Preview
FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
EXHIBIT "D
FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
SUPREME COURTOF THE STATE OF NEW YORK
COUNTY OF BRONX (ECF)
___ _____...____________-......._____......____.-·----X
CARLTON L. MOITT, JR., as Administrator of the
Estate of CYNTHIA MOITT,
Plaintiff, CERTIFICATION OF
ADMISSION AGREEMENT
-against-
THROGS NECK OPERATING COMPANY, LLC,
THROGS NECK REHABILITATION & NURSING
CENTER and ELENA VEZ2;A, M.D.,
Defendant.
---..-------- ________-----------...---------X
. a
, hereby affirms the following to be
true pursuant to the penalties of perjury:
1. I am the duly authorized custodian at THROGS NECK OPERATING
COMPANY, LLC d/b/a THROGS NECK REHABILITATION & NURSING CENTER or other
qualified witness and I have the authority to make this certification.
2. To the best of my knowledge, after reasoñable inquiry, the attached records or
copies thereof is a complete and accurate version of the Admission Agreement for CYNTHIA
MOITT relative to her residency at THROGS NECK OPERATING COMPANY, LLC d/b/a
THROGS NECK REHABILITATION & NURSING CENTER.
3. The records or copies produced were made in the regular course of business, at
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NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
the time of the transaction, occurrence or event recorded therein, or within a easonable time
thereafter, and that it was the regular course of business to m .. h records.
1
Sworn to before me this
day of d, 2021
mommy a
Not.
rý
. CoinmissionE pl es yenuary l3 024
Dated: 2 lo 202
Signed .
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NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
THKOGS NBCK REHABILTTATION & NURSING CENTER
ADMISSION AGREEMENT
Agreement dated . 204 (hereinafter tha'Agreement") between Throgs Neck Operating
Thrd s T R idN Nusing 7 Th oghléckÉpire ÔWay;Èi Y
10465 (hereinafter "Facility ) and (hereina r ref fred to as esident")
whose ce=munny residence is ted at and
(hereinafter "Resident Represen tive") residing at
and
Rasident's spouse and/or sponsor (if not listed as "Resident Repressñtatve") (hersiñafter "Sponsor") residing at
.
The Facility accepts the Resident for admission subject to the following terms and conditions:
l. ADMIS$ION AND CONSENT
The undersigned hereby agrees, subject to federal and state laws, rules and regulations, that the Resident will be
admitted to the Facility only upon the order of a New York State iicensed physician and upon a determination that the
Resident satisfies the admiesian assessment criteria set by the New York State Departmsñt of Health and by the
Facility. The Resident, Resident Representative and/or Sponsor hereby consent to such routine care and treatment as
may be provided by the Facility and/or ancillary providers in accordance with the Residents plan of care, including but
not limited to, transfer to an acute care hospital when necessary, dental, medical and/or surgical consultatûñ, .
.exanjination by medical and nursing staff, routine diagñcstic tests.and procedures, nursing services, and medication
administration. The Resident, Resident Representative and/or Sponsor shall have the right to participate in the
development of the plan of care and shall be provided with information concerning his or her rights to consent or refuse
treatment at any time to the extent allowa.ble under applicable law. The Resident, Itesident Representative and/or
Sponsor hereby understand and agree that admission to the Facility is conditioned upon the review and
execution of this Agreement and related documents as more fully set forth herein.
II. MUTUAL CONSIDERATION OF THE PARTIES
The Facility agrees to provide all basic (routine) servicas to the Resident, as well as either provide or arrange for
"A"
available ancillary services, that the Resident may require. Attachment lists the routine, ancillary and additional
services provided and/or arranged for by the Facility. A list of private pay charges for certain anelllary and other
available services is included in your admission package.
By entering this Agreement, the Resident, the Residents Sponsor and/or the Resident Representative on the
Resident's behalf, understand and agree to the following Resident payment obligations. The Resident agrees to pay
for, or arrange to have paid for by Medicald, Medicare or other insurers, all services provided under this Agreement,
and agrees to pay arty required third party deductibles, coinsurance or monthly income budgeted by-the Medicaid
program. The Resident, the Residents Sponsor and/or the Resident Representative accept the duty to ensure .
continuity of payment, including. the duty to arrange for timely Medicaid coverage, if Medicaid coverage becomes
necessary.
