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Home My WebLink About02-1334IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff PATRICIA CASTILLO, Individually, and on Behalf of ]ames ]. Lackey, Deceased, Defendant NO. OA- /23'/ CIVIL ACTION - LAW NOTICE You have been sued Jn 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 usted quaere defensas de esas demandas expuestas en las paginas, siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notifiation. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a last demandas en contra de su persona. Se avisado que si used no se deflenda, 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 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 SERVIClO VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTEA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUlR ASSITANCIA LEGAL. Lawyer Referral Service Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 IN THE COURT OF COHHON PLEAS OF CUHBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, Plaintiff VS. : CIVIL ACTION - LAW PATRICIA CASTILLO, Individually, : and on Behalf of : James J. Lackey, Deceased, : Defendant : COHPLAINT AND NOW, this J~ day of J/J/[(~f ~(g~ , 2002, comes the Plaintiff, HCR Hanor Care, by and through its a~corney, Amy F. Wolfson, Esquire, and the law firm of Wolfson E 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 place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Patricia Castillo, is an adult individual with a last known address of 501 Criswell Drive, Boiling Sprin~s, Cumberland County, Pennsylvania 17013. 3. Defendant was appointed as the lawful Attorney-in-Fact for her father, ]ames ]. Lackey pursuant to a Power of Attorney dated April 5, 1988. A true and correct copy of the Power of Attorney is attached hereto, incorporated herein, and marked as Exhibit "A". 4. That on or about August 8, 1998, Defendant signed an Admission Agreement, 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'. 5. That on or about August 8, 1998 through February 17, 2001, Defendant's father, ]ames ]. Lackey, deceased, was a health care resident of Plaintiff, where he received various necessary residential health care services and treatment by Plaintiff. A true and correct copy of the itemization of said services is attached hereto, incorporated herein, and marked as Exhibit 'B". 6. That ]ames ]. Lackey died while a resident at Plaintiff's healthcare facility. 7. That Defendant signed the Admission Agreement with Plaintiff in order for her father to receive Plaintiff's healthcare treatment and services. 8. That Defendant appointed herself to be the responsible Party for her father. See Exhibit "B', the page titled Exhibit A - Responsible Party Appointment, previously identified and incorporated herein by reference. That Defendant agreed to abide by the conditions and terms of the Admission See Exhibit "B', the page titled Conditions, previously identified and Agreement. incorporated herein. I 0. That pursuant to the Power of Attorney appointment, the Defendant was given full responsibility for applying for ]ames ]. Lackey's admission to nursing homes, paying his bills, managing his affairs, and doing every act that he would do, if capable. See Exhibit "A', previously identified and incorporated herein. 11. That pursuant to the Admission Agreement, the Defendant agreed to utilize the financial resources and income of James J. Lackey to pay the Plaintiff for the debt incurred, if any, while Mr. Lackey was a resident in Plaintiff's facility. See Exhibit "B", the page titled Conditions, Paragraph 1, previously identified and incorporated herein by reference. 12.. That pursuant to the Admission Agreement, the Defendant agreed not to dissipate the financial resources and income of James J. Lackey. See Exhibit "B", the page titled Conditions, at Paragraph 4, previously identified and incorporated herein by reference. 13. That James J. Lackey was entitled to and receiving pension benefits at the time of his admission with the Plaintiff's healthcare facility. 14. That Defendant caused the pension benefits to be terminated as of Hay 1999 when she failed to remit the voluntary self contribution required to continue the coverage. A true and correct copy of the Plumbers and Pipefitters Local No. 52.0 Benefit Fund correspondence, dated June 21, 1999, is attached hereto, incorporated herein and marked as Exhibit "C". 15. That Defendant requested the pension benefits be reinstated and paid the overdue voluntary self contribution for the months outstanding and requested the pension benefits be sent to her. A true and correct copy of the Plumbers and Pipefitters Local No. 52.0 Benefit Fund correspondence, dated July 2.4, 2001, is attached hereto, incorporated herein and marked as Exhibit "D'~. 16. That Defendant received the pension benefits from the Plumbers and Pipefitters Local No. 520 Benefit Fund which rightfully belonged to ]ames ]. Lackey and were available to pay the Plaintiff for the services provided to Mr. Lackey while he was a resident with the Plaintiff's healthcare facility but Defendant did not forward the benefits to Plaintiff for payment oi~ Mr. Lackey's account balance. 17. That Plaintiff acted reasonably when it relied on Defendant's representations with regard to the Admission Agreement and the terms and conditions contained therein, and her representation that the Plaintiff would be paid from the financial resources of ]ames ]. Lackey when they accepted Mr. Lackey into the facility. 18. That Plaintiff submitted to Defendant a copy of the itemization of services accurately showing all debits and credits for transactions with the Plaintiff. A true and correct copy of the itemized statement of the account balance is attached hereto, incorporated herein and marked as Exhibit ~'E". ! 9. That Defendant did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendant. 2.0. That Defendant did not pay the Plaintiff for their health care services in direct violation of the terms and conditions of the Admission Agreement entered into with the Plaintiff. 21. That Defendant willfully and knowingly violated the Admission Agreement when she failed to remit full payment to Plaintiff for the services her father received as a resident at Plaintiff's health care facility. 22. Defendant knew or reasonably should have known that her father would incur health care expenses while a resident at Plaintiff's facility and that such expenses would be his personal debt obligation. 23. Defendant knew or reasonably should have known that if she failed to pursue and cooperate with the Department of Public Welfare in securing any available public assistance benefits her father would incur personal debt for the services Plaintiff provided. See Exhibit "B", previously identified and incorporated herein. 24. That Defendant did not identify nor represent to Plaintiff that another person would be the Responsible Party under the Admission Agreement and therefore it was solely incumbent on Defendant to act on behalf of James J. Lackey to secure financial assistance and to remit payment from his income and financial resources. See Exhibit "B" previously identified and incorporated herein by reference. 25. That Defendant further violated her contractual duties and responsibilities under the Admission Agreement she signed with the Plaintiff by not utilizing her father's financial resources to pay the Plaintiffwhen she knew or should have known that there were outstanding health care charges due and owing to Plaintiff. 26. That Defendant further violated her fiduciary duties and responsibilities under the Power of Attorney, during the life of James ]. Lackey, now deceased, when she did not utilize her father's financial resources to pay the Plaintiff when she knew or should have known that there were outstanding health care charges due and owing to Plaintiff. 27. That Defendant convened the financial resources of James ]. Lackey during his lifetime as his Attorney-in-Fact in direct violation of the Admission Agreement she executed on his behalf. 28. Despite Plaintiff's reasonable and repeated demands for payment, Defendant has failed, refused, and continues to refuse to pay all sums due and owing on Defendant's account balance, all to the damage and detriment of Plaintiff. 