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. 616 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 180
NK DM INDEX NO. 451549/2923
EEA) 2 a 0 ) OCOUN 06
NYSCEF DOC. NO. 616 RECEIVED NYSCEF: 06/28/2023
(4) ETin _ 870 (2} BILLING SERVICE NAME (IF APPLICABLE)
eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM
CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID
(3) As of (date) 07/27/2020 , ali 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
1D (NPI) -- REQUIRED unless 1366782534
exempted from NPI)
(6) (8-digit Medicaid Provider 00308769
Number -- If NPI exempt)
will be subject to the following certification
lam (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 spe 8, it any, required in connection with this claim; the
persons providing services, care and supplies have the necessary licensing, certification, t ing and experience lo pertorm the claimed services: |
have reviewed these claims; | (or the entity) have furnished or caused to be furnished the care, 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
another professional have to the best of my knowiedge been ordered by that professional in bona fide compliance with the procedures set forth in the
manual and revi is. All care, services and supplies for which clai made are medically necessary for the treatment of the named recipient, the
amounts listed are due and, except as noted, ne part thereof has been paid by, or to the bes! of my knowledge is payable trom 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 suppli itemized has been submitted or paid; ALL
STATEMENTS, DATA ANO 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 ol six years Irom 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
Deparment of Health, the Office of the Medicaid Inspecior General, the State Medicaid Fraud Control Unit or the Secretary of the Oepartment 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 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 485 relating to disclosures by providers; the Stale of New York througi {ts fiscal agent or otherwise is
hereby authorized to (1) make administrative corrections to claims submitted under this agreement to enable its automated processing, subject to
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 Oepartment 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 olficial bulletins of the Department. | understand and agree 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, standards, lee codes and procedures. ap
including, but not limited to, any duly made determination alfecting my (or my entity’s) past, present or future status in he Medicaid program and/or
imposing any duly considered sanction or penalty.
i UNDERSTAND THAT MY SIGNATURE HEREON 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 IDENTIFICATION ‘NUM STAPLE OR
CERTIFICATION REMAINS IN| EFFEC NO Ms. NTE
SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT. WRITEIN BAR |
CODE AREA
(7) (Signature) _9- & (8) (oatey_L/ 4/20 re
(9) (Print Name and Title 54°49 Devt sch coat folie
(10) (Telephone #) 7/P- 49-9700 ¢ #72 (11) (eMai, it available) 54.4 De tat WS hu lineSS, 078.
Notary Public
stare or NeW York Menachem Orzel
COUNTY OF B/ony (12) ID: 010R6365302
County: Rockland
Expires: 10/02/2021
On this es day ot Av bust 202.¢ , before me personally came
Tha Dib4 Se 6 to me know and known to me to their | described in and who
executed the foregoing instrument, and (s)he acknowledge to me 1 cuted the same.
(SEAL)
NOTARY PUBLIC
EMEDNY-490601 (12/10)
rr EE a)
Le ) 0 rs OOSDUN KK 06 DM INDEX NO. 451549/2923
NYSCEF DOC. NO. 616 RECEIVED NYSCEF: 06/28/2923
CERTIFICATION STATEMENT INSTRUCTION:
A Cettification Statement must be completed:
1, When you are appl ying Foran Electronic/Paper Transmitter J denti fication Number (ETIN) for the electronic or paper
submissionof New York Medicaid daa At leat ne Certification Staement must accompany the ETIN Application Form. If
you have multiple providers that you want linked to the new ETIN, you mus complete and notarize
a Certi fication Statement
for each provider that isto be linked to the new ETIN, and send the Cattification Statement(s) along with the ETIN A pplication
Form.
2. When you are alding
a provider ID number to an existing ETIN, you must complete
and notari zea Certi fication Statement for
the providerUD to be added,
and indicate
the ETIN in the top left cornerof the form.
In both instances above, if you want the provider/ETIN combination to recei ve remittances lectronically, you must also complete an
Electronic Remittance Request form for the provider(s) and ETIN you are certifying. You must do this gach time you link a new
provider to your ETIN, Failureto do so will result ina paper, rather than electronic, 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,
Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certi fication
Statement. You will be asked to update your Certification Statement on an annual basis:
Please DO NOT use white-out or red ink on these forms, as they are imaged.
