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. 605 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 169
FILED: NEW YORK COUNTY CLERK 06/28/2023 05:39 PM INDEX NO. 451549/2023
E20238.0004.075
NYSCEF DOC. NO. 605 RECEIVED NYSCEF: 06/28/2023
CENTERS FOR CARE LLC
(1) ETIN
00FT (2) BILLING SERVICE NAME (IF APPLICABLE)
eMedNYfMEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
fumished
(3) As of (date) 07N6f2020 , all claims submitted electronically or on paper to the State's Medicaid tiscal agent, tor sendees or supplies
SCHNUR OPERATIONS ASSÇÇIATES LLC (5) (10-digit National Provider
(4) by (provider narne) 123
ID (NPl) - REQUIRED unless
exempted from NPI)
[6) (8-digit Medicaid Provider 01090835
Number - If NPI exempt)
will be sut$ect to tite following certification.
provider enrolled with and authorized to
I am (or the business entity named In this form of which I am a partner, officer, or director le) a qualifted
with this claim; the
participate in the New York State Medical Assistence Programand in the professionor speciallies, if any, required In connection
perform the clelmed services; I
persons providing services, care and supplies have the necessary licensing,certiscation,training and experienceto
and supplies flamized end done so In
have reviewed these dalms; I (or the entity) have fumished or caused lo be fumished the care, services,
revisione thereto; all claims are
accordance with appilceble lederal and slate laws and regulations; I have read the eMedNY ProviderManuel and all
services and supplies provided al the order of
mode In full compliancewith the partinent provisionsof the Manual and revisions; eu claims for care,
forth In the
another professionalhave to the best c1 my knowledgebeen ordered by that professionalIn bona lide compliancewith the proceduresset
manual and revisions.AI)care, services and supplies for whIch claim is made are medicacynecessary for the treatment of the named recipient, the
other source ether
amounteIletedare due and, except as noted, rio port thereof has been paid by, or to the best of my knowledgeis payeble from any
other than a
1henthe Medical Assistance Program; payment of fees made in accordancewith establishedschedules la accepted as payment In full;
been submitted or paid; ALL
clelm rejected or denied or one for adjustment, no previous delm lor the care, services and suppIles Itemized has
OF MY KNOWLEDGE;NO
STATEMENTS, DATA AND INFORMATIONTRANSMITTEDARE TRUE, ACCURATEAND COMPLETETO THE BEST
FROM FEDERAL,
MATERIAL FACT HAS BEEN OMITTED: I UNDERSTANDTHAT PAYMENT AND SATISFACTUN OF THIS CLAIM WILL BE
STATE AND 1,OCALPUBLIC FUNOSAND THAT LMAY BE FINED AND/OR PROSECUTEDUNDER APPLICABLEFEDERALAND STATE LAWS
STATEMENTS OR
FOR ANY VIOLATION OF THE TERMS OF THIS CERTIFICATON, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS,
exempt are excluded; all records pertaining to the care,
DOCUMENTS,OR CONCEALMENTOF A MATERIALFACT; taxes irom which the State is supplies provided to
segvkes and supplies provided including all records which are necessary to disclose fully the extent of care, services and
such recordeand
individualsunder the New York Slate MedicalAssistanceProgramwill be kept for a period of six yeare from the date of payment, and
information regardingthese claims and payment thereforshall be prompily lumished upon request to the tocel Departmentof Soclel Services,the State
of Cepartrnantof Health
Departmentof Heath, the OfIIce of the Medicald InspectorGeneral,the State MedicaidFraudControl Unit or the Secretary the
504 of the Federal RehabilitationAct of
and Human Services; there has been compliance with the Federal Civil Rights Act of 1984 and with section
Jagree (or the entily agrees)
1973, as arnended,which forbid discriminationon the beatsof rece>color, national origin,handicap,age, sex end retlgIon;
the Slale of New YorlrtmoUgh Its fiscal agent or otherwiseis
-corriplywith the retfuirementof 42 CFR Part 455 relating to disclosures by providers;
under thia agreement to enable Its automated processing, suthect to
hereby authorized to (1) ineke administrativecorrections to clelms submRted
reversal by the provider, and (2) accept sis cisim underthis agreementas original evidenceof care, services end auppliesfurnished,
In subrnitting claims under thla agreement I understandand agree that I (or the entity) shall be subject to and bound by all rules, regulations,policies,
the Office of the Medicaid Inspector General as set lorth In
standesde,fee codes and procedures of the New York State Departmentof Health and
statute or title 18 of the Officlel Compilationof Codes,Rules and Regulationof New York State and other publicallons of the Department Induding
eMedNY Provider Manuals and olher officler bulletins of the Department. I understandand agree that I (or the entity) shall be subject to and shall
fee codes and procedures,
accept, subject to due process of the law, any delerminations pursuant to said rules, regulations, policies, standards,
present or future status in the Medicald program and/or
including, but not limited to, any duly made determinationaffecting my (or my entit/s) past,
imposingany duly considered sanctionor penalty.
