ " '.".: ~, 54 PRIOR PAYMENTS 55 EST. At.lO\JNT QUE 56 YEM : -.;' :~ i-. r. !":: S~.::'.,'= ~ ! i -= t..J "lIJ=I;;t;{.Jl~I1:/:.JII::t{i. .. 5~ ?REL so C8'lT. . SSN - HIC. ' iD NO. to t :! 0 7 =/-' 7 t.]. ~; ,: ~ 61 GROUP NAME 62 INSURANCE mm\;p NO. ~A=il'S NAME 'A TMENT AUTHORIZA noN ceOES 64 61:1 65 EMPLOYER NAME 66 EMPLOYEfl LOCA nON ~il~.'A,GJ.'.CO'1 llIICODe r_r",~ 7llCOCE ~I' 'T.?1i!d:~ESccoe r~"f'" ,,?co:.' > 1 ;?, "i 2. I '80 PRINCIPAL PROCEDURE 81 Oll1EllPROCEllURE ....~ -lIitn; ';1.. ,=": ~;'::Jll:~ cellE I DATE ClXlE l OATE ........,.- . ____\!:I,. '''~'' . ~O\.. O1l1ERl'ROCEOURE '~l:' -.i,:r.'v:. ",.; "-._~ OTHERP~Rf COllE I OATE ~~;.. ~~".~,,, .'-'~ COllE I OATE 74 ooce r.~v'.... .~~ 176 AOM;O'AG.co'ln E..:oOE I "" 't ,1::; 176 82 A TTENOING PHYS. 10 C 2 II! :: l:- .J:...i.,M. , }tj) lZeJ"iL~t;'l'h ):( Il3 0THell PtfYs. 10 "'~~s OnEA PHYs. \D 85 PROvIOER REPRESl:NT A nve x 1I8 04TE 11/19/2003 FA-14SO _OVEll 010111 NO. oe:JII..4279 COPV1 1___CERtWlCA1lCO<S0II_RlftlIK",",,-YTlln.IIU.___A'___. ~..~....,.,.",,,V:':.... 1JJ.. ,Lve -::3i:'1 is [.8 E\; :. 7013 5 FED. TAX NO. 16STA~~VERS~ 17COVO.1 ! 7l! i ~~3'-2031 ~~-o!()(Ojli.~ J.'f)ilI.l;')f "!'iQ<::c0f 0Lr '~~'~~;~:M~ L ':::. r :~,.:; s c< ! :. a S 11J PATIENT ADDRESS 5IRTI'DA~ . !15SEX!16MSI 170A,T!_ ~1"TmllllSAC 210HR22STATI23 MEDIClL RECORD NO, !; So 'J = i '! i. ~.,: ~ t! t.O t i "' V) t' I I ...J r ~ 3 ~ :.: OCCURRENCE ~.~ ~~, .'.'i!.i.::.,.':..,.~ 34 OCCURRENCE. f<f<__~ ~ '.'.~"l J6 OCCURAENCESPAH !lE I Oo\TE ~;.1iJ,,,,....,{, ~ cooe DATE ~ " "'~~ COOE FllOW TItAOUGIl ," .,' I - . . . 39 COllE VAlUE CODES NI(U{f ~~SAL:~ 5 AJ~ENT0 a b c d 45 SERVo DATE 48 SERVo uNITS .~~-,jiD ~ ..~..~~loiE~iTO ~' 1;; HA:\f:;8 END RD 0IL~3EU?S. ?A 1701S ~EV. CD. 4J DESCRIPTION 44 HCPCS I RATES :,j'_ '-~: tlo t.~ ~.;, d'J:_{.:J,l~.~..j ~J"'oo\.t<.c; ~,: 5:; PI Lb~Ei--L~_C-:{ ~ :.~ ~ ;. ~~; ~} \-~~M " ~2i~ TO?AL CEA~GES "~~ f 51 ?RO'lIDER NO. ~~Mt1~i'r 54 PRIOR 1>,~YMENTS - '.-. - -, ::... ~ -~ ;-'{-!. __.!'"':...:"'...~..,,:.t~ J.:,'",:" i1 Ii ::t~:{.J,r;il:l.:. t, I ::Ill;~"" IS.....~=:; S ~JAME ..~..,..>;-.~{J ..J.-.::.~"::j ~~ ~ ~9 P OSl 00 CEAr.' SSN - HIC ,10 NO. 51 GROUP NAME '_:' _ .:~ ',,) -, I:) I =-=- .,) ~:: .~. 'EAT'.IENT AUTHORIZATION COOES II ESe 55 EMPlOYER NAME 66 EMpt.OYEA lOCATION 8 J<l.C0. q.,j~::f 9 C~ 0'110 l-R 0'111 . -;, I Z' I ~ n ~ IJI :rT A B C ~." "~. 'f::,"~l\i-=-:-"~.,,,.'J'~~ 41 ~.:;~~, . l,t4!liBlJj cooe VAUJE CODES AOIOlHf 47 TOTAl. CHARGES 48 NON.CQVERED CHARGES 411 " - .!..: .: '4" ~'\\~ ,; d! 7 ~ ., r' ~ 4~:3'j~ 73 : ".. l('~~Ji.J -pel'- :.::~ 4'1.)(.t5~" '-I '7 3j, ., t , / 1.. i - b ,f /11 (. fCd.tr J ~/_'l1!.._IW~ e.ri,t 55 EST AMOUNT DUE 56 62 INSURANCE GROUP NO. ll~l, :~;~ col ~ ~ ~ r- ,..., . 'JC PRINC:P~L pqOCEOURE . dl , CODE I o.tE ~.-'J"".~ 176 A~M:.O~~CO.~ n.~DI" I I": H I 82 ATTENOING PIfIs, 10 ... - .- - -. -. :_....: . J_ In O;:~EA PIlOCCOUAE COOl: I o'~ i PlJiFR D~G. COOES . 1'0 COllE r."....,.,..... ,~, l '2 COllE r"''''' ..".~ OTHER PROCEDURE .~~.. "." ' .c, .. ,..5.~~' COllE I Oo\TE ~;utt-"~~'::r:" .,~'4,.,.-.~.<~ ,~~.l,j.. "". ;.' -",;, .~..;~. OTHER RE ,~ It.,~'r~-;Al . - ',"~~i!: COllE I 0Al1; 83 onEIl PIfI$. 10 11 COllE ,....RKS On-tEll ptlYS, ill 85 PROVIDER AEPAESeIT A fiVE 811 DATE 11/19/200.3 x ~':~~,"J:4 , ~~.;) X:;:~~~.;=7~~ C'. 1c:tJmFY _ (;BI11ACA_ OlIll41 RE'I!RSE In\.' TO nos 1lU._" _ AP__. HCFA-l450 ""PROVEn 0". NO._79 copy, -- -- ------- - ------ --------.------------ . ~ '~ -{ .. ,,, ,,' ;. \ I.' ., \,t j{Uro . ul/'-t ~9 t- 1000 Claremont Road Carlisle. PA 170 1).8805 rmin (717) 2043.2031 fax (717) 2"0-1952 abilitation Center APPLICANT FULL NAME ~\ ,'-e., S - ~ "eJ"n~b) PER.\tlANENT ADDRESS' \ (X") hranAO^ Wu vx- TELEPHONE # I 'l,() 0 40 ~ 3 SOCIAL SE<llJRlTY # 7 0-, tY,l..I ooR BIRTHDATE 9,9-/'> RELIGION ('a..--r-r.('l\;C tvlARlTAL STATUS v\lIdovJ-e..d SPOUSE NAME DID APPLICANT OR SPOUSE SERVE IN THE MILITARY? Y\ 0 BRANCH NA1\4E OF VETERAN . IS THE APPLICANT A UNITED STATES CITIZEN? '/ D PRlMARY FA..WLY CONTACT PERSON: ~ v \ 'd ~r 'fY\...1l r'\-\O Name and Relationship I \L\ Ro.~ CVlC\ roo c\ Address G .soY"". W ~ ~. -36S' I ~ E:!.ome Telephone # U\\\spv(O\ PA 1,0 \'1 \ J Work Te!ephone # SECONDARY CON1ACT PERSON: ~";::>I7D \ d S+v(')~ - 'O("DT"n.Q \? t Name ansi.Relationship 4 f2.Cll \ r oa c.\ A:.v ~ . YV\.t c.. VI. ~ 1\ Address ,10" 0 9/Y 0 Home Telephone # \lus S- Work Telephone # - DOES APPLICANT HAVE A LEGAL DURABLE POWER-Of-A TIORNEY? Y ~- <; Name and Relationship Address Telephone # TYPE OF NURSING HOME ADMISSION ANTICIPATED: , _ '\ IL to r-e..+Vr'f'. -\v OJ-1 \oo\C. ~o\l'\-t LONG TERM CARE : I (' a. \.:l u we V 'd \ 'C...( SHORT TERM REHAB "? IS APPLICANT HOSPlT ALlZ~D PRESENT!, Y? n D ADMISSION DATE 5- d"3 ' 03. A. HOSPITAL W.Q..S,+ S.nOf~ \.\e~\~ ~'t-..c... ~ SOCIAL WORKER W'~\o,...d\ AV\'e f'4~()""'" PHYSICIAN TELEPHONE # 7b3 - -r'O, 0 .tl sen~ice a!!fl1ctl of Cumberland C'Owllu ~ APPLICATION PAGE 2 \ EST OTHER HOSPITAL k'-:D l'.1..iRSP.-iG HOME STAYS r.-.r THE LAST 60 DAYS: -l:Aj S0 ~ -{ 3 -.;> ~ () z, - p re. >.e~ DOES THE APPLlCA~"T HAVE A HISTORY OF MES"! AL HEALTH TREA TME~"T? no HEALTH rnSlJRANCE POLICY NUMBERS: MEDICARE '2- 0 70 -, L} COG A BLL'E CROSS R 20'1 C1 \ \ 3 0 MEDICAID BLUE SHIELD AARP PACE OTHER LONG TER..\I CARE INSt.JRANCE FDiANCIAL STATUS: SOCIAL SECURITY S 500 . ~ A.~l't"UITY CNCOME S PENSIO:-; s z..~ 0 ' 00 OTHER S ASSETS: .' CHECKING ACCOUNT-BA4'lK tili\ApolY\.t . r'Y\\c\?€nn k\.!OUNTS I.00D- ?-OO- SA VrNGS ACCOlJr-.i.BANK J f")O'flL A..vIOU>IT S CERTIFICATE OF DEPOSIT-BANK r..O . AMOUNT $ CASH AND/OR OTHER INVESTME:--ITS 80,0:::0 - \-\'2~~( + p,;"''f\-v.\-v- c....C.lOlJlts LIFE R-iSlIRANCE.COtvIPA='iY '1." FACE VALUE S . - \ REAL ESTATE-LOCATION r"O f'\~ N.6.,M:E (S) ON DEED VALUE S LIST ANY AND ALL ASSETS THAT HAVE BEEN TRANSFERRED DURING THE PAST 3 YEARS, ~Cu..iDING THE DATES OF TRANSFER Ov,<- Y 0.. va 0.. r ~ \ (., o~ V\ (jfV'.-L- DOES THE APPLICANT ~VE A WILL? '1 e...<;. EXECUTOR'S NA."v{E \ c.or.+c-..c.+ EXECUTOR'S ADDRESS EXECUTOR'S TELEPHONE # (H) PREFERRED FUNERAL HOME (W) f"c\ \/'$.J~ rv f"\.,L '- a...1 o ~C.h. "CJ ...-...L Address TeIephone # ARE ARRANGEMENTS PRE-PAID? "J e. s (. ~ """c... .