Okaloosa County BOCC — March 18, 2014 — Settlement Agreement

STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS Steven St. Clergy, Employee/Claimant, VS. OJCC#: 98-020187NSW Date of Accident: 8/20/98 Okaloosa County Board of Commissioners, Employer, and Johns Eastern, Carrier/Servicing Agent. / TLEM ENT P TTO 44.0.2 & fe TATU 001 The above-named parties hereby set forth the following agreement made for the specific purpose of discharging the employer/carrier/servicing agent from any further liability as to any and all dates of accident or injury, including, but not limited to the date(s) of accident listed above, for all past and future benefits under the Florida Workers’ Compensation Law, in exchange for the payment of a lump-sum of money to the claimant. The parties, therefore, stipulate as follows: 1. JURISDICTION - The Florida Department of Labor and Employment Security and the Judge of Compensation Claims (hereinafter referred to as "judge") appointed under F.S. §440.45 have jurisdiction of the subject and the parties hereto. 2. ION_OF ED}_AC - On 8/20/98, the employee (hereinafter designated as the claimant), contends he was injured by accident as contemplated under FS. §440.02(1} arising out of and in the course of employment with the employer in Okaloosa County, Florida, when, while lifting a body into the van, the body fell and claimant injured his back. 3. A KLY WAG MPEN - At the time of the injury, the claimant's average weekly wage was $815.12, thus making the compensation rate $494.00 per week. 4, PTION BENE D LON: RY OF DI DE I TAGN PERFORM TURE OF ANY IGNIF- PRE- NDITIONS F_ DESC Y(IE PERFORMED, IF ANY - Following the injury, claimant was treated by Dr. Dale Johns, and following GED was Ey by Dr. Johns on 1/8/01. By 10/4/00, Dr. Johns concluded that claimant could return to his previous job in the medical examiner's office, although the job was not then available. By May of 2001, claimant commenced employment with the Broward County Medical Examiner's Office as Medical Legal Investigator. He left that position in February of 2005 and became employed by the Volusia County Medical Examiner’s Office as Forensic Investigator. He resigned in October of 2008, and commenced customer service work in March of 2009 for a period of three months. After moving from the Northwest Florida location, claimant came under the care of Dr. Jarolem who put claimant at JS QED and Dr. Villalobos who put claimant at SD with an GD Dr. Allende perforned Ey on 8/9/11, and placed claimant i. Dr. Allende limits claimant to QE Dr. Villalobos agreed with the FCE dated 7/3/13, placing claimant Qa 5. MAXIMUM_MEDICAL IMPROVEMENT, IMPAIRMENT RATING AND WORK RESTRICTIONS - Dr. Johns put claimant Si and return of claimant to previous employment. Dr. Jarolem placed claimant QS with a Dr. Allende placed claimant at Dr. Villalobos placed claimant at r. Allende said claimant can Qa and Dr. Villalobos concurs with the FCE placing claimant (qa 6. ESTIMATE OF COST OF FUTURE MEDICAL CARE - Dr. Villalobos stated on 7/26/12 that claimant should continue on (ig and Gaus. As of 9/9/13, Dr. Villalobos prescribed (iE and continued (Qiu This information was taken into consideration in arriving at a reasonable lump sum payment for the release from liability for future medical benefits. 7. AGE, EDUCATIONAL BACKGROUND AND WORK HISTORY - The claimant is 56 years of age (DOB: 6/15/57) and has a college education. He is able to read, write and do simple math. His work history includes employment as a medical examiner's assistant. At the time of the alleged injury, the claimant was working as a Special Assistant Forensic Investigator. 8. TT T NT DI RG M ATY F TUR MP TI - Subject to the approval of the judge pursuant to Florida Statutes §440.20(11}(c},(d) & (¢), employer/carrier/servicing agent will pay to the claimant $330,900.00 in accordance with the statutory formula, in full satisfaction of the obligation or liability to pay all past and future benefits of whatever kind or classification available under the Florida Workers’ Compensation Law including, but not limited to, future medical benefits, monetary compensation as contemplated under Section 440.15, Florida Statutes, impairment benefits, death benefits, attorney's fees, past medical benefits and rehabilitation and training and education benefits including temporary total disability compensation under Section 440.49(1989)&(1990) and 440.491(6)(b) (1993), Florida Statutes, on account of