Common use of Direction to Agent Clause in Contracts

Direction to Agent. You agree to promptly notify Facility of any and all changes in address, phone number or identity of any Agent. You direct all current and future Agents to comply with all obligations as set forth in the Admission Agreement. If you are declared legally incompetent under State law, all Rights and Responsibilities specified shall devolve upon your judicially designated legal representative. WHO CAN THE FACILITY COMMUNICATE WITH REGARDING YOUR CARE AND TREATMENT WHILE YOU ARE AT THE FACILITY: The Facility may disclose to a family member, other relative, a close personal friend, or any other person identified by you your protected health information directly relevant to that person's involvement with your care or the payment for your care. The Facility may also use or disclose your protected health information to notify or assist in notifying (including identifying or locating) such person of your location, general condition or death. However, this can only occur if you agree to a disclosure to such person. If you wish to name such a person and agree to such disclosures, please designate the family member, other relative, close personal friend, or any other person and to whom the Home may make such disclosures (a “Family Member/Friend”): ATTACHMENT C MEDICARE AND MEDICAID PAYMENT OF BASIC CHARGES FOR MEDICARE PART A COVERED RESIDENTS AND ALL NON-MEDICAID RESIDENTS: Resident, who is not covered by Medicare Part A, agrees to pay Facility the sum of $ (private) (semi-private) per day, plus any assessment levied by New York State from time to time, payable monthly in advance for the Basic Services. If Resident is a Medicare beneficiary whose stay is covered under Medicare Part A, the Basic Charge for the Covered Services shall be the Medicare Part A rate for Facility. The Covered Services for such Medicare Part A covered stays shall include the Basic Services, the audiology, rehabilitative therapies, laboratory and x-ray services, and certain transportation charges as detailed in the Agreement. Each Resident’s case is reviewed by Facility and the intermediary, in accordance with Medicare regulations, to determine eligibility and length of coverage, if any. If Resident has met all of the Medicare eligibility requirements, Resident will be eligible to receive up to one hundred (100) days of Medicare Part A coverage, per Benefit Period, if medically qualified. The full cost of Covered Services for the first twenty (20) days will be paid to Facility by Medicare through Medicare Part A rate. For the next eighty (80) days, providing the Resident continues to meet the eligibility requirements and remains a Medicare beneficiary, the Resident agrees to pay Facility the amount of co-insurance provided for in the applicable Medicare regulations, as amended. The balance of the cost of Covered Services for the next eighty (80) days will be paid to Facility by Medicare. The Finance Office will, at your request, tell you the current Medicare Part A rate. The current Medicare Part A co-payment amount is $_ per day. The Part A rate and co-payment amount are set by the federal government and are subject to change from time to time. The Resident is responsible for the annual Medicare Part A, Part B and Part D deductibles and for any and all Medicare Part A, Part B and/or Part D co-insurance. In addition to the Basic Charge, Resident will be charged for services requested that are not paid for by Medicare or other applicable insurance coverage. FOR MEDICAID ONLY RECIPIENTS WITHOUT MEDICARE PART D: If Resident is a Medicaid only recipient and not eligible for Medicare Part D, the Basic Charge for the Basic Services listed in the Agreement (Basic Services for Medicaid recipients shall also include prescription drugs and rehabilitative services) shall be the Medicaid rate for Facility. The current Medicaid rate is set by New York State. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid. FOR MEDICAID RECIPIENTS WITH MEDICARE PART D COVERAGE: If Resident has Medicare Part D coverage and is a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to appropriate and applicable Medicare Part D plan, and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). FOR RESIDENTS WITH MEDICAID APPLICATIONS PENDING AND WHO HAVE MEDICARE PART D COVERAGE: If Resident has Medicare Part D coverage and a Medicaid application pending or in process (i.e., the Resident is Medicaid pending) the cost of prescription drugs will be billed to the appropriate and applicable Medicare Part D plan, and the Resident will be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan. Once the Resident becomes a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to Medicare Part D plan and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). ATTACHMENT D

Direction to Agent. You agree to promptly notify Facility of any and all changes in address, phone number or identity of any Agent. You direct all current and future Agents to comply with all obligations as set forth in the Admission Agreement. If you are declared legally incompetent under State law, all Rights and Responsibilities specified shall devolve upon your judicially designated legal representative. WHO W HO CAN THE FACILITY COMMUNICATE WITH REGARDING YOUR CARE AND TREATMENT WHILE YOU ARE AT THE FACILITY: The Facility may disclose to a family member, other relative, a close personal friend, or any other person identified by you your protected health information directly relevant to that person's involvement with your care or the payment for your care. The Facility may also use or disclose your protected health information to notify or assist in notifying (including identifying or locating) such person of your location, general condition