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Residency Agreement

This agreement, together with attached schedules and the Information and Services
Guide (collectively, the .. Agreement") sets out the terms and conditi.ons of occupancy at
(' Q,.,.- w. Koc, (the "Home"). It is entered into by
.. :Ji)U:;:rJ:L '(the "Substitute Decision Maker"), as substitute
decision maker on behalf of \: n @\ j c!. o. '"'- \ (the "Resident"), as
resident, and :Dn Q ,,,_. m '- L -t
0
,i , operating as
" O'J " (the "Operator"), as the icenced operator
of the Home under the Nursing Homes Act (Ontario), as of
The following are the agreed upon terms and conditions:
1. On or before signing this agreement, the Substitute Decision Maker will provide
the Operator with a notarial copy of the Power of Attorney, which establishes the
Substitute Decision Maker's authority to enter into this Agreement on behalf of
the Resident (the "Power of Attorney"). The Substitute Decision Maker
represents and warrants that the Power of Attorney is valid and is in full force and
effect and is not being contested. The Substitute Decision Maker agrees to notify
the Operator in writing immediately upon any amendments in such Power of
Attorney, or in the event it becomes contested or otherwise affected in its validity
or effect. The Substitute Decision Maker covenants and agrees with the
Operator that the Substitute Decision Maker and the Resident are jointly and
severally bound in respect of all obligations of the Substitute Decision Maker or
the Resident under this Agreement.
2. The Operator agrees to provide the Resident with the accommodation and
personal care services selected by the Substitute Decision Maker from the list as
set out in Schedule a A" as may change from time to time (the "Accommodation
and Services").
3. The Substitute Decision Maker agrees to pay the Operator for the provision of
the Accommodation and Services, in advance on the first day of each month
during occupancy, at the rates as set out in Schedule (the a Rates"). Such
payments shall be convenienced by way of electronic fund transfer, In
accordance with the provisions of Schedule "8" (the "Electronic Fund Transfer
Forma).
4. The Substitute Decision Maker agrees that the Operator may increase the Rates
and may change the Accommodation and Services from time to time on 30 days
prior written notice to the Substitute Decision Maker, provided all necessary
Ministry of Health and Long Term Care approvals have been granted to the
Operator for such increase, if required. The Operator agrees that the Substitute
Decision Maker may discontinue any of the optional Accommodation and
Services on 30 days prior written notice.
5. The Substitute Decision Maker agrees that if any payment owed on account of
the Resident is not received by the Operator when due, then the Operator may
take any legal means available for the collection of the overdue accounts,
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including, without limitation, initiating an action against the Substitute Decision
Maker, garnishment of Old Age Security payments, Canada Pension Plan
payments, Guaranteed Income Supplement payments or any other source of
income, support or maintenance payments as permitted by law. The Substitute
Decision Maker further agrees that the Operator may withhold any optional
Accommodation and Services from the Resident until all overdue accounts are
pai9 in full and that, upon receipt of a written request from the Operator, the
Resident will move to standard room accommodation until all overdue accounts
are paid in full.
6. The Operator agrees to contact the Substitute Decision Maker in the event of a
medical or other emergency. The Operator will provide the Substitute Decision
Maker with all medical and other information which the Operator, acting
reasonably, believes necessary or prudent in the circumstances. All notices to
the Resident shall be made in writing to the Resident at the Home with a copy to
the Substitute Decision Maker at the address listed below. The Substitute
Decision Maker agrees to notify the Operator in writing immediately upon any
change in address or other contact information.
7. This Agreement shall commence as of the above date and shall terminate on the
date on which the Resident is discharged from the Home. Unless this
Agreement has been terminated, it shall remain in full force and effect during
temporary absences of the Resident from the Home, including temporary periods
of hospitalization, if any. The Substitute Decision Maker agrees that the
termination of this Agreement shall not release the Substitute Decision Maker or
the Resident from any obligations hereunder, including the obligation to pay all
outstanding accounts, which obligation shall survive termination.
8. The Substitute Decision Maker acknowledges receipt of an Information and
Service Guide from the Operator. Each of the Operator and the Substitute
Decision Maker agree that such Information and Service Guide together with the
attached schedules, fonns part of the entirety of this Agreement. Each of the
Operator and the Substitute Decision Maker agree to be bound by and conduct
themselves in accordance with the provisions of all rules and policies of the
Home, as may be amended from time to time by the Operator.