the alleged accident or occupational disease referenced herein which shall be allocated as follows: a. Past and future compensation Benefits $ b. Past medical expenses $ C. Future medical expenses $265,250.00 1. MSA for Medicare expense of $355,201.00 funded by annuity cost of $173,170.00 2. Up-front cash of $66,494.00 3. Non-Medicare covered medical costs of $25,586.00 d. Rehabilitation temporary total disability compensation and rehabilitation and training and education expenses $ 25,000.00 e. Attorney's fees and costs $40,650.00 TOTAL: $330,900.00 *It is not the intention of the Workers’ Compensation Carrier to shift responsibility of future medical benefits to the Federal Government. The sum of $ for future Medicare- covered expenses is intended directly for payment of these expenses. Upon proof that Medicare 2 covered expenses exceed $ those expenses will be forwarded to Medicare for payment of covered expenses with proper documentation. It is the responsibility of the claimant/ beneficiary to submit documentation of paid bills related to the work-related injury or illness totaling the amount of $ before Medicare will make payment on any covered expenses related to the work injury or illness. Consideration has been given to the fact that the claimant is currently receiving Social Security Disability benefits. This allocation is based on the workers’ compensation fee schedule. The injured worker should be advised that all payments to providers are to be adjusted accordingly, and any monies paid in excess of the fee schedule will not count toward the allocation. The Medicare set-aside funds in this case are to be self-administered by the claimant. Claimant has been provided with the directives issued by CMS regarding his rights and responsibilities in this regard as set forth in Exhibit “A” “Terms and Conditions for Beneficiary Administered Set Aside Account” attached hereto and incorporated by reference herein. Claimant understands that the MSA funds must not be used to pay the claimant's expenses. Claimant understands that the MSA funds must be placed in an interest-bearing account, and this account must be separate from the individual’s personal savings and checking accounts. The funds in this account may only be used for payment of medical services related to the work injury that would normally be paid by Medicare. If payments from this account are used to pay for services that are not covered by Medicare, Medicare will not pay injury-related claims until these funds are restored to the MSA account, and then properly exhausted. Claimant further understands that annual reporting must be prepared for submission to Medicare to include summaries of the transactions and status of the account. These summaries are to include the date of each service, procedure performed, diagnosis and paid receipt or canceled check. In the event the claimant is a Medicare beneficiary, there may be an outstanding Medicare lien at the time of the settlement in this case. If the Medicare lien remains outstanding at the time this case is settled, the lien will be satisfied by the claimant as part of the terms of the settlement. This settlement will not become final until the amount of the Medicare lien has been determined and the lien is satisfactorily resolved with Medicare by the claimant, The parties agree that the injured claimant has attained maximum medical improvement. In addition, the payment of the lump-sum set forth herein will definitely aid in the rehabilitation of the injured claimant or will otherwise be in his best interest. Upon receipt of the lump-sum, the employer/carrier/servicing agent will be forever released and discharged from the obligation or liability to pay any and all benefits of whatever kind or classification payable under the Florida Workers' Compensation Law. The claimant does hereby waive any right he may have to any and all penalties and/or interest on account of the accident or occupational disease referenced herein and specifically agrees that the employer/carrier/servicing agent will have thirty (30) days from the date of the entry of the Order approving the Motion for Approval of Attorney's Fee and Allocation of Child Support Arrearage to make payment. As further consideration for the aforementioned payment, the claimant agrees and does hereby release, discharge, and surrender any and all claims, whether or not asserted against the employer/ carrier/servicing agent, or any of its officers, agents, servants, employees, directors, successors, assigns, and any other person or entity so connected to the employer/ carrier/servicing agent, of any nature whatsoever, without any limitations thereof under Chapter 440. 