HomeMy WebLinkAbout04-6386
'\
HCR MANORCARE, INC.,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 2004- lj3<3b
CIVIL TERM
JACK R. GREY and
JAN POTZER, individually and as
the attorney-in-fact for
Jack R. Grey,
CIVIL ACTION-LAW
Defendants
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by an attorney and filing in writing with
the court, your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so, the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other claim
or relief requested by the plaintiff. You may lose money or property or other rights important to
you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LA WYER, THIS OFFICE MA Y 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, Pennsylvania 17013
(717) 249-3166
HCR MANORCARE, INC.,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
NO. 2004-
CIVIL TERM
JACK R. GREY and
JAN paTZER, individually and as
the attorney-in-fact for
Jack R. Grey,
CIVIL ACTION-LAW
Defendants
COMPLAINT
NOW, comes HCR ManorCare, Inc., ("ManorCare"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets
forth the following:
1. HCR ManorCare, Inc. is an Ohio corporation duly authorized to conduct business
in the Commonwealth of Pennsylvania with a business address of 940 Walnut Bottom Road,
Carlisle, Cumberland County, Pennsylvania.
2. Defendant, Jan Potzer, is an adult individual with a residence address of 110
South Hanover Street, #6, Carlisle, Cumberland County, Pennsylvania.
3. Defendant, Jack R. Grey, is an adult individual with a residence address of940
Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania.
4. By Power of Attorney dated January 12, 1993, Jack R. Grey appointed Jan Potzer,
then known as Jan Weaver, as his attorney-in-fact. A true and correct copy of the Power of
Attorney is attached hereto as Exhibit "A" and is incorporated by reference.
1
5. Upon information and belief, the Power of Attorney dated January 12, 1993 has
been in full force and effect at all times relevant hereto.
6. ManorCare owns and operates a skilled nursing facility located at 940 Walnut
Bottom Road, Carlisle, Cumberland County, Pennsylvania ("facility").
7. On or about August 14,2000, Jack R. Grey sought admission to the ManorCare
facility.
8. In connection with seeking admission, Jan Potzer met with ManorCare employees
at the facility and executed an Admission Agreement by and through her power as attorney in
fact for Jack R. Grey. A true and correct copy ofthe Admission Agreement is attached hereto as
Exhibit "B" and is incorporated by reference.
9. Jack R. Grey became a resident of the facility on August 14,2000 and remains a
resident to the date hereof.
10. On or about August 14,2000, Jan Potzer completed an Application for Residency
provided by ManorCare. A true and correct copy of the Application for Residency is attached
hereto as Exhibit "c" and is incorporated by reference.
11. In the Application for Residency, Jan Potzer represented she was receiving
pension and annuity benefits of Jack R. Grey in the monthly amount of $2,029.00.
12. From the date of his admission on August 14,2000, through approximately
January, 2004 the pension and annuity benefits of Jack R. Grey were received by Jan Potzer.
Upon information and belief, these receipts totaled in excess of $140,000.00.
13. The Cumberland County Assistance Office determined that Jack Grey was eligible
for Medical Assistance to pay for a portion of the costs of his care at the facility.
2
14. Upon granting Medical Assistance and annually thereafter, the Cumberland
County Assistance Office calculated an amount to be paid by Jack Grey from his monthly income
to ManorCare for the costs of his care. This amount is referenced as the Private Pay Portion.
15. True and correct copies of the Private Pay Portion calculations prepared by the
Cumberland County Assistance Office for Jack Grey are attached hereto as Exhibit "D" and are
incorporated by reference.
16. Pursuant to the Admission Agreement, Jack R. Grey agreed to pay from his own
funds any costs of care not covered by a third party payor.
17. Pursuant to the Admission Agreement, Jan Potzer agreed to pay from the income
of Jack R. Grey any costs of care not covered by a third party payor.
18. The Admission Agreement provides, in relevant part, as follows:
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing
shall be subject to a service charge equal to the highest legal rate of interest
permitted by State law as set forth in Attachment A on the past due balance each
month until such time as the balance due is paid n full. Should the Resident's
account for any reason be turned over for collection, the Resident agrees to pay
the Center's collection costs, including attorney's fees.
19. A true and correct Statement of Account reflecting the balance due ManorCare for
the costs of care provided to Jack Grey is attached hereto as Exhibit "E" and is incorporated by
reference.
3
COUNT I-BREACH OF CONTRACT
HCR MANORCARE, INC. v. JACK R. GREY and JAN POTZER
20. Plaintiff incorporates by reference paragraphs one through nineteen as though set
forth at length.
21. All conditions precedent to recovery under the Admission Agreement have been
fulfilled.
22. Jan Potzer was obligated to use the assets and income of Jack R. Grey to satisfy
the debt due and owing to ManorCare for the services and care provided to Jack R. Grey by
ManorCare.
23. The Admission Agreement provides, in relevant part, as follows:
2.02 Agreement to Make Payments on Behalf of Resident. The Legal
Representative agrees to pay promptly from the Resident's income or resources all
fees and charges for which the Resident is liable under this Agreement. The Legal
Representative shall not incur personal liability on behalf of the Resident except
for a breach of the duty to provide payment from the Resident's income or
resources for the fees and charges provide for in this Agreement.
24. The amount due and owing is not covered by a third party payor.
25. Jan Potzer has breached the Admission Agreement by failing and refusing to pay
for the service and care provided from the assets and income of Jack R. Grey.
26. Jack R. Grey has breached the Admission Agreement by failing and refusing to
pay for the service and care provided to him by ManorCare.
WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the
sum of $26,482.10 plus late fees, costs and expenses and attorney fees.
4
COUNT 11- MONEY HAD AND RECEIVED
HCR MANORCARE, INC. v. JAN POTZER
27. Plaintiff incorporates by reference paragraphs one through twenty six as though
set forth at length.
28. During the period of Jack R. Grey's residency at the facility, Jan Patzer received
the sum of at least $140,000.00 in pension and annuity benefits paid to Jack R. Grey.
29. The proper use of these funds would have been to pay the costs of care accruing
for the care of Jack R. Grey at the facility.
30. At the time of receipt ofthese funds, Jan Patzer knew she was obligated to pay
these funds over to ManorCare for the costs of Jack R. Grey's care at the facility.
31. Jan Patzer gave no consideration for the funds of Jack R. Grey received by Jan
Patzer.
32. Demand has been made upon Jan Potzer to tender the funds of Jack R. Grey and
she has failed and refused to do so.
5
WHEREFORE, Plaintiff requests judgment in its favor and against Jan Potzer requiring
her to:
a) return the subject matter in specie;
b) pay over the value if Jan Potzer has consumed the money in beneficial use;
c) pay its value if Jan Potzer has disposed of the funds received; and
d) award costs, expenses and interest.
Respectfully submitted,
David A. Baric, Esquire
J.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 2249-6873
Attorney for Plaintiff
da b.dir /manorcare/grey /com plaint2. pld
GENERAL POWER OF ATTORNEY
I
..
KNOW ALL MEN BY THESE PRESENTS: That I, JACK R. GREY, of York
CountYi Pennsylvania, hereinafter sometimes referred to as
". "Principal'i" 'have made,
... .: . .. .. . ., . ... . . .. ," ~ .
constituted and appointed,
and by these
presents do make, constitute and appoint my daughter JAN R. WEAVER,
'.. ....... ...... ".'
.. LUZERNE COUNTY, PENNSYLVANIA, hereinafter sometimes referred to as
", '. ".. .' '" ....
"my attorney," MY TRUE AND LAWFUL ATTORNEY, for me and in my name,
"
.:. . . >.' .: }.' ..'... ~'.~ \. . .'..." .
.:-.:';:.':'place'~and:stead,.. to ;.act, in and .manage all .my. estate,. present and
..'~:.: ~~- "~:;.": ..:. ".;;.(-:: ;::.:~~:. :-'>., ,,~.' . . ~ . .... I ..".. .,' . " . ." ...., . .
. . future, 'and. to conduct all my affairs, and for that purpose, and
for' my us'e and benefit, 'and as my' act. and deed, to do and execute,
..' or .:to....concur .-with..persons .interested .with myself therein in the'
....... ," ..' . . " .
. doing and.executing .of all or. any of the following acts, deeds and
. .... -:. ." ~ .' ....... ". '. .... '" '.
things, that is to say:
.' ~'''''', .: :' . ."'" . ". ..:. .. . '. ,. .
,.':.,' :.It:l., ~ne.e~ent :~y',dClughter.' JAN' R. WEAVER, is unable or
. ,', . ::. ." .' : :'.,' \:. . ~., '... . : : . '. . . '.. '. .' -. ..... . .' ..
'~"'. '.U~Wi,~i~~.~:'to':::~ct..~~...my:'attlo:n.~y-in"'.fact, 1. then appoint my son,
.:::' '~';": 'jA'ME.l:f::R<.-' GREY';':'.S'otrrlt'CARot:,INA:'.' .'. I'n.the-'.event'my' son,' JAMES R.' GREY I
..~ :'.: .~ . .-.' .~..:'.'~.<: .......:.:. ~.:..- ...:.;.:.....1: :.,. '.: :.":.... . '.: '. ,: . . .... .
..;::""i,s ~.uriaple':,or >'unwil1~ngto . act ,'as my' attorney,':"in-fact, I then
.' .:.'.~:".:::~~:~:~iri~ m~ :'.:~~ri,~:~~~A~~.\{. GREY, .YORK CO~TY, PENNSYLVANIA.
l'. ',........ . .....:" . .<(.'.. . : '.' . . '.
":.' .:. ::0:: .'. .:::"". i-i-}':'>:r6 ':'buy~ r~cel ,/e'; . lea:se;. 'accept or ~therwise acquire, to
.:' .~. .' s.e.ll, , .~t;.::pqp.l:ic pr .pJ;.i:'{ate. ~a.1.e.L . .conv~y, mOl::tgage, hypothecate,
. ':: ::, pledge., . '.qu~t:';"'d,iq.im~:'. assign;. .:transfer "or otherwise encumber or
.' d~?pose., of; . ot: .to: contrac;t or. agree 'for the acquisition, disposal
. . 'pp . encp.mlJr9.nc.:e ':'pf'ahy property' 'or 'part or 'parcel . thereof whatsoever
ancfwheresciever 'si'tuat'ed~'" be. it reai ,"personal or mixed, or any
'cus~ody,'" possession, interest, privilege or right therein or
. per't'aining:' thereto, 'upon.'.such' terms as my said attorney shall think
proper;
(2) To take, hold, possess, invest, re-invest, lease or let,
or , otherwise. manage any or all of my real, personal or mixed
property, or any interest therein; to eject, remove or relieve
teriants' or other ,persons froID, and recover possessions of, such
1
EXliIBI7 "11."
.......;:, ...~'_..,;,.,....,III'V".loN........":'AH':S..':-_....l". .......
mainta1n, p~u~~~~, ~.C~C.YC,
rebuild, odify or
(3) To make, do and transact all and every kind of business
of what nature or kind so ever, including the receipt, recovery and
adjustment of all accounts, judgments, mortgages, insurance
policies, legacies, bequests, interests, dividends, investments,
securities, annuities, notes, bonds, stocks, debts, taxes,
obligations, evidences, of indebtedness and all other demands
. ~hat.soev~~ which may now or herea.fter be due, owing, or payable to
. me. ',or. by..me; .. '" ..
...(4} To make,.endorse, accept, receive, .sign,. seal,.execute,
acknowledge .. and _. deli ver deeds, . assignments, '. agreements,
.certifications, hypothecations, checks, notes, bonds,' vouchers
receipts, and such other instruments in writing of whatever kind
and nature as may be necessary, convenient or proper in the
premises" including the payment of premiums of life or other
.:..i~sura,I1ce.."ri.9,w'..or:.:he;r~a~^ter ..ef!ec:t;.ed ,by,:me,whether on my life or
otherwise; .
.
,
\::'
I
, ,
I .
I.,.
i I ~ .
,,' . ,(5) ". .To incur. and. pay any bills . arid 'obligations 'for' my
maintenance, care, comfort and support and for any of my medical,
surgical and other unusual needs, including but not limi.ted to
"', "h'Qspita:).; '''i'\l.irsip(~t home ;" c6iivale$cent "care and "i'ieeds of invalidism;
. ... . .
! ;
. .' ..J?) . . To d~posi,t. al!d....~~.thdi;~w ~or the purp'ds~ .hereof, in
either my said attorney's riame or my name in and from any banking
institution, any funds, checking and savings accounts, negotiable
. : pap~.rs'.I": <;>r monies~.'whi9h 'may'" 'cbm~ Jntd-. my ',sa::i:d . atto:biey'..'s hand's as'
. . - I. .' .. '. . . . . . .
, ..su9.l:i att-p.rney..or.wh'l:ch';'I. now. orl)ereafter may' have 'on depos1t .or be
:;. ent'it~te:d':'t.o.; {ncludi.ng .h.~~e~ftet<~ay.'haVe on deposit o'r..beent1t::led.
: - .to';: inc.luqinq Ciny'.niordes' 'in 'my"name'al'one or" jointly . in" my"name and'
.:...:s.().~e.::Q:t?er.~"Per$o.n ~ s::'name., :~cl\lding.. my ,~said-attorney.f s. 'name; -".
