HomeMy WebLinkAbout01-5242 IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
GLADYS BURNS, Individually, and
SHARON DANIELS, Individually and on
Behalf of GLADYS BURNS,
Defendants
NO. O
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 is served, by
entering a written appearance, personally of by attorney, and filing in waiting 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 claim 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 paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita o en persona o pot abogado 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 pot cualquier queja o alivio que es pedido en la peticion de demanda.
Used puede perder dinero o sus propiedades o otros derechos importantes para used.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSlTANCIA LEGAL.
Lawyer Referral Service
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(717) 249-3166
IN THE COURT OF COI~II~ION PLEAS OF
CUI~IBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE,
Plaintiff
GLADYS BURNS, Individually, and
SHARON DANIELS, Individually and on
Behalf of GLADYS BURNS,
Defendants
CIVIL ACTION - LAW
COMPLAINT
AND NOW, this __ day of ,2001, comes the Plaintiff,
HCR lvlanor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law
firm of Wolfson ~ Associates, P.C., and files the within Complaint and in support avers
as follows:
1. Plaintiff, HCR I"lanor 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 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania 17011.
2. Defendant, Gladys Burns, is an adult individual with a last known
address of 6130 1Ss" Avenue, Sacramento, California 95820.
3. Defendant, Sharon Daniels, is an adult individual with a last known
address of 420 Rei[y Street, Harrisburg, Dauphin County, Pennsylvania 17102.
4. That Defendant Sharon Daniels represented himself to be the Power
of Attorney, and therefore the Legal Representative and/or Responsible Party, for
Defendant Gladys Burns. Defendant Sharon Daniels is the daughter of Defendant
Gladys Burns.
5. That on or about April 21, 2000, through on or about November 13,
2000, Defendant Gladys Burns 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 April 21, 2000, Defendant Sharon Daniels executed
an Admission Agreement, on behalf of Defendant Gladys Burns, 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
is attached hereto, incorporated herein, and marked as Exhibit "B".
7. By executing said Admission Agreement, Defendant
Sharon Daniels did assume and accept responsibility for the debt to be incurred by
Defendant Gladys Burns in the event of a breach of the duty to provide payment from
Defendant Gladys Burns' income or resources or for failure to provide information
about the finances of Defendant Gladys Burns requested by Medicaid which resulted
in a denial of Medicaid benefits. 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. That Defendants did not object to the above mentioned
2
Statement of Account submitted by Plaintiff to Defendants.
10. On or about October 24, 2000, the Department of Public Welfare sent
a notice to Defendants outlining additional information which was required to complete
the Medicaid application. A true and correct copy of the relevant portion of this
notice is attached hereto, incorporated herein, and marked as Exhibit "C".
I 1. On or about November 14, 2000, the Department of Public Welfare
forwarded another notice to Defendants which reiterated prior requests made to
Defendants to confirm the financial information of Defendant Gladys Burns. A true
and correct copy of the notice dated November 14, 2000, is attached hereto,
incorporated herein, and marked as Exhibit "D".
12. As of the date of the within Complaint, the balance due, owing and
unpaid on Defendant Gladys Burns' account as a result of said charges is the sum of
Twenty-Five Thousand Nine Hundred Eighty-Four and 37/100 Dollars ($25,984.37).
See Exhibit "A" as previously identified and incorporated herein by reference.
13. 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 Gladys Burns' account balance, all to the damage and detriment of the
Plaintiff.
14. Plaintiff has made numerous requests to Defendant Sharon Daniels, as
the Power of Attorney, and therefore the Legal Representative and/or Responsible
Party, for Defendant Gladys Burns, demanding that the sums due and owing to Plaintiff
be paid, and Defendant Sharon Daniels has ignored her fiduciary obligation to pay
necessary and appropriate bills and obligations for her mother, Defendant Gladys Burns.
15. That Defendant Sharon Daniels violated her duties and responsibilities as
the Power of Attorney, and therefore the Legal Representative and/or Responsible
Party, for Defendant Gladys Burns by not utilizing Defendant Gladys Burns' finances to
pay Plaintiff when she knew or should have known there were outstanding medical care
bills for Defendant Gladys Burns.
16. That the finances of Defendant Gladys Burns rightfully belonged to
Defendant Gladys Burns for her necessary and appropriate medical services and
treatment rendered by Plaintiff to Defendant Sharon Daniels's mother, Defendant
Gladys Burns.
17. Plaintiff has retained the services of the law firm of Wolfson ~
Associates, P.C., in the collection of the amounts due from Defendants.
18. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement,
Plaintiff is entitled to receive and Defendants have agreed to pay all court costs and
reasonable attorney's fees if the account is turned over to an attorney for collection.
See Exhibit "A".
19. As of the filing of this Complaint, Plaintiff has incurred reasonable
attorney's 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
4
proceedings in the amount of thirty percent (30%) of the principal balance due and
owing to the Plaintiff by the Defendants.
20. That the amount of attorney's fees which represents thirty percent
(30%) of the principal amount due and owing is the sum of Seven Thousand Seven
Hundred Ninety-Five and 31/100 Dollars ($7,795.31).
21. Pursuant to Section 1, Paragragh 1.03 of the Admission Agreement,
Plaintiff is entided to receive and Defendants agreed to pay contractual interest at a rate
of eighteen percent (18%) per year on balances not paid within thirty (30) days of
billing.
22. The amount of interest which has accrued from September 4., 2000
is the sum of Four Thousand Five Hundred Twenty-One and 93/100 ($4-,521.93).
23. Any and all conditions precedent to the bringing of this action have
been performed by Plaintiff.
24. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
5
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gladys
Burns, Individually, and Sharon Daniels, Individually and on behalf of Gladys Burns,
in the amount of Twenty-Five Thousand Nine Hundred Eighty-Four and 37/1 O0
Dollars ($25,984.37), reasonable attorney fees in the amount of Seven Thousand
Seven Hundred Ninety-Five and 31/100 Dollars ($7,795.31), contractual interest
in the amount of Four Thousand Five Hundred Twenty-One and 93/100 Dollars
($4,521.93), the costs of this action, and such other relief as the Court deems
proper and just.