\... u ^ PLEASE INCLUDE COPIES OF APPROPRIATE CARDS (SOCIAL SECURITY, MEDICARE, ETC.). PLEASE ADD ADDITIONAL SHEETS Of PAPER TO EXPLAIN INSURANCE INFORMATION. YOUR PHOTOGRAPH WILL BE USED FOR IDENTIFICATION PURPOSES IN THE MEDICAL RECORD Al"ID ELSEWHERE AS NEEDED FOR PROPER IDENTIFICATION. '-A../vr~ " ...~~: '"' t~~ -e> ~ Ii) ~ N .....? _ ) ...0 \' (t'" 1J \l'r~ f '-Z -, n l.:;> r:' ~,:' o -n I ~~ ;=rl (- -., J-n . 'j ~~) (~.) ;.:,') ,-, . 'J J. ',.1 r" ~ '~ r"l ~~ c-' G IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND CLAREMONT NURSING AND REHABILITATION CENTER, : 1000 Claremont Road Carlisle, PA 17013 Plaintiff, No. 04 .- 6232 Civil Term v. DAVID ARMENTO 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW NOTICE TO PLEAD TO: County of Cumberland Claremont Nursing and Rehabilitation Center c/o Latsha Davis Yohe & McKenna, P.e. Attn: Kimber L. Latsha, Esquire P.O. Box 825 Harrisburg, P A 17108-0825 You are hereby notified to file a written response to the enclosed Defendant's Preliminary Objections to Plaintiff's Complaint in the Nature of a Motion to Dismiss for Failure to Join a Necessary Party within twenty (20) days from service hereof or a judgment may be entered against you. Date: .,2/'I/OS ~ DaCd'~ ' IN THE COURT OF COMMON .PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND CLAREMONT NURSING AND REHABILITATION CENTER, : 1000 Claremont Road Carlisle, PA 17013 Plaintiff, No. 04- 6232 Civil Term v. DAVID ARMENTO 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW DEFENDANT'S PRELIMINARY OBJECTION TO PLAINTIFF'S COMPLAINT Defendant, DAVID ARMENTO, pro se, preliminarily objects to plaintiff's complaint pursuant to Pa. R.C.P. 1028(a)(5) as follows: PRELIMINARY OBJECTION RAISING NONJOINDER OF A NECESSARY PARTY 1. Plaintiff's complaint is based upon his claim that defendant is liable to plaintiff on a contract entered into between the plaintiff and defendant on behalf of defendant's mother on May 23, 2003. A copy of the Admission Agreement, attached to the complaint as Exhibit "A", is attached hereto as Exhibit "A". 2. Under the Admission Agreement, defendant, as responsible party under a durable power of attorney, was to assure that the resident's bills were to be paid from her funds. 3. The durable power of attorney became null and void upon the death of defendant's mother, Rosalie Annento on or about July 2004. 4. The decedent had a will which named two sons, neither of whom is the defendant in the instant matter as co-executors of her estate. 5. Under the contract agreement for nursing care services, the Estate of Rosalie Armento has a joint and severable liability to plaintiff in any claim and recovery under the Admission Agreement. 6. defendant. The Estate of Rosalie Armento has not been joined in the action as a party 7. Pursuant to Pa. R.C.P. 2227(a), the joinder of the Estate of Rosalie Armento in this action was compulsory. 8. No reason appears in the complaint for the omission of the Estate of Rosalie Armento as a party to this action. 9. indispensable dismissed. The Estate of Rosalie Armento is accordingly a necessary and party to this action and its absence requires that the complaint be WHEREFORE, defendant respectfully requests that his preliminary objections be sustained and plaintiff's complaint be dismissed. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND CLAREMONT NURSING AND REHABILITATION CENTER, : 1000 Claremont Road Carlisle, PA 17013 Plaintiff, No. 04 -- 6232 Civil Term v. DAVID ARMENTO 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW VERIFICATION I, David Armenta, verify that the statements made in the foregoing document are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa.C.s. S4904 relating to unswom falsification to authorities. Date:~_/I /fJ5 Q;e~ 'n~ ~ ') IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND CLAREMONT NURSING AND REHABILITATION CENTER, : 1000 Claremont Road Carlisle, PA 17013 Plaintiff, No. 04.- 6232 Civil Term v. DAVID ARMENTO 714 Range End Road Dillsburg, PA 17019 Defendant. CIVIL ACTION - LAW CERTIFICATE OF SERVICJi; I, David Armento, hereby certify that I am on this day serving a copy of the foregoing documents upon the person (s) and in the manner indicated below; Service by First-Class Mail, Postage Prepaid, and Addressed as Follows: KIMBER L. LATSHA, ESQUIRlE LATSHA DAVIS YORE & MCKENNA, P.C. P.O. Box 825 Harrisburg, PA 17108-0825 Date: ..o/t! ~ ') I @ // / fJYl.lrG . ~ <>'-? W"9 ~ . 1000 ClaremQnt Drive Corli,le. PA 17Q13-8805 .. . .. '''' ~ -... "... . \.. . ..' '-,# - .. mal. {717] ~43.~031 fa_17171 ~4Q.19S2 1{.ehabilitation Center '7 ~~{(lcG Resident Name ADMISSION AGREEMENT ! i /- ( j'. ({t.JrU!X[;) As part of admission to Claremont Nursing and Rehabilitatilln Center, the Resident and the Responsible Pa~f assisting tile resident acknowledge and agree to the following: 1. If Claremont Nursing and Rehabilitation Center determines that the Resident is not appropriate or does not qualify for nursing home care, the .Resident will discharge from Claremont Nursing and Rehabilitation Center following a 30 day notification of the need to make altemate living arrangements. 2. If the Resident cannot qualify for coverage under the Medical Assistance or Medicare programs, the Resident will pay daily rate for care at the nursing facility. l I I f tl. .'i 3. The Responsible Party (guarantor) assures that the Residenes bill will be paid from the Residenrs assets/funds. If the Resident does not have personal fund:; or when personal funds are exhausted, the Responsible Party will make application to Medical Assistance on behalf of the Resident. If the Resident does not qualify for Medical Assistance funding, the Responsible Party will arrange discharge for the Resident if the bill is not paid in a .timely manner. 4. The Resident author'.zes Claremont Nursing and Rehabilitation Center to release information conceming their assets. real or personal, to the Cumbenand County Soard of Assistance. 