08/15/1995BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ASSISTED LIVING FACILITY
FOR THE ELDERLY
SHORT TERM RESIDENTIAL
A G R E E M E N T
This agreement entered into this _ day of AA JJT 19_j�_,
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and VwA S c)d HOL-2
hereinafter called "RESIDENT", and Kim }44A(s ,
hereinafter called "RESPONSIBLE PARTY".
W I T N E S S E T H:
WHEREAS, RESIDENT desires to temporarily reside in the County
facility known as Bayshore Manor, for a period of: i day(s)
(NOT TO EXCEED THIRTY (30) DAYS) commencing on the tOl day of
AdoST 19 9S , and terminating at on the
day of Ad6L)J T 19 S__ and
WHEREAS, COUNTY has reviewed RESIDENT'S application for admission
to Bayshore Manor and has determined that RESIDENT is eligible
for admission, now therefore,
In consideration of the mutual covenants, promises and premises
herein contained, the parties agree as follows:
A. BAYSHORE MANOR:
1. Shall furnish room, board, linens and assistance with
activities of daily living as may be required, based
upon RESIDENT'S mental and/or physical limitations both
at and subsequent to the time of admission.
2. Shall arrange for transportation of RESIDENT to his/her
physician's office and/or arrange for RESIDENT'S
transportation to hospital if such transportation is
ordered by physician or if, in the opinion of the
Director or his surrogate, RESIDENT'S condition so
warrants. The RESPONSIBLE PARTY (as designated herein)
will be immediately notified if RESIDENT requires
hospitalization.
3. Shall make refunds on a per diem basis, commensurate with
the date of discharge from Bayshore Manor, as detailed
in Section C of this AGREEMENT. Refunds will not be
made for any days that personal belongings remain in
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RESIDENT'S room nor as long as there are outstanding
expenditures for services received by RESIDENT.
4. Shall, in the event of closure of the facility for any
reason, make a pro -rated per diem refund as of the date
of such closure. Such applicable refund will be made
within SEVEN (7) DAYS of closure, in compliance with
Florida Statutes.
5. Shall maintain no affiliation with any religious
organization, except to provide assistance to RESIDENT
in contacting such organization upon RESIDENT'S request.
6. Other rj1A
B. RESIDENT and/or RESPONSIBLE PARTY
1. Shall provide all clothing, medication, and personal
effects as required by RESIDENT during his/her residency
at Bayshore Manor.
2. Shall pay the full amount due upon executing this
AGREEMENT.
3. Shall comply with all requirements set forth in
the application for admission.
4. Shall fully comply with all rules and regulations as
now established by COUNTY or as may, in the
future, be amended or established.
5. Shall make arrangements for RESIDENT'S immediate
return to his/her home upon certification by either a
physician or the Director of Bayshore Manor that
RESIDENT is no longer capable of meeting the requirements
for continued residence in or use of the facility.
6. Shall maintain on file with Bayshore Manor an
up-to-date name, address and telephone number for
RESPONSIBLE PARTY or next of kin.
7. Shall provide RESIDENT'S personal physician with written
authorization to provide any medical care necessary
while RESIDENT is residing at Bayshore Manor under
terms of this AGREEMENT and provide Director of
Bayshore Manor with a copy of such authorization.
8. other: WA
C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY the sum of
SIXTY ($60.00) DOLLARS per day, with the total amount due for the
entire term of AGREEMENT at the time the AGREEMENT is executed.
D. STANDARD ADMISSION WAIVER
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COUNTY shall continually exercise such reasonable care as to
maintain the health and safety of RESIDENT. However, COUNTY does
not provide any assurance or guarantee for RESIDENT'S health and
safety and shall have no liability for same. COUNTY shall have
no liability or responsibility for cash or other valuables which
RESIDENT may, at any time, have in his/her possession on the
premises of Bayshore Manor. RESIDENT shall hold COUNTY
harmless for any and all claims arising directly or indirectly
from any negligent or intentional act of RESIDENT.
E. RESIDENT PERSONAL CASH
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
F. MEDICAL AND DENTAL SERVICES
COUNTY shall not be responsible for the payment of any medical,
chiropractic, dental or hospital bill incurred by RESIDENT.
Furthermore, COUNTY shall not be responsible for the payment of
RESIDENT'S "over-the-counter" or prescription medications.
RESIDENT'S personal physician is:
NAME CZ/0Pd PA-2F V&t.�.
ADDRESS I // I / 111 j q. Tl // 0
KIP Wf . CL 330ttv
PHONE (3 0 5, o 9,�6 2 y -L
G. TERMINATION OF AGREEMENT
At the time that RESIDENT vacates Bayshore Manor this AGREEMENT
shall automatically terminate, and RESIDENT or RESPONSIBLE PARTY
shall remove all of RESIDENT'S personal property immediately. If
property is not removed in a timely fashion, the parties agree
that COUNTY is authorized to remove and dispose of such property
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after having made a reasonable effort to deliver it to RESIDENT
or RESPONSIBLE PARTY, without success.
H. DURATION OF AGREEMENT
Unless otherwise terminated, this agreement shall remain in full
force and effect until such time as a new agreement is duly
executed.
I. AMENDMENTS TO AGREEMENT
This agreement may be amended at any time subsequent to its
execution by both parties, or their legal representatives, by the
parties or their legal representatives signing and executing
such an amendment.
J. NOTICE
Any notice required by this agreement to be made by either party
shall be made as follows:
BAYSHORE MANOR
Name:ROBERT E. LAZARUS, M.D.
Address: 5200 College Road
Key West, Fl. 33040
Phone: (305)294-4966
RESPONSIBLE PARTY
Name: KlM uA2Ed
Address: III WAITC NdVAg g.
miry WaT, FL. 3 3o t v
Phone: (3 0 SJ J- `i 3 ^ O 9 7
Parties may substitute the above by proper notice.
K. FLORIDA LAW
Both parties shall at all times comply with the Laws of the State
of Florida and Monroe County. Further, RESIDENT agrees that the
proper jurisdiction and venue of any claims arising under this
agreement shall be in Monroe County, Florida.
L. POST -TERMINATION PRESENCE
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COUNTY has no obligation to provide services except as stipulated
herein. Should RESIDENT remain on the premises of Bayshore
Manor after the expiration of the term, COUNTY may contact State
Protective Services and relinquish custody of RESIDENT thereto.
SIGNATURE OF R SIDENT
TO RESIDENT
WITNESSES AS TO RESPONSIBLE PARTY / .1
DATE:
#V�
�
DATE:
���6 �—
APPROVED:
RESPONSIBLE PARTY
SIGNATURE OF DIRECTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE OF MONROE
APPROVED AS T'� F-,.,
AMD LEGAL SUf @ N
ADMINISTRATOR
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