29. As of the date of the within Complaint, the balance due and owing and unpaid on Defendant's account as a result of said charges is the sum of NINE THOUSAND SIX HUNDRED SEVENTY and 50/100 ($9,670.50) Dollars. See Exhibit "E" previously identified and incorporated herein by reference. 30. Plaintiff has retained the services of the law firm of Wolfson 6: Associates, P.C., in the collection of the amounts due from the Defendant. 31. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson 6: Associates, P.C., in the collection of the amounts due and owing by Defendant, incident to the within action, and Plaintiff shall continue to incur 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 Defendant. 32. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of TWO THOUSAND NINE HUNDRED ONE and 15/100 Dollars ($2,901 .I 5). 6 33. Pursuant to Paragraph Eight (8) of the Fee Schedule which was attached to the Admission Agreement, Plaintiff is entitled to receive and Defendant has agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" previously identified and incorporated herein. 34. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance from July 30, 1999, is the sum of FOUR THOUSAND FIVE HUNDRED THIRTY-ONE and 50/100 Dollars ($4,531.50). 35. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 36. The amount in controversy is within the jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgement in favor of Plaintiff and against Defendant, PATRICIA CASTILLO, Individually and on Behalf of ]ames ]. Lackey, Deceased, in the amount of NINE THOUSAND SIX HUNDRED SEVENTY and 50/100 Dollars(S9,670.50), reasonable attorneys fees in the amount of TWO THOUSAND NINE HUNDRED ONE and 15/1 O0 Dollars ($2,901.15), contractual interest in the amount of FOUR THOUSAND FIVE HUNDRED THIRTY-ONE and 50/1 O0 Dollars ($4,531.50), the costs of this action, and such other relief as the Court deems proper and just. Respectfully submitted, Am~ F. W.~lfson, Esqu~ WOLFSO'N 6: ASSOCIATES, P.C. 267 East Market Street York, PA ! 7403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff 8 VERIFICATION !, lflichelle Thureson, being the Senior Financial Consultant for HCR Manor Care, verify that the statements made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. 1 understand that false statements herein are made subject to the penalties of ! 8 Pa. C.S. Secdon 4904, relating to unsworn falsification to authorities. HCR Manor Care hlicheJle Thureson Senior Financial Services Consultant EXHIBIT "A" FEB 13 2002 16:05 FR MANOR CARE-CARLISLE 717 249 0647 TO 8481146 P.08/20 POWER OF ATTORNEY KNOW ALL HEN BY THESE PRESENTS: That I, JAMES J. LACKEY, residing at 3268 ~ast Harrisburg Pike, Middletown, Dauphin County, Penn~ylvania, have made, constituted and appointed, and by these presents do make, cOnStitute and appoint my daughte=, PATRICIA A. CAST~LtO, my true and lawful attorney to act as ~ollows, that is to say= GIVING AND GRANTING unto my said attorney full Dower to buy, receive, lease, accept, or otherwise acquire; to sell, convey, mortgage, hypothecate, pledge, quitolaim, or otherwise encumber or dispose of; to contract or agree, for the acquisition, disposal or encumbrance of any property whatsoever and wheresoever situ- ate, be it real, personal or mixed, or any custody, possession, interest, or right thereon or pertaining thereto, upon such terms as my said attorney shall think proper, that is to say: 1. To take, hold, possess, invest, lease, or let, or other- wise manage any or all of my real, personal or mixed property, or any interest therein or pertaining thereto; to eject, remOVe or relieve tenants or other persons from, and recover possession of, such property by all lawful means; and to maintain, protect, pre- serve, insure, remove, store, transport, repair, rebuild, modify, or improve the same or any part thereof; -1- FEB 15 2002 16:05 FR MANOR CRRE-CARLISLE ?17 249 064? TO 8481146 P.OPx20 2. To make, do and transact all and avery kind of business of whatever kind or nature, including the receipt, recovery, col- lection, payment, compromise, settlement, and adjustment of all accounts, legacies, bequests, interests, dividends, annuities, Claims, damands, debts, taxes, and obligations, which may now or hereafter be due, owing, or payable by ma or to me~ particularly to attend the sattlemant of any sales of real estate ~ have made and to accept the proceeds therefrom and approve the distribution made therefrom; 3. To make, endorse, accept, receive, sign, seal execute, acknowledge, and deliver deeds, assignments, agreements, certifi- cates, hypothecations, checks, notes, bonds, vouchers, receipts, releases, and such other instruments in writing of whatever kind and nature, as may be necessary, convenient, or proper; 4. To make deposits or investments 'in, or withdrawals ~rom, any account, holding, or interest which ! may now or hereafter have, or be entitled to, in any banking, trust, or investment institution, including 9ostal ~avings depository offices, credit unions, savings and loan associations, and similar institutions; to exercise any right, option or privilege pertaining thereto; and to open or establish accounts, holdings, Or interests of whatever kind or nature, with any such institution in my name or -2- FEB 13 2002 16:06 FR MANOR CARE-CARLISLE 717 249 064? TO 8481146 P.10x20 in my said attorney's name or in her and my name jointly, either with or without right of survivorship and to enter any safe deposit box which I possess in my name at any bank or savings and loan institution; 5. To institute, prosecute, defend, compromise, arbitrate, and dispose of legal, equitable, or administrative hearings, actions, suits, attachments, arrests, distresses or other pro- ceedings, Or otherwise engage in litigation in connection with the premises; 6. This Power of Attorney shall not be affected by the dis- ability, incapacity, or incompetence of myself, since it is my desire that she have the power to act on my behalf should I become disabled, incapacitated, or incompetent. GIVING AND GRANTING unto my said attorney full power and authority to do and perform all and every act, deed, matter, and thing whatsoever in and about my estate, property, and affairs as fully and effectually to all intents and purposes as I might or could do in my own proper person if personally present, the above speclally enumerated powers being in aid and exemplification of the full, complete, and general power herein granted and not in limitation or definition thereof; and hereby ratifying all that my said attorney shall lawfully do or cause to be done by virtue of these presents. -3- FEB 13 2002 1B:OG FR MANOR CARE-CARLISLE 717 249 0G47 TO 848114G P.11/~0 And I hereby declare that any act or thing lawfully done hereunder by my said attorney shall be b~ndlng On myself, and my heirs, legal and personal representatives, and assigns; whether the same shall have been done before or after my death, or other revocation of this instrument, unless and until reliable intelli- gence or notice thereof shall have been ~ecelved by my said attorney. IN WITNESS WHEREOF, I, JAMES J. LACKEY, have hereunto set my hand and seal this ~- ' WITNESS= day of 1988. (SEAL) FEB 13 2002 16:00 FR MANOR CARE-CARLISLE ?17 249 0B47 TO 8481146 P.12x20 ACKNOWLEDG~4ENT COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF DAUPHI~ : On this, the ~- day of ~ , 1988, before me, a Notary Public, the undersigned officer, personally apgeared JAMES J. LACKEY, known to me (or satisfactorily pro~en) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same flor the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and o£[icial seal. EXHIBIT 'B' -C': i ADMISSION AGREEMENT, i · Ma_ao C_a:re oNTRACT BETWEEN PATIENT/RESIDENT :AND FACILITY~ ' [-{¢alth $¢r¥ices , -~u,e ^n~A~,~ ~EI:MENT (the "Agreement ') is entered into this ~ day of ~J'~ ~"~'~-,'"-~[';~"",'~'~)' ~_'(~] ,between Nano]:Ca~ce [-Zea:L'ch Se]:v~.ces (tbe"Faqi[Jty"),and J~'~-~'~.JZ. tubl (the "Patient/Resident"), and/or ~O0,-~Y'I'~,~.I'~" (the "Responsible Pa~"). As used herein, the term "Patient/Resident" shall also mean the Responsible Party, if any. The parties agree as follows: 1 Commencement. This Agreement shall begin on the date of admission of the Patient/Resident to the Facility. 