HomeMy WebLinkAbout01-5222 IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
VS. :
ISABELLE DIFFENDERFER, individually, and:
LINDA AMSLEY, Individually and on Behalf:
of ISABELLE DIFFENDERFER, :
Defendants :
No. dbJ -
CIVIL ACTION - LAW
NOTICE
You have been sued in Court. If you wish to defend against the claims set forth in the
followin~ pages, you must take action within twenty (20) days after this Complaint and Notice is
served, by entering a written appearance, personally of by attorney, and filin~ in waitin~ 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 document, or for any
other c[aim or relief requested by he Plaintiff. You may lose money or property or other right
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 TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la corte. Si used quaere defensas de esas demandas expuestas
en las patinas, si~uientes, used tiene viente (20) dias de plazo at partir de Ia fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita o en persona o por abo~ado y archivar en la
corte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Sea
avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra used
sin previo aviso o notificacion y por cualquier queja o alivio que es pedido en la pedcion de
demanda. Used puede perder dinero o sus propiedades o otros derechos importantes para used.
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVlCIO
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE
CONSEGUIR ASSITANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(717) 249-3166
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, : NO.
Plaintiff :
:
vs. : CIVIL ACTION - LAW
:
ISABELLE DIFFENDERFER, Individually, and:
LINDA AMSLEY, Individually and on Behalf
of ISABELLE DIFFENDERFER,
Defendants
COI"IPLAINT
AND NOW, this~/~ day of ,~/~./~/./,f-~, 2001, comes the Plaintiff,
HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire and the
law firm of Wolfson 6: Associates, P.C., and files the within Complaint and in
support avers as follows:
1. Plaintiff, HCR Manor Care is a health care provider qualified to
conduct business in the Commonwealth of Pennsylvania with offices and/or a place
of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania 17013.
2. Defendant, Isabelle Diffenderfer, is an adult individual with a current
mailing address of 94-0 Walnut Bosom Road, Carlisle, Cumberland County,
Pennsylvania 17013.
3. Defendant, Linda Amsley, is an adult individual with a last known
2
address of 548 2® Street, Carlisle, Cumberland County, Pennsylvania, 17013.
4. That Defendant Linda Amsley represented herself to be the Legal
Representative and/or Responsible Party for Defendant Isabelle Diffenderfer.
Defendant Linda Amsley is the daughter of Defendant ]sabelle Diffenderfer.
5. That on or about December 17, 1998, through the present,
Defendant lsabelle Diffender was a health care resident of Plaintiff, where she did
receive various necessary residential health care services and health care treatment
by Plaintiff. An itemization of said services is attached hereto, incorporated herein
and marked as Exhibit "A".
6. That on or about December 17, 1998, Defendant Linda Amsley
executed an Admission Agreement, on behalf of Defendant Isabelle Diffenderfer,
which Agreement outlined various terms of residential health care services to be
provided by Plaintiff and the Responsible Party therefor. A true and correct copy
of the Admission Agreement including addendums is attached hereto, incorporated
herein, and marked as Exhibit "B".
7. That by executing said Admission Agreement, Defendant Linda
Amsley did acknowledge that Plaintiff would be relying on the "Conditions", which
are incorporated into the Admission Agreement in admitting the Patient, and that if
Defendant Linda Amsley did not follow through with said Conditions, Plaintiff will
have detrimentally relied upon said Conditions and Plaintiff would suffer financial
3
harm and loss. See Exhibit "B" as previously identified and incorporated herein.
8. That Plaintiff submitted to Defendants a copy of the itemization of
services accurately showing all debits and credits for transactions with Plaintiff.
9. As of the date of the within Complaint, the balance due, owing and
unpaid on Defendant lsabelle Diffenderfer's account as a result of said charges, for
the period of the Defendant lsabelle Diffenderfer's stay with Plaintiff's facility
before Medical Assistance was approved, is the sum of Eight Thousand Seven
Hundred Sixty-Six and 55/100 Dollars ($8,766.55). See Exhibit "A" as
previously identified and incorporated herein.
10. Despite Plaintiff's reasonable and repeated demands for payment,
Defendants have failed, refused and continue to refuse to pay all sums due and
owing on Defendant Isabelle Diffenderfer's account balance, all to the damage and
detriment of the Plaintiff.
11. Plaintiff has made numerous requests to Defendant Linda ^msley, as
the Legal Representative and/or Responsible Party for Defendant Isabelle
Diffenderfer, demanding that the sums due and owing to Plaintiff be paid, and
Defendant Linda Amsley, as the Legal Representative and/or Responsible Party for
Defendant Isabelle Diffenderfer, has ignored her fiduciary obligation to pay
necessary and appropriate bills and obligations for her mother, Defendant Isabelle
Diffenderfer, for the period of Defendant Isabelle Diffenderfer's stay with Plaintiff's
4
facility prior to Medical Assistance approval.
12. That Defendant Linda Amsley violated her fiduciary duty and
responsibilities as the Legal Representative and/or Responsible Party for Defendant
Isabelle Diffenderfer by not utilizing Defendant lsabelle Diffenderfer's finances to pay
Plaintiff when she knew or should have known there were outstanding medical care
bills for Defendant Isabelle Diffenderfer, and therefore Plaintiff detrimentally relied
on Defendant Linda Amsley following through with the aforementioned Conditions.
1 3. That the finances of Defendant Isabelle Diffenderfer should have been
utilized to pay Plaintiff for her necessary and appropriate medical services and
treatment rendered by Plaintiff to Defendant Isabelle Diffenderfer, but Defendant
Linda Amsley failed to use Defendant Isabelle Diffenderfer's finances for that
purpose, and therefore Plaintiff detrimentally relied on Defendant Linda Amsley
following through with the aforementioned Conditions.
14. Plaintiff has retained the services of the law firm of Wolfson 8~
Associates, P.C., in the collection of the amounts due from Defendants.
1 5. Pursuant to Paragraph 13 of the Fee Schedule, which is attached as part
of the Admission Agreement, Plaintiff is entitled to receive and Defendants have
agreed to pay all court costs, reasonable attorney's fees, and contractual interest if
the account is referred to an attorney for collection. See Exhibit "B" as previously
identified and incorporated herein.
16. As of the filing of this Complaint, Plaintiff has incurred reasonable
attorneys fees from the law office of Wolfson ~ Associates, P.C., in the collection
of the amounts due and owing by Defendants incident to the within action, and
Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the
proceedings in the amount of thirty percent (30%) of the principal balance due and
owing to the Plaintiff by the Defendants.
17. The amount of attorney's fees which represents thirty percent (30%)
of the principal amount due and owing is the sum of Two Thousand Six Hundred
Twenty-Nine and c~7/100 Dollars ($2,62c2.c~7).
18. As of the filing of this complaint, the amount of contractual interest
which has accrued at a rate of eighteen percent 18%per year from March 28,
2001 is the sum of Five Hundred Sixty-Five and c22/100 Dollars ($565?22).
1 c~. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
20. The amount in controversy is within the jurisdictional amount
requiring compulsory arbitration.
6
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment in favor of Plaintiff and against Defendants, Isabelle
Diffenderfer, Individually, and Linda Amsley, Individually and on behalf of Isabelle
Diffenderfer, in the amount of Eight Thousand Seven Hundred Sixty-Six and
55/100 Dollars ($8,766.55), plus reasonable attorney fees in the amount of Two
Thousand Six Hundred Twenty-Nine and 97/1 O0 ($2,629.97), contractual
interest in the amount of Five Hundred Sixty-Five and 92/1 O0 Dollars ($565.92),
the costs of this action and other relief as the Court deems proper and just.
Respectfully Submitted,
Daniel F. Wolfson, Esquire / ~
WOLFSON 8~ ASSOCIATES, P.C.
267 East Market Street
York, PA 1740:3
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
7
VERIFICATION
I, Michelle Thureson, Senior Financial Services Consultant for HCR Hanor C~re, verify
that the statements made in the foregoing Complaint are true and correct to the best
of my information and belief. I understand that false statements herein are made
subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification
to authorities.
DATE:
Michelle Thureson,
Senior Financial Services Consultant
EXHIBIT "A"
08/17/200~ 02:47 7~72490647
HCR .M nor
M~ORCARE CARLISL~ 372
94~ W&LN13T BOTTOM ROAD
CARLISLe, PA 17012
(717)-2~g-5~85
LINDA AMSLKY
548 2ND 8T~SET
CA~IELE, Pa 17513
HANORCARE CARLISLE
PAGE
MEDICAID
PRIV&T~
ROOM 110
PleaSe Return Tt%is Po[~ion
With Your Payment
02
DI ~Fm. NDB~/~E~, ISABELL~ 96541 12/17/98 1~/31/99
SERVICE
15/12/99
15/31/99
15/55/99 11100
05/~1/99 ADJ
07/01/99 ADJ
~8/51/99 ADJ
- 09151199 ADJ
BALANC~ FO~4A~D
CABLE RENTAL
BBAUTY AND BARBER
PRIVAT~ POTION
ADV PUT
PVT ~ORTI~ 4/99'
~TION 5/99,
~BT 6/99
PUT ~RT 7/99
PORT 8/99
PVT ~RT
( QTY 1 )
5.50
5.50
32.00
676.85
675.55
676.e5 .-
676.05 -
676.55"
676.55'
5.00
AMOUNT DUr-
5,445 · 4~
08/17/200]. 02:47 7]. 7249~,547
WALNUT BOTTOM RO~O
(717)-249-088B
FOR ZSABELLE D[FFENDEDFER
548 2ND STREET
HANORCARE CARLISLE
PAGE
PRIU~TE
Please Return This PorUo.