Respectfully Submitted,
267 East Market Street
York, PA 17403
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
VERIFICATION
I, Michelle Thureson, Senior Financial Services Consultant for HCR Manor Care, verifi/
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"
HCR.Manor
MANORCARE CAMP HILL 583
1700 MARKET STREET
CAMP HILL, PA 17011
(717)-737-8551
GLADYS M. BURNS
FOR GLADYS M. BURNS
326 EMERALD ST.
HARRISBURG, PA 17110
MEDICAID
PRIVATE
ROOM 204 -B
PIease Return This Potion
With Your Payment
BURNS, GLADYS M
DATE OF
SERVICE I CODE
SERVICE RENDERED
49 06/10/00 11/13/00 02/28/01
CHARGES t CREDITS
02/01/01
BALANCE FORWARD
25,984.37
PAYMENT DUE BY THE 10TH
AMOUNT DUE
25,984.37
S3/29/E1 REBIDEN! LEDGER AS O~ DA~E OR RIRS~ ACTIVITY ~AGN 1
RESIDENT RNHIDNNY RNHIDNNT G/L -- ACCOUNTS RECNIVABLE --
NUMBER TYPE NAME DATE QT¥ ACCOUNT CHARGER CRNGITB BALANCE
MNDICAID BURNS, GLADYB M 16118111 ADM CNTR RNYE~
ROOM 2{4 -B LNVEL 2 11/13/81 DID PRIV PORTI i?{§.i{
*'PRIVATE - APR 18
11611 CABLE RRNYAL {41211{{ -- R4/31/{{ 1 59158411121
**RNDING BALANCI
'*INSURANCE - APR {R
29{{2 PHARMACY LEGEND 14/21/{{ -- 14/38/RN 1 54551217121 177.72
14112 PHYSICAL THERAPY VIGIT 04/24/{0 -- 14/28/{{ 15 5215820712{
14412 PHYSICAL TRNMAPY EVAL 14/24/{{ 2 52151217121 5{.{{
17412 OCCUP THERAPY EVAL {4/24/{{ 3 52551617121 75.{{
17112 OCCUP ?RNRAPY VISIT 14/25/11 -- 14/28/11 11 52551617121 251.{{
**ENDING BALANCE
**MCR CO INB- APR {{
1{218 PT B CO-INS LAB-GLUCONN M
5.10
32{8.36
14/21/{N 2 1.75
11218 PY B CO-ING LAB-GLUCOiE M 14122111 2 1.15
I{2RB PT B CO-INN LAB-OLUCORN M {4/23/{{ 2 t.75
11211 PY U CO-[NB LAB-GLUCORN M 14124/19 2 1.75
11210 PT B CO-ING LAB-GLUCORN M
11211 PY B CO-[NG LAB-GLUCORN M 1412H/11 2 1.7§
11218 PT B CO-INU LAB-GLUCODN M 14/28/RN 2 1.75
REV GLUCORN DEDCUCT 14131/11 14411151111 11,36
"ENDING BALANCE .RI
**MEDICARE B - APR 11
112R8 LAB-GLUCORN MONITORING 14/21/{{ 2 56151Rll12R 8.74
11211 PT B CO-IN8 LAB-GLUCORN M 14121/1{ 2 1.75
11218 LAB-OLUCOBN MONITORING {4/22/{{ 2 5615191112{ 8.74
11218 PY B CO-IRS LAB-GLUCOSE M 14/22/11 2 1.75
11211 LAB-GLUCORN MONITORING {4/23/{{ 2 5615191112{ 8.74
11211 PT B CO-INN LAB-GLUCOSE M 141231RN 2 1.75
11218 LIB-GLUCORN MONITORING {4/24/{{ 2 5615191112{ 8.74
11211 PY B CO-IRS LAB-GLUCOSE M {4/24/{{ 2 1.75
11218 LAB-OLUCORN MONITORING {4/25/{{ 1 5615191112{ 4.37
11218 PY B CO-INN LAD-GLUCORN N 14/25/11 1 .17
1R2{U LAB-GLUCORN MONITORING 14/26/RN 2 5615191112{ 8.74
11218 PY B CO-IN8 LAB-GLUCOHE M 14/2H/11 2 1.75
18218 LAB-GLUCORN MONITORING N4/2R/{{ 2 56151911121 8.74
11218 PT B CO-INB LAB-OLUCORN M 04121111 2 1.75
R~V GLUCORN DNDCUCT {4/3{/{8 14411{5{{{{ 11.36
"RNDING BALANCE 56.88
**PRIVATE ' MAY {{
BAL FWD 'LM' -31- -61- -98~ -121+-
5.0{ 5.NI
PAYMENT 05/1R/1{ 1121NN12{{{ 5.iN
11611 CABLE RENTAL
**ENDING BALANCE 5.{{
**[NGURANCN - MAY {8
B3129IB1
RMNIDRMT RESIDENT RESIDENT
SUMBSR TYPE HAMS
P~HIRMNT LNI~NN AH OF DATE OF FIRST ACTIVITY PAGE 2
G/L -- ACCOONTN RMCNIYABLN --
DATS OT¥ ACCOUN~ CHANGES CRSSITN BALANCE
49
RMDICAID BURMB, GLADYS N
ROOM 284 -B LNYEL
**INSURANCE - RAY SS
SAL FID -LM* -31-
32S8.36
29189 PNMRMACY LNGSWD
29889 PHARMACY LSGNWD
14182 PRYBICAL YRMRAPY VISIT
171B20CCUP THERAPY VISIT
29819 PHARMACY LEGGED
3BBB9 PHARMACY NONLEGNND
B61lB/BB
11/13/88
-60-
14121118 -- lB/19/ll
04/21/00 -- S§/19/SI
lB/Il/Il -- 8§131/88
lB/lllil -- 1§/16/11
If/Il/Il -- 05119188
lB/IS/Il -- S5/19/Bl
ROOM CBANGE AY 219,88 05/81/88 -- S5131180
**ENDING BALRMCN
**MCR CO INH - MAY SS
BAL FWD -LM- -35- -6N-
.BI
18208 PY B CO-INS LAN-GLUCORM M NS/il/NB
10288 PY B CO-INS LAS-GLUCORM M SB/131Ol
18208 PT N CO-IHS LAN-GLUCORM M lB/lB/II
18288 PT B CO-INS LAS-GLUCOSE R 85/18/SI
10208 PT B CO-IHS LAB-GLUCOSE M lB/lOINS
IB2BS PT B CO-IHS LAB-GLUCONS M 85/12/58
18218 PT B CO-INS LAN-GLUCOSE M SS/IS/OB
18288 PT B CO-INS LAB-GLUCONS M 85/17/SS
10208 PT B CO-INS LAB-GLUCOSE M BB/19/SN
18258 PY B CO-INS LAB-GLUCOSE M 85/22/85
18208 PT N CO-IHS LAN-GLUCORM N 85/24/10
10288 PT B CO-IHS LAB-GLUCOSE R B5126108
1B2SN PT B CO-INS LAB-GLUCOSE M S5/29/SS
18258 PT B CO-IN8 LAB-GLUCORM M 85/31/8!
REV 25% GLUC DEDUCT SB/31/SN
**ENDING BALANCE
**NEDICARN B - MAY
BAL FWD -LM- -3N-
5B.RM
ll2NS LAB-GLUCOSE MORI?ORING
IS258 PT B CO-IN8 LRM-GLUCOSS M
10288 LAB-GLUCOSE MONITORING
18258 PY B CO-INN LAB-GLUCOHS M
1N2BS LAB-GLUCOSE MONITORING
18288 PT B CO-INN LAB-GLUCOSE M
18288 LAB-GLUCOSE MONITORING