5. If the Resident is being covered by the Medical Assistance Program, the Resident and Responsible Party recognize that all income the Resident receives during the month of admission, must be paid to the Claremont Nursing and Rehabilitation Center, regardless of the day of admission, unless waived by the Cumbenand County Board of Assistance. The Resident and Responsible Party acknowledge that all future income received by the Resident while covered under the Medical Assistance Program, must be paid to Claremont Nursing and Rehabilit<ltion Center. Income not applied to charges for care will be placed in the Resident Guest Fund or refunded. .j C'l. . L v' " /1 . 1,1}11l~ .Ib>j.\ na ure or r1< Itf!!;\. ~Jd{LY' Witness . J ~~~~~u~ / ( /('Z ,r /1/.. //f/.I.;. . . '{.I 1_' _.{'... ,.,/L....;..- WItness I J {)5.~Jj.(J3 Date tJ5d!J oj Dale 05 .2303 Date {)S33<-'3 Date ,;ll sel"ice agency of Cumberland County ..-'32:~: --- (~ _n 1<\ C~) , "-"; ""',.. ~? Cr", (),:-> - . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILIT A TION CENTER, Plaintiff, v. No. 04-6232 DAVID ARMENTO, Defendant, JOHN DOE #1, Individually and in his capacity as Co-executor of the Estate of Rosalie Armento, Defendant, and JOHN DOE #2, Individually and in his capacity as Co-executor of the Estate of Rosalie Armento, Defendant. CIVIL ACTION - LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by 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. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, PA 17013 (717) 249-3166 AVISO USTED HA SIDO DEMANDADO/ A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y Aviso radicando personalmente 0 par medio de un abogado una comparecencia escrita y radicando en la Carte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se Ie advierte de que si usted falla de tomar acci6n como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda 0 cualquier otra reclamaci6n 0 remedio solicitado por el demandante puede ser dictado en contra suya por la Carte sin mas aviso adicional. Usted puede perder dinero 0 propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VA Y A A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE P AGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE EST A OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILIT A TION CENTER, Plaintiff, v. No. 04-6232 DAVID ARMENTO, Defendant, JOHN DOE #1, Individually and in his capacity as Co-executor of the Estate of Rosalie Armento, Defendant, and JOHN DOE #2, Individually and in his capacity as Co-executor of the Estate of Rosalie Armento, Defendant. CIVIL ACTION - LAW AMENDED COMPLAINT AND NOW, COMES, Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center ("Claremont"), by and through its attorneys, Latsha Davis Yohe & McKenna, P.c., and files the within Complaint against Defendants, David Armento, John Doe #1 in his capacity as the Co-executor of the Estate of Rosalie Armento, and John Doe #2 in his capacity as the Co-executor of the Estate of Rosalie Armento, and in support thereof, avers as follows: 96488 1. Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center (hereinafter "Claremont"), is a county residential long term skilled nursing care facility whose offices are located at 1000 Claremont Road, Carlisle, Pennsylvania 17013. 2. Plaintiff Claremont owns and operates a long-term care facility, providing medically necessary nursing services to the citizens of the Commonwealth, located at 1000 Claremont Road, Carlisle, Pennsylvania 17013. 3. Defendant, David Armento (hereinafter" Armento"), is an adult individual currently residing at 714 Range End Road, York County, Dillsburg, P A 17019. 4. Upon information and belief, Defendant, John Doe #1, is an adult individual and the Co-executor of the Estate of Rosalie Armento, deceased. John Doe #1 is a son of the decedent. After reasonable investigation, the identity and location of John Doe #1 is unknown to Plaintiff Claremont. 5. Upon information and belief, Defendant, John Doe #2, is an adult individual and the Co-executor of the Estate of Rosalie Armento, deceased. John Doe #2 is a son of the decedent. After reasonable investigation, the identity and location of John Doe #2 is unknown to Plaintiff Claremont. 6. Defendant Armento is the son, and was the attorney-in-fact and person responsible for the financial affairs of Rosalie Armento, deceased. 7. Rosalie Armento was admitted May 23, 2003 to Plaintiff Claremont's nursing care facility. 2 8. On or about May 23, 2003, Plaintiff Claremont and Rosalie Armento, by and through her attorney-in-fact Defendant Armento, entered into an Admission Agreement (" Agreement"), whereby Plaintiff Claremont agreed to accept Rosalie Armento as a resident at Plaintiff Claremont's nursing care facility and to provide her living accommodations, dietary services, medication/pharmacy services, and general nursing and medical care, in exchange for a promise to pay for these items and services. A true and correct copy of the Admission Agreement is attached hereto as Exhibit" A" and made a part hereof. 9. Defendant Armento, as Rosalie Armento's attorney-in-fact and person responsible for her financial affairs, agreed to perform Rosalie Armenta's duties pursuant to the Agreement, namely to use Rosalie Armento's assets and/ or resources to compensate Plaintiff Claremont for the nursing care and services which it provided to Rosalie Armento. 10. Defendant Armento has failed to use Rosalie Armenta's assets and/ or resources to pay Plaintiff Claremont for the nursing care and services which Rosalie Armento received at Plaintiff Claremont's nursing care facility. 11. As a result of Defendant Armento's failure to pay Plaintiff Claremont for the nursing care and services which it rendered to Rosalie Armento, an outstanding balance accrued and became due and owing in the amount $27,664.13. A true and correct copy of the A/R Account Detail from May 23, 2003 through October 28, 2003 is attached hereto as Exhibit "B" and made a part hereof. 3 12. As Rosalie Armenta's attorney-in-fact and responsible party, Defendant Armento had a duty to use Rosalie Armento's assets and/ or resources to keep her account current. 13. Defendant Armento has failed to use Rosalie Armento's assets and/ or resources to keep current her account with Plaintiff Claremont, and, instead, upon information and belief, has converted and/ or transferred Rosalie Armento's assets and/ or resources to himself and/ or others. 