9. TORNEY‘ P BY NT AND W;, - The claimant has been represented by Edward H. Hurt, Jr, Esquire, in connection with this matter who is entitled to a fee for legal services rendered. $40,000.00 is a reasonable fee for such services, and is within the guidelines for the determination of a reasonable fee as set forth in F.S. §440.34(1). In addition thereto, the claimant shall also reimburse the attorney $650.00 for non-taxable costs. Notwithstanding the provisions of F.S. §440.34(3)(a-d), the claimant and not the employer/carrier/servicing agent is responsible for the payment of his own attorney's fees because this settlement was made under FS. §440.20(11)(c), (d), & (e) F. S. (2001). The claimant has been informed of the right to a hearing on the amount of the fee charged by the attorney and hereby waives his right to such a hearing. The fee and non-taxable costs shall be paid from the settlement proceeds, thereby making the net settlement amount $290,250.00. The claimant guarantees to hold the employer/carrier/servicing agent harmless from any claim or lien for attorney's fees and costs by any attorney with respect to any date of accident listed in this settlement agreement. The parties further stipulate and agree that the claimant is responsible for said claims or liens of prior attorneys. 10. WAIVER OF RIGHT TO HAVE CASE HEARD BY JUDGE OF COMPENSATION CLAIMS RIGHT TO TIO R FI N - The claimant understands that he does hereby relinquish the right to have any unresolved conflicts or disputes involving the right to monetary compensation benefits, impairment benefits, death benefits, attorney's fees, past due medical benefits, future medical benefits and rehabilitation and training and education benefits heard and decided by a judge. 11. PRESENT WORTH AND POSSIBLE OFFSET FOR SOCIAL SECURITY DISABILITY BENEFITS CONSIDERED - In reaching this agreement, the parties have considered the present value of all future payment of indemnity benefits, impairment benefits, medical benefits and death benefits potentially payable to the claimant under the Florida Workers’ Compensation Law on account of the injuries referenced herein. The injured claimant was born 6/15/57 and his life expectancy is approximately 24 years, or 1,248 weeks. When the present value of the lump sum payment for future indemnity benefits of $25,000.00 herein is prorated on a weekly basis over the claimant's life expectancy, the lump sum is equal to payment of future indemnity benefits at a rate of $20.05 per week. This periodic repayment schedule results in a substantial loss to the claimant on a consistent basis. Taking that into consideration, the parties hereby agree that those weekly payments of indemnity benefits are the same as if the lump sum would have been paid to the claimant at a rate of $20.05 per week over his expected lifetime. The same is true for the lump sum payment of future medical benefits, which, when reduced to present value, is equal to $262,250.00. The iump sum consideration given for the settlement of future medical benefits is the same as if the lump sum would have been paid to the claimant at a rate of $210.14 per week over his expected lifetime. The employer's/carrier's/servicing agent's right to offset workers’ compensation indemnity and medical benefits due under Florida Workers' Compensation Law against benefits payable on account of total disability under Chapter 42, UNITED STATES CODE, including benefits payable under Medicare, is also included in these calculations and has been considered by the parties in reaching this agreement. 12. M N P P M EN ; R F TH AND REHABILITATIVE SERVICES UNDER F.5.8409,910 ( MEDICAID THIRD PARTY LIABILITY ACT) - The claimant confirms that no claim or right of reimbursement by Medicare or Medicare Secondary Payer Program exists, or lien of the Department of Health and Rehabilitative Services under F.S.