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
FILED: NEW YORK COUNTY CLERK 06/28/2023 05:39 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 604 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 168
FILED: INDEX NO. 451549/2023
2 8 NEW
3#5 f YORK
, U U U 3 COUNTY
. U 6 5 CLERK 06/28/2023 05:39 PM
NYSCEF DOC. NO. 604 RECEIVED NYSCEF: 06/28/2023
8CX
('1) ETIN (2) B1wNG SERVICE NAME (IF APPLICABLE)
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
(3) As of (dete) $2/12/2020. all claims submitted electronically or on paper to the State's Medlquid f'racal agent, for services or aupplies fumished
(4) by (provider name) SCHNUR OPERATIONS ASSOCIATES LLC (5) (10-digit Natiorial Provider
ID (NPI) -- REQUIRED urdess
exempted fsom NPI)
(6) (8-digit Medicaid Provider 01090835
Number --11 NPl exempt)
will be.8ubject to the following certification.
I em'(or the busineseentity named In this form of which I am a partner, officer, or director Is) a quenfiedprovider enelled with and authorizedto
participateIn Ihe New York State Medical AmelstanceProgram and in the profession or specialties, II any, required In connectionwith this claim; the
persons providingservices, care and supplies have the neoposary||censing,certification, training and experience to perform the claimed services; 1
have saviewedIbese daims; I (or the entity) have fumished or caused to be lumlahed the care, services, and supplies itemteedand done so la
accordancewith eppIlceblefederal and atate laws and regulations; I have read the eMedNY Prowder Manual and a revislans thereto;at claims are
made in fuBcornpilancewith the partinentprovisionsof the Manual and ravinlans; all claimefor care, services and supp!lesprovidedat the order of
another professlonelhave to the best of my knowledgebeen ordered by that professionalin bona fide compliancewith the procedureeset forth in the
manueland revisions.All care, services and supplies for which claim is made are medically necessary for the treatmentof the namedrecipient, the
amountstiatedare due end, except as noted, no part thereofhas been pold by, or to the best of my knowledgela payablefrom any other sourceother
than the Medical AssistanceProgram;payment of less made In accordancewith establishedachedulesle accepted as paymentin full; other then a
claim rejected or denied or one lor adjustment, no previous staJmtor the cere, serWcesand supplies ïtemized has been submittedor paid Al.L
STATEMENTS,DATA AND INFORMATIONTRANSMITTEDARE TRUE, ACCURATEAND COMPLETETO THE BEST OF MY KNOWLEDGE;NO
MATERIAL FACT HAS BEEN OMITTED; I UNDERSTANDTHAT PAYMENT AND SATISFACTIONOF THIS CLAIM WILL BE FROM FEDERAL,
STATE AND LOCALPUBLIC FUNDSAND THAT I MAY BE PINEDANDOR PROSECUTEDUNDER APPLICABLEFEDERALAND STATE LAWS
FOR ANY VlOLATION OF THE TERMS OF THIS CERTIFICATION,INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTSOR
OOCUMENTS,OR CONCEALMENTOF A MATERIAL FACT; taxes from which the State is exempt are excluded; an records pertainingto the care,
services and supplies provided including eff recorde which are necessary to disciote fully the extent of care, services end supplies provided to
IncAviduala under1heNew York State MedicalAssistanceProgramwalbe keptfor a period of six years from the date of payment,andeuch recordsand
Informationregardingthese delms and paymentthereforahallbe prornptlyfumished upon requestto the local Departinentof SocialServices,the State
Departmentof Health,the oflice of the MedicaldinspectorGeneral,the State MedicaldFraudContml Unit or the Secretaryof the Departmentc1Health
end Human Services;there has been compliancewith the Federal Civil RightsAct of 1964 and with section 504 of the FederalRehabilitationAct of
1973,as amended,whlohforbid discriminationon the basis of race,color, national origin, handicap.ago, sex and religion; I agree(orthe entity agreee)
10comply with the requirementof 42 CFR Part 455 relating to disclosuresby providers; the State of New York through its fiscal agent or otherwiseIn
hereby authorizedto (1) make adininistrativecorrections to daims submitted under this agreement to enable its automated proceselng,oubject to
reversalby the provider,and (2) accept the ofahrnunderthis agreementas eriginal evidenceof core, servloseand suppliesfumiahad.
