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. 590 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 154
=T INDEX NO. 451549/2023
NYSCEF BOC? WNEA5YUOS VIS RECEIVED NYSCEF: 06/28/2023
(1) ETIN_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) 06/10/2020, all claims submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnishod
(4) by (provider name) DELAWARE OPERATIONS ASSOCIATES LI ¢5) (10-digit National Provider 1689055295
1D (NPI) -- REQUIRED unless
exempted from NPI)
(6) (8-digit Medicaid Provider 01591506
Number - if NPI exemp!)
‘will be subject to the following certification,
(am (or the business entity named in this form of which | am a partner, officer, or director Is) a qualified provider envolled with and authorized to
participate in the New York Stata Medical Assistance Program and in the profession or speciallias, if any, required In connection with this claim; the
persons providing services, care and supplies have the necessary licensing, cartification, training and experience to perform the claimed services; |
have reviewed these claims; | (or the entity) have fumished or caused to be fumished the cara, services, and supplies itemized and done go in
‘accordance with applicable federal and state !aws and regulations; | have read the eMedNY Provider Manual and all revisions thereto; claims are
made In full compliance with the pertinent provisions of the Manual and ravisions; all claims for cara, services and supplies provided at the order of
another professional have to the best of my knowledge been ordered by that professional in bona fide compliance with the procedures eet forth In the
manyal and revisions. All care, sarvices and supplies for which clsim Is mada are medically nacassary for the treatmant of the named racipient, tha
amounts listed are due and, except as noted, no part thereo! has been paid by, or to the best of my knowledge Is payable from any other source other
than the Medical Assistance Program; payment of fees made in accordance wilh established schedules is accepted as payment in full; other than a
claim igjeciod oF dented oF ane for adjusimant, ne previous cleim for the cars, services end supplies itemized has been submitted or pald; ALL,
STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE;
MATERIAL FACT HAS BEEN OMITTED; | UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL,
STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINED AND/OR PROSECUTED 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; lavas from which the State is axampt ara axciudad; all records pertaining to the care,
services and supplies provided including all records which are necessary to disclose fully the extant of care, services and supplies provided to
individuals under the Naw York State Medical Assistance Program will be kept for a period of six yoars fram the date of payment, and such records and
information regarding these claims and payment therator shall be prompty fumished upon request to the tocal Departmentof Social Services, tho State
Department of Health, the Office of the Medicaid inspactor General, the State Medicald Fraud Control Unit
or the Secretary of the Department of Health
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 amend ‘which forbid diserimination on the basis of race, color, national origin, handicap, age, sox and religion; | agree (or the entity agrees)
to comply with the requirement of 42 CFR Part 455 relating to disclosures by providers: the State of New York through Its fiscal agent or otherwise Is
hereby authorized to (1) make administrative corrections to claims submitted undor this agraemant to anabfo Its automated procassing, subject to
reversal by the provider, and (2) accept the clalm under this agreament as original evidence of care, services and supplies fumished.
lo subinitny claims under this agreement | understand and agree that 1 {or the entity) shell be subject to and bound by all rules, regulations, poticlas, I
standards, fee codes and procedures of the New York Stata Department of Health and the Office of the Medicaid Inspector General as set forth in
statute or tile 18 of the Official Compilation of Codes, nd Regulation of New York State and other publications of the Department, Including
eModNY Provider Manuals and other otficte! bulletins of jepartment, | understand and agree that | (or the entity) shall be subject to and shall
accept, subjsct to due process of the law, any determinations pursuant to said rules, regulations, policies, standards, fea codes and procedures,
determination affecting my (or my entity's) past, prasant or future status in the Medicald program and/or
%
Including,
but net limited to, any duly mac
imposing any duly considered sanction or ity.
1 Noe TAN a
MY SIGNATURE SECA re ABOVE CEE et WILL
ALL CLAI
JBMITTED ELEC’ R ON PAPI OR PLEASE 00 NOT|
SOR MEDICAID PROVIDER “IDENTIFI TION NUMB STAPLE OR
e RTIFICATIO! MAINS IN EI CLAMS. UNTIL
M
SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT, WRITE IN BAR:
CODE AREA
(7) (Signature) LZ (8) (Date) bares
(9) (Print Name and Tith he er
(10) (Telephone #) 21%-43f-9: 1S _Seangsner
LAN
(11) (eMall, Hovalabi)_Scangs ner Econtersbusiness.or
ters Siners.or9
Ecantersbusiners.or
KALMAN ZINSTEIN
‘STATE OF euJ Voit NOTARY PUBLIC, STATE OF NEW YORK
GOUNTY OF Registration No. 01216228296
Qualified in Rockland County
this dayof, é. 20.222, betora me paraonaifvamaission Expires Sept. 20 2022
f to me know and known to ms to the individual described in and who
execuied the, going ietrument, and (s)he acknowledge to me (“<——
thet executed tha same.
