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. 615 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 179
jar T INDEX NO. 451549/2023
NYSCEEDOAL aa _ Agus 844 RECEIVED NYSCEF: 06/28/2023
(4) Erin _OOFT (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) 03/25/2020, all claims submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnished
(4) by (provider name) HOLLIS OPERATING CO LLC. (5) (10-digit National Provider
1366782534
ID (NPI) -- REQUIRED unless
exempted from NPI)
(6) (8-digit Medicaid Provider 00308769
Number -- If NPI exempt)
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 enrolled with and authorized to
Participate in the New York State Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim; the
persons providing services, care and supplies have the necessary licensing, cerification, training and experience to perform the claimed services; |
have reviewed these claims; | (or the entity) have furnished or caused to be furnished the cara, services, and supplies itemized and done so in
accordance with applicable federal and state laws and regulations; | have read the eMedNY Provider Manual and all 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
“ANOTEr prolessiGnial Nave fO the bes! of my knowledge been ordered by that professional in bona fide compliance 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 part thereof 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 with established schedules is accepted as payment in full; other than a
claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitted 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; all records pertaining to the care,
services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to
individuals under the New York State Medical Assistance Program will be kept for a period of six years from the date of payment, and such records and
information regarding these claims and payment therefor shall be promptly furnished upon request to the local Department of Social Services, the State
Department of Health, the Office of the Medicaid Inspector General, the State Medicaid 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 $04 of the Federat 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}
to comply with the requirement of 42 CFR Part 455 relating to disclosures by providers; the State ol New York through its fiscal agent or otherwise is
hereby authorized to (1) make administrative corrections to claims submitted under this agreement to enable its automated processing, subject 10
reversal by the provider, and (2) accept the claim under this agreement as original evidence of care, services and supplies furnished.
In submitting claims under this agreement | understand and agree that | (or the entity) shall be subject to and bound by all rules, regulations, policies,
standards, fee codes and procedures of the New York State Department of Health and the Office of the Medicaid Inspector General as set forth in
statute or title 18 of the Official Compilation of Codes, Rules and Regulation of New York State and other publications of the Department, including
eMedNY Provider Manuals and other official bulletins of the Department. | understand and agree that | (or the entity) shail be subject to and shail
Yh
accept, subject to due process of the law, any determinations pursuant to said 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 Medicaid program andior
imposing any duly considered sanotion or penalty.
| UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILL
LY TI LL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER, USING MY (OR PLEASE DO NOT|
THE ENTITY'S) NPI OR MEDICAID PROVIDER IDENTIFICATION NUMBER. STAPLE OR
CERTIFICATIO! REMAI IN ‘ECT ND API LAIMS " UNTIL WRITE IN BAR
SUPERSEDED BY ANOTHER PROPERLY EXECUTED C!SEATIFICATION STATI EMENT.
CODE AREA
(7) (Signature) € re“ Te (8) (Datey 3/2/22.
(9) (Print Name and Title) Shs Des tse 4 j cert lett
y
(10) (Telephone #) W/493/-9700 j72 55 or $
(41) (eMail, if available) $45 @ cert USbeS/at
state or er Vos
COUNTY OF Bfoax (12) Elisha M Schwab
Notary Public
ontris
fs & dayof “tafe 4 20_2u , before me personally came 018C6390623
ires 04/22/2094
Shh Dlopoct , to me know and known to me to the individuat described in and who
‘executed the foregoing instrument, and (s)ha acknowladge to ma that (s)he executed the same.
L440
(SEAL) Elisha M Schwal.
Notary Public
'D o1SCé639062"
E201 ERROR
OH taro) NOTARY PUBRIEIES 0872/2
=. T INDEX NO. 451549/2023
NYSCEF DOC. NO. 615 RECEIVED NYSCEF 06/28/2023
CERTIFICATION STATEMENT INSTRUCTIONS
,
A Catificaion Saement must be completed:
1. When you ae appl ying for an Electronic/Paper Transmitter Identifi ‘ion Number (ETIN) for the dl ectronicor paper
submissionof New York Medicaid data At leat one Certification Statement must accompany the ETIN Application Form. If
you have multiple providers that you want linked to thenew ETIN, you mus complete and notari ze a Certification Statement
for gach provider tha isto belinked to the new ETIN, and send the Certification Stement(s) al ong with the ETIN Application
2. When you are adding a provider1D number to an xisting ETIN, you must complete
and notarize
a Ceti fication Statement for
the provider ID to be added, and indicate the ETIN in the top left comer of the form.
In both instances above, if you want the provider/ETIN combi nation to rece ve remittances electronically, you must al so completean
Electronic Remittance Request form for the provider(s) and ETIN you wecatifying, You mus do this each time you link a ncw
provider to your ETIN. Failureto do so will result in a paper, rather than dectronic, remittance for that provider/ETIN combination,
NOTE: YOU MUST BE ENROLLED IN EITHER EMEDNY EXCHANGE OR FTP PRIOR TO REQUESTING
ELECTRONIC REMITTANCE. ALL DOCUMENTS PERTAINING TO ELECTRONIC REMITTANCE CAN BE
FOUND AT WWW.EMEDNY.ORG OR BY CALLING THE EMEDNY CALL CENTER AT: 1-800-343-9000.
oe
Certification Statements remain in ef fect and apply to all claims untit superseded
by another properly executed Cattificaiion
Statement. Y ou will be aked to update your Certification Statement on un annual bass
Plexe DO NOT use white-out or red ink on thee forms, as they are imaged.