§409.910 for treatment of the injuries arising from the work related accident referred to herein. Claimant hereby acknowledges that all responsibility for Medicare claims or Medicare Secondary Payer Program and/or all claims or liens of the Department of Health and Rehabilitative Services under F.S. §409.910, for any and all past treatment for which Medicare or Medicare Secondary 4 Payer Program and/or the Department of Health and Rehabilitative Services under F.S. §409.910 has a claim, if any, is that of claimant, subject to the rules and regulations of Medicare and/or the Department of Health and Rehabilitative Services under F.S. §409.910. Claimant indemnifies and holds harmless the employer/carrier/servicing agent against any liability in favor of Medicare or Medicare Secondary Payer Program and/or the Department of Health and Rehabilitative Services under F.S. §409.910. 13. WAIVER OF PENALTIES, INTEREST, AND FORMAL NOTICE - The claimant does hereby waive any right he may have to any and all penalties or interest on account of the alleged accident or occupational disease referenced herein. 14, ENT: RIES NAL DIS EVEA AN PE LA’ T - The claimant once again represents and affirms that all accidents, injuries and occupational diseases known to have occurred or sustained while employed by the employer have been revealed. All pending claims and notices of denial pertaining thereto are hereby voluntarily withdrawn. 15. AGREEMENT SUB TO APPROVAL OF [UPGE OF COMPENSATION CLAIMS. - The parties clearly understand that attorney fees and costs, as well as child support obligations of claimant must be approved by the Judge of Compensation Claims, before settlement becomes formally binding. The claimant understands that these items have been routinely disapproved by judges in the past and should not undertake any financially binding actions until formal approval is obtained. In the event these items are not approved by the judge the settlement shall be completely void and of no effect whatsoever. If such approval by the Judge is not forthcoming, the employer/carrier/servicing agent reserves the right to assert any and all defenses available under the Florida Workers’ Compensation Law. 16. MP ST. D ED TTLEMENT PROCEEDS - The claimant is currently unemployed. If the terms of this settlement are approved, the claimant plans to use the proceeds therefrom as follows: savings and to pay bills. The information set forth above was provided by claimant in response to the settlement questionnaire directed to claimant by attorney for employer/carrier/servicing agent. 17. SIMULTANEOUS LANGUAGE - This agreement is made contemporaneously to simultaneous agreement between claimant and employer/carrier entitled Motion for Approval of Attorney's Fee and Allocation of Child Support Arrearage for Settlements Under Section 440.20(11)(c), (d), & (e), Florida Statutes 2001, signed by the parties on the ______ day of , 2013. This lump sum settlement shall be void and of no effect in the event the above referenced Motion should not be approved simultaneously herewith. 18. SETTLEMENT AGREEMENT - The execution of this Settlement Agreement will discharge and release the employer/carrier/servicing agent from all further liability to the claimant for all past and future benefits available of whatever kind or classification including, but not limited to, future medical benefits, compensation for disability under Section 440.15, Florida Statutes, impairment benefits, past medical benefits, attorney's fees, death benefits and rehabilitation and training and education benefits including temporary total disability compensation under Section 440.49(1989)&(1990) and 440.491(6)(b)(1993) due under the Florida Workers’ Compensation Law upon payment of the lump-sum herein provided which shall not be subject to modification under FS. §440.28. This Settlement Agreement was signed by the employer/carrier/servicing agent on the _.... day of __, 2013, and by the claimant on the _ /4 __ day of __ Feb ___ 20144 ee Ly l/ a & STEVEN ST. CLERGY ; hdwacd H. Hurt, Jr, bsq. oo Post Office Box 677489 Orlando, FL 32867 407-673-3408 Fla. Bar #0340936 Attorney for Employee/Claimant Cass rigr Charles K. Windes, Jr., Chairman Roderic G. Magie, Esq. Okaloosa County Board 3 West Garden St, Suite 614 Of Commissioners Pensacola, FL 32502 850-432-2558 Florida Bar #094862 Attorney for Employer/Carrier/SA STATE OF K. y COUNTY OF _// 0 p King Before me, the undersigned authority authorized to administer oaths and take icknowledgements, personally appeared STEVEN ST. CLERGY, who (is personally known to me) (was identified by driver's license) (who has produced O¥tyer Liga identification) on this 14 day of Feb 20 Atwho upon being duly sworn certifies that the information furnished by him as incorporated in the foregoing agreement is correct and that he (has