14. At the time of her admission to the nursing facility, Rosalie Armento possessed in excess of $80,000.00 of assets and received monthly social security and pension income in the amount of approximately $760.00. A true and correct copy of Rosalie Armento's Admission Application containing her financial data is attached hereto as Exhibit "C' and made a part hereof. 15. Upon information and belief, Defendant Armento received Rosalie Armento's monthly pension and social security checks. 16. Upon information and belief, Defendant Armento breached his fiduciary duties owed to Rosalie Armento, to which Plaintiff Claremont is a beneficial party, by converting and! or fraudulently transferring Rosalie Armento's assets and/ or resources to himself and/ or others. 17. Upon information and belief, Defendant Armento converted and! or fraudulently transferred to himself and! or others Rosalie Armento's assets and/ or resources to hinder or delay their transfer to Plaintiff Claremont. 18. Rosalie Armento died on July 14, 2004. 4 19. A balance in the amount of $27,664.13, plus interest is currently due and owing to Plaintiff Claremont for the nursing care and services that it provided to Rosalie Armento. COUNT I - BREACH OF CONTRACT - ADMISSION AGREEMENT Claremont v. David Armenta 20. Paragraphs 1 through 19 above are incorporated herein by reference as if fully set forth at length. 21. Rosalie Armento, by and through her attorney-in-fact Defendant Armento, entered into an Admission Agreement with Plaintiff Claremont as more fully set forth above. See Exhibit" A". 22. From May 23, 2003 through October 28, 2003, Plaintiff Claremont provided nursing care and services to Rosalie Armento pursuant to the aforementioned Agreement. 23. From May 23, 2003 through the present, Rosalie Armento has carried an overdue balance in her account with Plaintiff Claremont, which is currently in the amount of $27,664.13, plus interest. 24. This balance remains unpaid, despite repeated demands for payment. 25. Defendant Armenta's failure to keep Rosalie Armenta's account with Plaintiff Claremont current from Rosalie Armento's resources constitutes a breach of the Agreement. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in the amount of $27,664.13 plus interest. 5 COUNT II - BREACH OF CONTRACT - ADMISSION AGREEMENT Claremont v. John Doe #1 and John Doe #2 26. Paragraphs 1 through 25 above are incorporated herein by reference as if fully set forth at length. 27. Rosalie Armento, by and through her Power of Attorney David Armento, entered into an Admission Agreement with Plaintiff Claremont as more fully set forth above. See Exhibit U AU. 28. From May 23, 2003 through October 29, 2003, Plaintiff Claremont provided nursing care and services to Rosalie Armento, the charges for which have not been paid as more fully set forth above. 29. Rosalie Armento's failure to pay this outstanding balance constitutes a breach of the Agreement. 30. John Doe #1 and John Doe #2's continued failure to pay this outstanding balance constitutes a breach of the Agreement. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendants John Doe #1 and John Doe #2 in their capacity as Co-Executors of the Estate of Rosalie Armento in the amount of $27,664.13 plus interest. COUNT III - QUANTUM MERUIT Claremont v. All Defendants 31. Paragraphs 1 through 30 above are incorporated herein by reference as if fully set forth at length. 6 32. Plaintiff Claremont has demanded payment in full for the nursing care and services which it provided to Rosalie Armento, and has not received payment for the same. 33. The Estate of Rosalie Armento have been unjustly enriched and enhanced by the receipt of the care and services which have been rendered to Rosalie Armento by Plaintiff Claremont in the amount of $27,664.13 plus interest. 34. To the extent that Defendants are beneficiaries of the Estate of Rosalie Armento, they have been unjustly enriched by the failure to pay for the care and services provided by Plaintiff Claremont to Rosalie Armento. 35. Plaintiff Claremont is entitled to receive payment in full for the reasonable value of the nursing care and services provided to Rosalie Armento. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendants Armento, John Doe #1 and John Doe #2 individually and in their capacity as Co-Executors of the Estate of Rosalie Armento in the amount of $27,664.13 plus interest. COUNT IV - BREACH OF FIDUCIARY DUTY Claremont v. David Armento 36. Paragraphs 1 through 35 above are incorporated herein by reference as if fully set forth at length. 37. Defendant Armento, at all times material to this cause of action, represented himself to be Rosalie Armento's attorney-in-fact and person responsible for her financial affairs. 7 38. Defendant Armento, at all times material to this cause of action, acted as Rosalie Armento's attorney-in-fact and person responsible for her financial affairs in dealing with Plaintiff Claremont. 39. As Rosalie Armento's attorney-in-fact and person responsible for her financial affairs, Defendant Armento had a fiduciary duty to Rosalie Armento, to which Plaintiff Claremont is a beneficial party, to ensure that Rosalie Armento's account with Plaintiff Claremont is kept current by using Rosalie Armenta's assets and! or resources to pay Plaintiff Claremont for the nursing care and services that it rendered to Rosalie Armento. 40. Defendant Armento breached his fiduciary duties owed to Rosalie Armento, to which Plaintiff Claremont is a beneficial party, by failing to use Rosalie Armento's assets and! or resources to keep Rosalie Armento's account with Plaintiff Claremont current, and, instead, converting and! or fraudulently transferring Rosalie Armenta's assets and! or resources to himself or others. 41. As a direct result of Defendant Armento's breach of his fiduciary duties, Plaintiff Claremont, as Rosalie Armento's primary care giver, the entity responsible for her day-to-day care, and the beneficiary of the fiduciary duty owed by Defendant Armento to his mother, has incurred damages in excess of $27,664.13 plus interest. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in the amount of $27,664.13 plus interest. 8 COUNT V - CONVERSION Claremont v. David Armento 42. Paragraphs 1 through 41 above are incorporated herein by reference as if fully set forth at length. 43. Upon information and belief, Defendant Armento converted, misappropriated and deprived Rosalie Armento of her right in, use and/ or possession of her property as more fully set forth above. 44. To the extent Defendant Armento's conversion, misappropriation and deprivation of Rosalie Armento's right in, use and/ or possession of the aforementioned property was for the purpose of hindering or delaying their transfer to Plaintiff Claremont, these actions were beyond Defendant Armenta's authority as Rosalie Armento's attorney-in-fact. 45. As a result of the foregoing unlawful actions of Defendant Armento, Plaintiff Claremont has incurred damages in the amount of $27,664.13 plus interest. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento in the amount of $27,664.13 plus interest. COUNT VI - FRAUDULENT TRANSFER Claremont v. All Defendants 46. Paragraphs 1 through 45 above are incorporated herein by reference as if fully set forth at length. 47. Upon information and belief, Rosalie Armento, either on her own or by and through her attorney-in-fact Defendant Armento, transferred her assets and/ or 9 resources without receiving reasonably equivalent value and/ or for the purpose of hindering and delaying their transfer to Plaintiff Claremont. 48. Upon information and belief, Defendant Armento and/ or John Doe #1 and/ or John Doe #2 accepted the transfer(s) of Rosalie Armento's assets and/ or resources with full knowledge that the transfer was not for reasonably equivalent value and/ or that the purpose of the transfer was to avoid paying Plaintiff Claremont for the nursing care and services that it has rendered to Rosalie Armento. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendants Armento, John Doe #1 and John Doe #2 in their individual capacity in the amount of $27,664.13 plus interest. COUNT VII - EQUITABLE SUPPORT Claremont v. All Defendants 49. Paragraphs 1 through 48 above are incorporated herein by reference as if fully set forth at length. 50. Upon information and belief, Defendant Armento, as Rosalie Armento's attorney-in-fact, transferred Rosalie Armento's assets to himself and/ or John Doe #1 and/ or John Doe #2, or otherwise misappropriated said assets. 51. Upon information and belief, the above-referenced transfer and/ or misappropriation of assets rendered Rosalie Armento indigent and unable to pay the outstanding balance owed on her account. 52. Pursuant to 62 P.S. S 1973, the children of indigent parents have an obligation to support their parents. 10 53. Defendants are Rosalie Armento's sons. 54. As a result of Defendant Armento's transfer or misappropriation of his mother's assets, Defendant Armento had the ability to satisfy his mother's debt to Claremont. 55. To the extent that Defendant Armento transferred his mother's assets to John Doe #1 and John Doe #2, both John Doe # 1 and John Doe #2 had the ability to satisfy thier mother's debt to Claremont. 56. To the extent that Defendants transferred, received or otherwise misappropriating their mother's assets and failed to pay for her care, Defendants violated 62 P.5. S 1973. 11 WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Armento, John Doe #1 and John Doe #2 in their individual capacity in the amount of $27,664.13 plus interest. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.c. Dated: J. Ji- d~ By: JJ)) Kimber L. Latsha, Esq. Attorney LD. No. 32934 Steven M. Montresor Attorney LD. No. 74244 P.O. Box 825 Harrisburg, PA 17108-0825 (717) 761-1880 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing & Rehabilitation Center 12 P2!23!~005 15:12 71 72401977 CNRC PAGE 02 VERIFICATION 1, Mary Kimmel, hereby verify that I am the Finance Manager for County of Cumberland, Claremont Nursing & Rehabilitation Center; that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. S 4904, relating to unsworn falsification to authorities. Dated; c;) h.3/tIS , , 4~ ?!~,/ Mary'. el 96488 - r: \'\!\ r,.X :'II \)1 . . -------- - .------ . ant J'ft.u-s/ :\Q;~ ~ ~~ 9? U ~ 1000 Claremont Drive Corlisl.. PA 17013-8805 main (717) 2<13.2031 fax (717) 2<10-1952 cf\.ehabilitatian Center /; '-/tc;~tci L L Resident Name i-' , o ADMISSION AGREEMENT / . (jL77U!.X.r;j As part of admission to Claremont Nursing and Rehabilitation Center, the Resident and the Responsible Parr/ assisting the resident acknowledge and agree to the following: 1. If Claremont Nursing and Rehabilitation Center determines that the Resident is not appropriate or dees not qualif{ for nursing home ore, the .Resident will discharge frem Claremont Nursing and Rehabilitation Center following a 30 day notJftotion of the need to make altemate living arrangements. 2. If the Resident cannot qualif{ for coverage under the Medical Assistance or Medicare programs, the Resident will pay daily rate fer care at the nursing facility. 3. Tne Responsible Party (guarantor) assures that the Residenrs bill will be paid from the Residenrs assets/funds. If the Resident does not have personal funds or when personal funds are exhauste<J, the Responsible Party will make application to Me<Jical Assistance on behalf of the R.esident. If the Resident does not qualify for Me<Jical Assistance funding, the Responsible Party will arrange discharge fcr the Resident if the bill is not paid in a .timely manner. 4. Tne Resident autheMzes Claremont Nursing and Rehabilitation Center to release information concerning their assets, real or personal, to the Cumberland County Soard of Assistance. 5. If the Resident is being covere<J by the Medical Assistance Program, the Resident and Responsible Party recognize that all income the Resident receives during the month of admission, must be paid to the Claremont Nursing and Rehabilitation Center, regardless of the day of admission, unless waived by the Cumberland County Board of Assistance. The Resident and Responsible Party acknowle<Jge that all future income receive<J by the Resident. while covered under the Medical Assistance Program, must be paid to Claremont Nursing and Rehabilitation Center. Income not applied to charges for care will be placed in the Resident Guest Fund or refunded. ()5..930j Date 1 --< . {FJ.3j oj Date {J5 !