18258 PT B CO-INS LAB-GLUCOSE M
10258 LAB-GLUCOSE MONITORING
IS288 PT B CO-INS LAB-GLUCOSE M
1N2SS LAB-GLUCONS MONITORING
18255 PT B CO-INN LAS-GLUCOSE M
1S2NS LAB-GLUCOSE MONITORING
-6B- -90-
15111lis
85/S3/J0
85/83/18
lBtlBIIS
I§/11/11
15/1t111
15/12/18
85/12/88
SB/l§lJS
ADM CNYR RMTN~ B.BO
DIS PRIV PORY~ 1755.80
-12S+-
3288.36
I 54551257128 189.01
1 54551287125
80 5215i287128 2iii. II
37 52551607126 925.98
1 54551287125 169.61
1 5495138712E 45.64
31 51351197126 6789.09
-12B+-
.Si
2 1,75
2 1.75
2 1.75
2 1.75
2 1.75
1 .87
2 1.75
2 1,7§
2 1.75
2 1,75
1 .87
2 1.75
2 1.75
2 1.75
14411856S08
-126+-
56.88
2 56151911125 8.74
2
2 56151911125 8.74
2
2 56151911125 8.74
2
2 56151911128 8.74
2 56151911125 8.74
1 56151911125 4.37
I
2 56151911125 8.74
189.61
22.72
1
1.75
1.75
1
1
.87
13157.0t
.83
(AB56)
RNSIDNNT NNSISNNT HSIDNNT GIL -- ACCOUNTS P,{CBIVABLB --
SUNBEN HPE SANE DATE QTY ACCOUNT CBANSES CNEDITS BALANCE
49
NOON 2ii -N LEYEL 2
"NBDICA~ B - NAY EE (COST)
18268 P? B CO-INS LAB-GLUCOSE N 65/15/BE
162E8 LAB-GLUCOSE NOEITONINU 65/17/EE
1Elis PT B CO-INS LAB-GLUCOSE M iS/ll/i6
1{2E6 LAB-GLUCOSE NONITONING 65/19/IE
192N8 PT B CO-INS LAB-GLUCOSE N 15119166
1iZES LAB-GLUCOSE NONIYONING 851221EE
162E8 PT N CO-INS LAB-GLUCOB8 N 15/22/6E
16299 LAB-GLUCOSE MONITONISU 65124/96
16268 PT B CO-INS LAB-GLUCOSE N i5/Z4/iE
1E268 LAB-GLUCOSE NONITONINU E5126/OO
16269 PT B CO-IRS LAB-GLUCOSE N 65/26/66
16266 LAB-GLUCOSE NOB[TONING 65/29/96
16268 PT B CO-INS LAB-GLUCOSE N 65/29/06
16298 LAB-GLUCOSE MONITONIHG 6513116E
18268 PT B CO-IRS LAB-GLUCOSE N E5/31/66
BEV 26% BLOC DEDUCT 15/31/EE
"ENDING BALANCE
HAL IWD -LM- -36- -SE- -90-
5,66
PAYNNNT 96114191
16268 SLOOO GLUCOS8 TEST 96/12/66
16268 BLOOD GLUCOSE TEST E6/14/66
16268 BLOOD GLUCOSE TEST 66/16/66
16268 BLOOD GLUCOS8 TEST E6/19/EE
16298 BLOOD GLUCOSE TSBT 16/2116E
16268 BLOOD GLUCOSE TEST 66/23/66
1SINS BLOOD GLUCOSE TEST 66/26/66
56161 CATS TNAY 66/29/69
NOON CHANGE AT 136.66 66/16/16 -- 66/13/66
NOOK CflANGN AT 142.11 ES/141BE -- 6S/3EIEE
ADV BOOM CHANGE AT 142,98 67/61/66 -- 67/31/66
'*ENDING BALM{CE
"INBUNANCE ' JUN 69
SAC 1~ -LB- -36- -66- -96-
9948.65 32E8.36
14102 PHYSICAL THERAPY VISIT
192i2 BLOOD GLUCOS8 TEST
3669? PBANNACY NON LEGEND
ANCILLARY BRITE OFF
**MCR CO
ES/El/06 -- i6/i9/SJ
96182/96 -- 96169106
66187/60
66/36/09
ROOM CHARGE AT 219.96 ES/El/NO -- ES/OB/ON
"ENDING BALANCE
INS ' 3UN iO
BAL WN~ -GM- -3E- -6E-
.62 ,61
66116108 ABM CNTR RATE: 8.66
11113/66 DIE PRIV PORT, 1785.66
56151911129 8.74
5615191112E 8.74
56151911126 8.74
2
2
2
2
2
2
2
I 56151911126 4.3?
1
2 56151911126 8.74
2
2 56151911129 9.74
2
2 56151911126 6.74
2
14411E59606 22.72
-126+-
5.86
11210802696
2 56151981226 8.74
2 56151981269 8.74
2 561519E129i 9.74
1 56151961296 4.37
2 56151991296 8.74
2 56151991266 8.74
2 56151991289 8.74
1 56154161266 t6.64
4 5135Ei11226 544.99
1? 51356001266 2414.66
13211698EEE 1412,E6
-126+-
13157.61
16 52156267126 456.86
? 56151967126 36.59
1 54951367126 .98
57557597126
9 51356167126 19?l.BE
-12E+-
.83
1.75
1.75
1.75
1.75
.87
1.75
1.75
1.75
176.46
5.60
7426.85
.96
15668.66
831291~] ~SID~OT LED~ AS O~ NAT] O~ ~IRN? ACTIVIH ~AGN 4
RN6IDOa? aE6IDEOT RNSIURN? G/L -- ACCOUNTS aECEIVABL! --
49
~DIONID BURN8, GLAD¥N a 86/IN/88 ADa CNTa aA?E, 8.88
NOON 284 -8 LEVEL 2 11113/88 NIN ~OIV POUT] 1785.88
'aCa CO IR6 - JUN 88 ICON?)
1~281 PT N CO-IDS LAN-GLUCOSE a t61281RN 2 1.75
18288 PT B CO-INS LAB-GLUCORN a 96131188 2 1.75
'RNDING NALANCE
NiL FaD -La- -38- -68- -91- -128+-
113.61 56.88 I79.48
11218 LAB-GLUCORN NONIT00IOG 86128111 2 56151911288 8.74
19288 PT N C0-II8 LAB-GbUCONN a 86128188 2
18288 LAS-GLUCORN aoNITOUIaG 86138/88 2 56]51911288 8.?4
18298 Pt B CO-INS LAB-GbucONi a 8613U88 2
'RNDIE NAL~CE
*'PRIVATE - JUL 88
18281
BAL FaD -La- -38- -61- -98- -128+-
?426.85 7426.85
aLOUD GLUCORN TEST 86128/88 -- 86/30/88 2 56151981288 8.74
BLOOD GLUCOSE TNNt 97/83{98 -- 97131/H 23 56151981288 1H.51
RNV LAST aO UC 17/81111 13211RNNRNN
NOON LOANS1 At 149.H 87/81/98 -- 87/31/98 31 51359881298 4619.81
AUV NOON ONAaoN 181111H -- 88/31/88 13211110110 4619.RN
*'INSUaRNCN - JUL RN
SAL FaD -La- -38- -68- -90- -128+-
245L59 9948.85 3218.38 15688.68
18287 BLOOD GLUCOSN tNSt 84/21/H -- 84/28/8N 13 561519172NN 56.81
11217 BLOOD GLOCORN TESt 95/91/88 -- 85/31/H 2[ 56151997291 113,62
ANCILLARY INIT! OF[ 1?/31/RN 57557517218
'*ENDING 8ALARC!