(SEAL)
E201 SA OUOS e512)
—iter
INDEX NO. 451549/2023
NYSCEF DOC. NO. 590 RECEIVED 'NYSCEF: ‘06/28/2023
ie aye ae
2
am -
=
L
s
E201 84,0005.035 .
a anes
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Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 590 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 154 =T INDEX NO. 451549/2023 NYSCEF BOC? WNEA5YUOS VIS RECEIVED NYSCEF: 06/28/2023 (1) ETIN_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) 06/10/2020, all claims submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnishod (4) by (provider name) DELAWARE OPERATIONS ASSOCIATES LI ¢5) (10-digit National Provider 1689055295 1D (NPI) -- REQUIRED unless exempted from NPI) (6) (8-digit Medicaid Provider 01591506 Number - if NPI exemp!) ‘will be subject to the following certification, (am (or the business entity named in this form of which | am a partner, officer, or director Is) a qualified provider envolled with and authorized to participate in the New York Stata Medical Assistance Program and in the profession or speciallias, if any, required In connection with this claim; the persons providing services, care and supplies have the necessary licensing, cartification, training and experience to perform the claimed services; | have reviewed these claims; | (or the entity) have fumished or caused to be fumished the cara, services, and supplies itemized and done go in ‘accordance with applicable federal and state !aws and regulations; | have read the eMedNY Provider Manual and all revisions thereto; claims are made In full compliance with the pertinent provisions of the Manual and ravisions; all claims for cara, services and supplies provided at the order of another professional have to the best of my knowledge been ordered by that professional in bona fide compliance with the procedures eet forth In the manyal and revisions. All care, sarvices and supplies for which clsim Is mada are medically nacassary for the treatmant of the named racipient, tha amounts listed are due and, except as noted, no part thereo! has been paid by, or to the best of my knowledge Is payable from any other source other than the Medical Assistance Program; payment of fees made in accordance wilh established schedules is accepted as payment in full; other than a claim igjeciod oF dented oF ane for adjusimant, ne previous cleim for the cars, services end supplies itemized has been submitted or pald; ALL, STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE; MATERIAL FACT HAS BEEN OMITTED; | UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS AND THAT | MAY BE FINED AND/OR PROSECUTED 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; lavas from which the State is axampt ara axciudad; all records pertaining to the care, services and supplies provided including all records which are necessary to disclose fully the extant of care, services and supplies provided to individuals under the Naw York State Medical Assistance Program will be kept for a period of six yoars fram the date of payment, and such records and information regarding these claims and payment therator shall be prompty fumished upon request to the tocal Departmentof Social Services, tho State Department of Health, the Office of the Medicaid inspactor General, the State Medicald Fraud Control Unit or the Secretary of the Department of Health 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 amend ‘which forbid diserimination on the basis of race, color, national origin, handicap, age, sox and religion; | agree (or the entity agrees) to comply with the requirement of 42 CFR Part 455 relating to disclosures by providers: the State of New York through Its fiscal agent or otherwise Is hereby authorized to (1) make administrative corrections to claims submitted undor this agraemant to anabfo Its automated procassing, subject to reversal by the provider, and (2) accept the clalm under this agreament as original evidence of care, services and supplies fumished. lo subinitny claims under this agreement | understand and agree that 1 {or the entity) shell be subject to and bound by all rules, regulations, poticlas, I standards, fee codes and procedures of the New York Stata Department of Health and the Office of the Medicaid Inspector General as set forth in statute or tile 18 of the Official Compilation of Codes, nd Regulation of New York State and other publications of the Department, Including eModNY Provider Manuals and other otficte! bulletins of jepartment, | understand and agree that | (or the entity) shall be subject to and shall accept, subjsct to due process of the law, any determinations pursuant to said rules, regulations, policies, standards, fea codes and procedures, determination affecting my (or my entity's) past, prasant or future status in the Medicald program and/or % Including, but net limited to, any duly mac imposing any duly considered sanction or ity. 1 Noe TAN a MY SIGNATURE SECA re ABOVE CEE et WILL ALL CLAI JBMITTED ELEC’ R ON PAPI OR PLEASE 00 NOT| SOR MEDICAID PROVIDER “IDENTIFI TION NUMB STAPLE OR e RTIFICATIO! MAINS IN EI CLAMS. UNTIL M SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT, WRITE IN BAR: CODE AREA (7) (Signature) LZ (8) (Date) bares (9) (Print Name and Tith he er (10) (Telephone #) 21%-43f-9: 1S _Seangsner LAN (11) (eMall, Hovalabi)_Scangs ner Econtersbusiness.or ters Siners.or9 Ecantersbusiners.or KALMAN ZINSTEIN ‘STATE OF euJ Voit NOTARY PUBLIC, STATE OF NEW YORK GOUNTY OF Registration No. 01216228296 Qualified in Rockland County this dayof, é. 20.222, betora me paraonaifvamaission Expires Sept. 20 2022 f to me know and known to ms to the individual described in and who execuied the, going ietrument, and (s)he acknowledge to me (“<—— thet executed tha same. (SEAL) E201 SA OUOS e512) —iter INDEX NO. 451549/2023 NYSCEF DOC. NO. 590 RECEIVED 'NYSCEF: ‘06/28/2023 ie aye ae 2 am - = L s E201 84,0005.035 . a anes ae es