HomeMy WebLinkAbout05-0975HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- g 7.5?
CIVIL TERM
CIVIL ACTION-LAW
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by an attorney and filing in writing with
the court, your defenses or objections to the claims set forth against you. You are warned that if
you fail to do so, the case may proceed without you and a judgment may be entered against you
by the court without further notice for any money claimed in the complaint or for any other claim
or relief requested by the plaintiff. You may lose money or property or other rights important to
you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
HCR MANORCARE, INC.,
Plaintiff
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-
CIVIL TERM
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
CIVIL ACTION-LAW
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:
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.
Defendant, Jan R. Potzer, is an adult individual with a residence address of 110
South Hanover Street, #6, Carlisle, Cumberland County, Pennsylvania 17013
Defendant, Jack R. Grey, is an adult individual with a residence address of 940
Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013.
Defendant, Emily R. Grey, is an adult individual with a residence address of 498
Devon Road, York, York County, Pennsylvania 17403.
5. By Power of Attorney dated January 12, 1993, Jack R. Grey appointed Jan R.
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.
6. Upon information and belief, the Power of Attorney dated January 12, 1993 has
been in full force and effect at all times relevant hereto.
ManorCare owns and operates a skilled nursing facility located at 940 Walnut
Bottom Road, Carlisle, Cumberland County, Pennsylvania ("facility").
8. On or about August 14, 2000, Jack R. Grey sought admission to the ManorCare
facility.
9. In connection with seeking admission, Jan R. 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 of the Admission Agreement is
attached hereto as Exhibit "B" and is incorporated by reference.
10. Jack R. Grey became a resident of the facility on August 14, 2000 and remains a
resident to the date hereof.
11. On or about August 14, 2000, Jan R. 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.
12. In the Application for Residency, Jan R. Potzer represented she was receiving
pension and annuity benefits of Jack R. Grey in the monthly amount of $2,029.00.
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13. 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 R. Potzer.
Upon information and belief, these receipts totaled in excess of $140,000.00.
14. 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.
15. 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.
16. 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.
17. 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.
18. Pursuant to the Admission Agreement, Jan R. Potzer agreed to pay from the
income of Jack R. Grey any costs of care not covered by a third party payor.
19. 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.
20. 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.
COUNT I-BREACH OF CONTRACT
HCR MANORCARE, INC. v. JACK R. GREY AND JAN R. POTZER
21. Plaintiff incorporates by reference paragraphs one through twenty as though set
forth at length.
22. All conditions precedent to recovery under the Admission Agreement have been
fulfilled.
23. Jan R. 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.
24. 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.
25. The amount due and owing is not covered by a third party payor.
26. Jan R. 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.
27. Jack R. Grey has breached the Admission Agreement by failing and refusing to
pay for the service and care provided to him by ManorCare.
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WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the
sum of $22,778.80 plus late fees, costs and expenses and attorney fees.
COUNT II- MONEY HAD AND RECEIVED
HCR MANORCARE, INC. v. JAN R. POTZER
28. Plaintiff incorporates by reference paragraphs one through twenty-seven as though
set forth at length.
29. During the period of Jack R. Grey's residency at the facility, Jan R. Potzer
received the sum of at least $140,000.00 in pension and annuity benefits paid to Jack R. Grey.
30. 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.
31. At the time of receipt of these funds, Jan R. Potzer knew she was obligated to pay
these funds over to ManorCare for the costs of Jack R. Grey's care at the facility.
32. Jan R. Potzer gave no consideration for the funds of Jack R. Grey received by Jan
R. Potzer.
33. Demand has been made upon Jan R. Potzer to tender the funds of Jack R. Grey
and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Jan R. Potzer
requiring her to:
a) return the subject matter in specie;
b) pay over the value if Jan R. Potzer has consumed the money in beneficial use;
C) pay its value if Jan R. Potzer has disposed of the funds received; and
d) award costs, expenses and interest.
COUNT III-SUPPORT
HCR MANORCARE v. EMILY R. GREY
34. Plaintiff incorporates by reference paragraphs one through thirty-three as though
set forth at length.
35. Emily R. Grey has been and is the wife of Jack R. Grey at all times relevant
hereto.
36. Upon information and belief, Emily R. Grey has been receiving some portion of
the monthly income of Jack R. Grey during the period of Jack R. Grey's residency at the facility.
37. Upon information and belief, Emily R. Grey has been and is of sufficient financial
ability to financially assist Jack R. Grey in meeting the costs of his care.
A Jack R. Grey, as a consequence of his failure to pay the amounts due and owing
for his care, is indigent.
39. Pennsylvania statutes permit a court to direct the spouse of an indigent person to
financially assist such indigent. 62 P. S. §1973.
40. The care and services provided by ManorCare to Jack R. Grey are necessaries.
41. A creditor who has provided necessaries for the support or maintenance of a
person may institute suit against that person's spouse for the price of said necessaries. 23 Pa.
C.S.A.§4102.
WHEREFORE, Plaintiff requests judgment in its favor and against Emily R. Grey in the
amount of $22,778.80 plus interest, costs and expenses.
Respectfully submitted,
O'BRIEN, BARIC & SCHERER
Ax??
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 2249-6873
Attorney for Plaintiff
dab. d it/ma norcare/grey/co m plaint3, p ld
02/16/2005 13:40 7172495755 OHS PAGE 09
The statements in the foregoing Comptaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they are tme and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 PA.C.S. §
4904 relating to umswom falsifications to authorities.
DATE: I I I O 5 I l M R "X&
Kim Wier
Business Office Manager
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS: That I, JACK R. GREY, of York
County; Pennsylvania, hereinafter sometimes referred to as
"Ptincipall^ 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,
,dace and stead; to.act.in and manage all my estate,. present and
future, and to conduct all my affairs, and for that purpose, and
for my use and benefit, and as my act-and deed, to do and execute,
or to concur-with persons .interested with myself therein in the i
doing and executing of all or,any of the following acts, deeds and
i
things, that is to say:
_In the event' my .daughter,, JAN R. WEAVER, is unable or
unwilling to`:act.As my, attorney-in-f act, L. then appoint my son,
JAMES I2 GREY, SOUTH.GAROLINA I'n`the"event my son, JAMES R. GREY;
is unable or unwilling to act as my attorney=in-fact, I then
appoint my aon,'JONATHAN..R GREY; YORK COUNTY, PENNSYLVANIA.
(1) -To`buy; receive, lease accept or. otherwise acquire, to
s:e.11. at,.:publ.'ic or private sale., convey,.. mortgage, hypothecate,
:.:pledge., gtiit.=claim; .assign,,. "transfer or otherwise encumber or
dispose of. or to: contract or.agree for the acquisition, disposal
or,encumbrance of any property or.'part or parcel thereof whatsoever
and wheresoever situated, be it real, personal or mixed, or any
custody, possession, interest, privilege or right therein or
pertaining; 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
tenants or other persons from, and recover possessions of, such
1
allrB-17 'Am
ropa y,.a11'!?.lawPul•meanr' and to maintain, prui_c??, y?=a=?v_,
nsI%ieG,^:,remove, store, tr sport, repair, rebuild, odify or
improve the same or any part thereof;
(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
whatsoever which may now or hereafter be due, owing, or payable to
me..or by. me;
...(4). To make, endorse, accept, receive, sign, seal, execute,
acknowledge ..and -.deliver 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
insutance..:now..or•...here.atter•effect.ed.by.-me, whether on my.life or
otherwise;
.(5) To incur. And. pay any bills and obligations for my
maintenance, care, comfort and support and for any of my medical,
surgical and other unusual needs, including but not limited to
;.,hospitai; nursing home; convalescent care and needs of invalidism;
(6) To deposit and 'withdraw for the purpose.,hereof, in
either my said attorney's name or my name in and from any banking
institution, any funds, checking and savings accounts, negotiable
papers',:=or monies-which inay 'come :into-.my "'said attorney':s hands as
suctr attorney or•which- :•I.now or-hereafter may have on deposit or be
entitled to.;ncluding hereafter:may.hade on.deposit or.be.entitled
:'.to';: ndluding any'monies:.in my`name alone or-'jointly in myname and
some.ether,person's::name.,:.including.my -said-attorney's name;
' (7) To`:institute,..prosecute, .defend,'compromise,_arbitrate,
and dispose of legal, equitable, or administrative hearings,
attachments arrests, distresses. or . other
proceedings or otherwise engage in litigation in connection with
the••premrses;
(•8j To:act as-my'attorney or proxy in respect to any stocks,
shares, bonds,, or other. investments., rights, or interest, I may now
or-hereafter:holdq
(9) To engage and dismiss agents, counsel, and employees,
and to appoint and remove at.pleasure any substitute for, or agent
of my said attorney, in respect to all or any of the matters or
things herein mentioned and upon such terms as my attorney shall
think fit;
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::cn.......-.-,+l?Q1.,au.itF?,..1. u.,a. ?uCr?yLIIX
returns, and other governmental-reports,`•and applications,.re_uAff s
and documents;
(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
necessary or convenient for such purposes.
(12). To sign admission orsdischarge agreements for my entry
into or discharge from a nursing home, hospital or other health
caire.facility.an.d to make health care decisions on my behalf as my
health care, agent.'
.(13) To sell, transfer, or purchase shares of stocks, bonds,
and securities upon such terms and for such prices as my attorney
deems-advisable..
(14) a: To, make such gift of property to others as I may
from time to time direct.
b. To make such gifts of my property to such one or more
of.my-spouse-and issue and-charities in such form and amounts as my
'attorney'believes would be in accordance with my. wishes.
c.•' To make such gifts of my property to such persons
and in such form and amounts as my attorney believes would be in
.accordance with. my wishes.
d. To make such gifts of my property to such persons
And.:in such form'..and.'amounts An my attorney's sole discretion
believes. are in :aiy..best interest.
(15) To estab'li.sh and fund •a Medicaid Qualifying Trust' or to
:create any other -trust"for my bene.fit..,
(16) To-`m ake additions to.. in existing trust for my benefit.
('17) 'To withdraw and 'receive the income or corpus of a
'trust...: _
To"claim:an elective share of the estate of my deceased
spouse.
.(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
attorney" within the prov ions of Section 5604, an,' also to be
subject to the provisions of Sections 5605, 5606 and 5? T (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
fully and effectually to'all intents and purposes as I might.or
could do in my own proper person if personally present, the above
specially enumerated powers being in aid and exemplification of the
full, complete, and general power 'herein--granted .and not in
limitation or definition thereof, and hereby ratifying all.that'
said attorney-shall lawfully 'do or cause by virtue.-of these
presents.
Furthermore, I hereby specifically declare that the authority
conferred by aie erein upon'iny' attorney shall be exercisable..by my
attorney as provided in this power on my behalf notwithstanding my
later :disability or incapacity under law or later uncertainty 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
disability or incompetence or. uncertainty..as to whether I am dead
or.alive or during any 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.as.if I.were alive,
competent and not disabled.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of 1993.
JACK GREY
Attorney-iri=Fact .:
4
COMMONWEALTH OF PENNSYLVAN
SS
CQUNTY.OF YORK
We, JACK R. GREY, guhLr and
(;/fjix-n /L L, 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 Power of Attorney and 'that he has
signed willingly (or willingly directed another to sign for him),
and that he executed it as his free and voluntary act for the
purposes therein expressed, and that each of the witnesses, in the
-presence and hearing of the undersigned, signed the General Power
of Attorney as witnesses affirm in writing that the undersigned
appeared to be at least eighteen (18) years of age (or to be
otherwise authorized to give medical consent as an adult pursuant
to this section), to understand and appreciate the consequences of
the general powerof attorney document, and for be under no
constraint .or.undue, influence.
K R. GREY
l? tam ? ? _.
Witn ss
Wl es
.Sworn and. subscrib d-to,
bore .me 'this j?~day of
1993.
ry Yuniic
My. Commission Expires:
Not-rW Seal . 6
Kotly L Brow,.. NoUry Pub&
SoringettsCuty T.w•010, York Cwunty
My CommissIm*F.otrss August 14, 190
N,^iMr, Drnn?N• is '- -Mlo? M Notarb/
COMMONWEALTH OF PENNSYLVANIA )
( ss:
COUNTY OF YORK )
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 knowledge, information and belief, the following is true and
correct:
1. 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
original of said Power of Attorney dated January 12,
1993, from Jack R. Grey; as Principal, to Jan R. Weaver,
a.ttorney-in=fAct, aow known as Jan 'R: Potzer.
r...
2. That said-Power of.Attgrney is still.-in full force. and
.-effect. and that the same.has not been revoked.
Kagen; squi
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 pip
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center%).
Center: MAN
Resident: [AC l4 6 r7 F- `I
Legal Representative:
Admission Date: R • Q. 0 t7 Deposit: S
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 RESPONSIBILITIES OF THE RESIDENT
1.01 Room and Board Rate.f For the basic services provided-fur-in Section 3.01, the
Resident 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'h) 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's 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 hill, along with the Room and Board Rate by the tenth
(10te) day of the month.
EXKZdZ7 "B°
1.03 Late Pa rry gents. Accounts not paid in full within thirty (30) days of billing 3W be
subject to a service charge equal to the highest legal rate of interest permitted by State law as $a
forth in Attachment A on the past due balance each month until such time as the balance due is
paid in 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.
1.04 Independent Providers. The Resident shall be directly responsible to independent
providers, including but not limited to, the Resident's 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 terms 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: _& _Medicare, x 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 determined 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 ("HMO"),
Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which.the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident 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 bill the Resident's third party payor as a service, but the Resident re&__..,ns liable for duff
not paid or covered by that third party payor including charges not paid within a reasonable
period of time.
1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge thu
they are responsible for paying the Center for items and services provided during the stay a< the
Center and during which time the Resident has not been determined to be eligible for Mediaid.
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 of
insurance cards, identification or verification of eligibility and coverage information.
-The-Resident and/or Legal Representative agree to provide the Center with notice
within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage,
failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as
the Center relies on the information supplied regarding such coverage. The Resident 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, a
govemmental 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 rimarily liable
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, medications6
and other care and services which may be delivered by the Center or its subcontractors. This
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Agreement serves as a written notice that the Center has notified 4... Resident and/or LW
Representative that services provided at the Center may not be covered by a govetnrnerital
third party payor or managed care organization. The Resident and/or Legal Representative age
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
1.11 Personal Physician. The Resident has the right to choose a personal physime
provided that the physician selected is properly licensed and agrees to abide by applicable law and
the rules and policies of the Center. At the time of admission, the Resident must supply the
Center with the name of his/her.personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or 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 home by the Resident.
