hca hospital staff steal boy for medicaid reimbursements
TRANSCRIPT
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onlyalleged accuser" f record, efendant artie, egan illing nd eceiving edicaid
reimbursements. pondiscoveiinghat defendant artie nd otherswithin he Doctors ospitalwere
nowsharing rivatemedical nformation ithMedicaid inorder o receive ederal emuneration)
plaintiffsmmediately roceeded o call and write he doctors ospital nd Medicaido demand hat al l
attempts o share rivatemedical nformationegarding he matter ease. hortly hereafter llbilling
of Medicaid alted.
As he current ecord tands, hisCourt s without vidence emonstratinghat plaintiffs re
culpable f any wrongdoing f any kindat anytime, et plaintiffs nd heir on, F.C.,were
unreasonably eized, iet armis, t around PMon December 1h,2012.
Plaintiffsbeneficiaries) ave commanded tate ctors Trustees) o produce oth he
"accuser" ndhis or her Oathed r affirmed tatement videncinghat plaintiffs ave ommitted ome
wrong o ustify heir'seizure. hose ommands ere met with acit esponse r"it'sconfidential"rom
state ctors. ounsel ordefendant OCTORS OSPITAL FAUGUSTAn addition o defendants
HeywardWells, homas Dorn, risha oster, hrisHaga,DonnaMasters, errell elverton, nd Julie
Lewis aveasserted hat hey are accusing laintiffsf some wrongdoing et are pointedlyefusingo
articulate hatacts plaintiffs idor didnot do whichput he ife of F.C. n mminent r probable
danger.
Defendants aga, Foster, nd he DOCTORS OSPITAL FAUGUSTA, LC
tampered with and alsified plaintiffs'medical ecords.
ln reviewing ocuments o support his ebuttal nApril9th,2014 laintiffsiscovered ew
evidence ighly uggestive f misrepresentation n he partof defendants.
Soonafterplaintiff annCross rrived ithhis son, F.C., o the doctors ospitalnAugusta
Georgia ate n he evening/night n December th,2012, laintiff rosswas presented ithand did
sign a "Conditions fAdmissions" ontract erisimilar o the document nnexed o this ebuttal t
exhibit . Prior o signing aiddocument, laintiff annCross id strike ny and all erms and
conditions e deemed nacceptable t hat ime.
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On March th,2013 plaintiffs uthorizedhe elease, rom he DOCTORS OSPITAL F
AUGUSTA, LC., f heirentiremedical ecord enerated n Decemb r 4, 5, and 6 of 2012.
Plaintiffseceived he "entiremedical ecord" o discover, ithin t, hat he "Conditions fAdmissions"
document, ithin whichplaintiff annCross ad struck everal erms and conditions rior o signing,
was missing, hedocument texhibit sat n tsstead.
As has earlier een evealed, laintiff annCrosswas at all imeswillingo lethospital taff
examine is D but was not agreeable o allowinghat D o be copied. Sometime hortly fter
defendant artie eftplaintiffs'oom n he morning f December th, 2012 detendant aga ntered
plaintiffs'oomand equested hat plaintiff annCross ccompany im o another oomwherein e
could sk plaintiff fewquestions. laintiffselieve efendant aga o be he DOCTORS OSPITAL
admissions ir6ctor t hat ime. Plaintiff annCross nddefendant aga exited laintiffs'oom 617)
and entered n empty nd adjacent oom, At this ime plaintiff annCross, efendant hrisHaga,
and defendant nd patient dvocate risha oster ere he onlyones attending o thismeeting,
Defendant aga equested o see DannCross's D. Plaintiff ross resented is D o Haga or
examination. aga ery briefly xamined ross's D and eturned t back o Crosswithno
expressions f concern egarding he D, Next, efendant aga brought ortha "Conditions f
Admission"ocument imilaro he one at exhibit , Haga, hile alm,was very irmand nsistent
that plaintiff annCross ignpage 5 of said document t exhibit . Equally almand irmwas plaintiff
Cross n refusing o sign another Conditions fAdmissions" ocument.Whiledefendant ndpatient
advocate oster tood no more han hree eet away) bserving aga and Cross, Defendant aga
said, Youmade many trikethroughs o the orm Conditions fAdmission) ousigned", owhich
Cross esponds, ldidnot agree withall he erms ndconditions n he orm so I struck hrough
them", Then, efendant aga to plaintiff ross's urprise) gain equests hat plaintiff annCross
signpage 5 of said document, o his epeated equest o signsaid document ross esponds, No".
Haga hen asks Cross f F,C. as Medicaid. ross ndicates hat F.C. oes not have Medicaid. aga
then ells Cross hat F.C.may be eligible or Medicaid. ross ndicates o Haga he he (Cross) s
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responsibleor F,C. nd hat Medicaid as not an option. Thismeeting nvolving aga, Cross, nd
Foster hen concluded.