::>:::..:>.,: .,.::.:.:"~:':c-'7f ,: T~~/i~~t'lt~:t'~'~ :'.P~9S'~'c{i't~',:d~'fendl'6o~prom'ise', 'arbit~ate,
~.: '.a.ri4. .d;i'sp~.se ' 9f : Tegal~~ '. eguit'able, . or . administra ti ve'. h~ar ings,
'..' ~C?~~O~S I..... .~:suit,s ,.: :....attac~.nu~nts,. ": arrests, q d.istresses . . or ..other
..... P.~<?.c~~d.':i7I;l<j~.' or othe~ise' engage .iD . litigation in connection 'with
: ..~e~ 'pJ;.e~J.~~s; '.. ..'.... . .... ' '. . . -: '" "
I
I,
11
"
nl
~ n
!.,
.,.r
. . . .
;.',,:: ':::..::': ':':" (8).. '..~o :'act '.as -my "attorne'y or-proxy. in respect to any stocks,
.": sha.J;'es, , bonqs.~ c)r' 'ot.her..fnvestments; 'rights, or interest, I may now
':.'.pr-: h~reafter'.holdi' . . . '... . . .
.. '. (9) . To engage and dismiss agents, counsel, and employees,
. . and .to' a:ppoint- and remove .at .pleasure any substitute for, or a,gent
" of "my said 'a ttorn'ey ~ in respe'ct to all or any of the matters or
things herein mentioned and upon such terms as my attorney shall
think fit;
2.
, .' . I\~. :.!" :.:: _ <~'. :>~ .~~:'(..-.~ _.'-: ~-.d:.~'.:;~~:ri~~~~.
~ . '.o.J' ..,". '... '~'l"',,, '\"~~'t~.r; f(~\
'. . . ,~'\~"".~"..~'.',' .':~.J,.:.'''',;:,,,,'' ~''''~~'_.:'~\';;I,..'.>.:'J\/,::.' .~,,~'~'.~~1~~'"
t;.:~-.:: ....;f-...
. .,...J
t~ :;.:...:,... :.~:. :......
~;L;ow~1;....~..... ','-
~~:r..~;.~;";,,..,.
----:-:--.----_...... ~.- -..
. . ~ ..
..
(11) To take possession and order the removal and shipment of
any of my property from any place of storage or safekeeping,
including safe deposit box in .any bank or trust company,
governmental or private; and to execute and deliver and release,
. .voucher ,receipt; shipping ticket ,. certificate, or other instrument
'necessar~..or.?onvenient for such purposes.
" '.(f2')'~' "To"s'i'g'n 'admission or; d{scharge 'agreements for my ent~y'
into or discharge from a nursing home, hospital or other health
'''care''facl1ityarid 'to"'make"health' care decisions on my behalf as my
hea.l :th', '~~r,~ .'. age~~ . '
. . (13) To sell,' transfer, or purchase shares of stocks, bonds,
and securities upon such terms and for such prices as my attorney
deems"advisab~e. . ' ,.....
. :....~....~:.;..~:... ~ .':..: ":.~'..'''''.:-' " ....:....-...... . .
g
(14) a~ ,To mak~ such gift of property to others as I may
~ro~ time to .time 'direc~.
b. To make such gifts of my property to such one or more
of'lI!-y...spouse..and iss.ue'and"charities in such:formand amounts as'my
"atto'rney'J:)'eiiev'es'would be in accordance' with my. wishes.'
. -. ':". ..
. ':.., .; ....... .,; ; . .. C'. ,. To: 111ake' such. gifts' of my property to such persons
and in such form and amounts as my attorney believes would be in
.accordance wi tl?- . my wishes.
. d. . To. make such gifts of my property to such persons
':. . !!lnd..:in suc~. f.orm'.. and.' amounts' ,in :my 'attorney's sole discretion
.' .peli~v.~.s:. 'are ': in my bes.t .interest..
.::..~ ..::t~....,~:.:...:,~.:.::;;.._~..'.._~.::.. ::..:...:............;.......:.: _::... .......:.~. .... .......... ,. _.. ..
';: ;<.:....~~. ':".(25.-('::... To" ~shabTish ahd ..fund'a'Mea:icaid Qualifying Trust.. or to
.:.....:..c?r~.~~e.:~~y':o..th:e~.....tr.lp;t..!o~n\y pene.fit.,.' ' .' . .'
.... '. '.' ". ':.. '. . " . ~.... '. .... '.' .
. .::':.. <::' ,"(1~:)..':.', :ro,"maf.e 'additio.ns to an existing .trust for my benefit.
. '. - :".:",
-.... , .' :('17): . ."To 'withdra* and 'receive the
'. . ':~~~~:~:..: . '.,~:.. '. "" ." ::. .... '. .
income' or corpus of a
..: . '. .., '.' 'C1.8 t' : ToC?laim' an elec;ti ve sha.re of the estate of my deceased
': sp.o~~.e.~ . . .'. ,.
'(.19)"To disclaim any interest in property.
(20) To renounce fiduciary positions.
This Power of Attorney shall not be affected by my subsequent
disability or incapacity, but is intended to be a "durable power of
3
. -
, . .' ... .:~ ).~ ~ -:-. L "J ..
-- ".
~;J6t;;j/~.r:.""
'attc~ney" within the pro'J ions of Section 5604, anr also to be
. subject to the provisions or Sections 5605, 5606 and 5, 7 (relating
to notice of death, affidavits establishing continuance of powers,
and powers of corporate attorneys-in-fact) of the Pennsylvania
Probate, Estate and Fiduciaries Code or any similar legislation at
any time hereafter in force.
GIVING AND GRANTING unto my said attorney full power and
authority to do and perform all and every act, deed matter and
thing whatsoever in and about my estate, property and affairs as
.. ..tri1ii .~n~'effectually to'all intents and purposes as I might.or
could do in my owri""proper pEfrsori"if,"personally present, the above
. sp.e.C?ialJ,.y enumerated powers being in aid and exemplif icatibn of the
full, complete. ~ . and . 'general power" herein'" granted'.and not in,
limita:t.ion 'or definition thereof , and hereby ratifying all, that'
said . attorney' sh'ail lawfully 'do . or . 'cause "by virtue.' of these.
presents.
.. ".. . ....,...._:.F~;-t.hepnore, . I 'h~reby 'specifically declare that the authority
conferre'd' :by 'me . 'herein upoh 'my' att'orneyshall' be . exercisable..by my
attorney as provided in this.power on my behalf notwithstanding my
l'ater':disability .~;- incapac::ity under law or later uncert.ainty as to
whether I am .dead or alive. All acts or things lawfully done by my
attorney pursuant to this power during any such period of my
'.': . '.' dis'apility or.' incompetence or. uncertainty. as to wh~ther I. am de,ad
or alive' 'o'r. durli"i"c.f an'y 'other.'time shall have the same effect and
inure to the .benefit, .of ..and bind me, my heirs, legatees, devisees,
,.... .., "legal and"personal'representatives and ,assigns .asif I. were alive,
competent and not disabled.
I
I
. t{ IN WITNESS'WHEREOF, I have hereunto set my hand and seal
_,,:(:.,d~:,~f~-'~?,.q:rA~K~~'!;;. .......
...~::.'..::...~~t:6.~ne~~.~~:..f~?t..... ,7:
.... ..... .. '." ,
this
. ....'. .
. ....
.. " . .';. . -,
........ J~..'R.. .:.W~VER
'. ~. .t. '.,
. ....-
. . " '. ~". .' ~ '. '. .'
.' . "'. ,. ":'JAMES R.' .G~EY. '. '" :....
.' ~'''.,
.' .... ...JONATHAN .R. GREY
4
..~-:. '.- ~ .
~_~ri~~:~'::~'~.\i~~;Y~~ :;r'..~ '
, '-.. -4,
"
, ..,....
. - , .': :,:~;~~fi:i;:it.
, ~ I .' ~ " : ,;';'.,'~' ~:'_~ I ~~:~4.-:~ -::"?'~.~
. . . ..;" " ,'. ,!.:.....", -'j 'n...~I; "~
. _" '. ;~ .(~l......r. ..
::.-. "'. .-
. COMMONWEALTH OF PENN5YLVAN
55
COUNTY OF YORK
.
l:)~P1'ISt L. J-I-ubC(
and
We, JACK R. GREY,
1!~/<;f)Jl/;; LJ 1L(lle K/ ;;:-
, the undersigned and the witnesses,
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare this
instrument to be his General Pawer of Attarney and 'that he has
signed willingly (ar willingly directed anather to. sign far him),
and that he executed it as his free and voluntary act for the
purpases tl?-ere-in .express~d, and that each af the witnesses, in the
. ..... .'
.p~esence and hearing af the undersigned, signed the General Power
af Attorney as witnesses affirm'in writing that the undersigned
appeared. to. . be at least eighteen (18), years af age (ar to be
otherwise autharized to. give medical cansent as an adult pursuant
to this section), to. understand and appreciate the cansequences af
: ,
.. .. j . . '. .' . . .
~he ' general power: . 'of 'attorJjey da.cum~nt,
. .' .' .'" "," .'
arid to.' be under
. , .
, ,
.....co~~~.raintor undue'bi~lue~;e~adHA:" · .'
Cd' . . . ...... ~~ ~~A:y t: 7i~
... (lk;Jh~(2~~/-z
"
, ,
. .
.,:,:sw~i::ri . a~d :, sUbs9ri:.~d . ,ta" : .
'~~re ,~e' .this /~. day af :
. ytlJ?
My. Commission Expires: '.
I . ' . Nt'H"'1 ~MI '. 6,
tc.Ily L Brow... HOtuy PublIc
Sl)I'lnlettsburv T,w' s/iID. Yon CountY
~ My Commlas~' F lolr" AUlust 14. 19Q!
-
M~"'l"". ~"...vl~ b '., ''''flo-o :tf ~ol"l..
I
I
I
I
I
I.
!
I
no.
....--..-....--.
<-
,
.__--..___..__-r-____ --_.'
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF YORK
ss:
Before me, the undersigned officer, personally appeared ANDREW
F. KAGEN, ESQUIRE, who, being duly sworn according to law, deposes
and says that he is counsel for Jack R. Grey, and that to the best
of his kn.owledge, information and belief, the following is true and
correct:
... 00' ~
That the attached Pennsylvania MEdical Power of Attorney
Medical Proxy, marked Exhibit A and made a part hereof,
for Jack R. Grey; is a true and correct copy of the
qriginal of said Pow~r of Attorney dated January 12,
. ,,1993, from Jack R. IGr~y( as Principal, to Jan R. Weaver,
:". ..'".. ".~,i;:to':Fn~y:.~n-',fact, no'<o1 '~hown as.. Jan . R~p<?tzer.
, ..::..:.... ", '.':',; '::'. . . .',> :". ....: t... " " ,.,. , ,
'2.. . .~h'a~ said:,.power of .Att,Q~,ney is stil)...in full force and
.; . ef.fect,' and ..tha t. the saRie. has .not,heen revoked. .
" ., .' . ~'r"" . .
1 .
. ,- ..
~ ..... .~ ," ': . .......
. . 0". ','
F~agen,)qUire
.0'.
'. .
(~ .
..i....... ',.
..:.::.,.:~":~.~.:.
" ,. .
. .,' .
.,....:...::.~..:-. "... ',:':":',;. :', f . :':..'..,.,..: .,...,,;..,. ':..'.~.~~,;.-'.
::..,. ....:.......,.. cic/"';':'" ~"."," : :";" .... ,. ..,' .; .:':J">;"
. _.1' /~., "..,.'
~. . . '.. . "" 00 ....... , . . .. . . . . 00 'Jt ','.
..,. . .' ..,.'..,.' Not,ary Publ,~c . . " .. '.: "., .l.. .
',. ' Mt' cq""1'isSi()ne~~i;',el"":; f
. ..' 0'
,.
... 0' . I ,,',,',. .... .
;".'~ :::...::S~6;r::n,; ~ri? ~:t:l~'~c~d.~~~.;'tq '. :.::.
.......-be,fo+'e :,.me' th1.g.:.I~~:d.ay"': .' '.
........ 'of'> tJ(::;t;z;~..., 1997'" ,..,
',..,', :. ,.., . . ...'. '.' .':'.:' ..f., :';'" '. .< . .' ".
.' .,' .'...'.~. '
, " . .', , '.' , ',... "OTARIAL .$tAL .
''''''. . '.:" .' .$U$AN.M,......NPERsoN... .:.....
, ,. s '., .. , · Notory ft.,L"_.
. .' ." p".n"-b'" .... . nt"'""
. . , "v... ory Tw.. . :y ..L C '
'. . .:' . .', I" c; . : . ., :r..,.,'.Or!" ..ounty, P....:
...', :, .' .y otl:~:s.slOn 'ExpirM Mo',rcn..19, 2001
, ,
. ,,~
to., .. '.
) .
HCR Manor Care
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR Manor Care, the Resident, and the
Legal Representative, for the purpose of providing for the rights and responsibilities of the pani
with respect to the Resident's stay at this HeR Manor Care's Health Care Center ("Center-). es
Center: mA.jJ()ILCAfJ-E-/ C .Q-12.t...VU
Resident: :'1 A ( JL ('~n ~ ..../
,
Legal Representative: J A~ Of) T2 ~ (2-.
Admission Date: q. q. DO Deposit: S 0
" -
(m ~ ( CJ4-f'-r;.. ) ,
Term: This Agreement shall begin on the day the Resident enters the Center and end on
the day the Resident is discharged.
I. RIGHTS AND RESPONSmILITIES OF THE RESIDENT
1.01 Room and Board Rate.s For the basic services provided-forin Section 3.01, the
Resid~nt agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto.