Whh Yodr Payment
DIFFENDERFER~
~ D~E OF
t1/01/99. .... B~L~NCE FORWARD
11/16/99 PAYMENT
11/$9/99 I150~.C~8LE RENTAL
12/~1/99 ~'OV. PVT PORTION
CHARGES t OREDtT~
5,445.40
( OTY I )
AMOUNT DUE
6,~8g.45
MANOROARE OARLISLE
PAGE
NEDICAID
L[NOA ANSLEY PRIVATE
FOR ZSABELLE DIFFENDENFER ROO~ 110
548 2NO STREET Ple~eRetumTh~Po~On'
CARliSLE, PA ~7e13 With Your Paymant
DZFFENDERFER, ISABELLE g6~1 12/17/98 12t$1/99
DATE OF I CHARGES
SERVICE I CODE I SERVICE R~NDERED
12/el/gg BALANCE FORWARD 6,e69'45
12/~1/9~ ~6ee CABLE RENTRL ( QTY ~ ) 5.GG
12/14/99 ~[~ee BEAUTY ~ND BARBER ( ~TY 1 ) 32.~e
eZle~/ee nov PVT PORTION 676.e5
I CREDrT~.
AMOUNT DUE
08/17/2001 02;47 7172490~47 HANQRCARE CARLISLE PAGE 05
Gtetement
HANORCARE 0ARLIgL~ 372
9~0 bJAL~UT BOTTOt~ ROAD
CARLISLE, PA 17013
LI~DA AN~LE¥
FOR ISA~LLE OIFFE~OERFER
648 2ND STREET
CARLISLE; PA 1701~
NEDI¢~ID
PRIVATE
gOON
DATE OF
el/et/ee eA[ANC~ rORWA~O
ozltSio~ PAYMENT
~1/31/00 1160~ CABLE RENTAL
02/~1/~0 ADV PVT PORTION
760.~
( QTY 1 )
CHARGE8
AMOUNT DUE
6,606,
08/~?/200Z 02:47 ?~72490~47 ~GE 86
HANORCA'RE CARLISL~ 372
940 ~ALNUT BOTTOM ROAO
CARLISLe, PA
(7:7)-24B-eBBS
L~NDA .ANBLEY
FOR ~A~ELLE D~FFEND~RFER
~4B 2ND STREET
CARLISLE, PA 17~3
HANOF~CAt~E CARLISLE
MEOICAIO
PRIVATE
ROOM
Please Return Thia Po~Jon
With Your PAyment
CHAR~
CREO~
[~ DAT~ OF I
~ S,RV,CE t 'C~ I SERVICERENOERE*
eZ/e~/ee BALANCE FORNARD 6,686.5~
769.ae
e21~4lae
e2/29/ee
PAYMENT
CABLE RENTAL ( QTY I ) 6.B0
BEAUTY AND BARBER ( QTY [ ) 36,CB
aOV PVT PORTION 676.eB
AMOUr,iT DUE
~NORC~RE C~RL~SLE 372
940 W~LNUT a0TTOM ROAD
CARL~SLEj PA
M~NORC~E CARLISLE
PAGE 07
L.~NI3~, AMSLEY
POR ZSABELLE DIFFENOERFER
CARL?SLE. PA 17~B13
PRIVATE %
ROOM 1~0 -B.
DIFFENDERFER, [$ABELLE 96~A1 [2/[7/98 3/ /~0
~E~¥IGE I CODE [ SE~ICEREND~RED
o~/27/oe PAYMENT
o3/27/0e PAYMENT
e.4/e~/ee AOV PVT PORTION
( QTY · )
CHARGES 1 CREDI?S ....
~69~oe
6,505.65
08/17/2001 02=47 7172490647 HANORCARE CARLZSLE PAGE 00
HCR.Mar orCare
94~ WALNUT BOTTDH ROAD
CARLISLE, PA 17053
MEDICAID
PRZVATE
PAYMENT
C~BLE RENTAL
( QTY i ) 5.QQ'
6~'6 ,eS
5.,448.7
08/~7/2~0~ 02:47 7~72490~47 P~GE 09
I .ManorC e
~0RCARE CARLISLE 372
ga0 WALNUT BOTTOM ROAD
CARLISLE, PA t70~3
(717)-249-e0BS
L[NOA ANSLEY
FOR ZSABELLE O[?FENDERFER
CARLISLE, PA 17~13
HANORCARE CARLISLE
Statement
MEDICAID
PRZVATE
ROOM l!e -..B
Plee~e Return "Chis Potion
With Your Payment
~"D~[FFENDEI~FER, ZBABELLE 96e41 12/17/98 eB,/31/Oe
~:6/el/ee BALANCE FORWARO 6,4~B.70
e~/23/ee PAYMENT
es/zl/ee l~Tee CABLE RENTA~ ( QTY I ) 6;ee
.~s/le/ee z[~ee BEAUTY AND BARBER ( QTY I ) 9.e0 ..,
-~5/2~/ee ~Iiee.BEAUTY ANO BARBER ( QT¥ [ ) 9-ee~-,
eT/el/o~ ADV PVT PORT~ON 675.e5
AMOUNT DUE
~,337,7
0~/17/2001 02:47 7~?~490647 I~NO~C~RE CA~LI~LE P~E 10
MAi'.iORCARE CARLTSLE 372
940 bJALNUT BOTTOH ROAD
OARLIS'LE, P~
i LIND~. AM~ L.EY
~ FOR ISABELLE DIFFENO~RFER .~OON 11~ -B~
: CARLISLE, PA 170~3 ~ W, th Your payment ~
DZFFENDERFE~, -~'
- ~, .... ~;.- ....... ~ .... ~ ........... ~ ......
eet~le~ PAYMENT 784.
e613e/oe ~6eo CAeL~ RENTAL ( OTY ~ ) 5.ee
e~/es/ee [&zee BEAUTY AND ~RBER ( QTY 1 ) ~7.6e
pT/el/ce AmY PVT PORTION
i1/3e/99 ADJ REV If4~ PR~M [1/99 AS.5S ~'~
~/al/a~ ADJ REV IN~ PREM 1/~
e3/31/e~ ADO REV INS PREM 3/00
372
948 ~JALNUT DOTTDM ROAD
HANORCARE CARLISLE
PC~E' 11
,3,;D 2i4D
CARLISLE, PA :.l 7 O t 3
/
"BIFFE~DERFER, ISABELL~ D6041 i2/~7/9B ,. 07/3i/~0
17/~&'¢O0 BALANCE FORWARD 6,49~¢~
37/26/00 PAYHENT , 883.00
)7/3&/00 &160~ CABLE REHTAL ( @TY t ) 6,00~
17t3~1~0 ~900
~710~-0713z]ee
)21.~/oe ,
~/e%/ee noo
INS PREM NOD FAC PO(PA)
BEAUTY AND BARBER
REV LAST MO PP
pRiVATE PORT[ON
A0V PVT PDRTION
REV PVT PORT
PRIVATE PORT
REV PVT PORT 2/50
PRIVATE PORT
REV PVT PORT 3~00
PRIVATE PORT 3/ee
( QTY ~-) ~ -
734.2~
,-' 676 05
?~4.2 0 · ~,
/
"676,0~
734.20
676.05
734.20
SUB TOTALS
le,209.80
3,632.70
AMOUNT DUE
CARRIED .FWD
OARL~$L~o PA
HANORCARE CARLISLE
PAGE
PAGE
12
2
f.; ~: D .'< C A. L'
..., .......... ~-- ]~ .............. ~.. ........ ~ ............ ~ ...... ~.= .................................
