IN THE COMMONWEALTH COURT OF PENNSYLVANIA. [NAME OF PETITIONER] Petitioner. COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, Respondent

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1 [SEE PA. R.A.P. (42 PA. C.S.A.) 1501, et. seq. Judicial Review of Governmental Determinations and also , Relating to Form of Documents and number of copies. IN THE COMMONWEALTH COURT OF PENNSYLVANIA [NAME OF PETITIONER] Petitioner v. COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, Respondent PETITION FOR REVIEW Appeal from Final Order issued by Commonwealth of Pennsylvania, Department of Public Welfare, Case No. [NUMBER], dated [DATE OF ORDER]. Attorney for Petitioner Attorney I.D. # Baglyos Circle, Suite A-14 Bethlehem, Pennsylvania (610)

2 IN THE COMMONWEALTH COURT OF PENNSYLVANIA [NAME OF PETITIONER], ) Petitioner ) ) vs. COMMONWEALTH OF PENNSYLVANIA, ) DEPARTMENT OF PUBLIC WELFARE, ) Respondent ) ) No. ) PETITION FOR REVIEW TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Petitioner, [NAME OF PETITIONER], by HIS/HER attorney, Stanley M. Vasiliadis, Esquire, respectfully represents that: 1. Jurisdiction for this appeal derives from Section 9, Article V, of the Constitution of Pennsylvania, as implemented by Statute at 2 Pa. C.S.A. 702 and 42 Pa. C.S.A. 5105(a)(2). 2. This action is commenced on behalf of [NAME OF PETITIONER] by and through HIS/HER Agent under power of attorney, [NAME OF AGENT]. 3. Respondent, Commonwealth of Pennsylvania, Department of Public Welfare, is an administrative agency within the meaning of Section 9 of Article V of the Constitution of Pennsylvania. 1

3 4. On [DATE OF FINAL ORDER], Respondent issued a Final Order, a copy of which, marked Exhibit A, is attached hereto and made a part hereof, from which Petitioner seeks review by your Honorable Court. 5. Petitioner objects to the aforesaid Final Order in that Respondent [erred as a matter of law][based its decision upon findings of fact that are not supported by substantial evidence][violated the Petitioner s rights under the Constitution of [the United States][the Commonwealth of Pennsylvania] in [STATE REASON FOR APPEAL, FOR EXAMPLE [imposing a period of ineligibility upon the Petitioner for Nursing Home Medical Assistance (Medicaid) eligibility] [calculating the period of ineligibility properly imposed upon Petitioner for Nursing Home Medical Assistance (Medicaid) benefits, thereby imposing an incorrect eligibility date for said benefits] [finding that Petitioner failed to timely file an administrative appeal] [. (b) acting under color of state law, deprived the Petitioner of her right, under the federal Medical Assistance Program, Title XIX of the Social Security Act, 49 Stat. 620, as amended, 42 U.S.C. 1396, et seq., to obtain Nursing Home Medical Assistance (Medicaid) benefits, in violation of the provisions of 42 U.S.C. 1396p(c)(1) (A) and 1396p(c)(1)(D)(ii), relating to calculation of the start date for imposition of periods of ineligibility for benefits; and (c) acted in violation of Article VI of the Constitution of the United States of America (Supremacy Clause) in failing to adhere to the requirements of federal law set forth in 42 U.S.C. 1396p(c)(1) (A) and 1396p(c)(1)(D)(ii), relating to calculation of the start date for imposition of periods of ineligibility for Nursing Home Medical Assistance benefits. 2

4 WHEREFORE, Petitioner requests (a) that the [DATE OF FINAL ORDER] Final Administrative Action Order of [INSERT NAME OF TITLE OF PERSON WHO SIGNED THE FINAL ORDER] be reversed and that the Court [STATE REQUESTED RELIEF, FOR EXAMPLE [direct the Department of Public Welfare to make Petitioner eligible for Nursing Home Medical Assistance (Medicaid) benefits effective [DATE]] [reinstate the Petitioner s administrative appeal] [direct the Department of Public Welfare to revise the Petitioner s period of ineligibility for benefits so as to run from DATE to DATE]; (b) an award to Petitioner of the costs of this proceeding and reasonable attorney s fees, to be paid by the Commonwealth of Pennsylvania, Department of Public Welfare, pursuant to 42 U.S.C. 1988; and (c) such other relief as may be proper and just. Respectfully submitted, Attorney for Petitioner Attorney I.D. #

5 [CAPTION] CERTIFICATE OF SERVICE I hereby certify that I am this day serving the foregoing Petition for Review upon the persons and in the manner indicated below, which service satisfies the requirements of PA R.A.P. 122 and Service by certified mail, return receipt requested:[confirm THESE ADDRESSES] Department of Public Welfare [VERIFY THE CORRECT NAME Bureau of Hearings and Appeals AND ADDRESS OF THE ATTORNEY P.O. Box 2675 GENERAL OF PENNSYLVANIA FOR 1401 N. 7 th Street, 6 th Floor PURPOSES OF ACCEPTING COPY Harrisburg, PA OF APPEAL AND INSERT HERE.] Dated: [INSERT DATE] 2551 Baglyos Circle, Suite A-14 Bethlehem, Pennsylvania (610) Attorney for Petitioner, [NAME OF PETITIONER] Attorney I.D. #