}?J O~ Date )/11 . , ;( /((2/1_ Witness ":-;) ) ///' 1/1 /i1. __-r~ .; :_" L............ IJ 05;9303 Date ;;:1 service agency of Cumberland County . .,.:-,',.' ..~:. --...- - \' \ ~ ~ y\,,\7' /-~ Charges due and owing at December 31, 2003 May 2003 Medicare Co-Insurance June 2003 Medicare Co-Insurance June 2003 Private Pay Bill July 2003 Private Pay Bill August 2003 Private Pay Bill September 2003 Private Pay Bill October 2003 Private Pay Bill $925.75 $2,730.00 $780.00 $6,226.67 $6,095.82 $6,012.98 $4,892.91 $27,664.13 Total Due and owing at December 31,2003 06/22/2004 Resident Open A/R File [PA614] 4329 Rosalie SArmento G/L Due Fin Type Notes Fac State Bill date From C1 Level Chg. Balance P^ 05/31/2003 PI' MCA 3NF COIN 92, .7' P^ 06/30/2003 PI' MC^ 3NF COIN 2,730 .00 " 0(,/:>'0/2003 PI' PI' 3MF BB 7'0 .00 P^ 07/31/2003 PI' PI' 3NF RB 6,045. 00 PA 07/31/2003 PI' PI' 3NF ANC 181- 67 1 P^ 08/31/2003 PI' PI' 8NF RB 6,045. 00 PA 08/31/2003 PI' PI' 8NF ANC 50. 82 PA 09/30/2003 PI' PI' 8NF RB 5,850 .00 PA 09/30/2003 PI' PI' 3NF ANC 162 98 PA 10/n/200:>, BC PI' 3MI' ANC ,0 .01 FA 10/31/2003 PI' PI' 8NF RB 4 .875 .00 PA 10/31/2003 PI' PI' 3NF ANC 17 . 91 75 Claremont Dr v arllsle PA 17131 71 4 nEW NAt.lE p . RTl-lO.AiTE N. CD. 43 O!:SCRIPTlQN 132 12 25 30 42 42 PPS ROOM AND BOARD CHAR R & B NURSING CARE - SE PHARMACY LABORATORY PHYSICAL THERP PHYS THERP/EVAL OCCUPATION THERP OCCUPATION THERP/EVAL SPEECH PATHOL SPEECH PATH/EVAL ~3r ~~1 44 00 TOTAL CHARGES r\ ,:. ii-i: .r ?'",t~ . ^ .~ ',I _ ~ ,:U,) ~~ ..... ,_.' r \~ - . u>:'.,-' . N'~'\..l-"" '.0 ".'._: ~:-:~\ .\'l:~b ,YER 51 PROVIDER NO. ed:care Part ;.. rivate Pay ;,U1=lEO'S"'-'ME rmento Rosalie S 0 rmento Rosalie S . 0 e,.:.Tl.lENTAlITHCRllATlONCOCE~ 6l~ 65 EMPlOYER NAME 7 OCCl..lRAEJrraSPN4 37 ""'" " 03190 032213 B ::,":-~::- 3IJ VAlUECOOES COOE . 0 000 4~.0 ~, VALU~~j;,~ ;:-: 41 V1LUE COOES COOE N<<>>if . ! c d 44 HCPCSIRATES 45 SERVo DATE 46 SEAV.UNrTS RHC 11 1352713 195.0 30J5'... "t :; :?7~ H p,.,r '7,,)). Go i OW~~ 'f4S' pc-A /q.,)..~ 1IWt- 1~5 7S 41 TOTAl. CHARGES 48 NON~veflED CHARGES 49 :.130 1755:.00 ,.44 13!-00 211,.14 64).60 447;.53 67:.57 217:.14 12L 24 2897:,66 55 EST. AMOUNT DUE " 0395660 0395660 61 GROUP NAME B2 ;NSURANCE GROUP .'10. 207071iil08A 2071374008 66 E/.4P!QvtOllOCArlCN OTl-lEA PHYS. lO ""''' 390004 - 03/19/03 TO 03/22/03 95223 - 133/22/03 TO OS/22/03 95660 - 135/23/03 - ADMIT DAY 63 l-IoC"....-l.!oO APPROVED 0"'8 NO. ~79 . --_. -.-. -~- --~- ~- - --~-- --'~_.- ~ ~----~---- -_..~_.~~~--- -~_._---~.<- COPY I l~ntI!Cl!I'I1YlCAnQJISOHntI!REVVISl,ll'l't,rontlSlllU.""""oUII!lU.OI!.'MfHpeHlI'. / X ~~~ ~!dL~mOnL KOa arlisle fA 17013 717) 240-1908 ,nENiNAtolE 4329 I~ S 31 VAWE OOOES """" ~ :V.CD. 02 . 02 02 12 ^" ~ -' 30 42 43 44' PPS ROOM AND EOARD PPS ROOM Ai\jD BOARD R & B NURSING CARE PHARMACY LABORP.TORY PHYSICAL THERP OCCUP.z'<TION THERP SPEECH PATHOL 44 HCPCSIRATES 45 SERVo DATE 46 SERV, UNITS 47 TOTAl CHARGES 48 NQN-GOVERED CHARGES .. ell RHC07 1 010 RMB02 10m 195.10 2 510710 10m 139 94 51 82 840 03 734 8m 72 38 6908 97 0(':' . TOTAL CHARGES (" ..~...j. t~)\ ;s:..o'" j, '1 :; '; ;-:." ~ ,.~:.. Co~. ')1300 r, r.;\ "1~..l ,;.l , W1~i~. ".0 ~=q~53.5~ 5$ EST, AI,IOUNT CUE " YEA ~::l:care art. A rivate pay/ J.;F.E-)'SNAME ~mento :manto S 5;P.RE!. 60 CEiH.-SSN.HIC -IONO. J JJ) b' '" 207107410108 61 GAOUPNAME 52 iNSURANCE GROUP NO. :,o,i"llalf A,IJ11-IOAIZAnQNCOOES 51 E5C 55 EMPlOYEFI NAME 66 EMPLOYEH lOCATION ..., ~ --1 ., , '" N. orAG. CO. ~ :1 .' ..~. "',. B3 OT'HERPtR'S.1O U"K::; .j ...\,; / .... 1. J 103/22/103 TO OS/22/03 OS/23/03 - ADMIT DAY 63 DISCHARGE TO NON-CERT BED on;E.~ PHYs. 10 15223 - 15660 - ;/26/03 r , x 07/21/210103 <:'F.....u.SO- APPROVED OMIl NO. OiQ8-02T1t COPl'1 1cen'Ff""C:EJml'lC.ulOltSON'DIfAE'YDl$(Am.'l'OTlaIlLLNtIlAMIWll!A'AItl"~. 6. nENT NAME \.rmento, FED, TAX NO. .000 Claremont urlve :arltsle ~A 17013 .717) 243-2031 ,IRTHOAT'E 1- 31 lOSALIE SARMENTO )AVID P ARMENTO '14 RANGE END RD HLLSBURG, PA 17019 :II ""'" VAlLIE COOES """" . VALUEOJOfS """'" a b c d lEV. CO. ~ DESCRIPTION ,1.':':' << 44 HCPCS I RATES 45 SERVo DATE 46 SERV, UNITS 47 TOTAL CHARGES 48 N()H.COVERED CHARGES 49 h ~"-' - ,:) }: 100' TOTAL CHARGES 780 00 AYER It' rl..l..u SI AAOVIOEA NO. I...iL c..l 54 PRIOR PAY"'ENTS 55 EST. AMOUNT CUE " ISUREO'S NAME 53 P.~EL 50 CERT, SSN. HIC. ,10 NO 61 GRCVPNAI.4E S2 iNSURANCE GROIJP NO. J..l, ... - ~E.~T1.!E."lT AUTHORIZATION ceDES 51ESC as EMPlO'r'ERNAME 66 &:MPlOYSF! LOCATiON lIN.D1AG.CO. .. .~. . "',":>,1'- " " ;Igo .. 83 OMR PWYS-IO ,WRKS Oi}tER PHY5. 10 8S v N" x 07/15/2003 "CF"_\4$O APPRoVeo 01018 1'40, ~79 CoPY I ICl:l'IlFI'nMIC~T'IONIONTIll!RI!VVI$f:AWl.lTOTMlSIllU.AND...ItAOl!'''IlIfTHlMOl". 101010 Claremont Drive :arl isle PA171013 7 7 \TIENTNAl.4E 5 FED. TAX NO. 4329 10 ""j" 1= JIATl1DATe: ,Q Q """"""'" "". " ""'" VAWE COOES .."., V,\U)E COOES OSALIE SARMENTO 'AVID P ARMENTO 14 RANGE END RD T Ell. co. 43 DESCRIPTION a b c d 44 HCPCS/RATES 45 SEElY. CATE 46 SERV, UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 12 R & B NURSING CARE - SE 25 .PHARMACY 195.10 31 1 61045 ! 1010 181(67 1010 TOTAL CHARGES 3 6226;67 R~V~;TE PAY CLAREMONT 55 EST_ AMOUNT QUE 56 'YER 51 oFlOVIOER NO. SiJREDSNAl.4E "mento Rosalie S , ., -.. ~ "~a 60 GEAT. . $SN. rllC. 10 NO 61 GROUP NAME 1;2 iNSURANCE GROUP NO. 10 2107107410108 !:ANENT AlJT1-+(lAIZAnQN CODES StfSC 65 EMPlOyER NAME 66 EMPlOYef'l LOCATION IN. DlAG_CO. ~54 BD ~. COOE 78 fl,::.......:..I,., HARM MO KENNETH R OT><ER""""","", ""'" .. ""'" "'.. S30'1lERPHYS.1O 1,IJt..~',(5 OTi-l~PHYS.1D ~ ~ X 108/18/210103 >iCFA-l"-50 ,tJ>PROVfO 0,,",8 /IfO. CJe3ll.-O:Z79 COPYt ICVl'TJII"YTMI!~TlQNSOIfnll~"""'-1T01'ItISaL.I,IC)""IU.OIA'MrfHelfOl'. --'-.-----.--'-- -,---"---------_.-----"- ~ -'--~""""""'" ~--- . (>,,~ . '<,;~.'t.~ C 1 ~.:':-::'_O;~ ': CrilJ€ - 4':329 IOl-l"j" c _~ a :: ~ i ::; .~ -= ~~;. .!.. '/'3 L 3 - L ~; Z4J-~/)3l ITlENTNAME !