It has been overa year since plaintiff ross truck ertain f he provisionsrom he Doctors
Hospital Conditions fAdmissions" ocument. ince he DOCTORS OSPITAL FAUGUSA, LC
and ts agents aw it o omitor destroy he actual ocument igned yplaintiff ross, here s no
precise ecord f whatwas "struck"romsaid document. owever, laintiffan disclose o this Court
those provisions e most ikely truck romsaid contract: n page 1 of exhibit , allof paragraph
"FinancialAgreement"ndallof paragraph iveon page 1 and eading ntopage 2. On page wo of
exhibit "release f nformation" rovisions ould ot be agreeable orwouldbe provisions
regarding Assignment fBenefits". lease ote he bottom ight hand corner f page wodoes no t
contain he hafrdwritten xpression fF,C. bove Patient abel" s does page one, Plaintiff ross
would lso e disagreeableo allof he anguage n he op paragraph n page hree, n additiono
provisions ithin IVledicareatient ertification ndAssignment fBenefit n page hree. Plaintiff
Cross most ikely id nitialhe "acknowledge"ection fpage our, Noteagain hat he hand written
patient abel s mysteriously bsent n page as t s missing n page 2. On page iveof exhibit
plaintiff rosswouldnot be agreeable o open ended anguage uchas "agrees o pay allcharges"
and didsign isname o he ight f he X"on page iveof he original ocument. nly he
DOCTORS OSPITAL F AUGUSTA, LC., y way of ts human epresentatives, an explain hy
plaintiff annCross's igned ontract ith he DOCTORS OSPITAL FAUGUSTA tyled s
"Conditions fAdmissions" as eliminatedromhis entiremedical ecord" equest ndwas eplaced
with he one as evidenced t exhibit , Please ote hat defendants aga and Foster ere wellaware
that DannCross ad struck rovisionsromand signed he Conditions fAdmission" ontract et
proceeded o fashion new contract without annCross s a signatory) hich xpresses n page
five,"required or patients nable o sign withouta representative r patients who refuse o sign".
Discoverys required or plaintiffso have any chance o determine f hisparticularalsified ecord ad
something o do with F.C. eingput nto he care and keeping f he Trustwherein e was enabled o
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receiveMedicaid. laintiff annCross's riginal Conditions fAdmission" ould have prohibitedhe
sharing f any and all nformation ithMedicaid. n act, he original ontract ouldhave made t
legallympossibleor defendants o billanyone xcept DannCross nd wouldalso have made t
legallympossibleor defendants o assign r ransfer ny alleged ebt ncurred uring he nstant
case. Put another ay,DOCTORS OSPITAL FAUGUSTA, LCwouldnot be able o simply
convey accounts eceivable", ermane o thismatter, o a factor r debt collectoror quick, lbeit,
discounted emuneration. iddefendants, ncluding OCTORS OSPITAL, amperwithand alsify
the "Conditions fAdmissions"n order o share F.C,'smedical nformation ithMedicaid? iscovery
and depositions re equired o determine f he plaintiffs'nalienable ightswere iolated or he mere
remunerative enefits o these defendants.
After hismeeting ith Haga and Foster andafterbeing ubjected o Cartie's erroristic
threats) DannCross,Sharon Cross, nd her ather sked urse KathyEcks o calldefendant nd
nurse manager, onna Masters, o hat hey could omplain o defendant asters bout he abuses
thus ar suffered. laintiffs ere quite haken y whatwas occurringo them when defendant asters
entered he oom. Defendant asters t 10:30 M December th,2012 expresses ithin er notes
that plaintiffs re not onlyupset withhow hey have been reated ut hat plaintiffs ay not be F.C.'s
parents. n hese ame notes efendant asters eveals hat she reassured he ather hat surgery
was delayed ue o the act hat Dr,Hassan as n he operating oomwithanother atient".Nurse
notes made by defendant elverton arlier hat morning t7 10 AMclearly ndicated he ollowing,
"Per Dr.Cartie, atient s not cleared or hisAMuntilhe receives etanus acqination r otheruuise
cleared yDr.Cartie".Defendant asters upervises efendant elvertonhus defendant asters s
here caught eceiving atients hen at 10:30AM he asserts n her notes, reassured he ather ha t
surgery as delayed ue o the act hat Dr.Hassan as n he operating oomwithanother atient".
Afterdeceivinghe plaintiffs s o whysurgery as delayed or F.C, he hen continues nwith he
deception ymanufacturing n elaborate ivepoint use mplyinghat he recently errorized laintiffs
may not be F,C.'s arents. Defendant asters's otes, t 10:30AM, trongly uggest abricationso
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support efendant artie's otes made earlier t 8:30 AM wherein artie writes, dad emains
unwittingo provide copy of ID for admittnpu4ooses | have sig concerns @ fhis point hatwe have o
way o verify who parents ctuallyare much ess T hls s even heir child have o have D of childor
parent'.
The evidence hus shown an ead one o reasonably onclude hat defendant asters ied o
the plaintiffsboutwhyF.C.'s urgery as delayed nd henwent on o manufacture oncerns
consistent ithCartie's arlier manufactured false) oncerns. llof hese oncerns abricated y
Masters, artie, nd Haga he eported ross's D o be ampered ith) ulminated ith defendants
Wren,Cole, ane Doe, anet Doe,and Masters oming ogether ith plaintiffs t noon n he surgical
waiting oomwherein t was discovered yallpresent hat said abrications ere abject eceptions.