1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right 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 pharmacy has a medication distribution system similar to the Center's
ancillary pharmacy's medication distribution system.
IL RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE
2.01 Legal 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 resources 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 must
notify the Center in writing when the application for Medicaid is made. If the Leggy
Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and
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 in a
timely and proper manner.
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Med clK on
Legal Representative shall provide such information about the Resident's finances as
representative shall require for continued coverage of the Resident and be personally respoe
for any charges denied the Center due to any lack of cooperation.
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 meant of
transportation and to deliver the Resident to the residence address of the Legal Representative, if
the Resident's condition permits, who shall unconditionally be obligated to accept the Resident
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.
III. RIGHTS AND RESPONSIBILITIES OF THE CENTER
3.01 Room an 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,i 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, if any, noted at
the beginning 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 and/or Legal RepresentAtivc
hereby consents to the release of his/her medical records to the following persons:
personnel, attending physicians and consultants; and person, finn, government entity, third per'
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 assurarn
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 liabWq
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. cue
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily
activities; and general nursing care, the administration of medications and treatments, and the
performance, of therapies, as prescribed by the Resident's personal physician in the Resident's
Plan of Care, or as required from time to time in the exercise of good nursing judgment, "subject to
any rights provided to the Resident by federal 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 for Center and staff to identify the Resident. ,
4.04 Notice of Services. Policies and Additional Information The Resident and/or
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 Payment of Benefits. See Attachment D.
C. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Detemunation Notice. See Attachment F.
e. Medicare Secondary Payor Questionnaire. See Attachment G.
f. At the request of the Resident and/or Legal Representative, the Center
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
6
Authorization and any other related documents. See Attachment ii -I sod
H-2.
g. The Center's polity and procedure on bedholds, election of bedholds gad
readmission. See Attachment I (Center Supplement).
h. Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
i. Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
j. 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).
k. The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
1 Procedures, name, address and phone number on how to file a complaint
-- with the state survey and certification agency concerning resident abuse,
neglect, mistreatment and misappropriation of property. See Attachment I
(Center Supplement).
m. The Resident Handbook. See Attachment J.
n. Resident/Patient Rights. See Attachment K.
o. Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments. See Attachment L.
P. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR 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 his/her medical treatment. See Attachment M-1
and M-2.
q. Privacy Act Notification. See Attachment N.
r. Inventory sheet and/or policy of personal items. See Attachment O.
7
S. ASM Form. See attachment P.
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 information 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 ev n (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 (including the Center), except in the case of negligence of the
employees and agents.'a
4.08 Changes in the Law. Any provision of the Agreement that is found to be hr aLd
or unenforceable as a result of a change in State or Federal law will not invalidate the remanft
provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the
Center will continue to fulfill their respective obligations under this Agreement consistent with the
law.
THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY
HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND
THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY
SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION.
Signature of Resident: Date:
Signature of Legal Representative, if signing on behalf of Resident:
Signature of Legal Representative, signing on his/her own behalf:
Date: J
Date:
Center Representative: 1(/jni j.1. J .L Ar)n Date: C(. OU
ASM
We are pleased that you will allow Ancillary Services Management, Inc. ("ASM")
to serve your Medicare Part 8 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 govemmental
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 8 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,
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 8 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 8 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 Signature,
Date Signature of Legal Representative
White Copy - ASM, tnc. Yellow Copy - Facility
G2E`l
COMMONWEALTH OF PENNSYLVANIA , JA C(G
.DO
AOR1LT q, Q .00
DEPARTMENT OF PUBLIC WELFARE 55' 1. q ?35p
ADMISSIONS NOTICE PACKET
IMPORTANT INFORMATION FOR
NURSING FACILITY RESIDENTS AND THEIR SPOUSES
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 U.S.C. § 1396r
(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. §1396r (c) (1) (B) and (e) (6) were provided to me at
the time of my admission to: ,
Fill in Name of Facility
OR
Signature of Resident t n ture of Re1re ent iv
9 g 9010 -
Date Relationship to Resident
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)
.Iety davq after the date below or 300ner. at my
Patient's S' ature Date
*Guardian espon a ature Date
Witness Sign re Jul Date a q, 2o00
*This signature is necessary on when the patient has a guardian or is unable to sign
Resident Name: C q jprd Medical Record #::X pp
13
ManorCare Health Services
CONSENT TO PHOTOGRAPH
As used below, the term "Photograph" includes video photography,
COMPLETE ALL SECTIONS
PUBLIC RELATIONS (Check One)
1 do give 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.
1 do not give 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.
ADMIM, TRATIVE (Check one)
1 do give my consent for me/the Patient/ Resident 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.
1 do not give my consent for me/the Patient/Resident to be photographed, by or on
i-&half 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)
1 do give my 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 give my consent for me/the Patient/Resident to be photographed by the
Facility for medical monitoring and/or educational purposes.
cjaa/li2tar, -- -
Pali r/Resident or Re nsible Parry Signature
Patient/Resident or Responsible Party Signature
7< /• 6 b ?}
Date
Nsawmrs Name (LAst, First. mn Attending Physician Rode Number PetNnt7Residerlr Numssr
CsP--F `1 i )ACID DAN L LS ('d'7 ?UUg2
12/961
mn? SAll) r rLEq.p-(
ADVANCED DIRECTIVE STATU:
(TO BE USED IN CONAINCTION WITH Hi
TREATMENT POLICy)
ADMISSION DATE: DATE
RECEIVED SIGNAT
URj
ON ADMISSION ,
? Receipt of HCR Manor Care "Refusal of Life-Sustaining Treatment" Handout
? 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*)
RESPONSIBLE PARTY x.m*aty
O Resident (Competent)
O Legal Guardian (Resident Incompetent)
(Indicate if Guardian is over person, property, or both)
O Durable POA/Health Care Proxy
O Legal Representative / Family
O None of the Above
ADVANCED DIRECTIVES*
? Living Will/Declaration
O Durable Power-of-Attorney 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.
NO CPR/DNR ORDERS --
? Physician's Order (Original order must be hand written on physician's
order sheet and placed on the chart - computer printout accepted thereafter.)
? Physician Documentation of Informed Consent in Progress Note
? Compliance with HCR Manor Care Policy in Section 3 of the Limited Treatment Polity
ual
? HCR Manor Care Release of Liability for the No CPR/DNR Order ("Note)
LIMITED TREATMENT
? Physician's Order (See above under "Physician's Order")
? Physician Documentation of Infdrmed Consent in Progress Note
? Compliance with HCR Manor Care Policy in Section 2 of the Limited Treatment Policy
? HCR Manor Care Release of Liability for the LIMITED TREATMENT Order ("Note)
ual
ORGAN DONOR
? Receipt of Information Related to Organ Donation
? 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 CPR/DNR or Limited Treatment Order.
"Note: After the physician bas obtained informed consent, obtain the signature of the resident or legal
representative(s) on the HCR 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 Cs ?r r JAG( (- Medical Record #
34
HCR*ManorCare
To apply for admission to our Nursing Center, please complete the following questionnaire, sign, and
return it to the Admissions Office This application will become a part of the "Admission Agreement"
and should be completed in its entirety. All information will be held in confidence. The complete
medical history and physical examination results will be recorded on another document
Date: ?- - 114 - O r2
Name of Prospective
Date of Birth:
(line 2)
Marital Status: Married Widowed Single
JG
If Married or Widowed, Name of Spouse
Social Security No: I (a 1a - I y - '73 S D Mf dcare No: 1(0 (o l q S 0 -q
HMO/Insurance: Provider Eja . &0- /$S \,,
IDNo: Pf}E1 1(a1o1 y735D Group No: P#H 3 (n I Policy No.
Insurance is: PrimarySecondary Co-insurance
Other Insurance: Provider
ID No Group No
Insurance is: PrimarySecondary
Name of In uirer:
Address: IJ4(V->,&
(line 2) 1/ Other persons to contact in case of emergency:
Name: ..n , b±-7 yi)
Address:// //n S stl,lwddek 3f #(o
(line 2)
How did you hear about
Personal Referral
Hospital i/
Physician
Other Professional
Mailing/Brochure
Other Nursing Ctr._
Save you visited any other Nursing
ones? FOX ki d Mt AA,4
(Se:: F M_1l
Telephone No.:
Policy No. _
Co-insurance
Relationship: &
Telephone No.: ig S/'dal irk=
Other Phone No.:
Relationship: G?Q Gl! / M
Telephone No: d,5'8 -055 b
Other Phone No.: ?U- 901- Illy
Center?
Newspaper/Magazine
Television/Radio
Yellow Pages
Health Dept.
Seminar/Event
_ Assisted Living Ctr..
or Assisted Living facilities? If yes, which
EXR113I7 'Co
Mother's Maiden Name:
Father's Name: iMiAroc In nX-Iws (i
Place of Birth: City I.),Kloorn¢ ' pCounty
Church Preference (Optional): / ?
Preferred Ambulance Company (Optional): Na
City
Diagnosis 61A
Curreut Prima Physician: Telephone No.: 7y/-50/l?
Physician to follow at Facility: it Telephone No.:
Tell us about the Resident/Patient: (please check all that apply)
-Mentally alert Ambulatory -Confined to bed
_k-Slightly forgetful L:?alks with assistance -Eats without assistance
-Continent
Incontinent
-Requires assistance with
eating
Admission desired on: 0-14- o o
Resident/patient currently at: L202.b,
If hospital: Date admitted 00 Admitted from FR M -z
Where; has the resident/patient lived in the last 60 days?: F &A L,.
The facility requires that a source of payment by identified to pay for the Resident/Patient's care.
A person, other than the resident, may wish to be financially responsible for the cost of the care
("guarantor'). The facility does not require a "guarantor".
Name of the "Guarantor":
Telephone No.: Work No.: Other No.:
(This person(s) must also complete the "Guarantor" information and sign the application.)
Has a trust fund been established for the Resident/Patient?: -Yes No
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")?:
J,,:?es _No If yes, please provide a copy.
Has a legal guardian been appointed by a court? -Yes vNo
If yes, please provide a copy.
Has a Burial Trust been established?: _ Yes 61--NN-o
If yes, with whom?:
If not who is the preferred funeral service for the Resident/Patient's family?:.
To process your application, the following information is required. The information supplied is confidential
and allows us to assist you in your longterm planning. The financial data should be` that of the
Resident/Patient and or the Guarantor. AM income and amounts listed, 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 not mandated that a Resident have a Guarantor, only that a source of payment be identified. Thus,
any person who agrees to be a Guarantor is doing so voluntarily.
Cash $ S
Checking
Savings
Money-Market
Certificates of Deposit
Securities (Stocks/Bonds)
Trust
Annuities (if not yet paying
IRA monthly)
Salary $ S -
Social Security
Pensions/Annuities (if not above) r7 0 (2q
EPA (if not above)
Interest/Dividend Income
Rental Income
Trust
Investments/Other
Long-Term Care Insurance NA
..........: ............:...::.. qn^..?I,, ..... .... ...... .. .. ........ :fin..
Property: Y1 a n e___
Name on Deed/Title
Property:
Name on Deed/Title z
Cash Value Life Insurance Vl ni1 P
Vested Pension Benefits
Business Interests ale
Automobiles V1 rM Q
Other
Total Assets:
Home Mortgage S ..:.$ --
Credit Cards/Charge Accounts ?-
Loans
Other Debts
Taxes Owed i
Total Liabilities:
NET WORTH: $ $
(assets - liabilities)
PLEASE SIGN BELOW:
I hereby warrant and represent that the information provided is accurate and complete. 1 understand
that the nursing facility will rely upon the accuracy and completeness of the above financial information
in making an admission decision. I also understand that if any of the information is not accurate or not
complete, the Facility will have detrimentally relied upon the above financial information and will suffer
financial loss and harm. The assets listed are in fact available to the Resident to pay for the Resident's
care.
,V4 4 P -1Cq '06
or Respo le Party's Signature Date
Guarantor's Signature ;
Reviewed by:
Director Signature
Signature
Date
k-lq-OD
Date
Date
4
OCT 28 2004 1138 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755 P-02/06
. d Rey, .rack -- -- --
RECORD NUMBER 5"
INITIAL
/a/vD 01
01 06 lc, 0710i
`!0/YR /YR
0 MO/YR
GROSS SS lrl?lo•aL iao70'0 i?u7L?0 ?a07v0
9.6 q/b3.GV w3• d.Gy 9?i3•Q`/
2?,QS icy %l 00 ? l v?. cn ??,?.a? r/o2.00
vPm s8l•Up &n.00
G?a,eQ
??a•40
TOTAL GRASS QNEARNED ?1?'?•G=! j6p,79,9q
ESTIMATED INTEREST q, 07 4.07 4.07 N•07
TOTAL INCOME USED .?U17 •1J
- PERSONAL CARE
ALLOWANCE
_so•UD_ _
?. ?U
- COMMUNITY szoasE/ qr?.?W 443,70 cIy3.7(D t7 75,%
GROSS PATIENT PAY (53) AWA-5 acilQ.gS c'WWa5
- MEDICAL EXPENSES 100.10 LESS MEDICAL EXPENSES PAID MONTHLY
(See below) a9Q.7s'
NET PATIENT ?AY (57)
MEDICAL EXPENSES LISTED ?JOIE Future changes in medical expenses
!. ? c9% t7l should be repented to the Nuning FuMtp.
MO/YR MO/YR
DRUGS (54)
]CO-1 t? )100 MEDICARE (55)
3C/HS/OTHER MEDICAL ZNS (55)
OTHER MEDICAL (56)
jW.10 i 10.CdT MONTHLY TOTAL ??II..,,
?en?dr:U ?Cl??'' ???lc?
SIGNATURE DAIS
OCT 28 2004 11:39 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755 P. 03/06
CUMBERLAND CAO Notice ID: 49971311
33 WESTMINSTER DRIVE ADVANCE NOTICE PAGE I Of 1
P,O, BOX 599 REDUCE
CARLISLE PA 17013-0599
CAO RETURN ADDRESS UNIT o0 CSLD 0015 21 00895!1 TA 0 `
IF YOU W WT UMMWAW OUR CECJS101 CR HAVE AVY
WES7IONS. PLEASE CONTAC7 YOVR WeItER 115 OiArE(Y.