The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room
and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10~ day
of each month. The Resident shall be responsible for the Room and Board Rate for the day of
admission as well as the day of discharge. This Section shall not apply if the Resident is covered
under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care
Organization (see Section 1.06). .
1.02 Ancillary Charges. The Resident further agrees to pay to the Center all charges for
additional medical) therapeutic: or personal care services or supplies that may be requested by the
Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The
Center reserves the right to charge for personal care items of the Resident if necessary for ,the
well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto) and
a current ancillary charge list is maintained at the Center' 5 business office for review during
regular business hours. Ancillary Charges shall be included in the Resident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(1 O~ day of the month. .
EXIllB17 II lJ"
1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shaU be
subje~t to a service charge equal to the highest legal rate of interest permitted by State law as let
forth In Attachment A on the past due balance each month until such time as the balance due .
paid in full. Should the Residenfs account for any reason be turned over for collection, th~
Resident agrees to pay the Center's collection costs, including attorney's fees.
1.04 Independent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Residenfs attending physician for any health or
personal program in accordance with the terms of the program.
1.05 Governmental Programs. If the Resident is eligible for coverage under any
governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and
the Center participates in such program, the Center shall accept payments under such program in
accordance with the terms of the program on the contract the Center has with the program. The
Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according
to the same tenns and conditions applicable to private pay residents. The Resident must comply
with all program requirements. In the event the Resident's coverage under the governmental
program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay
residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: .1LMedicare, ~Medicaid and/or .....:.- VA
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the
Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident
also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable
charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative
agree to pay any required deductible, any required co-insurance, and any non-covered services
according to the same terms and conditions applicable to private pay residents. For Medicaid, see
Attachment L for additional information. The Resident and/or Legal Representative are
responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of the Room and Board Rate from their monthly income.
The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this
Agreement, the contribution amount as detennined and -periodically adjusted by the State and/or
local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the
contribution amount,' the Center may take such legal action as necessary, including requesting a
court to order such payment.
1.06 Third Party Payors and Managed Care Organizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization (uHM:O"),
Preferred Provider Organization ("PPOU), Provider Sponsored Organization (UP SO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which.the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident shall be responsible for any co-payments, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents. If the Center has
not executed a provider agreement with the Resident's third party payor, the Center
2
. _ will b~ the Resident's third party payor as a service. but the Resident rek..~ns liable for chara
not paId or covered by that third party payor including charges not paid within a reuonahr
period of time. e
1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident has not been detennined to be eligible for Medicaid.
The Resident and/or Legal Representative agree to notify the Center promptly if there is
insufficient income or assets to meet the financial obligations to the Center or to make prompt
application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify
the Center in writing when application to Medicaid is made. The Resident and/or Legal
Representative agree to cooperate fully in applying for Medicaid and in the eligibility
determination process. If the Resident is no longer able to pay for care at the Center and the
Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to
discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook
and State and federal laws.
1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal
Representative to notify the Center and to provide any needed information regarding all third
party payors or governmental coverages on admission and throughout the stay including copies ~f
insurance cards, identification or ve~cation of eligibility and coverage information. .
_The-Resident and/or Legal Repfesentative agree to provide the Center with nonce
within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage.
failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as
the Center relies on the information supplied regarding such coverage. The Resident and/or Legal
Representative acknowledge that if they fail to provide such information, they may be responsible
for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs
associated with the failure to provide such notice in accordance with the terms and conditions of
this Agreement.
1.09 _ Application for Benefits. It shall be the responsibility of the Resident and/or Legal
Representative to apply for coverage and to establish. eligibility under any governmental. third
party payor, managed care or private insurance program. The Center shall be under no .
obligation to bill any third party payor other than the Legal Representative and, when applicable. .&
governmental program third party payor or managed care organization with which the Center IS
under contract.
1.10 Primary Responsibility for Payment. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall remain primarily 1i~te
for any and all charges for which the Center may agree to bill a third party. The Resident and/or
Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or
managed care provider may not pay for non-covered services. supplies. equipment. medicatio~
and other care and services which may be delivered by the Center or its subcontractors. ThiS
3
_ Agreement serves as a written notice that the Center has notified t..... Resident and/or
Representative that services provided at the Center may not be covered by a governmental :::
third party payor or managed care organization. The Resident andlor Legal Representative '
to be responsible for non-covered services. A price list of services is always available :r:
business office upon request.
1.1 1 Personal Physician. The Resident has the right to choose a personal physi .
provided that the physician selected is properly licensed and agrees to abide by applicable law a:
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name of hislherpersonal physician. IT the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notify the Center of
the new physician's name. If the physician chosen by the Resident fails to provide needed
coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have
the right to call another physician to attend the Resident and, the fees charged by such physician
shall be borne by the Resident.
'f
1. 12 Pharmacy. The Resident and/or Legal Representative acknowledge the light to
choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and
supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies
and procedures and the phannacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distribution system.
II.
RIGHTS AND RESPONSmILITY OF THE LEGAL REPRESENTATIVE
I ,
f.OI Le~al Authority. The Legal Representative hereby represents that he/she has legal
access to the Resident's income or resources and that the documents supporting such authority, if
any, have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative
agrees to pay promptly from the Resident's income or resources all fees and charges for which the
Resident is liable under this Agreement. The Legal Representative shall not incur personal
liability on behalf of the Resident except for a breach of the duty to provide payment from the
Resident's income or r~sources for the fees and charges provided for in this Agreement.
2.03 Requested Items. The Legal Representative shall be personally liable for any
services or products specifically requested by the Legal Representative to be supplied to the
Resident, unless such services or products are covered by a governmental program.
2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such
that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative =
notify the Center in writing when the application for Medicaid is made. If ~e . d
Representative fails to notify the Center in writing or fails to file for Medicaid in a timely an
proper manner, the Legal Representative shall be personally liable for all charges and fees .not
covered by Medicaid which otherwise would have been covered had application been made an a
timely and proper manner.
4
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such infonnation about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be perSOnally responsibl
for any charges denied the Center due to any lack of cooperation. e
2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in
the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of
the Resident from the Center. If after notice the Resident is not removed as requested, then the
Center is authorized and empowered to remove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Representative if
the Resident's conditionpennits, who shall unconditionally be obligated to accept the Resid~nt
and to pay promptly all charges.
2.07 Additional Responsibilities. The Legal Representative acknowledges the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement and
Attachments.
ID. RIGHTS AND RESPONSmILITIES OF THE CENTER
3.01 Room and Standard Services. As part of the Room and Board Rate. the Center
shall furnish basic room, board, common facilities. housekeeping, laundered bed linens and
bedding, 'general nursing care, personal assessment, social. services, and such other personal
services, as may be required pursuant to the plan of care ,prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general well-being of the
Resident.
3.02 Other Services. The Center shall act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, ifany, noted at
the beginni_ng of this Agreement. The Deposit shall be applied to the charges for the first month
of the Resident's stay at the Center.
3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by
the Center within thirty (30) days after discharge or transfer or within the time frame required by
State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days
of the Center's receipt of the final Medicaid payment for care of the Resident.
IV. GENERAL PROVISIONS
4.01 Consent to Release of Information. The Resident andlor Legal Represen~tive
hereby consents to the release of hislher medical records to the following persons: Center
persoMel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organization responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utilization review or quality assurance
5
.;'!
reviews or payment audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perform such functions care
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
including but not limited to, assistance with bathing, hygiene, dressi~g, toiletry, and daily
activities; and general nursing care, the administration of medications and treatments, and the
performance. of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in the exercise of good nursing judgment, Subject to
any rights provided to the Resident by federal and/or state law.
As applicable, the undersigned Legal Representative hereby represents that he/she
has the legal authority to make health care decisions on behalf of the Resident, that documents
supporting such authority have been delivered to the Center, and that such Legal Representative
hereby consents on behalf of the Resident to the Treatment described above.
4.03 Consent to Photograph. The Resident and/or Legal Representative agree to
consent to the Center taking a photograph of Resident for use in identifying the Resident~ for
placement of the photograph in the Medication Administration Record or other records and for
any other similar uses of the photograph f<;>r Center and staff to identify the Resident.
4.04 Notice of Services. Policies and Additional Information. The Resident andlor
Legal Representative acknowledge that the items listed below have been explained and have
received copies of the items or policies and procedures, if applicable. The Resident and/or Legal
Representative acknowledge they have had the opportunity to ask questions and questions have
been answered satisfactorily.
a. Authorization for Release or Review of Medical Information. See
, Attachment C.
b.
Authorization for Paymen(ofBenefits. See Attachment D.
c.
Social Security Administration Appointment. See Attachment E.
d.
SNF Medicare Detennination Notice. See Attachment F.
e.
Medicare Secondary Payor Questionnaire. See Attachment G.
At the request of the Resident and/or Legal Representative, the Cel)ter
shall maintain the Resident's personal funds in compliance with the laws
and regulations relating to the Center's management of such funds. A
description and/or policies and procedures of protection of resident funds
and the Personal Trust Fund Agreement, Resident Personal Funds
f.
6
. -
.
J.
k.
I
m.
n.
o.
p.
q.
r.
Authorization and any other related documents. See Attachment H-l and
H-2.
g.
The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
h.
Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
.
1.
N arne, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
The location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state survey and certification
agency, the state licensure office, the state ombudsman program, the
protection and advocacy network and the Medicaid fraud control unit. See
Attachment I (Center Supplement).
The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phon~ number on how to file a complaint
with the state survey and certification agency concerning resident abuse,
neglect, mistreatment and misappropriation of property. See Attachment I
(Center Supplement).
The Resident Handbook. See Attachment J.
ResidentlPatient Rights. See Attachment K.
MedicarelMedicaid information and display of such information including
how to apply for and us~ Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HeR Manor Care's
Limited Treatment Practices and "No Cardiopulmonary Resuscitation
Orders" and a copy of the State summary of its laws governing the
Resident's right to direct hislher medical treatment. See Attachment M-l
and M-2.
Privacy Act Notification. See Attachment N.
Inventory sheet andlor policy of personal items. See Attachment O.
7
s. ASM Form. See attachment P.
1. Consent to Photograph See Attachment Q.
u. See Attachment R.
v. See Attachment S.
w. See Attachment T.
x. See Attachment U.
y. See Attachment V.
z. See Attachment W.
4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby
requests that payment of authorized government and/or third party payor benefits as described in
Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to
me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal
Representative hereby authorizes the Center and any holder of medical or other information to
release such infonnation to the Health Care Financing Administration and its agents and to third
party payors any information needed to determine these benefits or benefits for related services.
4.06 Termination. Discharge and Transfer. This Agreement may be terminated 'as set
forth below and as set forth in the Resident Handbook under the Section Heading "Discharge".
The Resident and/or Legal Representative may terminate this Agreement before the Resident's
discharge from the Center by providing the Center written notice of the Resident's desire to leave
at least ~ (7) days .in advance of the Resident's departure. If the Resident leaves before the
end of that time, the Resident must still pay for each day of the required notice unless the Center
fills the bed before the end of the notice period. Except in the event of an emergency or death, the
Resident shall be responsible for all charges for the Room and Board Rate and for all services
performed up to the end of the day that the Admission ends. Discharge from the specialized units
such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice.
If discharge or transfer becomes necessary because the Resident and/or Legal Representative or
someone else abused the Resident's funds, the Center will request that local, state and federal
authorities, as appropriate investigate, which may result in prosecution.
4.07 Indemnification. The Resident shall defend, indemnify and hold the Center
harmless from any and all claims, demands, suit and actions made against the Center by any
person resulting from any damage or injury caused by the Resident to any person or the property
8
-;
of any person or entity (mcluding the Center), except in the case of negligence of the Center'
employees and agents. I
4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal law will not invalidate the r~ini1\
provisions of this Agreement and, it is agreed that to the extent possible, the Resident and th~
Center will continue to fulfill their respective obligations under this Agreement consistent with the
law.
THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEy
BA VE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND
THAT THEY HAVE BAD AN OPPORTUNIlY TO ASK QUESTIONS AND THAT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATlSFACI10N.
Signature of Resident:
Date:
Signature of Legal Representative, if signing on behalf of Resident:
Date: ~~Ja;tJ
Signature of Legal Representative, signing on hislher own behalf:
Date:
Center Representative:
~//fJ I Ja/U AUf)
, (/'
Date:
CI. Cf-oo
i
9
"
~ .J!
Ancillary Services iHanagement, Inc.
5tS!M
We are pleased that you will allow Ancillary Services Management, Inc. (" ASM" )
to serve your Medicare Part B supply needs. ASM is a national Medicare Part B
provider and has an agreement with this facility to provide certain medical products
for eligible nursing home residents. Some of the products ASM supplies include
nutritional supplies for tube feeding, foley catheters for urological patients, surgical
dressing supplies, as well as ostomy and tracheostomy supplies for those patients
who require them. The Health Care Financing Administration, which is the governmental
agency responsible for the Medicare program, requires providers like us to obtain
authorization to supply, bill and receive payments on behalf of the beneficiary from
the beneficiary and/or responsible party.
In the event you need the supplies noted above, we can supply and bill
Medicare Part B on your behalf. Please sign and date below, authorizing ASM to
bill Medicare Part B on behalf of the beneficiary.
Once again, thank you for your business. If you have any questions, please
feel free to contact ASM at (419) 252.6000.
Sincerely,
:1~1J~
Frank A. Jannazo
Director of Operations
................................................................................................................
SELECTION OF ASM
Patient Name:
,--'";
Last
First
Middle
Social Security #
Facility
-" /', ..": . ~:
The resident and/or legal representative hereby selects ASM to provide Medicare
Part B supplies ordered by the resident's attending physician.