No matter eciuse he defendants ere going o press n using he onlyammo heyhad eft against
the plaintiffsplaintiffs'bsolute nd unequivocal efusal f he etanus oxoid accine. t 8PM
defendant ewiswith he assistance fdefendant elverton ndState ctor efendant ren eized
F.C. nd his parents iet armis o force administer 100o/o on-essential edical rocedure tetanus
toxoid) ith side-effectsnclusive f death, Said defendants hen proceeded o forceadminister, ltra
vires, dditional angerous, ntested, ndexperimental ubstances ntoF,C.'s ody.
Unreasonable eizure
Said eizure ccurred ithout warrant, ithout robable ause, ithout nyexigent
circumstance, ndwithout arental onsent.
Said eizure as unreasonable ecause oone ncluding uvenileudgewas willingo
produce warrant upported y Oath or affirmationas s required y Law or allseizures fhuman
beings) o haveF.C. eized, oo, o one was willing r has been willingo articulate robable ause
or exigent ircumstances hichwould ustify he seizure f F,C. nd his parents,
Natural ersons nd defendants eywardWells, homas Dorn, risha oster, hrisHaga,
DonnaMasters, errell elverton, nd JulieLewis onspired ithdefendant ichard artie nd
defendants oleand state actor efendants ren, lbritton, arr, ane Doe,and Janet Doe o deprive
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plaintiffs f heir undamental arental ights o refuse he overtly nnecessary edical rocedure
known s a tetanus oxoid accination. aving o probable r reasonable ause o seize F.C.
themselves, he defendants onspired ogether o utilize tate ctors o unreasonably eizeF.C. nd
his parents n December th,2012at approximately PMvia misrepresented nd purely
manufacturednformation.
The egal erson nddefendant OCTORS OSPITAL FAUGUSTA, LC. s named n his
action ecause laintiffs ere oldby Donna Masters hat hospital eetings ere n process n which
plaintiffsoncerns ere being iscussed. t is plaintitfs' eliefhat hose meetings ncluded egal
representatives f he DOCTORS OSPITAL FAUGUSTA, LC, Therewas also, llegedly,
meeting etween embers fDOCTORS OSPITAL FAUGUSTA, LCwhich ncluded tate ctor
defendants ariet nd Jane Doe. Furthermore, xhibitAs a five page DOCTORS OSPITAL F
AUGUSTA Conditions fAdmission" ocument hich was created y Haga and Foster o replace he
contract truck nd signed yplaintiff ross. Plaintiffs o not or one moment elieve hat defendant
Haga nd Foster ommittedhis misrepresentation ithouthe ullblessings f he egal
representatives f he DOCTORS OSPITAL FAUGUSTA, LC. Defendant asters's otes eveal
that she keptdefendant eywardWells ully nformed t each tep n he process o leading p o the
point twhich laintiffs ere deprived f heir ights.
Rights Deprived
Workingn concert ithState ctors, efendants eprived laintiffsf at east heirFourth, ifth
("norbe deprived f ife, iberty, rproperty, ithout ue process f av/'),and Ninth Amendment ights
in additiono heir undamental arental ights,
Relevant udicialConversations
A parent's ight o the care and companionship f hisor her children re so undamental, s o
be guaranteed rotection nder he First,Ninth, nd Fourteenth mendments f he United tates
Constitution.n re: J.S. and C., 324 A 2d g0; supra 129 NJ Super; at 4gg.
The ights fparents o the care, ustody nd nurture f heir hildrens of such character hat
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it cannot e deniedwithout iolatinghose undamental rinciples f iberty nd usticewhich ie at he
base of allour civiland politicalnstitutions, nd such ight s a fundamental ightprotected y his
amendment First)andAmendments 5, 9, and 14. Doev. rwin, 441 F Supp 1247;u.S. D.C. of
Michigan, 1985).
The iberty nterest f he amily ncompasses n nterest n retaining ustody f one's hildren
and, hus, a state may not nterfere itha parent's ustodial ights bsent ue process rotections,
Langton v. Maloney, 527 F Supp 538, D.C.Conn. 1981).
Parent's nterest n custody f her childrens a liberty nterest hichhas eceived onsiderable
constitutionalrotection; parentwho s deprived f custody fhis or her child, ven hough
temporarily, uffers hereby rievous oss and such oss deserves xtensive ue process rotection. n
the lnterest of Coopen 621P 2d 437;5 Kansas App Div 2d 594, 1990).
The Due Process lause f he Fourteenth mendment equires hat severance n he parent-
child elationship aused y he state ccur nlywith igorous rotectionsor ndividualibertynterests
at stake, Bellv. city of Milwaukee, 746 F 2d 1205;uS Ct App 7th Cir wt, (1994).
The Court tressed, the parent-childelationships an mportant nterest hat undeniably
warrants eference nd,absent powerful ountervailingnterest, rotection." parent's nterest n
the companionship,are, ustody ndmanagement fhisor her childrenises o a constitutionally
secured ight, iven he centrality f amily ifeas he ocus or personal eaning nd esponsibility.
Stanley . I[Iinois, 05US 645,651;92 S Ct 1208, 1972).