I UNDERSTAND THAT MY SIGNATURE HEREQN THE ABOVE CERTIFICATION WILL
APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER USING MY OR PLEASE DO NOT
THE ENTITY*S) NPI OR MEDICAID PROVIDER IDENTLFICATION NUMBER. IS STAPLE OR
CERTIFICATON REMAINS IN EFFECT AND APPLIES TO ALL CLAIMS UNTIL
CERTIFICATION STATEMENT. WRITE IN BAR
SUPERSEDED BY ANOTHER PROPERLY EXECUTED
CODE AREA
(T) (signaturet (8) (Oate)
(9) (Print Name and Title)
5 , of Sc4 ,, C Mlb // V __
xT' UA 5 anT "A$
(10) (Telephone #) r (11) (eMail, If available) 4
STATE OF Menachem Ofzel
COUNTY OF (12)
ID: 010R6365302
County: Rockland
On this W) day of 20E..., before me personally came Expiles: 10tO2)2O21
I/f¼ 4 . to me know and known to me to the individual described in and who
executed the foregoIng instrument, and (s)he acItnowledge to me that executed the same
(SEAL)
NOTARY PUBUC
EMEDNY-490601 (12/10)
Preview
FILED: NEW YORK COUNTY CLERK 06/28/2023 05:39 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 605 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 169 FILED: NEW YORK COUNTY CLERK 06/28/2023 05:39 PM INDEX NO. 451549/2023 E20238.0004.075 NYSCEF DOC. NO. 605 RECEIVED NYSCEF: 06/28/2023 CENTERS FOR CARE LLC (1) ETIN 00FT (2) BILLING SERVICE NAME (IF APPLICABLE) eMedNYfMEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID fumished (3) As of (date) 07N6f2020 , all claims submitted electronically or on paper to the State's Medicaid tiscal agent, tor sendees or supplies SCHNUR OPERATIONS ASSÇÇIATES LLC (5) (10-digit National Provider (4) by (provider narne) 123 ID (NPl) - REQUIRED unless exempted from NPI) [6) (8-digit Medicaid Provider 01090835 Number - If NPI exempt) will be sut$ect to tite following certification. provider enrolled with and authorized to I am (or the business entity named In this form of which I am a partner, officer, or director le) a qualifted with this claim; the participate in the New York State Medical Assistence Programand in the professionor speciallies, if any, required In connection perform the clelmed services; I persons providing services, care and supplies have the necessary licensing,certiscation,training and experienceto and supplies flamized end done so In have reviewed these dalms; I (or the entity) have fumished or caused lo be fumished the care, services, revisione thereto; all claims are accordance with appilceble lederal and slate laws and regulations; I have read the eMedNY ProviderManuel and all services and supplies provided al the order of mode In full compliancewith the partinent provisionsof the Manual and revisions; eu claims for care, forth In the another professionalhave to the best c1 my knowledgebeen ordered by that professionalIn bona lide compliancewith the proceduresset manual and revisions.AI)care, services and supplies for whIch claim is made are medicacynecessary for the treatment of the named recipient, the other source ether amounteIletedare due and, except as noted, rio port thereof has been paid by, or to the best of my knowledgeis payeble from any other than a 1henthe Medical Assistance Program; payment of fees made in accordancewith establishedschedules la accepted as payment In full; been submitted or paid; ALL clelm rejected or denied or one for adjustment, no previous delm lor the care, services and suppIles Itemized has OF MY KNOWLEDGE;NO STATEMENTS, DATA AND INFORMATIONTRANSMITTEDARE TRUE, ACCURATEAND COMPLETETO THE BEST FROM FEDERAL, MATERIAL FACT HAS BEEN OMITTED: I UNDERSTANDTHAT