The numbered fieldson the Certification Statement correspond with the explanations given below. Any changes to fields 1-12 must
be initialed by the provider.
a
Field 1: TIN A ransmitt If you are using this form to obtain an ETIN,
leave this field blank. If you wish to add aprovider[ID number to an existing ETIN, please indicate
the ETIN in
the top left corner of the form.
Field 2: BILLING SERVICE NAME Tf applicable, emer the name of the bil ling service that the provider is enrol
with. If you are not using abil ling service, leave this field blank.
Field 3: DATE Enter the date the Certification Staanem is submitted to the fiscal agent.
Field 4: PROVIDER NAME Enter the name of the provider whose si gnature
is bei ng notarized, or nameof
organization.
Field 5: 10-Digit National Provider Identifier (NPI) Enter the NPI, unless exempted from NPI.
Field 6: §-Digit Medicaid Provider ID Number — Enter the Medicaid Provider ID number if NPI exempt.
Field 7: SIGNATURE _ Enter the signatureof the indi vidual indicated in Field 4. This must be an original signature.
Field 8: DATE — Enter the date the Certification Statement was 4 gnad and notarized.
TT Field 9: NAME
AND TITLE Print thenameand the title of the person whose si gnature appears in Fidid 7.
Field 10: TELEPHONE # — Enter the telephone number of the person whose
s gnaure appears in Field 7.
Field 11: EMAIL ADDRESS (If Ayailable) If available, enter the email addressof the person whose ¢ gnature
appears
in Field 7.
Field 12: NOTARY PUBLIC — To becompleted and signed by the Notary Public. The fiscal agent cannot accept
Catti ‘ati on Statements
that are not notarized, In addition to the notary signature, NYSDOH requiresa notary
seal or damp on this document. The notary’s commission ex pi ration dae/year must beentered and Jegible. This
information may behand-w7itten if it does not appear on the stamp/seal. The provider's name Must be entered
as the person Who persorial ly Gtine before the notary.
Please mail original (FAX copiesare not acceptable) compl cad Catti fication Statements to:
eMaiNY
ATTN: Farall ment Support
PO Box 4614
Renssalaer, NY 12144-3614
EMEDNY-490501 (11/16)
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 616 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 180 NK DM INDEX NO. 451549/2923 EEA) 2 a 0 ) OCOUN 06 NYSCEF DOC. NO. 616 RECEIVED NYSCEF: 06/28/2023 (4) ETin _ 870 (2} BILLING SERVICE NAME (IF APPLICABLE) eMedNY/MEDICAID MANAGEMENT INFORMATION SYSTEM CERTIFICATION STATEMENT FOR PROVIDER BILLING MEDICAID (3) As of (date) 07/27/2020 , ali 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 1D (NPI) -- REQUIRED unless 1366782534 exempted from NPI) (6) (8-digit Medicaid Provider 00308769 Number -- If NPI exempt) will be subject to the following certification lam (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 spe 8, it any, required in connection with this claim; the persons providing services, care and supplies have the necessary licensing, certification, t ing and experience lo pertorm the claimed services: | have reviewed these claims; | (or the entity) have furnished or caused to be furnished the care, 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 another professional have to the best of my knowiedge been ordered by that professional in bona fide compliance with the procedures set forth in the manual and revi is. All care, services and supplies for which clai made are medically necessary for the treatment of the named recipient, the amounts listed are due and, except as noted, ne part thereof has been paid by, or to the bes! of my knowledge is payable trom 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 suppli itemized has been submitted or paid; ALL STATEMENTS, DATA ANO 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 ol six years Irom 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 Deparment of Health, the Office of the Medicaid Inspecior General, the State Medicaid Fraud Control Unit or the Secretary of the Oepartment 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 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 485 relating to disclosures by providers; the Stale of New York througi {ts fiscal agent or otherwise is hereby authorized to (1) make administrative corrections to claims submitted under this agreement to enable its automated processing, subject to 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 Oepartment 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 olficial bulletins of the Department. | understand and agree 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, standards, lee codes and procedures. ap including, but not limited to, any duly made determination