The resident and/or legal representative hereby request that Medicare benefits be
paid directly to ASM for any medical supplies provided to the resident which are
covered under Medicare Part B and hereby authorize ASM to bill and collect for
such medical supplies directly from Medicare or other third party payor. I further
authorize any holder of medical information about me to release to the third party
payor( s) and its agents any information needed to determine these benefits.
Date,
"
Resident Signaturtr' ,
,~ .: ._ ~~~~l--:;~_::-;~.~~.~ ~~
Date
Signature of Legal Representative
White Copy - ASM, Inc. Yellow Copy - Facility
FASM020R (Rev. 5/961 BRIGGS, Des MOines, IA 50306 18001247,2343 PRINTED IN USA
G-R..E-"'{ / <J"A C(z
f\DmLT q. q .00
DEPARTMENT OF PUBLIC WELFARE
ADMISSIONS NOTICE PACKET ~~ ~ \66- \\.{-'7350
IMPORTANT INFORMATION FOR
NURSING FACILITY RESIDENTS AND THEIR SPOUSES
COMMONWEALTH OF PENNSYLVANIA
This information packet contains important information about your rights as a
resident of a nursing facility, and information about Medicaid (also known as Medi-
cal Assistance), a program which can help pay for nursing facility care for people
who cannot pay all of the costs of care by themselves. Federal law, 42 D.S.C. 91396r
(c) (1) (B) and (e) (6), requires the nursing facility to give you this information.
Even if you are paying for your nursing facility care yourself, or if Medicare or an-
other insurance is paying, it is important for you to learn about Medicaid before you
might need it.
There are four (4) parts to this Admissions Notice Packet.
PART 1 - Pages 1 - 8 Notice of Rights of Nursing Facility Residents
Applies to Everyone
PART 2:- Pages 9 - 12 Medicaid Payment for Nursing Facility Care
Eligibility Requirements and Procedures
Everyone should read this part - Even if you do not need
Medicaid Now
PART 3 - Pages 15 - 18 Protecting Resources and Income for the Spouse
Living at Home
Applies if you have a spouse who is living in the community, i.e., is
not in a nursing facility or medical institution
PART 4 - Pages 19 - 22 Resource Assessment Form (PA 1572)
To be used by a couple when one of them is in a nursing
facility or other medical institution, and the other lives in
the community
I certify that the notices required by 42 U.S.c. s1396r (c) (1) (B) and (e) (6) were provided to me at
the time of my admission to: ~
::r'\A t\J 0 ({CArlE <2 PrruJ ~ l f.
Fill in Name of acility ()~
OR a1lt:-J (" )
1 n tu~e ~(Je7bf;
Relationship to Resident
I
Signature of Resident
9- Cj- JtJ()O
Date
., ", ...-~ ~: i.:
MA401 (7-96)
1f.~-I.I~"'ll'J..".'
Authorization for Release or Review of Medical Information
Authorization is hereby granted for a:
Record Review
Name of Reviewer
Release of Information
To:
From:
Patient's Name
Patient's Name
Admission Date
Discharge Date
D.O.B.
Copies Requested
Final Diagnosis
Diagnosis Summary
History and Physical Examination
X-Ray Reports
EKG Reports
Laboratory Reports
Nursing Notes
Physical Orders
Psychiatric ·
Other (please Specify)
This consent will expire on
or sixty days after the date below or sooner, at my discretion.
Patient's ~. ature" t?~ Date .
IJ4-t.. }Vr6, .
*Guardian ~~oT ~ a . ature Date 7-ttjaJff
Witness SignatUre K CUM1I :"1. J aD" Date q . 'f, 1.000
*This signature is necessary ont{ wben the patient bas a guardian or is unable to sign
, Resid~nt Name: G-r$'i J :TAd '-
Medical Record #: :). 00 2. '2.. .
13
. ~..:!
ManorCare Health Services
CONSENT TO PHOTOGRAPH
As used below, the term "Photograph" includes video photography.
COMPLETE ALL SECTIONS
PUBLIC RELATIONS (Check One)
J I do Qive my consent for me/the Patient/Resident to be photographed, or to have
my /the Patient's/Resident's voice recorded, by or on behalf of the Facility, for advertising
or public display, or by the news media.
~
"
I do not Qive my consent for me/the Patient/Resident to be photographed, or to have
my/the Patient's/Resident's voice recorded, by or on behalf of the Facility, for advertising
or public display, or by the news media.
ADM7RATlVE (Check One)
I do aive my consent for me/the Pattent/Resldent to be photographed, by or on behalf
of the Facility, for administrative purposes including but not limited to proper identification
for drug administration and treatment, and all other purposes related to my/the
Patient's/Resident's health, safety or admission to the Facility.
_ I do not Qive my consent for me/the Patient/Resident to be photographed, by or on
-i-J15ehalf of the Facility, for administrative purposes including but not limited to proper
identification for drug administration and treatment, and all other purposes related to
my /the Patient's/Resident's health, safety or admission to the Facility.
MEDICAL, (Check One)
-.J.. I do Qive mv consent for me/the Patient/Resident to be photographed, by the Facility,
for medical. monitoring and/or educational purposes and/or reimbursement purposes,
including, but not limited to wound and skin care, if necessary. Such photographes would
not include identification except Patient/Resident medical record number.
,
I do not Qive mv consent for me/the Patient/Resident to be photographed by the
Facility for medical monitOring and/or educational purposes.
(7tl4vt (1~W,
U",.-.t t:~~ Party .........
Patient/Resident or Responsible Patty Signature
7- 7. tf).60r)
Date
Aeeldenfa Name (Last, First, MIl
Attending PhysIcian
Room Number PatlentJReaklent Number
(, f2..E.. ~ J ::J ACJ L.
DAIV ;~L~
{47 ~oo 6;::2...
I'IICotN3112/9Cl1
CONSENT TO PHOTOGRAPH
~f'If) F 'Lf:AUV( ~ILOUuH ( II-J
ADVANCED DIRECTIVE STATUS WORKSHEET
(TO BE USED IN CONJUNcnON wrm HCR MANOR CARE LIMITED TREATMENT POLIcY)
ADMISSION DATE: DATE
RECEIVED SIGNA TUlt:
ON ADMISSION
o Receipt of HCR Manor Care "Refusal of Life-Sustaining Treatment" Handout
o Signed Acknowledgment of Receipt of HCR Manor Care Policy on Limited Treatment
, Practices and no Cardiopulmonary Resuscitation Orders
o Provided with "State's Advance Directive" Forms - if desired
(See Advanced Directives.)
RESPONSmLE PARTY
o Resident (Competent)
o Legal Guardian (Resident Incompetent)
(Indicate if Guardian is over person, property, or both)
o Durable PONHea1th Care Proxy
o Legal Representative I Family
o None of the Above
ADVANCED DIRECTIVES.
o Living Will/Declaration
o Durable Power-of-Attomey for Health Care
o Other
Note: If out of state advance directive, an old -advance directive, if
there are missing dates, signatures, or an improperly witnessed
advanced directive, contact the Legal Department for assistance.
Name a: Phone /I
NO CPRlDNR ORDERS --
o Physician's Order (Original order must be hand written on physician's
order sheet and placed on the chart - computer printout accepted thereafter.)
o Physician Documentation of Infonned Consent in Progress Note
o Compliance with HCR Manor Care Policy in Section 3 of the Limited Treatment Policy Manual
o HCR Manor Care Release of Liability for the No CPIVDNR Order (UNote)
LThIITED TREATMENT
o Physician's Order (See above under "Physician's Order")
o Physician Documentation of Inf9nned Consent in Progress Note
o Compliance with HCR Manor Care Policy,in Section 2 of the Limited Treatment Policy Manual
o HCR Manor Care Release of Liability for the LIMITED TREATMENT Order (UNote)
ORGAN DONOR
o Receipt of Information Related to Organ Donation
o Organ Donation Desired
Note: Update advanced directive orders on a monthly basis. Verify that the resident or legal representative
continues to want the ordered treatment withheld/withdrawn or DNR status. For residents with no orders for
DNR or Limited Treatment, verify periodically and with a significant change in status or terminal
diagnosis, whether they desire a No CPRlDNR or Limited Treatment Order.
UNote: After the physician has obtained infonned consent, obtain the signature of the resident or legal
representative(s) on the HeR Manor Care Release of Liability form unless the situation makes it impossible to
do so. Try faxing, mailing or reading the form (on the phone with another witnessing) to the legal
representative in each child sign the Release form.
Resident Name:' G Ct-E.:'{ ) 'J A C\ L
Medical Record ## :
34
HCR.ManorCare
To apply for admission to our Nuning Center, please complete tbe following qUestiODDaire, sign, and
return it to tbe Admissions Office. This application will become a part of tbe "Admission Agreement"
and sbould be completed in its entirety. All information win be beld in confidence. The complete
medical history and pbysical examination results will be recorded on another document.
Date: ~-J 4 - 00
Name ofProspedive Resident/Patient: l~.I'...k lA . cffi;~
Date of Birth: I ~ I J-J./I OJd-. f (Sex: F_M~
Address:~~'71 f..JrO)O (jJ~A4 ~ (A d . Telephone No.:
(line 2) ~ p1f /13/,Z;-
Marital Status: Married Widowed Single I --- f':\
If Married or Widowed, Name of Spouse \LJ
Social Security No: 1ft; ~ -14 - '7.~5 0 M~care No: J 1.0 ~ /4 '71, ~ D'"If
HMO/Insurance: Provider r:.vX.. ~t.J I b ~ \.:::? )
JD No: Pltt..J I ~"It{BS 0 Group No: p-ftH ..3 in , Policy No.
~surance is: Primary Secondary Co-insurance
Other IDsurance: Provider
JD No: - Group No:
Insurance is: Primary Secondary
Name of In~irer: 1.4,.fL/ cR1A.(JJ'-t/
Address: l ,fl- fhJ.Jf/' .
(line 2)
Other persons to contact in case of emergency:
Name: ~ ~ t~+::c..{l..v
Address:- !/jilis: 1-IOA1tJue~ ~f #(0
(line 2) {!,tMh..JII / fJ7f-
Policy No.
Co-insurance
Relationship: Irf
Telephone No.: >>'5/- ~ ~J-R
Other Phone No.:
Relationship: da..u- / fr71J't
Telephone No: JS8 - 45'-1 D
Other Phone No.: ~ - q 0 1- q!Q 75"
Jj
Bow did you hear about
Personal Referral
Hospital V
Physician
Other Professional
MailinglBrochure
Other I.'lursing Ctr.
/lA/hd\!lf7JA1. .J Nursing Center?
7/ . NewspaperlMagazine
TelevisionlRadio
Yellow Pages
Health Dept.
Seminar/Event
Assisted Living etr.
Have you visited any other ~ursing Cenj or Assisted Living facilities? If yes, which
ones? Fo X P-idr-f ..fx4A1 ~
1
CXfLlBI7 "C"
"W~ . '~~~'" ~'ii*.<iW'!'
".Iffl ' . ~ ;::~: I!3IWlN,tl'
'(11 ~_ '1 'a,.", _____ I
11 . ~ ",. ~ " if~ Un--
fl , -,,.,1 ~ I' , "'"', I '
~. .,', ~;, ,~, ".""j, l ~.Ii ~,lln~
Mother's Maiden Name: i(.<.f'~a..tt
Father's Name:\lftt\W\fos. rCI\tL\r-('P.s ~
Place of Birth: City WI"\o\)fI\Q . County (1}o.r~~\~
Church Preference (Optional): I~ fk.IJII~A~
Preferred Ambulance Company (Optional): Na{b(AlAnrJ ~
City
. i'i;;........... ,'- '. ~
~1'"
<~ , '~.. ~jJ ,
State 9 A
Diagnosis: 4$ / p- (ji) A k It
Current Primary Physician: { tit . ~f'~ ~
Physician to follow at Facility: - f ~i
. Telephone No.: IY/ - OtJ/ ()
Telephone No.:
Tell us about the ResidentJPatient: (please c~eck all that apply)
_Mentally alert _Ambulatory _Confined to bed
.J:::::::Slightly forgetful ~ alks with assistance ~ without assistance
_Confused _Continent _Requires assistance with
_Incontinent eating
Admission desired on: ft - / t..( - 0 0 '
Resident/patient currently at: Gt1C1A ~.
Ifhospita1: Date admittecf '7-J 7~OO -1' Admitted from F fJ-M./
Where, has the resident/patient lived in the last 60 days?: F ~M ___
, ',. "" ",," "~I "', ,..' ~~"""'''''''I
' ,'., .," " ',,,~II~, ~I.,'," .~ I'l!:, l ': ".. .'11 ,". I ~I .'.~~~'.~;~II~I:,.r, :i''''~~')!''.'I~''''~~....;~lj
I': I.,' 1'''''''~,r'"".~,:",,~I, ,_ ",':' ''':~, . .,. , "", I: ~,' I' "",' :, I"'~"~.t,~ "' ~~"rl:~ll~m::~'.' ','" Si~.l . .l'~
... ...., ,',. ,~.~NGIA:L~ID)i",~",.""""",I."l,ft$<~~~,....",.,,. ~~
- - . .--. ..' ." - - - -
The facility requires that a source of payment by identified to pay for the ResidentJPatient's care.
A penon, other than the resident, may wish to be fmandally responsible for the cost of the care
("guarantor"). The facility does not require a "guarantor".