. D~T~ ~, '~r' "' ~ S~RV/~E~ ~- ~ ~ED ' CHARGES CREDITS
~ SERVtOE · , ·
FWO FRON' P~CED~N~ ,/ / ie.zes.ee 3,632~
REV PV,T ~RT '4/eo f . ~ / / ,/ 676 05
' AOJ PBZVAT~PPORT ~,' ," ./.¢ ' 734.2¢
AD~ ~E~?PVT PO~,~}O~/ 676.~5
-/
AMOUNT DUE
8,751.65
34D WALNUT ~OTTO~ ROAD
CARk~SLE, PA 17015
MANORCARE CARLISLE
PAGE
13
DTFFENDERFER, ZSABELLE "i
BALANCE FORWARD
/15/e¢, PAYMENT
/Oito~"11B~O CABLE REr~TAL
/2310'8 ~llOO BEAUTY AND BARBER
,lell~o ~Dv PMT PORT[O~
( QTY
( OTY
(
( QTY
( ~TY
i )
· 1 ) "~'
:L,)
9,0~
9,00
9.00
754.20
08/17/2001 02:4? 7172490047
.Manor .. e
CARLISLE
Statement
HANORCARE CARLISLE 8¢2
949 {14L~IUT BOTTO~ ROAD
PC,GE
14
F~OOi.. :L~:~, --F.~
DIFFENDERFER, ISABELLE 9 $ O 4.1. 12/2.7/95
'5 4 ;5' ;~ft0
CARLISLE, PA
39/0[/00 BALANCE FORWARD
~9t30te0 &&6De CABLE RENTAL ( QTY Z )
39/30/00 [[900 ZN$ PRE~ lqCD FAC PO(PA) ( QTY &,-)
39/13/ee [~o0 BEAUTY AND BARBER ( OTY ~ )
~Slz3/oe zz~oo HAZRNET ( OTY & )
~9/20/e~ Z~00 BEAUTY ANb BARBER ( QTY ~ )
[e/os/me A0V PVT PORTION
5.~0
9,00
1.00
36.08
734,28
45.5e
AMOUNT DUE
08/17/2~01 02:~7 7172~906n7 bt~4ORCARE CARLISLE PAGE 15
MANORCARE CARLISLE 372
~4~ tJALMUT BOTTO~ ROAO
5~ 2HO STREET
CARLISLE, PA 17013
/
ele[/ee BALANCE FORbJARO
e/12/o0 PRY~ENT
~/31/0~ 119~G ~NS PERM MOD FAC P~(~A)
1/el/ee AmY PVT PORTION
· CHARGES I CREDITS I
7.4ei.95
( QTY ~ ) 5.~0
( QTY I ) 9.00
754.20
7,3I~3,65
AMOUNT DUE ~.
HCR.2VIm or
MANORCARF- CARL]~LE '37;~
WALNUT BOTTOM ROAD
(7].7)~249-0085
/
L[NOA A~$LEY
FOR [sABELLE DIFFENOERFER ~
E48 2N0 STREET
CARLISLE, PA 17013
HCC4ORCARE CARLISLE
MEDICAID
PRIVATE
~OOM 11Q'-B
- DIFFENDERFER, ISA~ELLE 96041 12/17/9~
DATE OF.
7.303.68
( QTY 1 ) B,eO ,.
( QTY 1 ) 3.7,80
( QTY I )
734.20
I CRED'fT$
AMOUNT DUE
8,07B. 3;.
08/17/2081 02:47 7172490647 HANOROARE CARLISLE PAGE l?
MAtI0~CARE CARL~tE 572
$)40 WAL)IUT BOTTOM ROAD
(717)--~49-008~
LIflOA A~SLEY
FOR ISABELLE OIFFENOERFER
CAE~ISLE, PA 17~13
flEBIBAID
PRIVAT~
RO0~ 110
/
DIFFENDERFER, ISABELLE 960~1 12/17/98 -12/31/~e
L OATE OF
SERV,CE [ CODE 1 .... SERVICE ~ENOERED } CHAR~$ { C~D~S
12/~t/ea BALANCE FORWARD $,078.35
12/3[/ee l~6ee CABLE RENTAL ( QIY I ) 5.~0
zz/2e/ee [l[OO BEAUTY ANO BARBER ( QTY I ) 9.ee
~OS/Ol/B[ ADV PVT PORTION · 734.2e .
A,~/'OUNT DU~-
0~/17/2001 02:47 ?~72490647 ~AC~ 18
HCi 'M o
MANORCAR~ CARI. iSL!~ ~72
940 WALNUT BOTTOM ~OAD
CA~L~L~ P~ 17013
(717)-.~49-~085
HANORCARE CARLISLE
St~tam¢13t
FOR [$ABELLE DIFFENDERFER
CARLISLE, PA 17~13
t~EDICAXO
PRIVATE
ROOH 11~
Please Return This Port, on
With Yo~ Payment
PAYMENT DUE BY THE
lOTH OF THE HONTH
AMOUNT OUE
Statement
HCR'M or
MANORCARE CARLISLE 372
940 ~dALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249--0085
MEDICAID
LINDA A~ISLEY PRIVA'FE
fOR ISABELLE DIFFENDERFER ROOM 110 -.8
548 2ND STREET 91easeRe~rnThisPo~ion
CARLISLE, PA ~7013 Wir:,rou:Payn, e~t
DIFFENDERFER, ISABELLE 96041 12/17/98 0]/16/01 02128/0t
LZ,,~TE Q- , ] CODc I SER'v',CE RENDERED I ,* CHARGES J CREDIT~
· ~- RVIUE ]
02/01/0]. BALANCE FORt, JAR D 8,776,55
PAYMENT DUE BY THE
10TH OF THE t,IONTH
8,776,55
A~ IOU:~;T DUE
EXHIBIT "B"
CT ADMISSION AGREEMENT ' FAC U' TY ManorCare
BETWEEN PATIENT/RESIDENT AND acal~h Services
------'--- ............
THIS/ADMISSION AGRb~...M~ tu~e ,~u,~,,, ' .......... ~,,~ (the "Facility '), ana
Z/~/~ ~ 19
(the "Responsible E~(ty"). A~sed here~n, me term ~a~e
Party, if any. The parties agree as foltows:
1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident
to t~e Facility.
2. Termination of Agreement, Discharge and Transfer.
- a. Termination by Patient/Resident. The Pationt/Resident may terminate this Agreement by
giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible
for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually
leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (il before the attending
physician discharges the Patient/Resident, or (ii) against medical advice, the Patignt/Resident and
Responsible Party agree to assume all responsibility for injury or harm to the Patient/Resident, and
hereby release the Facility, its employees and agents, from all liability connected with such departure.
b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat-
lent/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs
cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi-
duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the
Patient/Res'dent s health has improved sufficiently so that the Patient/Resident no longer needs the
services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be
transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or
~tiRnt/R ident's medical needs; (2) the Patient/Resident presents
discharge is required due to the P ....... es
a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not
resided in the Facility for thirty (30) days. Such notice sha~l be given as soon as practical. The
Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident s right
to appeal a discharge decision with State authorities and the appeals process. If this Agreement is
terminated and/or the Patient/Resident is discharged by the Facility, the Responsible Party agrees
to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate
the Patient/Resident's discharge.
3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party
appointment.
4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and
charges for supplemental services and supplies not paid by any third party as described in the Fee
Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and alt
expenses of discharge or transfer.
5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities tc
release all or any part of his/her medical/health records to the Facility. The Patient/Resident aisc
authorizes the release of records or information to any health care institution to which the Patient,
Resident may be transferred, any provider involved in the care of the Patient/Resident, any thir(
party payor, including, but not limited to, government and private insurers, or any other person entitle~
or authorized to receive such information by law or by the Patient/Resident.
ederal Resident Rights
esid~nt ReSponsibilities
ife Sustaining Treatment Policy
· Medical/Nursing Education
· Denta~, Vision and Hearing Services
· Interdisciplinary Care Conference
· Utilization Review Meetings (if applicable)
· Personal Laundry Policy
· Barber/Beauty Services
· Mail Policy
· Voting Materials
· Photo/Media Events
· Personal Fund Account Procedure
· Tobacco Policy
· Grievance Procedures
· State Resident Rights (if applicable)
14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN
ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS
LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW
SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH
ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH
AMENDMENTS SHALL BE A PART OF THIS AGREEMENT.
The prov s OhS of this Agreement shal b nd the pa~ties, their resp. ective executors,
15. Miscellaneous. beneficiaries, and assigns. The waiver by either'party of any ~)reach or default
ministrators, heirs,
of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions
of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the
entire agreement and any changes shall be in writing and signed by both parties.
IN WITNESS WHEREOF, the parties hereto have executed this d~missi~nt as of the d y
and year above written. ,, ~ j
~acility Representative -~ Prir~d Name & Title R~sp~n$ible Party - Pr'
· //-/7 u
Date
Date
MHC-OOe4tO (Rev. 4/96) pg 5
____ _XHIBIT A -- RESPONSIBLE PARTY APPOINTMENT
Pat ent/Resident s Responsible Party may be any person legally responsible for the
Resident. A competent Patient/Resident shall not be required to designate a Responsible Party.
Please check one of the four following, whichever is most appropriate.
The undersigned has been legally appointed guardian, conservator and/or holder of a power
of attorney to act on the behalf of the Patient/Resident and shall serve as Responsible Party
for the Patient/Resident. The undersigned has delivered to the Facility copies of the legal
documents designating him/her as the guardian, conservator and/or holder of a power of
attorney of the Patient/Resident. In consideration of the Facility's agreement to admit the
Patient/Resident to the Facility, the undersigned, individually and personally, hereby warrants,
represents, covenants and agrees to the Conditions (as herein after set forth and defined).
[] .-~..he Patient/Resident does not have a legally appointed representative and wishes to give
tt~e responsibility to someone else. I hereby appoint
as ~my~ representative (the "Responsible Party") and hereby a.p. thorize him/h, er ~o handle my
a m expenses receive my personal funds and, ~f I am una~l~t/~ execute the
fnanc s, p y Y · · es onsible Party
,~;;~ Anreement on my behalf. Any s,gnature of Pat,ent/Res,dent ~ .....
