On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 592 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 156
NK DM INDEX NO. 451549/2923
FIEED? (EW OUURK)CCOUN 06
NYSCEF DOC. NO. 592 RECEIVED NYSCEF: 06/28/2023
(1) TIN _OODF (2) BILLING SERVICE NAME (IF APPLICABLE) _CENTERS FOR CARE LLC
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
(3) As of (date) 06/11/2022 all ctalms submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnished
(4) by (provider name) _ DELAWARE OPERATIONS ASSOCIATES LL@&) (10-digit National Provider 1689055295
ID (NPI) -- REQUIRED unless
exempted from NPI)
(6) (8-digit Medicaid Provider 01591506
Number It NPI exernpt)
will ba subject to the following certification,
| am {or tha business entity nemed in this form of which { am a partner, officer, of director |s) a qualified provider enrolled with and authorized to participate
in the New York State Modical Assistance Program and in the profession or specialties, It any, required In connection with this claim; the pereons providing
services, care and supplies have the necessary licensing, certification, training and experience to perform the clalmed services; | have reviewed these
claims; | (or the entity) have fumished or caused to be fumished the care, services, and supplies itemized and done so in accordance with applicable federal
and state laws and regulations; | have read the eMedNY Provider Menual and ell revisions thereto; all claims are made in full compliance with the pertinent
provisions of the Manual and revisions; all claims for care, services and supplies provided at the order of enother professional have to the best of my
imowlodge been ordered by that professicnal in bona fide compilance with the procedures set forth in the manual and revisions. All care, services and
‘supplies for which claim Is made are medically necessary for the treatment
of the named recipient, the amounts listed are due and, except as noted, no pan
yraof has been paid by, or to the best of my knowledge is payable from any other source cther then the Medical Assistance Program; Payment of fees:
made in accordance with established schedules is accepted as payment in full; other than a claim rejected or denied or one for adjustment,
cieim far the care, services and supplies itemized has bean submitted or patd; ALL STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE
TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED; | UNDERSTAND THAT
PAYMENT AND SATISFACTION OF THIS CLAIM WILL SE FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINED
ANDYOR PROSECUTEO UNDER APPLICABLE FEDERAL AND STATE LAWS FOR ANY VIOLATION OF THE TERMS OF THIS CERTIFICATION,
INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTS OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT; taxes ‘rom
whieb the Stata le exempt are excluded; all records pertaining to the care, services and supplies provided including all records which are n
disclose fully the extent of care, services and suppiles provided to individuals under the New York State Medical Agsistance Program wit! be kept (ora porod
of six yaars from the date of payment, and such secords and information reganting these claims and payment therefor shall be promptly fumished upon
request to the local Department of Social Sarvices, the State Department of Health, tho Office of the Medicald inspector General, the Stato Medicald Fraud
Control Unit or the Secretary of the Department of Heaith and Human Services; there has been compliance with the Federal Civil Rights Act of 1964 and
with section 504 of the Federal Rehabilitation Act of 1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap,
age, sex and religion; { agree (or the entity agrees) ta comply with the requirement of42 CFR Part 455 relating to disclosures by providers; | (or the entity)
have adopted and implemented, where . an etfective compliance program pursuant to Naw York State Social Services Law section 363-d, and
havo satlstied tho requirements of Tile 18 of the New York Codes, Rules and Regulations Pant S21; the Slale of New York through iis fiscal agent or
otherwise Is hereby autherized to {1} make administrative corrections to claima submitted under this agreement 10 enable its automated processing, subject
to reversal by the provider, and (2) accept the claim under this agreement as original evidence of caro, services and supplies fumlshed.
In submitting ctaims under this agreement | understand and agrea that | (or the entity) shail be subject to and bound by al! rules, regulations, policies,
standards, {ee codes and procedures c! the New York State Department of Health and the Office of the Medicaid Inspector General as sel forth in statute or
{itle 18 of tha Official Compilatian of Codes, Rules and Regulation of New York State and other publications of the Department, Inctuding eMedNY Provider
‘Manuals and other afficial bulletins of the Department. | understand and agree that | (or the entity} shall be subject to and shall accept. subject to due
process of the law, any determinations pursuant to sald rules, regulations, policies, standards, fee codes and procedures, including, but not limited to, any
duly made determination affecting my {or my entity's) past, present or future status in the Medicald program and/or imposing any duly conldared sanction
— ‘oF penalty.
t UNDERSTAND. THAT My, SIGNATURE HEREON THE ABOVE SERTIFICATION WILL,
PI LECT! RONIC R ON PAPE! iS MY (OR PLEASE 00 NOT|
THE ENTITY’: SNe OR “MEDICAID PROVIDE FIDENTIFICATION UM STAPLE OR
CERTIFICATI N REMAINS IN E FECT Aine UNTIL
SUPERSEDED BY ANOTHER BROPERLY EXECUTED CERTIFICATION STATEMENT. WRITE IN BAR:
CODE AREA
(7) (Signature) (8) (Date) af. s[ 2022.