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA
17013
you disagree with our
BEGINNING
MEDICAL ASSISTANCE 10/16/2002
DISREGARD THE ABOVE BEGINNING DATE. Persons who receive Federal Retirement,
Survivors or Disabit ity benefits will get cost of living increases in January.
Railroad Retirement. Black Lung and Veterans bencifIts may also be increased.
Your payment toward the cost for nursing facility care increases January 2002,
Monthly Income Computation:
SSA / RR / SL Income S 1239.80
VA Benefits $ 0.00
Civil Ser / Private Pension $ 2717.94
Interest ! other. income $ 4.07
TneinurSing facility Will deduct the following
your monthly Payment: Medicare $ 118.80
Other medical insurance premium $ 0.00
The nursing facility will deduct other medical
expenses to them.
Regulations: 55 PA Code 181.1, 181.451,
LEGAL SERVICES.INC,
8 IRVINE ROW
CARLISLE PA 17013
..... OU" HERE
t_u sir M
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
WORKER D CAMPBELL
WORKER 10:
TELEPHONE (717) 240-2700
DATE: 09/27/2002
NOT. 330 OPT: 1 TYPE; R
Gross Income S 3961,81
Personal Care Allow.-$ 30.00
Spouse/Depend.Allow.-$ 1015.75
Home Maint. Allow. -$ 0.00
YOUR MONTHLY PAYMENT $ 2916.05
verified medical expenses from
expenses if you verify the
181.452, 181.453
You have the right to
orai request Tor a nearing is received in the County Assista
written request is Postmarked or received on or before 1I
ante will continue Pending the haarind decision, except when
See attached
fir hearing, If
:e ce or
is
WAM WN _.......... .,
CUMBERLAND CAL)
33 WESTMINSTER DRIVE
P.O. BOX 599
CARLISLE PA 17013-0599
OD?:M`: t.A¢COkt71''LSLY"?.L'G;rs tR9'L.`.=:.
21 0089511 TA p
WORKER: D CAMPBELL
APPEAU 10/10/2002
TELEPHONE: (717) 2AO-2700
DATE: 09/27/2002
NOT., 330 OPT:1 TYPE: R
02135A
PAIPS 1928 09197
OCT 29 2004 11:39 FR MANOR CRP,E-CRP,LISLE 717 249 0647 TO 2495755 P. 04/06
1.UM;hkN ANU a.AU nwatw w. .ray, ice,
33 WESTMINSTER DRIVE ADVANCE NOTICE PAGE 1 OF
P.O. BOX S99 REDUCE
CARLISLE PA 17013-0599
CAO RETURN ADDRESS UNIT 00 CSLD 0015
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA
17013
3Li^..:NEOtlRC;`''.5+^k."ATd:.:46.tL , VVO;
21 0089511 TA 0
IF YOU 00 RDT UNDEWAm MR DECISION OR ROTE ANY
O/ESiIOVS. RIEASE CWrACT Y&A R00V IAREDIATELY.
WORKER 0 CAMPBELL
WORKER 1D:
TELEPHONE (717) 240-2700
DATE: 09/27/2002
NOT: 335 OPT: I TYPE: R
BEGINNING
MEDICAL ASSISTANCE 10116/2002
All of your monthly income must be used to compute your payment toward the
cost of nursing facility services. As a result of a Change in your income
oeylnninp 07/01/02 you must pay $ 2983. 44 to the nursing facility toward the
cost of care each month.
Income Deductions
SSA/RR/BL Income $ 1239. 80 Personal Care Allow. -S 30.00
VA/Civil Service/Pension $ 2814. 33 Spou4e/Oepemd.AI1OW. -$ 1044.76
Interest/Other Income $ 4. 07 Home Maint.Allow. -S .00
TOTAL $ 4058. 20 TOTAL -S 1074.76
The nursing facility will deduct the following verified medical expenses from
your monthly payment: Medicare $ 118.80
Other Medical Insurance Premium $ .00 The nursing facility will deduct
other medical expenses if you verify the expenses to them.
oue to SERS Increase eff. 7/1/02,
Regula11ehs: 55 PA Code i81.1, 181.3, 181.451, 181.452, 181.453
'LEGAL SERVICES,INC.
8 IRVINE ROW
CARLISLE PA 17013
If you disagree with our decision, you have the right to appeal. See attached
form for a complete expianation of your right to appeal and to a fair hexing. If
your oral request for a -hexing 15 reCened m the GOunty ASS'Siatlce Utt1Ce or
your written request is Postmarked or received on or before, 10/10/2003our
assistance will continue pending the hexing decision, eycept when -50 FIEZVO is
............... DETACR HERE
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
r?•
CUMBERLAND CAD
33 WESTMINSTER DRIVE
P.O. BOX 599
CARLISLE PA 17013-0599
MTKU HERE ...._-.......
`CGi'i f.fffiCO6O`',`.s oAT" '•.SKf.:?.,TA157 .':
21 0089511 TA O
WORKER: 0 CAMPBELL
APPEAL: iO/t0/2DO2
TELEPHONE . (717) 240-2700
DATE 09/27/2002
NOT. 335 OPT:1 TYPE: R
02135A PA/FS 162A 09197
OCT 28 2004 11:39 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755 P.05i06
6UM5CRLANU ?Aw Notice lu: 1222"t11
'33 WESTMINSTER DRIVE ADVANCE NOTICE PAGE 1 OF 1
P.D. Box 599 REDUCE
CARLISLE PA 17013-0599
CAO RETURN ADDRESS NIT 00 CSLD 0017
JACK R GREY
MANORCARE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA
17013 1111
APR 17 2003
------------------------
GO ;:; R6CORp ;.vx,CnY „CG'..:_ 01ST, ?:':
21 0089511 TAN 0
If YW DO MA UNDERSTAND d/R OfCIS/OM OR RNF ANY
0063TIONS, PLEASE CONTACT YOUR NORkER IMIEDIA/ELY.
WORKER: D KLINGENSMITH
WORKER 11
TELEPHONE (717) 240-2700
DATE: 03/31/2003
NOT, 330 OPT. 1 TYPE R
. . •. -2114VA-3110, 'A'1000000000
BEGINNING
MEDICAL ASSISTANCE 04/15/2003
I
DISREGARD THE ABOVE BEGINNING DATE. Persons who receive Federal Retirement,
Survivors or Disability benefits will get cost of living increases in January.
Railroad Retirement, Black Lung and Veterans benefits may also be increased.
Your payment toward the Cost for nursing facility care increases January 2003.
Monthly Income computation: Gross Income $ 4094.69
SSA / RR / SL Income $ 1257.10 Personal Care Allow.-$ $0.00
VA Benefits $ 0.00 Spouse/Depend.Allow.-S 1028.33
civil Ser / Private Pension S 2837.33 Home Maint. AIIOW. -$ 0100
Interest / Otner income $ 0.26 YOUR MONTHLY PAYMENT $ 3036.36
The nursing facility will deduct the following verified medical expenses from
your monthly payment: Medicare S 129.10
Other metlical insurance premium $ 0.00
The nursing facility will tletluct other metlical expenses if you verify the
expenses to them.
Regulations: 55 PA Code 181.1. 181.3. 181.451, 181.452, 181.453
LEGAL SERVICES,INC.
8 IRVINE ROW
CARLISLE PA 17013
our decision, you have the right to appeal. See attached
a fair hearing. If
explanation of your right to appeal and to
a hearin0 is received 1n the ounN Assistance TICe Or
............... DETACH HERE
JACK R GREY
MANORCAPE CARLISLE
940 WALNUT BOTTOM ROAD
CARLISLE PA 17013
If you disagree
form for a con
your Oral fequE
is
written request is postmxked or received on or bet
3nee Will continue pending the hearing deci>.oQn. ?-cc;!
DETACH HERE .............
CUMBERLAND CAD
33 WESTMINSTER DRIVE
P.D. BOX 599
CARLISLE PA 17013-0599
..c0: .:-Pdcdhh Y: ,e4t? GG Dist.;:'.
...
21 0089511 TAN 0
WORKER: D KLINGENSMITH
APPEAL 04/13/2003
TELEPHONE: (717) 240-2700
DATE 03/31/2003
NOT: 330 OPT: 1 TYPE: R
02135A PAPS 162A 09197
OCT 28 2004 11:40 FP. MANOR CARE-CAPLISLE 717 249 0647 TO 2495755 P,06y06
CUYHERZANa CAC Notice 1D: c6gg54„
33 WOSTMIN57ER aa: ADVANCE NOTICE ;?ACE 1 OF 1
REDUCE
C.?4LISLE 599 PA 17013-0599
CAO RETURN ADDRESS UNIT 00 CSLD 09:'1 cl OC99`_L' ^_?\ J
IF YOU D7 N07 UNDIWAlp OUR DECISION CO NME AW
WESIIONS. PIE" CiM Xr YOUR 0000 INVIA/ELY.
JACK R GREY -
MA40RCARZ C -UISLE
940 WALNUT BOTTOM ROAD
CAORLISL'a PA 17013
WORKER: D XL_nG?taxIta
WORKER ID:
TELEPHONE i7i7) 240-270.
DATE 04/13!20C4
NOT. 330 OPT: 1 TYPE: R
BEGINNING
MEDICAL ASSISTANCE 05/03/2004
DISREGARD THE ABOVE BEGINNING DATE. Persons who receive Federal Retirement.
Survivors or Disability benefits will get cost of living increases to January.
Railroad Retirement, Black Lung and Veterans benefits may also be increased.
Your payment toward the cost for nursing facility care increasee January 2004.
Monthly Income Computations Gross income $ 4158.82
SSA / RR / BL Income $ 1283.50 Personal Care Allow -$ 30.00
--VA Benefits $' 0.00 Guardian4hip Fee -$ 0.00
Civil Ser / Private Pension $ 2374.33 Spouse/Depend.Aliow.-$ 1039.62
Interest / Other Income $ 0.99 Home Maint. Allow. -$ 0.00
YOUR MONTHLY PAYMENT $ 3089.20
The nursing facility will deduct the following verified medical expenses from
your monthly payment: Medicare $ 146.50
Other medical insurance premium $ 0.00
Regulations: 55 PA Code 181.1. 161,3, 181,451, 181.452. 181.453
if you disagree with our decision, you have the right to appeal. See attached
LEGAL SERVICES,ItiC. ' form for a complete explanation of your right to appeal and to a fair h4winnS If
a IRVINE ROSH your oral request fora eamng s receive m the ounty Assfstan- c's bTf ee or
CARLISLE PA 17013 your written request is postmarked or received an or before 0412612004 your
assistance will continue pending the hearing decision, except when the change is
JACK R ORZY
xANORCARE CAELISLE
940 WALNUT BOTTOM, ROIJ
CARLISti PA 1%013
CUMSERLADW CAO
33 WIESTNINSiER DRIVE
P.O. Box 599
CARLISLE ?A 17013-0593
02135A
WAM MERE _..
21 0099511 TAV 0
WORKER a 1::.Ihc%tisxZTn
APPEAL 04/26;2004
TELEPHONE: (717) 240-2700
DATE 04/13/2004
Nor 330 OPT: 1 TYPE: R
PA/FS 102R 09/97
x: TOTAL PAGE.06 **
OCT 12 2004 0809 FR MRNOR CARE-CARLISLE 717 249 0647 TO 2495755 P.09i13
HCRWanorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM
TOTAL DUE UPON RECEIPT $1,10@,08
Payment Due Upon Receipt
Amount Due $2,21'$.72
UkfZ317 #6'
10126/00 PAYMENT RECEIVED -$538.50
10/31/00 HAIRCUT $10.50
11/07/00 PAYMENT RECEIVED -$754.50
12/31/00 PRIVATE PORTION DUE $2,381.08
OCT 12 2004 09:09 FR MANOR CARE-CRRL I SLE 717 249 0647 TO 2495755
HKCR*ManorCare
P. 10/0
PRIVATE
STATEMENT
ROOM
01/03/01 PAYMENT RECEIVED -$938.50
01131/01 PRIVATE PORTION $2,910.25
01/31/01 MEDICARE B PREMIUM CREDIT 4110,00
02122/01 PAYMENT RECEIVED -$3,000.00
02/28101 PRIVATE PORTION $2,910.25
02128/01 MEDICARE B PREMIUM CREDIT -5110.00
03/01-03/31/01 CABLE RENTAL $5.00
03131/01 PRIVATE PORTION $2,910.25
03/31/01 MEDICARE B PREMIUM CREDIT -$110.00
04104101 PAYMENT RECEIVED -$1,392.24
04101-04130/01 CABLE RENTAL $5.00
04130/01 PRIVATE PORTION $2,910.25
04130101 MEDICARE B PREMIUM CREDIT -$110.00
05/01.05/31101 CABLE RENTAL $5.00
05131/01 PRIVATE PORTION $2,910.25
05/31/01 MEDICARE B PREMIUM CREDIT -$110.00
06101-05130101 CABLE RENTAL $5.00
06130101 PRIVATE PORTION $2,911.25
06/30/01 MEDICARE B PREMIUM CREDIT -$110.40
07/01.07/31/01 CABLE RENTAL $5.00
07/31/01 PRIVATE PORTION $2,879.25
07/31/01 MEDICARE B PREMIUM CREDIT $140.00
08101-08/31101 CABLE RENTAL $5.00
08/31/01 PRIVATE PORTION $2,879.25
06131/01 MEDICARE B PREMIUM CREDIT 4110.00
09/11101 PAYMENT RECEIVED -$10,801.50
09/01-09130/01 CABLE RENTAL $5.00
09/30/01 PRIVATE PORTION $2,879.25
09130/01 MEDICARE B PREMIUM CREDIT -$110.00
10/15/01 PAYMENT RECEIVED -$7,000.00
1 0 /01-1 013 110 1 CABLE RENTAL $5.00
10131101 PRIVATE PORTION $2,879.25
10131/01 MEDICARE B PREMIUM CREDIT -$110.00
11101-11!30101 CABLE RENTAL $5.00
11/30/01 PRIVATE PORTION $2,879.25
11/30/01 MEDICARE B PREMIUM CREDIT 4110.00
12/14101 PAYMENT RECEIVED 44,000.00
12/01-17131/01 CABLE RENTAL $5.00
12131/01 PRIVATE PORTION $2,879.25
12131/01 MEDICARE B PREMIUM CREDIT -$11d.00
TOTAL DUE UPON RECEIPT $7,444.82
Page 1
2001
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
OCT 12 2004 08:10 FR MANOR CARE-CARLISLE 717 249 0647 TO 2495755
' HCR*ManorCere
2002
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-2490085
P.11/13
PRIVATE
STATEMENT
ROOM
01107102 PAYMENT RECEIVED 52,500.00
01/31/02 PRIVATE PORTION $2,916.05
01/31/02 MEDICARE B PREMIUM CREDIT -$118.80
02/25/02 PAYMENT RECEIVED -$2,000.00
02/28102 PRIVATE PORTION $2,916.05
02128102 MEDICARE B PREMIUM CREDIT -$118.80
606
00
-$2
03122/02 PAYMENT RECEIVED .