The Resident, Resident Representative and Sponsor agree to comply with all applicable policies, procedures,
regulations and rules of the Facility..
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III. . ANTICIPATED SERVICES
Genem!!y, Residents are admitted to the Facility for one of the following masons: sub-acuts care; long term care, or .
hospice care. .
*phiegsWgfeRehébiÈtátiop& lu$ing Centendéfihestsub-acµ‡e care fq g al ori d,joÓjrkh 6, I papelf care
designed Jor à n individudl whá hascan acute IIIness, thjury; or ëxacerbatiòn of a disease process. Glenerally, sub-acute
care is rendered at the Facility immõ‡atsiy after, or instead of, acute hospitafization. Sub-acute care lasts for a limited
time or until a condition is stabilized or a predetermined treatment course is completed.
Residents, who are admitted for sub-acute care, are admitted with the expectation. that they will be discharged once
short-term services are no longer required unless continued placemêñt in the Facility is medically appropriate. It is the
mutual goal of the Resident and the Facility that the Resident retums to his/her home or a less restrictive setting, If
appropriate. The Resident, Resident Representative and/or Sponsor agree to facilitate discharge as soon as medically
appropriate, and hereby represent and agree that they will work with the Facility staff to secure an apprcpriate and
timely discharge. The Resident's failure to cooperate with discharge constitutes a waiver of any limitation that might
othsrwise apply to private collection.
Residents admitted for sub-acute care are responsible for applicable copaymênts, dedüctibles, and/or coinsurance,
and for any charges that may accrue after terminaiion of their third-party coverage if they remain in the Facility for any
reason. Residents covered by Medicare Part A are responsible for a daily coinsurance amount for days21 to 100 of a
Part A covered stay.
If the Resident is admitted for sub-acute services and thereafter remains in the Facility for long term care, an
inte-See!!Ey;room change or transfer to a more appropriate setting may be necessary. Any such room change
shall be carried out in accordance with appilcable law and the Facility's policies and procedures.
IV. -FINANCIAL ARRANGEMENTS
(a) Oblications of Resident. Soonsor andfor Resident Representative
i. Resident and/or Sponsor. A Sponsor, usually the Resident's spouse, as defined in 10 N.Y.C.R.R.
§415.2 la "the entity or the person or persons, other than the resident, responsible in whole or in part for the financial
Facility."
support of the Resident, including the costs of care in the Accordingly, the Sponsor may be personally
responsible for paying for the costs of the Resident's care In the Facility from his/her own funds.
The Resident and/or Sponsor agree to pay, or arrange for payment of, any portion or all.of the applicable
private pay room and board rate and the ancilianf charges incurred for services not covered by third party payors
and/or required third party deductibles and/or coinsurance including moñthty the income contribution (NAMI) budgeted
by the Medicaid program. If the Resident has no third or if the Resident remains in the Facility after
party coverage,
nacessary"
any such coverage terminates because covered services are deemed no longer "medically or fbr any other
reason consistent with sppliusble law, the Resident arid/or Sponsor agree to pay or arrange for pay.ment at the private
pay rate for room and board and the ancillary charges·incurred until discharge or until another source of coverage
beœmes available. The Resident and/or Sponsor agree to take the necessary steps to ensure that the Facility and its
ancillary providers receive payment from all third party payors, including the timely disclosure of available insurance
coverage and production of infomiation and documentation needed to meet the eligibility criteria of the Medicaid
program (e.g., proof of income, resources, residency, citizenship, and explanation of past financial transacticñs).