Parent's ights ave been ecognized s being essential o the orderly ursuit fhappiness y
free man."Meyerv. Nebraska,262 S 390;43 S Ct625, 192J).
The U.S.Court fAppeals or he 9th Circuit California)eld hat he parent-childelationship
is a constitutionallyrotected ibertynterest. See; Declaration f Independence life, iberty nd he
pursuit fhappiness nd he 14th Amendment f he United tatesConstitution- No state an
deprive nyperson f ife, iberty r property ithout ue process f awnordenyany person he
equal protection f the aws.) Kelson v. Springfield, 67 F 2d 651;US Ct App 9th Cir, lgSS).
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The parent-childelationships a liberty nterest rotected y he Due Process lause f he
14thAmendment. Bett . City o,fmitwaukee, 746 2d 1205, 1242^Q45; S Ct App 7th Cir WI,
(1e85).
No bond s more precious ndnone hould e more ealously rotected y he aw as he
bond between arent and child." Carson v. Elrod, 411 F Supp 645, 649;Dc E.D. vA (1976).
A parent's ight o the custody fhis or her childrens an element f "liberty"uaranteed y
the5th mendment nd he 14th Amendment f he United tates Constitution. atter of Gentry, 369
NW2d 889, Ml AppDiv (1983).
The ight f a parent ot o be deprived fparental ightswithout showing f itness,
abandonment r substantial eglect s so undamental nd basic s o rank among he rights
contained n hisAmendment Ninth) ndUtah'sConstitution, fticle t $ t. In re lJ.P., 48P 2d 1J64;
Utah, (1982).
"The ight o he custody nd control fone's hild s a fiercely uarded ight n our society nd
inour aw. t s a right hat hould e nfringed pon nlyunder he most ompellingircumstances."
Brooks .Parkerson, 65Ga. 189,454 .E.2.d 69 1gg5).
O.C.G.A. 9-7-5 s not relevant o this instant action
Georgia tatute 9-7-5 ppears o encourage et does notexpressly ermit as defendants
assert) efendants o subject, r cause o be subjected, nycitizen f he United tates r other
person ithinhe urisdictionhereof o be deprived fany ights, rivileges, r mmunities ecured y
the Constitution.In any event, laintiffs avewellevidenced unishment, alice, nd bad aith efforts n he
parts f defendants OCTORS OSPITAL FAUGUSTA, eywardWells, homasDorn, risha
Foster, hrisHaga,DonnaMasters, errellYelverton,nd JulieLewis iven heirdemonstrablesubjugation fplaintiffs.
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Novak . Cobb CountyKennestone ospitalAuthority
Defendants' ssert t page ourof document 82 by way of heir itingNovak .CobbCounty
Kennestone ospitalAuthority,Plaintiffs ouldhave hisCourt ind...[a] conspiracy'anytime doctor
renders hismedical opinion o a state actor who n turn seeks udicial etiefon an ex parfe basis
because he doctor's ssessmenf f the emergency ightbe ncorrect r exaggerated." hiscould
not be urther rom he ruth. The plaintiffsn his nstant matterwould of have he court elieve ha t
"a conspiracy ccurs ny ime a doctor enders medical piniono a state actorwho n urnseeks
judicial elief...." he plaintiffs ould ave he courtbelieve hat a conspiracy xistswherein he doctor
in question aligns he patient's arents theplaintiffs)o state actors, abricates nformation/evidence
to state actors, nd ntentionally isrepresents he situation o state actors all n conjunction ith
other ospital efendants) n order o facilitate he emoval fplaintiffs'on rom his parent's are.
Novak s as nteresting s t s differentn circumstancerom he nstant ction,Defendants,for
the irst ime, appear o be asserting hat he he absence f he etanus oxoid accine forF.C.)
would ave elevated ,C,'smedical onditiono hat of an "emergency". f said assertion s he actual
position f defendants hen heir bad aith and malice oward laintiffss urther evealed nd
galvanized,
Withinhe emergency edical ontext he patientmust be mmediately tabilizedest hat
patientmmediatelyie. f he medical efendants renowclaiminghe vaccine o be an emergency
medical rocedure hen said claim s revealed s bad aith given heirdelayand participationn he
delay to he point f deceivinghe patients bout he delay f he veryprocedure hichwouldmost
mitigatefnoteliminate potential etanus nfection) fsurgery. udhermore, ne does not have o
be a nurse r doctor, s many of he defendants re, o realize owperfidiouss he assertion hat he
tetanus oxoid accine s an emergency edical rocedure, Plaintiffs'esearch as notyielded
single nstance n which etanus oxoid accination as ever been onsidered n emergency
procedure.Would he defendants ave hisCourt elieve hat F.C.'s ifewas n mminent anger fhe
didnot eceive he etanus accine n December th,2012? f so. hen claim o.