Name of the "Guarantor":
Address:
Telephone No.: Work No.: Other No.:
(This person(s) must also complete the "Guarantor" information and sign the applicatio.n.)
Has a trust fund been established for the ResidentlPatient?: Yes No
r - -
Has a Power of Attorney been conferred on the person(s) to be financially responsible,
or on the person(s) who will act on behalf of the resident ("Responsible Party")?:
~es _No If yes, please provide a copy.
Has a legal guardian been appointed by a court? _Yes t..---No
If yes, please provide a copy.
Has a Burial Trust been established?: -=--Yes ~
If yes, with whom?:
If no{who is the preferred funeral service for the ResidentIPatient's family?:
2
To process your application, the foUowing information is required. The information supplied is confidential
and aUows us to assist you in your long-term pl8DDiDg. The rmancial data should be; that of the
ResidentlPatient and or the Guarantor. AU income and amounts 6sted, whether listed under the Resident or
Guarantor column, must either be owned by the Resident or in fact be available to the Resident to pay for the
Resident's stay at the facility. Your cooperation is appreciated in order to expedite admission. Please note
that it is Dot mandated that a Resident have a Guarantor, only that a source of payment be identified. Thus,
any persoD who agrees to be a Guarantor is doing so voluntarily.
'.A':'."...':S.,.....'SE;'wu...w~m....s...w:tf;r'w'..:,T~;.~');;:?;1:~~t~'j,:.~;'~:7tt.:<'~':~:~~~.~._;:....... .,~~"''''.-....,..f':_.,.,...w ',,_, ' . . . , , .' -' " ".".~,~,
'" , ...,~".i~,(~l~",.,~;.~" . , ,," ,.";\:',, , ~,,;,t'I'l"'" ~ "I' . . ,'~~"~, ' , '. , ,~"
.. , '. '" ~':,. ''Po.II', I ,,'" ,'~ ' ,~ ' .~~. ~~I~:'" '"., "', " ,. '~: "'~ .~ ,I " . .. I
Cash
Checking
Savings
Money-Market
Certificates of Deposit
Securities (StockslBonds)
Trust
Annuities (if not yet paying
IRA monthly)
'l\IONTHIN:m-OOME:" "
Salary
Social Strcurity
Pensions/Annuities (if not above)
IRA (if not above)
InterestlDividend Income
Rental Income
Trust
Investments/Other
Long-Term Care Insurance
$
$
I . ~ r1
,,,, I.,' W' ,'I
I ;:',' "i,~',t.~:"f,;, I.~: I:' l,' I I, ~ I
, i
I'
" " ~ I~ I ,:'
I ~.,: ~ ~"'~'I::,
$
$.
~00q
NA
RE'ALE' ST' 'Jt;<cm'E":'~"~"'ll""""""~""tiOii7I'" '".::..atiO~....~,:".:).i,;,.....~. .'", .."....:.... .,.'....i"'.:.'.;,:;,..;.,," ..~,.."'.,',.,
, " . ..' " ...~'" escnp '. 0': . . ..~..".: ", ,.',.,........ .'.......~'>~....<....w"J<'>..':. ......~ "",'.'
. . ..'...::,0;...... . ......{'".. ~, ",' ,..,.. ........ .., ","",X::",'::::'" ...:.(:r"::.....'r....~,.:'o(, n...:<<"~~y..
:.' ..{.....l:.. . .. .::-. -:.........~.,. ,............... :. " ....... ..:":":"-." .:..;..;.....~.;,. ':'~"-:.u:.~',,~.,:.
Property: Y1 0 Vl <E:.-
Name on Deedffitle
Property:
Name on Deedffitle
I O"J:"OER ASSETS( .,
Cash Value Life Insurance
Vested Pension Benefits
Business Interests
Automobiles
Other
Total Assets:
or
, i
----!
~ ()Vl't'
V\ffi\'E'
V\6V'\..Q
;.
3
~~ .. -~
, ~';- ::. ~. \.
..
, ~~ I~... I I II, '\ 'II .011I ' " ~. ". .
~ $: ~ ... . I; . .... I' ... "
" '
Home Mortgage.,; , ..
Credit Cards/Charge Accounts
Loans
Other Debts
Taxes .owed ,.. '....
"
."~
$
-
-
. 1..
Total Liabilities:
NET WORTH:
(assets - liabilities)
$
'J .. ~
.., ;'$
~,; :
I
.r
$
PLEASE SIGN BELOW:
I bereby warrant and represent that the information provided is aecurate and complete. I UDdentand
tbat tbe nuniDg facility will rely upon the accuracy and completeness of the above f'manclal information
in making an admissioD decision. I also undentand that If any of the information is not accurate or not
complete, the Facilit) will bave detrimentally ~lied upon tbe above financial information and will suffer
f'mancialloss and barm. Tbe,auets listed are in fact available to the Resident to pay for tbe Resident's
care.
!.fl! ~orty" Sipmure
Guarantor's Signature .
Reviewed by:
~
'4f kt /'
Adnii D'S Di~ctor Signature
Administrator's Signature
4
Date
Date
?-/Y--O"O
-
Ff2/ t(- 00
;?'-/t,f-oC)
Date
Date
OCT 28 2004 11:38 FR MANOR CARE-C^RLISLE 7
M 17 249 0647 TO 2495755
P.02/06
NAME
CREY Jatk
I
jq 511
RECORD NUMBER
INIT IAL
J~ /OD O~OJ , _Oh /lJl ()7/0;
~O/YR O/YR MO/YR
GROSS SS /1(,;6),10 la07.00 /~1.1, ()~ I~07,oO
~16 QiP3. q4 q~3JI" '.'Q(!3. qtj q/p3.C1'/
-...-- .......
D~;4S If) 7/. oD.. tJO~.t() i , ('J:!.{)6 /IO/l.{)O
: 0 Pt11 sJ)'() 0 {;;OJ.oO 60 ~,oO boa .00
TOTAL GaOSS UN'EARNED _379~.o4 ..JJ'7Q/ILj ~,q", , ~.cN
ESTlMAT'ED INTEREST /.j,t..l7 ~.O7 ~.O7 4.()7
..
TOTAL INCOME USED .~7.j6 .,J J ~J..2i9 ~ 0/ 2RJ5.0i .1&J5.0}
- PERSONAL CARE .30.00 9; .1)0
ALLowiUiCE !b.oD )c. 00
.
- COMMUNITY SPOUSE/ QtJ6,7(P <./'13.70 Q75.?ft;
iiO!>n"" ~~, 1\(f":'~:Al:OC q 5'ft;.J,~
GROSS PATIEN! PAY (53) d1Clqf~ ,'5 i/'J/O .~5 a9 /1. ~5 ~m.a5
-
- MEDICAL EXPENSES lCO-ID LESS MEDICAL ~{PENSES PAID ~ONTHLY
(See below) ,- ...._. -
.-~49~.,(.r ;
NET PATIENT 'PAY ~57) 1~7?i;7S-
-
MED~CAL EXPENS~~ LISTED ~OTE: Futun dlaqes in medical expeases
1~/oo OilOI should be reperted to the Nursing FadHty.
MO/YR MO/YR
DRUGS (54)
J (."0.,0 J JO 00 MED I CARE (55)
BC/BS/OTHER MEDICAL INS (55)
O'!liER MED 1 CAL ( 56 )
,CO.la
11O.I."YJ
MONi'HLY TOTAL
cA;ltV. K~w'
S!GNA.TURE
'flalol
DAtE
UfilBI7 "D"
~
OCT 28 2004 11:39 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755 P.03/06
CUM!3E~LAND CAO Notice 10: 49'71311
33 IiESTMINST!;:R DRIVE ADVANCE NOTICE PAGE 1 OF 1
P.O. BOX 599 REDUCE
CA R LX 5 L E P A 1 70 1 3 -059 9 J}::tJ:~"~1;~:~;~~~~i~~~~~1.:)t"'~],;;:2';:~'~fT
CAO RETURN ADDRESS IUNIT 00 Icsl..D 0015 21 008Sl511 TA 0
\., I. ~
l' YOU tJC NOT IIHDERSr AND ooR OECJS1Ot1 011 HAlE AllY
I;XJESTlfRi. PlEASE C()KT.<<:T YOUR I1IORXER 11MEJJI JTELY.
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA
17013
WORKER: 0 CAMPBELL
WORKER 10:
TELEPHONE: (717) 240-2700
DATE: 09/27/2002
NOT: 330 OPT: 1 TYPE: R
. .
.
. . .
,~ .
, . . :J
.
BECINNING
MeOrCAL ASSISTANCE 10/16/2CO~
_'-"'.f.NlI
.~':I"'''.1''II.h'.='.1..'':J~;~''If~'~.;I~';J,'':.''j.'"j=-']~.:1:=-i.j.ti1'i'Jl~l
~ACTS AND
:T:{~.I.~..r.)~t.::
DISREGARD THE ABOVE BEGINNING DATE. Persons WhO reeeivQ FGdaral Retirement.
S~rv1vQr~ or 01sab11 1ty benefits will get cost of living inereases in January.
Railroad Retirement. Black Lung and Veterans baneflts may also be inereased.
Your payment towa~d the eost for nursing faCility ca~a inc~eases ~anuary ~002.
Monthly Income computation;
SSA / RR / 8L Income $ 12Jg.80
VA Benefits $ 0.00
Civil Ser 1 Private Pension $ 2717.94
Interest / Other. Income $ 4.07
The; nursing faCility Will deduct the fOllowing
your monthly payment: Medicare $ 11B.ao
Other medieal insurance premium $ 0.00
The nursing faCility will deduct other medical expenses if you ver1fy the
expenses to them.
RegUlations: 55 PA Code 1B1.1. 161.3" 181.451. 181.452. 181.453
Gross Income $ 3961.81
Personal Care Allow.-$ 30.00
Spouse/Depend.Allow."$ 1015.76
Home Maint. Allow. -$ 0.00
YOUR MONTHLY PAYMENT $ 2916.05
verified medical expenses from
LEGAL HELP IS
:\YI:ll...:m.
APPEAL AND FAIR H~ARING
If you disagree with our decision. YOU have the right to appeal. See attaehed
form for a complete explanation of your right to appeal an.g, t,o a fair hearing. If
your oral request tor a hearIng is received In the County ASSistance Office or
your written request is postmarked or received on or before 10/10/200:tour
assistancl!I will continue pending the hearing decision. except when the c::h~se is
clue to State or Feder...1 La.w~
............... OETJCH HfJlE DErN;/! HfRi ............,.
1~::=;:~S~ii:\~4;;i~~_~;;';:~~~J;I::i(i~l~;;:aAEKi:i:()Sf:~JHIS:ii;~~!;;i~~l.'J~~~~~i;~~I\;~~~,~tH:faN~;m(UG'A~~:1
~EGAL SERVICES,INC.
S IRVINE ROW
CA~LISLE ~A 17013
NAME AND ADDRESS
~ACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
'/6ci,t;;:i~:(~~~~:E:;~#+.t~;it~~t;:~~~:~$f,\;:~i;(
21 ooS9511 TA 0
."
"~l._.:.'.JIJ:t..~
WORKER:
APPEAL:
TELEPHONE:
DATE:
NOT: 330
D CAMPSEI..L
10/10/2002
(717) 240-2700
09/27/2002
OPT: 1 TYPE: R
CUMSERlAND CAD
33 WESTMINSTER DRIVE
P.O. BOX 699
CAR~ISLE PA 17013-0599
0213510.
PA/FS 162R 09/97
OCT 28 2004 11:39 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
P.04/06
l..UMi!.I<Io!L..ANU LAU
33 WESTMINSTER DRIV~
P.O. BOX 599
CAR~IS~E PA 17013-0599
CAO RETURN ADDRESS IUNIT 00 I CSLD 00 15
t.Ull'-'iC ",.
~::J:.J J ... I I
ADVANCE NOTICE
REDUCE
PAGE 1 OF 1
::,:~~:;t}':~:~cOll:O\::i:;i:~..ti:~'<3~Si;,~$.j~t}~~;
210089511 TA 0
1. YOO 00 NOT UNDERSTANO OOR OfCISlOH OR HAolE ~
QUESTlfMS. PlEASE COHf'I&T rCXJR WOR1rlR lIMEDIATELY.
JACK R GREY
MANQRCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA
17013
WORKER: 0 CAMPSI;LL
WORKER 10;
TELEPHONE: (717) 240-2700
DAT~ 09/27/2002
NOT: 335 OPT: 1 TYPE: R
THIS (S TO NOTIFY YOU THAT OUR OFFICE HAS TAKEN ACTION TO CHANGE YOUR BENEFITS LISTED BELOW
8EGINNING
MeOICA~ ASSISTANCE 10/16/2002
THIS AC"rION HAS BEEN TAKEN
:J:llf;\lio"'l =-.l_I;I~i.ll{ 1{.1'1'1I~1
All of you~ monthly income mu~t be u~ed to compute
cost of nurs1ng facility $ervices. As a ~e$ult of
beg1nning 07/01/02 you must pay $ 2983.44 to t~e
cost of care each month.
Income
SSA/~R/Bl Income
VA/Clvil Service/Pension
Interest/Other Income
TOiAL
FACTS AND
:i:l(C1'I"~"'I.l~1f:
your ~aymont toward the
a change in your Income
nurslng facll1ty towara
tne
$ 1239.80
$ 2&14.33
$ 4.07
$ 4058.20
Deductions
Pe~sonal Care Allow. -$
Spouse/Oepemd.Allow. -$
Home MQint.AllOw. -$
TOTAL -$
30.QO
1044.76
.00
1074.76
Th~ nY~s1ng facility will deduct the following verified mediOal expen~a~ from
your month'y payment: Medicare $ 118.80
Other Medical Insurance Premium $ .00 The nursing faeility will deduot
other medica' expenses if you verify the expenses to them.