ii. Res[dent Representative. The Resident Representative is . the individual designated to receive
information and assist and/or act on behalf of the Resident to the extent pe=Ued by .State law. Unless the Resident
Representative is also the Resident's spouse or Sponsor, the Resident Representative is not obligated to pay for the
cost of the Resident's care from his/her own funds. Notwithstanding. the foregoing, to the sident the Resident
Raptosentative breaches the. obligations personally undertaken to onsure that the Resident has a payment
source for.his/her nursing home care (either from private funds and/or a thirdpaity payor) helshe inay be
personally liable to the Facility for the damages caused by said breach. By signing this Agreement, the Resident
FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
Representative represents and warrants he/ she the Resident s funds to pay for the
hereby that shall (1) utilize
Resid*ent's care at the Facility to the extent he/she has access to
such funds; (11) timely provide information and
documsatation requested by the Facility or a third party payor Including, but not limited to, insurance and/or Medicaid;
and (lil) timely provide accurate and complete information and documentation to the Facility regarding such matters as
the Resident's financial reso.urces,. citizsaship or immigration status and third party insurance coverage. The Resident
Bepresentative hereby. agr.ees to indemnify and.helii the . Facility harmlegs from any oss dgmpggor ex epge, the
y i isnâEreséit)Ã’fÈÃÊ f théÚò of Îè$re EiâÌiÈNs'and Wariantiesdh Resiti
. Representatil/e ackfiOw|êdges that nothing herein constitutes an impermissible third party guarantee of payment;
rather, this Agreement sets forth independént obligations that are being voluntarily undensken by the Resident
Representative, The provisions in this paragraph shall survive termination of this Agreement for arly reason.
iii. Resident, Sponsor and/bf Resiqent Represenfaffre. The Resident, Sponsor, and Rsskisñt
Representative understand that the Facility is ayallable to assist with securing third party coverage (including but not
limited to Medicaid), but it is ultimately the responsibility of the Resident, Sponsor and Resident Representative and
the Resident, Sponsor and Resident Repressniaiive shall take all necessary steps to apply for, and qualify for, such
coverage in a timely manner. Care provided to á Resident who does not meet the eligibility criteria for coverage by
third party payors will be billed at the Facility's private pay room and board rate.
The Resident, Sponsor and Resident Representative agree to provide. the Facility in a timely manner
with all relevant information and documentation regarding all potential third party payors including, but not
IImited to, what benefits, if any, may be available from the Resident's insurance and/or managed care plan and
to notify the Facility immediately of any change in Resident's insurance status or coverage Depending on the j
insurance coverage, managed care plan and/or written agreement with the Facility,, additional charges,
including co-insurance, deductibles and/or co-payments, may be imposed. Furthermore, prior authorization
by the insurance carrier or managed care plan does not guarantee coverage and/or reimbursement. in the
event of dental of payment by a third party payor, exhaustion of benefits and/or terinination of coverage, the
Itesident andtor Sponsor shall be responsible for payment to the Facility. The Resident must protnptly notify
the Facility of any notice of a third party payor's discontinuation of payment (coverage),
(c) Private Payment
The Rssidsnt does not have a third party payment source in place, his/her care will be billed at private pay rates. The
private pay room and board rate ("D.ally Basic Rate") Is $ per day for a private room and $
per day for a semi-private room. Ancillary services are not included in the Daily Basic Rate. Ancillary services, such
as physician services, rehabilitation therapies, oxygen, dental and diagnostic services, laboratory, x-ray, podiatry
optometry, medications, urinary care supplies, trach and ostomy supplies, surgical supplies, parenteral and enteral
feeding supplies, transportation servicese and extraonfinary rehabilitative devices, are not iñciudad in the Daily Basic
providers'
Rate and will be billed separately according to the Facility's andfor the service charge schedules. Rates of
payment to the Facility may differ for individuals with additional sources of payment such as third party coverage. A
copy of the Facility charge schedule for ancillary services is attached to this Agreement and included in your admission
package. In addition,
items and services, certain
such as beauty/barber services; personal telephone, newspaper
delivery etc. (see Attachment A - "Non-Clinical Service") are not covered in the Daily Basic Rate or by health insurance
plans and the Resident is responsible to pay for such ssivicss, Room and board charges are billed monthly on a one-
month advance basis. Anciliary charges are billed in the month following the month that the services were provided.
Bills are gsñsrated at the end of each month and cover the next month of room and board charges ("Monthly Advance
Payment") and the previous month's ancillary charges. All payments are due upon receipt of the monthly bill. The
Daily Basic Rate and charges for ancillary and/or additicñal.services are subject to increase upon thirty (30) days
written notice to the Resident, Resident Representative and/or Sponsor.