or death. However, this can only occur if you agree to a disclosure to such person. If you wish to name such a person and agree to such disclosures, please designate the family member, other relative, close personal friend, or any other person and to whom the Home may make such disclosures (a “Family Member/Friend”): ATTACHMENT SCHEDULE C MEDICARE AND MEDICAID PAYMENT OF BASIC CHARGES FOR MEDICARE PART A COVERED RESIDENTS AND ALL NON-MEDICAID RESIDENTS: Resident, who is not covered by Medicare Part A, agrees to pay Facility the sum of $ (private) (semi-private) per day, plus any assessment levied by New York State from time to timetime (e.g., NYS Assessment), payable monthly in advance for the Basic Services. If Resident is a Medicare beneficiary whose stay is covered under Medicare Part A, the Basic Charge for the Covered Services shall be the Medicare Part A rate for Facility. The Covered Services for such Medicare Part A covered stays shall include the Basic Services, the audiology, rehabilitative therapies, laboratory and xFacility (plus any applicable cost-ray services, and certain transportation charges as detailed in the Agreementsharing amount). Each Resident’s case is reviewed by Facility and the intermediary, in accordance with Medicare regulations, to determine eligibility and length of coverage, if any. If Resident has met all of the Medicare eligibility requirements, Resident will be eligible to receive up to one hundred (100) days of Medicare Part A coverage, per Benefit Period, if medically qualified. The full cost of Covered Services for the first twenty (20) days will be paid to Facility by Medicare through Medicare Part A rate. For the next eighty (80) days, providing the Resident continues to meet the eligibility requirements and remains a Medicare beneficiary, the Resident agrees to pay Facility the amount of co-insurance insurance/co- payment provided for in the applicable Medicare regulations, as amended. The balance of the cost of Covered Services for the next eighty (80) days will be paid to Facility by Medicare. The Finance Office will, at your request, tell you the current Medicare Part A rate. The current Medicare Part A co-payment amount is $_ $ per day. The Part A rate and co-payment amount are set by the federal government and are subject to change from time to time. The Resident is responsible for the annual Medicare Part A, Part B and Part D deductibles and for any and all Medicare Part A, Part B and/or Part D co-insurance. In addition to the Basic Charge, Resident will be charged for services requested that are not paid for by Medicare or other applicable insurance coverage. FOR MEDICAID ONLY RECIPIENTS WITHOUT MEDICARE PART DRECIPIENTS: If Resident is a Medicaid only recipient and not eligible for Medicare Part DMedicaid covers Resident’s stay, the Basic Charge for the Basic Services listed in the Agreement (Basic Services for Medicaid recipients shall also include prescription drugs and rehabilitative services) shall be the Medicaid rate for Facility. The current Medicaid rate is set by New York State. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a upon qualifying for Medicaid recipientcoverage for Resident’s stay, has been will be advised by the Department of Social Services (or other comparable agency) that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services (or other comparable agency) may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services (or other comparable agency) to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid. FOR MEDICAID RECIPIENTS WITH MEDICARE PART SCHEDULE D COVERAGEDIRECT PAYMENT AUTHORIZATION FORM Resident Name Resident ID Financial Institution Name on Account _ Transit Routing Number Account Number _ ( ) Checking ( ) Savings Effective Date Withdrawals to be applied to: If Resident has Medicare Part D coverage ( ) Monthly Room & Board and is a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to appropriate and applicable Medicare Part D plan, and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). FOR RESIDENTS WITH MEDICAID APPLICATIONS PENDING AND WHO HAVE MEDICARE PART D COVERAGE: If Resident has Medicare Part D coverage and a Medicaid application pending or in process (i.e., the Resident is Medicaid pending) the cost of prescription drugs will be billed to the appropriate and applicable Medicare Part D plan, and the Resident will be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan. Once the Resident becomes a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to Medicare Part D plan and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). ATTACHMENT DAncillary Charges

Direction to Agent. You agree to promptly notify Facility of any and all changes in address, phone number or identity of any Agent. You direct all current and future Agents to comply with all obligations as set forth in the Admission Agreement. If you are declared legally incompetent under State law, all Rights and Responsibilities specified shall devolve upon your judicially designated legal representative. WHO CAN THE FACILITY COMMUNICATE WITH REGARDING YOUR CARE AND TREATMENT WHILE YOU ARE AT THE FACILITY: The Facility may disclose to a family member, other relative, a close personal friend, or any other person identified by you your protected health information directly relevant to that person's involvement with your care or the payment for your care. The Facility may also use or disclose your protected health information to notify or assist in notifying (including identifying or locating) such person of your location, general condition or death. However, this can only occur if you agree to a disclosure to such person. If you wish to name such a person and agree to such disclosures, please designate the family member, other relative, close