Due to SERS 1ncrease eff. 7/1/02.
Regulations: 55 PA Code 191.1. 1R1.~, 1R1.451, 181.452,181.453
,II" ..
LEGAL HElP IS
i\'111'.11:]' .
APPEAL AND FAIR HEARING
If you disagree with Our decision. YOU have the right to appeal. See attached
form for a complete explanation of your right to appeal and to a fair hearing. If
your Qrill request tor a.hearing is rece,ved in the County Assistance OffIce or
vour written request is postmarked or received on or before 10/10/200~our
assistance will continue pending the hearing decisicln. exc!!pt w!'le!'l the el"-=;'lge is
..d.u.e t.o Stat~ OJ federal Law.
..m...m.... DfT.<<:H HERE DfTM:II HERE ...............
1::!tjXq;;.tM~"~~hft;lt:~;i;~~R~~~~\;,~t:b'i:t:'~~~i1~~i(;:'i!~E!:i~;\;ttlS?!~J.'lol'l:W\Nu;~~~~~;:;:~Hl::'ll~~~!::~'~~~il.~r!;Q.l~~P~;:t
~1;,i~1Il(.,~'~...,n~'I'J~..l.'~.p;'.~.l,;'~" NotIce 10:
LEGAL SERVICES,INC.
a IRVINE ROW
CARLISLE PA 11013
vACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
:,;j:ti:ii;ii,i'{~~:'~:t'cii:i;:~*~:;Gi:i:::r,::~!:Diri~;<:l:
21 0089511 TA
o
. i.,.m:l~~
WORKER:
APPEAl:
TELEPHONE; .
DATE:
NOT: 335
o CAMPBELL
10/10/2.002.
(117) 240-2700
09/27/2002
OPT: 1 Type R
CUM8eRLANO CAD
33 WESTMINSTE~ ORIVE
P.O. BOX 599
CARLISLE PA 17013-059B
02135A
PA/FS Hl2R 09/97
FR MRNOR CRRE-CRRLISLE
NOtiCe IU:
P.05/06
~:l:lbb/l1
717 249 0647 TO 2495755
PAGE 1 OF 1
OCT 28 2004 11:39
...r..II"I:)!:KL.L\NU "'L\U
33 ~~siMINSTER DRIVE
".0. BOX 599
CARLISLE PA 17013-0599
CAO RETURN ADDRESS IUNII 00 1 C~~D 0017
ADV ANCE NOTICE
REDUCE
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM
CARLISLE PA
17013
ROAD
~[?(iUJ7nnm:r~
APR 1 7 2003 il):
.m I
_ J(:)~15U u ~'LV
~__________._J________..
. .
.
se<;INNING
MEDICAL ASSISTANCE 04/15/2003
e
. . : ,
jelll. el','" ~ I~#:.l""'''!1 ~ '1":1 ::(ctlJ ,,~, Il-1 ~.'-J
OIS~EQA~O TH~ Aaov~ 5~QINNING DATE. Parsons who receive Federal Re~irement.
SurvIvors or D~sab~llty benefits wil, get COSt of living increases in January.
~atiroa~ ~etlrement. Slack Lung and V~terans benefits may also be increased.
Your payment tOward the cost for nursing facility care increases January 2003.
-
THIS ACTION HAS BEEN TAKEN BECAUSE OF THE
Monthly Income com~utation:
SSA / ~~ / SL Income $ 1257.10
VA BenefIts $ 0.00
C1Vl1 5er / Pr~vate pension $ 2837.33
Interest I Oth~r Incom~ $ 0.26
The nursing faci'lty will deduct tha fOllowing
your monthly payment: Medicare $ 129.10
Other medic~l insyr~nce premium $ 0.00
The nursing fac~11ty will deduct other madic~l
expenses to them.
F<e91.11ations; 55 PA Code 181.1.181.3.181.451.
LEGAL HELP IS
AT:
'C~', ::~~~~~'i: ~;'e....1: : -or;; '.I?~~:r,.::.;
21 0089511 TAN 0
IF YOU DO NOT IJNtJEflSTAND OUfl DECISION 0fI HAlE ANY
OiJESTIONS. PLEASE CONTICT YOUR /NfJRJfEfI IIrIIIEDIATELY.
WORKER: D KLINGENSMITH
WORKER 10:
TELEPHONE: (717) 240- 2700
DAT~ 03/31/2003
NOT: 330 OPT: 1 TYPl:: R
Gross rncome $ 4094.69
Personal Care Allow.-$ 30.00
SPousa/Depand.Allow.-$ 1028.33
Home Maint. Allow. -$ 0.00
YOUR MONTHLY PAYMENT $ 3036.36
verified medical expen~es from
axpenses if yOu varify the
181.452, 181.453
m ~.:.'~:.1I~.:.'_:.'~I'.:J~'I~.:I:r~':n~{l
I
N/~'I"i'.J.
If you disagree wi1h our decision, you hive the rl9"t to lJI:l~eal. See attached
form for ~ cOMpl..,te explanation Ql your right to ~~e"',,_,lll)~.. to ~ .fair hearin.l,;!. If
your or~1 request for a hearing is received in the County ASSlst.mce Office or
your written request is postmarked or received on or before 04/1.3/200:?our
assistance will continue pending .he heari,,; de:;i~:on, ~:.:c~pt ......~:;n t~e c!"",~!' is
dv.e t.o _State ,or ..Federal L~w.
.....'......... DfIIaI HERE oETACH HERS .............
f.:1F;:::;j~I;J:.;Mt,t$,~2[O,::'AP~€At~~..C.QMBl:El:E/:J:HE:;6AQK:~:'0f.",:~'~I'$':;f.$.BlVI' ',~~ J3ET~..:j't]e::J30TTGM;PORJTGN;d:O'~CAQ;::J
!':.l:.lIl(~W~~f~'~ll::lr~~.'IJ'l:l~'1o: Notice 10: ~2266711
L~G~L SERVICES.INC.
a IRVIN~ ROW
CARLISLE PA 17013
JACK R GREY
MANO~CA~E CA~L~S~~
940 WA~NUT BOTTOM ~OAD
CARLISLE PA 17013
".n."'J'l:I~"'J:
CUMBERLAND CAD
33 WESTMINSTER DRIVE
P.O. BOX 599
CARLISLE PA 17013-0599
02135A
,~2..::: '. ;,FlE~i;{!ID.= ::,: ::::c~f.'::,:G(r ."j)is'y: ,":
21 00a9511 TAN 0
WORKER:
APPEAL:
TEL.EPHONE:
DATE:
NOT: 330
D KLINGENSMITH
04/13/2003
(717) 240-2700
03/3t/2003
OPT: 1 TYPE: R
PAIFS 162Ft 09197
OCT 28 2004 11:40 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
P.06/06
CUMBERLAl\1::l c.::,o
31 WESTMI~STER DRIVE
P.O. SOX 599
CARLISLE PA 17013-0599
CAO RETURN ADDRess IUNIT 00 I~~LD' 0017
Notice 10:
';5898H1
ADVANCE NOTICE
REDUCE
';~":~'~~~~:S.~"""'~\~~^""
,.:':IM''''''''A~51\''lil':'!\'~.~~.lIt.''!::",!';,~~';''',.~;lfl;' "",
PA~S 1 o~ 1
21 008951: ~>~ 0
IF yO/} {)() Nl1T UNtJEfIST AND {JtJ(/ /JEC/SION OR HIPIE MI'f
~ESTIOHS, PlEASE COHTN:T YOUllll/Ollj(fR t*EDlIO'ELY.
J;'CK R GREY
~~ORCA-qE C?_qLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
WORKER:
WORKER 10:
TEL.EPHONE:
DATE:
NOT: 330
D KL::JI:Gt.."'5MITH
(71 i) 2~0-2700
04/13/200~
OPT: 1 TYPE: R
THIS IS TO NOTIFY YOU THAT OUR OFFICE HAS TAKEN ACTION TO CHANGE YOUR Bt:N€f'ITS USTED BELOW
M~DIGAL ASSISTANCE
BEGINNING
05/03/2004
...:I....~'ti.I.]~.:':.lr:,.:l:1:t...f~l~~:ll'.:t:(.,!"I~~_.)_I~I-;.l~~t"J~~
FACTS AND
:1:(et'II.~1I.(.]~~
DIS~EGARO THE ABOVE BEGINNING DATE. Persons who ~aeaiva Fader~l Retirement,
Su~vivor5 or Disability benefits Wll1 gat COst of living increases In January.
Railroad Retirement. Black Lung and Veterans benefits may alSO De inereased.
Your payment towara the cost for nursing ~acility care inc~easas January 2004.
Monthly Ineom~ Computation:
SSA / RR / SL Income
-::-::VA Benef 1 ts
Civil Ser / Private Pension
In~erest / Other Income
$ 1283.50
$' 0.00
$ 2874.33
$ 0.99
Gro~s InGome $ 4158.e2
Pe~sonal Care Allow -$ 30.00
GUardianship Fee -$ 0.00
Spouse/Oepend.Allow.-$ 1039.62
Home Malnt. Allow. -$ 0.00
YOUR MONTHLY PAYMENT $ 30S9,20
verified medical expenses f~om
The nu~sing faCility will deduct the follOWing
your monthly payment: Medieare $ 146.50
Other mediea' insurance premium $ 0.00
Regulations: 55 PA Code 181.1,181.3.181.451.181.452.181.45:3
LEGAL HELP IS
~"'.:.Vf;H-':
APPE;AL AND FAIR HEARING
LEGAL SERVICES,INC.
a IRVINE ROW
CARLISLE PA 17013
If. you disagree with our decision. you have the right to ippeal. See attached
form for i complet~ explanation of your right. to appeal ~md to a fair hearing. If
your oral request for a h~arlng 1$ received' in the County AS$ist.;nce Office or
your written request is postmarked Or received on or before 04/26/2004 your
3ssist:ance will continue pending the hearing decision. except when the change is
due to ~t.ate. or F~td.era' Law.
"" DfJN:H HERE
I~*_~~~_~i~;
'~~:lII.(.,.~~'.l1.J':-'~JI":.'I.'!I'..:.~'J'];l~'" Notice 10:
DETACH HERE.
...,'~;.~
5689M11
JACK R GR,y
MANORCARE CARLISLE
940 WALNl,lT 13O'I'T0!1 ROAn
CARLISL~ FA 17013
"'iA~~~~~~~~
21" -0089511 TAN ." .. 0 '
CAO ADDRESS
CUMBERLl'.ND CAO
33 ~mS~IINSTER DRIVE
P.O. BOX 59!?
CARLISL~ FA l701~-0599
WORKER D KLINGiNSllITH
APPEAL: 04126/2004
TELEPHONE: (717) 240-2700
DATE: 04/13/2004
NOT: 330 OPT: 1 TYPE: R
OZ135A
PA/FS 11l2Fl 09/97
** TOTAL PAGE.05 **
OCT 12 2004 08:09 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
P.09/13
."
.:, ;,
;.
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
'"
"
PRIVATE
STATEMENT
ROOM
" '
..
, ' '
GREY. JACK
fOA.:r~:9.f.::: ,~:' .-1:~':: ,'.:'. Df~R.IPT'lp~'qF ~,.Ft~a; ,
'S'E'm'l1~E'" '.. , ; ",',",', " " ., "
I n'V;,,",-,' .." ',' ,.',... ":.. .,' ; . I.. ... . '~.' I, _
09i27.'CO ... .. -. t~A;RCUT . , . . -' n_"_
1 0/26/00 PAYMENT RECEIVED
10/31/00 HAIRCUT
11/07/00 PAYMENT RECEIVED
12/31/00 PRIVATE PORTION DUE
20082 12/10/00
I" .-. ~-~(;A'~ ",."., -.., 'J .... . "" ~~AS' .".....*.\
.: II I ~ ',' I,: :<"rv"\.i'lt:Ieg:,~~'~:I~~~~~~ !,~~t~I"~.~.::' IiIW~I.~.'~'~~~~~".~
" ,. . I." ',': ." :...."..:...,1 ~Il., 11,\....,._..."..lllIIlIiB,...,~r;.":.~:'.;,.,"S...M
:', I " .: I,:' I~" I' : ,: ',: ~:: ;~.~'{:I.:.,'.:':..~~:~ ~;~~,::~'~'~~Ir: ,:.~~~ ;;'1:'~~ ,,:,,~~.i,;~~."?I~:~:~
, . .- - 'sn 5C . ,
,;",.; i'f;
,.
-$53e.~0
$10.50
-$754.50
$2,381.06
.;
," ..!'