(d) Precald DecositsfAdvence Payment
Unless otherwise specified herein, prior to admission and/or restricted by law, the Facility requires an advance
payment irt cash or certified check equal to three (3) months of services at the Facility's Daily Basic Rate from private
Such- sum represents and the Monthly
pay residents. a two (2) month punpaidesecurity deposit ("Prepaid Deposit")
Advance Payment for t e first month stay at the Facility. The Prepaid Deposit, including any interest accrued, shall
continue to be. the.property of the depositor. However, the I"acility shall have the right to apply, at its sole discretion,
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NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
the Prepaid Deposit toward payment for services provided under this Agreement. The Resident, Sponsor and/or
Resident Representative agree to deposit additional funds with the Faqility to replenish the Prepaid Deposit to a sum
equivalent to two (2) months of the current Daily Basic Rate within ten (10) days of written notice to the Resident. The
FacHity may deduct a fee of 1% per year from Prepaid Deposit amounts to cover admiñistrative costs in accordance
with applicable law. Upon Residents discharge from the Facility, the balance of the prepaid amount in excess of
outstanding bills wlil be refundedin accordance with.Facility's policy within thirty (39) days of tiw disqharge However
Ifblipáfe sinh 4û sht avèsdtlie:‰1lityM#eeWe ilbin trid@i 2 ñPEcoñtihMtitffoUthjNing (5)daý0
. prior notice; the Facility will retain an additional amount npt to exceed one ft) days Daily Basic Rate.
Prepaid deposits/advance payment are not required upon admission from Individuals eligible for Medicare,
Medicald and/or Veterans Administration benefits. However, immediately upon the ineligibility of a Resident
and/or the expiration or discontinuation of coverage for services at the. by such government
Facility
a Prepaid Deposit and Advance Payment will be required in accordance with the above-
programs, Monthly
mentioned Prepaid Deposit policies of the Facility.
(e) Late Charnes
Interest at the rate of fifteen (15%) percent per annum [1¼ % per month] or the maximum aHowed by State law wiH be
assessed on all accounts more than thirty (30) days overdue.
Attorneys'
(f) Collection Coster including Reasonable Fees and Related Expenses
In the event of any arbitration or Utigatica arising from this Agreement, the Facility shall be entitled to reasonable.
attomeys'
fees. The Resident, Sponsor and/or Resident Represeñtative shall be responsible for the expenses related
attorneys'
to collecting damages hereunder, incitiding but not limited to reasóüñe fees and other coHection-related
costs and disbursements, in addition to the late charges imposed on any overdue payments.
(g) Third Par(y Private insurance and Afanaged Care
If the Resident is covered by a private insurance plan or under a managed care benefit plan that has a contract with
the Facility, payment wiH be according to the rates for coverage of skilled nursing facility benefits agreed upon by such
plan and the Facility. Residents who are members of a managed care benefit plan that has a contract with the Facility
to provide spacified services.to plan members win have such services covered as long as the Resident meets the
sugibiuty requirements of the mâñaged care benefit plan. To the extent the Resident nieets the eligibility requirements
of the managed care benefit plan, he or she wiH be financially responsible.only for payment for those services not
covered under his or her plan and for applicable copayments, coinsurance andfor deductibles.
If the Resident is covered by a private insurance plan or managed care benefit plan that does not have a contract with
the FacHity, and where the private insurance or managed care plan reimburement is insufficient to cover the cost of
care, the Resident will be responsible for any difference in accordance with federal and State laws and regulations..
Paymêñf'
The Facility will bRI the Resident for any such difference on·a monthly basis as described in the "Private
section above The coverage requirements ibr nursing home care vary depending on the terms of the insurance or
managed care plan. Questions regarding private lñsurance and managed care coverage should be directed to the
social work staff and/or the Residents Insurance or managed care plan, carrier or agent. The Resident, Sponsor
and/or Residenf Represâñtative shall notify the Facility immediately of any change in Residents insurance status or
coverage including, but not limited to, ineligibility, termination, discontinuation of coverage, and/or any decrease or
increase in benefits.
If the Resident is covered by a private insurance plan or under a managed care benefit plan for either aHor a portion of
the Facility's charges pursuant to the terms of the Residents plan, by execution of this Agrêarñsat the Resident hereby
authorizes the Facility to utilize participating physicians and providers of anciHary services or suppRes, If required by
the plan for fuH benefit covsrage, unless the Resident specifically requests a nonparticipating provider with the
understanding that there may be additional charges to the Residentfor using such nonparticipating providers. .