~'~"'oo'~'~son A~reement and/or this or any other exhibit or doc~ent attached mere~o
on tn~ ~[-~ ._ ~ ~- ~ ~onsidered binding on both thep~ient/Resident and the
or reterenced~er~n sn~,,, u? ~ ~ ~-~ ~nre~ ~ he Condit~n/s (as herein after set forth
Responsible Part~ ~ ne unaers~gneu .u,~. -~ ..... o t
and defined). ~
Facility Representative - SignatuYe - ~ati~ ~r~~
~acitity Representative - ~,~Name ~,le .~,Tent/Resident - Printed .ame~/
........ ' ...... *ent a68~es not have a court-appointed guard,an:, conse~-
~ The Hadent/Hes~o~ ,~ ~' "~-~'~'~;n~ted a Responsible Party, but alone shall execute
vator or power ot attorney anu n~ '.'T 7~_-~. · .- .~- =~*., th~ ndersigned here~y
eement. In cons deratio~ ot his/her 8~ISSlO~ [O tuu ~,,,,~, -..- U _
the Agr ..... ~t~ tn the Condition(as herein after set forth and dehned).
agrees, warrants ano re~. ......... ~ '
· ident is mentally or phy~lY incapa~ of executing this Agreement, handling
D The Pat,ent/Res /. · -. ~hl~ P'artv ~d does not have a guard,an, conser-
his/her own affairs.~r appointing a mu~pu~o~u,~ .... ~ ~,~ , . ....
vator or durable/~ower of attorne~e Patient/Reside~ physician will certi[y m wrmng
t ........ ~-- dent is ncapable of execut ng the Agre~ent and that placement in the
Fac ty is appropriate. The undersigned voluntarily agrees, un u~,~,. .....
to act and'~erve as Responsible Party for the Patient/Resident. In c~nsideration of the Facility's
hereby
agreement to admit the Patient/Resident to the Facility, the undersigned individually
warrants, represents, covenants and agrees to the Conditions (as herein after set forth and
defined).
1 of 2
MHC-OO8-20 (Rev. 4/96) Pg 6
C~onditions_ (collectively referred to as "Conditions")
1. The assets of the Patient/Resident will be utilized to pay, when due, all costs jnc~rre, d by
the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth
in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of
personal clothing and care supplies as needed or desired by the Patient/Resident and as
required by the Facility.
2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other
property of the facility, other Patient/Residents or employees of the facility damaged by the
Patient/Resident.
3. All of the information, including but not limited to that contained on the attached Application
for Residency, dated ~'-,,~_~,~.,~ .~.-.~,- ~ "] , 199 ~ , and which is attached hereto and
made part of this Exhibit and of the Admission Agreement, is true and accurate as of this
date and all assets listed in the application are in fact available to the Patient/Resident for
the Patient/Res'dent s care while at the facility.
4. Neither the Responsible Party nor the Patient/Resident will ta~e action to dissipate or other-
wise transfer the Patient/Resident's assets and/or assets which are available for the Pat-
ient/ Resident's care so as to prevent such assets from being used to pay for the care of
the Patient/Resident while at the facility.
5. When the assets available to pay for the Patient/Resident's care at the Facility are not
sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident
will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and
other documents necessary or advisable to qualify him/her for all third party payor programs
for which he/she may be eligible, including Medicaid.
6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/
Resident will provide financial information regarding monthly credits, increases and decreases
in the Patient/Resident's bank account(s) and other assets to the Facility to enable the
Facility to provide requested data to Medicaid representatives.
7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident
will be utilized to pay extra charges not covered by the third party payor in a timely manner,
and to notify the administrator of the Facility of any problem anticipated in paying such charges.
The undersigned understands and acknowledges that the Facility is relying upon the above Conditions
in admitting the Patient/Resident to the Facility and understands and -Iges that if the above
warranties and representations are not true, or if the-.a~ ~nts are not
--~ ' ~financial
complied with, the Facility will have detrime
harm and loss.
- Printed Name
?-
Dete
MHC-~OS-20 (Rev. 4/96) Pg 7 2 of 2
CEXHIBIT B -- FEE SCHEDULE
Daily Rate. The daily rate is $ i~?, ~ . The monthly rate equals the daily rate multi¢ie(~ by the '~
of da~/s in the month. The daily rate is billed one month in advance and includes:
· Routine Nursing Care · Linens · Social Services
· Mea s (additional fees may app~ ,-~ctivities · Housekeeping
· Room (circle one): Private lfSemi-P~ Triple
The following are paid by Medicare in"~to the items included in the daily rate:
· Approved Rehabilitative/Therapy Services · Approved Medications
· Approved Nursing Supplies · Approved Equipment
The following are paid by Medicaid in addition to the items included in the daily rate (to the extent
covered and paid for by the state program):
· Approved Rehabilitative/Therapy Services · Approved Medications
· Approved Nursing Supplies · Approved Equipment
· Approved Routine Personal Hygiene Items/Services
· Other approved services/items covered and paid for under the!state Medicaid program.
2. Supplemental Services & Supplies. The daily rate may not include the following items, which
will be provided at request of Patient/Resident and/or by physician order at the rate set forth in
the attached facility rate sheet and will be the responsibility of the Patient/Resident.
ITEM
· Private Room
· Prescription & Non-Prescription Drugs
· Nursing & Personal Care Supplies
· Transportation
· Nursing Care (Other than ordinary nursing care)
· Physical, Occupational & Speech Therapies
· Phone, Cable TV, Newspaper, Barber/Beauty
· Special Equipment
· Bed Hold Fees
· Personal Laundry (Personal Clothing)
· Nutritional Supplements
· Alternative Nutrition (Tube Feeding, TPN, etc.)
RATE
Based on location & level of care
As determined by pharmacy
See business office for current prices
As determined by transport company
See attached fee list
See attached fee list
See attached fee list
See attached fee list
See attached fee list
See attached fee list
See attached fee list
See attached fee list
3. Bed Hold Fee. The Facility charges a daily fee for reserving a bed whenever a Patient/Resident
leaves the Facility. For Medicaid Patient/Residents, bed holds are pursuant to state law.
4. Other Charges. Because at Admission, the Facility is unable to ascertain all services/supplies
which may be needed by and provided to the Patient/Resident, all additional costs/charges may
not be listed here. If such services/supplies are provided to the Patient/Resident, the bill will reflect
associated charges and he/she agrees to pay them in accordance with the Agreement.
5. Adjustment of Charges. The Facility may adjust any and all rates upon thirty (30) days prior
written notice, or, in case of emergency or change in level of care, with such prior notice as is
reasonably possible. Adjustments shall be deemed agreed to by the Patient/Resident unless the
Facility is notified in writing to the contrary within ten (10) days after mailing such a notice. If the
Patient/Resident does not consent to the rate adjustment, the Patient/Resident agrees to leave the
Facility no later than the day before the rate increase is effective. ·
MHC-OOS-20 (Rev. 4/96) pg 8 1 of 2
Refunds.. Refunds shall be paid within thirty (30) days after discharge or transfer.
7. Funding Sources. The Facility makes no assurances that the Patient/Resident's car,6 w,ill be
covered by any third party payor.
8. Payment Policy. All amounts due shall be paid promptly within ten (10) days of billing. Failure
to pay any amount when due is a breach of this Agreement for non-payment of stay and grounds
for termination of this Agreement and discharge of the Patient/Resident. Any account not paid in
full shall be subject to a one and one-half percent (11/2%) service charge on the past due
balance each month until the balance due is paid in full. This amounts to eighteen percent
(18%) annually on the unpaid balance. If the maximum annual service charge allowed by state
law is less than eighteen percent (18%), the maximum interest rate allowed by state law shall
apply. Should the Patient/Resident's account be turned over for collection to an attorney or
collection agency, or should the Facility seek to interpret or enforce any other provision of the
Agreement, the Patient/Resident agrees to pay all court costs and reasonable attorney's fees
of the Facility if the Facility prevails.
9. Responsibilities. The Patient/Resident is responsible for, and shall;pay, the daily j~ate and charges
for supplemental services/supplies not paid by any third party, as well as applicable co-insurance
and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/
Resident is transferred to a different room or the level of care or payor status changes. The Patient/
Resident and/or Responsible Party will be notified of the rate change. If the Patient/Resident or
Responsible Party refuses supplemental services/supplies or to make payment for them, the Facility
is released from all liability for harm which may result.
Medicare Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage is
established by federal guidelines which limit payment to a fixed number of days. If the Patient/Resident
enters the Facility and the Medicare application is denied, the Patient/Resident shall be liable for
all charges. The Patient/Resident is responsible for payment for items covered by Medicare supple-
mental insurance and for applying for reimbursement from his/her insurer.