\!.' ~~i:.-: ~-;'1'. 0 _ 1 ~ p. .s lIRTI'OATE !)~,'.,~',,19: OCCUAAENCE "''' 31 " cooe VALUE COO€S """'" VAlLIE CODES """'" ~~.:;c5,~~"S::E ..1RR~.1ENTG a b c d !~.;".;':D ? .~c(HE:~l::'O '; 14 P.ANG'Z END RD ~.~':T...LS2r..~'?_G ,::'j\. 170 ~? lEV. CO. 43 DESCRlP1lON 44 HCPCS { RATES ~ - .. -) ? ", Ij I,n..~:.~_.:) :NG -~,'" n- '-........:.~c, .5..:.:. l i:J:: .1.5 4S SEAv. DATE J 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES .. -' -;.:;).~ ~. ;JIt SQL 82 ,... -~ ,. .c:....;.:; 2H.n.RM.-r....C'l ~)20 l.'C'I'AL C:i.r.u'".\GES 60:33.82 .- :i,' 'j ::.. ~.:. :-.' "'" '.....:.........~ttl:.:...1...)l"fl 54 PRIOR PAY~ENTS 55 EST. AMOUNT DUE " ~,"'{E? 51 ?ROVIOER NO. 'NSUREO'SNAME 59 P.o,EI. 50 CEHT. SSN. HIC. 10 NO. 61 GflOUPNA"'E 62 iNSURANCE GROUP NO. . i::'_~ :': ":'.:1 [~. ~ ,:",: .:.':' ,- ;,-: -::::'.. :' :,'; ; 'j./QIi.l:-:. fPEAiMENT AUTHORIZATION CODES StESC 65 EMPlOYER NAI.lE 66 EMPLOYER LOCATION 'C too Oll< 1...,..:,.. /4-. ,~ .:<. If . U !\.::"L 'lCd, " D~IN, OIAG. co 'v ;1 .., ~.' M cooe " cooe G.COOES n cooe """" 78 ; ;..... OTItERPflOCEDl.JP;E cooe "''' "''' 83 OTl--lm PHYS. 10 ,:;EMARKS orrlER PH'l'S. 10 .. A .. 11/19/2003 n HCFA-U$O x "'PF'I'lOVEO 0....8 NO. 0ll3B-<l2n COPY 1 ICElnYTTlfl!CVITlI'IC.ll'lONSONnf1!JlEYERSIAl'Pt.TtonaIllU.AIClAlll!-..DlA'AllTItUII!Cll". --- : C:.~0CJ :::! ?.':-"'J"':'!o~_t D.ci ',te '.' "'. :..~..p C~/ I "'1~ j ~ ':;: I ,'-... \:" . , -~"'2. :" ..~ 1-::,;" ,,);:, 17013 5 feD. TAX NO. II srA~ENTCO~~ I 7 COY 0./ 8~.cD. I 9C.Jq.jl0l'A.:qll . " 7 I 213 .2 :;}31 23 ti'.J\t31i ~'1011O:Jl IO';J'I>19j! \OJ';! I I I - 'ATIENTNAME 113 PATIENT ADDRESS ;:.:: 'J.E;:;. 7. :'"~ ':-'.'':i5::::: 1 ie ::; I~TI 5IRThDi\iE ",sex/IS MS I 170ATC ~~ ttl'YP'E'20SA:: 21 DHAJ22-STATIZ3 ~EDICALAECOAONO. I ~ " b '190-:2:t, fl/l 062701l I I H 3~ 4329 I I IlCaJRRENCf ~.""., ~ OCOJAAENCE - ,...~~ OCOJAAetCE SPAN " DE o...tE ._'_-.<0' ,,'. ~~ tlo\T'E ~" t. ,', c:oot "'" """"" A I B 39 VAUJE COOES ~ ,- u-,,,,' ,').,.,., VAlJJE COOES coo< ...... .,.." """'" S-G<3p.L I E ,- ARHENTO . "' GAiJID f ;'HIEi,TO b - ; ~: RN!GE END RD c S~~I.LSBURG i FA A "'"""1 0 d 1 .!.. 1'<:,.' _ ~ 'lEv. CO. 4;) DESCRIPTION 44 HCPCS ( AA TES 45 SERV.DATt: 46 saw. UNITS 47 TOTAlCHAAGfS 48 NQN-COVffiED CHARGES .. ., , R ?. :~Tj?3:NG CARE - SE I 195 .0 o. 5 E; 50i. 0-2 ,'",.: <, 0:5.1 PEj:.-iU..-fAC? 16-' 98 Lj. C~~4.RGES 3 -01-' 98 ZI!~G TOTA~ ~ -4- ~ ! ! , HE;:; " PAOVIOER NO. 0- 54 PRIOR PAYMENTS ~ .:ST. AMOUNT OUE 56 )?-.,=-:7"......:':-:::. ~;Y...C{ GL,LRr...M:ONT I - . !fi6.~ 3t;M~iJ'S NAME S;?REl 50 C;;;:;T.. SSN. HIC. - iO NO 61 GROUP NA.ME 62 INSURANCE GROt.;P NO. -. :,;"':i. r) F~.:.:.~;: 3. ! L~ ~ to .:.'1: I'.J,', tj.,f.;It;~ , .. EATMENT AUTHORIZATION ceDES .tiC 65 EMPlOyER NAME 66 EMPlOYEfilOCAnON ~l. iJIAG. CD.1 ~~ ..,.. N""" -~~- -.. ,,~ -..",,..j 78 ADM. OIAG. c01 77 E{;QDE r" ~ :::. J, I I;; f ;;: I I I I I I ~,'i c" ::1 I I 160 q;'::'NCIPAL PROCED~~11 I" QniER P~H~lC ..'. '-","'-B 112 ATTENDING PHYS, 10 -t:'::-~ I ~ I (,;C I ! , - t""'Y..i."\M, ~lU l\.t.l'.jN!:. _ M "'- OThER PROC<llORE "'.,::1"." ...,,,. , 83 OTHER PHYS. 10 """ "'''' .. COC< "'''' I I I .~RKS OTl-lER PHY5.1Q I " AliVE "0.",, X 11/19/20103 'CFA-1A50 APPROvtO 0"8 NO. ~ COPY 1 IClRIYI'1'H!~TIOf'ISOfIInteA!VERSl!Al'P'LTTOllIIS8lU.AoNOAAllIIACt",'MfHDeOll'. ......"'--- _.~~ \.....lo.l:(~mO[:::.. U!. L Vt::: ~ i s l8' f';\ :. -, C) 13 ~..: ~~j 10 L.R D. 11 c:: .i. '..!~I',:J ! 71. (i ~~3'-2031 PATlENH4AME " " :-. ':: ~;\ '~ 1. I.. '..:- :'C .~ OCCURRENCE :OEl D.l.l"E QCCUARENCE SPAN """ rcJ31 3IRTl-'OATE (;~''.;'3 J.-:1 " COOE VAWf COOES """" " COOE VAlUE CODES """" ;,.: S.'\L:: G S .:".B.Jo~-SNT(J , . j'.- '..1:-\' .1.1-' " :U~ ;'iENTO a b c d ; 1; HAil:';" END aD i.},L.:...'LjBU'?,G. ?;.1.. 17QtlS "EVCD. 4J DESCRIPTlON .u HCPCS f RA res 4S SERVo DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COvEREO CHARGES 49 ..'j'-,- l'~ l'~'..: :...:.J.l. ~"!'.:i' ,....At<.::.. ,~~ -> .....- . '.i- -;''-'- CL:S i?liJ\HM,.:"CY f),:lj. 73 " 4:;='~. .:3 ......:>-- '.',,'i.,l(,' TOT.;L CEA:~~GES w :-1 i.{..'1-.J.ll 6"5 L.': I: _pelT '1 a,:Jf ., '6 -bYi7' 11 :'7; ctr:JJ i f1J)(" C 1,J'j f Lf 81/J .1/ ,.:~; .- .:-l-r '- ~.__'..:,i:.;."".~ ;L''-:. 54 PRIOR l)..~YMENTS 35 EST AIdOUNiDVE " ;J ~'::=l 51 ~RO'l:DER NO. . ,,;. :" ~ () ,<':::,; cd .:: 59 P ~SL 50 CERT . SSN . Hie. iO NO. '-~' .'~ '..1 ':J' -=~J J': .;. 1)1 GROUP NAM~ &2 INSURANCE GROUP NO. ~13U:;!;;S'S~IAME 'H2AT'.tENT AUTl-lORllATION CODES smc 65 EMPLOYER NAME 68 EMPLOYER LOCATION . ~ '" " -~.-~ "lt~1 ;rAG. CO C '3C 112 ATreNOJNG PHYS.1D '__~:'J_ !'~..~_..~1, 1''-'' ~':"'.I-"J.'f,-...\,~. C". ~:,.., '~~:~t' I "'" 8301l1ERPHYS.1O E\.I~R"S OniEflpt./y5..;o .. 10 A V " 11/19/200.1 x !~CFA-I450 AP!"FlOVED OM8 NO. ~n COPY, 1cPn"l''nll!aIlTlFlCA1IOfdOft1'He:RI!VI!RSEUfI'I.YTOTMlS8I.LJIfOARllIWllIA'ARTIfIJlfOl". - -- -~-_.__.~ ~- ---.------ -- -'-'--- --- _._-----_.~~-------'-- C)~lbl~L ~- , ,. I ~ ;{ .. ".. ... :'" \,', ., .t J{Uro . U/,,? C?9 ~c;:- I 000 Claremont Road Carlisle, PA 17013-8805 tabilitation Center <m;n (717) H3-2031 roo. (717) 2~0-1952 APPLICANT FULL NAME ~\;-€- S' A. 'e.m~I'h) PER!vIANENT ADDRESS II en hraf'lc\CrA \/'Ju ~ TELEPHONE # 1",0' 40 ~ 3 SOCIAL SE RlTY # G. 0, D,U bOS BIRTH DATE 9.9' '" RELIGION r",-ty-.,());C /vIARlTALSTATUS vv,dovJ.e.d SPOUSE NAME OlD APPLICANT OR SPOUSE SERVE fN THE MILITARY? Y'\ C) BRANCH NA..'vlE OF VETERAN . IS THE APPLICANT A UNITED STATES CITIZEN' 'I ~ PRll\1ARY FAMILY CONTACT PERSON: ~V\"d p..",""-.e,,-'.;O $:)...... Lf~)..-36<;1 Name and Relationship '" I;l.ome Telephone # 11 L\ Ro"C\Q, EVlC\ r OQ c\ , U\\\sbU("'.. I-'A I ,0 \~ Address ---cJ '.J Work Telephone # SECO:-IDARY CON1ACT PERSON: \-\..=1:'0 \d S+nl\~_ brD1Y\Q y, Name an>i.Rc:lationship L\ l2.o..(i road. f\v~ Y'fu.c...h. ~ 1\ Address I~~' 9/YO Home Telephone # \lLJr.;S- Work T eIephor.e # DOES APPLICANT HAVE A LEGAL DURABLE POWER-OF-A TIORNEY? Y f> <; Name and Relationship Address Telephone # TYPE OF NURSfNG HOME ADMISSION ANTICIPATED: . - '\ Tn re.-\-lJ r\". -\<i OJ'! 100 Ie. eo,,,~ LONG TERM CARE '7 I\""'''u WC\Jld \'u SHORTTERMREHAB 7 [S APPLICANT HOSPIT ALIZ~D PRESENT!,. Y? n Q ADMISSION DATE ? d ~ . Os HOSPITAL \,0.es+ S'no(~ \J.ec.