*INCa CO INS - JUL II
BAL PW~ -La- '38' -68- -90- -128~-
3.59 .82 .11 3.53
EEV PT N CO-IN8 84/31/H 144111511H
RNV ~t B CO-IN8 15/31/89 14411158iH
RNV PT B CO-IN6 86/38/N8 14411858R88
**NNDICARN B - JUL eN
NAL ~ND -La- -38- -68- -98- -120+-
13,~8 113.61 56.88 184.38
10288 LAB-GLUCORN aoNITONING N?/N3/NN 1 56151911288 4.37
18298 LAB-GbUCON! NONITONtNG 971931H -- 87131188 23 56151911298
1N288 LAHLOCORN NoNITOaING 87/05188 2 56151911288 8.74
18298 LAB-GLUCORN aONITON[NG 87187/88 2 56151911298 8.?4
18288 LAB*GLUC08N NONITOBING 87118188 2 56151911288 8.74
11298 LAB-GbUCO61 RONItoNING 97112/H 1 56151911289 4.3?
I8288 bAN-~LUC081 NONITONIaG 87/14/H 2 56151911288 8.?4
18298 LAB*GbUCORN NONItO~ING 87/I?188 2 56151911288 8.?4
1.75
1,75
4482,RN
170.43
.81
3.58
189.51
3.53
184.38
12372,19
15698.68
8312818!
R8~IDMET ~NIDRMT RMSIDEN~
NUMBNN TYPg NAME
RgGIDNRT GgDGgR AG OP DATg OP PIRM? ACTIVITY PAGE 5
GIL -- ACCOUNTS P&¢NIVABL8 --
ROOM 284 -B LNVgL 2
N6118108 A~M CNTE RAT),
11/13/8) DIB PNIV PORT~ 1785,88
**MEDICA~ B - JUL 88 (CONT)
10288 LAB-GLU¢ORM MONITORING
1"288 LAB-GLUCOEE RO)[TONING i?/21/H
18288 LAB'~LUCONE MONITORING
1)288 LAB'GLUCO6) MONITORING
18288 LAB-GLUCOSE MONITORING 87/28/08
10288 LAB-GLUCOBE MONITORING 87/31/))
REV BT B CO-INN 84138188
REV GLUCO8! tJBt 8413)18)
NJV Pt B CO-INN 85/31/1)
REV GLU¢O8! tJ~t 85/31/)8
R)V Bt B CO-INN 861381))
RMV GLUCO6! t)Bt
**RMDING
'*PRIVATE ' AUG 08
8AL FWD -LM- -38- -60- -98-
934?.25 3824.85
REV LASt WD RC 08/81/08
28% CO-PAY 5/18 85/81/88
**NWDIRG DALRMC!
**#8DICAID - AUG )8
38081 PHARMACY NON LEGEND 08/21/00
A#CILLANY WRITE OFF 88/31/88
AT 149.00 08/81/06 -- 88/31/08
OB/II/BP -- 88/31/88
2 561519]12)0
2 56151911288 8.74
2 561519112N8 8.?A
2 56151911288 8.?4
2 561519112)) 8.?4
5?55?511288 .81
1 56151911288 4.3?
14411)D888
56151911128 56.81
14411858088
56151911128 11~.62
144118§)))8
5615191120) 1?.48
-12)+-
12372,1)
132118088N0 4619.08
14411858808 216,29
1 54951382288 .98
5755758228)
31 513500)2208 4619.N)
31 51557{82288 1293,63
ROOM CHANG)
NOON NRIT) OFF
'*NRDINO BALANC8
"188UNANCE - AUG 08
BAL FWD -LR- -30-
2451,59
PAYMENT BC RAJ WED
PAYMENT BLRM CROftS MA; ME
REV 2)) ¢0-~A¥ 5/80
*'ENDING BALANC)
'*NiDICAR) B - AUG 88
BAL FWD -LM- -38-
.81-
'*)WDIRG BALANCN
'*PRIVAY8 ' 8)P 88
BAL FWD -Il(- -38-
216.29 4728.25
CABLE RJNTAL
PRIVATE PORTION
ADV PVT PORTION
-6)- -90- -128+-
9948.65 3208,36 15688.68
88104/80 11218882880 3208,36
88184188 11218882)88 9732.36
85/81/88 1441185#08 216.29
-68- -98- -120+-
-6)- -90- -120+-
3824.85 7969,39
09/81/08 -- 89/3)108 1 591584812N8 5.80
89/81/88-- 09/38/88 38 1785.88
1N/81/88 13211000888 1785.08
.81-
?969.39
3325.37
245t.59
,81-
{AR56}
R~$IDNNT RESIDENT REHIDENT G/L -- ACCOUNTS RECEIVABLE --
NUMBER TYPE NAME DATE OTY ACCOUNT CHARGES CRWDIT8 BALANCE
49
MNDICAID BU~S, GLADYU M
ROOM 2B4 -B LEVEL 2
*'PRIVATE - NAP 00 {CONT)
*'ENDI#G BALANCE
**MEDICAID - HEP 00
BAL FWD -LM- -30- -66- -98-
3325.37
3SNOI PHARMACY NON LEGEND S9/01/00 -- 09/23/N0
51501 IRRIGATION PlNTON TRAY ER/ON/OB
ANCILLARY WRITE OFF 09/30/00
ROOM CHANGE AT 149.00 E9/01/00 -- 09/30/E0
ROOM WRITE OFF
DWDUCY PVT PORT
*'ENDING BALANCE
'*INSURANCE - BEP 00
BAL FWD 'LM' -30-
"ENDING BALAWCN
*'MEDICARE B - HEP OB
BAL FWD -LM-
*tENDING BALANCE
**PRIVATE - OCT 00
BAL FWD -LM-
3575.80
11600 CABLE RENTAL
REV LAST MO PP
PRIVATE ~RTION
ADV PVT PORTION
REV RMCHG 8/00
REV RM CHG 6/08
REV GLUCOSE TEST
REV CATH TRAY
EHT PRIV PORTION
REV GLUCOSE TUT
REV RMCHG 7/00
8UT PHI PORT 7/NB
NET PRI PORT 8/00
**ENDING BALANCE
"MEDICAID - OCT 06
.01-
-30-
216.29
3HEel
388B2
51581
N9/01/00 -- 09138/00
09101/00 -- 09/3B/BO
06/10/N0 ADH CNYR RATE, 0.00
ll/13/BB DIS PRIV PORTu 1785.88
-120+-
3325.37
1 549513N2260 69.19
I 54151502200 4.81
575575022SN 74.NB
38 51350002280 44TN.BO
30 51557002200 1251.98
30 1785.00
-60- -90- -120+-
2451,59 2451,59
-60- -90- -120+-
-60-
4728.25 3024.85
10/31/1l
18/01108
10/01/80 -- 10/31/00
ll/Ol/IJ
0613N/00
OS130/JO
86/30/00
BB/3B/OB
06/30/00
B?/311BO
B7/31/60
BT/31/OJ
08/31/00
1
31
BAL FWD -LM- -30- -60- -00-
1433,18 3325.37
PHARMACY NON LEGEND 06107/88 -- 1B/06100 1
PHARMACY NON LRGEWD 06/07180 I
CATHETER TRAY 10/N4/08 1
ANCILLARY WRITE OFF 18/31/08
ROOM CHARGE
AT 149.08 18/81/00 -- 18131100 31
-120+-
11544.39
59158401208 5.00
13211808888 1785.88
1785.60
13211888008 1785.0B
5135000122S 544.N0
5135BNBI220 2414.08
56151901200 56.81
56154101208 18,84
14411656600 1785.00
56151961260 199.25
51358101206 4619.00
14411050808 1785.0i
14411N58N00 1785.N8
-129+-
475B.47
54951382200 39.42
549513022B8
54151502200 10.80
57557502288 48.52
51350662206 4619.60
11544.39
4758.47
2451.59
.01-
18936.29
{AR56}
RESIDENT RESIDENT RRRIDRNT
NUMBER TYPE NAM8
RESIDENT LEUGRR AS OF DAYR OF FIRHT ACTIVITY PAGE 7
G/L -- ACCOUNTS RECEIVABLE --
DATE ~T¥ ACCOUNT CHARGES CREDIYR BALANCE
49
MEDICAID BURN, GLADYR l
ROOM 294 -B LEVEL 2
'*~DICAID - OCT 99 {CONY)
R~M WRITE OFF
DEDUCT PVT PORT
WDY PRIV POTION
EHY PR[ PORT 7/99
EST PRI PORT 8/69
*'ENDING BALANCE
*'INSURANCE - OCT N6
BAL FWD -LM-
'*ENDING BALANCE
"MEDICARE B - OCT 99
BAL FWD -LM- -39-
192ND LAR-GLUCORE MONITORING
19268 LAB-GLUCOHE MONITORING
16268 LAB-GLUCOSE MONITORING
19298 LAB-GLUCOSE MONITORING
16268 LAN-GLUCOSE MONITORING
19298 LAB-GLUCOSE MONIYORIWD