PAYMENT AND SATISFACTUN OF THIS CLAIM WILL BE STATE AND 1,OCALPUBLIC FUNOSAND THAT LMAY BE FINED AND/OR PROSECUTEDUNDER APPLICABLEFEDERALAND STATE LAWS STATEMENTS OR FOR ANY VIOLATION OF THE TERMS OF THIS CERTIFICATON, INCLUDING BUT NOT LIMITED TO FALSE CLAIMS, exempt are excluded; all records pertaining to the care, DOCUMENTS,OR CONCEALMENTOF A MATERIALFACT; taxes irom which the State is supplies provided to segvkes and supplies provided including all records which are necessary to disclose fully the extent of care, services and such recordeand individualsunder the New York Slate MedicalAssistanceProgramwill be kept for a period of six yeare from the date of payment, and information regardingthese claims and payment thereforshall be prompily lumished upon request to the tocel Departmentof Soclel Services,the State of Cepartrnantof Health Departmentof Heath, the OfIIce of the Medicald InspectorGeneral,the State MedicaidFraudControl Unit or the Secretary the 504 of the Federal RehabilitationAct of and Human Services; there has been compliance with the Federal Civil Rights Act of 1984 and with section Jagree (or the entily agrees) 1973, as arnended,which forbid discriminationon the beatsof rece>color, national origin,handicap,age, sex end retlgIon; the Slale of New YorlrtmoUgh Its fiscal agent or otherwiseis -corriplywith the retfuirementof 42 CFR Part 455 relating to disclosures by providers; under thia agreement to enable Its automated processing, suthect to hereby authorized to (1) ineke administrativecorrections to clelms submRted reversal by the provider, and (2) accept sis cisim underthis agreementas original evidenceof care, services end auppliesfurnished, In subrnitting claims under thla agreement I understandand agree that I (or the entity) shall be subject to and bound by all rules, regulations,policies, the Office of the Medicaid Inspector General as set lorth In standesde,fee codes and procedures of the New York State Departmentof Health and statute or title 18 of the Officlel Compilationof Codes,Rules and Regulationof New York State and other publicallons of the Department Induding eMedNY Provider Manuals and olher officler bulletins of the Department. I understandand agree that I (or the entity) shall be subject to and shall fee codes and procedures, accept, subject to due process of the law, any delerminations pursuant to said rules, regulations, policies, standards, present or future status in the Medicald program and/or including, but not limited to, any duly made determinationaffecting my (or my entit/s) past, imposingany duly considered sanctionor penalty. I UNDERSTAND THAT MY SIGNATURE HEREQN THE ABOVE CERTIFICATION WILL APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER USING MY OR PLEASE DO NOT THE ENTITY*S) NPI OR MEDICAID PROVIDER IDENTLFICATION NUMBER. IS STAPLE OR CERTIFICATON REMAINS IN EFFECT AND APPLIES TO ALL CLAIMS UNTIL CERTIFICATION STATEMENT. WRITE IN BAR SUPERSEDED BY ANOTHER PROPERLY EXECUTED CODE AREA (T) (signaturet (8) (Oate) (9) (Print Name and Title) 5 , of Sc4 ,, C Mlb // V __ xT' UA 5 anT "A$ (10) (Telephone #) r (11) (eMail, If available) 4 STATE OF Menachem Ofzel COUNTY OF (12) ID: 010R6365302 County: Rockland On this W) day of 20E..., before me personally came Expiles: 10tO2)2O21 I/f¼ 4 . to me know and known to me to the individual described in and who executed the foregoIng instrument, and (s)he acItnowledge to me that executed the same (SEAL) NOTARY PUBUC EMEDNY-490601 (12/10)