(h) nfedicate
If the Resident meets.the eligibiBty requirements for skilled nursing facility benefits under the Medicare PartA Hospital
FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E
NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021
Instirance
Preview
FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 EXHIBIT "D FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 SUPREME COURTOF THE STATE OF NEW YORK COUNTY OF BRONX (ECF) ___ _____...____________-......._____......____.-·----X CARLTON L. MOITT, JR., as Administrator of the Estate of CYNTHIA MOITT, Plaintiff, CERTIFICATION OF ADMISSION AGREEMENT -against- THROGS NECK OPERATING COMPANY, LLC, THROGS NECK REHABILITATION & NURSING CENTER and ELENA VEZ2;A, M.D., Defendant. ---..-------- ________-----------...---------X . a , hereby affirms the following to be true pursuant to the penalties of perjury: 1. I am the duly authorized custodian at THROGS NECK OPERATING COMPANY, LLC d/b/a THROGS NECK REHABILITATION & NURSING CENTER or other qualified witness and I have the authority to make this certification. 2. To the best of my knowledge, after reasoñable inquiry, the attached records or copies thereof is a complete and accurate version of the Admission Agreement for CYNTHIA MOITT relative to her residency at THROGS NECK OPERATING COMPANY, LLC d/b/a THROGS NECK REHABILITATION & NURSING CENTER. 3. The records or copies produced were made in the regular course of business, at FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 the time of the transaction, occurrence or event recorded therein, or within a easonable time thereafter, and that it was the regular course of business to m .. h records. 1 Sworn to before me this day of d, 2021 mommy a Not. rý . CoinmissionE pl es yenuary l3 024 Dated: 2 lo 202 Signed . FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 THKOGS NBCK REHABILTTATION & NURSING CENTER ADMISSION AGREEMENT Agreement dated . 204 (hereinafter tha'Agreement") between Throgs Neck Operating Thrd s T R idN Nusing 7 Th oghléckÉpire ÔWay;Èi Y 10465 (hereinafter "Facility ) and (hereina r ref fred to as esident") whose ce=munny residence is ted at and (hereinafter "Resident Represen tive") residing at and Rasident's spouse and/or sponsor (if not listed as "Resident Repressñtatve") (hersiñafter "Sponsor") residing at . The Facility accepts the Resident for admission subject to the following terms and conditions: l. ADMIS$ION AND CONSENT The undersigned hereby agrees, subject to federal and state laws, rules and regulations, that the Resident will be admitted to the Facility only upon the order of a New York State iicensed physician and upon a determination that the Resident satisfies the admiesian assessment criteria set by the New York State Departmsñt of Health and by the Facility. The Resident, Resident Representative and/or Sponsor hereby consent to such routine care and treatment as may be provided by the Facility and/or ancillary providers in accordance with the Residents plan of care, including but not limited to, transfer to an acute care hospital when necessary, dental, medical and/or surgical consultatûñ, . .exanjination by medical and nursing staff, routine diagñcstic tests.and procedures, nursing services, and medication administration. The Resident, Resident Representative and/or Sponsor shall have the right to participate in the development of the plan of care and shall be provided with information concerning his or her rights to consent or refuse treatment at any time to the extent allowa.ble under applicable law. The Resident, Itesident Representative and/or Sponsor hereby understand and agree that admission to the Facility is conditioned upon the review and execution of this Agreement and related documents as more fully set forth herein. II. MUTUAL CONSIDERATION OF THE PARTIES The Facility agrees to provide all basic (routine) servicas to the Resident, as well as either provide or arrange for "A" available ancillary services, that the Resident may require. Attachment lists the routine, ancillary and additional services provided and/or arranged for by the Facility. A list of private pay charges for certain anelllary and other available services is included in your admission package. By entering this Agreement, the Resident, the Residents Sponsor and/or the Resident Representative on the Resident's behalf, understand and agree to the following Resident payment obligations. The Resident agrees to pay for, or arrange to have paid for by Medicald, Medicare or other insurers, all services provided under this Agreement, and agrees to pay arty required third party deductibles, coinsurance or monthly income budgeted by-the Medicaid program. The Resident, the Residents Sponsor and/or the Resident Representative accept the duty to ensure . continuity of payment, including. the duty to arrange for timely Medicaid coverage, if Medicaid coverage becomes necessary. The Resident, Resident Representative and Sponsor agree to comply with all applicable