9. The Substitute Decision Maker acknowledges that the Substitute Decision Maker
has discussed the information contained in Schedule "C" with a representative of
the Operator.
10. The Substitute Decision Maker acknowledges thafthe Substitute Decision Maker
has read and understands the entirety of this Agreement.
11. Each of the Operator and the Substitute Decision Maker agree that this
Agreement shall enure to the benefit of and be binding upon each of them and
the Resident and their respective heirs, executors, administrators, successors
and assigns.
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12. Each of the Operator and the Substitute Decision Maker agree that this
Agreement shall be governed by the laws of Ontario and the laws of Canada
applicable therein.
Signed at C. \..) \:\- c c
first above written.
Substitute Decisio
Information
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SCHEDULE "A"
ACCOMODATION AND SERVICES
The Operator is required under the Nursing Homes Act (Ontario) and the Regulations
thereunder (as amended) (collectively, the caActa) to provide basic accommodation and
services to residents of the Home. The Ministry of Health and Long Term Care (Ontario) (the
.. Ministry") provides funding to the Operator to cover a portion of the fees for the provision of
such basic accommodation and services. Residents are responsible for the balance of any
fees not funded to the Operator by the Ministry for such basic accommodation and services.
Residents may, however, choose to upgrade their accommodation or have extra services
provided to them. The Act requires written authorization (by signature or initialling) for the
provision of and charging for any accommodation upgrade or extra services which may be
requested by the Resident. The fees for basic accommodation and services, and the
applicable fees for accommodation upgrades and extra services. payable by the Resident are
itemized below.
ACCOMMODATIONS
The Operator Is paid for providing Basic Accommodation at prescribed or agreed upon rates
by the Ministry except only for the accommodation co-payment of $ :SlG . It; Cf per day to
be paid by the Resident (the .. Resident Co-paymenr). The Resident Co-payment is subject
to periodic adjustment In accordance with the rates established by the Ministry. In the event of
any conflict between the rates contained tn this Agreement and the rates established by the
Ministry. the Ministry rates will apply. If the Resident Is financially unable to make the Resident
Co-payment, then he/she shall sign any and all documents required by the Operator to apply
for a subsidy from the Province of Ontario for such payment.
In addition. the Operator offers Semi-Private and Private accommodations for an additional
fee. These Premium Accommodations are not included in Basic Accommodations. but are
made available by the Operator of the Home at the rates Indicated below. which are subject to
change from time to time on 30 days prior written notice to the Resident.
Please select one of the following types of accommodation. payment for which shall be
charged to the Resident's monthly bill:
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Type of Accommodation
Basic
Semi-Private
Private
Short-Stay
ACCOMMODATION CHARGES*
(Effective July 1, 2001)
$Dally $Monthly Authorization
5l t.t ((
No. of Consecutive
Days
Initial
Initial
Initial
Note: Accommodation Charges subject to change in accordance with the rates
established by the Ministry.
SERVICES
The Operator offers a variety of services to Residents of the Home. While many of these
services are offered at no additional charge, a number of these services are optional, and
require an additional fee. Please indicate which (if any) of the following optional services you
are interested in:
.. . .. . . . .
L .,...,.
'1 ,r. ,
. .
_;..l.; .... ...:.... _.....;_ .......... !..... J ... - -- ... -
VALET SERVICE- A fee of S15.00 per month Charge to monthly

provides for garment repair bill
Optional
as required e.g. hemming.
seam repair, button
replacement.
2
LAUNDRY- Centre to do laundry Nil
Basic
Laundry services and labeling for
Family to do laundry
Residents' clothing is provided at no
cost. However we recommend that
clothing be made of durable fabrics to
withstand a ucommercialv laundry such
as ours.
3
DRY CLEANING- N/A Nil
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005
' . "'
! . .
..... .. .. ----- .. ..... ....,. ...
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HAIRDRESSING I BARBERING-
Optional
Beaulicianlbarbering services are
provided by appointment.
TRANSPORTATION
Optional
The provision for payment of taxi or
other fares required by the Resident to
attend appointments, clinics, etc. in the
absence of available family.