alfecting my (or my entity’s) past, present or future status in he Medicaid program and/or imposing any duly considered sanction or penalty. i UNDERSTAND THAT MY SIGNATURE HEREON 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 IDENTIFICATION ‘NUM STAPLE OR CERTIFICATION REMAINS IN| EFFEC NO Ms. NTE SUPERSEDED BY ANOTHER PROPERLY EXECUTED CERTIFICATION STATEMENT. WRITEIN BAR | CODE AREA (7) (Signature) _9- & (8) (oatey_L/ 4/20 re (9) (Print Name and Title 54°49 Devt sch coat folie (10) (Telephone #) 7/P- 49-9700 ¢ #72 (11) (eMai, it available) 54.4 De tat WS hu lineSS, 078. Notary Public stare or NeW York Menachem Orzel COUNTY OF B/ony (12) ID: 010R6365302 County: Rockland Expires: 10/02/2021 On this es day ot Av bust 202.¢ , before me personally came Tha Dib4 Se 6 to me know and known to me to their | described in and who executed the foregoing instrument, and (s)he acknowledge to me 1 cuted the same. (SEAL) NOTARY PUBLIC EMEDNY-490601 (12/10) rr EE a) Le ) 0 rs OOSDUN KK 06 DM INDEX NO. 451549/2923 NYSCEF DOC. NO. 616 RECEIVED NYSCEF: 06/28/2923 CERTIFICATION STATEMENT INSTRUCTION: A Cettification Statement must be completed: 1, When you are appl ying Foran Electronic/Paper Transmitter J denti fication Number (ETIN) for the electronic or paper submissionof New York Medicaid daa At leat ne Certification Staement must accompany the ETIN Application Form. If you have multiple providers that you want linked to the new ETIN, you mus complete and notarize a Certi fication Statement for each provider that isto be linked to the new ETIN, and send the Cattification Statement(s) along with the ETIN A pplication Form. 2. When you are alding a provider ID number to an existing ETIN, you must complete and notari zea Certi fication Statement for the providerUD to be added, and indicate the ETIN in the top left cornerof the form. In both instances above, if you want the provider/ETIN combination to recei ve remittances lectronically, you must also complete an Electronic Remittance Request form for the provider(s) and ETIN you are certifying. You must do this gach time you link a new provider to your ETIN, Failureto do so will result ina paper, rather than electronic, 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, Certification Statements remain in effect and apply to all claims until superseded by another properly executed Certi fication Statement. You will be asked to update your Certification Statement on an annual basis: Please DO NOT use white-out or red ink on these forms, as they are imaged. The numbered fieldson the Certification Statement correspond with the explanations given below. Any changes to fields 1-12 must be initialed by the provider. a Field 1: TIN A ransmitt If you are using this form to obtain an ETIN, leave this field blank. If you wish to add aprovider[ID number to an existing ETIN, please indicate the ETIN in the top left corner of the form. Field 2: BILLING SERVICE NAME Tf applicable, emer the name of the bil ling service that the provider is enrol with. If you are not using abil ling service, leave this field blank. Field 3: DATE Enter the date the Certification Staanem is submitted to the fiscal agent. Field 4: PROVIDER NAME Enter the name of the provider whose si gnature is bei ng notarized, or nameof organization. Field 5: 10-Digit National Provider Identifier (NPI) Enter the NPI, unless exempted from NPI. Field 6: §-Digit Medicaid Provider ID Number — Enter the Medicaid Provider ID number if NPI exempt. Field 7: SIGNATURE _ Enter the signatureof the indi vidual indicated in Field 4. This must be an original signature. Field 8: DATE — Enter the date the Certification Statement was 4 gnad and notarized. TT Field 9: NAME AND TITLE Print thenameand the title of the person whose si gnature appears in Fidid 7. Field 10: TELEPHONE # — Enter the telephone number of the person whose s gnaure appears in Field 7. Field 11: EMAIL ADDRESS (If Ayailable) If available, enter the email addressof the person whose ¢ gnature appears in Field 7. Field 12: NOTARY PUBLIC — To becompleted and signed by the Notary Public. The fiscal agent cannot accept Catti ‘ati on Statements that are not notarized, In addition to the notary signature, NYSDOH requiresa notary seal or damp on this document. The notary’s commission ex pi ration dae/year must beentered and Jegible. This information may behand-w7itten if it does not appear on the stamp/seal. The provider's name Must be entered as the person Who persorial ly Gtine before the notary. Please mail original (FAX copiesare not acceptable) compl cad Catti fication Statements to: eMaiNY ATTN: Farall ment Support PO Box 4614 Renssalaer, NY 12144-3614 EMEDNY-490501 (11/16)