policies, procedures, regulations and rules of the Facility.. FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 III. . ANTICIPATED SERVICES Genem!!y, Residents are admitted to the Facility for one of the following masons: sub-acuts care; long term care, or . hospice care. . *phiegsWgfeRehébiÈtátiop& lu$ing Centendéfihestsub-acµ‡e care fq g al ori d,joÓjrkh 6, I papelf care designed Jor à n individudl whá hascan acute IIIness, thjury; or ëxacerbatiòn of a disease process. Glenerally, sub-acute care is rendered at the Facility immõ‡atsiy after, or instead of, acute hospitafization. Sub-acute care lasts for a limited time or until a condition is stabilized or a predetermined treatment course is completed. Residents, who are admitted for sub-acute care, are admitted with the expectation. that they will be discharged once short-term services are no longer required unless continued placemêñt in the Facility is medically appropriate. It is the mutual goal of the Resident and the Facility that the Resident retums to his/her home or a less restrictive setting, If appropriate. The Resident, Resident Representative and/or Sponsor agree to facilitate discharge as soon as medically appropriate, and hereby represent and agree that they will work with the Facility staff to secure an apprcpriate and timely discharge. The Resident's failure to cooperate with discharge constitutes a waiver of any limitation that might othsrwise apply to private collection. Residents admitted for sub-acute care are responsible for applicable copaymênts, dedüctibles, and/or coinsurance, and for any charges that may accrue after terminaiion of their third-party coverage if they remain in the Facility for any reason. Residents covered by Medicare Part A are responsible for a daily coinsurance amount for days21 to 100 of a Part A covered stay. If the Resident is admitted for sub-acute services and thereafter remains in the Facility for long term care, an inte-See!!Ey;room change or transfer to a more appropriate setting may be necessary. Any such room change shall be carried out in accordance with appilcable law and the Facility's policies and procedures. IV. -FINANCIAL ARRANGEMENTS (a) Oblications of Resident. Soonsor andfor Resident Representative i. Resident and/or Sponsor. A Sponsor, usually the Resident's spouse, as defined in 10 N.Y.C.R.R. §415.2 la "the entity or the person or persons, other than the resident, responsible in whole or in part for the financial Facility." support of the Resident, including the costs of care in the Accordingly, the Sponsor may be personally responsible for paying for the costs of the Resident's care In the Facility from his/her own funds. The Resident and/or Sponsor agree to pay, or arrange for payment of, any portion or all.of the applicable private pay room and board rate and the ancilianf charges incurred for services not covered by third party payors and/or required third party deductibles and/or coinsurance including moñthty the income contribution (NAMI) budgeted by the Medicaid program. If the Resident has no third or if the Resident remains in the Facility after party coverage, nacessary" any such coverage terminates because covered services are deemed no longer "medically or fbr any other reason consistent with sppliusble law, the Resident arid/or Sponsor agree to pay or arrange for pay.ment at the private pay rate for room and board and the ancillary charges·incurred until discharge or until another source of coverage beÅ“mes available. The Resident and/or Sponsor agree to take the necessary steps to ensure that the Facility and its ancillary providers receive payment from all third party payors, including the timely disclosure of available insurance coverage and production of infomiation and documentation needed to meet the eligibility criteria of the Medicaid program (e.g., proof of income, resources, residency, citizenship, and explanation of past financial transacticñs). ii. Res[dent Representative. The Resident Representative is . the individual designated to receive information and assist and/or act on behalf of the Resident to the extent pe=Ued by .State law. Unless the Resident Representative is also the Resident's spouse or Sponsor, the Resident Representative is not obligated to pay for the cost of the Resident's care from his/her own funds. Notwithstanding. the foregoing, to the sident the Resident Raptosentative breaches the. obligations personally undertaken to onsure that the Resident has a payment source for.his/her nursing home care (either from private funds and/or a thirdpaity payor) helshe inay be personally liable to the Facility for the damages caused by said breach. By signing this Agreement, the Resident FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 Representative represents and warrants he/ she the Resident s funds to pay for the hereby that shall (1) utilize Resid*ent's care at the Facility to the extent he/she has access to such funds; (11) timely provide information and documsatation requested by the