09/15/1982f.-&••lZ
Bayshore Manor a/k/a
cI0; ROE COUNTY HONE, ADULT CO:�G REGI,=
LIVING FACILITY FOR THE ELDERLY - LEVEL II
A G R E E M E N T
This Agreement entered into this 15th day of
September , 19 82 , by and between the County of
Monroe, State of Florida, hereinafter called "County", and
John Disdiel
hereinafter called "Resident", and none
Party"
, hereinafter called "Responsible
W I T N E S S E T H:
0
WHEREAS, the Resident desires to use the facilities
of the County known as The Monroe County Home, 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. THE MONROE COUNTY HOME
a/k/a Bayshore 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 deductible, 80% of hospital
services after Medicare pays for lst 14 days,
80� physicians services after Medicare pays.
5. Other: none
B. TIIF RESIDENT OR RFSPONSIELE PARTY
1. To provide such personal clothing and
effects as needed or desired by the
Resident.
2. To pay the monthly rate agreed upon and
such charges as determined by the Monroe
County Nome to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the Administrator 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 Pesident 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. Applicant 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: Resident's personal assets will pay
Life Insurance premium.
C. FINANCIA..L ARPANGFMFNTS
The Resident and/or responsible party agrees to
pay to the County $ 322.00 , per month as
rent for use of the facilities.
Payment will be from. the following sources:
1. Personal funds of Resident $
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social Security $ 322.00
Civil Service Annuity $
VA Pension $
Other $
D. STA"IDARD ADMISSION WAIVFR:
The County through its employees has agreed to
exercise such reasonable care toward the Resident as his or
her known condition may require, however, this home is in no
sense an insurer of his or her safetv or welfare and assumes
no liability as such.
The Management of this home will 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 hom.e.
E. TFRMINATION
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. MEDICA.L SERVICES
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 . DURATION OF AGRFF2 1FNT
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 remain
in the facility against his/her will for any length of time.
�i tore of Resident
:�sident
Signature of Responsible
Witnesses as to
Partv
Responsible Party
SzauoTS_ STur,UOD � unoa
go p.z 'og Aqunx4uUngs
ozuoW
tuzTLL�� pLp go
d0
KdQ ),,wC-1L HHZ NO Q`IHH 91.1ILL'3dW -dIHH1 jV sdaNO SSIinWOD
7ilKfl00 d0 Qdi'VO9 �ZNIIOO HOHNOW dHI, 2 U CJIJIJ,Td SVIrl
HOJ,VZd!SINIvKDf AJMIOD 3Hj, CI&V 3140H 2ijjl\ II00 HH! 2�9 Qdl�OuddNZ
SV LLN3I dd—dDV NOISSIWQK SIHI DfHw 2�dIDdH0 Ow SI SIHJL
S z u �i
azn�-eubzS
SaoznzaS TPTaoS
fquno0 aozuoW ' zogoaz icj
anTgnoaX3 go azngpub S
OwOH AqunoJ aozuoW go
anTgequasazdad jo azngpubTS
= aanoxddV
Z86T `+ j xagma3as JJIV(j