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Goingback o Novak, "Thehearing egan at g:35a.m. n the hospital's ntensive are unit
where Gregory Novakwas confined. udge Hineshandted he hearing imself n that he, alone,
examined he witnesses: rs. Henderson nd Tucker, Novak's rimary reating physicians, nd
members f the hospital's taff.The hospital's ttorneys,Pedrick and Landers, implysfood by. The
physicians estified hat Novak's onditionwas continuing o deteriorate nd hat, without a btood
transfusion, e would robably ie." Plaintiffs avenotstudied ovak xtensively, owever pon
quickperusal tdoes appear hatmultiple medical rofessionalsdoctors)were ersonally laiming
(nothearsay), n person, o a Judge hat hey hemselves hought he patient ould probablydie, s
in death was mminenf, without he medical rocedure nown s "blood ransfusion". urthermore,
medical octors sserted irectly o the Judge hat Novak's ondition as worsenrng s ime
progressed. here s no evidence efore hisCourt hat defendants including medical octor) ver
once sserted o anyone hat F.C,'s ifewas n mminent anger nd hat he would robably ie fhe
didnot eceive he etanus oxoid accine.
Defendants' edical nd professional pinions ere superseded y heirdesire o punish
plaintiffsor plaintiffs'efusal o consent o a a medically njustifiednd non-exigent rocedure,or
plaintiffs'firingfdefendant artie, nd or plaintiffseing ninsured ndnotapplyingorMedicaid.t
is possible hat othermotivations xist i.e. uchas an attempt o punish laintiffsor personal hoices
to which he defendants trongly bjected). owever,hiswouldbe a matter o determine n
discovery.
Of more elevance n his nstantmatter han Novak s Bendiburg .Dempsey 09 F.2d 469
(11thCir. 1990) n which his Court uled hat f "privatedefendants ntentionatly xaggerated he
emergency ature of [plaintiff's]medicalproblems, nd ndeed did this or the purpose f supptying he
state officialswith he necessary acts o obtain ex parte emporary ustody on a court order with he
impliedapprovalfor a consent o the surgical rocedures, hey have acted n concert with he state
actors n sucha wayas fo subT'ecthem o iabilityor a Sec. 1983cause f action, nder he cases
thathave been decided inceDennis .Sparks 49 U.5.24, 101S.Cf.783,66 L.Ed.2d 1AS 1990).
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r yr - -- .
See Rende//-Baker . Kohn,457U.S. 830, 838n. 6, 102 S.Ct. 2764, 2769,T3L. Ed.2d 41A 1991)
(acts of private arty attributableo state when private arty acts n concert ith state actors); Strength
v. Hubert, 854 F.2d 421 (11th Cir. 1988) conspiratorial cts must mpinge upon ederat ight).
For he oregoing easons nd all he others evealed n the plaintiffs' omplaint, efendants'
motion o dismiss his nstant ction hould e denied.
Respectfullyubmittedhis 1Oth ay ofApril
plaintiffsn propria ersona
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Certificate of Service
I hereby ertifyhat have electronicallyiledplaintiffs'ebuttal o defendant's otion o dismissbrief doc. 2)with he Clerkof Court sing he CM/ECF ystem.
AIMEE SANDERS imeesanders@frailswijsonlawcom
BRETT [email protected],ehowa d@ nsleyrace. omBRYANM GRANTHAM [email protected]
DAVI V JOHNSON [email protected],cdeel@nsleyrace. om,[email protected]
JOHNSLADEEDWARDS [email protected]
Joseph Charles imothy ewis [email protected]
KEVINP RACE [email protected],[email protected]
KIMMJACKSON jackson@hptylawcom, easton@hptylaw,com, hyde@hptvlaw,com
ROGER HARRIS [email protected],[email protected]
SHANNON HINSON [email protected]
SUSANELIZABETHEASTER [email protected], [email protected],[email protected],gov
WILLIAM ALLASESMITHlll [email protected]
I further ertifyhat have hisday served copyof hisdocument ia U.S.Mail o:
Randolph rails211 Peasant ome RoadSuite -1Augusta, A30907
This1Oth ay ofApril,2014.
'//r*"rr
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of Admigim
l. Cuuent to Trerlmeut, I consent o ille which rny be performed dudqg hie horyitalizatiotr r on anoulpatienl basis, ncluding emergeocy hatmenl or and shich rrny include but are nd limited to laboatoryprooedrle$ x.ray exrmination, diagno*lic nrdical. mrning or curgical bratrrcnt or pnrocduret. ancrthcsia.mhorpital eervioesrrdered o rrc a$orfued by or otlrq hesltbcarr rofessionaln heho'spitat'e ediralstaff. undantsrd hat ss Fert of ilreh trnining, stu in hesltb csrc Dducntion uypm'ticipote n lhe delivcry of myrnedical are ld trgalnnt or be obeervern hile I nrcdicrl crue and tatrrnnt at ths Hocpital, nnd hat hese6tudeDt$ ill be zupervired y inenucrcrs nd he maff. funher consenr rh hoepiul cfirducrhg blood-borupinfc*tiourdimre tesdn& uclrrding ut not to testhg for heprtitis, Acquird runune Deficiacy Syndmrne(AIDS), nnd Hurnan nunwndrficirncy Virue if a Sryuician olders sush test6 or if arden;d by prutwol. Iunderulaud hat hopoteilial side effece nnd compl of this testing ale gencrally minor and arc oomparable o fteroutlrF collsctioo of blood specirrm, including fmm the needle stick md/tr sliSfit burning, blseding orsorErrsrs r hG urchlls sine- hs rcsulte f this ost bocomo art of myconfidefiial rndical romrd.