Facility or a third party payor Including, but not limited to, insurance and/or Medicaid; and (lil) timely provide accurate and complete information and documentation to the Facility regarding such matters as the Resident's financial reso.urces,. citizsaship or immigration status and third party insurance coverage. The Resident Bepresentative hereby. agr.ees to indemnify and.helii the . Facility harmlegs from any oss dgmpggor ex epge, the y i isnâEreséit)Ã’fÈÃÊ f théÚò of Îè$re EiâÌiÈNs'and Wariantiesdh Resiti . Representatil/e ackfiOw|êdges that nothing herein constitutes an impermissible third party guarantee of payment; rather, this Agreement sets forth independént obligations that are being voluntarily undensken by the Resident Representative, The provisions in this paragraph shall survive termination of this Agreement for arly reason. iii. Resident, Sponsor and/bf Resiqent Represenfaffre. The Resident, Sponsor, and Rsskisñt Representative understand that the Facility is ayallable to assist with securing third party coverage (including but not limited to Medicaid), but it is ultimately the responsibility of the Resident, Sponsor and Resident Representative and the Resident, Sponsor and Resident Repressniaiive shall take all necessary steps to apply for, and qualify for, such coverage in a timely manner. Care provided to á Resident who does not meet the eligibility criteria for coverage by third party payors will be billed at the Facility's private pay room and board rate. The Resident, Sponsor and Resident Representative agree to provide. the Facility in a timely manner with all relevant information and documentation regarding all potential third party payors including, but not IImited to, what benefits, if any, may be available from the Resident's insurance and/or managed care plan and to notify the Facility immediately of any change in Resident's insurance status or coverage Depending on the j insurance coverage, managed care plan and/or written agreement with the Facility,, additional charges, including co-insurance, deductibles and/or co-payments, may be imposed. Furthermore, prior authorization by the insurance carrier or managed care plan does not guarantee coverage and/or reimbursement. in the event of dental of payment by a third party payor, exhaustion of benefits and/or terinination of coverage, the Itesident andtor Sponsor shall be responsible for payment to the Facility. The Resident must protnptly notify the Facility of any notice of a third party payor's discontinuation of payment (coverage), (c) Private Payment The Rssidsnt does not have a third party payment source in place, his/her care will be billed at private pay rates. The private pay room and board rate ("D.ally Basic Rate") Is $ per day for a private room and $ per day for a semi-private room. Ancillary services are not included in the Daily Basic Rate. Ancillary services, such as physician services, rehabilitation therapies, oxygen, dental and diagnostic services, laboratory, x-ray, podiatry optometry, medications, urinary care supplies, trach and ostomy supplies, surgical supplies, parenteral and enteral feeding supplies, transportation servicese and extraonfinary rehabilitative devices, are not iñciudad in the Daily Basic providers' Rate and will be billed separately according to the Facility's andfor the service charge schedules. Rates of payment to the Facility may differ for individuals with additional sources of payment such as third party coverage. A copy of the Facility charge schedule for ancillary services is attached to this Agreement and included in your admission package. In addition, items and services, certain such as beauty/barber services; personal telephone, newspaper delivery etc. (see Attachment A - "Non-Clinical Service") are not covered in the Daily Basic Rate or by health insurance plans and the Resident is responsible to pay for such ssivicss, Room and board charges are billed monthly on a one- month advance basis. Anciliary charges are billed in the month following the month that the services were provided. Bills are gsñsrated at the end of each month and cover the next month of room and board charges ("Monthly Advance Payment") and the previous month's ancillary charges. All payments are due upon receipt of the monthly bill. The Daily Basic Rate and charges for ancillary and/or additicñal.services are subject to increase upon thirty (30) days written notice to the Resident, Resident Representative and/or Sponsor. (d) Precald DecositsfAdvence Payment Unless otherwise specified herein, prior to admission and/or restricted by law, the Facility requires an advance payment irt cash or certified check equal to three (3) months of services at the Facility's Daily Basic Rate from private Such- sum represents and the Monthly pay residents. a two (2) month punpaidesecurity deposit ("Prepaid Deposit") Advance Payment for t e first month stay at the Facility. The Prepaid Deposit, including any interest accrued, shall continue to be. the.property of the