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. 610 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 174
0 DM INDEX NO. 451549/2023
We OUN
Oe K 4
NYSCEF DOC. NO. 610 RECEIVED NYSCEF: 06/28/2023
(1) ETIN _ 870 (2) BILLING SERVICE NAME (IF APPLICABLE)
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
(3) As of (date) 97/27/2017, all claims submitted electronically or on paperto the State's Medicaid fiscal agent, for services or supplies fumished
(4) by (provider name) HOLLIS OPERATING CO LLC (5) (10-digit National Provider
ID (NPI) ~ REQUIRED untess 1366782534
exempted from NPI
(6) (8-digit Medicaid Provider 00308769
Number~ If NPI exempt)
will be subject to the following certification.
| am (or tha business entity named in this form of which | am a partner, officer, or director is) a qualified provider enrotled with and authorized to
participate in the New York State Medical Assistance Program and in the profession or speciattiss, If eny, required In connection with this claim; the
persons providing services, care and supplies have the nocssary licensing, certification, training and experience to pertorm ihe claimed services; |
have reviewed these claims; | (or the entity) hava 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 aMedNY Provider Manual and all revisions thereto; all clalms aro
madeIn full compliance with the pertinent provisionsof the Manual and revisions;all clalms for care, 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 complance with the procedures eet forth in tha
‘manual and revisions. All care, services and suppiles for which claim is made are medically necessary for the treatment of the named recipient, tha
amounts listed are dua and, except as noted, no part thereof has been pald 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 with established schedules is accepted as payment in ful; other than a
clalm rejected or denied or one for adjustment, no previous claim for the care, services and supplios ltemized has been submittad or paid; 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 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; taxes from which the State is exempt are excluded; ail records pertaining to the care,
services and suppiles provided Including all records which necessary to disclose tully the extent of care, services and supplies provided to
individuals under the New York State Medical Assistance Program wii! be kept for a period of six years from the date of payment, and such records and
Information these clalms and therefor shall be promptly fumished upon request to the loca! Departmant af Social Services, the State
Department of Health, the Office of the Medicald Inspector General, the State Medicald Fraud Contro! Unit or the Secretary of the Departmentof Health
‘and Human Services; thara has been comptiance with the Federal Civil Rights Act of 1984 and with section 504 of the Federal Rehabitiation Act of
1973, es. amended, which forbld discrimination on the basis of race, color, national origin, handicap, age. sex and religion; | agree (or the entityagrees)_
to comply with the requirement of 42 CFR Part 455 relating to disclosuresby providers; the State of New York through its fiscal agent or
hereby authorized to (1) make administrative corrections to clalms submitted under this agreement to enable Its Processing, subject to
reversal by the provider, and (2) accept the claim under this agreement as original evidence of care, services and supplies fumishad.
.
In submitting clalms under this agreement | understand and agree that | {or the entity) shall be subject to and bound by all rules, regulations, policies, fw
4
standards, fee codes and procedures of the New York State Department of Health and the Office of tha Madicald Inspector General as set forth In
statute er ttle 18 of the Officlal Compilation of Cedes, Rules and Regulalion of Naw York Stata and other publications of the Department, Including
eMedNY Provider Manuats and other official bulletins of the Department. | understand and agroe that | (or the entity) shall be subject to and shall
‘accept, subject to due process of the law, any determinations pursuant to said rules, regulations, policies, standants, fee codes and procedures,
Including, but not limited to, any duly mada detemmination affecting my {or my entity's) past, present or future status in the Medicald program and/or
Imposing any duty considered sanction or penalty.
UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILI
APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALL’ OR ON PER, NG MY,THs PLEASE DO NOT]
Ee ENTITY'SMEDICAID PROV IDER OF TIFICATION NUM
RelA oR STAPLE OR
EFFEC Me” " UNTI
SUPERSEDED BY ANOTHER PRO! PERLY ExecureD CERTIFICATION Sr ATEMENT. WRITE iN BAR.
l
CODE AREA
(Signature) _S - DLT (6) (001) aff 2of7
(9) (Prin Name and Tite) 54:4 Deve ses , < oAf oft be
£49) (Telaptione 4) 7/7 FIG Joo 2 (14) (eMail, if available) 542 @ © lat Ysbes'ab SS OFS
STATE OF
COUNTYOF (2)
in this lay 2012. before me porsonally camo
Va id known to me to the Individual described in and who.
the foregoing instrument, and (s)he acknowledge to me that (s)he jad the same.
ZIN!
/NOTARY PUBLIC, STATE OF NEW YORK.