Vledicaid Beneficiaries: (circle correct number)
1) The Facility does not currently participate in the Medicaid program. Accordingly, persons who
are admitted as another payor status will be unable to convert to Medicaid status. In order to facilitate
proper discharge planning, the Patient/Resident and/or Responsible Party agree to provide the
Facility with at least four (4) months prior written notice of the Patient/Resident's becoming eligible
for the Medicaid coverage or their being unable to pay privately; OR
The Facilitv currently participates in the Medicad program. If the Patient/Resident believes
she qualifies for Medicaid he/she shall prompt y complete 'and submit all documents required
~~d~nYt will be liable for all charges from the admission date. When Medicaid pays for only a
to a I for coverage including pre-admission approval. If Medicaid coverage is denied, the Patient/
portion of the incurred charges, the Patient/Resident shall be responsible for paying his/her portion,
as determined by Medicaid regulations. This charge will be billed to the Patient/Resident by the
Facility and shall be his/her responsibility. The Patient/Resident shall also be responsible for pay-
ment of Facility's current charges for any requested non-Medicaid covered services/supplies. The
Patient/Resident will provide financial information regarding monthly credits, increases/decreases in
the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaid
~representatives.
2of2
MHC-OO8-20 (Rev, 4/96) Pg 9
( EXHIBIT C -- PHARMACY AGREEMENT
T"-he FacilitY/Ila;s 8eveloped policies and procedures for drug therapy, distribution and controF which"
provide for a uniform medication distribution system. The Facility has selected a pharmacy (the
"Designated Pharmacy") to provide medication under such distribution system. The Facility reserves
the right to change the Designated Pharmacy at any time.
The Patient/Resident is hereby notified that the Facility's parent corporation (i.e., Manor HealthCare
Corp. or one of its affiliates) has a significant financial interest in Vitalink Pharmacy Services, Inc.,
which operates under the following names: Vitalink, Northern Nursing Home Pharmacy, West End
Family Pharmacy, Propac Pharmacy, Apothecary Pharmacy Services, Parker's Pharmacy, Home
Intravenous Care and Brentview Pharmacy. The Facility may have selected one of these entities as
the Designated Pharmacy.
The Patient/Resident has the right to use any pharmacy so long as that pharmacy will furnish the
same medication distribution system noted above, and comply with the Facility policies and pro-
cedures and all applicable laws and regulations. For Medicaid Patient/Residents, the Designated
Pharmacy will file claims for payment directly with the Medicaid Program for any covered claims. If
the Patient/Resident utilizes a different pharmacy, the Patient/Resident must make arrangements
with such pharmacy for similar filing of claims for payment.
All charges shall be billed to the Patient/Resident or the Patient/Resident's third party payor directly
and shall be payable in full. The Designated Pharmacy reserves the right to terminate any account
for any reason after written notice of such intent has been given to the Patient/Resident.
liThe undersigned selects the Designated Pharmacy (as may be changed by the Facility
from time to time) as the supplier of medications prescribed for the Patient/Resident while
at the Facility.
The undersigned selects as the
supplier of medications prescribed for the Patient/Resident while at the Facility. The
undersigned understands and agrees that such pharmacy must comply in all respects with
the Facility's uniform medication distribution system, all Facility policies and procedures
and applicable law. If such pharmacy fails to do so, the undersigned shall be required to
select another pharmacy. The above pharmacy shall a~.. o~e-a~ agree in writi.n,g
that it will comply with the Facility's uniform medication distril~-ution syste, m, the Facility s
policies and procedures and applicable law .v~.--~--' ~" / ' ~
· jResp~nsible/.,h:~ty -- Signature
R~t3~,r{'sible Party - Printed Name
Date
MNC-OOe-20 (Rev. 4/96) pg 10 1 of 1
SCREENING QUESTIONNAIRE
Ask all four questions of each Medicare Patient/Resident. If the Patient/Resident responds "Yes"
to any question, continue to page two asking all applicable questions. The Patient/Resident or repre-
sentative should sign the form whenever possible.
qOTE: It is important to ask all questions and document ail answers regarding MSP. A provider
may be held liable if an overpayment occurs and Medicare finds that the provider furnished
erroneous information or failed to disclose facts it knew were relevant to payment.
is the Patient/Resident covered by the Veterans Administration, the Black Lung Program or
Workers Compensation?
( u//) No: Proceed to question #2 . · ,,
( ) Yes: Bill the other insurer prior to Medicare
Is the illness or injury due to any type of accident?
( J ) No: Proceed to question #3 or #4
) Yes: Complete next page and continue with questions below
#3IF 65 OR OVER
#4IF UNDER 65
Is the/Patient/Resident 65
( ¢ ) No:
or over and employed, or is the spouse employed at time of service?
Retirement Date: Patient/Resident
Spouse
Continue: See Note Below
) Yes: Complete next page - Medicare may not be primary
4. is the Patient/Resident under 65 and covered under any Employer Group Health Plan (EGHP)
or ~.~e Group Health Plan (LGHP)?
( ) No: See note
( ) Yes: Complete next page - Medicare may not be primary
wer to a uestions s "No", biJlMeSicare as primary./ ' \ ---
Note_ If ans q
If any response is "Yes", conti~!.~age; M~dicar~(may n~t
Patient/Resident/Representative S'g .~.~ ---y "
I of 3
MHCO08-20 (Rev. 4/96) pg 13
Patient/Residen~
Service Date's: ~
Medicare No.:
Check the appropriate box and answer the questions.
1. ILLNESS/INJURY CAUSED BY ACCIDENT
A. ( ) Motor Vehicle: Name of Patient's/Resident's Automobile Insurer
B. ( ) Another p~y was responsible for accident.
Name and address of L'ra,~lity Insurer
Name and address of attorne
C. ( ) Work Related: Name
~nan's Comp.
D. ( ) Other accident (Slip and fall,
)lain where accident occurred:
Has the Patient/Resident filed or file a suit?
( ) No: Bill Medicare and send of all nent documentation
( ) Yes: Name and address ~:
Liability Insurer /
Attorney /
Bill other Insurer prior to,~/edicare; submit docL Medicare if conditional payment
requested. / ~
EMPLOYER GROUP/COVERAGE FOR THOSE 65 AND OVER ' ' s
A. ( ) Patient/~esident employed at time of this service Pat ent s/Res dent
company/emplo/v~r
Does Employer employ 20 or more employees? ( ) Yes ) No
Does the Patient/Resident have an Employer Group Health Plan (EGHP) by reason of his/her
current employment? ( ) Yes ( ) No
If "No" give Date of Retirement
If "Yes" give the name of the EGHP
Bill EGHP prior to Medicare
2of3
MHC.O08-20 (Rev, 4/96) Pg 14
spouse's company/employer .-- --
Does the spouse's employer employ 20 or more employees (
Does the spouse have an EGHP by reason of current employment
ident? ( ) Yes ( ) No
If No, give the date of retirement
If Yes, give the name of EGHP.
Bill EGH'"P~ior to Medicare
EMPLOYER'GROUP COVERAGE FOR THOSE YOUNGER
A. ( ) Patient/Resident is entitled to Medicare
and in the first 18,~onths of Medicare entitlement. Date
Kidney transplant:
MM/YY
this service. Give name
Pat eat s/Resident s spouse employed at the time of
have coverage
aalth Plan?
Does the
guardian's Employer
) No: Medicare
Give name f
Bill EGHP prior to Medicare
B. ( ) The Patient/Resident
have/has not had ESRD).
Does the Patient/Resident have
guardian's Employer Group
) No: Medicare Primary
) Yes: Continue
Does employer(s) employ It ) No: Bill
) Yes: If yes,
) Ye.' ( ) No
the Patient/Res-
65
to End Stage Renal Disease
first Dialysis treatment or date of
his/her, his/her spouse's, a parent's or
) Yes:
name of the employer -- ~
to Medicare s_olely, because of disability (does not
rough his/her, his/her spouse's, a parent's or a
or more employees?
-- / din
Give name of..~orreeponding
me of each insured whose policy c~ent:
employer: .
Bill EGHP(s) prior to Medicare
EGHP:
3 of 3
(Rev, 4/96) pg 15
i i
EXHIBIT D -- STATE LAW ADDENDUM
The Admission Agreement is amended in the following manner, in order to comply with state law
and/or regulation:
Indicate additions to, and/or deletions from, the Admission Agreement required by state law. If no
additions/deletions are necessary, indicate "NONE".)
"NONE"
MNC-OOa-~O (Rev. 4/96) pg 11 1 of 1
_MEDICARE ACCEPTANCE POLIC _. ManorCare
'Hearth Services
This is to confirm that
of admission and found to be eligible for Medicare benefits. Of course, the Medicare program may
change coverage, eligibility or co-payments at any time.
It is understood that as long as the Patient/resident meets the criteria for coverage, at present
Medicare Part A will pay for Medicare Part A covered, services for the first twenty (20) days.
Beginning on the 21st day, there is a co-payment of $ ~t¢.01~ per day for the next 80 days,
a co-payment set by the federal agency which administers the Medicare program. But regardless
of medical status, the maximum Medicare Part A benefit period is 100 days, which may include
covered days at another facility- ~-,~O~k-~ ~x¢.~--~
It is also understood that as long as the Patient/Resident meets the coverage criteria, at present
Medicare Part B will pay 80% of the allowed rate for Medicare B covered services. There is a 20%
co-payment for these services that is the responsibility of the benefibiary. Vitalink Infusion Services
may be the supplier contracted to supply enteral/parenteral feeding products and is an affiliate of
Manor HealthCare.
At the time Medicare coverage is denied or expires, a 30-day advance payment on the current
Daily Rate will be required if the Patient/Resident is to remain at the Facility and if the care will not
be paid by another approved third party payor.