depositor. However, the I"acility shall have the right to apply, at its sole discretion, FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E h NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 the Prepaid Deposit toward payment for services provided under this Agreement. The Resident, Sponsor and/or Resident Representative agree to deposit additional funds with the Faqility to replenish the Prepaid Deposit to a sum equivalent to two (2) months of the current Daily Basic Rate within ten (10) days of written notice to the Resident. The FacHity may deduct a fee of 1% per year from Prepaid Deposit amounts to cover admiñistrative costs in accordance with applicable law. Upon Residents discharge from the Facility, the balance of the prepaid amount in excess of outstanding bills wlil be refundedin accordance with.Facility's policy within thirty (39) days of tiw disqharge However Ifblipáfe sinh 4û sht avèsdtlie:‰1lityM#eeWe ilbin trid@i 2 ñPEcoñtihMtitffoUthjNing (5)daý0 . prior notice; the Facility will retain an additional amount npt to exceed one ft) days Daily Basic Rate. Prepaid deposits/advance payment are not required upon admission from Individuals eligible for Medicare, Medicald and/or Veterans Administration benefits. However, immediately upon the ineligibility of a Resident and/or the expiration or discontinuation of coverage for services at the. by such government Facility a Prepaid Deposit and Advance Payment will be required in accordance with the above- programs, Monthly mentioned Prepaid Deposit policies of the Facility. (e) Late Charnes Interest at the rate of fifteen (15%) percent per annum [1¼ % per month] or the maximum aHowed by State law wiH be assessed on all accounts more than thirty (30) days overdue. Attorneys' (f) Collection Coster including Reasonable Fees and Related Expenses In the event of any arbitration or Utigatica arising from this Agreement, the Facility shall be entitled to reasonable. attomeys' fees. The Resident, Sponsor and/or Resident Represeñtative shall be responsible for the expenses related attorneys' to collecting damages hereunder, incitiding but not limited to reasóüñe fees and other coHection-related costs and disbursements, in addition to the late charges imposed on any overdue payments. (g) Third Par(y Private insurance and Afanaged Care If the Resident is covered by a private insurance plan or under a managed care benefit plan that has a contract with the Facility, payment wiH be according to the rates for coverage of skilled nursing facility benefits agreed upon by such plan and the Facility. Residents who are members of a managed care benefit plan that has a contract with the Facility to provide spacified services.to plan members win have such services covered as long as the Resident meets the sugibiuty requirements of the mâñaged care benefit plan. To the extent the Resident nieets the eligibility requirements of the managed care benefit plan, he or she wiH be financially responsible.only for payment for those services not covered under his or her plan and for applicable copayments, coinsurance andfor deductibles. If the Resident is covered by a private insurance plan or managed care benefit plan that does not have a contract with the FacHity, and where the private insurance or managed care plan reimburement is insufficient to cover the cost of care, the Resident will be responsible for any difference in accordance with federal and State laws and regulations.. Paymêñf' The Facility will bRI the Resident for any such difference on·a monthly basis as described in the "Private section above The coverage requirements ibr nursing home care vary depending on the terms of the insurance or managed care plan. Questions regarding private lñsurance and managed care coverage should be directed to the social work staff and/or the Residents Insurance or managed care plan, carrier or agent. The Resident, Sponsor and/or Residenf Represâñtative shall notify the Facility immediately of any change in Residents insurance status or coverage including, but not limited to, ineligibility, termination, discontinuation of coverage, and/or any decrease or increase in benefits. If the Resident is covered by a private insurance plan or under a managed care benefit plan for either aHor a portion of the Facility's charges pursuant to the terms of the Residents plan, by execution of this Agrêarñsat the Resident hereby authorizes the Facility to utilize participating physicians and providers of anciHary services or suppRes, If required by the plan for fuH benefit covsrage, unless the Resident specifically requests a nonparticipating provider with the understanding that there may be additional charges to the Residentfor using such nonparticipating providers. . (h) nfedicate If the Resident meets.the eligibiBty requirements for skilled nursing facility benefits under the Medicare PartA Hospital FILED: BRONX COUNTY CLERK 02/12/2021 01:41 PM INDEX NO. 35921/2020E NYSCEF DOC. NO. 23 RECEIVED NYSCEF: 02/12/2021 Instirance