Registration No. 01216228296
on PUBLIC
E17 TG £0 it)
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 610 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 174 0 DM INDEX NO. 451549/2023 We OUN Oe K 4 NYSCEF DOC. NO. 610 RECEIVED NYSCEF: 06/28/2023 (1) ETIN _ 870 (2) BILLING SERVICE NAME (IF APPLICABLE) eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID (3) As of (date) 97/27/2017, all claims submitted electronically or on paperto the State's Medicaid fiscal agent, for services or supplies fumished (4) by (provider name) HOLLIS OPERATING CO LLC (5) (10-digit National Provider ID (NPI) ~ REQUIRED untess 1366782534 exempted from NPI (6) (8-digit Medicaid Provider 00308769 Number~ If NPI exempt) will be subject to the following certification. | am (or tha business entity named in this form of which | am a partner, officer, or director is) a qualified provider enrotled with and authorized to participate in the New York State Medical Assistance Program and in the profession or speciattiss, If eny, required In connection with this claim; the persons providing services, care and supplies have the nocssary licensing, certification, training and experience to pertorm ihe claimed services; | have reviewed these claims; | (or the entity) hava 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 aMedNY Provider Manual and all revisions thereto; all clalms aro madeIn full compliance with the pertinent provisionsof the Manual and revisions;all clalms for care, 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 complance with the procedures eet forth in tha ‘manual and revisions. All care, services and suppiles for which claim is made are medically necessary for the treatment of the named recipient, tha amounts listed are dua and, except as noted, no part thereof has been pald 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 with established schedules is accepted as payment in ful; other than a clalm rejected or denied or one for adjustment, no previous claim for the care, services and supplios ltemized has been submittad or paid; 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 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; taxes from which the State is exempt are excluded; ail records pertaining to the care, services and suppiles provided Including all records which necessary to disclose tully the extent of care, services and supplies provided to individuals under the New York State Medical Assistance Program wii! be kept for a period of six years from the date of payment, and such records and Information these clalms and therefor shall be promptly fumished upon request to the loca! Departmant af Social Services, the State Department of Health, the Office of the Medicald Inspector General, the State Medicald Fraud Contro! Unit or the Secretary of the Departmentof Health ‘and Human Services; thara has been comptiance with the Federal Civil Rights Act of 1984 and with section 504 of the Federal Rehabitiation Act of 1973, es. amended, which forbld discrimination on the basis of race, color, national origin, handicap, age. sex and religion; | agree (or the entityagrees)_ to comply with the requirement of 42 CFR Part 455 relating to disclosuresby providers; the State of New York through its fiscal agent or hereby authorized to (1) make administrative corrections to clalms submitted under this agreement to enable Its Processing, subject to reversal by the provider, and (2) accept the claim under this agreement as original evidence of care, services and supplies fumishad. . In submitting clalms under this agreement | understand and agree that | {or the entity) shall be subject to and bound by all rules, regulations, policies, fw 4 standards, fee codes and procedures of the New York State Department of Health and the Office of tha Madicald Inspector General as set forth In statute er ttle 18 of the Officlal Compilation of Cedes, Rules and Regulalion of Naw York Stata and other publications of the Department, Including eMedNY Provider Manuats and other official bulletins of the Department. | understand and agroe that | (or the entity) shall be subject to and shall ‘accept, subject to due process of the law, any determinations pursuant to said rules, regulations, policies, standants, fee codes and procedures, Including, but not limited to, any duly mada detemmination affecting my {or my entity's) past, present or future status in the Medicald program and/or Imposing any duty considered sanction or penalty. UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILI APPLY TO ALL CLAIMS SUBMITTED ELECTRONICALL’ OR ON PER, NG MY,THs PLEASE DO NOT] Ee ENTITY'SMEDICAID PROV IDER OF TIFICATION NUM RelA oR STAPLE OR EFFEC Me” " UNTI SUPERSEDED BY ANOTHER PRO! PERLY ExecureD CERTIFICATION Sr ATEMENT. WRITE iN BAR. l CODE AREA (Signature) _S - DLT (6) (001) aff 2of7 (9) (Prin Name and Tite) 54:4 Deve ses , < oAf oft be £49) (Telaptione 4) 7/7 FIG Joo 2 (14) (eMail, if available) 542 @ © lat Ysbes'ab SS OFS STATE OF COUNTYOF (2) in this lay 2012. before me porsonally camo Va id known to me to the Individual described in and who. the foregoing instrument, and (s)he acknowledge to me that (s)he jad the same. ZIN! /NOTARY PUBLIC, STATE OF NEW YORK. Registration No. 01216228296 on PUBLIC E17 TG £0 it)