._ UTHORIZATION OF PAYMENT OF MEDICARE BENEFIT
TO PROVIDER
~T-certify that the information given by me in applying for payment of Medicare Part A or Par--'-~7~
benefits under Title XVlll of the Social Security Act is correct. I authorize any holder of medical or
other information about me to release to the Social Security Administration or its intermediaries or
Carriers any information needed for this or a related Medicare claim.
I further request that payment of authorized benefits be made on my behalf. I assign the benefits
payable for the physician services to the physician or organization furnishing the services or authorize
such physician or organization to submit a claim to Medicare for payment to me.
For outpatient services, I request this authorization apply to the p.ef!od -~_&
t,' '
Facility ~epre~ema -- 9 - '
~ ~ ..... "" "~itle ~ECnsible Party - Crinted Name
Facility Represen~auve - FrCzeo ~ame a ~
Date 1 of I
HC.OO8.2O (Rev, 7/96) Pg 19
AUTHORIZATION TO PAY INSURANCE BENEFITS
Patient/Resident's Name /' J~ ~-//--C/q (~,(-' Claim#
Insured Policy #
To (Insurance Company): /'~u~
ManorCare
H ea~l~:h Services
hereby authorize you to make direct payment to:
MANORCARE HEALTH SERVICES
Facility Name ,,
940 WALNUT BOTTOM RD. CARLISLE, PA 17013
Facility Address
herein after referred to as "Facility", otherwise payable to me,
understand that certain items/services, including but not limited to personal care items/services,
are not covered by the third party payor named above. Items/services including but not limited to
beauty/barber services, lotion, laundry services, etc. are considered personal care items/services.
I further understand that the Facility does not guarantee payment by the above third party for any
items/services provided by the Facility. I agree that charges for personal items/services, as well
as any other charges denied or not paid in full by the above third party for any reason will be my
responsibility. /7. -~'~, ('~" ~ ,/~'"~ ~---~
Facility Representative L Signature _ ~6~poflsible Party -- Signature / ~
. ~
~sib~ ~rty - Printed Name ~
Facility Representative' P~{ed Name & Title
Date Date
MHC-OOe-20 (Rev. 7/96) pg 20
INSURANCE COVERAGE
ManorCare
Health Service*.
ManorCare Health Services wants to be sure that all possible sources of insurance to pay
for the resident/patient's care while staying with us are identified properly. Some insurance
companies require precertification before they will pay for care provided.
Please help us by listing all sources of insurance, and most important, by letting us know
of any changes in the insurance company or types of coverage as soon as yot. I become aware
of the changes.
Please state the correct order of the resident/patient's health insurance:
1. Primary Insurance:
2. Secondary Insurance:
Is the resident/patient covered by Medicare? '--'"~Yes No
Is the resident/patient covered by a commercial Medicare HMO? Yes ~ No
Does the resident/patient plan to change insurance carriers? _ Yes "-~_ No
Has the resident/patient stayed at a hospital or skilled nursing facility within
the past 60 days? .~. Yes . No
The information you provide will be used to bill the proper insurance company. If we are
not given the correct information, or not informed of changes, the insurance company or Medicare
may not cover care we provide. The resident/patient or the guarantor {if any) will then be
responsible for paying for that care.
Thank you for your help.
(If Resident is unable to sign)
Date
AUTHORIZATION TO RELEASE
MEDICAL RECORDS
Center Name
Date
MANORCARE HEALTH SERVICES
940 WALNUT BOTTOM RD. CARLISLEt PA 17013
Dear Doctor/Medical Record Administrator:
Phone
(717)
249-0085
The person named below was hospitalized in your hospital or was under your care in the past and is now
a resident at our center.
RESIDENT'S NAME I BIRTHDATE -' SOCIAL SECURITY NUMBER
It is necessary that the nursing center obtain copies of the following from you for the resident's chart in
order for us to provide appropriate care for the Resident and comply with Medicare/Medicaid requirements
for a Nursing Facility.
E] CURRENT HISTORY AND PHYSICAL - A xerox copy is acceptable.
[] HOSPITAL DISCHARGE SUMMARY - As soon as possible.
[] CURRENT CBC REPORT - Please include date. A xerox copy is acceptable.
[] CURRENT UA REPORT - Please include date. A xerox copy is acceptable.
[] CURRENT CHEST X-RAY - Report and date.
[] (OTHER)
Could you please forward to us the most current information that you have on file at your earliest
convenience.
Thank you.
Ithhee~;bntYera. Uthorize all E.e~?gs__and/or entities to release all or any part of my medical/health records to
MHC-008-16 A59-A6
N1anorCare Health Services
CONSENT TO PHOTOGRAPH
As used below, the term "Photograph" includes video photograph'/.
COMPLETE ALL SECTIONS
PUBLIC RELATIONS (Check One)
V/"/ J dO qive my consent for me/the Patient/Resident to be photographed, or to have my/the
Patient's/Resident's voice recorded, by or on behalf of the Facility, for advertising or public
display, or by the news media.
I (JO not eive my oonsent 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.
ADM~NISTRA TIVE (Check One)
I do oive 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.
I do not oive 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 ali other purposes related to my/the Patient's/
Resident's health, safety or admission to the Facility.
MEDICAL (Check One)
/ I do qive my qQnsent 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 m ted to wound and skin care, if necessary. Such phot~j:aphs-~vould not include
identification except Patient/Resident medical record num~"~.~
I do not cive mv oonsent for me/t~.a~sidenxt-~° ~e pj~otog~aphed ~Y t~d,~ for
medical monitoring and/or educati~n~purpos~. [ ~
..~ent/Resldent or Responsible Pa~ Signatu~
Patient/Resident or I
First, Mi)
Date
Attending ptt~sician:
Room Number
Patient/Resident Number
Page 40 V 1.0 Wound and Skin Standards
DEPARTMENT OF '~
HEALTH AND HUMAN SERVICES
~ HEALTH CARE FINANCING ADMINIsTRATIoN
~NAME (P.[int or Type) ,'~ H.I. CLAIM NUMBER
S~cti~'~l I ~' A'PPOINTMENTOF REPRESENTATIVE
appoint this individual:
(Print or type name and address of individual you want to represent you.)
to act as my representative in connection with my claim or asserted right under Titles XI, or XVIII of the Social
Security Act. I authorize this individual to make or give any request or notice; to present or to elicit evidence; to
obtain informat~.;.and~ .o~.~any notice in connection with my claim wholly in my stead.
Section II [ ACCEPTANCE OF %PPOINTMENT
I, , hereby accept the above appointment. I certify that I
have not been suspended or prohibited from practice before the Social Security Administration or the Health Care
Financing Administration; that I am not, as a current or former officer or employee of the United States, disqualified
from acting as the claimant's representative; and that I will not charge or receive any fee for the representation
unless it has been authorized in accordance with the laws and regulations referred to on the reverse side hereof.
In the event that I decide not to charge or collect a fee for the representation I will notify the Social Security
Administration and the Health Care Financing Administration (completion of Section Ill (optional) satisfies this require-
ment).
I am alan ADMINISTRATOR, MANORCARE HEALTH SERVICES
~T~ E (~epresen.t~)~/y/
TELEPHONE NUMBE~~'-'-'~'~
(Area Code) (717) 249-0085
Section III I
{Attorney, union representative, relative, law student, etc.)
ADDRESS
940 WALNUT BOTTOM RD.
CARLISLE, PA 17013
]ATE
WAIVER OF FEE OR DIRECT PAYMENT
(Note to Representative: You may use this portion of the form to waive a fee or to waive direct payment of the
fee from withheld past-due benefits.)
I waive my right to charge and collect a fee for representing ~.,_~~__E._~ ~
before the Social Security Administration or Health Care Financing Administration.
SIGNATURE IDATE
( Se~ important information on reverse)
FORM HCFA-1696-U4 (10-84) 1 of 1
MHCoOO8-20 (Rev. 4/96) pg 12
ManorCare
Health Ser'.q'ces '
PATIENT SELF-DETERMINATION ACT ACKNOWLEDGEMENT
To Our Residents:
Pursuant to federa~ law, it is this Facility's policy to: (1) provide you with written information
regarding your rights under state law to make decisions regarding your care, including the right
to refuse care and to make advance directives (living wills and durable powers of attorney for
health care); (2) provide you with the Facility's written policies regarding implementation of those
rights; (3) document in your medical record whether you have an advance directive; (4) not to
condition the provision of care or otherwise discriminate against you based on whether you have
executed an advance directive; and (5) ensure compliance with state law regarding advance
directives.
To assist us in complying with these requirements, please complete, sign and date the
following information:
1. I, the undersigned Resident/Responsible Party (circle ~)ne) have received a copy
of the Facility's Guidelines for "NO Heroics" Requests, as well as a copy of state
law information concerning medical care decision-making and advance directives.
2. The Res dent .does/does not (circle one) have an advance directive at this time.
If the Resident has an advance directive, it is a living will/durable power of
attorney for health care (circle one). A copy of the advance'directive is attached.
L I , i ~/' .:
,~ -_~-~.