. "\ ,'f'
. . ~
TOTAL DUE UPON RECEIPT
$1,10Q,06
.t) :
<,
".' "
Payment Due Upon Receipt
Amount Due
$2,21~8A2
[XfLlBI7 "["
OCT 12 2004 08:09 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
GREY. JACK 20082 12/10/00
, . , '" I '" . ~ .... . UI'':f "...::.' 't" , "-=iJirll~':':':''' ... ::':':"'"'::":":""':"'lis P.lI' ""..". J
I OATE. OF, , '. ,'. ,DL:.aCHIf-" 10N:Or'~~ Me,.; , ".~" I":,! ""~I'T."",~~:':~l:~:.~!~' ':::':~":'::~~~~f.Er;...s: ~1'.t'.:'f.~;:'.~
I' "~"I'. . ... ,{ ... .,0 I. ..,....'" I II "''1'' ., .,".". ",1 .~, '..'.1'.1"11".,\".".1,.-",,. :;'):1...'11I..'.,I....~'IIo.III"IfII,Ii.....,'~'...I.....~:=~./
SERVJ~E'..:.' j,: I, '.. :. ':, 'I' . :,'" :,' iii,::," : . '::',:;'.: ,r ':.:': ".': :~:,: ::.~ ,;:7:: :,.. ~'~ ~I ',~:::'~:l:!;~".\:~~:::- ~T:r!i~:~;!:e1~::!:'::.FL:~?t.t.::,~:':
01 'O~.C, Ui':.,~.NCL I OI~WAnD" . . . -' . "" . ~.. -...- ....-....- $1.1 ~s 06
01103/01 PAYMENT RECEIVED
01/31/01 PRIVATE PORTION
01/31/01 MEDICARE B PREMIUM CREDIT
02/22101 PAYMENT RECEIVED
02128/01 PRIVATE PORTION
02128/01 MEDICARE B PREMIUM CREDIT
03/01-03/31/01 CABL.E RENTAL
03/31/01 PRIVATE PORTION
03/31/01 MEDICARE B PREMIUM CREDIT
04/04/01 PAYMENT RECEIVED
04/01-04/30/01 CABL.E RENTAL
04/30/01 PRIVATE PORTION
04/30/01 : MEDICARE B PREMIUM CREDIT
05/01-05/31/01 CABLE RENTAL
05/31/01 PRIVATE PORTION
05/31/01 MEDICARE B PREMIUM CREDIT
06/01-06/30/01 CABLE RENTAL
06/30/01 PRIVATE PORTION
06/30/01 MEDICARE B PREMIUM CREDIT
07/01-07/31/01 CABLE RENTAL
07/31/01 PRIVATE PORTION
07/31/01 MEDICARE B P.REMIUM CREDIT
08/01-08/31/01 CABLE RENTAL
08/31/01 PRIVATE PORTION
08/31/01 MEDICARE B PREMIUM CREDIT
09/11101 PAYMENT RECEIVED
09/01-09/30/01 CABL.E RENTAL
09/30/01 PRIVATE PORTION
09/30/01 MEDICARE B PREMIUM CREDIT
10/15/01 PAYMENT RECEIVED
10/01-10/31/01 CABLE RENTAL
10/31/01 PRIVATE PORTION
10/31/01 MEDICARE B PREMIUM CREDIT
11/01-11/30/01 CABLE RENTAL
11/30/01 PRIVATE PORTION
11/30/01 MEDICARE B PREMIUM CREDIt
12/14/01 PAYMENT RECEIVED
12/01-12/31/01 CABLE RENTAL
12/31/01 PRIVATE PORTION
12/31/01 MEDICARE B PREMIUM CREDIT
HCR*ManorCare
2001
MANORCARE CARLISLE 372
940 WALNUT BonOM ROAD
CARLISLE. F'A 17013
(717)-249-0085
TOTAL DUE UPON RECEIPT
Page 1
$2,910.25
$2,910.25
$5.00
$2,910.25
$5.00
$2,910.25
$5.00
$2,910.25
$5.00
$2,911.25
$5.00
$2,879.25
$5.00
$2,879.25
$5.00
$2,879.25
$5.00
$2,879.25
$5.00
$2,879.25
$5.00
$2.879.25
P. HV13
PRIVATE
STATEMENT
ROOM
-$938.50
-$110.00
-$3,000.00
-$110.00
-$110.00
-$1,392.24
-$110.00
-
-$110.00
-$110.00
-$11'0.00
:C, ',:
-$110.00
-$10,801.50
~}, r:
-$110.00
-$7.000.00
,\
-$110.00
-$110.00
-$4,OOE);OO
~ ::.
-$110.00
$7,444.82
'\J'
.
OCT 12 2004 08:10 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
HCR*ManorCare
2002
MANORCARE CARLISLE 372
a40 WALNUT BOTTOM ROAD
CARLISLe, PA 17013
(717).249-0085
PRIVATE
STATEMENT
ROOM
P. 11/13
.... .;
: ','. i
"',
GREY, JACK 20082 12/10/00 \ :~
"DAlE'Of':" ;.::-..'J..' .': '.:DESCHiP"flC'JN Ot"S~)j~"1:.: . :';':":I:,::~:.;,..<t:),~.r.QBEs:;;~,m~,:~t::..~;..:,:;,:;~Df:iSs'~,~\:::':'~.;;~
I '"....~, ~,I' ,....1. '.. . 'Ill I I '1.,.'": . ,."',,, ....,'. "':",.,~:r::!:U.:~I~."~"""'."::' ~'t,,~....~::-::,':"'I::;r:E:F~H"h_..r'~~""~~I~.
.seRVIGE.~.':' ..... .:..'.. I " '..'.....' . I.:::.....;.. :' .::~ ."'.:':.~::;:':" ;."'; ....:''',~1,':,~':.i~:,:::J::: ~1:'::L:r;':"'~I;;;':~.;:r:~::~'!'~'M~''1,':~
OFC1,'O' h~.LA~r.:= ='OR\lVAR~ .., ..-. - - - '-."'$7,1/448:> ...- . .......
01/07/02
01/31/02
01/31/02
02/25/02
02128/02
02128/02
03/22/02
03/31/02
03/31/02
04/30/02
04/30/02
05/01/02
05/31/02
05/31/02
06/07/02
06/30/02
06/30/02
07/31/02
07/31/02
08/05/02
08/31/02
08/31/02
09/02/02
09/05/02
09/16/02
09/01-09/30/02
09/30/02
09130/02
1 0/04/02
10/31/02
10/31/02
11/04/02
11/11/02
11/30/02
11/30/02
12/04/02
12101-12131/02
12131/02
12131/02
PAYMENT RECEIVED
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PAYMENT RECEIVED
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PAYME:NT RECEIVED
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PRIVATE PORTION
CABLE RENTAL
PAYMENT RECEIVED
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PAYMENT ReCEiveD
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PRIVATE PORTION
MEDICARE 8 PREMIUM CREDIT
PAYMENT RECEIVEO
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PAYMENT RECEIVED
PAYMENT RECEIVED
PAYMENT RECEIVED
CABLE RENTAL
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
PAYMENT RECEIVED
PRIVATE PORTION
MEDICARE 8 PREMIUM CREDIT
PAYMENT RECEIVED
PAYMENT RECEIVED
PRIVATE PORTION
MEOICARE B PREMIUM CREDIT
PAYMENT RECEIVED
CABLE RENTAL
PRIVATE PORTION
MEDICARE B PREMIUM CREDIT
TOTAL DUE UPON RECEIPT
Page 1
$2,916.05
$2,916.05
$2,916.05
$2,916.05
$2,916.05
$2,916.05
$2,983.44
$2,983.44
$5.00
$2,983.44
$2.983.44
$2,983.44
$5.00
$2,983.44
-$2,500.00
-$118.80
-$2.000.00
. '. ~':
, '
-$118.80
.$2.606.00
.$118.80
1~
.$118.80
.$2,40~.OO
.$11~.80
.$5,000..00
-$11:~.80
-$118\.80
-$1.121.00
, '
-$11:s'.80
.$1,121,00
-$3.500,00
-$1,2OC.6o
.$118'.?0
-$1,121.00
-$118.80
-$1.12,1=.00
-$3,00.6.00
-$118;80
-$1,12f.00
, ~
-$118..80
': .:.~ ~:.
$13,621.1'6
. ' ,
,", :.
.:1 t
OCT 12 2004 08:10 FR MANOR CARE-CARLISLE ?1? 249 064? TO 249S?SS
GREY, JACK 20082 12110100
rOA:TEPf ':.: "-j " : :.'U~SCRI?,TiON OF~ERY;~E':;': :..,".t:....~'l';~;:,CH~Es:!:~::f:~::j:,=.:J:.(;:;,~a;.::.~.nt!"i~
iSERVlcE' ;:,::' .':': "j .: ':,' , ~. ~~:.:.::.i~~. ,: '::,:' '::.: :::, ,:.:: '.' ; ',' : ':~:-:, l}1L~.::.::.!~::.~i1:m:~~ii:lf~![({;f;l~-r:rf~f~il~~:1ff~~f::::;::~Hi:1tf:i:;
C1.'01,OS 9,\:..I\N:::' i ORWA.Rn $13,fi;>1 1'3
01/06/03 PAYMENT RECEIVED
01/31/03 PRIVATE PORTION
01/31/03 MEDICARE B PREMIUM CREDIT
02/04103 PAYMENT RECEIVED
02/01-02128/03 CABLE RENTAL
02/28/03 PRIVATE PORTION
02/28/03 MEDICARE B PREMIUM CREDIT
03/04103 PAYMENT RECEIVED
03/01-03/31/03 CABLE RENTAL
03/31/03 PRIVATE PORTION
03/31/03 MEDICARE B PREMIUM CREDIT
04/04/03 PAYMENT RECEIVED
04/30/03 PRIVATE PORTION
04/30/03 MEDICARE B PREMIUM CREDIT
05/05/03 PAYMENT RECEIVED
05/31/03 PRIVATE PORTION
05/31/03 MEDICARE B PREMIUM CREDIT
06/04/03 PAYMENT RECEIVED
06/10/03 PAYMENT RECEIVED
06/30/03 PRIVATE PORTION
06/30/03 MEDICARE B PREMIUM CREDIT
07/03/03 PAYMENT RECEIVED
07/31/03 PRIVATE PORTION
07/31/03 MEDICARE B PREMIUM CREDIT
08/04/03 PAYMENT RECEIVED
08/31/03 PRIVATE PORTION
08/31/03 MEDICARE B PREMIUM CREDIT
09/04/03 PAYMENT RECEIVED
09130/03 PRIVATE PORTION
09/30/03 MEDICARE B PREMIUM CREDIT
10/06/03 PAYMENT RECEIVED
10/07/03 PAYMENT RECEIVED
10/31/03 PRIVATE PORTION
10/31/03 MEDICARE B PREMIUM CREDIT
11/04/03 PAYMENT RECEIVED
11/07/03 PAYMeNT RECEIVED
11/30/03 PRIVATE PORTION
11/30/03 MEOICARE B PREMIUM CREDIT
12/04/03 PAYMENT RECEIVED
12/10/03 PAYMENT RECEIVED
12/31/03 PRIVATE PORTION
12131f03 MEDICARE B PR.EMIUM CR.EDIT
. . 'HCR*ManorCare
2003.
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
Page 1
TOTAL DUE UPON RECEIPT
$3,036.36
$5.00
$3,036.36
$5.00
$3,036.36
$3,036.36
$3,036.36
$3,036.36
$3,036.36
$3,036.36
$3,036.36
$3,036.30
$3,03e.3S
$3,036.36
PRIVATE
STATEMENT
ROOM
P.12/13
;", "
',:! t..:
, '
> ..
-$1,128.00
-$129.~O
-$1,128.00
~ .I ~
-$129.:10
-$1,128.00
-$118.80
-$1.128.00
-$129.10
-$1,121tOO
-$1 ~9., 10
-$1,128.00
-$3,500.00
-$129.10
-$1,12SjJO
-$12g.~0
-$1, 12~tOO
..,,', ,..
...{J ~tJ
-$1~9..10
-$1,128.00
, ':!
-$129.10
-$1,128.00
-$7,OOtj.OO
,,<,
.~.'."
-$129.10
-$1,128.00
~$1,079;62
-$1~~.10
-$1, 12~.GO
-$1,879.26
-$1,?9.10
~4. ..
:...:/ ...
. '"
$21,533.70
. fj ~.