2. Termination of Agreement, Discharge and Transfer. a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by g~ving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible for payment of ail 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 (i) before the attending physician discharges the Patient/Resident, or (ii) against medical advice, the Patie. nt/Resident and Responsible Party agree to assume all responsibility for injury or ha~'m 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- ient/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/Resident'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 discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents 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 shall 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 all expenses of discharge or transfer. 5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to release all or any part of his/her medical/health records to the Facility. The Patient/Resident also 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 third party payor, including, but not limited to, government and private insurers, or any other person entitled or authorized to receive such information by law or by the Patient/Resident. MHC.O08.'~O {,Rev. 7/96) Pg 3 I of 3 Consent to Treatment. Patient/Resident acknowledges that he/she is under the medical treat? ment and care of an attending physician, and consents to the Facility rendering nurSing Care, theraPeutic, ~nd other treatment under the general or special instructions of said physician or in case of emergency. 7. Attending Physic. The Patient/Resident is solely responsible for selection of a licensed;~' attending physician. The Patient/Resident agrees 'that the Facility may require the Patient/Resident to utilize another physician if the attending physician (1) has his/her own professional license limited, suspended or revoked; (2) fails to follow the Facility's rules and regulations; or (3) is unavailable in case of emergency. The Patient/Resident is responsible for all charges for physician services. 8. Pharmacy. The Patient/Resident shall execute the Pharmacy Agreement attached as ..Exhibit C. 9. Independent ContractorS. The Patient/Resident acknowledges and agrees that all dentists and barbers/beauticians, including those whose services are arranged by the Facility, are independent contractors and are not employees or agents of the Facility, and the Facility shall be responsible for their acts or omissions or for the consequences of following physician or dentist orders. 10. Private Duty Personnel. The Patient/Resident acknowledges that all priy.'~te duty personnel tha' the Patient/Resident utilizes are not employees or agents of the Facility and that the Facility is not liable for acts or omissions by such personnel. Employees of the Facility may not be employed as private duty personnel at the Facility. All private duty personnel shall comply with all policies and procedures of the Facility as may be amended from time to time without notice. Failure to do so may result in their being denied access to the Facility. Patient/Resident and Responsible Party shall be solely responsible for the cost of private duty personnel. 1 1. Facility Guidelines for "No Heroics" Requests. Decisions regarding life support should be con- sidered by each Patient/Resident or his/her authorized surrogate decision-maker. The Patient/ Resident acknowledges receipt of rights under state law to make decisions about medical care, in- cluding rights to accept or refuse care and rights to make an advance decision about care. The Patient/Resident acknowledges receipt of a summary of the "Facility Guidelines for No Heroics Requests" (the "Guidelines"). A full text of the Guidelines will be provided upon request. In part,, the Guidelines provide that the Facility will not withhold or withdraw life-sustaining or life-prolonging measures from a Patient/Resident without a written and legally sufficient authorization of a competent Patient/Resident or legally authorized surrogate decision-maker and a physician order. The Patient/ Resident agrees to comply with the Guidelines. 12. Liability and Indemnification. The Patient/Resident understands that the Facility is liable only for injuries caused by the negligent acts or omissions of the Facility and as required by law. The Patient/Resident'~shall indemnify and hold the Facility harmless from any and all claims, suitsand actions made. against the Facility by any person resulting from any damage or injury caused:~by the Patient/Resident t(~ any person or the property of any person or entity (including the Facility). :-~.3.~..Patient/Resident's Handbook. The:Patient/Resident acknowledges receipt of:the Facility's :,Resident~s Handbook and agrees to comply with such Rules and Regulations containedltherein, The Patient/Resident acknowledges and agrees that he/she shall be responsible for and shall-hold t.he Facility harmless for any injuries or damages which are caused by the Patient/Resident's failure to comply .with 'sbch rules and regulations. The policies, procedures, rules and regulations:~'egarding the following areas, among others, are detailed in the Resident's Handbook: :.. r~'' MHC-OOa-20 (Rev. 4/96) pg 4 2 of 3 · Federal Resident Rights · Resident Responsibilities · Life Sustaining Treatment Policy · Medical/Nursing Education · Dental, 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 ~ENDMENTS SHALL BE A PART OF THIS AGREEMENT. 15. Miscellaneous. The provisions of this Agreement shall bind the par~ies, their respective executors, administrators, heirs, beneficiaries, and assigns. The waiver by either ~3arty of any b"reach o.r: default 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 Admission Agreement as of the day and year above written. ,lity Rep~ese[~tative - Signature _ ility Representative - ~rinted']qarne & Title /..~sponsible Party - Sign_..ature R~Spy~S~(~ ~ty - Printed Narne Dat~e -- ~ (Rev, 4/96) Pg 5 3 of 3 ~ · , onsible Party may be any person legally responsible for The Pat~ent/Res~de. nt s R.e. sp. t be re uired to designate a Responsible Party. ~t. A competent Pabent/Res~dent shall no q I Please check one of the four following, whichever is most appropriate. ..~ . le all appointed guardian, conservator and/or holder of a power The undersigned has been g Y ........ ~irl~nt ~nd shall serve as Responsible Party to act on the behalf ot me Pattern/mu .......... . of attorney ...... -~ ,.-~ delivered to the Facility cop~es of the legal r the Patient/Resident· ~ne unae .rs?neu .,,.o_~ d or holder of a power of fo · ' him her as me guard,an, conservator an / . ~documents des,gna!lng /. ....... ,,~l~rAt' n of the Facility's agreement to adm,t t.he attorneyof the Pabent/Res,aen[.. m u.u. ..... a!~°,ndividuall., and personally, hereby warrants, · acilit the unaersignea, ) Y Patient/Res,dent to the F. Y' .... ,-,.,~,~i~,~,n~ ~.~ h ' fter set forth and defined). represents, covenants ana agrees to me ~,,, ......... __ ..ereln a · does not have a legally appointed repre~sentative an.d wishes to give The Patient/Resident . . · ~ ~)c~ ~', c.. C~ P,~m-%3~-~ I.\ ~O . · .. e e~se. I hereoy appo~m the respons, b~hty to someon . ,, eb adthorize him/h,er to handle my as my representative (the "Respons,ble Party ) and her y finances, pay my expenses, receive my personal funds and, if I am unable; to exec. ute the Admission Agreement on my behalf. Any signature of Patient/Resident or Responsible Party on the Admission Agreement and/or this or any other exhibit or document attached thereto or referenced therein shall be considered binding on both the Patient/Resident and the Responsible Party. The undersigned hereby agrees to the Conditions (as herein after set forth and defined). ~e~ility Re'pFesent~i~e .u.. Signature ~acility epr sen_tative - pr~ecl Name & Title Date /Res, iden. t - Sigl;~tur . Date The Patient/Resident is competent and does not have a court-appointed guardian, conser- vator or power of attorney and has not appointed a Responsible Party, but alone shall execute the Agreement. In consideration of his/her admission to the Facility, the undersigned hereby agrees, warrants and represents to the Conditions (as herein after set forth and defined). The Patient/Resident is mentally or physically incapable of executing this Agreement, handling his/her own affairs or appointing a Responsible Party and does not have a guardian, conser- vator or durable power of attorney. The Patient/Resident's physician will certify in writing that the Patient/Resident is incapable of executing the Agreement and that placement in the Facility is appropriate. The undersigned voluntarily agrees, on behalf of the Patient/Resident, to act and serve as Responsible Party for the Patient/Resident. In consideration of the Facility's agreement to admit the Patient/Resident to the Facility, the undersigned individually hereby warrants, represents, covenants and agrees to the Conditions (as herein after set forth and defined)· a.c.