In submitting delms under this agreernentI understandand agree that I (or Ihe entity) anall be subject to and bound by all rules, regulations,policles,
standards,fee codes and procedureeof the New York State Departmentof Health and the 011100of the Medicald InspectorGeneretas set forth in O
atatuteor title 18 of the Offidel Compilationof Codes, Rulse and Regulationof New York State and other publicationeof the Department,including
eMedNY ProviderManuals and other official bulletins of the Department.I underetendand agree that I (or the entity) shall be subject to and shall
accept, subject to due process of the law, any determinationepursuant to sold rules, regulations, policies, standards, fee codesand procedures,
Induding. but not fimited to, any duly inade determinationeffectingmy (or my entity's) past, present or future status In the Medicaldprogram and/or
Imposingeny dulyconsideredeenotion*orpenalty.
I UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILL
APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY DR ON PAPER USING MY (OR PLEASE DO NOT
THE ENTITY'S NPI OR MEDICAID PROVIDER IDENTIFICATION blUMBER. THIS STAPLE OR
CERTIFICA REMAINS IN EFFECT AND APPLIES 70 ALL CLAIMS UNTIL
SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT. WRITE IN BAR
(D (Signature) C (8) (Date)
IM tPdnt Namn anrf Tidn) T LPh ret
(10) (Telephone m) 7 / /1 (11) (eMan, If aveltable) C4 d s #To
STATE OF
Menachem orzel
COUNTY OF (12)
ID: 010R6365302
County: Rockland
On this day of . 201f, before me personally came Empires: 30tnt2n3
$c ,to me knowand known to me fo the radMdual described Inand who
executed the foregoIng instrument, and (s)he acknowledge to me that (s)h 8te same.
(SEAM
²
E2006MNx1 f
Preview
FILED: NEW YORK COUNTY CLERK 06/28/2023 05:39 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 604 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 168 FILED: INDEX NO. 451549/2023 2 8 NEW 3#5 f YORK , U U U 3 COUNTY . U 6 5 CLERK 06/28/2023 05:39 PM NYSCEF DOC. NO. 604 RECEIVED NYSCEF: 06/28/2023 8CX ('1) ETIN (2) B1wNG SERVICE NAME (IF APPLICABLE) eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID (3) As of (dete) $2/12/2020. all claims submitted electronically or on paper to the State's Medlquid f'racal agent, for services or aupplies fumished (4) by (provider name) SCHNUR OPERATIONS ASSOCIATES LLC (5) (10-digit Natiorial Provider ID (NPI) -- REQUIRED urdess exempted fsom NPI) (6) (8-digit Medicaid Provider 01090835 Number --11 NPl exempt) will be.8ubject to the following certification. I em'(or the busineseentity named In this form of which I am a partner, officer, or director Is) a quenfiedprovider enelled with and authorizedto participateIn Ihe New York State Medical AmelstanceProgram and in the profession or specialties, II any, required In connectionwith this claim; the persons providingservices, care and supplies have the neoposary||censing,certification, training and experience to perform the claimed services; 1 have saviewedIbese daims; I (or the entity) have fumished or caused to be lumlahed the care, services, and supplies itemteedand done so la accordancewith eppIlceblefederal and atate laws and regulations; I have read the eMedNY Prowder Manual and a revislans thereto;at claims are made in fuBcornpilancewith the partinentprovisionsof the Manual and ravinlans; all claimefor care, services and supp!lesprovidedat the order of another professlonelhave to the best of my knowledgebeen ordered by that professionalin bona fide compliancewith the procedureeset forth in the manueland revisions.All care, services and supplies for which claim is made are medically necessary for the treatmentof the namedrecipient, the amountstiatedare due end, except as noted, no part thereofhas been pold by, or to the best of my knowledgela payablefrom any other sourceother