· / ....! .-,!~--;/ ."----_-:-/ -~.
By: 'v
(Signature of Resident/Responsible Party)
Print Name:
(If Responsible Party, check here and indicate relationship to Resident)
Date:
(If the Resident does not have an advance directive and wishes to make one, please contact
your attorney or the local Ombudsman, State Department of Health or Office on Aging for valid
forms.)
~r~ Name (Last, First, MI) .' ~'-'i r^tt~ndi~e p,~ysician ,
~.c-oo~-~' ~/gel / /
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE
No. 01-5222
VS.
ISABELLE DIFFENDERFER, Individually and
LINDA AMSLEY, Individually and on Behalf
of ISABELLE DIFFENDERFER
548 2ND STREET
CARLISLE, PA ! 7013
Action in: Civil-Law
PRAECIPE FOR JUDGMENT
ENTER JUDGMENT in the above case for failure to file, enter, an
ANSWER TO THE COMPLAINT
against Linda Amsley
in favor of HCR Manor Care
in the sum of $ 11,962.44 with interest AS ALLOWED BY STATUTE
Total: $ 11,962.44
+ COURT COSTS
Daniel F. Wolfson, Esquire
(~C-~'Jrr'x-~c~'e--~ o2 ,/ ,20 O} Judgment entered
by the Prothonotary this day according to the tenor of the above statement.
Prothonotary
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
vs. :
ISABELLE DIFFENDERFER, Individually, and:
LINDA AMSLEY, Individually and on Behalf:
of ISABELLE DIFFENDERFER, :
Defendants :
NO. O!-5222
CIVIL ACTION - LAW
NOTICE OF ORDER, DECREE OR JUDGMENT
TO: ( ) PLAINTIFF (X) DEFENDANT ( ) GARNISHEE ( ) ADDITIONAL DEFENDANT
YOU ARE HEREBY NOTIFIED THAT THE FOLLOWING ORDER, DECREE OR JUDGMENT HAS
BEEN ENTERED AGAINST YOU ON
IN ACCORDANCE WITH THE PROVISIONS OF PA.R.C.P. 236
( ) DECREE NISI IN EQUITY
( ) FINAL DECREE IN EQUITY
(X) JUDGMENT OF
( ) CONFESSION ( ) VERDICT
(X) DEFAULT ( ) NON-SUIT
( ) NON-PROS ( ) ARBITRATION AWARD
(x)
()
JUDGMENT PS IN THE AMOUNT OF $11,962.44 PLUS COSTS $45.50
FOR A TOTAL OF $12,007.94.
DISTRICT JUSTICE TRANSCRIPT OF JUDGMENT IN CIVIL ACTION IN THE AMOUNT OF
$ PLUS COSTS.
()
IF NOT SATISFIED WITHIN SIXTY (60) DAYS, YOUR MOTOR VEHICLE OPERATOR'S
LICENSE WILL BE SUSPENDED BY THE PENNSYLVANIA DEPARTMENT OF
TRANSPORTATION
ROTHONQTARY ./)
IF YOU HAVE ANY QUESTIONS CONCERNING THE ABOVE, PLEASE C .
NAME OF (ATTORNEY/FILING PARTY):
ADDRESS:
TELEPHONE NUMBER:
NOTICE SENT TO:
Linda Amsley
548 2nd Street
Carlisle,
WOLFSON &ASSOCIATES, P.C.
267EAST MARKET STREET
YORK, PENNSYLVANIA 17403
(717) 846-1252OR 800-321-8467
PA 17013
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
VS.
ISABELLE DIFFENDERFER, Individually, and:
LINDA AMSLEY, Individually and on Behalf:
of ISABELLE DIFFENDERFER, :
Defendants :
NO. 01-5222
CIVIL ACTION - LAW
CERTIFICATION
I, Daniel F. Wolfson, Esquire, due hereby certify that on October 5,
2001, I caused a true and correct copy of the 10 Day Notice attached
hereto to be served on the Defendant, Linda Amsley.
Date:
WOLFSON 6t ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717) 846-1252
I.D. # 20617
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS OF
ERIE COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
VS. :
ISABELLE DIFFENDERFER, Individually, and:
LINDA At,'ISLEY, Individually and on Behalf:
of ISABELLE DIFFENDERFER, :
Defendants :
NO. 01-5222
CIVIL ACTION - LAW
CERTIFICATE OF RESIDENCE
I, Daniel F. Wolfson, Esquire, due hereby certify that the last known address of the
above referenced Defendant is as follows:
LINDA AMSLEY
548 2ND STREET
CARLISLE, PA 17013
Date:
Respectfully submitted,
WOLFSON & ASSOCIATES, P.~'.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 20617
Attorney for HCR Manor Care
IN THE COURT OF COHHON PLEAS OF
CUHBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, :
Plaintiff :
VS. :
ISABELLE DIFFENDERFER, Individually, and:
LINDA AMSLEY, Individually and on Behalf:
of ISABELLE DIFFENDERFER, :
Defendants :
NO. 01-5222
CIVIL ACTION - LAW
AFFIDAVIT OF NON-MILITARY SERVICF
COI"'II"IONWEALTH OF PENNSYLVANIA :
COUNTY OF YORK :
l, Daniel F. Wolfson, Esquire, being duly sworn according to law, depose and say that I am
the Attorney for the Plaintiff in the above-captioned matter, and that to the best of my
knowledge, information and belief, Linda Amsley, Defendant, above named; is over 21 years of
age; is last known to reside at 548 2nd Street, Carlisle, PA 1 70l 3, is not in the military
service of the United States or its Allies, or otherwise within the provisions of the Soldiers' and
Sailors' Civil Relief Act of Congress of 1940 and its Amendments.
267 East Market Street
York, Pennsylvania 17403
Attorney I.D. #20617
Attorney for the Plaintiff
Sworn and subsc~bej[~to
bef,o~e, n'w this _.~day
of~ 2001.
Notary Public
M~e~oM.~h,.~_~/.~u°' I
Oity of York, YOmgoun n~I
My Commission Expires Aug. 12, 2002 J
.ATTORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
Donald L, Hoage*
..COUNSEL
Mordson B. Williams
PARALEGAL.S
Margaret L. Burg
Michele M. McHugh
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
267 East Market Street
York, Pennsylvania 17403
(717) 846-1252
(800) 321-8467
FAX (717) 848-I 146
e-mail: dfwolf$on @debtcollect~on.net
BRANCH OFFICE:
8 Manchester Street
Glen Rock, PA 17327
(717) 235-5014
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFICE
October 5; 2001
Llnda Amsley
S48 2nd Street
Carlisle, PA 170
HCR Manor Care vs Isabelle Dlffenderfer, Et. Al.
Docket No. 2001-05222(CP Cumberland County)
Collection Matter
Dear Ms. Amsley:
We enclose a 1 O-Day Notice pursuant to Rule 237.1 of the Pennsylvania Rules of Civil
Procedure.
SincerelY,
WOLFSON ~ ASSOCIATES, P.C.
Daniel F. Wolfson, Esquire -" ~
DFW/cc
enclosure
IN THE COURT OF COHHON PLEAS OF
CUHBERLAND COUNTY, PENNSYLVANIA
HCR HANOR CARE,
Plaindff
ISABELLE DIFFENDERFER, Individually, and
LINDA AhlSLEY, Individually and on Behalf
of ISABELLE DIFFENDERFER,
Defendants
NO. 01-5222
CIVIL ACTION - LAW
TO: Llnda Amsley
54-8 2nd Street
Carlisle, PA ! 70
DATE OF NOTICE: October 5, 2001
IFIPORTANT NOTICF
YOU AREIN DEFAULT BECAUSE YOU FAILED TO TAKE THE ACTION REQUIRED OF
YOU IN THIS CASE. UNLESS YOU ACT WITHIN TEN (10) DAYS FROFI THE DATE OF THIS
NOTICE; A ]UDGI"IENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND
YOU HAY LOSE YOUR PROPERTY OR OTHER IklPORTANT RIGHTS.
YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING
OFFICE TO FIND OUT WHERE YOU'CAN GET LEGAL HELP.
Court Administrator
Cumberland County Court House.
1 Court House Square, 4'h Floor
Carlisle, Pennsylvania 17013
(717) 240-6200
Daniel F. Wolfson, Esquire
WOLFSON 6: ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 1 7403-2000
Telephone: (717) 846-1252
I.D. # 20617
Attorney for Plaintiff
HCR MANOR CARE,
VS.
PRAEClPE FOR WRIT OF EXECUTION (MONEY JUDGMENT)
P.R.C.P. 3101 to 3149
Plaintiff
..~ ,~D.'-LLF_ D:FF.'-,~;D.'-RFrTM, ............ ~
LINDA AMSLEY, t.d~v,~uo,,y
ISA~,ELLE uu-F,-NDERFER,-
Defendant(s)
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
JUDGMENT NO. 01-5222
PRAECIPE FOR WRIT OF EXECUTION
(MONEY JUDGMENT)
To the Prothonotary: ISSUE WRIT OF EXECUTION IN THE ABOVE MATTER,
(1) Directed to the Sheriff of Cumberland County, Pennsylvania;
(2) against, bc.b¢::~ D;~;'~,,,~fi'..; ',r,~M~uc',',y --.nJ. Linda Amsley, Indl;':,~u---',::¢ and ~.;-, C~;,,~i~ u~
'~I¢~4.~-B~-~m~% 548 2nd St., Carlisle, PA 17013
Defendant(s);
(3) and against, M & T Bank, I W. High St., Carlisle, PA 17013 Garnishee(s);
(4) and indexthis writ ~
(a) ,against, I ...... ,-,;~..~A ,..,; ................