~,~-~ (R~v. 4/98) ~ 6 I of 2 Conditiens (collectively referred to as "Conditions") I The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred 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. · ~' ~udin but not limited to that contained on the attached Application 3. All of the informabon, in~lc~ ~ g. . ~ ~,n ~ and which is attached hereto and for Residency, dated-','~ /-H.~/~_~'-r o , ,~o _ --~r~ ~o *r..- nd accurate as of this made part of this Exhibit andJ3~ the Admission Agreu,,,~-,,', ..... a date and all assets listed in the application are in fact available to the Patient/Resident for the Patient/Resident's care while at the facility. , 4. Neither the Responsible Party nor the Patient/Resident will take 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 acknowledges that if the above warranties and representations are not true, or if the above covenants and agreements are not complied with, the Facility will have detrimentally relied upon them and the Facility will suffer financial harm and loss. .~"~c~.~ ~'~'onsible Party - Sign~.ature , Responsible Pa Date (Rev. 4/96) Pg 7 2 of 2 Daily Rate. The dally r The monthly rate equals the dally rate rhultiplied by n~ber of d~ys in the month. The daily rate is billed one month in advance and includes: · Linens · Social Services · Routine Nursing Care · Meals (additional fees may apply) · Activities · Housekeeping · Room (circle one): Private Semi-Private Triple The following are paid by Medicare in addition 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 Medical.cl.. 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. '- _RATE_ !TEM_ · 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.) . ~ 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 Pat!ent/Residents, bed holds are pursuant to state law. to ascertain all services/supplies 4. Other Charges. Because at Admission, the Facility is unable which may be needed by and provided to the Patient/Resident, all additional costs/charges may 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. Adiustment 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. ~-- lof2 pg 8 6. Refunds.. Refunds shall be paid within thirty (30) days after discharge or transfer. 7. ~rces. The Facility makes no assurances that the Patient/Resident'~ care' will 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 I~aY 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 ~hould 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. ~' The Patient/Resident is responsible for, and shall pay, the daily rate and charges for supplemental services/supplies not paid by any third party, as well as applicable co-in'~urance and deductibles and all expenses of discharge or transfer. The daily rate may change if the Patient/ ;sident is transferred to a different room or the level of care or payor status changes. The Patient/ :{esident 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. Beneficiaries: The Patient/Resident understands that Medicare eligibility and coverage 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- [insurance and for applying for reimbursement from his/her insurer. · iaries' (circle correct number) Beneficiaries; ........ ~,,, ~,art~~' Accordingly, persons who 1) The Facilit ooes not cuu~-,, ' facilitate are admitted as another payor status will be unable to convert to Medicaid status. In order to 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 t ~ The Fac_;!!t cur~n th~,-aid--~r~--r~a~m' If the Patient/Resident believes ' submit all documents required .... · A~,~,-aid he/she shall promptly complete and Patient/ -de/she qualifies ~o~ w~u,,-, , to apply for coverage, including pre-admission approval, if Medicaid coverage is denied, the :~esident will be liable for all charges from the admission date. When Medicaid pays for only a 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 ir, the Patient/Resident's bank account(s), and other assets to the Facility for provision to Medicaic l/1~¢-0os-2o ~Rev. 4/96) ~g 9 2 of 2 EXHiBIT C ---PHARMACY AGREEMENT) Facility has developed policies and procedures for drug therapy, distribution arid control 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. 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. The 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. as the The undersigned selects 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 acknowledge and agree in writing that it will comply with the Facility's uniform medication distribution system, the Facility's policies and procedures and applicable law. sible ~Party~ - Sig~.~ture ~, Responsible. Party - Printed Name Date {Rev. 4/96} pg 10 I of 1 ~ EXHIBIT; D?~STATE LAW, ADDENDUM, ~ he Admission Agreement is amended in the following manner, in order to comply) with 'state law land/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" 14;c.oo~-=o (Rev, 4/96) 13g 11 1 of I ~ or T e)~ ~ ~ =~'~'~'~=~'~H.I. CLAIM NUMBER ' NAME (Print YP ..-¢'- · I . ,, I/ . . '~ ~ ' ' I "~ ~-~'(.~'--'] ~ ~o~-.-I ~'~ Section I ~ ' ' I appoint this individual: ' ~pd~t or y~t name and address of individual you wa~ 7 - to act as my representative in connection with my claim or hss~rted right under Titles 'XI, or XVIII of the So~ial Security Act. I authorize this individual to make or give any request or notice; to present or to elicit evidence.; t? obtain information; and to receive any notice in connection with my claim wholly in my stead. ' ....... ~'DDRESS ~Beneficiary) · EPTANCE OF rAPPOIN~MENT~'~ ,~o:~ ~!-:~ , hereby-accept the above appointmen~l .~_.ert!fy that i . - Health :Care have not been suspended or .pro.hibited from practice before I. he Social Security Administration or the Financing Administration;- that I am not, as a current or former officer or er:nployee of the United States, disqualif!e_d 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 h_e.re.o.f. 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 (compJetion ,of section Ill (optional) satisfies this require- ment). I am a/afl (Attorney, union representative, relative, law student, etc.) . ' ADDRESS T~O~ [OA.D '; '" ' ' 940 WALNUT BO ' ' CARLISLE, PA 17013 NUMBER 717-249-0085 ~ Code) Section III (Note to Representative: fee from withheld past-due benefits.) OR DIRE(~T PAYMENT~: ' ~ WAIVER OF FEE ; ? ~' ~' ~'~?~'"-' ~'~ ~'~ You may use this portion of the form to waive a fee or to waive direct payment .of the I waive my right to charge and collect a fee for representing before the Social Security Administration or Health Care Financing Administration. '---~ATE on reverse) ~HCFA-1696-U4(lO-84) 1 of 1 Mt4c-oo8-~4 (10/96) Service Dates: ~ 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. NOTE: It is important to ask al/questions and document al/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 Work, s Compensation? , ( ~,' ) No: Proceed to question #2 :' "' . ( ) Yes: Bill the other insurer prior to Medicare Is the illness or injury due to any type of accident? (/) No: proceed to question ~f3 or ~f4 ( ) Yes: Complete next page and continue with questions below Note: Patient/Resident/Representative Signature Date ~l~l~) '- #3 IF 65 OR OVER #4 IF UNDER 65 Is the/Patient/Resident 65 or over and employed, or is the spouse employed at time of service? ( ,,/' ) No: Retirement Date: Patient/Resident- Spouse Continue.: See Note Below ( ) Yes: Complete next page - Medicare may not be primary Is the Patient/Resident under 65 and covered under any Employer Group Health Plan (EGHP) or La,ge Group Health Plan (LGHP)? (v/) No: See note ( ) Yes: Complete next page - _Medicare may not be primary If answer to all questions is "No", bill Medicare as primary. If any response is "Yes", continue to next page; _Medicare may not be primary.. I of 3 .-------- (10/96) Patient/Resident Name: Service Dates: 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 party was responsible for accident. Name and address of Liability Insurer Name and address of attorney .