(9) (Print Name and Titta) STH lenge Loe foot lem
(10) (Telephone #) 218-87/-7 700. (11) (Mall, if available) centr @ centerrbusiness ay
STATE OF A Lectfo
YEHUDA ALPERT
COUNTY OF ebay (12) Notary Public, State of New York
6e Reg. No. 02AL6361908
On this dayof 2022, vstora me personally cameQualified in New York County
VEN leary nef tome know and known to ma to hs indhdual described
TMB WARIO” Expires 07/17/2025
executed the ing istrument, and (s)he acknowledge to me that (s)he executed the same,
(SEAL)
LA
EMEDNY-490601 (10/20) wy NOTARY PUBLIC
_ —_ —_ -
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 592 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 156 NK DM INDEX NO. 451549/2923 FIEED? (EW OUURK)CCOUN 06 NYSCEF DOC. NO. 592 RECEIVED NYSCEF: 06/28/2023 (1) TIN _OODF (2) BILLING SERVICE NAME (IF APPLICABLE) _CENTERS FOR CARE LLC eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID (3) As of (date) 06/11/2022 all ctalms submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnished (4) by (provider name) _ DELAWARE OPERATIONS ASSOCIATES LL@&) (10-digit National Provider 1689055295 ID (NPI) -- REQUIRED unless exempted from NPI) (6) (8-digit Medicaid Provider 01591506 Number It NPI exernpt) will ba subject to the following certification, | am {or tha business entity nemed in this form of which { am a partner, officer, of director |s) a qualified provider enrolled with and authorized to participate in the New York State Modical Assistance Program and in the profession or specialties, It any, required In connection with this claim; the pereons providing services, care and supplies have the necessary licensing, certification, training and experience to perform the clalmed services; | have reviewed these claims; | (or the entity) have fumished or caused to be fumished the care, services, and supplies itemized and done so in accordance with applicable federal and state laws and regulations; | have read the eMedNY Provider Menual and ell revisions thereto; all claims are made in full compliance with the pertinent provisions of the Manual and revisions; all claims for care, services and supplies provided at the order of enother professional have to the best of my imowlodge been ordered by that professicnal in bona fide compilance with the procedures set forth in the manual and revisions. All care, services and ‘supplies for which claim Is made are medically necessary for the treatment of the named recipient, the amounts listed are due and, except as noted, no pan yraof has been paid by, or to the best of my knowledge is payable from any other source cther then the Medical Assistance Program; Payment of fees: made in accordance with established schedules is accepted as payment in full; other than a claim rejected or denied or one for adjustment, cieim far the care, services and supplies itemized has bean submitted or patd; ALL STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED; | UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL SE FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINED ANDYOR PROSECUTEO UNDER APPLICABLE FEDERAL AND STATE LAWS FOR ANY VIOLATION OF THE TERMS OF THIS CERTIFICATION, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTS OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT; taxes ‘rom whieb the Stata le exempt are excluded; all records pertaining to the care, services and supplies provided including all records which are n disclose fully the extent of care, services and suppiles provided to individuals under the New York State Medical Agsistance Program wit! be kept (ora porod of six yaars from the date of payment, and such secords and information reganting these claims and payment therefor shall be promptly fumished upon request to the local Department of Social Sarvices, the State Department of Health, tho Office of the Medicald inspector General, the Stato Medicald Fraud Control Unit or the Secretary of the Department of Heaith and Human Services; there has been compliance with the Federal Civil Rights Act of 1964 and with section 504 of the Federal Rehabilitation Act of 1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap, age, sex and religion; { agree (or the entity agrees) ta comply with the requirement of42 CFR Part 455 relating to disclosures by providers; | (or the entity) have adopted and implemented, where . an etfective compliance program pursuant to Naw York State Social Services Law section 363-d, and havo satlstied tho requirements of Tile 18 of the New York Codes, Rules and Regulations Pant S21; the Slale of New York through iis fiscal agent or otherwise Is hereby autherized to {1} make administrative corrections to claima submitted under this agreement 10 enable its automated processing, subject to reversal by the provider, and (2) accept the claim under this agreement as original evidence of caro, services and supplies fumlshed. In submitting ctaims under this agreement | understand and agrea that | (or the entity) shail be subject to and bound by al! rules, regulations, policies, standards, {ee codes and procedures c! the New York State Department of Health and the Office of the Medicaid Inspector General as sel forth in statute or {itle 18 of tha Official Compilatian of Codes, Rules and Regulation of New York State and other publications of the Department, Inctuding eMedNY Provider ‘Manuals and other afficial bulletins of the Department. | understand and agree that | (or the entity} shall be subject to and shall accept. subject to due process of the law, any determinations pursuant to sald rules, regulations, policies, standards, fee codes and procedures, including, but not limited to, any duly made determination affecting my {or my entity's) past, present or future status in the Medicald program and/or imposing any duly conldared sanction — ‘oF penalty. t UNDERSTAND. THAT My, SIGNATURE HEREON THE ABOVE SERTIFICATION WILL, PI LECT! RONIC R ON PAPE! iS MY (OR PLEASE 00 NOT| THE ENTITY’: SNe OR “MEDICAID PROVIDE FIDENTIFICATION UM STAPLE OR CERTIFICATI N REMAINS IN E FECT Aine UNTIL SUPERSEDED BY ANOTHER BROPERLY EXECUTED CERTIFICATION STATEMENT. WRITE IN BAR: CODE AREA (7) (Signature) (8) (Date) af. s[ 2022. (9) (Print Name and Titta) STH lenge Loe foot lem (10) (Telephone #) 218-87/-7 700. (11) (Mall, if available) centr @ centerrbusiness ay STATE OF A Lectfo YEHUDA ALPERT COUNTY OF ebay (12) Notary Public, State of New York 6e Reg. No. 02AL6361908 On this dayof 2022, vstora me personally cameQualified in New York County VEN leary nef tome know and known to ma to hs indhdual described TMB WARIO” Expires 07/17/2025 executed the ing istrument, and (s)he acknowledge to me that (s)he executed the same, (SEAL) LA EMEDNY-490601 (10/20) wy NOTARY PUBLIC _ —_ —_ -