l. .Flnedd Agructnmt. Ia coosideratisn f services to b rcrdtred to rtEr or to th patient for *hom I am
Regmdless, agree hat excep wlrcre prohibitcdBme fte undatignod. a$ce o psy sr:y scrvlcce
the pdient'r account t ft ratc8 statsd n tlrc hospiul"s prim li*the charge s prmsred for the serriic rovided,which rates arclemr ofthir agreement o Fy thc potirnt'r account. $oms spccial
maybillmy uoinance ompury, ut s mt obligatcdo do ro,0re inancialmsponsibilityor the servicesendered elongsoane or covered nd covered hnrges ot patd n full by my
Patient Label
Pr$ I cf5
Pag 1 of 5
insuanm compmry. Thir includeq hut s not imi to, coinnunnm, eductibks, on-covercd enefitn ue o polkywitr Insrnnncc lan rquiremeots. aleo agroe ht if the hospinlimiu policy xclurlonsr wellas tllurt to
mu* initirtc colloction cfforts io rsoollcr fimounts by rnc, thsn in addition to smorrGts nsured lbr the tenrices
DOSI-ORSOSPITALFAUGUSTA
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eccerptitrgeryoncihility, individually pmmisc o(hrown a* tlre *Charge lvh*terJ eff*tive on thehcrrfry xp'errly iucorporaed y rcftmocc ar theitemswill bepdceil Eptrfltelyf there s no priae or rhcChtrgrMr$tsr. if rhccborgcs tistcd auero.Ancsdmac of ffc anddpatrd clurges fc rcr"clccs o to tbe psrieflt is available upon rc$rest fmn the hospital.htirnter mey vary slgnificantly rom tlre final ba,red n n variay of fwtors, including bot not limind to th
and$c noce$sity f providingadditional ood$ ndservioc$.firr$c f ualmedl ileilsity of care physlclan
Ttn hospital ill provide rnedical creoningdeerrrine if therc s an emergency mrdicel
ar roquirod o all paticn$ who rr making modical rvima towitbout egard o the patient'e bility to poy. f tlrerc s an
snergcDcy nrdical coditiur, thc hosFitil wiil stabilizing reatrnent wittrirt ts capacity. trowcvcr, aticnts whodo not qualify undcr thc hcftpitrl's charity ercfor iltese servioes.
or otb* applicahlc policy arc oot rclicycd of thcir oblQation to I6y
If supplicrand eerrices re pmvided o a p*tientprivstc bcalth nsurmcc plans, he hospital may
hat coverage ,to,rCh s gpvemmental pogran r througb certain
eycnt lny p[ymnt rqurd from thc undcreigncda di$unted Fayrmnt or thoge supplies and rerricoe. h thisbc detffmincd by the tenrn of the govcmmcntal rogram or
ad not covcred y a gorrernmenhl rogranL he prient mey beivae heslft insurmcc plan. If the patient s uni
eltgible to have hls or her sccounl disoounted or rmder the hospital"r uninsured discount m charity careprogrflls in etbct at ihe lim sf trEafrrFnlhoepiul.
thrt I nay rquEst nformation ehut lltse prograns iqri thr
I also wdcrdand that, m a coudc$y o mo, hc
iltililulililutlcoAs 1 16 mll
atLgnLl ct rqn I e0007tlte66 Encourltr 0 0554 0 L724
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 14 of 18
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renderd will pry, to $re extcnt pcrmiued by law: (a) any and all costs ncurrerl by the hmpital n pursuing ollecrim,including, ut ftot iruitsd o. msooablc attorneys sEE, nd b) Bnycout costs or othr cosh of litigatbn incunEd by lhshmpitd that appticuble ulesor statutes rndl *E horpital o recover,
3. Consert to Wrl|rcs Telqhurc Calh. If at rny rinn I provids a wireless elcphom nuurber at which I may becontactrd, consctrt o reeirrc cdls (induding autodialcd allr and preremrdd urcssages) t hlr $inelese umbcr fromtbe nspital, itc cuccocsorr nd aseigm, lnd lc rf[liuor, agcnft and ndependent onlracfirs, mluding mrvicers and