{ ~ C. ( ) Work Related: Name of Workman's Comp. Insurer D. ( ) Other accident (Slip and fall, etc.): Explain where accident occurred: Has the Patient/Resident filed or intend to file a liability suit? ( ) No: Bill Medicare and send copies of all pertinent documentation ( ) Yes: Name and address of: Liability Insurer Attorney Bill other Insurer prior to Medicare; submit documentation to Medicare if conditional payment requested. EMPLOYER GROUP COVERAGE FOR THOSE 65 AND OVER A. ( ) Patient/Resident employed at time of this service. Give name of Patient's/Resident's company/employer. 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.OOS-2S (10/96) B. ( ) Patient's/Resident's spouse employed at the time of this service. Give name of spouse's company/employer. Does the spouse's employer employ 20 or more employees ( ) Yes ( ) No Does the spouse have an EGHP by reason of current employment which covers the Patient/Res- ident? ( ) Yes ( ) No If No, give the date of retirement If Yes, give the name of EGHP Bill EGHP prior to Medicare EMPLOYER GROUP COVERAGE FOR THOSE YOUNGER THAN 65 A. ( ) Patient/Resident is entitled to Medicare solely due to End Stage Renal Disease and in the first 18 months of Medicare entitlement. Date of first Dialysis treatment or date of Kidney transplant: MM/YY !' t. Does the Patient/Resident have coverage through his/her, his/her spouse's, a parent's or guardian's Employer Group Health Plan? ( ) No: Medicare Primary ( ) Yes: Give name of the employer Give name EGHP Bill EGHP prior to Medicare B. ( ) The Patient/Resident is entitled to Medicare solely because of disability (does not have/has not had ESRD). Does the Patient/Resident have coverage through his/her, his/her spouse's, a parent's or a guardian's Employer Group Health Plan? ( ) No: Medicare Primary ( ) Yes: Continue Does employer(s) employ 100 or more employees? ( ) No: Bill Medicare ( ) Yes: If yes, give name of each insured whose policy covers the resident: ao Give name of corresponding employer: Give name of corresponding EGHP: Bill EGHP(s) prior to Medicare bo 3 of 3 (10/96) DETERMINATION ON ADMISSION Health Services To: .J Address: ' RE: Name of Beneficiary'T- HICN: Date of Admission: ~r_~~ ~.~oRcARs ~SALT~ SSRVZCSS Center Name: ~ Address: 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 Phone: 717-249-0085 On ~ I~ ! ~ (date), we received your medical informa.~on available a..t the time of, or to, your admis.,s, ion, and we believe that the services .~-(;~.._~c_~ ~._O-c_~ .. (you or beneficiary s name) needed did not meet the specific requirements for beverage under Vledicare as indicated below. uj' d We are placing you in a part of this Facility which is not appropriately certified by Medicare becaus~ you do not require a level of care that will qualify as skilled nursing care. Non-qualifying services furnished to a Patient/Resident in a non-certified or inappropriately certified bed are not payable by Medicare. This decision has not been made by Medicare. It represents our judgment that the services you needed did not meet Medicare payment requirements. Normally, under this situation, a bill is not submitted to Medicare. A bill will only be submitted to Medicare if you request that a bill be submitted. Furthermore, if you want to appeal this decision, you must request that a bill be submitted. If you request that a bill be submitted, the Medicare intermediary will notify you of its determination. If you disagree with that determination, you may file an appeal. Under a provision of the Medicare law, you do not have to pay for non-covered services determined to be custodial care or nct reasonable or necessary unless you had a reason to know the services were non-covered. You are considered to know that these services were non-covered effective with the date of this notice. If you have questions concerning your liability for payment for services you received prior to the date of this notice, you must request that a bill be submitted to Medicare. We regret that this may be your first notice of the non-coverage of services under Medicare. Our efforts to contact you earlier in person or telephone, were unsuccessful. Page 1 of 2 (Rev. 7/96) pg 16 cl~eck One of the following boxes to indicate whether or not you want your bill su Medicare and sign the verification notice of receipt. yours, ~RMEDIARY R~ I do want my bill submitted to the intermediary for a Medicare decision. You w-~be informed when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should contact:. ~ ~ (name and address of intermediary). Please note: After October 1, 1989,'a beneficiary will not be required to pay for services which could be covered by Medicare until a Medicare determination has been made. I do not want my bill submitted to the intermediary for a Medicare decision. I understand that I do not have Medicare appeal rights if no bill is submitted. ~ERiFiCATION OF RECEIPT OF NOTICE~ This acknowledges that l re~(~i~_~notice of non-coverage of services under (date of receipt). Medicare on ~ presentative Contacte~ This is to confirm that you were advised of the non-coverage of the services under Medicare by telephone on ~ (date of telephone contact), Please keep a copy of this for your records and return a copy to the center. Page 2 of 2 MHC-OOe:~O {Rev. 4/96) Pg 17 AUTHORIZATION TO PAY INSURANCE BENEFITS) Man.o Care Health Services Patient/Resident's Name Insured To (Insurance Company): Claim Policy I hereby authorize you to make direct payment to: Facility Name Facility Address herein after referred to as "Facility", otherwise payable to me. I understand that certain items/services, including but not limited to personal care items/services 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. 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. Facility Represen{ative - Signatu Facility Representative - 15rinted Name & Title Date ~.~,tonsible Party - Signature Responsible Party - Pr~nted-~ame Date MNC.O08-~oO (Rev. 7/96) Pg 20 INSURANCE COVERAGE ManorCare Health Ser~lc~ 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 you 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? Y~es ~ No Is the resident/patient covered by a commercial Medicare HMO? ~ Yes Does the resident/patient plan to change insurance carriers? Yes Has the resident/patient stayed at a hospital or skilled nursing facility within the past 60 days? Yes ~No ~/ 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. Resident/Patient Date l~esponsible Party Date (If Resident is unable to sign) MHC-001.'128 (6/97) ManorCar. e Health Services PATIENT SELF-DETERMINATION AC+ ACKNOWLEDGEMENT To Our Residents: Pursuant to federal 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: . *; ; t. ned Resident R~sesponsible (circle'one) have received a cOPY 1. I, the unders g .... ~ ..... .~.~... o~,~, sts as we as a copy of state of the Facility's GuiDelines tor mo n~,u,~o ,,~,~,~e , law information concerning medical care decision-making and advance directives. 2. The Resident/'~°es not (circle one) have an advance directive at this time. If the Residents an advance .dir.ective, it.is a living will/durab~ower o! e (circle one). A copy ot the advan~ve is attached. ~ (,~g~ature of Resident/Responsible rty Print Name: ~(~Lr-i ~'[ ~L 0 ~'~Jf-~ I ~ 0 (if Responsib~ ~ty, check ~re and i~icate 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.) (7/96) EXHIBIT "C" Plumbers and Pipefittem Local No. 520 Benefit Fund 2207 Forest Hills Drive, Suite 14 · P.O. Box 6480 · Harrisburg, PA 17112-0480 (717) 671-8551 · FAX (717) 671-8602 D.H. EVANS ASSOC1ATE$, Itac. Contract Administrator June 21, 1999 James Lackey 940 Walnut Bottom Road Carlisle, PA 17013 RE: Plumbers & Pipefitters Local No. 520 Termination Notice Dear Participant: We regret to inform you that due to your failure to remit the voluntary self contribution required to continue coverage under the Health and Welfare Fund, your benefits have been terminated as of May 1, 1999. Information regarding continuing your coverage under Cobra, will be mailed separately. Sincerely, D. H. Evans Associates, Inc. Contract Administrator : na CC: Local No. 520 EXHIBIT "D" Plumbers and Pipefitters Local No. 520 Benefit Fund 2207 Forest Hills Drive, Suite 14 · P.O. Box 6480 · Harrisburg, PA 17112-0480 (717) 671-8551 · FAX (717) 671-8602 