MEDICATION-
The provision for medications
ordered by the Attending Physician
which are not covered under the Drug
Benefit Plan.
The Resident agrees to use the
home-contracted pharmacy.
The Mlmstry of Heallh Drug
Coverage for LTC Centre Residents
requires a $2.00 /prescription/month co-
payment.
Weekly ____ _
Cha<ge $""'''
bill . Biweekly. ___ _
Monthly. ____ _
@Resident Request. ___ ----1 To be paid
@ Fam1ly Request -------1 directly __ _
Note: A list of current prices
and hair care services is
included In your Information
and Service Guide.
Directions:
To be paid directly
to service
provider
To be paid directly
to Pharmacy.
Initial
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Initial
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ESCORT SERVICE -
ef- Optional
Where family are not To be paid directly
available to accompany a to Agency.
The provision for payment of Escort
Resident who is
Initial
Service charges required by the
unable/unsafe to travel alone.
Resident to attend appointments etc.
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DENTURE LABELLING To be paid directly
~
to service
Optional
provider.
Initial
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DENTAL SERVICES -
Optional
To be paid directly
to the dentist.
tfE-
The provision for payment of an initial
e.g.
and annual dental examination.
The Resident/representative
Initial
.. Any dental work required, as well as
wishes to use the services
resulting charges to be discussed with
available in the home
the Resident/ representative and
approved prior to being done.
10
PERSONAL WHEELCHAIR
MAINTENANCE -
~ Optional
Initial
Any costs incurred for maintaining
maximum safety and security of
wheelchairs owned by the Resident.
11
CHIROPODY I PODIATRY I
PROFESSIONAL FOOT CARE
SERVICES-
~
Optional
For any cost not covered by OHIP for
the provision of professional foot care.
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OPTOMETRIST AND/OR
AUDIOLOGIST SERVICES-
l@f-
Optional
The prov1sion for payment of an
Initial
optometrist/audiologist exam ina lion
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--. -, ....
" .
. '. ... .. . . . .
:._ I L _,- - - - -
where not covered by OHIP.
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VISION CARE-
Optional
The provision for purchases of repairs of
glasses.
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INCONTINENCE SYSTEM -
Basic
The Home prov1des a quality re-useable
incontinence system. Following
assessment of the Resident's needs and
the implementation of an Individually
adapted program of lollellng, the
Resident may require the use of an
Incontinence containment system.
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MEALS
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AND
BELATED COSTS FOR
RECREATIONAL OUTINGS-
Optional
The provision of meals, trips,
transportation and related costs for
recreational outings_
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Telephone-
Optional
The provision of telephone serv1ce for
1ndiv1dual Residents.
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CABLE T.V. -
Optional
The provision of ceble service for
individual Residents.
Both the provision and
laundering of the system are
provided without charge.
Estimated amount per month
$ It QC.
Nil
Charge to monthly

e.g.
To be paid directly
to service provider
e.g.
To be paid directly
to service
-il-
Initial

Initial
Initial
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OTHER
Optional
Initial
The Resident understands and agrees that tt shall be charged the total of the following, for
each month, payable on the first day of each month In advance in accordance with paragraph
2 of the Home's Residency Agreement:
(a) the Resident Co-payment (unless same is subsidized by the Province of Ontario):
(b) the total of all optional Accommodation and Services selected, at the applicable rates;
(c) all hospital charges, transportation charges and all other related charges which result in
the event that, in the reasonable opinion of the Operator, the hospitalization of the
Resident becomes necessary or advisable. For greater certainty, the Operator shall not
be responsible for any costs incurred by or on account of the Resident in the event that
it is hospitalized and the Resident hereby indemnifies and agrees to repay the Operator
for any such costs Incurred by or charged to the Operator on the Resident's behalf:
(d) all charges for any services provided to the Resident in accordance with this agreement,
including, without limitation, the services indicated in this Schedule "A" above.
