12/01/1981 Agreementt
BAY SHORE MANOR A/K�A
NO::ROE COU:,!TY HO:•:E, ADULT CO::GREG .\TE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
AGREEZMENT
This Agreement entered into this lst day of
December 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Seely C. Knowles ,
hereinafter called "Resident", and None
hereinafter called "Responsible
Party"
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 deductible, 80% of
balance after medicare for lst, 14 days
of hospital care, 80% of balance after medicare
or physicians services.
5. Other: None
II.
C.
1. To provic'e Such personal clothin-: anc'.
effects -isnt'nr:' ;'_1 or C'- —red, by :.he
Resident.
2. To pay the monthly rate agreed upon and
such charges as deter_r-ineO. by the Monroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the 1Pdministrator of the Home, that
the Pesident 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 ir.mediate
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 disaualification.
4. To comply with all reauirements 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
cours-e of residency, up to the maximum rate.
7. Other: None
FINANCIAL ARPANGF.MENTS
The Resident and./or responsible party agrees to
pay to the County $ 170.60
rent for use of the facilities.
, per month as
Payment will be fromthe following sources:
1. Personal funOs of Resident $
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social. Security $ 170.60
Civil Service annuity $
VA Pension $
Other $
D. Sm; .?rc�.i.n ..f".tTSS TO", `? .'T
'he County ,' tI rOu<in 1 tS Cii'PI-c- Ces has aQrCeC to
exercise such reasonable care toward the nesi('_ert 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 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 home.
E. TFPIIINA TION
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
re.^iove 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. MEDICAL 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. DURATIO' OF AGRFF_,TFNT
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'. b2 forced to remain
in the facility against his/her will for any length of time.
Witnesses as to Resident
Witnesses as to
Responsible Party
'r
r � `
Sic�nare of Resident".0
Si.rnature of Responsible
Party
DATE
APPROVED-
Signature of Representative
of Monroe County Home aka
Bay Shore Manor
Signature`of Fxecutive
Director, Monroe County
Social Services
SiJ ature of County
ACministrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGRFF'MFNT AS
APPROVED BY THE COUi'TTY HOME 7'NND THE COUNTY 7Di`1I1\TISTP-7=R
WAS R.ATIFIFD BY THE MONROF COUNTY BOARD OF COUNTY
CO�IfII1IS IONFRS AT THEIR. MEFTI27G HELD ON THE DAY
OF &13E 19 _� .
Sig f ture of the Cha' rman
Mo roe County Board f
County Commissioners