.
03/31102 PRIVATE PORTION $2,916.05
03131102 MEDICARE B PREMIUM CREDIT -$118.80
04/30/02 PRIVATE PORTION $2,916.05
04130/02 CABLE RENTAL •$118.80
05101102 PAYMENT RECEIVED -$2,400.00
05/31/02 PRIVATE PORTION $2,916.05
05/31102 MEDICARE 8 PREMIUM CREDIT •$118.80
06/07/02 PAYMENT RECEIVED 45,000,00
06130102 PRIVATE PORTION $2,916.05
06/30/02 MEDICARE B PREMIUM CREDIT $11,.80
07/31/02 PRIVATE PORTION $2,983.44
80
-$118
07131/02 MEDICARE 8 PREMIUM CREDIT .
08/05102 PAYMENT RECEIVED '51+121.00
08/31/02 PRIVATE PORTION $2,983.44
-$I lt40
08131102 MEDICARE B FREMIUM CREDIT
09/02102 PAYMENT RECEIVED -$1,121.00
09105102 PAYMENT RECEIVED '$3,500.00
09/18/02 PAYMENT RECEIVED -$1,200.60
09101-09130/02 CABLE RENTAL $5.00
09/30/02 PRIVATE PORTION $2,983,44
09/30/02 MEDICARE B PREMIUM CREDIT 4118.80
10104/02 PAYMENT RECEIVED 41,124,00
10131/02 PRIVATE PORTION $2,983.44
10/31/02 MEDICARE B PREMIUM CREDIT 4118.80
11/04102 PAYMENT RECEIVED -51,i2f.00
11111/02 PAYMENT RECEIVED -$3,000.00
11/30102 PRIVATE PORTION $2,983.44
11130/02 MEDICARE B PREMIUM CREDIT
CEIVED -$118;80
-$1,121'.00
12/04102 PAYMENT RE
12101-12131102 CABLE RENTAL $6.00
12131/02 PRIVATE PORTION $2,983.44
12131/02 MEDICARE B PREMIUM CREDIT -$118,80
TOTAL DUE UPON RECEIPT 513,621.16
Page 1
DCT 12 2004 08 10 FR MRNDR CRRE-CRRLISLE 717 249 0647 TO 2495755
H%;R*ManarCare
2003
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
P, 12/13
PRIVATE
STATEMENT
ROOM
01/06/03 PAYMENT RECEIVED 41128.00
01/31/03 PRIVATE PORTION $3,036.36
01131103 MEDICARE B PREMIUM CREDIT $129.10
02104103 PAYMENT RECEIVED -$1,128.00
02/01.02128103 CABLE RENTAL $5.00 ,
02/28/03 PRIVATE PORTION $3,036.36
02!28/03 MEDICARE B PREMIUM CREDIT $129.10
03/04/03 PAYMENT RECEIVED 41,128.00
03/01.03/31/03 CABLE RENTAL $5.00
03/31/03 PRIVATE PORTION $3,036.36
03131/03 MEDICARE B PREMIUM CREDIT •$118.80
04/04103 PAYMENT RECEIVED -$1.128.00
04/30103 PRIVATE PORTION 53,036.36
04/30/03 MEDICARE B PREMIUM CREDIT 4129.10
05105/03 PAYMENT RECEIVED $1,1?.# 00
05/31/03 PRIVATE PORTION $3,036.38
05131/03 MEDICARE B PREMIUM CREDIT -$129,10
05/04103 PAYMENT RECEIVED 41,128.00
06/10103 PAYMENT RECEIVED 43,500.00
06/30103 PRIVATE PORTION $3,036.36
05/30103 MEDICARE B PREMIUM CREDIT -$129.10
07/03/03 PAYMENT RECEIVED $1,47$:60
07131/03 PRIVATE PORTION $3,038.38
07/31/03 MEDICARE B PREMIUM CREDIT -$129.10
08/04/03 PAYMENT RECEIVED -$1,1l$,GO
06/31/03 PRIVATE PORTION $3,036.36
08/31/03 MEDICARE 8 PREMIUM CREDIT -$129.10
09/04/03 PAYMENT RECEIVED -$1,128A0
09/30/03 PRIVATE PORTION $3,036.36
09/30/03 MEDICARE B PREMIUM CREDIT -$129:10
10106/03 PAYMENT RECEIVED -$1,128.00
10/07103 PAYMENT RECEIVED -$7,009.00
10131/03 PRIVATE PORTION $3,036.36
10131/03 MEDICARE B PREMIUM CREDIT -$129.10
11104/03 PAYMENT RECEIVED 41,12$,00
11/07/03 PAYMENT RECEIVED -$1,079:62
11130103 PRIVATE PORTION $3,036.36
11130/03 MEDICARE B PREMIUM CREDIT -$129.10
121:00
-$1
12/04/03 PAYMENT RECEIVED ,
76
879
-$1
12110/03 PAYMENT RECEIVED ,
,
12131/03 PRIVATE PORTION $3,036.36
70
$129
12131103 MEDICARE 9 PREMIUM CREDIT .
.U v
Page 1
TOTAL DUE UPON RECEIPT
$21,533.70
OCT 12 2004 08:11 FR MANOR CARE-CARLISLE ?1? 249 064? TO 2495?55 P.13i13
HCR*ManorCare
2004
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)449-0065
PRIVATE
STATEMENT
ROOM
01105104 PAYMENT RECEIVED -$1,137.00
01/31/04 PRIVATE PORTION $3,089.20
01/31/04 MEDICARE B PREMIUM CREDIT 4146.50
02/05/04 PAYMENT RECEIVED -$1,137.00
02120104 PAYMENT RECEIVED 42,800.00
02128/04 PRIVATE PORTION $3,089.20
02128/04 MEDICARE B PREMIUM CREDIT -$146.50
03104104 PAYMENT RECEIVED -$1,137.00
0381104 PRIVATE PORTION $3,089.20
03131104 MEDICARE 8 PREMIUM CREDIT -$146.50
04106/04 PAYMENT RECEIVED -$1,137.00
04/20/04 PAYMENT RECEIVED 43,500.00
0480104 PRIVATE PORTION $3,089.20
0480104 MEDICARE B PREMIUM CREDIT -$146.50
05/04/04 PAYMENT RECEIVED •$1,137.00
0581/04 PRIVATE PORTION $3,089.20
05/31/04 MEDICARE 8 PREMIUM CREDIT -$14$.50
06/04!04 PAYMENT RECEIVED 41,137,00
06/14/04 PAYMENT RECEIVED -$2,500:00
0880/04 PRIVATE PORTION $3,089.20
06/30/04 MEDICARE B PREMIUM CREDIT 414464
07106104 PAYMENT RECEIVED 41,13740
07/26104 PAYMENT RECEIVED -$2,250.00
0781104 PRIVATE PORTION $3,089.20
07/31/04 MEDICARE B PREMIUM CREDIT 4146:50
08105104 PAYMENT RECEIVED -$1,13Y.60
08/25/04 PAYMENT RECEIVED •$1,870.00
0881104 PRIVATE PORTION $3,089.20 F
08131/04 MEDICARE 8 PREMIUM CREDIT $144.50
09/08/04 PAYMENT RECEIVED -$1,1Ab0
09130/04 PRIVATE PORTION $3,08920
09130/04 MEDICARE B PREMIUM CREDIT •$146.50
p
TOTAL DUE UPON RECEIPT $24,865.00
Page 1
** TOTAL Par.F ,? wW
DEC 14 2004 12:11 FR MANOR CRRE-CARLISLE 717 249 0647 TO 2495755 P.05i06
kwmanorcare
2004
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM
GREY, JACK 20082 12/10!00
JDATE OF DESCRIPTION OF SERVICE CHARGES CREDITS
SERVICE
01101104 BALANCE FORWARD $21,533.70
01/05/04 PAYMENT RECEIVED
01131/04 PRIVATE PORTION
01/31/04 MEDICARE B PREMIUM CREDIT
02105104 PAYMENT RECEIVED
02120104 PAYMENT RECEIVED
02t28104 PRIVATE PORTION
02/28/04 MEDICARE B PREMIUM CREDIT
03104104 PAYMENT RECEIVED
03/31/04 PRIVATE PORTION
03/31/04 MEDICARE B PREMIUM CREDIT
04/5/04 PAYMENT RECEIVED
04/20/04 PAYMENT RECEIVED
04!30/04 PRIVATE PORTION
04/30/04 MEDICARE B PREMIUM CREDIT
05/04104 PAYMENT RECEIVED
05/31/04 PRIVATE PORTION
0581104 MEDICARE B PREMIUM CREDIT
06104/04 PAYMENT RECEIVED
06/14/04 PAYMENT RECEIVED
0680/04 PRIVATE PORTION
08/30/04 MEDICARE B PREMIUM CREDIT
07106/04 PAYMENT RECEIVED
07/26/04 PAYMENT RECEIVED
07/31!04 PRIVATE PORTION
0781/04 MEDICARE B PREMIUM CREDIT
08/05104 PAYMENT RECEIVED
08/25/04 PAYMENT RECEIVED
08/31104 PRIVATE PORTION
0881/04 MEDICARE B PREMIUM CREDIT
09/06104 PAYMENT RECEIVED
0980/04 PRIVATE PORTION
09/30/04 MEDICARE B PREMIUM CREDIT
10/05/04 PAYMENT RECEIVED
10118/04 PAYMENT RECEIVED
1081/04 MEDICARE B PREMIUM CREDIT
10/01-10/31104 PRIVATE PORTION
11/05/04 PAYMENT RECEIVED
11/31/04 MEDICARE B PREMIUM CREDIT
Page 1
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,08920
$3,089.20
$3,089.20
$3,089.20
$3.089.20
-$1,137.00
-$148.50
-$1,137.00
-$2,800.00
-$148.50
-$1,137.00
-$148.50
-$1,137.00
-$3,500.00
-$148.50
-$1,137.00
-$146.50
-$1,137.00
-$2,500.00
-$146.50
-$1,137.00
-$2,250.00
-$146.50
-$1,137.00
-$1,870.00
-$146.50
-31,137.00
-$146.50
-$1,137.00
-$3,800.00
-$146.50
-$1,137.00
-$146.50
DEC 14 2004 12:11 FR MANOR CARE-CARLISLE 717 249 0647 TO 249S755 P,06i06
11/04-11!30/04 PRIVATE PORTION 2004 $3,089.20
12108/04 PAYMENT RECEIVED -$1,137.00
12/31/04 MEDICARE 8 PREMIUM CREDIT -$148.50
12101-12/31104 PRIVATE PORTION $3,089.20
TOTAL DUE UPON RECEIPT $26,482.10
Page 2
** TOTAL PAGE. 06 **
Feb D4 05 C1: 16p
p.2
2004
HCR*ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM
GREY. JACK
20082 12110100
DATE OF DESGRIPTIDi?j IF SERVICE GHAROES ' CREDIT$
SERVICE
01/01/04 BALANCE FORWARD
01/05/04 PAYMENT RECEIVED
01/31/04 PRIVATE PORTION
01131104 MEDICARE B PREMIUM CREDIT
02/05/04 PAYMENT RECEIVED
02/20104 PAYMENT RECEIVED
02/28/04 PRIVATE PORTION
02/28104 MEDICARE B PREMIUM CREDIT
03/04/04 PAYMENT RECEIVED
03/31/04 PRIVATE PORTION
03/31/04 MEDICARE B PREMIUM CREDIT
04!06/04 PAYMENT RECEIVED
04120104 PAYMENT RECEIVED
04130104 PRIVATE PORTION
04/30/04 MEDICARE S PREMIUM CREDIT
05/04/04 PAYMENT RECEIVED
05/31/04 PRIVATE PORTION
05/31104 MEDICARE B PREMIUM CREDIT
06/04/04 PAYMENT RECEIVED
06114104 PAYMENT RECEIVED
06/30/04 PRIVATE PORTION
06/30/04 MEDICARE B PREMIUM CREDIT
07/06104 PAYMENT RECEIVED
07126104 PAYMENT RECEIVED
07/31/04 PRIVATE PORTION
07131/04 MEDICARE B PREMIUM CREDIT
08/05/04 PAYMENT RECEIVED
08/25/04 PAYMENT RECEIVED
08/31/04 PRIVATE PORTION
08131/04 MEDICARE B PREMIUM CREDIT
09106104 PAYMENT RECEIVED
09/30/04 PRIVATE PORTION
09/30/04 MEDICARE 8 PREMIUM CREDIT
10/05/04 PAYMENT RECEIVED
10/18/04 PAYMENT RECEIVED
10/31/04 MEDICARE B PREMIUM CREDIT
10101-10/31/04 PRIVATE PORTION
$21,533.70
$3,089.20
$3,08920
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
$3,089.20
-$1,137.00
-$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
-$146.50
-$1,137.00
-$2,500.00
-$146.50
-$1,137.00
-$2,250.00
-$146.50
-$1,137.00
-$1,870.00
-$146.50
-$1,137.00
-$146.50
-$1,137.00
-$3,800.00
-$14650
Page 1
Feb 04 05 C1:16p
p.3
11105104 PAYMENT RECEIVED 2004 -$1,137.00
11/31/04 MEDICARE B PREMIUM CREDIT -$146.50
11/01-11/30/04 PRIVATE PORTION $3,089.20
12/06/04 PAYMENT RECEIVED -$1,137.00
12/31/04 MEDICARE B PREMIUM CREDIT -$146.50
12/01-12/31/04 PRIVATE PORTION $3,089.20
TOTAL DUE UPON RECEIPT $26,482.10
Page 2
P.4
HCR*ManorCare
2005
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
STATEMENT
ROOM
GREY, JACK
01/03/05
01/05/05
01/27105
01/31105
01/31/05
BALANCE FORWARD
PAYMENT RECEIVED
PAYMENT RECEIVED
PAYMENT RECEIVED
MEDICARE B PREMIUM CREDIT
PRIVATE PORTION DUE
TOTAL DUE UPON RECEIPT
Page 1
12/10/00
$26,
$3,089.20
-$3,500.00
-$1,146.00
-$2,000.00
-$146.50
J $22,778.80
b
C: j
t.l
rl
HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTTER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
PRAECIPE TO REINSTATE
TO THE PROTHONOTARY:
Please reinstate the Complaint filed in the above-captioned matter on February 24, 2005.