read the agreement) (has had the agreement read to him) and believes the lump-sum settlement to be in his best interest. Lauls $ lyk ( natin Number 4A V3 IK’ My Commission Expires: /e- G-J0 4 6 The undersigned, STEVEN ST. CLERGY, for the sum of ONE HUNDRED AND 00/100THS Dollars ($100.00), paid to him by OKALOOSA COUNTY BOARD OF COMMISSION ERS, and other s0o0d and valuable consideration, the receipt and sufficiency of which is expressly ackriowledged and confessed, does hereby réledse and forever discharge - OKALOOSA COUNTY BOARD OF COMMISSIONERS and its felated corporations and its officers, agétits and associates both past and present; from all claims, demands, causes of action, including without restricting the foregoing generality, any and all claims for back pay, paid time off (PTO), workers’ compensation benefits (including medical), salary céntinwation benefits, health insurance benefits, sick leave accrued, long tern: disability benefits. (LTD). avid other fringe benefits, liquidated damages, exemplary damages, punitive damages, consequential daniages, datiages for mental atigdish, damages for loss of employment prospects; damages: for loss of reputation, damage for breach of contract, negligence, mistepresentation, intentional acts, attorney fees of any kind, whether known of unknown and whether asserted or'nét. . STEVEN ST. CLERGY hereby promises riot torfile, or authotize any other individual, ageney,.or private or'gevernmental entity to file on his behalf, any state or federal lawsuit orany state, federal or muni¢ipal administrative charge or complaint against OKALOOSA COUNTY BOARD OF COMMISSIONERS and hereby waives and-releases any and all claims, rights, arid causes of action, in law or equity of any Kind, whatsoever; which STEVEN ST. CLERGY or his heirs, executors, administrators, assigns or other legal represeitatives have-or niay have apainst .CKALOOSA-COUNTY BOARD OF COMMISSIONERS at this: tinie: or which are based on ‘any past acts: or ornissions of STEVEN ST. CLERGY, including, but-not:limited to, those arising out of his employment with or separation from OKALOQSA:COUNTY BOARD OF COMMISSIONERS including, but not limited’ to thdse elaims,. rights;, anid causes: of action’ based on any federal, state or local law, statute, ordinance, administrative regulation; public’ policy or Executive Order, such Ss the Fair Labor Statidards Act. of 1988, as artiended, 29°USIC. Sec. 201-209: the Civtl Rights Act of 1964,.as amended, 42. U-S.C. Sect. 2000e-2000e-17; the.Civil Rights Act of 1991, thé Civil Rights Act of 1866, as amended, 42 U.S.C. See. "1981; the Civil Rights Actof 1671, as amended, 42 U.S.C. Séc. 1983, 1985; Executive Order 11246; the Rehabilitation Act of 1973, as amended, 29 U.S.C. Sec. 701-7961; thé National Labor Relations Act, as amended, 29 U:S.C. Sec. 141-187; the Age Discrimination ia Employment Act of 1967, as amended, 29 U.S.C: Sec, 621-634; (the Florida Humnan Rights Act, as amended, Fla. Stat. Sec. 760.01-760.10;) the Americans with Disabilities Act of 1990, 42U.S.C. Sec. 12111 et seq,; retaliatory discharge claim or wrongful discharge claim; claitis under Section 440.205, Florida Statutes, retaliatory discharge claims, or any other state or federal constitutional claim, right, public policy or cause of action founded in tort, contract, or othér common law cause of action including, but not limited to, actions: based on misrepresentation, defamation, invasion of privacy, interference with prospective economic advantage, interference with contractual relations, or negligence. This document shall not inipair or impede claimant's right to unemploymient compensation that might otherwiséexist. STEVEN ST. CLERGY understands. and grees that the.consideration provided by. OKALOOSA COUNTY BOARD OF: COMMISSIONERS to him is ia, fall accord. atid. satisfaction. of doubtful and . disputed claims, and that the-consideration for this release is for the purpose of enabling OKALOOSA COUNTY BOARD OF COMMISSIONERS. to avoid the expense and inconvenience of litigation, and does not coristitite an admission of liability on ‘its patt ard’ ‘that OKALOOSA COUNTY BOARD OF COMMISSIONERS expregsly:denies that it has violated any law with respect to:‘STEVEN ST. CLERGY. Infurther consideration of the premises STEVEN ST. CLERGY desires to sever his employment relationship with OKALOOSA COUNTY BOARD OF COMMISSIONERS after an effort by OKALOOSA COUNTY BOARD OF COMMISSIONERS to reasonably accommodate him. Also, STEVEN