colleaiur agefis, of cnch of them eguding re hospialiration, hoservics eodrd. r my relnrul insncial obliguions.rL Relelse d lrtrormafm. I p+rmit tlrc hospital and the phyoicians r other hcalth pnrfessimals nvolved n thcinpatieil c outpaticnt ut to relcnse calthcan: nformation or purposes f htatileflq payrcnt or healthcart pemdmc,Ilcalthcare nforrnalion egarding + prior tdr.iseio.r(s) st other IICA afiiliated facilitics ruay bc madc availablc osubsatrucnt CA-affiliatodadmining rcitities ts coordinat atient carp for caso milragomcnt purpo$6t- Healthcarcinfmnratianmay bo rcloaccd o any puson or ontity irbb for pflyment m the pntienfs behslf n order o verify coverageff prlrnrest qucrlions, o'for any other purporc elatrd o benelit nymcnt. tftalthcart. nformetioa mey also he releasslto my omglqrur'r danipre whem he rrn icaB dElivered e related o a claim undEr woltsr's compenr,nticn. f I anroovmed y Medicore r Medicaid, authmize he elea$e f healthsme nformntion o the Social $ecruityAdministreti
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necessry 0 s$$ist re horyinlanilor horyftalshould he hospitnl r horpital bosed hyricians
physicians t collccting paynunt rromany srrch hird part, pry*rto collect such psyrnEnL n thc cwnt ths hoepitel andior hospiUl
bused hyricirns elect o cxercis. ts indcpendent, right of recoycry gain* the prticnt's insuer or healihplan, I hereby appofurthc hospital as my reprcsentrtive lf,utue, any administrative erudie+ claimsand/m larrysuiE on nry bdralf and at the hospital dection, ngniust ny resp:nsiblc bird party, medical nstuer, orenployer ponsood nedicnl beoefit plan or of collecdng any and ll hospitalbancfits duc rrc for thc paymcntof the clurgpl rcftrrcd to in scction 2 eborc, If tbe elects o trusuc a claim or lawsuil apinst a rhird party paycr
as authurizrd eprcscntatirr, agree o refule n lswef of &uome1i,f requected, udrodzing he hospital o ttkeal.nimor lawsuil induding nllo'nring hE hospital o brmg $uitll acdotts scesery r ry'ptopriuen pusuil ofagainrl tlr thtd prty payer n my nsmc. I Egffi roor aunuit rought n mybehatf y he hmpital up
oyer o thc horpital nrncdiaaly all sums ccsvcrcd n nnyclairnths amoun of drohoepitrl"scharges, lur expenAsrd attorney'r
foos). I hovo rcod and bcco glvcn lhc opportmity ask qrrcstionr about thir assignmcnt of beuefrts. and I hnire eigncdtbir drurpnr freely and vritbou iduceimng o$erphyricims.
tho rendirionof scrvicer by tht hnryitrl sn#or hmpitnl bnsod
+Hwphsl-hased phyticiaw imlufu bN are limhcd to: hncrgency Depmwn Plryslclaa4 Pailnlog[srs,Rndialogistt, fu Aae$lrcsiologists, ryduil*nstr. or other Behavlnm alth Pronldtrs. Thr,lr scrtrr.sare rcnducd by indqadmt conlroctors and arc*'porutely hy wh phlr icim's hil ng conzpany.
prt of your hospitvl bill. TIlesc rcttket will hs hilkd for
6. hiyrlr foorn. I wlderetsnd rd qgrce hat or party rerponsible s poyment or ho*pital and mcdical crvicc* rrerymiblc for any addltionat *ugee $$oeiated the cqus$t nd/0fufe of a glvare room
?. Conunnicatlols aburt My ltrealttrcare. I my hcalthcare nfsrnation b be drcloscd fu purporcs ofoonununisulnge*ul[r, indln8s, nd cerc rc my family msrnbcrs urd othc,n rcupmsible u my car6 ordesign*ed y me. I will provide hose ndivtdual$ a pass*ord r othcrveriflcadolmcanr pcclfrcd y hc hospitnl,
L Medimre Fflthnt Certification rnd of Benoft. I ce*ify d-rat ny infounation I provide in applying forFflymBnr n&r Title xvIII (l{edicEr}ol Title xD( icaid) of the Social Scflrity Act is coffect- I rcqucrt pa]rflEnlof authmized ef,cfrc o bc rmde m ury bchalf uo horpiral or horpitrltorcd physician y tlrc Mdicsrc 0r MEdicridp(o$asr
P. Olher Acknovledgemtt*
a. Pemond Vnlnsblcs. I understand the hospital naiorains safe for the snfekoaping f rnorcy aadvalurbler, md thr. hospital trall not bo fm 0re osc of u rlamage c any noloy. ftrwolry, oflnFnts.furs. ur coats and ur germents, m uticles of unurual aluc and rmall size' mless lnmd n tire srfc,and nlull not bc liablc for the losc or emNgec any otherpcrsonrl rop{rty. unlcss cpositcd ith thc
thehoopitalor s6sof nnypreornl propedy hat s depoeited irho the geater of flve hrmdrrd o[ors $5m.00)or thc mnxirnrm
hoepital or safeleeping. The inbilicythe hospitnl or safekeeplng s llmindrtquircd by law, unlcs$ a wrrttcn rccci lor a grcatcr a$punl hru htrn ohaincd fmm thc horpiul by thcpadenc.