Respectfully submitted,
JO''BRIEN, BARIC ?SCCjHER
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
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SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2005-00975 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANORCARE INC
VS
GREY JACK R ET
R. Thomas Kline
, Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT , to wit:
GREY EMILY R
but was unable to locate Her
deputized the sheriff of YORK
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
on April 28th , 2005 , this office was in receipt of the
attached return from YORK
Sheriff's Costs: So answers
Docketing 18.00
Out of County 9.00 Surcharge 10.00 R. Thomas Kline
Dep York County 21.62 Sheriff of Cumberland County
Postage .74
59.36
04/28/2005
O'BRIEN BARIC SCHERER
Sworn and subscribed to before me
this j day of
p2(dps A.D.
Prothonotary
in his bailiwick. He therefore
SHERIFF'S RETURN - REGULAR
CASE NO: 2005-00975 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANORCARE INC
VS
GREY JACK R ET AL
SHANNON SHERTZER Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
POTZER JAN R
was served upon
DEFENDANT
the
, at 1945:00 HOURS, on the 6th day of May , 2005
at 110 SOUTH HANOVER STREET #6
CARLISLE, PA 17013
JAN POTZER
by handing to
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 6.00
Service 3.70
Affidavit .00
Surcharge 10.00
.00
19.70
Sworn and Subscribed to before
me this //0 day of
'" , -2UD5) A. D.
nn
Vr thonotary
So Answers:
R. Thomas Kline
05/09/2005
OBRIEN BARIC S(CCHHERER
By:
eputy Sheii
COUNTY OF YORK
OFFICE OF THE SHERIFF
45 N. GEORGE ST., YORK, PA 17401
SERVICE CALL
(717)771-9601
SHERIFF SERVICE INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LM 1 THRU 12
DO NOT DETACH ANY COPES
3
HCR Manorcare Inc
Jack R. Grey et al
4. TYPE OF WRIT Oft COMPLAINT
Notice & Complaint
SERE 5 NAME OF INDIVIDUAL. COMPANY, CORPORATION, ETC TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED. OR SOLD
Ehiily R. Grey
fi. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO.. CITY, BORO. TwP., STATE AND ZIP CODE)
AT 498 Devon Road York, PA 17403
7. INDICATE SERVICE'. O PERSONAL 13 PERSON IN CHARGE DEPUTIZE U CERT. MAIL U 1 ST CLASS MAIL U POSTED 'J OTHER
NOW March 1 2005 I, SHERI COUNTY, PA, do hereby d ;pyt}z ?thhe, sheriff of
yrlrk COUNTY to execute-ttjisi/Vtikording
to law. This deputization being made at the request and risk of the plaintiff. „- a €
8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION TI4AT
01? Cr (70U I'C"
Please mail return of service to Cumberland County Sheriff. Thank
ALiC.' t PD
NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sherd levying upon or attaching any property under within writ may leave same
without a watchman, in custody or whomever is found in possession, after notifying Person of levy or attachment. without liability on the part of such deputy or the sheriff to any plaintiff
herein for any loss, destruction, or removal of any property before sheriffs sale thereof.
9. TYPE NAME and ADDRESS of ATTORNEY r ORIGINATOR and SIGNATURE 10. TELEPHONE NUMBER 11. DATE FILED
U1 J
12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed it notice is to be mailed)
'll „<CT,, 11il (.;'.)
SPACE BELOW FOR USE OF THE SHERIFF ' DO NOT WRITE BELOW THIS LPE
13. 1 acknowledge receipt of the wrt 14. DATE RECEIVED 15. ExpiratiordHearing Date
or complaint as indicated above. ) ^ ? 2 05
16. HOW SERVED: PERSONAL) RESIDENCE POSTED( ) POE ( ) SHERIFF'S OFFICE ( ) OTHER ( ) SEE REMARKS BELOW
17. U 1 hereby certify and return a NOT FOUND because I am unable to locate the individual, company, etc. named above. (See remarks below.)
18. NAME ANVITLE OF INDIVIDUAL SERVED/ LIST ADDRESS HERE IF NOT SHOWN ABOVE (Relationship to Defendant) 19. Yale f Service 20. Time of Service
7/ r - r {iw , L , f ? It /c L / ' 3 z C? S .2 G7 S
2t1 TTEMPTSJ D to Time es 1/0. Time Mdes / Int. Dafe Time Mdes Int. Date Time Miles Int. Date Time Mies Int. Date Time Miles fnt.
H12t1af
27. Advance Costs 24. Service Costs 25. NLF 26 . Mileage 2
1a, 28. Sub Total
?z 29. Pouts 70 Notary
,GY, 31. Surchg. 32. 7d. Coats 3] Costs Due eland
0. heck a
tlu4
34. Foreign County Costs 35. Advance Costs 36Service Costs ry Cert. 38MileagerPoslage Not Found 39. Total Costs 40. Costs Due or Refund
41. AFFI RMED and subscribed to before me this 1 u SO A SWERS
42 1
re of
p, 5. ATE
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SHAFFER, NIR
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Y_rk York County
pnl2
08 ARY
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DAT
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of Foreign
Sheriff 49 DATE
^^ ?'^^^' Inc 1
ORITY AND T TL 51. DATE RECEIVED
OF A TNORIZED ISSUING AUTR
1. WHITE - (suing Authority 2. PINK - Atorney 3. CANARY - Sheriffs Office 4. BLUE - Shenfrs Office
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HCR MANORCARE, INC., NO. 2005-975
Plaintiff
V.
CIVIL ACTION - LAW
JACK R. GREY AND JAN R. POTZER,
Individually and as the attorney-in-fact for
Jack R. Grey and EMILY R. GREY,
Defendants
NOTICE TO DEFEND
Pursuant to PA R.C.P. 237.5
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN
WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE
CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN
DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE
ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE
YOUR PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF
YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET
FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY
BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES
THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A
REDUCED FEE OR NO FEE
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
717-249-3166
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HCR MANORCARE, INC., NO. 2005-975
Plaintiff
V.
CIVIL ACTION - LAW
JACK R. GREY AND JAN R. POTZER,
Individually and as the attorney-in-fact for
Jack R. Grey and EMILY R. GREY,
Defendants
NOTICE TO PLEAD
To: HCR Manorcare, Inc.
c/o David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
You are hereby notified to file a written response to the enclosed New Matter within
twenty (20) days from service hereof or a judgment may be entered against you.
C _Douglas I Gen , Esquire
Sup. Ct. No. 29964
1157 Eichelberger Street
Hanover, PA 17331
(717) 632-4040
Attorney for Defendant, Emily R. Grey
2
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HCR MANORCARE, INC., NO. 2005-975
Plaintiff
V.
CIVIL ACTION - LAW
JACK R. GREY AND JAN R. POTZER,
Individually and as the attorney-in-fact for
Jack R. Grey and EMILY R. GREY,
Defendants
ANSWER NEW MATTER AND CROSS CLAIM OF DEFENDANT
EMILY R. GREY
NOW COMES, this "-?G?day of G(l 2005, the Defendant,
Emily R. Grey, by her attorney, Doug q las H. Gent s -ire and files the within Answer,
>
New Matter and Cross Claim, to wit:
Admitted.
2. Admitted.
Admitted in part and denied in part. It is admitted that at the time of
the filing of the Complaint Defendant, Jack R. Grey, was an adult individual residing in
the Plaintiff's facility. However, on or about March 7, 2005, Defendant, Jack R. Grey,
died. No estate has been probated on his behalf.
4. Admitted.
Admitted.
6. Admitted.
7. Admitted.
8. Admitted.
9. Admitted in so far as the information set forth in the admission agreement
(Exhibit B to the Complaint) is true and accurate. The Answering Defendant does not
otherwise have sufficient knowledge independent thereof to answer this allegation.
10. Admitted in part and denied in part. It is admitted that Jack R. Grey
became a resident of the facility on or about August 14, 2000. It is denied that he
remains a residence of said facility. As set forth above, on or about March 7, 2005, Jack
R. Grey died.
11. Admitted in so far as the information set forth in the application for
residency (Exhibit C. to the Complaint) is true and accurate. The Answering Defendant
was not involved in said action and does not independently have information to verify the
same.
12. Denied. The application for residency speaks for itself. The Answering
Defendant was not present or involved in the preparation of said document and
information.
13. Denied. After reasonable investigation the Answering Defendant is
without sufficient knowledge or information to form a belief as to the truth of the
averment set forth in paragraph 13 of the Complaint. Strict proof thereof, if relevant, is
demanded at trial.
14. Admitted.
4
15. Upon information and belief the Answering Defendant admits paragraph
15 of the Complaint. Defendant Potzer was primarily involved in this process.
16. Admitted in part and denied in part. It is admitted that copies of the
private paid portions of the calculations are attached to the Complaint as Exhibit D.
Whether the information contained therein is true and accurate is denied in that the
Answering Defendant is without sufficient knowledge or information to form a belief as
to the averment set forth in said documents. Strict proof thereof, if relevant, is demanded
at trial.
17. Denied. The Admission Agreement speaks for itself. The Answering
Defendant is otherwise without sufficient knowledge or information to confirm or deny
what may have been the state of mind of Jack R. Grey or any agreement he may have
entered into directly or through his agent, Defendant Potzer.
18. Admitted.
19. Denied. By way of further answer, any implication that the Answering
Defendant is obligated to pay any service charges, attorney's fees and/or collection costs
is denied. The Admission Agreement speaks for itself.
20. Admitted in part and denied in part. It is admitted that a statement of
account is attached to the Complaint as Exhibit E. The Answering Defendant is without
sufficient knowledge or information to form a belief as to the truth of whether said
statement of account is true and correct and is, therefore, denied. Strict proof thereof, if
relevant, is demanded at trial.
COUNT I. - BREACH OF CONTRACT
HCR MANORCARE INC. V. JACK R. GREY AND JAN M POTZER
No response is required to Paragraphs 21 through 27 in that these paragraphs are
directed to defendants other than the Answering Defendant.
COUNT H. - MONEY HAD AND RECEIVED
HCR MANORCARE. INC. V. JAN R. POTZER
No response is required to Paragraphs 28 through 33 in that these paragraphs are
directed to defendants other than the Answering Defendant.
COUNT III. - SUPPORT
HCR MANORCARE INC. V. EMILY R. GREY
34. The Answering Defendant's answer set forth in paragraphs 1 through 33
are incorporated herein by reference as though set forth in full.
35. Admitted in part and denied in part. It is admitted that Answering
Defendant is the wife of Jack R. Grey. Any implication that the Answering Defendant is
obligated to support Jack R. Grey by reason of the marriage relationship, or has any
liability to the Plaintiff is expressly denied.
36. Admitted in part and denied in part. As set forth in New Matter below,
it is admitted that the Answering Defendant has received a portion of the monthly income
of Jack R. Grey during the period of his residency at the facility. Any implication arising
6
therefrom that the Answering Defendant is liable to the Plaintiff for any portion of its
claim against the other Defendants is expressly denied.
37. Denied. It is denied that the Answering Defendant has been or is of
sufficient financial ability to financially assist Jack R. Grey in meeting the costs of his
care.
38. Denied. It is denied that Jack R. Grey, by reason of his failure to pay any
amounts due and owing the Plaintiff for his care is indigent. By way of further answer,
Defendant, Jan R. Potzer received more than adequate funds on behalf of Jack R. Grey to
pay amounts due and owing to the Plaintiff for his care. Further, this constitutes a legal
conclusion to which no response is required.
39. Paragraph 39 of the Complaint is a legal conclusion to which no response
is required.
40. Paragraph 40 of the Complaint is a legal conclusion to which no response
is required. By way of further answer, it is denied that the care and services provided by
the Plaintiff to Jack R. Grey are necessaries.
41. Paragraph 41 of the Complaint is a legal conclusion to which no response
is required. By way of further answer, it is denied that the Answering Defendant is liable
to the Plaintiff for any portion of its claim against Jack R. Grey.
WHEREFORE, the Answering Defendant respectfully requests the Honorable
Court to enter Judgment in her favor and against the Plaintiff and direct that the
Answering Defendant be reimbursed by the Plaintiff for reasonable attorney's fee and
costs.
NEW MATTER
42. Paragraphs 1 through 41 of this Answer are incorporated herein by
reference as though set forth in full.
43. The Answering Defendant and Jack R. Grey (hereinafter referred to as
Jack) separated in 1972 but neither party filed for a divorce.
44. The separation was the result of marital infidelity on the part of Jack.
Subsequent to the separation of the Answering Defendant and Jack in 1972, Jack resided
with a girlfriend substantially until his admission into Plaintiff's nursing home.
45. Subsequent to the separation of the Answering Defendant and Jack, and at
all times relevant hereto, the Answering Defendant had grounds for divorce from Jack as
a result of his ongoing marital infidelity.
46. At the time Answering Defendant and Jack separated, they amicably
divided the marital assets and entered into an oral agreement pursuant to which Jack paid
reasonable spousal support to the Answering Defendant in fulfillment of his legal
obligation to support the Answering Defendant under the laws of the Commonwealth of
Pennsylvania.
47. All assets of the Answering Defendant, consisting primarily of her
personal residence, the contents therein, and a modest sum of money in her bank accounts
are in her sole name and were acquired either as part of the amicable division of marital
assets in 1972 or had been acquired subsequent to separation.
48. Except for the payment by Jack of monthly spousal support, the
Answering Defendant has not been the recipient of any gifts of assets at any time during
his residency at the Plaintiff's nursing home or within three years prior thereto.
49. Upon Jack's retirement, Jack and the Answering Defendant agreed that
Jack would pay approximately $1,500.00 per month as continuing spousal support to the
Answering Defendant. Said amount constituted approximately '/z of Jack's monthly
retirement income.