OCT 12 2004 08:11 FR MANOR CRRE-CRRLISLE 717 249 0647 TO 2495755
GREY, JACK 20082 12/10/00
r~A:'I"~nJ:.- .'-::-::--r" ~i::'-"""RI:)'I~-r';:;-"I;OT:,~~E..V-fC;:':"'. .'.m, : "'.:":-;;".'t,'!t::I:ll.~I:'<<'.''':'' ''':'''::l"''''':i'''' ""nrH=AI"-I!.". '~'.~~
~I~~~.~~~/::~,,:....... . : ..I"',~~I. t':'~I~~.~'1 :'i~'I;;,~", ":- .; ~:,"~" :"~:':':'~"',,~~1'I~~~'~\l,:~~~~::,~,':. ,-:~I.'~I.. :~~l~~!~";~~'I!I~~I:~:i::~J
'S~!5\.I'I~'E'."" . J I ,.. .' ". " -I "'.'. .". I ", " -/"'.~, ..""''11,.,1. ,,"f.I""""~II."''''I~' ....,...."."'......III.~...I.llr..."""lh., """11Io"."-1
r.:;;~1f,'" :," '.. : I I" ~ .'~ . .... I ',", I .:,: I . I " .', ;"",", loti: .; ,.',', '~,': ..1I'..,;:::,:......'.".~~:. ~'~;:~: :", :......:,':',I,~ .::~::..::':'" i'"';~=,~:""~.~:,
C1i01io4 UALANC("FORWARo- ...-. -.--.--- - -$i1]E'io .... -
01/05/04 PAYMENT RECEiVED -$1,137.00
01/31/04 PRIVATE PORTION $3,089.20
01/31/04 MEDICARE B PR.EMIUM CREDIT
02105/04 PAYMENT RECEIVED
02120/04 PAYMENT RECEIVED
02128/04 PRIVATE PORTION
02128/04 MEDICARE B PREMIUM CREDIT
03/04/04 PAYMENT RECEIVED
03/31/04 PRIVATE PORTION
03/31/04 MEDICARE a PREMIUM CREDIT
04/06/04 PAYMENT RECEIVED
04/20/04 PAYMENT RECEIVED
04/30/04 PRIVATE PORTION
04/30/04 MEDICARE a PREMIUM CREDIT
05/04/04 PAYMENT RECEIVED
05/31/04 PRIVATE PORTION
05/31/04 MEDICARE B PREMIUM CREDIT
06104104 PAYMENT RECEIVED
06/14/04 PAYMENT RECEIVED
06130/04 PRIVATE PORTION
06/30/04 MEDICARE B PREMIUM CREDIT
07/06/04 PAYMENT R.ECEIVED
07/26/04 PAYMENT RECEIVED
01/31/04 PRIVATE PORTiON
07/31/04 MEDICARE B PREMIUM CREDIT
08/05/04 PAYMENT RECEIVED
08/25/04 PAYMENT RECEIVED
06/31/04 PRIVATE PORTION
08/31/04 MEDICARE B PREMIUM CREDIT
09/08/04 PAYMENT RECEIVED
09/30/04 PRIVATE PORTION
09/30/04 MEDICARE B PREMIUM CREDIT
2004
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717).249-0085
TOTAL DUE UPON RECEIPT
Page 1
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
PRIVATE
STATEMENT
ROOM
P.13/13
-$146.50
-$1,137.00
-$2,800.00
-$146.50
-$1,137.00
-$146.50
-$1,137.00
-$3,500.00
-$146.50
-$1,137.00
-$1~..50
-$1,137.00
-$2,50a,oo
-$146,50
-$1,131;00
-$2,250.00
-$146.50
-$1.13i.~0
-$1,870.00
'-6.:
-$14&.50
-$1,131.00
-$146.50
~h..
;3
$24,865.00
** TOTAL PAGE.13 **
,:::*C;.
DEC 14 2004 12:11 FR MRNOR CRRE-CRRLISLE 717 249 0647 TO 2495755
P.05/06
2004
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM
GREY, JACK 20082 12/10/00
IDATE OF r DESCRIPTION OF SERVICE. I... ., CHARGES. ,..._, CREDITS
SERVICE,
01/01/04 BALANCE FORWARD $21,533.70
01/05/04 PAYMENT RECEIVED -$1,137.00
01/31/04 PRIVATE PORTION $3,089.20
01/31/04 MEDICARE B PREMIUM CREDIT -$146.50
02105/04 PAYMENT RECEIVED .$1,137.00
02120/04 PAYMENT RECEIVED -$2,800_00
02128/04 PRIVATE PORTION $3,089.20
02128/04 MEDICARE B PREMIUM CREDIT -$146.50
03/04/04 PAYMENT RECEIVED -$1,137.00
03/31/04 PRIVATE PORTION $3,089.20
03/31/04 MEDICARE B PREMIUM CREDIT -$146.50
04/06/04 PAYMENT RECEIVED -$1,137.00
04/20/04 PAYMENT RECEIVED -$3,500.00
04/30/04 PRIVATE PORTION $3,089.20
04/30/04 MEDICARE B PREMIUM CREDIT .$146.50
05/04/04 PAYMENT RECEIVED -$1,137.00
05/31/04 PRIVATE PORTION $3,089.20
05131/04 MEDICARE B PREMIUM CREDIT -$146.50
06/04/04 PAYMENT RECEIVED -$1,137.00
06/14/04 PAYMENT RECEIVED -$2,500.00
06/30/04 PRIVATE PORTION $3,089.20
06/30/04 MEDICARE B PREMIUM CREDIT ~$146.50
07/06/04 PAYMENT RECEIVED -$1,137_00
07/26/04 PAYMENT RECEIVED -$2,250.00
07/31/04 PRIVATE PORTION $3.089.20
07/31/04 MEDICARE B PREMIUM CREDIT -$146.50
08/05/04 PAYMENT RECEIVED -$1 J 137.00
08/25/04 PAYMENT RECEIVED -$1,870.00
08/31/04 PRIVATE PORTION $3,089.20
08/31/04 MEDICARE B PREMIUM CREDIT -$146.50
09/06/04 PAYMENT RECEIVED -$1,137_00
09/30/04 PRIVATE PORTION $3,089.20
09/30/04 MEDICARE B PREMIUM CREDIT -$146.50
10/05/04 PAYMENT RECEIVED -$1,137.00
10/18/04 PAYMENT REceIVED -$3,800.00
10/31/04 MEDICARE B PREMIUM CREDIT -$146.50
10/01-10/31/04 PRIVATE PORTION $3,089.20
11/05/04 PAYMENT RECEIVED -$1,137_00
11/31/04 MEDICARE B PREMIUM CREDIT -$146.50
Page 1
DEC 14 2004 12:11 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
11/01.11/30/04
12/06/04
12131/04
12/01-12/31/04
PRIVATE PORTION
PAYMENT RECeIVED
MEDICARE 8 PREMIUM CREDIT
PRIVATE PORTION
2004
$3,089.20
$3,089.20
TOTAL OUE UPON RECEIPT
Page 2
P.06/06
~$1,137.00
-$146.50
$26,482.10
** TOTRL PAGE.06 **
.. .
.
VERIFICATION
I verify that the statements made in the foregoing Complaint are true and correct to the
best of my knowledge, information and belief. This verification is signed by David A. Baric,
Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as
documents reviewed by the undersigned as attorney for Plaintiff. This verification will be
substituted and ratified by a verification signed by the Plaintiff who is presently unavailable to
sign said verification. I undersigned that false statements herein are made subject to penalties of
18 Pa.C.S. ~4904, relating to unsworn falsificat~ons to aUthOfitieS'i1
David A. Baric, Esquire
Dated,!) I;; ILlt!
"
~
~~
~ ~
~~
~
~\;\~
\ ~ ~
\\\
~ ~
('\ t....."'Io
I~_' ~-:-",;, ~".- J
. .r:. _ '"11
I ;(:~ ~jJ;, T!
, !"): ' I ' ,'~
, --, "/
:'''111, '-'
_' ,. 'I '
,c ',: ~::' '; i I
"" .C.... ~ i
(., I ,.<
IN THE COURT OF COMMON PLEAS
OF THE 9TH JUDICIAL DISTRICT
CUMBERLAND COUNTY - PENNSYLVANIA
HCR MANORCARE, INC.,
Plaintiff
CIVIL ACTION - LAW
No, 2004 - 6386
v,
JACK R GREY and
JAN POTZER, individually and as the
Attorney-in-Fact for JACK R GREY,
Defendants
ANSWER TO COMPLAINT
1, Admitted.
2, Admitted.
3, Admitted.
4. Admitted.
5, Admitted.
6. Admitted.
7. Admitted.
8. Admitted.
9. Admitted.
10, Admitted.
11. Admitted.
12, It is admitted that Jan POTZER received pension and annuity payments on behalf
of Jack R GREY, It is denied that the amount received was $140,000,00,
13. Admitted.
14, Admitted.
15, Admitted.
16. Admitted,
17. Admitted.
18, Admitted.
19, Denied, The Defendants are without knowledge, information or belief to admit
or deny the averments of Paragraph 19. Strict proof thereof is demanded.
Count I - Breach of Contract
HCR Manorcare, Inc. v. lack R Grey and Jan Potzer
20, Defendants incorporate Paragraph 1-19 of the Answer herein by reference as
though fully set forth,
21. Paragraph 21 is a conclusion to which no responsive answer is required,
22. Paragraph 22 is a conclusion to which no responsive answer is required.
23. Admitted,
24. Denied. The costs due and owing are covered by a private carrier, Tri-Care,
which has refused to pay,
25. Denied. On the contrary, Defendant, Jan paTZER, has complied with the
Admission Agreement by paying from Jack R GREY's resources the costs of his
care as permitted.
26, Denied, On the contrary, Jack R GREY has complied with the Admission
Agreement to the best of his ability.
WHEREFORE, Defendant's request your Honorable Court to dismiss the
Complaint of Plaintiff, with prejudice,
Count II - Money Had and received
HCR Manorcare, Inc. v. Jan Potzer
27. Defendants incorporate by reference Paragraphs 1,26 as though fully set forth
herein.
28. Denied. On the contrary, Jan paTZER did not receive the sum of $140,000,00,
29. Denied. By way of further answer, it is averred that Jan POTZER utilized these
funds in accordance with the direction of the Cumberland County and York
County Offices of Aging, and the Cumberland County Assistance Office, based
on the resource assessments.
30, The averments of Paragraph 30 are conclusions to which no response is
required.
31. The averments of Paragraph 31 are conclusions to which no response is
required.
32. Admitted,
WHEREFORE, Defendant, Jan POTZER requests your Honorable Court to dismiss the
claim of Plaintiff with prejudice.
Date:
2. \u,. 'U:D>:;
.~
. . .......
Forest I Myers, Esquire
Attorney 1.0. #18064
137 Park Place West
Shippensburg PA 17257
Phone 717.532.9046
Fax 717..532,8879
e-mail fnrnyers@earthlink.net
I verify that the statements made in the foregoing Answer to Complaint are true
and correct. I understand that false statements herein are made subject to the
penalties of 18 Pa. Cons. Stat. 9 4904, relating to unsworn falsification to
authorities.
Date: c..,q.o;;
... -.)~"- GI2<?'<
IN THE COURT OF COMMON PLEAS
OF THE 9TH JUDICIAL DISTRICT
CUMBERLAND COUNTY - PENNSYlVANIA
HCR MANORCARE, INC.,
Plaintiff
CIVIL ACTION - LAW
No. 2004 - Q386
v,
lACK R GREY and
IAN POTZER, individually and as the
Attorney-in-Fact for lACK R GREY,
Defendants
CERTIFICATE OF SERVICE
I, Forest N. Myers, Esquire, certify that a true and correct copy of the foregoing
document was served by depositing the same in the United States Mail, Filsl Class, postage
prepaid, at Shippensburg, Pennsylvania, on the 14'h day of February, 2005, on the
following:
David A 8aric, Esquire
Attorney for the Plaintiff
19 West South Street
Carlisle PA 17013
-\;ooo~d--
Forest N, Myers, Esquire
Atty I.D.# 18064
137 Park Place West
Shippensburg, PA 17257
Phone 717.532.9046
Fax 717.532.8879
e-mail fnmyers@earthlink.net
\ \Server\shareddocs\ Word Processing\civi/\forms\cert of svc. form .reV Apr02 .doc
-.
HCR MANORCARE, INC.,
Plaintiff,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
: NO. 2004-6386 CIVIL TERM
JACK R. GREY and
JAN POTZER, individually and as
the attorney-in-fact for
Jack R. Grey,
: CIVIL ACTION-LAW
Defendants.
PRAECIPE TO DISCONTINUE WITHOUT PREJUDICE
TO: Curtis Long, Prothonotary
Please mark this action as being discontinued without prejudice.
O'BRlliN: BAR~ IIR
David A. Baric, Esquire
ID#44853
I 9 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
'-...
CERTIFICATE OF SERVICE
I, David A. Baric, Esquire, certifY that a true and correct copy of the foregoing Praecipe to
Discontinue Without Prejudice was served by depositing the same in the United States Mail, first
class, postage prepaid, on the}-Y ~y of February, 2005 on the following:
Forest N. Myers, Esquire
137 Park Place West
Shippensburg, P A 17257
O'BRIEN, BARIC & SC/rR
, t! ( ~"
David A. Baric, Esquire
ID#44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
;:;::::,
~
:+:-
g
VI
1"\
1""1
tp
~
~
'!?
N
--.~.~-
I ,
SHERIFF'S RETURN - REGULAR
CASE NO: 2004-06386 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HRC MANOR CARE INC
VS
GREY JACK R ET AL
RONALD HOOVER
, Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
GREY JACK R
the
DEFENDANT
, at 1500:00 HOURS, on the 5th day of January , 2005
at 1201 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
by handing to
a true and attested copy of COMPLAINT & NOTICE
together with
JAN POTZER, DEFENDANT'S POA
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.00
3.70
.00
10.00
.00
31.70
~,,^"~ ~~;f}/ ~'~ .
/c~., .~
/7~.;I".;;;~...",c",,~ /r:. '
, "
R. Thomas Kline
01/06/2005
OBRIEN BARIC SCHERER
Sworn and Subscribed to before
By:
C52k-F///
Deputy Sheriff
tv
me thi s ,;( 1/ v day of
'I
l )aAA.~:AAl ;2uo:/ A. D .
( 1'_. Q, "!-hLIPh- ,-
;p~tl;onotary ,~
SHERIFF'S RETURN - REGULAR
CASE NO: 2004-06386 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HRC MANOR CARE INC
VS
GREY JACK R ET AL
, Sheriff or Deputy Sheriff of
RONALD HOOVER
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
was served upon
POTZER JAN
the
DEFENDANT
, at 1500:00 HOURS, on the 5th day of January , 2005
at 1201 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
by handing to
JAN POTZER
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
6.00
.00
.00
10.00
.00
16.00
/,,7
~./>- ~~:>;:,:'-""'.
/"~""'<"
? .,.....
R. Thomas Kline
01/06/2005
OBRIEN BARIC SCHERER
Sworn and Subscribed to before
By:
~~
Deputy Sheriff
If:-
mej:.his :Ill day of
~ ~5' A.D.
Cr." J () 'Jvujf-,~ ..~
P?drhonotary