D.H. EVANS ASSOCIATES, INC. Contract Administrator july 24, 2001 Ms. Patricia Castillo 501 Criswell Drive Boiling Springs, PA 17007 RE: Plumbers & Pipefittm~ Local No. 520 Health & Welfare Funds James Lackey, 207-07-8215 Dear Ms. Ca~tillo: This letter comes in response to your telephone inquiry regarding the self-contribution paymentS made on behalf of your hte father, James Lackey. Enclosed you wilJ, find a Contribution Profile for your father. Accorfling to the Fund records, you requested that we begin forwarding your father's monthly pension benefit to Manor Care in August 1998. (You letter is dated August 1997, but postmarked 1998.) It then took until D~mal~,L.ofl~sJL for payment to be sent to the Fund for the health coverage. Then there was another gap in payment at which point we teinfinated his coverage in May 1999. You were able to have his coverage reinstated and then-r~quested that we begin to send the monthly pension benefits in care of your address again_ Payments for the health benefits were then made on a reg-h~ basis. Hopefullythis information will be helpful to you. If you have any other questions, please do not hesitate to contact me. Sincerely, Contract Admin~trator Enclosures EXHIBIT 'E" FEB 13 2002 16:09 FR MANOR CARE-CARLISLE 717 249 064? TO 848114G P.l?x20 IPATRICIA CASTILLO FOR JAMES LACKEY 501 CRISWELL DRIVE BOILING SPRINGS, PA 17007 I ...... 'i IMANORCARE HELATH SERVICES 372 1~40 WALNUT BOTTOM ROAD . ICARLISLE~ PA 17013 I(717) '24~0085 , !08/26/98 09/04/98 09/04/98 09/28/98 09/30/98 10/135/98 10/05198 10/27/98 10/31/98 11/04/98 11/04/98 11/30/98 11~0/98 12/03/98 12/03/98 12/28/98 12/31/98 12/31/98 =BEGINNING BALANCE pAYI~_NT DEPOSIT TO PATIENT FUNDS PAYMENT PATIENT PORTION FOR SEPTEMBER 1998 PAYMENT DEPOSIT TO PATIENT FUNDS PAYMENT PATIENT PORTION FOR OCTOBER 1998 PAYMENT DEPOSIT TO PATIENT FUNDS PAYMENT PATIENT PORTION FOR NOVEMBER 1998 PAYMENT DEPOSIT TO PATIENT FUNDS PAYMENT PAYMENT DEPOSIT TO PATIENT FUNDS $30.00 $1,394.08 $30.00 $1,394.08 $30,00 $1,394.08 $30.00 $30.00 ($373.50) ($927.00) ($373.50) ($927.00) ($373.50) ($927.00; ($373.503 ($927.00; ($373.50; ($938,00; FEB 13 2002 FR MANOR CARE-CARLISLE ?17 249 064? TO 8481146 P.18/20 IPATRICIA CASTILLO FOR JAMES LACKEY 501 CRISWELL DRIVE BOILINOSPRING~, PA 17007 i~, ,~Y; ,~Me~ I IMANORCAF~I~ ~IEAL.T.H ,~ERVIOE8 372 ~4o WALNUT eOTTOM ROAO CARLISLE,' PA 17015 (717) -249-0085 IMI;;;UIC;AIU .... PRIVATE ROOM 114-B 12/31/g§ 12/~1/98 01/27/99 01/~1/99 02/17/99 02/26/99 02/28/99 03/22/99 03/25/99 03/31/99 04/1 ~/99 04/28.99 04/;30/99 05/26/99 05/:31/99 05/31/99 06/04/99 06/29/99 ~EGINNING~CE ~ATIENT PORTION FOR DECEMBER 1998 aAYMENT aATIENT PORTION FOR JANUARY 1999 ~AYMENT PAYMENT PATIENT PORTION FOR FEBRUARY 1999 PAYMENT PAYMENT PATIENT PORTION FOR MARCH 1999 PAYMENT PAYMENT PATIENT PORTION FOR APRIL 1999 PAYMENT PATIENT PORTION FOR MAY 1999 FINANCE CHARGE PAYMENT PAYMENT $1,394.08 $I ,394.0~ $1,$94,08 $1,394,08 $1,394.08 $1 ,$94.08 (s2,1'~1.2~ ($375.5C ($9o~.o¢ (S373.6C ($908.0[ ($373.5( ($908.0C (~99.6~ (,'r~99.6~ (~9o8.o, ($399.6. FEB 13 2002 1G:09 FR MANOR CARE-CARLISLE ?l? 249 0G47 TO 848114G P.19x20 IPATRICIA CASTILLO FOR JAMES LACKEY 501 CRISWELL DRIVE BOILING SPRINGS, PA 17007 IMANORCARE HELATH,SERVICES 372 1940 WALNUT BOTTOM ROAD ~CARLISLE, .PA ~17013 . ' (717) -249-0085 IMP..,;[~I~SAID PRIVATE ROOM 114-B 06/30/99 BEGINNING BALANCE 06/30/99 PATIENT PORTION FOR JUNE 1999 07/0~Jgg PAYMENT 07/31/99 PATIENT PORTION FOR JULY 1999 08/05/99 PAYMENT 08/31/99 PATIENT PORTION FOR AUGUST 1999 09/07/99 PAYMENT 09/30/99 PATIENT PORTION FOR SEPTEMBER 1999 10/06/99 PAYMENT 10/31/99 PATIENT PORTION FOR OCTOBER 1999 1 I/18/99 PAYMENT 11/30/99 PATIENT PORTION FOR NOVEMBER 1999 11/16/99 BARBER CHARGES 12/07/99 PAYMENT 12/31/99 PATIENT PORTION FOR DECEMBER 1999 12/31/99 REV BARBER CHARGES FOR NOVEMBER 01/31/00 PAYMENT 12/06/99 OTHER MEDICAL EXPENSE ~231.77 $1,394.08 $1,394.08 $1,394.08 $1,394.08 $1,394.08 $1,394.08 $58.00 $1,394.08 $41 25 ($908.00) ($9os.o( ($go8.oc ($9o8.oc ($908.oc ($908.0£ (Sss .oo ($93~.o~ FEB 13 2002 1G:09 FR MANOR CARE-CARLISLE ?l? 249 0G47 TO 848114G P.20x20 IPATRICIA CASTP' LO FOR JAMES LACKEY 501 CRISWELL DRIVE BOILING SPRINGS, PA 17007 JMANORCARE.HEALTH SERVICES 3-/2 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717) -249-0085 JMEDICAID PRIVATE ROOM 114-B 01/31/00 BEGINNING BALANCE 01/14/00 PRIVATE ROOM DIFFERENCE 01/31/00 PRIVATE ROOM DIFFERENCE 02/08/00 ~'AYMENT 01/0~/00 DENTAL SERVICES 01/26/00 ~ODIATRIST 02/10/00 'PRIVATE ROOM DIFFERENCE 02/28/00 PRIVATE ROOM DIFFERENCE 02/29/00 PATIENT PORTION FOR 2/29/00 01/31100 REV OTHER MEDICAL EXPENSE 01/31/00 REV PVT ROOM DIFF 03/16/00 PAYMENT 03/31/00 PATIENT PORTION FOR MARCH 2000 03//31/00 MEDICARE B PREMIUM FOR MARCH 2000 04/13/00 PAYMENT 04/30/00 PATIENT PORTION FOR APRIL 2000 04/30/00 MEDICARE B PREMIUM FOR APRIL 2000 D5118/00 PAYMENT ~,653.08 ,t~2,8.00 $289.00: $25.00 $18.00 $170.00 $102.97 $1,498.87 $1,498.87 ($41.75~ ($527.00) ($~31.00) ($45.50) ($931 .oo) ($45.50) ($~31.00) TOTAL PAGE.20 ~ FEB 1~ 2002 16:19 FR MANOR CARE-CARLISLE 717 249 064? TO 8481146 P.01x01 IPATRICIA C;ASTILLO FOR JAMEB LACKEY 501 CRISWELL DRIVE 17007 BOILING SPRINGS. PA Ir~uK'EY, "'J"~u iI~IANOR(~ARE HELATHSER~/iCE5 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717) -249-0085 PRIVATE ROOM 11 10/31/00 BEGINNING BALANCE 11/16/00 PAYMENT 11/30/00 MEDICARE B PREMIUM FOR NOVEMBER 2000 11/30/00 PATIENT PORTION FOR NOVEMBER 2000 12/20/00 PAYMENT 12/31/00 MEDICARE B PREMIUM FOR DECEMBER 2000 12/31/00 PATIENT PORTION FOR DECEMBER 2000 01/22/01 PAYMENT 01/31/01 MEDICARE B PREMIUM FOR JANUARY 2001 01/31/01 PATIENT PORTION FOR JANUARY 2001 02/04/01 PAYMENT 02/16/01 MEDICARE B PREMIUM FOR FEBRUARY 2001 02/16/01 PATIENT PORTION FOR FEBRUARY 2001 $7,481.2§ $1,498.87 $1.498.87 $1,534,37 $1,534.37 ($931.00) ($931.00), (S45.5o)' ($962,00) ($962.00) TOTAL PAGE.01 zz SHERIFF'S RETURN - REGULAR CASE NO: 2002-01334 p COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS CASTILLO PATRICIA IND & ON BEII BRYAN WARD , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon CASTILLO PATRICIA IND & ON BEHALF OF JAMES J LACKEY DEC'D the DEFENDANT , at ~517:00 HOURS, on the 20th day of ~arch at 501 CRISWELL DRIVE , 2002 BOILING SPRINGS, PA 17007 PATRICIA CASTILLO by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing ~er attention to the contents thereof. Sheriff,s Costs: Docketing 18 00 Service ' Affidavit 4.14 .00 Surcharge 10.00 .00 32.14 Sworn and Subscribed to before me this 2;~ day of ~4.,',.,.., ,,. ,,2..6.'O.~5 A.D. - ~ I Prot~honotary ,~ ; So Answers: R. Thomas Kline 03/21/2002 WOLFSON & ASSOC Deputy ~eriff - HCR MANOR CARE Plaintiff VS. PATRICIA CASTILLO, Individually, and on Behalf of James J. Lackey, Deceased Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 02-1334 CIVIL : CIVIL ACTION - LAW TO: HCR Manor Care, Plaintiff You are hereby notified to file a written response to the enclosed New Matter and Counterclaim within twenty (20) days from service hereof or a judgment may be entered against you. R. Mark Thomas, Esq. Attorney for Defendant HCR MANOR CARE Plaintiff VS. PATRICIA CASTILLO, Individually, and on Behalf of James J. Lackey, Deceased Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 02-1334 CIVIL : CIVIL ACTION- LAW ANSWER. NEW MATTER AND COUNTERCLAIM AND NOW, comes the defendant Patricia Castillo, by and through her attorney, R. Mark Thomas, Esquire, and files the following Answer: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted in part, denied in part. It is admitted that the defendant signed the Admission Agreement in her capacity as Power of Attorney for James J. Lackey. It is denied that Exhibit B contains the entire agreement made between plaintiff and defendant. 6. 7. 8. Party". 9. 10. Admitted. Admitted. Admitted. Denied. Defendant signed only as Power of Attorney and not as "Responsible Admitted. Admitted.. 11. Admitted in part, denied in part. Admitted that defendant would utilize the financial resources and income of James J. Lackey to pay plaintiff, but only to the extent that financial resources and income were under her control. 12. Admitted. 13. Denied. All pension benefits to which James J. Lackey was entitled were conditioned upon a monthly fee of twenty-five ($25.00) dollars to be paid to Plumbers and Pipefitters Local No. 520 Benefit Fund. 14. Denied. The pension benefits for James J. Lackey were terminated due to the failure of plaintiff to pay the monthly fee and/or self contribution. 