50. Upon Jack's admission to the Plaintiff's nursing home and his approval
for Medicaid benefits, the Answering Defendant has received less than the amount
determined by the Department of Public Welfare as her spousal allowance from Jack's
monthly income.
51. At all relevant times Jack's income and finances were in the sole and
exclusive possession and control of Defendant, Jan R. Potzer (hereinafter referred to as
Potzer).
52. The Answering Defendant only received, at the instruction of Potzer,
$1,000.00 per month as her spousal allowance, even though the actual allowance
permitted by the Department of Public Welfare was in excess of $1,000. This continued
through December of 2003. Exhibit D of the Plaintiffs Complaint sets forth the specific
spousal allowance allocated the Answering Defendant and exceeds the amount Potzer
permitted the Answering Defendant to receive.
9
HCR MANORCARE, INC.
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
ANSWER TO CROSS CLAIM
EMILY R. GREY V. JAN POTZER AND THE ESTATE OF JACK R. GREY
AND NOW, TO WIT, this 5th day of August, 2005, comes the Defendant, JAN R.
POTZER, both individually and as attorney-in-fact for Jack R. Grey, by and through her
attorneys, Kagen, MacDonald & France, P.C. and more specifically, Douglas P. France,
Esquire, and in answer to the Cross claim does aver as follows:
60. No responsive pleading is required.
61. Admitted.
62. Admitted.
63. Admitted in part and denied in part. It is admitted that Potzer was acting as
agent for Jack Grey in the process of medicaid qualification with the
Department of Public Welfare, however, it is specifically denied that Emily
Grey's involvement was limited to providing information as was requested of
her by the Department of Public Welfare. Strict proof thereof is demanded
at the time of trial.
64. Denied. It is specifically denied that at all times relevant hereto Potzer
advised Emily Grey of her spousal allowance permitted by the Department
of Public Welfare and under represented said amount. It is further denied
that Potzer deprived Emily Grey of several thousands of dollars of income
permitted by the Department of Public Welfare. Strict proof thereof is
demanded at the time of trial.
65. The averments in paragraph 65 are a conclusion of law to which no
responsive pleading is required. However, to the extent deemed factual in
nature, it is specifically denied that Potzer failed in her fiduciary obligations
as power of attorney to pay all legal obligations to the Plaintiff and strict proof
thereof is demanded at the time of trial.
66. The averments in paragraph 66 are a conclusion of law to which no
responsive pleading is required. However, to the extent deemed factual in
nature, it is specifically denied that Potzer, via her fiduciary obligation, failed
in any respect to pay Jack Grey's legal obligations with the monies available
and strict proof thereof is demanded at the time of trial.
67. Denied. It is specifically denied that Potzer on any occasion stated to Emily
Grey or other family members that she was keeping some or all of Jack's
monthly income on the basis that she was disputing how much of his income
was required to be paid to Manor Care and strict proof thereof is demanded
at the time of trial.
68. Denied. It is specifically denied that Potzer has in her possession any
portion of Jack's income that was not turned over to Manor Care or that she
has not exhausted all income of Jack to pay his legal obligations and that
any amounts remain to pay any amounts claimed due and owing to Plaintiff
and strict proof thereof is demanded at the time trial.
69. The averments in paragraph 69 are a conclusion of law to which no
responsive pleading is required. By way of further answer, it is also
specifically denied that Potzer would be liable to answering Defendant for
any attorneys fees or costs incurred and strict proof thereof is demanded at
the time of trial.
70. Denied. It is specifically denied that Potzer fraudulently represented to Emily
Grey the amount of Emily Grey's spousal allowance under the determination
by the Department of Public Welfare and strict proof thereof is demanded at
the time of trial.
71. Denied. It is specifically denied that Potzer fraudulently represented to Emily
Grey anything in relationship to any funds to be paid to Emily Grey pursuant
to the determinations of the Department of Public Welfare. It is further
specifically denied that Potzer has unlawfully retained $3,840.00 which is
claimed to be due and owing to Emily Grey and strict proof thereof is
demanded at the time of trial. By way of further answer, it is believed and
therefore averred that total payments provided to Emily Grey were in fact in
excess of the spousal allowance determined by the Department of Public
Welfare.
WHEREFORE, Jan Potzer respectfully requests this Honorable Court to dismiss the
cross claim of Emily R. Grey in its entirety and with prejudice.
Respectfully Submitted:
& FRANCE, P.C.
Douglas ance, Esquire
Attorney I No. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
VERIFICATION
I, DOUGLAS P. FRANCE, Esquire, do hereby verify that I am the attorney of record
for the pleading party herein, and that the facts set forth in the foregoing Answer and New
Matter are true to the best of my knowledge, information and belief, upon information
supplied by Defendant Jan R. Potzer. The verification of Defendant cannot be obtained
within the time allowed for filing this pleading.
I understand that false statements made herein are made subject to the penalties
of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities.
Dated: S OS
KAGEN, MACDONALD & FRANCE, P.C.
BY: LL olric??
Douglas P. nce, Esquire
Supreme Court I.D. 48744
2675 Eastern Boulevard
York, Pennsylvania 17402
(717) 757-4565
CERTIFICATE OF SERVICE
AND NOW, to wit, this 5th day of August, 2005, I, Douglas P. France, Esquire, do
hereby certify that I have this date served a copy of the foregoing Answer by depositing
same in the United States Mail, First Class mail, postage prepaid, addressed to counsel
of record as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street
Hanover, Pennsylvania 17331
David A. Baric, Esquire
19 Wets South Street
Carlisle, Pennsylvania 17013
Respectfully Submitted:
N, MACDONALD & FRANCE, P.C.
Douglas P. ra ce"Esc
Attorney ID o. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
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53. In December of 2003, Potzer notified the Answering Defendant that her
spousal allowance had been reduced by the Department of Public Welfare to $800.00 per
month. Consequently, beginning in January of 2004 the Answering Defendant only
received $800.00 per month even though Exhibit D of the Plaintiff's Complaint
evidences that the Department of Public Welfare continued to allow the Answering
Defendant a monthly spousal allowance in excess of $1,000.
54. Upon information received the Answering Defendant believes, and
therefore avers, that Potzer received and retained substantial amounts of Jack's monthly
income that she failed to turn over to the Plaintiff on a monthly basis which would have
been sufficient to pay the balance due the Plaintiff as set forth in the Complaint.
55. The Plaintiff has failed to state a cause of action against the Answering
Defendant in that the determination of the Department of Public Welfare constitutes a bar
to the Plaintiff's claim against the Answering Defendant.
56. The Plaintiff's Complaint fails to state a claim against the Answering
Defendant in that the separation of the Answering Defendant and Jack in 1972, and their
continuing separation thereafter, constitutes a bar to the Plaintiff recovering any portion
of its claim from the Answering Defendant.
57. The Plaintiff fails to state a cause of action against the Answering
Defendant in that the Plaintiff, at all relevant times, was negligent in failing to collect
payment from lack and/or his Agent. Plaintiff was negligent because it was
knowledgeable about Jack's monthly income and resources, had knowledge about the
determinations by the Department of Public Welfare, and had knowledge that the
10
substantial majority of Jack's income was received by Potzer and the Plaintiff failed to
require Potzer to turn over said income to the Plaintiff on a monthly basis as required by
the contractual arrangement between Jack, Potzer and the Plaintiff, and as required by the
Medicaid regulations.
58. The Plaintiff's Complaint fails to state a cause of action against the
Answering Defendant in that the facts alleged in the Complaint and in the Exhibits
attached thereto establish that Jack was not indigent giving rise to a claim against the
Answering Defendant under 62 P.S. § 1973.
59. The Plaintiff's Complaint fails to state a cause of action against the
Answering Defendant in that the facts alleged in the Plaintiffs Complaint and the
Exhibits attached thereto fail to establish that the Plaintiff provided necessaries for the
support and maintenance of Jack giving rise to liability on the part of the Answering
Defendant under 23 Pa.C.S.A. § 4202.
WHEREFORE, the Answering Defendant respectfully requests the Honorable
Court to enter judgment in her favor and against the Plaintiff and direct the Plaintiff to
reimburse the Answering Defendant for reasonable attorney's fees and costs.
CROSS CLAIM
EMILY R. GREY V. JAN R. POTZER AND THE
ESTATE OF JACK R. GREY
60. Paragraphs 1 through 59 of this Answer and New Matter are incorporated
herein by reference as though set forth in fill.
11
61. At all times relevant hereto Potzer was the duly appointed Agent for Jack
pursuant to the Power of Attorney attached as Exhibit A to the Plaintiff s Complaint.
62. During all times relevant hereto, Potzer was in the exclusive and complete
control and possession of all of Jack's assets and income.
63. At all times relevant hereto, Potzer, acting as Agent for Jack, handled the
process for Medicaid qualification with the Department of Public Welfare. The
Answering Defendants involvement was limited to providing such information as was
requested of her by the Department of Public Welfare.
64. At all times relevant hereto, Potzer advised the Answering Defendant of
her spousal allowance permitted by the Department of Public Welfare and under
represented said amount thereby depriving the Answering Defendant of several thousands
of dollars of income permitted by the Department of Public Welfare.
65. At all times relevant hereto, Potzer as Agent for Jack, was obligated to pay
Jack's remaining income as determined by the Department of Public Welfare to the
Plaintiff on a monthly basis.
66. At all times relevant hereto, Potzer failed to turn over all of Jack's income
to the Plaintiff as required by the agreement with the Plaintiff and Medicaid regulations.
67. On one or more occasions Potzer stated to the Answering Defendant and
other family members that she was allegedly keeping some or all of Jack's monthly
income on the basis that she was disputing how much of his income was required to be
paid to Plaintiff.
12
68. The Answering Defendant believes, and therefore avers, that Potzer has in
her possession a substantial portion of Jack's income that was not turned over to the
Plaintiff that would be sufficient to pay any amounts due the Plaintiff on its claim.
69. In the event the Court should find the Answering Defendant is liable to the
Plaintiff for any portion or all of the Plaintiff's claim, Potzer is liable over to the
Answering Defendant for all such amounts plus reasonable attorney's fees and costs
incurred by the Answering Defendant.
70. Potzer fraudulently represented to Answering Defendant the amount of the
Answering Defendant's spousal allowance under the determination by the Department of
Public Welfare.
71. By reason of Potzer's fraudulent representation to the Answering
Defendant the Answering Defendant has been denied, and Potzer has unlawfully retained,
approximately $3,840.00 of Jack's income that was to be paid to the Answering
Defendant pursuant to the determination of the Department of Public Welfare.
WHEREFORE, the Answering Defendant respectfully requests the Honorable
Court to enter judgment in her favor and against Potzer in the sum of $3,840.00 plus
interest, costs and reasonable attorney's fees, and a judgment in the Answering
Defendant's favor and against Potzer for such sums if any the Answering Defendant is
found to be liable to the Plaintiff on the Plaintiffs claim, costs and reasonable attorney's
fees.
13
Respectfully submitted,
Douglas H. Gent, Esquire
Sup. Ct. I.D. # 29964
1157 Eichelberger Street
Hanover, PA 17331
(717) 632-4040
Attorney for Defendant, Emily R. Grey
14
VERMCATION
I, Emily R. Grey, verify that the statements made in this Answer, New Matter and
Cross Claim are true and correct. I understand that false statements herein are made
subject to the penalties of 18 Pa.C.S. § 4904, relating to unworn falsification to
authorities.
4),
Date:
By:.
Emily R. Grey
15
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HCR MANORCARE, INC., NO. 2005-975
Plaintiff
V.
JACK R. GREY AND JAN R. POTZER,
Individually and as the attorney-in-fact for
Jack R. Grey and EMILY R. GREY,
Defendants
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
The undersigned, counsel for the Defendant, Emily R. Grey, does hereby certify
that a true and correct copy of the Answer, New Matter and Cross Claim was served by
first class U.S. mail postage pre-paid on 2005, to the
following:
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
Jan R. Potzer
110 South Hanover Street, #6
Carlisle, PA-17013
l ? ?
By:
Douglas . Gent, Esquire
Sup. Ct. I.D. No. 29964
1157 Eichelberger Street, Suite 4
Hanover, PA 17331
(717) 632-4040
Attorney for the Defendant, Emily R. Grey
16
HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
REPLY TO NEW MATTER
NOW, comes HCR ManorCare, Inc. ("ManorCare"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Reply to New Matter and, in support
thereof, sets forth the following:
42. Plaintiff incorporates by reference its averments as set forth in its complaint at
paragraphs one through forty-one as though set forth at length.
43. After reasonable investigation, Plaintiff is without knowledge or information
sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
44. After reasonable investigation, Plaintiff is without knowledge or information
sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
45. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, Plaintiff answers that after reasonable
investigation, it is without knowledge or information sufficient to form a belief as to the truth of
these averments and they are, therefore, denied.
46. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, Plaintiff answers that after reasonable
investigation, it is without knowledge or information sufficient to form a belief as to the truth of
these averments and they are, therefore, denied.
47. Admitted in part and denied in part. It is admitted only that present real property
records with the Recorder of Deeds of York County indicate that Answering Defendant is the
sole owner of her personal residence. As to the remaining averments, after reasonable
investigation, Plaintiff is without knowledge or information sufficient to form a belief as to the
truth of these averments and they are, therefore, denied.
48. Admitted in part and denied in part. It is admitted that Answering Defendant
received funds from the income of Jack Grey during the period of Jack Grey's residency at the
ManorCare facility. Plaintiff is not presently aware of any other funds or property being
delivered from Jack Grey to Answering Defendant during Jack Grey's residency at the
ManorCare facility or during the period beginning three years prior to Jack Grey's admission to
the facility. Plaintiff reserves the right to amend this answer in the event discovery reveals gifts
of property had been made by Jack Grey to Answering Defendant during the period.
49. After reasonable investigation, Plaintiff is without knowledge or information
sufficient to form a belief as to the truth of these averments and they are, therefore, denied.
50. Admitted in part and denied in part. It is admitted only that the Department of
Public Welfare prepared calculations which included a reference to a spousal allowance for
Answering Defendant. After reasonable investigation, Plaintiff is without knowledge or
information sufficient to form a belief as to the truth of the remaining averments and they are,
therefore, denied.
51. Denied. Plaintiff is not able to determine from these averments the period of time
referred to as "At all relevant times". To the contrary, Jan R. Potzer became the attorney-in-fact
for Jack R. Grey on or about January 12, 1993.