19268 LAB-GLUCOSE MONITORING
19298 LAB-GLUCOHR MONITORING
16268 LAB-GLUCOSE MONITORING
19268 LAB-SLUCONE MONITORING
19268 LAB-GLUCOSE MONITORING
192E8 LAB-SLUCORE MONITORING
16298 LAB-GLUCOSE MONITORING
19296 LAB-GLUC088 MONITORING
10298 LAB-GLUCOHE MONITORING
19298 LAB-GLUCOHE MONITORING
19268 LAB-GLUCOSE MONITORING
MED B AD8
*'END[NS BALANCE
**PRIVATE - NOV 66
BAL FWD -LM- -39-
8939.99 1786.99
REV LAST MO PP
PRIVATE PORTION
*'ENDING BALANCE
"*MEDICAID - NOV 99
BAL FWD -LM- -39-
1646.39 1433.19
399N9 PBA~ACY NONLEGRND
ANCILLARY WRITE OFF
N8/18169 ADM CNTR RATE: 9.99
11/13/96 DIS PRIV PORY~ 1785.99
1616119N-- 19131199 31 515§7992229 1187.61
16/91199-- 19/31/91 31 1785.69
96139169 14411259929 1785.99
97131/96 14411959999 1786.66
68/31/69 14411956929 1785.96
-68- -96- -122+-
2451.59 2451,59
-SE- -89- -126+-
.91- .91
19/92/N6 2 56151911299 8.74
11/94/99 2 58151911299 8.74
19/96/99 2 56151911299 8.74
19199199 2 58151911266 8.74
19/16/66 2 56151911296 8.74
1E/11/99 2 56151911299 8.74
16/12196 2 58151911269 8.74
19/13/99 2 561§1911299 8.74
16/14/96 2 56151911269 8.74
19/1§/99 2 56151911299 9.74
19/16/29 I 56181911299 4.37
19119/99 2 58151911299 6.74
16/26/9R 1 56151911299 4.37
19/23/99 2 58151911299 8,74
19125199 1 56151911292 4.37
19/27/69 I 56151911299 4.37
16/39/99 2 56151911269 8.74
19/31/99 57557511269
97191199 57557511296 .91
-6N- -96-
216.29
11161169
11/N1/99 -- 11112199
-129+-
10938.29
13211296629
12 1328.28
-66- -99-
1549.37 1785.99-
16166199
11/39/99
-126+-
178§.99- 1949.86
1 54951392296
57557592299 199.51
28.23
1785.69
199.81
1949.86
2451.59
194.87
19479,57
~31291R1
{AR56)
RRHIDEN? RBHIDEEY RE$IDEN?
NUWDWD TYPE NAME
R{HIDEN? LWDGER AH OF DA?R OF FIRHY ACYIVI?Y PAGE 8
G/L -- ACCOU#YH RECEIVABLR --
DAYR OYY ACCOUNY CIANO{H CRWDIYR BALANCE
49
MEDICAID BURNH, GLADY8 M 16111/II
ROOM 214 -B LEVEL 2 11113/10
"MRDICAID ' NOV Ri {CON?)
ROOM CEA{GE AY 149.{{ il/El/ER -- 11/12/00
ROOM WRIYR OFF 11/{I/{{ -- 11/12/{{
DWDUCY PV? PORY 11/01/00 -- 11/12/{{
RM CRG
RII CRG 16/31/1t
RM WIO 16/3l/!1
~WIO 16/31/11
GLUCOSE Y{HY 16/30/11
CATR TRAY 16/31/11
ANC WIO
RM C{G I]/]1/11
RM M/O 17/31/11
ARC W/O 07/31/{{
'*ENDING BALANCE
"I{RURANC{ - NOV {{
BAL FWD -LM' -30- '60' -9l-
ADM CNTR RAYR, {.{0
DIE PRIV PORY~ 1785.11
12 51350002210 1788.0l
12 51557182210 459.72
12 1328.28
51350802220 544.08
5135111222l 2414.18
515570}2220 128,24
5155700222{ 647.{2
561519{22{{ 56,81
561541R2200
575575{22{{ 66.85
5135{{E2200 4619.00
51557{02288 1293.63
5615190220{
575575{2200 189.25
2451,59 2451.59
"RWDtNG BALANCE
"WDDICAR{ B - NOV II
BAL FWD -LM- -30- -60- -90- -120+-
164,67 1i4.97
'*{WDIRG BALANCR
"PRIVAYE - DEC {0
BAL FWD -EM- -30- -60- -96- -128+-
1328.28 7145.80 179{.{l 216.29 10479.57
BC RRTROYO PRIVAYR 1611{/Il 5215820112{ 450.{R
8C R{YRO TO PRIVAY{ 86/89/80 5615191712{ 31.59
06/191ll 513500{112{ 1971.{0
*'ENDING BALANCE
"MEDICAID ' DEC OB
BAL FWD -LM-
-3R- -60- -90- -120+-
1646.39 1433.11 154{.37 1938.11 655?.97
-128+-
2451.59 2451.59
52150217121
561519R7120 30.59
5135{J07121
"REDIMG BALANCR
'*[WDURANC{ - DEC Bi
BAL FWD -LM-
-3{- -6{-
BC RRTRO TO PRIYAYR
BC R{?RO TO PRIVATE
BC R{YRO TO PRIVAYR
"ENDING BALANCE
"MWDICAR{ B - DEC BO
BAS FWD -LM-
1{4.87
**ENDING BALANCE
-66- -RI- -126+-
164.67
6557.97
2451.59
104.87
12931.16
655?.97
104.87
RESIDENT RERIDE#T RESIDENT
G/L -- ACCOURT8 RRCEIVABLR --
DATE OTY RCCO~RT CHARGE8 CREDIT8 BA~RRCE
49 MEDICAID BR~q6, 6hADY8 M
ROOM 2E4 -B LEVEh 2
*'PRIYATE - JAR I1
BAh 8~ -LM-
1328,20
REV ~CHG ADg
REV PET POET AD~
REV PVT PORT AD3
ROOM CHARGE
~OOM CHA~GE
CRTRETER TRAY
ROOM
REV PVT
REV PET
ROOM
'*MEOICAID - JAR E1
BAL 8~ -LM-
-30-
REV ~ CRG ADJ
REV CATE TRAY AD~
REV AEC #10 A~J
REV PVT POET ADJ
REV ~MR/O ADJ
REV AEC M/O AB~
RE¥ PET PORT ADJ
REV EM CEO
REV RE R/O
REV PVT PORTIOR
REV IREIO PISTON TRY
REV AEC W/O
REV ROOM CHARON
REV RMW/O
REV CATH TRAY
REV ARC W/O
REV RM CEO
7145.88
-68-
1646.39
O6/lO/OJ ADM CNTR RATR~ e. OE
I1/1318E DI8 PRIV PORT, 1785.le
-90- -12E+-
llg{.eJ 2667.88 12981.16
J6/3O/RO 5135Ree122E 544.00
86138188 5135IICI228 2414.80
O6/3J/JE 561541812ER IR.E4
86/38/E8 1441185iE18 1765.96
OTl3l/JJ 51356661260 4619.66
97/31/EE 14411858808 1765.98
88/31/09 144llRSEOEE 17RS.ER
EB/31/EE 5135E6912EE 4619.ie
89/3~/E8 14411ESEOEE 1785.RE
EE/3E/EE 54151591298 4.81
89/3R/E8 5135RER12EE 4619.ER
19/31/ER 541515812~E 1E.EE
1E/)l/EE 5135EEE12RE 4619.ER
19/31/E6 1441195EEEE 1765,9i
ll/3R/RE 1441165RERE 1328.28
11/38/86 5135EEE12E6 1847.64
-ER- -12R+-
1433.18 3478.4E 6557.97
96130199 513§RE{222E 2414.08
E6/3R/RR 51557R8222R 128.24
86/38/J0 5155718222E 647,{2
J6/3RIJ6 561519022ER 56.81
EH/38/RE 56154192296 19.E4
66136166 §75575E22R} 66.85
86/36/6E 14411650666 176§,ii
OT/3l/iO 1441185ROJJ 1785.66
E7/31/88 5135EEE22RE 4619.E{
Ol/31/OJ 51557602286 1293.63
ET/31/RE 561519822EE 189.25
ET/31/{E 575575E2288 1E9.25
8B/31/EE 14811E58{{E 1785.EE
}8/31/E} 51557{E228{ 1293.63
EE/3{/EE 541515}22~E 4.81
89/3E/{$ 575575E22EE 4.81
iE/31/E} 54151582288 IR.ER
1E/31/E{ 5135E}E22E{
25984.37
~6ID{NT ~{8IO~N? I~6ID~N!
G/L - A¢COU~T6 ~¢EIVABL~ --
N~DICAID BU~9, GLAR¥6 M
ROOM 2{4 -B LRVIL 2
**MIDICAID - JAR 81 (C09T]
~lV PV~ PO~TI09
~iV ~ N/O
**INDING BALARC9
"{NDIRG BALARCg
BBC ~WD -bM- -3{-
'MRDICA~! B - P{B {1
BAL ~WD -CM-
*'~NDING 9ALARC!
