12/01/1981 AgreementBAY SHORE MANOR A/K/A
NOROE COU' TY HO:-IE , ADULT CO::G EG ,�TE
LIVING FACILITY FOR THE: ELDERLY - LEVEL II
AGREE -I E N T
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
Percy Ralph Page
hereinafter called "Resident", and
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: None
5. Other.
None
1. To provide suct: pnrsOnmil clo,1--hinr: and
effects as nuec'C''d or ]ireU b�,' ie
Resident.
2. To pay the monthly rate agreed upon and
such charges as determined by the %Ionroe
County Dome 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 conta.ctinc: 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 Ppplication 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: To be responsible for all medical
and hospital costs.
C. FINANCIAL ARPAN- GF1MNTS
The Resident and/or responsible party agrees to
pay to the County $ 665.00
rent for use of the facilities.
, per month as
Payment will be fromthe following sources:
1. Personal funds of Resident $ 665.00
2. Responsible party will pay $
3. Unearned. income of Resident
will pay:
Social Security $
Civil Service Annuity $
VA Pension $
Other
C
The Count, throuc;n its crnolo'y(�es has acTrced 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 N.anacement of this hone will not be respon-
sible for anv valuables or m.onev left in the x)ossession of
this person while he or she is a resident of this home.
E. ITFMITNA^TON
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. MEDICAL SERVICES
The parties agree that Monroe County shall not be
or assuL-ne 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. DUPATIO',? OF AGRFE,IFNIT
Fither party may terminate this agreement on five
(5) days written notice. Otherwise, it will remain in
effect until a different agree_-ient is executed. However,
this does not mean that a Resident wilt be forced to remain
in the facility against his/her will for any length of time.
�0l
1 'gx�Ltmj
Witnesses as to Resident
Witnesses as to
Responsible Party
Signature of Resident
Signature of Responsible
Partv
DAT F
APPROVED: �?.A
Signature of Representative
of Monroe County Home aka
Bay Shore Manor
72 ��r
Sig ature o xecutive
Director, Monroe County
Social Services
S'a ature of County
Ac .inistrator _
THIS IS TO CERTIFY THAT THIS ADMISSION AGRFF'MENT AS
APPROVED BY THE COUNTY HOME AND THE COUNTY A.D� .INISTP-ATOR
117AS P.ATIFIFD BY 'TFF MONROE COUNTY BOARD OF CO Ter, Y
C='MIS IONFRS AT THEIR. MPFTING HELD ON THE DAY
OF &,L t k 19 .
Signature of the Chairman
Monroe County Board of
County Commissioners