-\-\-Y\ ee",c... '? SOCIAL WORKER P e..' .All tS.{I'e A~<J-. PHYSICIAN TELEPHONE # 7"=>"3 - -ro 7 (.) . tl sen'ice af!PIlW of Ctlmberland COWllu ~~l./rT~ APPLICATION PAGE 2 LIST OTHJ;R HOSPtTAL k~D NURSr>iG HOME STAYS f.'I THE LAST 60 DAYS: LO'j S0 e.;~ 3-~).. ()", - p roe $;2'-'+ DOES THE APPLICA:-'t HAVE A HISTORY OF ME::-'tAL HEALTH TREATME"',? hO HEALTH INSURANCE POLlCY NUMBERS: MEDrCARE '2.- 0 lOlL} CJ::,'0, A BLUE CROSS Q 20~c; II ~ 0 MEDICAID BLUE SHIELD AARP PACE OTHER LONG TER.\'[ CARE INSURANCE Fr>iANCIAL STATUS: SOClAL SECURITY S 5co . cO A,,<,,iUlTY [NCOME S PENSION S 2:.'- 0 . 00 OTHER S ASSETS: . CHECKlNG ACCOUNt-BANK till ~oo,,,,-L . rY\ \ c\ ?i(r,t\ kvlOUNT S \, (lOD - ").00- SA VINGS ACCOL"'t-BANK 1)0"'([.., A..'vIOUNT S eER TIFICA TE OF DEPOSrr-BAl't1<:. \'"\0 AMOUNT S CASH ANDiOR OTHER Il'iVESTME;.fTS PD,O::O- \-\2Q:-\~(+ p,('."v,~ c...c.,-o~ UFE INSlJRANCE-CO/YlPANY '. FACE VALUE S \ REAL ESTATE-LOCATION ,,0 Y'\-t... NA1\llE (S) ON DEED VALUE S LIST ANY AND ALL ASSETS THAT HAVE BEEN TRANSFERRED DUlUNG THE PAST 3 YEARS, INCLI.JDrNGTHEDATESOFTRANSFER OVI(J '^ V;So... ~\<... o~ \r\CJtv0-.- DOES TIlE APPLlCAl'<1 ~VE A WILL? '-t e_s. EXECUTOR'S N^,"'IE \ co>,,+c-..c..+ EXECUTOR'S ADDRESS EXECUTOR'S TELEPHONE # (H) PREFERRED FUNERAL HOME (W) (Y\"t~ rvN.-i,-cWl. ~c.Y\. 'r--CJ "'-'L Telephone # Address ARE ARRANGEMENTS PRE-PAID?~ e. 50 c.. 'N':.c--",a..\...., " PLEASE INCLUDE COprES OF APPROPRlA TE CARDS (SOCIAL SECURITY, MEDICARE, ETC.). PLEASE ADD ADDITIONAL SHEETS OF PAPER TO EXPLAIN INSURANCE INFORMATION. YOUR PHOTOGRAPH WILL BE USED FOR !DENTIFIGA TION PURPOSES IN THE tl'lEDICAL RECORD ^,'fD ELSE"\YHERE AS NEEDED FOR PROPER IDENTIFICATION. CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a true and correct copy of the foregoing Amended Complaint has been served by first-class United States mail, postage prepaid, upon the following: David Armento 714 Range End Road Dillsburg, PA 17019 sil)l Dated: d' cJ if. c9ct1') Steven M. Montresor 76399 J0 -:> > .L- t...) '6 ,.-' -- n\ CP :; ..., ~ ~ C ..v:) SHERIFF'S RETURN - OUT OF COUNTY , . .. CASE NO: 2004-06232 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CUMBERLAND COUNTY OF ET AL VS ARMENTO DAVID R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: ARMENTO DAVID but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, to serve the within COMPLAINT & NOTICE On January 31st , 2005 , this office was In receipt of the attached return from YORK Sheriff's Costs: Docketing Out of County Surcharge Dep York County 18.00 9.00 10.00 92.91 .00 129.91 01/31/2005 LATSHA DAVIS So a~._.:f~. ........".....~..;_.......... ~- .-~ ~.... Z. :--j' _____..-.. . R. Thomas Kline Sheriff of Cumberland County YOHE & MCKENNA Sworn and subscribed to before me this 3J.-(,( day of .3~ 2iJt SA. D . L~{2~~ /I Prothonotary' COUNTY OF YORK OFFICE OF THE SHERIFF SERVICE CALL (7)7) 771-9601 45 N. GEORGE ST., YORK, PA 17401 SHERIFF SERVICE PROCESS RECEIPT and AFFIDAVIT OF RETURN INSTRUCTIONS PLEASE TYPE. ONLYUNE 1 THRU 12 DO NOT. DETACH ANY COPES 1. PLAINTIFF/SI County 3 DEFENDANT/Sf David Armento 2 COURT NUMBER of CUmberland Claremont Nursing & Rehabilitation -6232 civil 4 TYPE OF WRIT OR COMPLAINT Notice and Canplaint SERVE { 5. NAME OF IN IDUAL, COMPANY. CORPORATION. HC TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED. ATTACHED. OR SOLD ....... David Armento ..". 6. ADDRESS (STREET OR RFO IMTH BOX NUMBER. APT. NO. CITY. BORO. T\NP. STATE AND ZIP CODE) AT 714 Range End Road Dillsburg, PA 17019 7. INDICATE SERVICE: 0 PERSONAL 0 PERSON IN CHARGE ;I DEPUTIZE U CERT MAil U 1 ST CLASS MAil U POSTED U OTHER NOW DecE!!lber 14 r , 20~ I, SHERIFCftO~~dCOUNTY. PA. do hereby deputize the sheriff of York COUNTY to execute this Wrft ,aA~ p:Jake return therepf~cording _~,~~;p,,'.' t. /~ .,-;"'" ..,'...1'._ ..eY ..~4 to law. This deputization being made at the request and risk of the plaintiff. '?' ,..~,;;:t;(e'R;~F';F-.t~'::~""'<:'''''' 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT IMll ASSIST IN EXPEDITING SERVICE r an vu.t 0 r f.l LI n,!/ Please mail return of service to CUmberland County Sheriff. Thank you. ('u..vvtbR.rl.cu-J , Vctnad Ptl.L NOTE: OHl Y APPLICABLE ON WRIT OF ECUTlON: N.B. IVER OF WATCHMAN. Any deputy sheriff levying upon or attaching any praperty under within Writ may leave same without a watchman, in cuslody af whomever is found in possession, after notifying person of levy or attachment, wlthoutliabilify on Ihe part of such deputy or the sheriff to any plaintiff herein for any loss, desltuction. or removal of any property before sheriff's sale thereof. ' 9. TYPE NAME and ADDRESS of ATTORNEY I ORIGINATOR and SIGNA TU . H 11 Og -U8'2~ 10. TELEPHONE NUMBER ~ggQ 11 DATE FILED I J -1.3-0/ 16. HOW SERVED: PERSONAL ( OTHER ( SEE REMARKS BELO\ \o~v 41. AFFIRMED and subscribed to before me this 1"1 ,)" 42 day of ~ q", . 20 ~ 43 44. Signature f Dep.She If 46. Signature"~ork County She . '7":-- 1" f -,' ":\, .J .. 0..' ".l ,,~, 48. Signature of Foreign County Shenff 50. I ACKNO'M..EDGE RECEIPT OF THE SHERIFF'S RETURN SIGNATURE OF AUTHORIZED ISSUING AUTHORITY AND TITLE " 0 PROTHY/NOTARY < 'q 1 ... DINK - Attorney 3. CANARY - Sheriff's Office 4. BLUE - Shenff's Office , .. tl IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff, v, No. 04-6232 DAVID ARMENTO, et al. Defendant, Civil Action - Law PRAECIPE TO WITHDRAW WITHOUT PREJUDICE Kindly mark the above-captioned matter as withdrawn, discontinued, and ended without prejudice. Respectfully submitted, LATSHA DAVIS & YOHE, P.c. Dated: .,. d'6. }oo1 elL By: Steven M. Montresor, Esq. Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, P A 17050 (717) 620-2424 Attorneys for Plaintiff, Claremont Nursing & Rehabilitation Center 114570 .-. ~ CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date the foregoing Praecipe to Withdraw Without Prejudice was served by first class mail, upon the following: David Armento 714 Range End Road Dillsburg, P A 17019 LATSHA DAVIS YOHE & McKENNA, PC Dated: ,.~,. ) 00, By: Steven M. Montresor 114570 ,...., g \".:::::. ~~" ~.........Jl -< :It ~r-']!1I ;:0 <..) o -0 -r'" _.;i,;.l'" <-'" .' - --