11/13/1~ DIG PgIV ~9~ 1785,~
ll/31/{I 515571~2251 1187.6]
ll/31/ll 1~11858118 1328.28
ll/3e/H 5135mZZfi
ll/3i/{I 51557i822i8 459.72
-6i- -91-
184.87
86/38/i{ 56151911228 56.81
8713118i 56151911221 1i9,25
-68- -9i- -128+-
18~7.68 9989,AR 1~147.73 2598~,37
-68- -98- -12~+-
118.87 166.86
1788,88
2?8.93
25984.37
EXHIBIT "B"
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 fights and responsibilities of the parties
with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center").
Center:
Resident:
Legal Representative:
Admission Date:
Deposit:
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. For the basic services provided for 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 rn~intained at the Center's business office for review during
regular business hours. Ancillary Charges shall be included in the Rasident's statement for the
succeeding month, and are payable in full, along with the Room and Board Rate by the tenth
(10th) day of the month.
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 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 Proerams. 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: L-'~vledicare, ~-//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
respons~le 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 fi.om 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 Pa¥ors and Managed Care Organizations. Ifa Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Orga~i?ution ("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
will bill the Resident's third party payor as a service, but the Resident remains liable for charges
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 that
they are responsible for paying the Center for items and services provided during the stay at the
Center and during which time the Resident bas not been determined to be eligible for Medicaid.
The Resident and/or Legal Representative agree to notify the Center promptly if there is
insufficient income or assets to meet the financial obligations to the Center or to make prompt
application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify
the Center in writing when application to Medicaid is made. The Resident and/or Legal
Representative agree to cooperate fully in applying for Medicaid and in the eligibility
determination process. If the Resident is no longer able to pay for care at the Center and the
Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to
discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook
and State and federal laws.
1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal
Representative to notify the Center and to provide any needed information regarding all third
party payors or governmental coverages on admission and throughout the stay including copies of
insurance cards, identification or verification of elig~ility and coverage information.
The Resident and/or Legal Representative agree to provide the Center with notice
within five (5) days 6f 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 respons~le
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 ~n for Benefits. It shall be the respons~ility 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
governmental program third party payor or managed care organization with which the Center is
under contract.
1.10 Primary Responsibility for Payment. Except for payments for services covered
under governmental programs or provider agreements, the Resident shall rem primarily 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, medications,
and other care and services which may be delivered by the Center or its subcontractors. This
Agreement serves as a written notice, that the Center has notified the Resident and/or Legal
Representative that services provided at the Center may not be covered by a governmental payor,
th/rd party payor or managed care organ/zation. The Resident and/or Legal Representative agrees
to be responsible for non-covered services. A price list of services is always available at the
business office upon request.
1.I 1 Personal Physician. The Resident has the right to choose a personal physician,
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 ofhisgner personal physician. If the Resident changes physicians at any time
after admission, the Resident and/or Legal Representative must immediately notif3, the Center of
the new physician's name. If the physician chosen by the Resident fails to provide needed
coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have
the right to call another physician to attend the Resident and the fees charged by such physician
shall be borne by the Resident.
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.
H. RIGHTS AND RESPONSIBILITY OF THE LEGAL REPRESENTATIVE
2.01 Legal AuthoriW. The Legal Representative hereby represents that he/she has legal
access to the Reaident'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 firom 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 l~om 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 elig~le for Medicaid, the Resident and/or Legal Representative must
notify the Center in writing when the application for Medicaid is made. If the Legal
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.