than the Medical AssistanceProgram;payment of less made In accordancewith establishedachedulesle accepted as paymentin full; other then a claim rejected or denied or one lor adjustment, no previous staJmtor the cere, serWcesand supplies ïtemized has been submittedor paid Al.L STATEMENTS,DATA AND INFORMATIONTRANSMITTEDARE TRUE, ACCURATEAND COMPLETETO THE BEST OF MY KNOWLEDGE;NO MATERIAL FACT HAS BEEN OMITTED; I UNDERSTANDTHAT PAYMENT AND SATISFACTIONOF THIS CLAIM WILL BE FROM FEDERAL, STATE AND LOCALPUBLIC FUNDSAND THAT I MAY BE PINEDANDOR PROSECUTEDUNDER APPLICABLEFEDERALAND STATE LAWS FOR ANY VlOLATION OF THE TERMS OF THIS CERTIFICATION,INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, STATEMENTSOR OOCUMENTS,OR CONCEALMENTOF A MATERIAL FACT; taxes from which the State is exempt are excluded; an records pertainingto the care, services and supplies provided including eff recorde which are necessary to disciote fully the extent of care, services end supplies provided to IncAviduala under1heNew York State MedicalAssistanceProgramwalbe keptfor a period of six years from the date of payment,andeuch recordsand Informationregardingthese delms and paymentthereforahallbe prornptlyfumished upon requestto the local Departinentof SocialServices,the State Departmentof Health,the oflice of the MedicaldinspectorGeneral,the State MedicaldFraudContml Unit or the Secretaryof the Departmentc1Health end Human Services;there has been compliancewith the Federal Civil RightsAct of 1964 and with section 504 of the FederalRehabilitationAct of 1973,as amended,whlohforbid discriminationon the basis of race,color, national origin, handicap.ago, sex and religion; I agree(orthe entity agreee) 10comply with the requirementof 42 CFR Part 455 relating to disclosuresby providers; the State of New York through its fiscal agent or otherwiseIn hereby authorizedto (1) make adininistrativecorrections to daims submitted under this agreement to enable its automated proceselng,oubject to reversalby the provider,and (2) accept the ofahrnunderthis agreementas eriginal evidenceof core, servloseand suppliesfumiahad. In submitting delms under this agreernentI understandand agree that I (or Ihe entity) anall be subject to and bound by all rules, regulations,policles, standards,fee codes and procedureeof the New York State Departmentof Health and the 011100of the Medicald InspectorGeneretas set forth in O atatuteor title 18 of the Offidel Compilationof Codes, Rulse and Regulationof New York State and other publicationeof the Department,including eMedNY ProviderManuals and other official bulletins of the Department.I underetendand agree that I (or the entity) shall be subject to and shall accept, subject to due process of the law, any determinationepursuant to sold rules, regulations, policies, standards, fee codesand procedures, Induding. but not fimited to, any duly inade determinationeffectingmy (or my entity's) past, present or future status In the Medicaldprogram and/or Imposingeny dulyconsideredeenotion*orpenalty. I UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILL APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY DR ON PAPER USING MY (OR PLEASE DO NOT THE ENTITY'S NPI OR MEDICAID PROVIDER IDENTIFICATION blUMBER. THIS STAPLE OR CERTIFICA REMAINS IN EFFECT AND APPLIES 70 ALL CLAIMS UNTIL SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT. WRITE IN BAR (D (Signature) C (8) (Date) IM tPdnt Namn anrf Tidn) T LPh ret (10) (Telephone m) 7 / /1 (11) (eMan, If aveltable) C4 d s #To STATE OF Menachem orzel COUNTY OF (12) ID: 010R6365302 County: Rockland On this day of . 201f, before me personally came Empires: 30tnt2n3 $c ,to me knowand known to me fo the radMdual described Inand who executed the foregoIng instrument, and (s)he acknowledge to me that (s)h 8te same. (SEAM ² E2006MNx1 f