12/01/1981BAY SHORE MANOR A/K/A
NO"iROE COU:,ITY HO::E , AD LT CO;+G EGk \TE
LIVING FACILITY FOR THE: ELDERLY - LEVEL II
AGREEMENT
This Agreement entered into this 1st day of
December 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Angel Alvarez
hereinafter called "Resident", and
Party"
, hereinafter called "Responsible
W I T N E S S E T H:
WHEREAS, the Resident desires to use the facilities
of the County known as The Monroe County Home, aka Bay Shore Manor -.
and, -
WHEREAS, the County has reviewed the application
of the Resident for admission to The Monroe County Home and
has determined that the Resident is eligible for admission
to said home, now, therefore,
IN CONSIDERATION of the mutual covenants, promises
and premises herein contained, the parties agree as follows:
A. BAY SHORE MANOR
1. To furnish room, board, linens, prescribed
medicines and general personal care.
2. To arrange for the transfer of the
Resident to the hospital of Resident's
choice, when ordered by the attending
physician or the health of the Resi-
dent requires same, and immediately
notify any responsible party (as
designated herein) of such transfer.
3. To make refunds in accordance with the
policy of the Home. Refunds cannot
be made as long as personal belong-
ings remain in the Resident's room.
Refunds cannot be made as long as
there are outstanding expenditures
for services received by the_Resident.
4. Other: To pay medicare deductib4,"balance of
hospital services after medicare for lst
14 days. To pay 80% of balance after medicare
Phystcians services.
5. Other: To reimburse resident $ 10.00 ner
month for personal spending funds.
L
1. To previc'e suc' t erson.Dl clothin-, anc`.
of fectS as nee ,': ,i or cc -sired by the
Resident.
2. To pay the monthly rate agreed upon and
such charges as determined by the Monroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the Pdministrator of the Home, that
the Resident is no longer capable of
meeting the requirements for occupancy
in this facility, the Resident, next of
kin, legal representative, or agency
acting on the Resident's behalf, will
be notified and the resident will have
to make arrangements for immediate
transfer_ to an appropriate facility.
In the event a Resident has no person
to represent him./her, this facility
shall assist Resident in contacting an
appropriate social service agency for
placement. Fppl_icant agrees to vacate
the facility within forty-eight (48)
hours after disQualification.
4. To comply with all requirements as set
forth in the Application made by the
Resident.
5. To comply with all rules and regula-
tions established by the County for
operation and control of said home.
6. Agrees, if not paying the maximum rate,
to pay any increases in in come during the
course of residency, up to the maximum rate.
7. Other:
C. FINANCIAL ARRANGEMENTS
The Resident and/or responsible party agrees to
pay to the County $ ,3 /q CP 6 , per month as
rent for use of the facilities.
Payment will be fromthe following sources:
1. Personal funds of Resident $
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social Security $ 314.60
Civil Service :,'�nnuitt. $
VA Pension $
Other
S
The Count; throuc;h its em lo,;ees ,,as agreed to
exercise such reasonable care toward the nesi('_ent as his or
her known condition may require, however, this home is in no
sense an insurer of his or her safety or welfare and assumes
no liability as such.
The ,?anacgement of this home ,iill not be respon-
sible for any valuables or money left in the possession of
this person while he or she is a resident of this home.
E. TFRI?TNA` Tn�T
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence shall automa-
tically terminate this Agreement and the Resident shall
remove all of his or her property or belongings immediately.
If Resident fails to remove same, the Resident does hereby
authorize the County to remove said property or belongings
and deliver same to Responsible Party.
F. MIEDTC'A.T. SPRVT("P.
The parties agree that Monroe County shall not be
or assume any responsibility for payment of any medical or
hospital services, unless specifically agreed to by the
parties or their representatives at the time of the render-
ing of service.
G. nTTPATTnrT nP Ara7F',irN7m
Fither party may terminate this agreement on five
(5) days written notice. Otherwise, it will remain in
effect until a different agreement is executed. However,
this does not mean that a Resident wil..' be forced to remai;,"'-'�
in the facility against his/her will for any length o tim.
Signature of Resident
Witnesses as to Resident
�C
Witnesses as to
Responsible Party
'C e
Signature of Responsible`
Party
D AT F
APPROVED:
Signature o€ Representative
of Monroe County Home aka
Bay Shore Manor
Sic ature o.- Executive
Director, Monroe County
Social Services
Sim ture of County
Aeministrator
THIS IS TO CERTIFY THAT THIS ADMISSTON AGR;PMENT AS
APPROVED BY THE COUNTY HOi,TE A-�JD THE COUNTY ADrAINISTRATOR
PIAS P.ATIFIFD BY TNF MONROE COUNTY BOARD OF COUNTY
CO�L`IISSION/FRS AT THEIR MEFTIT G MELD ON THFDAY
OF x-e—A 19 A2.
S]c'rffture of the Chai an
Monroe County Board of
County Commissioners