52. Admitted in part and denied in part. It is admitted only that the Department of
Public Welfare made the calculation as set forth on Exhibit "D" to the complaint. After
reasonable investigation, Plaintiff is without knowledge or information sufficient to form a belief
as to the truth of the remaining averments and they are, therefore, denied.
53. Admitted in part and denied in part. It is admitted only that the Department of
Public Welfare made the calculation as set forth on Exhibit "D" to the complaint. After
reasonable investigation, Plaintiff is without knowledge or information sufficient to form a belief
as to the truth of the remaining averments and they are, therefore, denied.
54. Admitted in part and denied. It is believed, and therefore, averred, that Jan Potzer
received funds paid for the benefit of Jack Grey and Jan Potzer failed to pay over those funds to
ManorCare to pay the private pay portion of Jack Grey's costs of care. The remaining averments
are denied. Upon information and belief, the amounts wrongfully retained by Jan Potzer were
substantial and may have been sufficient to pay the costs of care.
55. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, it is denied that the determination of the
Department of Public Welfare operates as a bar to the claim asserted against Emily Grey. To the
contrary, the determination of the Department of Public Welfare is premised upon Emily Grey
representing that she is the spouse of Jack Grey and, therefore, Emily Grey is liable as the spouse
of Jack Grey for the costs of his care.
56. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, it is denied that the alleged separation
constitutes a bar to recovery against Emily Grey. To the contrary, Emily Grey sought and
received a spousal benefit from the income of Jack Grey through the Department of Public
Welfare which benefit required a representation from Emily Grey that she was married to Jack
Grey.
57. Denied. To the contrary, it was the actions of Defendants Emily Grey and Jan
Potzer which prevented payment of the debt including, but not limited to, those actions and
activities referenced in the complaint which are incorporated herein by reference.
58. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, the averments are denied. To the contrary,
Jack Grey was indigent within the context of the referenced statute and Emily Grey is liable for
support.
59. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, the averments are denied. To the contrary,
Plaintiff did provide necessaries for the support of Jack Grey and Emily Grey is liable for
payment for those necessaries under the referenced statute.
WHEREFORE, Plaintiff requests judgment in its favor and against Emily Grey as prayed
for in the complaint.
CROSS CLAIM
60. Plaintiff incorporates by reference paragraphs one through forty-one of its
complaint and paragraphs forty-two through fifty-nine as set forth above as though set forth at
length.
61.-71. These paragraphs are directed at co-defendant, Jan Potzer, and no response
is required.
Respectfully submitted,
O'BRIEN, BARIC & SCH R
Y
David A. Baric, Esquire
I.D.# 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/manorcare/grey/newmatter.rep
VERIFICATION
I verify that the statements made in the foregoing Reply to New Matter 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 falsifications to authorities.
David A. Baric, Esquire
Dated: J s
CERTIFICATE OF SERVICE
I hereby certify that on June 13, 2005, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Reply to New Matter, by first class U.S. mail, postage prepaid, to
the party listed below, as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Jan R. Potzer
110 South Hanover Street, #6
Carlisle, Pennsylvania 17013
David A. Baric, Esquire
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
PRAECIPE TO ATTACH SUBSTITUTE VERIFICATION
Please attach the following Substitute Verification to the Reply To New Matter filed in
this matter on June 13, 2005.
Date:
Respectfully submitted,
dab. d it/m a norca re/grey/su bstituteverification. pra
David A. Baric, Esquire
I.D.#44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
06/15/2005 16:07 7172495755 on PAGE
t[t%RMCATION
I, Kim Etzler, verify that the statements made in the foregoing Reply To New Matter are true
and correct to the best of my knowledge, information and belief..
I hereby ratify the verification previously supplied by my attorney, David A. Baric, Esquire
and execute this verification as a substituted verification.
I understand that false statements herein ate made subject to the penalties of 18 Pa.C,S.
§4904 relating to unworn falsifications to authorities.
Date: Ol(/? `?X/V
Kim +ttler
Business Office manner
CERTIFICATE OF SERVICE
I hereby certify that on June 20, 2005, 1, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Praecipe To Attach Substitute Verification, by first class U.S.
mail, postage prepaid, to the parties listed below, as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Jan R. Potzer
110 South Hanover Street, #6
Carlisle, Pennsylvania 17013
David A. Baric, Esquire
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HCR MANORCARE, INC.
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
NOTICE TO PLEAD
To: HCR Manorcare, Inc.
c/o David A. Baric, Esquire
19 West South Street
Carlisle, Pennsylvania 17013
You are hereby notified to file a written response to the enclosed Answer and
New Matter PURSUANT TO PA.R.C.P. 1026(a) within twenty (20) days from service
hereof or a judgment may be entered against you.
Respectfully Submitted:
, MACDONALD & FRANCE, P.C.
Douglas rance, Esquire
Attorney I No. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
Dated: July 5. 2005
HCR MANORCARE, INC.
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
ANSWER
AND NOW, TO WIT, this 5t' day of July, 2005, comes the Defendant, JAN R.
POTZER, both individually and as attorney-in-fact for Jack R. Grey, by and through her
attorneys, Kagen, MacDonald & France, P.C. and more specifically, Douglas P. France,
Esquire, and in answer to the Compliant does aver as follows:
1. Admitted.
2. Admitted.
3. Denied. It is specifically denied that Jack R. Grey is an adult individual with
a residence address of 940 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania 17013, and by way of further answer, Defendant Jack R. Grey died testate
on March 7, 2005.
4. Admitted.
5. Admitted.
6. Admitted.
7. Admitted.
8. Admitted.
9. Admitted.
2
10. Admitted in part and denied in part. It is admitted that Jack R. Grey became
a resident of the facility on August 14, 2000; however, it is specifically denied that as a
result of his death on March 7, 2005, that he remains a resident.
11. Admitted.
12. Admitted.
13. Admitted
14. Admitted.
15. Admitted.
16. Admitted.
17. Admitted.
18. Admitted.
19. Admitted.
20. Admitted.
COUNT I - BREACH OF CONTRACT
21. No responsive pleading is required under the Pennsylvania Rules of Civil
Procedure.
22. Denied. It is specifically denied that all conditions precedent to the recovery
under the admission Agreement have been fulfilled and strict proof thereof is demanded
at the time of trial.
23. Admitted, however by way of further answer, to the extent the averments
contained in this paragraph contend that Jan R. Potzer did not exhaust all of the funds
received for Jack R. Grey's benefit and, therefore, has assumed liability under the
Admission Agreement, these allegations are strictly denied and strict proof thereof is
demanded at the time of trial.
24. Admitted.
3
25. Admitted.
26. Denied. It is specifically denied that Jan R. Potzer has breached the
Admission Agreement by failing and refusing to exhaust all of Jack R. Grey's funds for his
use and benefit and if any breach of the Admission Agreement has occurred, the liability
would rest with the Estate of Jack R. Grey.
27. The averments contained in Paragraph 27 refer to a party other than the
Answering Defendant and, therefore, no responsive pleading is required.
WHEREFORE, Defendant Jan R. Potzerrespectfully requeststhis Honorable Court
to dismiss Count I in its entirety and with prejudice.
COUNT II - MONEY HAD AND RECEIVED
28. No responsive pleading is required under the Pennsylvania Rules of Civil
Procedure.
29. Admitted
30. Admitted in part and denied in part. It is admitted that it would have been
proper to utilize funds for the costs of care accruing for the care of Jack R. Grey at the
facility, however, it is specifically denied that Defendant Potzer was not authorized
pursuant to the Power of Attorney to utilize his funds for payment of other legally-
enforceable obligations or expenses.
31. Admitted in part and denied in part. It is admitted that Defendant Potzer was
obligated to pay funds to ManorCare for costs of Jack R. Grey's care at the facility,
however, as a result of the position as Power of Attorney, she was also obligated to utilize
these funds for other enforceable obligations and expenses of Mr. Grey and any indication
that she has failed in this obligation is strictly denied and strict proof thereof is demanded
at the time of trial.
4
32. Denied. It is specifically denied that Jan R. Potzer gave no consideration for
the funds of Jack R. Grey received by her and strict proof thereof is demanded at the time
of trial.
33. Admitted in part and denied in part. It is admitted that demand was made
upon Jan R. Potzer to tender funds of Jack R. Grey for the outstanding balance and that
she has failed and refused to do so, however, it is specifically denied that she has any legal
obligation to pay for these debts as she exhausted all of Jack R. Grey's funds for his care
and benefit by payment of all his legally-enforceable obligations and expenses.
WHEREFORE, Defendant Jan R. Potzer respectfully requests this Honorable Court
to dismiss Count II against her in its entirety and with prejudice.
COUNT III - SUPPORT
34 THROUGH 41. These averments relate to another party Defendant and no
responsive pleading is required by this Defendant.
NEW MATTER
42. Paragraphs 1 through 41 above are incorporated by reference herein as
though more fully set forth at length.
43. Plaintiffs claim is barred by the doctrine of estoppel as the account was in
delinquent status from its inception and Plaintiff took no actions toward collection for the
account.
44. The instant claim or a portion of it is barred by the applicable statute of
limitations, specifically all unpaid charges on the account prior to four years previous to the
date of filing of the instant action.
5
WHEREFORE, Defendant Jan R. Potzer respectfully requests this Honorable Court
to dismiss the Complaint in its entirety and with prejudice.
Respectfully Submitted:
KIAZYEN, MACDON?LP & FRANCE, P.C.
Douglas P,*rance, Esquire
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
6
VERIFICATION
I verify that the statements made in the foregoing document are true and correct to
the best of my knowledge, information, and belief. I understand that false statements
herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn
falsification to authorities.
Dated:
By: 6
J R. Potzer 47
CERTIFICATE OF SERVICE
AND NOW, to wit, this day of July, 2005, I, Douglas P. France, Esquire, do
hereby certify that I have this date served a copy of the foregoing Answer and New Matter
by depositing same in the United States Mail, First Class mail, postage prepaid, addressed
to counsel of record as follows:
David A. Baric, Esquire
19 Wets South Street
Carlisle, Pennsylvania 17013
Respectfully Submitted:
N, MACDQN#LD & FRANCE, P.C.
Douglas finance, Esquire
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
REPLY TO NEW MATTED.
NOW comes HCR ManorCare, Inc. ("ManorCare"), by and through its attorneys,
O'BRIEN, BARIC & SCHERER, and files the within Reply to New Matter of Jan R. Potzer and,
in support thereof, sets forth the following:
42. Plaintiff incorporates by reference paragraphs one through forty-one of its
Complaint as though set forth at length.
43. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, the averments are denied in part and
admitted in part. It is admitted only that Jan R. Potzer was delinquent in making payments due
and owing. The remaining averments are denied. To the contrary, the facts presented do not
give rise to a claim of estoppel.
44. To the extent these averments constitute conclusions of law, no response is
required. To the extent a response may be required, the averments are denied. To the contrary,
Plaintiff is not time barred from recovering the delinquent amounts.
WHEREFORE, Plaintiff requests that judgment be entered in its favor and against the
Defendants as prayed for in the Complaint.
Respectfully submitted,
O j: N, BARK & SCHERER
David A. Baric, Esquire
I.D.# 4485:3
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
d a b.dir/manoreare/grey/newmatter2. rep
VERIFICATION
I verify that the statements made in the foregoing Reply To New Matter are true and
correct to the best of my knowledge, information and belief. I understand that false statements
herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to
authorities. r
David A. Baric, Esquire
`? i 2-
DATED:
CERTIFICATE OF SERVICE
I hereby certify that on July 12 , 2005, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Reply to New Matter, by first class U.S. mail, postage prepaid, to
the parties listed below, as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
David A. Baric, Esquire
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION-LAW
MOTION TO COMPEL
NOW, comes Plaintiff, HCR ManorCare, by and through its attorneys, O'BRIEN, BARIC
& SCHERER, and files the within Motion to Compel and, in support thereof, sets forth the
following:
Plaintiff initiated this action to recover a debt owed for services and care provided
by Plaintiff.
On or about July 27, 2005, Plaintiff served Interrogatories upon counsel for
Defendants. A true and correct copy of the Interrogatories is attached hereto as Exhibit "A" and
is incorporated.
On or about July 27, 2005, Plaintiff served a Request for Production of
Documents upon counsel for Defendants. A true and correct copy of the Request for Production
of Documents is attached hereto as Exhibit "B" and is incorporated.
4. To date, Plaintiff has received no response to the Interrogatories or the Request
for Production of Documents.
WHEREFORE, Plaintiff requests that Defendants be ordered and directed to answer the
Interrogatories and produce the Documents propounded upon Defendants within thirty (30) days
of said order.
Respectfully submitted,
BRIEN, BARIC' & SCHERER
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for HCR ManorCare
da b.d i r/manorca re/grey/compel. mot
HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
INTERROGATORIES OF HCR MANORCARE, INC.
PROPOUNDED UPON DEFENDANT
TO: Jan R. Potzer
c/o Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
PLEASE TAKE NOTICE that you are hereby required pursuant to Pennsylvania Rules
of Civil Procedure 4009. 1, to file the original and serve upon the undersigned a copy of your
Answers and Objections, if any, in writing and under oath, to the following Interrogatories within
thirty (30) days after service of the Interrogatories. The Answers shall be inserted in the spaces
provided. If there is insufficient space to answer an Interrogatory, the remainder of the answer
shall follow on a supplemental sheet.
These shall be deemed to be continuing Interrogatories. If between the time of filing your
Answers and the time of trial of this matter, you, or anyone acting on your behalf, learn of any
further information not contained in your Answers, or if you learn that any information set forth
in your Answers is or has become inaccurate or incorrect, you shall promptly file and serve
supplemental answers.
