Arbitration Signature(s) Decision Tree

1. Arbitration Signature(s) Decision Tree Legal-Authorized Representative for Resident also signs on Resident’s signature line for Resident ONLY if Resident is physically unable to do so STEP 1 Resident Admitted If physically able, ALWAYS get resident to sign or “mark” EVEN IF resident has been adjudicated to be mentally incompetent or if potentially cognitively impaired Yes Both sign the arbitration agreement with supporting documents attached. ALSO Yes If Resident is not obviously cognitively impaired or you don’t know Resident signs on the resident’s signature line. Does resident also have a POA, Guardian, or Conservator? Yes No File signed arbitration agreement in Financial Record If applicable, be sure good mental status is well documented upon admission in medical record 12.23.2013

2. Arbitration Signature(s) Decision Tree STEP 2 Is there a Guardianship or Conservatorship in effect? File signed arbitration agreement in Financial Record Guardian or Conservator ALSO signs arbitration agreement on the Legally -Authorized Representative signature line Yes No Attach Guardianship/Conservatorship/ or POA documents Is there a power of attorney (POA) in effect? Have the holder of the POA ALSO sign the arbitration agreement agreement on the Legal-Authorized Representative’s signature line Yes File signed arbitration agreement in Financial Record No If no POA/guardian/conservator; spouse, child, or next of kin (in that order) signs as legal-authorized representative. Have the Responsible Party sign the arbitration agreement along with the Resident If none of these exist, close friend or anyone else affiliated with the resident signs as legal-authorized representative. 12.23.2013

3. Arbitration Signature(s) Decision Tree STEP 3 Will the resident be more alert and in near future? Calendar for follow-up for resident’s signature when medication effects or transient condition subsides ALSO have legal/authorized representative sign AGAIN at the same time Maybe No Keep 1st and 2nd arbitration agreements. 2nd agreement should NOT state it is intended to replace 1st agreement If no POA/guardian/conservator; spouse, child, or next of kin (in that order) signs as legal-authorized representative. Have the Responsible Party sign the arbitration agreement along with the resident File signed arbitration agreement in Financial Record If none of these exist, close friend or anyone else affiliated with the resident signs as legal-authorized representative. 12.23.2013