......... ,-for ............. ,,~,,~ Linda Amsley, ,,,,~,.,~..~' ........... "' c- ~^h~'~
Defendant(s) and
(b) against, M & T Bank, Garnishee(s),
as a lis pendens against the real property of the Defendant(s) in the name of the Garnishee(s) as follows: (Specifically
describe property)*
***ADDRESS*** 548 2nd Street, Carlisle, PA 17013
ALL PERSONAL PROPERTY OF ANY NATURE LOCATED WITHIN THE HOUSEHOLD OR IMMEDIATE VICINITY
OF THE DEFENDANT(S) ADDRESS AND ALL OTHER PERSONAL PROPERTY WITHIN THE DOMINION AND
CONTROL OF THE DEFENDANT(S) WHEREVER IT IS LOCATED SHALL BE SUBJECT TO THE LEVY.
You are directed to attach the property of the Defendant(s) not levied upon in the possession of
M & T Bank
1 W. High St.
Carlisle, Pa 17013 Garnishee(s)
All accounts including but not limited to all savings, checking and other accounts, certificates of deposit, notes
receivables, collateral, pledges, documents of title, securities, coupons and safe deposit boxes.
Amount due $11,962.44
Interest from October 31, 2001
At an interest rate of 6% per year
To Be Determined
Total $11,962.44 Plus costs & interest
Dated
Atto irenle~, i &ol2f~)%r~,¢ ~
267 E. Market Street
York, PA 17403
(717)846-1252
,, IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
NO. 01-5222
Plaintiff
VS.
ISABELLE DIFFENDERFER, Individually and
LINDA AMSLEY, Individually and on Behalf of
ISABELLE DIFFENDERFER,
Defendant
CIVIL ACTION-LAW
TO:
INTERROGATORIES TO GARNISHEE IN AID OF EXECUTION
M & T Bank
1 W. High Street
Carlisle, Pa 17013
PURSUANT TO RULE 3114 OF THE RULES OF CIVIL PROCEDURE, THE FOLLOWING
NTERROGATORIES HAVE BEEN SERVED UPON YOUR INSTITUTION. GARNISHEE IS HEREBY
REQUIRED TO ANSWER EACH OF THE FOLLOWING INTERROGATORIES SEPARATELY AND
FULLY. PLEASE COMPLETE THE FOLLOWING INTERROGATORIES TO ASSIST THE
CREDITOR'S
EFFORTS TO SATISFY THE LAWFUL OBLIGATION OF THE ABOVE REFERENCED
DEBTOR(S).
IMPORTANT NOTICES AND INSTRUCTIONS TO GARNISHEE!
A. You are required to file answers to the following interrogatories within twenty (20) days after
service upon you. Failure to do so may result in judgment against you.
B. The term "Defendant(s)" means the individual(s) or entity against whom the Writ of
Execution was issued.
C. "You" means the main office and all branch offices, representatives, employees, and agents
of your organization.
D. By service of the Writ of Execution upon you, all property of the Defendant(s) subject to
attachment which is in your possession custody or control is attached, including all property of the
Defendant(s) which comes nto your possession thereafter.
E. These Interrogatories are considered to be continuing and therefore should be modified or
supplemented as you receive further or additional information.
F. VVhere exact information cannot be furnished, estimated information is to be supplied. When
an estimate is to be used, it should be identified as such, and an explanation should be given as to the
basis on which the estimate is made, and the reason the exact information cannot be furnished.
G. Where knowledge or information in possession of a party is requested, such request
includes knowledge of the party's agents, representatives, and attorneys.
SS#175-03.3320 & 168-36-9058
PLAINTIFF'S INTERROGATORIES TO GARNISHEE
DEFENDANT - ISABELLE DIFFENDERFER AND LINDA AMSLEY
SS# ISABELLE 175-03-3320 & LINDA 168-36-9058
1. DEPOSITORY ACCOUNTS: At the time you were served or at any subsequent time,
state whether or not the Defendant(s) maintains any checking, savings, lines of credit
certificate of deposit's or other depository accounts with your institution. If so, state the
identification numbers of those accounts, and the amount or amounts the Defendant(s) has
in each account. If the Defendant(s) maintains any of these jointly with
give t.heir name and address, any other person or
BAL~!CES PROVIDED
NOT qEFLECT
~JN~ ~,3TED
FtANSACTIONS
lA. DIRECT DEPOSIT ACCOUNTS: Are any of the accounts you have listed above
:tirect dep6~it accounts? If yes, please s!ate the identification numbers of those accounts.
2. SAFE DEPOSIT BOXES: At the time you were served or at any subsequent time,
state'whether or not the Defendant(s) maintains any safe deposit box or boxes. If so nclude
the identification number or other designation of the box or boxes. Include a full description
of the contents and also the amount of cash among those contents. If the Defendant(s)
amdacjrnteasisn. S any of these jointly with any other person or persons give their full name and
/7O
3. PERSONAL PROPERTY: At the time you were served or at an subs ·
_w_h_e,t_h_ ,er,o, r no! D,efe. ndan. t(s) owns' any personal nronert~, ~+ ..... ~Y ...... Rq_u. ent t. lme, st.a. te
?u[l[rOl. I]' SO Incluoe a tull descr' ' -- . · y. .. po.ssesslon uno/or
ocation State also whether or no]p~i~°-n-°-f--all--persOnal .property glvl.n.g tu! value and present
· · L.~ a~ any encumDerances or miens holders, the present
balance of the encumberance. State where and when the enCumberances Or liens was
recorded. If the Defendant(s) owns any personal property jointly with any person or persons
give names and address.
4. O..T. HER ASSETS: At the time you were served or at any subsequent time, did you
know of the existence of any other asset(s) of the Defendant(s) which are not disclosed in the
preceding Interrogatories. If so, please set forth all details concerning those asset.
5. PROPERTY: At the time you were served or at any subsequent time, was there in
your possession, custody, or control or in the joining possession, custody, or control of yourself
and one or more other persons any property of any nature owned solely or in part by any
Defendant(s)? If so, please describe for each Defendant each item of property including its
value.
3..REAL PROPERTY: At the time you were served or at any subsequent time, did you hold
or equitable title to any property of any nature owned solely or in part by the
Jant(s) or in which and Defendant(s) held or claimed anv nterest? If so ·
each Defendant ea ' · - · , describe for
Defendant(s). ch ~tem of property ncludlng ~ts va ue and the interest held by the
7. PROPERTY HELD AS A FIDUCIARY: At the t me you were served or at any
subsequent time, did you hold as a fduciary any property in which an D
int.erest? If so,.please describe for each DeC d~nt(~ tl~ .......... y efen.da.nt(s.) .h. ad .an
va~ue and the interest of Defendant(s). en .... ,-, ._.. -,~ure oT [ne properzy ~nc~ud~ng ~ts
Dc)
8. _TRANSFER OF PROPERTY: At any time before or after you were served, did any
Defendant(s) transfer or deliver any property to you or to any person or place pursuant to your
direction or consent f so, for each [~efendant(s) describe the property transferred or delivered
including the dates of delivery or transfer and state the consideration paid.
9. FEES OUTSTANDING TO GARNISHEF: Are there any attorneys fees or processing fees
chirped byyou against the Defendant(s) oFaccount(s) ofthe Defendant s for the co
of thls Answer If' es outli ( ) mpletion
or the att .... :; ,A.Y,,._, .... .n,e the. ex.a. ct amount.of any fees. due and owing to the garnishee
,,,.=y ~uJ t.~ g~mlsnee Tor me preparation of the Answer.
WOLFSON & ASSOCIATES, P.C.
Dated:
Daniel F. Wolfson EsquireS?'
Attorney .D. # 20617
267 East Market Street
York, PA 17403
(717) 846-1252
MANUFACTURERS AND TRADERS
TRUST COMPANY
Name: Nancy J{A~o~5~mson
Title: Legal Document Analyst
Legal Document Processing
PO Box 844
Buffalo New York 14240
(716) 635-0210
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff,
V.
ISABELLE DIFFENDERFER, Individually and
LINDA AMSLEY, Individually and on Belalf
of ISABELLE DIFFENDERFER
Defendant,
V.
M & T Bank
Garnishee,
NO. 01-5222
CIVIL ACTION-LAW
PRAECIPE TO DISCONTINUE ATTACHMENT EXECUTION
TO THE PROTHONOTARY:
Kindly mark the attachment against the Garnishee, M & T Bank discontinued, upon
payment of costs only.
Respectfully submitted,
WOLFSON & ASSOCIATES, P.C.
Dated:
Daniel F. Wolfson, Esquire
Attorney for Plaintiff
WOLFSON & ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717)846-1252
Attorney I.D. No. 20617