personal friend, or any other person and to whom the Home may make such disclosures (a “Family Member/Friend”): ATTACHMENT SCHEDULE C MEDICARE AND MEDICAID PAYMENT OF BASIC CHARGES FOR MEDICARE PART A COVERED RESIDENTS AND ALL NON-MEDICAID RESIDENTS: Resident, who is not covered by Medicare Part A, agrees to pay Facility the sum of $ (private) (semi-private) per day, plus any assessment levied by New York State from time to timetime (e.g., NYS Assessment), payable monthly in advance for the Basic Services. If Resident is a Medicare beneficiary whose stay is covered under Medicare Part A, the Basic Charge for the Covered Services shall be the Medicare Part A rate for Facility. The Covered Services for such Medicare Part A covered stays shall include the Basic Services, the audiology, rehabilitative therapies, laboratory and xFacility (plus any applicable cost-ray services, and certain transportation charges as detailed in the Agreementsharing amount). Each Resident’s case is reviewed by Facility and the intermediary, in accordance with Medicare regulations, to determine eligibility and length of coverage, if any. If Resident has met all of the Medicare eligibility requirements, Resident will be eligible to receive up to one hundred (100) days of Medicare Part A coverage, per Benefit Period, if medically qualified. The full cost of Covered Services for the first twenty (20) days will be paid to Facility by Medicare through Medicare Part A rate. For the next eighty (80) days, providing the Resident continues to meet the eligibility requirements and remains a Medicare beneficiary, the Resident agrees to pay Facility the amount of co-insurance insurance/co-payment provided for in the applicable Medicare regulations, as amended. The balance of the cost of Covered Services for the next eighty (80) days will be paid to Facility by Medicare. The Finance Office will, at your request, tell you the current Medicare Part A rate. The current Medicare Part A co-payment amount is $_ $ per day. The Part A rate and co-payment amount are set by the federal government and are subject to change from time to time. The Resident is responsible for the annual Medicare Part A, Part B and Part D deductibles and for any and all Medicare Part A, Part B and/or Part D co-insurance. In addition to the Basic Charge, Resident will be charged for services requested that are not paid for by Medicare or other applicable insurance coverage. FOR MEDICAID ONLY RECIPIENTS WITHOUT MEDICARE PART DRECIPIENTS: If Resident is a Medicaid only recipient and not eligible for Medicare Part DMedicaid covers Resident’s stay, the Basic Charge for the Basic Services listed in the Agreement (Basic Services for Medicaid recipients shall also include prescription drugs and rehabilitative services) shall be the Medicaid rate for Facility. The current Medicaid rate is set by New York State. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a upon qualifying for Medicaid recipientcoverage for Resident’s stay, has been will be advised by the Department of Social Services (or other comparable agency) that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services (or other comparable agency) may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services (or other comparable agency) to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid. FOR MEDICAID RECIPIENTS WITH MEDICARE PART SCHEDULE D COVERAGEDIRECT PAYMENT AUTHORIZATION FORM Resident Name Resident ID Financial Institution Name on Account Transit Routing Number Account Number ( ) Checking ( ) Savings Effective Date Withdrawals to be applied to: If Resident has Medicare Part D coverage ( ) Monthly Room & Board and is a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to appropriate and applicable Medicare Part D plan, and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). FOR RESIDENTS WITH MEDICAID APPLICATIONS PENDING AND WHO HAVE MEDICARE PART D COVERAGE: If Resident has Medicare Part D coverage and a Medicaid application pending or in process (i.e., the Resident is Medicaid pending) the cost of prescription drugs will be billed to the appropriate and applicable Medicare Part D plan, and the Resident will be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan. Once the Resident becomes a Medicaid recipient, the Basic Charge for the Basic Services listed in the Agreement shall be the Medicaid rate for Facility. The cost of prescription drugs will be billed to Medicare Part D plan and the Resident will not be responsible for meeting all applicable cost sharing responsibilities specified by the Medicare Part D plan, which shall be paid by Medicaid. The Finance Office will, at your request, tell you the current Medicaid rate. This rate may be changed from time to time by the State Government without notice to the Resident. Resident, if a Medicaid recipient, has been advised by the Department of Social Services that Resident will be responsible for paying a portion of the charges made by Facility and the Department shall pay the balance (See the County Department of Social Services Budget Letter(s) made a part of this Agreement by your signing this Agreement). Resident understands that the Department of Social Services may from time to time change the portion of the charges Resident must pay. Resident agrees to forward a copy of each and every Budget Letter received from the Department of Social Services to the Finance Office within seven (7) days after receipt of each Budget Letter. In addition to the Basic Charge, Resident will be charged for services requested and for which payment is not made by Medicaid (for example, the room rate differential between a semi-private and a private room, except where Resident must occupy a private room for therapeutic reasons). ATTACHMENT DAncillary Charges