In addition, the Resident acknowledges and agrees that:
(a) he/she is responsible to pay all physician's fees, medications and other treatments or
aids ordered by a physician unless otherwise covered or provided by the Ontario Health
Insurance Plan (OHIP), Ontario Drug Benefit Program or Fonnulary (ODB), Home Care
Program (HCP), Asslstive Devices Program (ADP), Ontario Government
Pharmaceutical and Medical Supply Services (OGPMSS), and/or funding provided to
the Home under the provisions of any applicable laws, If applicable, it being agreed that
it will purchase all prescription medication from the Operator's designated pharmacy
services provider;
(b) he/she is responsible to obtain on a regular basis appropriate clothing, adequate
footwear, prosthetic devices (such as, for example, glasses, dentures. hearing aids,
personal wheelchairs, walkers, canes) and any other personal items which are
reasonably necessary for occupancy at the Home and that the Operator is not
responsible for any maintenance, repair, improvement or alteration of any of the
Resident's personal effects:
{c) he/she assumes full responsibility and liability for any financial loss or harm occurring as
a consequence of the management by the Resident of its own personal financial affairs;
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(d) while he/she is absent from the premises of the Home, including for vacations or casual
leaves of absence, the Resident assumes full responsibility and liability for its own
welfare and care requirements and hereby releases the Operator and its staff from any
liability resulting therefrom:
(e) he/she shall be responsible to reimburse the Operator for any bank charges or fees paid
by the Operator in the event of late payment owing to insufficient funds:
(f) he/she is solely responsible for the care, protection and well-being of all of its valuables.
including but not limited to, personal effects, prosthetic devices or cash:
(g) in the event that a Resident deposits monies with the Operator for safekeeping, the
Operator shall be responsible for such monies and shall keep such monies in an
interest-bearing trust account, with Interest to accrue for the Resident's benefit in
accordance with all applicable laws;
(h) if this Agreement is for a short-staY' then the Resident will vacate the Home on 24
hours notice by the Operator; and
(i) the Operator shall comply with the provisions of the Personal Information and Electronic
Documents Act (Canada). as required pursuant to the provisions thereof.
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SCHEDULE ua"
ELECTRONIC FUNDS TRANSFER FORM
BENEFITS TO RESIDENTS AND RESPONSIBLE PARTIES
No need to worry about missing a payment.
No need to worry about making sure your payment is on time.
Eliminates need to make a special trip to pay bill.
Eliminates late payment charges.
Continue to receive monthly statement.
TERMS AND CONDITIONS
I (we) authorize C ~ t-\ Cc- (the '*Operator") to debit my (our)
account, as indicated on the "void
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cheque attached hereto, under the terms and
conditions agreed to by me (us) with the Operator until such time as written
notice to the contrary is given.
I (we) acknowledge that delivery of my (our) authorization to the Operator
constitutes delivery by me (us) to the branch of the financial institution at which I
(we) maintain an account and that such financial institution Is not required to
verify that the payment(s) are drawn in accordance with this authorization.
Termination of the authorization does not terminate the contract for goods or
services exchanged.
I (we) will notify the Operator in writing of any changes in the account information
or termination of this authorization prior to the next due date of the pre-authorized
debit.
Items charged under any of the following conditions will be reimbursed subject to
written notification by me (us) to the branch of account within 90 days:
(a) I (we), never provided authorization to the Operator.
(b) The pre-authorized debit was not drawn in accordance with my (our)
authorization.
(c) My (our) authorization was revoked.
(d) The debit was posted to the wrong resident account due to the
invalid/incorrect account information supplied by the Operator.
Upon discharge of the Resident from the Home. I (we) understand that the
Operator will discontinue processing debits against my (our) account, except to
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AUTOMATIC PAYMENT PLAN AUTHORIZATION
Resident Name ___ ..... .... . ____ _
Resident Identification No. - - -----'---..::'----------------
I
Indemnifier Name (if applicable) __ :.>o>- ...
Yes! I want to join and enclose my "void" cheque.
I (we) authorize the Home to process a debit, in paper, electronic or other form,
for the Resident's accommodation (including rate increases) and any
miscellaneous charges appearing on my statement/invoice. I (we) understand
that this will occur on the 1st day of each month beginning De ( .? c c <. /.
The Home will forward a statement of account in support of the debit to me (us)
on or within 5 days of processing the debit.
I (we) acknowledge that I (we) have read and understood all the provisions
contained in the terms and conditions of the automatic payment plan and that I
(we) have received a copy.
f\JQ.J :;) ccrJ=
(Date)
[PLEASE STAPLE VOID CHEQUE HERE]
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