EXHIBIT "A"
DEFINITIONS
A. The term "document" as used herein shall mean the original and any copy,
marked up copy, revision, amendment, modification, non-identical copy and/or draft, or any
written, printed, typed, drawn or other graphic matter of any kind or nature, however, produced
or reproduced, whether or not sent or received, including without limitation; memoranda, reports,
computations, estimates, communications, financial reports or statements, notes, transcripts,
letters, correspondence, infra or inter office communications, envelopes, telegrams, cables,
telephone messages, messages, summaries or records of telephone conversations, summaries or
records of personal conversations or interviews, minutes, notes, notations, tabulations, studies,
analyses, reports, evaluations, projection, work papers, summaries, journals, statistical records,
calendars, appointment books, diaries, plans, drawings, blue prints, modules, specifications, data,
sketches, maps, boring logs, soil tests, soil charts, soil reports, sketch books, quantity books,
material books, time log sheets, purchase orders, invoices, checks, receipts, payroll records,
summaries or records of meetings or conferences, minutes or tape recordings of meetings or
conferences, summaries or reports of investigations, opinions or reports of consultants,
questionnaires, surveys, charts, graphs, books, notebooks, note charts, articles, magazines,
newspapers, booklets, circulars, bulletins, press releases, notices, instructions, manuals,
photographs, schedules, network diagrams, bar-charts, line-charts, motion picture film,
microfilms, photographs, tapes or other recordings, punch charts, computer programs, magnetic
tapes, discs, data cells, drums, printout and other data computations from which information can
be obtained, and marginal comments appearing on any documents, and all other writings in the
possession, custody or control of Plaintiffs or their agents, officers, employees or attorneys.
B. "Plaintiff' means HCR ManorCare, Inc.
C. "Person" or "Persons" shall mean any natural individual or corporation, firm,
partnership, proprietorship, association, joint venture, governmental entity or any other business
or government organization.
D. "Meeting" shall mean any assembly, convocation, encounter or coincidence of two
or more persons for any purpose, whether or not planned, arranged or scheduled in advance.
E. "Communication" shall mean any utterance made, human speech heard,
overheard, or intended to be heard by any person, whether in person, by telephone, by means of
sounding recording, or otherwise.
F. "Identify" means:
(a) When used in reference to a document, describe with sufficient
particularity to form the basis for a Request for Production under Pa. R.C.P. 4009,
including but not limited to the date it was prepared or created, the identity of its
author or originator, the type of document (e., letter, telegram, chart,
photograph, sound recordings, etc.), the identity of its addressee, its present
location and the identity of its present custodian(s). If such document was, but is
no longer, in your possession or subject to your control, state what disposition was
made of it;
(b) When used in reference to a natural person or business entity, "identify"
means to state his or her or its full name, present or last known home address, present or
last known business address, present or last known home telephone number, present or
last known position or affiliation.
G. "Matter", "incident" or "occurrence" mean the transaction or occurrence or series
of transactions or occurrences giving rise to the matters for which HCR ManorCare is seeking
damages as indicated in the Complaint.
INTERROGATORIES
1. Please identify by bank name and account number any and all accounts held in the
name of Jack R. Grey which you accessed in any manner as the agent of Jack R. Grey at any time
during the period January 12, 1993 through March 7, 2005.
ANSWER:
2. Please identify by date, dollar amount and payor any and all cash, checks or other
property you received as agent for Jack R. Grey at any time during the period January 12, 1993
through March 7, 2005.
ANSWER:
3. Please identify by date, dollar amount and payee any and all payments you made
using assets of Jack R. Grey at any time during the period January 12, 1993 through March
7, 2005.
ANSWER:
4. For each payment identified in response to Interrogatory #3, please state the
purpose for the payment.
ANSWER:
5. Please describe all actions taken by you to seek Medical Assistance for Jack R.
Grey.
ANSWER:
6. Did you receive any life insurance proceeds from any insurer upon the death of
Jack R. Grey?
ANSWER:
7. If the answer to Interrogatory #6 is in the affirmative, please state the name of the
insurer(s) and the amount(s) paid out by the insurer(s).
ANSWER:
8. During the period January 12, 1993 through March 7, 2005 how much money was
received into accounts of Jack R. Grey from the Social Security Administration?
ANSWER:
9. Do you presently have in your custody, possession or control any property, real or
personal, of Jack R. Grey?
ANSWER:
10. If the answer to Interrogatory #9 is in the affirmative, please identify all such
property.
ANSWER:
11. Was your name on ever on any bank account as a joint tenant with Jack R. Grey?
ANSWER:
12. If the answer to Interrogatory # I I is in the affirmative, please identify each such
account.
ANSWER:
13. During the period January 12, 1993 through March 7, 2005 did you transfer any money
you received on the behalf of Jack R. Grey to yourself?
ANSWER:
14. If the answer to Interrogatory # 13 is in the affirmative, please provide the following
information for each transfer:
a. the date of the transfer;
b. the dollar amount of the transfer;
C. the reason for the transfer;
d. the consideration given by you for the transfer.
Respectfully submitted,
O EN, BARK SC?i E
/CS ,
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
dab.dir/manorea re/grey/detendant.int
CERTIFICATE OF SERVICE
I hereby certify that on July42l . 2005, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Interrogatories Of HCR ManorCare, Inc. Propounded Upon
Defendant, by first class U.S. mail, postage prepaid, to the parties listed below, as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
David A. Baric, Esquire
HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
REQUEST FOR PRODUCTION OF DOCUMENTS OF HCR
MANORCARE PROPOUNDED UPON DEFENDANT
TO: Jan R. Potzer
c/o Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
Plaintiff, HCR ManorCare by its attorney, David A. Baric, Esquire, requests that the
Defendant make available copies of the following documents within thirty (30) days of service of
this Request.
Plaintiff incorporates herein by reference the definitions set forth in the Interrogaiories of
HCR ManorCare, Inc. Propounded Upon Defendant. If you object to the production of any
documents on the grounds that the attomey-client, attorney work product or any other privilege is
applicable thereto, with respect to that document:
(a) state its date;
(b) identify its author;
(c) identify each person who prepared or participated in the preparation of the document;
(d) identify each person who received it;
(e) identify each person from whom the document was :received;
(f) state the present location of the document and all copies thereof,
EXHIBIT "B"
(g) identify each person who has ever had possession, custody or control of it or copy
thereof, and
(h) provide sufficient information concerning the document and the circumstances thereof
to explain the claim of privilege and to permit the adjudication of the propriety of that
claim.
Please produce any and all bank statements for accounts of Jack R. Grey which
contain, reflect or include any transactions conducted by you as agent for Jack R. Grey during the
period January 12, 1993 through March 7, 2005.
2. Please produce any and all canceled checks for accounts of Jack R. Grey which
checks were signed by you as agent for Jack R. Grey during the period January 12, 1993 through
March 7, 2005.
Please produce copies of any documents relating, directly or indirectly, to any
transfers of property of Jack R. Grey made by you as her agent during the period January
12, 1993 through March 7, 2005.
4. Please produce copies of any documents you submitted on behalf of Jack R. Grey
to obtain Medical Assistance for Jack R. Grey.
Please produce copies of any bills for Jack R. Grey submitted during the period
January 12, 1993 through March 7, 2005.
6. Please produce any and all records which support your contention that ".... she
was also obligated to utilize these funds for other enforceable obligations and expenses of
Mr. Grey..." as set forth at paragraph #31 of your Answer.
7. Please produce any and all records which reflect, refer or relate to any of the
"enforceable obligations and expenses of Mr. Grey" as set forth at paragraph # 31 of your
Answer.
Respectfully submitted,
O EN, BARK SCC/?HE
David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff,
HCR ManorCare, Inc.
dab.dir/manorca re/grey/defendantdocument2. req
CERTIFICATE OF SERVICE,
I hereby certify that on Jul , 2005, I, David A. Baric, Esquire of O'Brien, Baric &
Scherer, did serve a copy of the Request For Production Of Documents Of HCR ManorCare
Propounded Upon Defendant, by first class U.S. mail, postage prepaid, to the parties listed below,
as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
David A. Baric, Esquire
CERTIFICATE OF SERVICE
I hereby certify that on September 22, 2005, David A. Baric, Esquire, of O'Brien, Baric &
Scherer, did serve a copy of the Motion To Compel, by first class U.S. mail, postage prepaid, to
the parties listed below, as follows:
Douglas H. Gent, Esquire
1157 Eichelberger Street, Suite 4
Hanover, Pennsylvania 17331
Douglas P. France, Esquire
Kagen, Macdonald & France, P.C.
2675 Eastern Boulevard
York, Pennsylvania 17402
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David A. Baric, Esquire
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION-LAW
Defendants
RULE TO SHOW CAUSE
AND NOW, this /3'day of
2005, upon consideration of the
Motion To Compel, a rule is issued upon Defendant to show cause, if any there be, why the relief
requested in the Motion should not be granted.
Rule returnable ?-0 days from service.
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BY THE COURT,
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HCR MANORCARE, INC
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
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CERTIFICATE OF SERVICE `•''
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AND NOW, this 7" day of November, 2005, I, Douglas P. France, Esquire, hereby
certify that I have, this date, served a copy of the Answers to Interrogatories by Defendant
Jan R. Potzer in the above-captioned matter, by depositing same in the United States Mail,
First Class mail, postage prepaid, addressed as follows:
David A. Baric, Esquire
19 West South Street
Carlisle, Pennsylvania 17013
Respectfully Submitted:
KAGEN, MACDDONALD & FRANCE, P.C.
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Douglas rance, Esquire
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402
Phone: (717) 757 - 4565
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HCR MANORCARE, INC.
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
AND NOW, this 7" day of November, 2005, I, Douglas P. France, Esquire, hereby
certify that I have, this date, served a copy of the Answers to Request for Production of
Documents by Defendant Jan R. Potzer in the above-captioned matter, by depositing same
in the United States Mail, First Class mail, postage prepaid, addressed as follows:
David A. Baric, Esquire
19 West South Street
Carlisle, Pennsylvania 17013
Respectfully Submitted:
KAGEN, MACDONALD & FRANCE, P.C.
&O,F-?--
Douglas FLI?rance, Esquire
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402
Phone: (717) 757 - 4565
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HCR MANORCARE, INC.
Plaintiff
vs.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
AND NOW, this 7" day of March, 2006, I, Douglas P. France, Esquire, hereby certify
that I have, this date, served a copy of Defendant Jan R. Potzer's Interrogatories directed
to Plaintiff in the above-captioned matter, by depositing same in the United States Mail,
First Class mail, postage prepaid, addressed as follows:
David A. Baric, Esquire
19 West South Street
Carlisle, Pennsylvania 17013
Respectfully Submitted:
KAGEN, MACDONALD & FRANCE, P.C.
J
Douglas P F nce, Esquire
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402
Phone: (717) 757 - 4565
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HCR MANORCARE, INC.
Plaintiff
VS.
JACK R. GREY and
JAN R. POTZER, individually
and as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005-975 CIVIL TERM
CIVIL ACTION - LAW
PRAECIPE FOR ENTRY OF APPEARANCE
TO THE PROTHONOTARY:
Kindly withdraw the appearance of Douglas P. France, Esquire, as attorney for
Defendant Jan R. Potzer, individually and as attorney-in-fact for Jack R. Grey, in the
above-captioned matter and mark the docket accordingly.
Respectfully Submitted:
a G N, MACDO D & FRANCE, P.C.
Douglas France, Esquire
Kindly enter the appearance of Jan R. Potzer, Pro Se, in the above-captioned
matter and mark the docket accordingly.
qax R`
Jan otter, Pro Se
Attorney ID No. 48744
2675 Eastern Blvd.
York, PA 17402-2905
Phone: (717) 757-4565
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, JUDGES OF SAID COURT:
David A. Baric, counsel for the Plaintiff in the above-captioned action, respectfully
represents that:
1. The above-captioned action is at issue.
2. The claim of the plaintiff in the action is $8,629.56 plus attorney fees and costs.
The following attorneys are interested in the case(s) as counsel or are otherwise
disqualified to sit as arbitrators: Jan R. Potzer, pro se.
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3)
arbitrators to whom the case shall be submitted.
11,
Respectfully sub JX
David A. Baric, Esquire
O'Brien, Baric & Scherer
19 West South Street
Carlisle, PA 17013
(717) 249-6873
ORDER OF COURT
AND NOW, , 2006, in consideration of the foregoing petition,
Esq., , Esq. and , Esq. are appointed
arbitrators in the above-captioned action (or actions) as prayed for.
BY THE COURT,
J.
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HCR MANORCARE, INC.,
Plaintiff
V.
JACK R. GREY and
JAN R. POTZER, individually and
as the attorney-in-fact for
Jack R. Grey and
EMILY R. GREY,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 975 CIVIL TERM
CIVIL ACTION-LAW
PETITION FOR APPOINTMENT OF ARBITRATORS
TO THE HONORABLE, JUDGES OF SAID COURT:
David A. Baric, counsel for the Plaintiff in the above-captioned action, respectfully
represents that:
1. The above-captioned action is at issue.
2. The claim of the plaintiff in the action is $8,629.56 plus attorney fees and costs.
The following attorneys are interested in the case(s) as counsel or are otherwise
disqualified to sit as arbitrators: Jan R. Potzer, pro se.
WHEREFORE, your petitioner prays your Honorable Court to appoint three (3)
arbitrators to whom the case shall be submitted.
Respectfully submj?'t ,
?A
David A. Baric, Esquire
O'Brien, Baric & Scherer
19 West South Street
Carlisle, PA 17013
(717) 249-6873
ORDER OF COURT
AND NOW, -21 , 2006, inconsideration of the foregoing petition,
Esq., Esq. and uACsq. are appointed
arbitrators in the above-captioned action (or actions) as prayed for.
BY T ,
J.
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A8VIGNOHI ; 3Hl JO
8
HCR MANORCARE, INC., : IN THE COURT OF COMMON PLEAS OF
PLAINTIFF : CUMBERLAND COUNTY, PENNSYLVANIA
V.
JACK R. GREY and
JAN R. POTZER, individually and as
the attorney-in-fact for Jack R. Grey
and EMILY R. GREY,
DEFENDANTS 05-0975 CIVIL TERM
ORDER OF COURT
AND NOW, this f dh day of October, 2006, the appointment of a
Board of Arbitrators in the above-captioned case, IS VACATED and Hubert X. Gilroy,
Esquire, Chairman, shall be paid the sum of $50.00.
Hubert X. Gilroy, Esquire
Court Administrator
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Edgar B. Bayley, J.
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Curtis R. Long
Prothonotary
office of the 3protbonotarp
Cumber[aub Countp
Renee K. Simpson
Deputy Prothonotary
John E. Slike
Solicitor
/j_5, - q %5CVIL TERM
ORDER OF TERMINATION OF COURT CASES
AND NOW THIS 28TH DAY OF OCTOBER, 2009, AFTER MAILING NOTICE OF
INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE
CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA
R C P 230.2.
BY THE COURT,
CURTIS R. LONG
PROTHONOTARY
One Courthouse Square • Carlisle, Pennsylvania 17013 • (717) 240-6195 • Fax (717) 240-6573