12/01/1981 Agreementr
BAY SHORE MANOR A /KlA
, :ROE COUNTY HO :- E AD LT CO: :G REG %I�TE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
A G R E E M 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
Edward Walter Zydel
hereinafter called "Resident ", and None
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:
.• I uM►•'
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 1st 14 days of
hospital care, 80% of balance after medicare for
physicians) -servtces.
5. Other: To reimburse $ 10.00 per month
for personal spending money.
B. TTTT- ni CT^£` ;m
1
1. To provlc such: rerse:.. ?l clot 11: anc'
of fects as r, ec ed or -!_sired, by the
Resident.
2. To pay the monthly rate agreed upon anti
such charges as determined by the Monroe
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 Pesident is no longer capable of
meeting the requirements for occupancy
in this facility, the Resident, next of
kin, ler.,al 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 re_nresent 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 reaui
forth in the Application
Resident.
5. To comply with all rules
tions established by the
operation and control of
cements as set
made by the
and regula-
County for
said home.
6. Agrees, if not paying the maximum rate,
to pay any increases in in come during the
sours -e of residency, up to the maximum rate.
7. Other: None
C. FINANCIAL ARPAINGF
The Resident and /or responsible party agrees to
pay to the County $ 270.
rent for use of the facilities.
, per month as
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 $ 270.20
Civil Service 'annuity $
VA Pension $
Other $
Thc_ Counts' throuc;:h its o ^loy ^es has aC'rr_.ed 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 safety or welfare and assumes
no liability as such.
The Management of this horse will not be respon-
sible for any valuables or money left in the TDcssession of
this person while he or she is a resident of this horse.
E. TFRPIINATION
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 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. DUPTTION OF AGRFF_4FNT
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 tim.e.
Gr
Witnesses as to Resident
Witnesses as to
Responsible Party
f
Signature f Resident
Sic- nature of Responsible
Party
DATE
xv,�� Luv-1
Signature o Representative
of Monroe County Home aka
Bay Shore Manor
Si ature of Fxecuti.ve
Director, Monroe County
Social Services
APPROVED:
Sig ature of County
Aeministrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGRFFPIFNT AS
APPROVED BY THE COUNTY HOVE A'� ?D THE COUNTY A.DMINISTP- TOR
WAS RATIFIED BY THE MONROE COUNTY BOARD OF C T'QTY
CO�L�IISSIOr1ERS _ _ THEIR. MEETING HELD ON THE k- DAY
OF uL C',
19 .
Si(::rpt of the Chairman
Monroe County Board of
County Commissioners