The numbered fields on the Certification Statement correspond with the exp! anati ons given bdow. Any changes to fields 1-12 must
be initialed by the provider.
Field 1: . ‘ansmi Identification Ni er) If you are using this form to obtain an ETIN,
leave this fidd blank. If you wish to add aproviderID number tom existing ETIN, please indicate the ETIN in
the top left corner of the form.
Field 2: BILLING SERVICE NAME If applicable,
enter the name of the bil ling servicethat the provider
is enrolled
with. If you are not using abilling service, leave this fidd blank,
Field3: DATE Enter the date the Cattificati on Statement is submitted to the fiscal agent.
Field 4: PROVIDER NAME Enter the name of the provider whose si gnature
is being notarized,
or name of
organization.
Field 5: -Digit tional Pr« 1 Ider Enter the NPI, unless exempted from NPL.
Field 6: $-Digit Medicaid Provider ID Number — Enter the Medicaid Provider ID number
if NPI exempt.
Field 7: SIGNATURE
=
Enter the si gnaure of the individual indicated in Fidd 4. This must bean original signature.
Field 8: DATE = Enter the date the Certification Statement was si gned and notari zed.
Field 9: NAME AND TITLE Print the name and the title of the person whose si gnature appears in Field 7.
Field 10: TELEPHONE # Enter the td ephone number of the person whose si gnature appears in Field 7.
Field 11; ADDRESS
EMAIL. (If Available) If available, enter the emai] address of the person whow signature
appears
in Field 7.
Field 12: NOTARY PUBLIC To becompleted and s gned by the Notary Public. The fiscal agent cannot accept
Cattification SXatements that are not notarized. In addition to thenotary signature, NYSDOH requires a notary
seal or stamp on this,document. The notary's commission expiration date/year must beaitaed and legible. This
information may -be hand-written if it does not appear on the samp/scal.. The provider'sname must be entered,
asthe person who parsonally came before the notary.
Please mail original (FAX copies ae not acceptable) completed Certification Statements to:
eMeiNY
ATTN: Enroll ment Support
PO Box 4614
£20191, 2098.044 ns Ransdar, NY 12144-8614
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 615 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 179 jar T INDEX NO. 451549/2023 NYSCEEDOAL aa _ Agus 844 RECEIVED NYSCEF: 06/28/2023 (4) Erin _OOFT (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) 03/25/2020, all claims submitted electronically or on paper to the State's Medicaid fiscal agent, for services or supplies furnished (4) by (provider name) HOLLIS OPERATING CO LLC. (5) (10-digit National Provider 1366782534 ID (NPI) -- REQUIRED unless exempted from NPI) (6) (8-digit Medicaid Provider 00308769 Number -- If NPI exempt) 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 enrolled with and authorized to Participate in the New York State Medical Assistance Program and in the profession or specialties, if any, required in connection with this claim; the persons providing services, care and supplies have the necessary licensing, cerification, training and experience to perform the claimed services; | have reviewed these claims; | (or the entity) have furnished or caused to be furnished the cara, services, and supplies itemized and done so in accordance with applicable federal and state laws and regulations; | have read the eMedNY Provider Manual and all 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 “ANOTEr prolessiGnial Nave fO the bes! of my knowledge been ordered by that professional in bona fide compliance 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 part thereof 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 with established schedules is accepted as payment in full; other than a claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitted 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; all records pertaining to the care, services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to individuals under the New York State Medical Assistance Program will be kept for a period of six years from the date of payment, and such records and information regarding these claims and payment therefor shall be promptly furnished upon request to the local Department of Social Services, the State Department of Health, the Office of the Medicaid Inspector General, the State Medicaid 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 $04 of the Federat 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} to comply with the requirement of 42 CFR Part 455 relating to disclosures by providers; the State ol New York through its fiscal agent or otherwise is hereby authorized to (1) make administrative corrections to claims submitted under this agreement to enable its automated processing, subject 10 reversal by the provider, and (2) accept the claim under this agreement as original evidence of care, services and supplies furnished. In submitting claims under this agreement | understand and agree that | (or the entity) shall be subject to and bound by all rules, regulations, policies, standards, fee codes and procedures of the New York State Department of Health and the Office of the Medicaid Inspector General as set forth in statute or title 18 of the Official Compilation of Codes, Rules and Regulation of New York