ST.. CLERGY waives any right to reinstatement or reemploymietit and. agrees: not to apply for, solicit, seek or otherwise attempt:to obtain employment -with OKALOOSA COUNTY: BOARD OF COMMISSIONERS or any ofits related agencies.and ‘further agrees that-OKALOOSA COUNTY BOARD OF COMMISSIONERS is not or will not be at.any time:under any obligation to employ hirn. . STEVEN ST. CLERGY utiderstatids and agrees that.the aforesaid amount shall represent full damages.and attorney fees in this inatter, with réspect to items covered by this General Release and Waiver of Employment. STEVEN ST. CLERGY understands and agrees that the anjount is not In any manner baséd_on lost:cornpensation as the measure of damages; rather, the amounit is to. be-paid by OKALOOSA GOUNTY BOARD OF COMMISSIONERS and accepted by STEVEN ST. CLERGY to avoid further costs and uncertainties of trial and the uncertainties of liability and smeowely of any relief Sought or contemplated by STEVEN ST. CLERGY. It is understood further that all federal, state and local taxes, if any, on the amount of this ' claim are the sole responsibility of STEVEN ST. CLERGY. This Reléase shall Ee binding upon the heirs, executors, administrators and assigns of STEVEN ST, CLERGY. SIGNED THIS 2 DAY OF _=lom woes 2014 Post Office Box x e7PA89 Orlando, FL 32867 407-673-3408 Fla Bar#. OSHOISE Attorney for Employee/Claimant STEVEN ST. CLERGY UNDERSTANDS THE CONTENT AND THE EFFECT OF THIS GENERAL RELEASE. HE HAS CONSULTED WITH OR HAD THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY AS TO SUCH CONTENTS AND THEIR EFFECT WITH RESPECT TO HIM. STEVEN ST. CLERGY UNDERSTANDS: THAT HE IS NOT BEING ASKED TO WAIVE. CLAIMS OR RIGHTS ARISING AFTER THE DATE OF EXECUTION OF THIS AGREEMENT; THAT THE CONSIDERATION HE IS RECEIVING FOR THIS AGREEMENT IS IN ADDITION TO HIS OTHER ENTITLEMENT, ESPECIALLY WORKERS' COMPENSATION. STEVEN ST. CLERGY ACCEPTS EACH AND ALL OF THE TERMS, PROVISIONS, AND CONDITIONS OF THIS: GENERAL RELEASE, AND DOES SO VOLUNTARILY AND WITH FULL KNOWLEDGE AND UNDERSTANDING OF THE CONTENTS, NATURE, AND EFFECT OF THIS GENERAL RELEASE AND WAIVER’ OF EMPLOYMENT AGREEMENT. STEVEN = CLERGY > _ BEFORE ME, the undersigned authority on this date personally appeared STEVEN ST, CLERGY, who has produced Dri vey Lisens¢, as identification, who did/did not take an oath, and who acknowledged to me that he executed the above Release for the purpose and consideration therein expressed, ~ oa . _—_—_ Given under my hand and seal of office this 2. e aay of Vanuary, 2014. NOTARY PUBLIC, in and for the state of MY COMMISSION EXPIRES: 10-94-20 iq Notary ID No: G2AgBA EXHIBIT “A” TERMS AND CONDITIONS FOR BENEFICIARY ADMINISTERED MEDICARE SET-ASIDE ACCOUNT Medicare Beneficiary: Steven St. Clergy Federal regulations provide that the liability for work-related injury lifetime medical expenses should not be shifted to Medicare from the responsible party. Accordingly, a portion of a Medicare beneficiary’s workers compensation settlement must be set aside to pay for the beneficiary’s future work-related injury or illness medical expenses 42CFR, 411.46. Federal regulations also provide that Medicare will not pay for any medical expenses for the work-related injury or illness, after a workers’ compensation settlement is received, until the amount of the lump sum settlement allocated to future medical expenses is exhausted. Consequently, in order to comply with the applicable federal regulations and to reasonably recognize Medicare’s interests, the carrier will fund the MSA at a cost of $186,098.00, not including seed money, for the annuity from the workers’ compensation settlement award to fund a Medicare Set-Aside Account. After adhering to the following terms and conditions in administering the Set-Aside Account, then, when the set-aside funds are depleted and a satisfactory accounting has been provided to the Center for Medicare & Medicaid Services, (CMS), Medicare will pay for any Medicare covered medical treatment received as a result of the injury sustained at work. However, failure to adhere to any of the following terms and conditions, CMS may regard such a default as a failure to reasonably recognize Medicare’s interests and may deny Medicare coverage for all medical treatments due to his work-related injuries. The terms and conditions are as follows: Initial Set-Aside Account Funding - The Medicare Set-Aside Account shall initially be funded with $45,529.00 from the proceeds of