15. Admitted. By way of further answer, this was due to plaintiff's refusal to pay the monthly fee after it had previously agreed to pay the monthly fee. 16. Admitted in part, denied in part. Admitted only that defendant was able to get benefits reinstated. Denied that plaintiff was entitled to these funds. 17. Admitted. 18. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 19. Denied. Defendant has continuously questioned the Statement of Account and has denied personal liability therefore. 20. Denied. Defendant paid and/or transferred control over all the assets of James J. Lackey to plaintiff. 21. Denied for the reasons set forth in Paragraph 20. 22. Admitted. 23. Denied to the extent that this averment implies that defendant willfully failed to cooperate with Department of Public Welfare. 24. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 25. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 26. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. Denied. Defendant turned over all the financial resources of James J. Lackey to 27. plaintiff. 28. 29. Denied. Defendant is not responsible for any sums due and owing to plaintiff. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 30. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 31. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 32. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 33. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. To extent that any interest may be due plaintiff has waived its right to pursue any interest. 34. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 35. Denied. Defendant is without sufficient information based on reasonable investigation, knowledge and belief to either affirm or deny this allegation and therefore same is denied and strict proof thereof demanded at time of trial. 36. Denied. This allegation is a conclusion of law for which no responsive pleading is required and therefore same is denied. WHEREFORE, Defendant, Patricia Castillo, Individually and on Behalf of James J. Lackey, Deceased, prays this Honorable Court will enter judgment in favor of defendant and against plaintiff, HCR Manor Care. NEW MATTER 37. Paragraphs 1 through 36 are incorporated herein as if set forth at length. 38. Plaintiff was fully aware that James J. Lackey's pension benefits were contingent upon payment of $25.00 each month to the Plumbers and Pipefitters Local No. 520 Benefit Fund. 39. Defendant turned over all of James J. Lackey's assets to plaintiff and plaintiff agreed to maintain James J. Lackey'~ pension benefits. 40. Plaintiff's failure to pay the $25.00 monthly fee to the Benefit Fund resulted in the termination of James J. Lackey's pension benefits. 41. Despite requests from defendant for plaintiff to have pension benefits reinstated for James J. Lackey the plaintiff refused to do so. 42. Defendant used her own limited resources to have pension benefits for James J. Lackey reinstated. 43. Plaintiff abandoned or waived its rights to James J. Lackey's pension benefits. 44. Plaintiff is estopped from now claiming that it was entitled to James J. Lackey's pension benefits. 45. It is believed and therefore averred that plaintiff did receive payment from the Department of Public Welfare for the same expenses it now seeks to recover from defendant. 46. Plaintiff is precluded from recovering these moneys from defendant by the doctrine of laches. WHEREFORE, defendant prays this Honorable Court will enter judgment in favor of defendant and against plaintiff. COUNTERCLAIM 47. Paragraphs 1 through 46 are incorporated herein as if set forth at length. 48. At the time of his death James J. Lackey had eight hundred fifty-five dollars and sixty-nine cents ($855.69) on his personal account. 49. Defendant was the named beneficiary of James J. Lackey's personal account. 50. Plaintiff has refused and continues to refuse to turn these funds over to defendant. WHEREFORE, defendant prays this Honorable Court will enter judgment in favor of defendant and against plaintiff on this counterclaim in the amount of eight hundred fifty-five dollars and sixty-nine cents ($855.69) plus interest and costs. Respectfully submitted, R. Mark Thomas, Esquire ID# 41301 101 S. Market Street Mechanicsburg, PA 17055 (717) 796-2100 VERIFICATION I verify that the statements made in the foregoh~g document are true and correct. I understand that false statements herehl are made subject to the penalties of 18 Pa. C.S. §4904, relating to unswom falsification to authorities. CERTIFICATE OF SERVICE I, R. Mark Thomas, Esquire, hereby certify that I have served a copy of the within document on the following by depositing a true and correct copy of the same in the U.S. Mail at Mechanicsburg, Pennsylvania, Postage pre-paid, addressed to: Amy F. Wolfson, Esquire Wolfson & Associates, P.C. 267 East Market Street York, PA 17403 Date: R. Mark Thomas, Esq. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MANOR CARE, : Plaintiff : : VS. : : CASTILLO, Individually, : NO. 02-1334 Civil CIVIL ACTION - LAW on Behalf of ]ames ]. Lackey, Deceased,: Defendant : PLAINTIFF'S REPLY TO NEW MATTER AND ANSWER TO COUNTERCLAIM AND NOW, TO WIT, this 16TM day of May, 2002, comes the Plaintiff, HCR Manor Care, by and through its attorneys, Amy F. Wolfson, Esquire, and the law firm of Wolfson ~ Associates, P.C., and files the following Reply to New Matter and Answer to Counterclaim and in support thereof, avers as follows: The allegations and averments contained within paragraphs One ( 1 ) through Thirty- Six (36) of Plaintiff's Complaint are incorporated herein by reference as if set forth in full. REPLY TO NEW MATTER 37. Paragraph 37 of Defendant's New Matter and Counterclaim is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in Plaintiff's Complaint are incorporated herein by reference as if set forth in full. 38. Denied. It is specifically denied that Plaintiff was aware that the pension benefits of ]ames ]. Lackey, Deceased, were contingent upon a payment of $25.00 each month to the Plumber's and Pipefitter's Local No. 520 Benefit Fund. Therefore same is denied and strict proof is demanded at trial. 39. Denied. It is specifically denied that Defendant turned over all assets of ]ames Lackey, Deceased, to Plaintiff, as Plaintiff was unaware of the extent of his assets. It is further specifically denied that Plaintiff agreed to maintain the pension benefits for ]ames ]. Lackey, Deceased. To the contrary, the assets of ]ames ]. Lackey, Deceased, were known to the Defendant, and were under the control of the Defendant as she had been appointed as Attorney-in-fact for ]ames ]. Lackey, Deceased, pursuant to the Power of Attorney executed by him on April 5, 1988. By way of further response, the Defendant was charged with the responsibility to maintain the financial resources and assets of James ]. Lackey, Deceased, as his agent pursuant to the Power of Attorney appointment and as his Legal Representative and/or Responsible Party pursuant to the Admission Agreement she signed with the Plaintiff. Therefore, same is denied and strict proof is demanded at trial. 40. Denied. It is specifically denied that the termination of pension benefits for James ]. Lackey, Deceased resulted from any act or alleged failure to act on the part of Plaintiff. To the contrary, the legal and fiduciary obligation to James J. Lackey, Deceased, lies with the Defendant, as his agent, pursuant to the Power of Attorney. By way of further response, pursuant to the Admission Agreement, the Plaintiff's obligation to ]ames ]. Lackey, Deceased, was that of health care provider, and at no time did the Plaintiff ever accept or undertake responsibility for the income and/or financial resources of ]ames ]. Lackey, Deceased. 41. Denied. It is specifically denied that Plaintiff was responsible for reinstating the pension benefits of James J. Lackey, Deceased. To the contrary, the legal and fiduciary duty to James J. Lackey, Deceased, lies with the Defendant, his agent, pursuant to the 2 of Attorney. By way of further response, Plaintiff was not authorized to act on ]ames ]. Lackey, Deceased, with regard to his financial responsibilities, and not receive any monthly notices of default notices that the pension obligation 42. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 43. Denied. The allegations contained in paragraph 43 of Defendant's New Hatter and Counterclaim are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. By way of further response, Plaintiff provided services to ]ames ]. Lackey, Deceased, for which Plaintiff deserves just compensation. At no time did Plaintiff waive or abandon its right to recovery for the services rendered to ]ames ]. Lackey, Deceased. 44. Denied. The allegations contained in paragraph 44 of Defendant's New Matter and Counterclaim are conclusions of law to which no response is required. To the extent that a response is necessary, same is denied and strict proof is demanded at trial. By way of further response, Plaintiff provided services to ]ames ]. Lackey, Deceased, for which Plaintiff deserves just compensation. At no rime did Plaintiff waive or abandon its right to recovery for the services rendered to ]ames ]. Lackey, Deceased. 45. Denied. It is specifically denied that Plaintiff received payment from the Department of Public Welfare for the same expenses sought in this action. To the contrary, Plaintiff received partial payment from the Department of Public Welfare for 3 expenses not included in this action. Therefore, same is denied and strict proof is at trial. 46. Denied. The allegations contained in paragraph 46 of Defendant's New and Counterclaim are conclusions of law to which no response is required. To the at a response is necessary, same is denied and strict proof is demanded at trial. WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Defendant's New Matter and Counterclaim and enter judgment in favor of Plaintiff and against Defendant, along with the allowable costs of this action, and such further relief as the Courts deems appropriate. ANSWER TO COUNTERCLAIM 47. Paragraph 47 of Defendant's New Matter and Counterclaim is an incorporation paragraph to which no response is required. To the extent that a response is necessary, same is denied and the allegations contained in Plaintiff's Complaint are incorporated herein by reference as if set forth in full. 48. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 49. Denied. After reasonable investigation, Plaintiff is without sufficient information or knowledge to form a belief as to the truth or veracity of this allegation. Therefore, same is denied and strict proof is demanded at trial. 4 50. Denied. After reasonable investigation, Plaintiff is without sufficient nformation or knowledge to form a belief as to the truth or veracity of this allegation. , same is denied and strict proof is demanded at trial. WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Matter and Counterclaim and enter judgment in favor of Plaintiff and Defendant, along with the allowable costs of this action, and such further relief as Courts deems appropriate. Respectfully submitted, Amy F..,~lfso~, ~Cl~ WOLF~JON ~ ASSOCIATES, P.C. 2.67 East Market Street York, PA 17403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA "ICR MANOR CARE, : Plaintiff : : VS. : ~ATRICIA CASTILLO, Individually, : ~nd on Behalf of James J. Lackey, Deceased,: Defendant : NO. 02-1334 Civil CIVIL ACTION - LAW CERTIFICATE OF SERVICE AND NOW, this 16th day of May, 2002, I, Amy F. Wolfson, Esquire, do hereby :ertify that I have served a copy of the foregoing Reply to New Matter and Answer to Counterclaim upon counsel of record in the following manner and addressed as follows: REGULAR MAIL POSTAGE PRE-PAID R. Mark Thomas, Esquire 101 South Market Street Mechanicsburg, PA ! 7055-385 ! (Counsel for Defendant) WOLFSON 6: ASSOCIATES, 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 87062 Attorney for Plaintiff P.e. HCR MANOR CARE VS PATRICIA CASTILLO, Individually, and on Behalf of James J. Lackey, Deceased IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 02-1334 CIVIL 19 RULE 1312-1. The Petition for Appointment of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Amy F. Wolf son, Esquire , counsel for the plaintiff/defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions.) is (are) at issue. 2. The claim of the plaintiff in the action is $17 ,103 .15 plus costs The counterclaim of the defendant in the action is $855.69 The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: __ R. Mark Thomas, Esquire WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Re Sl~C t fu 11)5 subn~jt~, ORDER OF COURT ~O NOW, ~~ -_/~ . 1~, i~ consideration of the Esq., ~d ~~ ~ , Esq., ~ lppointed ~bitrators in ~e above captioned action (or actions) ~ ~yed fort By the Co IN THE COURT OF COMI'4ON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR I~ANOR CARE, : NO. 02-1334. Plaintiff : PATRICIA CASTILLO, Individually, and on Behalf of ]ames ]. Lackey, Deceased, : Defendant : CIVIL ACTION - LAW CERTIFICATE OF SERVICF I hereby certify that on the ~.0~day of ~~"2002, I have served a copy of the foregoing Petition for Appointment of Arbitrators upon Counsel for Defendant, via First Class United States mail and Certified U.S. Mail return receipt requested, addressed as follows: R. Mark Thomas, Esquire 101 South Market Street Mechanicsburg, PA 17055-385 (Counsel for Defendant) Respectfully submitted, WOLFSO'N ~ ASSOC~TES, P.C. 267 East Market Street York, PA ! 7403 (71 7) 846-1252 ID No. 87062 Attorney for Plaintiff HCR MANOR CARE PATRICIA CASTILLO, Individually, and on behalf of James J. Lackey, Deceased IN RE: ARBITRATION : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA 02-1334 CIVIL ORDER OF COURT AND NOW, February 3, 2003, the Court having been informed that the above-captioned case has settled prior to hearing, the panel of arbitrators previously appointed is vacated, and Bradley Griffie, Esquire, Chairman of the Arbitration Panel, shall be paid the sum of $50.00. Bradley Griffie, Esquire Susan Hartman, Esquire James Robinson, Esquire Court Administrator By the Court, P,J, Bradley L. Griffie, Esquire Maryiou Matas, Esquire Wendy J. F. Grella, Esquire Robin J. Goshorn Legal Assistant Reply to: Carlisle q yyi & s ocIA Attorneys and Counselors at Law January30,2003 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 38 North Main Street Chambersburg, PA 17201 (717) 26%1350 (800) 34%5552 Fax (717) 243-5063 The Honorable George E. Hoffer Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 HRC Manor Care v. Castillo No. 02-1334 Civil Term Dear Judge Hoffer: I previously had been appointed as chairman on the arbitration panel to hear the above captioned matter. On the evening before the arbitration hearing, I was notified by counsel that an agreement has been reached. I have since been provided with a photocopy of the stipulated agreement, which is not being made, part of the record. Rather, counsel has simply asked that I return the file and have the panels appointment vacated so that they can proceed with their unrecorded, private stipulation. I was advised by the Prothonotary's Office to notify you of this so that you authorize payment to the panel members as is appropriate. Your attention is appreciated. BLG/kjl Very truly yours, e IN THE COMMON PLEAS COURT OF CUMBERLAND COUNTY Linda C. Smith, Plaintiff V. Robert E. Smith, : Defendant : Cumberland County _. No. 2003-01334 PRAECIPE TO TRANSMIT RECORD To the Prothonotary: Transmit the record, together with the following information, to the court for entry of a divorce decree: 1. Ground for divorce: irretrievable breakdown under § 3301 (c) of the Divorce Code. 2. Date and manner of service of the complaint: By certified mail dated March 20, 2003. 3. Date of execution of the affidavit of consent required by § 3301(c) of the Divorce Code: by Plaintiff execution August 22, 2003, filed on August 26, 2003; by defendant executed August 24, 2003 and flied on August 26, 2003. 4. There are no related claims pending. 5. Date defendant's Waiver of Notice was filed with the Prothonotary: August 26, 2003. Linda C. Smith (Plaintiff) 21120_1 IN THE COURT OF COMMON OF CUMBERLAND COUNTY STATE OF ~~ PENNA. Linda C. Smith PLEAS Plaintiff VERSUS Robert E. Smith Defendant No. __2003-01334 DECREE iN DIVORCE AN D NOW, ~~J~~r ~0~'~ ~' _ , IT IS ORDERED AND DECREED THAT T,~n~a R. AmiSh AND Robert E. Smith ARE DIVORCED FROM THE BONDS OF MATRIMONy. ,PLAINTIFF, ,DEFENDANT, THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECORD IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT YET BEEN ENTERED;