Paying for The Resident's Care. A. Who Can be Required to Pay for the Resident's Care. Only the Resident and the Resident's insurers can be required to pay for the Resident's care. You cannot be required to pay for the Resident's care from your own funds, unless you knowingly and voluntarily agree to pay for the cost of the Resident's care with your own funds.1 1 Whenever the phrase "you will be charged", "you pay", or "you agree to pay" are used in this Agreement, it shall be subject to the qualifications of thisparagraph. By signing this Agreement, you and the Resident agree to pay for care and services provided to the Resident with the Resident's income, funds and assets. (Bysigning this Agreement, you intend to bind the Resident to all obligations of this Agreement, including payment for care and services.) If you fail to pay a Facility bill, we may request a court to order such payment. You understand you may not use the assets or income of the Resident for any purpose that is not authorized by the Resident, or that is not necessary for the direct and immediate welfare of the Resident.2 You agree to provide us with all information about the Resident's finances and health. You understand that, if we later find that you knowingly provided the Facility with incomplete or inaccurate information, we will consider that a breach of this Agreement. It is anticipated that the Resident's care will be paid for by: Γ The Medicare Program; Γ The Medicaid Program (also known as "Medical Assistance"); Γ Other third-partyinsurer, please specify: ; Γ You with the Resident's income, funds and/or assets; Γ You with your own income, funds and/or assets; Γ Other, please specify: .
Paying for The Resident's Care. Payment for the Resident’s care is the responsibility of the Resident. However, a Resident may have insurance, public benefits, and/or other third party payers to assist the Resident with the payment of this obligation. No other person, regardless of whether they are a family member, friend, neighbor, legal agent or guardian (even if they sign this document as an Agent for the Resident), can be required to pay for the Resident’s care from his or her own funds unless that person knowingly and voluntarily agrees to pay for the cost of the Resident’s care. The Facility requires the Resident or any other person responsible for making payments on the Resident’s behalf to pay for the Resident’s care under the terms of this contract by the tenth of the month. The Facility may not hold the Resident responsible for the payment of attorneys’ fees or any other cost of collecting payment. It is anticipated that the resident’s care will be paid for by one or more of the following: _____ The Medicare Program; (Explain the Co-pay.) _____ The Medicaid Program; (Explain the Cost of Care.) _____ Other insurance coverage(s); Please list: ________________________________ _____ The Resident, with the Resident’s own funds;
Paying for The Resident's Care. A. Who Can Be Required to Pay for the Resident’s Care Payment for the Resident’s care is the responsibility of the Resident. However, a Resident may have insurance, public benefits and/or other third party payors to assist the Resident with the payment of this obligation. No other person, regardless of whether they are a family member, friend, neighbor, legal agent or guardian (even if they sign this document as an Agent for the Resident), can be required to pay for the Resident’s care from his or her own funds unless that person knowingly and voluntarily agrees to pay for the cost of the Resident’s care. Other than amounts required under this contract, the Facility may not charge, solicit, accept or receive any gift, money, donation or other consideration as a precondition of the Resident’s admission or to expedite the Resident’s admission or to continue the Resident’s stay once the Resident is admitted to the Facility. The Facility requires the Resident or any other person responsible for making payments on the Resident’s behalf to pay for the Resident’s care under the terms of this contract within _______ days of receipt of the Facility’s monthly bill. The Facility may not hold the Resident responsible for the payment of attorneys’ fees or any other cost of collecting payment. It is anticipated that the resident’s care will be paid for by one or more of the following: o The Medicare Program; (If the Resident is responsible for a co-pay, it will be explained to the Resident.) o The Medicaid Program; (If the Resident is responsible for a Cost of Care, it will be explained to the Resident.) o Other insurance coverage(s); Please list: ______________________________________ o The Resident, with the Resident’s own funds; o Another person, with the Resident’s funds; Name: _____________________________________ Address: _____________________________________ Phone: _____________________________________ Legal Authority: _____________________________________ o Another person who has voluntarily agreed to pay with his/her own funds. Name: _____________________________________ Address: _____________________________________ Phone: _____________________________________ The Resident agrees to provide all information requested by the Facility about the Resident’s health and financial status in an accurate and timely manner and to update this information while the Resident is a resident at the Facility. It is understood that Medicare and Medicaid will make the determinati...
Paying for The Resident's Care. Payment for the Resident’s care is the responsibility of the Resident. However, a Resident may have insurance, public benefits, and/or other third party payers to assist the Resident with the payment of this obligation. No other person, regardless of whether they are a family member, friend, neighbor, legal agent or guardian (even if they sign this document as an Agent for the Resident), can be required to pay for the Resident’s care from his or her own funds unless that person knowingly and voluntarily agrees to pay for the cost of the Resident’s care. The Facility requires the Resident or any other person responsible for making payments on the Resident’s behalf to pay for the Resident’s care under the terms of this contract by the tenth of the month. The Facility may not hold the Resident responsible for the payment of attorneys’ fees or any other cost of collecting payment. It is anticipated that the resident’s care will be paid for by one or more of the following: The Medicare Program; (Explain the Co-pay.) The Medicaid Program; (Explain the Cost of Care.) Other insurance coverage(s); Please list: The Resident, with the Resident’s own funds; Another person, with the Resident’s funds (list below); to include monthly Cost of Care Another person who has voluntarily agreed to pay with his/her own funds (list below). Responsible Party Signature Legal Authority Telephone Number Address City State Zip The Resident agrees to provide all information requested by the Facility about the Resident’s health and financial status in an accurate and timely manner and to update this information while the Resident is a resident at the Facility. It is understood that Medicare and Medicaid will make the determinations concerning the Resident’s medical and financial eligibility for those programs. The Facility is not permitted to require the Resident to waive any rights to Medicare or Medicaid or require the Resident to give written or oral assurances that the Resident is not eligible for, or will not apply for, Medicare or Medicaid benefits. The Resident is entitled to apply for Medicare or Medicaid at any time. The resident and representative understand that if the resident dies and there is an outstanding balance due to the facility, the facility will file a claim for the outstanding amount against the resident’s estate to cover the balance.