the settlement award received in your workers’ compensation lawsuit. This account shall be a separate account from your personal savings or checking account. Set-Aside Account Interest Income - The Medicare Set-Aside funds shall be placed in an interest bearing account that is insured by the Federal Deposit Insurance Corporation. A copy of the documents establishing the Medicare Set-Aside Account shall be sent to CMS within 30 days of the workers compensation settlement award being disbursed. Distribution of the Set-Aside Account Funds - The funds in the Medicare Set-Aside Account shall be used solely for legitimate medical expenses incurred for those medical needs related to or resulting from your work-related injury, which would otherwise be reimbursable or paid for by Medicare. Funds in the Medicare Set-Aside Account shall not be used to pay for medical services not covered by Medicare. A copy of the booklet, “Medicare & You” can be obtained from your local Social Security office for a list of services not covered by Medicare. If there are any questions concerning what Medicare covers, please call 1-800-MEDICARE. Set-Aside Account Interest Income - All interest earned on the Medicare Set-Aside Account will be allowed to accrue in the account and will be used solely for medical expenses, that would otherwise be covered by Medicare. Reimbursement to Medicare - In the event CMS determines that Medicare has paid benefits prior to the depletion of funds in the Medicare Set-Aside Account that should have been paid from the set-aside account, CMS, or its designated fiscal intermediary or carrier, shall have the right to seek and receive reimbursement of any such conditional payments or overpayments from the Medicare Set-Aside Account to the extent that there are funds remaining in the account at that time. Accounting Records - The claimant shall maintain accurate records of the distribution and expenditures from the Medicare Set-Aside Account. Your records should indicate the date of services, the diagnosis, the service received, who received payment and the date of the payment. You shall also retain a receipt or the evidence of each and every payment made from the Medicare Set-Aside Account. Annual & Final Accounting - The claimant will submit an annual accounting to CMS and the appropriate fiscal intermediary for each calendar year no later than March 1 of the following year. You shall notify CMS and the appropriate fiscal intermediary once the Set-Aside Account is depleted and shall submit a final accounting within, 60 days of the funds being depleted. The annual and final accounting will include the information set forth in the paragraph above, “Accounting Records” and a copy of the receipt or other evidence of every payment made from the Medicare Set-Aside Account. Delivery of Notices & Accountings - All required accounting and notices shal! be sent via certified mail to the Centers for Medicare and Medicaid Services office where the settlement occurred, as well as the Medicare fiscal intermediary. Distributions Following Death of Beneficiary - In the event that the claimant dies before the funds in the Medicare Set-Aside Account are depleted, the account will continue to exist for 180 days from the date of death to enable any outstanding bills for work-related injury medical expenses that would otherwise be covered by Medicare to be paid. After the 180 days has elapsed, any funds remaining in the Medicare Set-Aside Account shall be paid to the claimant’s estate or subject to the State Law. Misappropriated Set-Aside Funds - If, after the Medicare Set-Aside Account is depleted, the final accounting reveals that funds in the account were used to pay for items other than legitimate medical expenses for medical needs related to or resulting from the work -related injury, which would otherwise be covered by Medicare, CMS will withhold Medicare coverage until these funds are restored to the set- aside fund, and then exhausted. I, STEVEN ST. CLERGY. have read and understand the above-listed terms and conditions. I agree to abide by these terms and conditions in order to protect my ability to obtain Medicare coverage for my work-related injury medical expenses once the Medicare Set-Aside Account is depleted. I understand that if I fail to abide by the above-listed terms and conditions, I may not be eligible for Medicare coverage for my work-related injury medical expenses. STEVEN ST. aot 2 a, DATE: | z.] 19 | ZO73