4
2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the
Legal Representative shall provide such information about the Resident's finances as Medicaid
representative shall require for continued coverage of the Resident and be personally responsible
for any charges denied the Center due to any lack of cooperation.
2.06 Accentance U~on 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 ns requested, then the
Center is authorized and empowered to remove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Legal Representative, if
the Resident's 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 and Standard Services. As part of the Room and Board Rate, the Center
shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and
bedding, general nursing care, personal assessment, social services, and such other personal
services as may be required pursuant to the plan of care prepared by the Res!dent'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 at, er 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 Representative
hereby consents to the release of his/her medical records to the following persons: Center
personnel, attending physicians and consultants; and person, firm, government entity, third party
payor or managed care organization responsible for all or any party of the payment or
reimbursement of the Resident's charges, including any utili?ation review or quality assurance
reviews or payment audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
insurance carrier; and any person authorized by law to review the medical records.
4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this
Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care
and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident,
including but not limited to, assistance with bathing, hygiene, 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 fi.om 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 Photo a~h. 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 staffto identify the Resident.
4.04 Notice of Services, Policies and Additional Information. The Resident and/or
Legal Representativee 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 oppommity to ask questions and questions have
been answered satisfactorily.
Authorization for Release or Review of Ivledical Information.
Attachment C.
See
b. Authorization for Payment of Benefits. See Attachment D.
c. Social Security Administration Appointment. See Attachment E.
d. SNF Medicare Determination Notice. See Attachment F.
e. Medicare Secondary Payor Questionnaire. See Attachment G.
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
Authorization and any other related documents. See Attachment H-I and
H-2.
The Center's policy and procedure on bedholds, election of bedholds and
readmission. See Attachment I (Center Supplement).
Social Service Agencies and Advocacy Groups addresses and phone
numbers. See Attachment I (Center Supplement).
Name, address and phone number of Ombudsman. See Attachment I
(Center Supplement).
The location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state survey and certification
agency, the state licensure office, the state ombudsman program, the
protection and advocacy network and the Medicaid l~aud control unit. See
Attachment I (Center Supplement).
The name, specialty and way of contacting the attending physician, medical
director and other physicians who serve the Center. See Attachment I
(Center Supplement).
Procedures, name, address and phone number on how to file a complaint
w/th the state survey and certification agency concerning resident abuse,
neglect, mistreatment and misappropriation of property. See Attachment I
(Center Supplement).
rra The Resident Handbook. See Attachment J.
n. Resident/Patient Rights. See Attachment K.
Oo
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.
po
Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Cafe's
Limited Treatment Practices and "No Cardiopulmonary Resuscitation
Orders" and a copy of the State summary of its laws governing the
Resident's fight 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.
U.
W.
X.
y.
Z.
ASM Form. See attachment P.
See Attachment Q.
See Attachment R.
See Attachment S.
See Attachment T.
See Attachment U.
See Attachment V.
See Attachment W.
4.05 ~s__~mment 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 th~ Center and any holder of medical or other information to
release such information to the Health Care Financing Admires' tration and its agents and to third
party payors any infofiration 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 seven (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 speclaliTed 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 fi:om any and all claims, demands, suit and actions made against the Center by any
person resulting fi'om any damage or injury caused by the Resident to any person or the property
of any person or entity (including the Center), except in the case of negligence of the Center's
employees and agents.
4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid
or unenforceable as a result of a change in State or Federal law will not invalidate the remaining
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 bet~.'
Date:
Date:
EXHIBIT "C"
~,,~,6~.8-95 NOTICE TO APPLICANT DEPARTMENT OF PUBLIC WELFARE
CUMBERLAND COUNTY ASSISTANCE OFFICE
33 WESTMINSTER DR
e .~ · ~ .- "-' J · '* " PO BOX 599
........... ' CARLISLE PA 17013-0599
' NOT 1~800-269-0173 (717) 240'2700
BENEFIT ~u~le~ EUGIBLE PENDING
ASSISTANCE After tpa first ctmck which may be a special amount you will receive $
[] CHECK [] Twice a Month [] Orme a Month [] In the Mail [] At the Bank
[~SfiDICAL
StSTANCE ~ [] You have a patient pay liabilily of $
for the perio~l beginning and ending __ [] Effective Date
FOOD You will receive $ lor the month{s) of then y~u will receive food stamps in the amount of $
~] ?,~MPS a month from to [] ~n the Mail [] At the Bank
~URSING HOME CARE~// Level of care authorized you are expected to pay $ a month toward your care.
Since your application is~30 day ~,ro?essing, time (55 PA code 125.84(e)) and the
verification of ~ I I/71oo is still to
be presented. We are extending the application proc'essing time to 45 days. Please
remember to provide all pending on the attached notice as soon as possible or the application
will be discontinued and vou will need to reaoolv.
Name
TOTAL GROS9 MONTHLY INCOME
GRO ~S8 MONTHLY DEPENDENT CARE COSTS
GROSS MEDICAL COSTS
Name
UNEARNEDINCOME
Telephone
Electdc
JCO I RECORD NUMBER CAT CTR DIG DIST
L_
Date Telephone Number
LEGAL SERVICES, INC.
8 IRVINE ROW
CARUSLE PA 17013.3019
717-24.3-9400 717-766-8475
CLIENT COPY
EXHIBIT "D"
,~Fs~ ~gs NOTICE TO APPLICANT DEPARTMENTOFPUBLICWELFARE
CUMBERLAND COUNTY ASSISTANCE OFFICE
33 WESTMINSTER DR
~ ~ . ._~, e = = POBOX599
BENEFIT ELIGIBLE NOT )ENDiN~ 1-800-269-0173 (717) 240-2700
~ CHE~ ~ Twice a Month ~ Once a Montl~ ~ [n the Mail ~ At the Bank
me FOEL~NGPERSoNS ARE iNCLUDED
I
~ ~ AS~ISTA'NCE CHECK . · N~rca:~r ~f P~rs~ns [~.
EARNED INCOME Name GE,~ RD NS SE DM~NcToHMLEY
~ 7////~ * //////~
· 7///// * //////~
GROSS MONTHLY
GROSS MONTHLY Name UN~RNED INCOME
Name UNEARNED INCOME
~ ,'//?~/, * 7////,
~ ~////~ ~ //////~
TOTAL GROSS MONTHLY INCOME $ TOTAL GROSS MONTHLY iNCOME $$
GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MONTHLY DEPENDENT CARE COSTS
~ROSS MEDICAL COSTS $ ,, ,
relepho,e Water/Sewage ~ MEDICAL ~sISTANCE NUmber of Pe~
GROSS MONTHLY
Elect r~c Garbage/Trash Name EARNED INCOME
Gas Utility installation $ /J/J/J/
o,, Ot,,r * ~?////~
GROSS MONTHLY
RENT/MORTGAGE $ ////~ Name UNEARNED INCOME
iNSURANCE COST ON HOME $ / / ~ / ~ $~/?~ ~/ /
TOTAL SHELTER COST $ $ ////,/~
· ThehoUsehe/dmay switch baleen the actual uHfi~ costs and the TOTAL GROSS MONTHLY INCOME $
standard Utlli~ allowance at the time of reapplication and one NET MONTHLY INCOME/NET SEMI-ANNUAL INCOME $
additional 8me during each ~elVe-month period, iNCOME LIMIT $
RECORD NUMBER 7-~ CTR DIG DIST
L_ ·
you do not understand our decision or have any questions, contac/your worker.