State and other publications of the Department, including eMedNY Provider Manuals and other official bulletins of the Department. | understand and agree that | (or the entity) shail be subject to and shail Yh accept, subject to due process of the law, any determinations pursuant to said 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 Medicaid program andior imposing any duly considered sanotion or penalty. | UNDERSTAND THAT MY SIGNATURE HEREON THE ABOVE CERTIFICATION WILL LY TI LL CLAIMS SUBMITTED ELECTRONICALLY OR ON PAPER, USING MY (OR PLEASE DO NOT| THE ENTITY'S) NPI OR MEDICAID PROVIDER IDENTIFICATION NUMBER. STAPLE OR CERTIFICATIO! REMAI IN ‘ECT ND API LAIMS " UNTIL WRITE IN BAR SUPERSEDED BY ANOTHER PROPERLY EXECUTED C!SEATIFICATION STATI EMENT. CODE AREA (7) (Signature) € re“ Te (8) (Datey 3/2/22. (9) (Print Name and Title) Shs Des tse 4 j cert lett y (10) (Telephone #) W/493/-9700 j72 55 or $ (41) (eMail, if available) $45 @ cert USbeS/at state or er Vos COUNTY OF Bfoax (12) Elisha M Schwab Notary Public ontris fs & dayof “tafe 4 20_2u , before me personally came 018C6390623 ires 04/22/2094 Shh Dlopoct , to me know and known to me to the individuat described in and who ‘executed the foregoing instrument, and (s)ha acknowladge to ma that (s)he executed the same. L440 (SEAL) Elisha M Schwal. Notary Public 'D o1SCé639062" E201 ERROR OH taro) NOTARY PUBRIEIES 0872/2 =. T INDEX NO. 451549/2023 NYSCEF DOC. NO. 615 RECEIVED NYSCEF 06/28/2023 CERTIFICATION STATEMENT INSTRUCTIONS , A Catificaion Saement must be completed: 1. When you ae appl ying for an Electronic/Paper Transmitter Identifi ‘ion Number (ETIN) for the dl ectronicor paper submissionof New York Medicaid data At leat one Certification Statement must accompany the ETIN Application Form. If you have multiple providers that you want linked to thenew ETIN, you mus complete and notari ze a Certification Statement for gach provider tha isto belinked to the new ETIN, and send the Certification Stement(s) al ong with the ETIN Application 2. When you are adding a provider1D number to an xisting ETIN, you must complete and notarize a Ceti fication Statement for the provider ID to be added, and indicate the ETIN in the top left comer of the form. In both instances above, if you want the provider/ETIN combi nation to rece ve remittances electronically, you must al so completean Electronic Remittance Request form for the provider(s) and ETIN you wecatifying, You mus do this each time you link a ncw provider to your ETIN. Failureto do so will result in a paper, rather than dectronic, remittance for that provider/ETIN combination, NOTE: YOU MUST BE ENROLLED IN EITHER EMEDNY EXCHANGE OR FTP PRIOR TO REQUESTING ELECTRONIC REMITTANCE. ALL DOCUMENTS PERTAINING TO ELECTRONIC REMITTANCE CAN BE FOUND AT WWW.EMEDNY.ORG OR BY CALLING THE EMEDNY CALL CENTER AT: 1-800-343-9000. oe Certification Statements remain in ef fect and apply to all claims untit superseded by another properly executed Cattificaiion Statement. Y ou will be aked to update your Certification Statement on un annual bass Plexe DO NOT use white-out or red ink on thee forms, as they are imaged. The numbered fields on the Certification Statement correspond with the exp! anati ons given bdow. Any changes to fields 1-12 must be initialed by the provider. Field 1: . ‘ansmi Identification Ni er) If you are using this form to obtain an ETIN, leave this fidd blank. If you wish to add aproviderID number tom existing ETIN, please indicate the ETIN in the top left corner of the form. Field 2: BILLING SERVICE NAME If applicable, enter the name of the bil ling servicethat the provider is enrolled with. If you are not using abilling service, leave this fidd blank, Field3: DATE Enter the date the Cattificati on Statement is submitted to the fiscal agent. Field 4: PROVIDER NAME Enter the name of the provider whose si gnature is being notarized, or name of organization. Field 5: -Digit tional Pr« 1 Ider Enter the NPI, unless exempted from NPL. Field 6: $-Digit Medicaid Provider ID Number — Enter the Medicaid Provider ID number if NPI exempt. Field 7: SIGNATURE = Enter the si gnaure of the individual indicated in Fidd 4. This must bean original signature. Field 8: DATE = Enter the date the Certification Statement was si gned and notari zed. Field 9: NAME AND TITLE Print the name and the title of the person whose si gnature appears in Field 7. Field 10: TELEPHONE # Enter the td ephone number of the person whose si gnature appears in Field 7. Field 11; ADDRESS EMAIL. (If Available) If available, enter the emai] address of the person whow signature appears in Field 7. Field 12: NOTARY PUBLIC To becompleted and s gned by the Notary Public. The fiscal agent cannot accept Cattification SXatements that are not notarized. In addition to thenotary signature, NYSDOH requires a notary seal or stamp on this,document. The notary's commission expiration date/year must beaitaed and legible. This information may -be hand-written if it does not appear on the samp/scal.. The provider'sname must be entered, asthe person who parsonally came before the notary. Please mail original (FAX copies ae not acceptable) completed Certification Statements to: eMeiNY ATTN: Enroll ment Support PO Box 4614 £20191, 2098.044 ns Ransdar, NY 12144-8614