Oate, Telephone Number
LEGAL HELP IS AVAILABLE AT
LEGAL SERVICES, INC.
8 IRViNE ROW
CARLISLE PA 17013-3019
717-243-9400 717-766-8475
IN THE COURT OF COFIMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR hIANOR CARE,
Plaintiff
VS.
GLADYS BURNS, Individually, and
SHARON DANIELS, Individually and on
Behalf of GLADYS BURNS,
Defendants
NO. 01-5242
CIVIL ACTION - LAW
..CERTIFICATE OF SERVICE
I hereby certify that I have served the foregoing "Court of Common Pleas
Complaint" upon Defendant, Gladys Burns, via First Class United States mail and Certified
mail receipt number 7099 3220 0008 3197 4309 as follows:
Gladys Burns
6130 15~h Avenue
Sacramento, CA 95820
Date:
Respectfully submitted,
Daniel F. Wolfson, Esquire ~
WOLFSON ~ ASSOCIATES, P.C.
267 East IHarket Street
York, PA 17403
(717) 846-1252
ID No. 20617
Attorney for HCR Manor Care
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR HANOR CARE,
Plaintiff
VS.
GLADYS BURNS, Individually, and
SHARON DANIELS, Individually and on
Behalf of GLADYS BURNS,
Defendants
NO. 01-5242
CIVIL ACTION - LAW
PROOF OF SERVICE BY MAIL
I, Daniel F. Wolfson, Esquire, do hereby certify that on or about September 4, 2001,
a copy of the "Court of Common Pleas Complaint" filed in the above referenced matter was
served upon defendant, Gladys Burns, via certified mail, return receipt 7099 3220 0008
3197 4309, requested as follows:
Dated:
GLADYS BURNS
6130 15TM AVENUE
SACRAMENTO, CA 95820
WOLFSON 6t ASSOCIATES, P.C.
267 East Market Street
York, Pennsylvania 17403
Telephone No. (717) 846-1252
I.D. No. 206 ! 7
Attorney for Plaintiff
SENDER: I also wish to receive the
a Complofe items.1 and/or 2 f.o~r addllional services, following services (for an
· Complete items~, 4a. end 4~. extra fee):
· prfot~our name and address on the reverse of this form so that we can return this 1. [] Addressee's Address
i· A~tta~c~t~is iorm to the ,ro~, of the rnallpie~, or o~ the back, space does not ,~ rm == * ',-,=~1 I'~,iv.rv
trait. · ece below the article number.
~_ ?h~ eR ;~m~r~ ReCeipt Pwit'fR=owU~tto~v~ho°~m~t ~ em~idd~ e was betivered and the date Consult postmaster for fee.
~e[ivered. - 4a A~tice ~umber
3. Article Addresseo to: '
7099 220 0008 3197 4309
GLAD~ $ BIIR.~S 4b. Service Type
6130 15't"a A1/Et~1tIE [] Registere~,.~,~ ~_. Certthed
SAC~.A-.'~NTO, CA 95820 [] Expre~t~l~i~ll ~. r..J Insured
[] []cod
6. $ignst~e: (_Addressee o~gent)/,.~
=,, tas~-~-~-o~ Domestic Return Receipt
~-~ PS Form 3811, December 1994
JPostage & Fees Paid
/us~
l, Pe m t" .
· Print your name, address, and ZIP Code in this box ·
~OLFSON & ASSOCIATES, P.C.
267 EAST MAP. KET STP, EET
YORK, PA 17403
i: SEP 17 ~001 ill.!
ATTN: CRIS ~
I-,111,,,I,1,,111-,,,11,,,i,111,,.,I,i,,I,1,11.1,,,1o11,,i
SHERIFF'S RETURN -
CASE NO: 2001-05242 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
BURNS GLADYS ET AL
Thomas Kline
OUT OF COUNTY
mo
duly sworn according to law, says, that he made
and inquiry for the within named DEFENDANT
DANIELS SHARON
Sheriff or Deputy Sheriff who being
a diligent search and
to wit:
but was unable to locate Her in his bailiwick.
deputized the sheriff of DAUPHIN County,
serve the within COMPLAINT & NOTICE
He therefore
Pennsylvania,
to
On October 31st , 2001 , this office was in receipt of the
attached return from DAUPHIN
Sheriff's Costs:
Docketing
Out of County
Surcharge
Dep Dauphin Co
18.00
9.00
10.00
25.50
.00
62.50
10/31/2001
WOLFSON & ASSOC
Sheriff of Cumberland County
Sworn and subscribed to before me
this ~ day
A.D.
Prothonotar~ '
Mary Jane Snyder
Real Estate Deputy
William T. Tully
Solicitor
Dauphin County
Harrisburg, Pennsylvania 17101
ph: (717) 255-2660 fax: (717) 255-2889
Jack Lotwick
Sheriff
J. Daniel Basile
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
Commonwealth of Pennsylvania
County of Dauphin
HCRMANOR CARE
vs
:
DANIELS SHARON ON BEHALF OF GLAYS BURN
Sheriff's Return
No. 2670-T - - -2001
OTHER COUNTY NO. 01-5242
I, Jack Lotwick, Sheriff of the County of Dauphin, State of
Pennsylvania, do hereby certify and return, that I made diligent
search and inquiry for DANIELS SHARON ON BEHALF OF GLAYS BURNS
the DEFENDANT named in the within NOTICE & COMPLAINT
and that I am unable to find him/her in the County of Dauphin, and
therefore return same NOT FOUleD, October 23, 2001
NOTICE & COMPLAINT EXPIRED. DEFENDANT MOVED FROM 420 REILY ST., HBG., PA
17102 TO 321 EMERALD ST., HBG., PA 17110.
Sworn and subscribed to
before me this 23RD day of OCTOBER, 2001
PROTHONOTARY
So Answers,
Sheriff of Dauphin County, Pa.
By
Deputy Sheriff
Sheriff's Co$ts:$50.00 PD 09/21/2001
RCPT NO 154368
Iff The Court of Common Pleas of Cumberland County, Pennsylvania
HCR Manor Care
VS.
Gladys Burns et al
SERVE: Sharon Daniels, individually MO. 01 5242 civil
and on behalf of Gladys Burns
]X~ow, Septemberl0, 2001
hereby deputize the Sheriff of
, I, SHERIFF OF CUMBERLAND COUNT'Y, PA, do
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff.
Sheriff of Cumberland County, PA
Affidavit of Service
Now, ,20 , at o'clock ~ M. served the
within
upon
at
by handing to
a
and madeknownto
copy of the original
So answers,
the contents thereof.
Sheriff of County, PA
Sworn and subscribed before
me this day of
,20
COSTS
SERVICE
MILEAGE
AFFIDAVIT