b . @ I and agrre hat f tb hospitat t any inr believee hee nay be aw{Frn, erpl,oeive device, illegal or drug or Er[/ almholie beverage n my room or with my
DOCTORSO5PITALFAUGUSTA
coNDrTroN$ F ADMrsSrONENGLTST-D
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Pag 3 of, 5Ga o0097,i9e66 Encourta 0 05540L724{
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belolrglngp,he hospitd rmy sqarch my room and my belungiqgr, onfr*ele any of lhe ahovc. tnms hatartfourrt, and dirlnre af tlnm as appopriata, ncluding delivery of eny tem to law cnforoerncnt uthoritier.llotflmet Prolidon for Admlldon of ltfioors. t the underrigned, ckoowlcdglclnd vcrify thnt I am ielegal gugrdianm cuntodian f ttr mincfincapacitated alie.rrt.Lcrd nduionshltr Betucen Hosltd snd Ptvqlflm$. Morl or a[ of thE hcilh c*re prnfeseioraleprformiry *rvices ir the ho$pitd rr+ lndcpemddt t8ntrcf,br:r erd arc mt fospltal r83n$ tr$nNfG. Independent nntrrtfrr rre rurymdble lor lhdr wn actions mrl tfte hotpftel rhsll not hG
lit& lm thc ectr or omislonr of ml' ndr indqcnderl contrac'lm* I understond lut physicianu rothcr hcalth cre gofc*sianalc nay bc cailcd upon o Frovtdcear r renises to m or on my beholf, but thtI may not actnally c tr be exrmined by, all physicinnr or hcalth cuc professionals articipating n mycarc; for ex1rrrple, may not sce phyricians pmvlling radiologr, patholo4ry, EKO inrcrpuation flndancerhoeiolo6ycwiccc. t undcrstand hff, in Drort n$taffic therc wiU be a separalc hargc u profossionolsryicss endergd y phyricianc o nre or on my behalf, d thar will rocoive a bill for there professiornlrcrviel thet e separnte rom hc bill fm hosflnl serviccc-Padsrt V<rffm Rtlhh. I urderrhnd that I have h right to rcaiw. the vigitore whom or my rupPottprson dcelgnercs, rlrhou rtgsrd to nry reluionrhip to thors vi$trrs. I alro lsve the right b witbdraw mdcny such cmocilt at any lnc. I wlll mt bc denied isitniur privileges on ths bssis of facg,c01or, atiomlmish. rdigion. rcl. jpndir idcnity, scxual micotation or disability, AII vigitut I deeignrtc will enjoy fulland equal visirs-tion rivisee ftal uE no filore tstricdvc then thom drat ny imrpdiatc famity memhersunrld enjuy, Furthcr, understand at tha hospital may rcd to plrce dtricrlly nece$$ary r rcflsonflblerccrictionr u liinitaliom on my viaittns o fotct my hcrlth and safety n addition o thr health and saf*y
of other,pmionts. IF hoapinl will clenrly explalfl he rearon or ony Eonictions fi limitatimg if impored.ff I bclicvc thaf my yi$itation ightl hnrmbeen violatedn or my repmrsntstiyo at $e rlglr m urtlir $ehorpital'r comphint esoluliein yrlcm.
I haw been giten tbe opportunity o rerd and 6$k qur$tions bour hc nfmntion conrained n this form aswsll ar fiis rcqdon of ths furm, and aclnowledge lut I either have no qrstions or thar my guestionr aletrtn amurcrcd o my ratirfrction
Acknowledge: (Initial)
10. hicrf Sdf Deiemimtlon Act.i hsu ben urnished nfmmation egarding Advanc Dircctivec sucb m durablc por,vtrcf anomey or healthcare nd
Hrdngwiltr),I hrvc also bocn urnirhcd witl writtcn nfumtion egarding patient dglrts and rcsponsibilities nd orlrer
infmm*im rclnted D my hy. Pleme nitirl or plncca mark nert to one of fte follo*lng spplicoblc $tsEIInoID:
DOCTOESOSPITALFAUGUSTA
coNDlTroN$F ADMlssloNEl.lGUsH)
Patienl Labl
d.
coAg 1218 Afil
Eat1st c
?agr 4 of I
Page 4 of 5
I crautcd an AduanocDiroctive and hnw heorcqucstcd rosupply a 6HIlo thc hmpital
I haw fiot erccuted an AdvaneDirctive wishnereclm oonndhavcrcceivcd information on lrour to execnEan Advance Directive
I hsYE not srccutal onAdvauce ircmiw ud do notwlsh ro ef,utc one at ilristirrE
lq H o 0 0 0 T1 9 e6 6 EDrorurtE s0 0554 01?24
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ll, Noticc of hiuacy Prrctipr. I arhrowledgc ldesuibs lre wey*'in which dn hocpitel mey nsehealtheoru pa'atioos ald othcr prcccribcd and pchorpital tivacy Officer dmignaEd n the notice f I
Acknowledgc: =_ __,._._ _ (Initinl)
I hsve cscived ho hospital'sNotic.e f hivacy hacrim, whichI dimloue ny healthcare nformation or its uleatnrcot, ayfiffitttcd uscs and disclosurcs, uudsrahnd hat I rny contast hEre a questim or complaint.
Date: I, fte undersigncd, srea{ and ully end conAurhoriznrionor MedrAdmission nd Authorand agree o be boundguaranlees om anyonlrreatment f senri{Ds,ofterwise unavailable,insruer,
c patiffitor legal agent f tbe pntient, ereby ertify havellclclyundcrstand his Conditions f Adurission nd
Tirne: nl trcatmcng nd hu I have sfuned his Cooditiorcofntioft or Medical reatmcot nowingly, ieely,voluntffilyy its temrs. have cceived o pomises, assurancesi ras o thc rcsult$ hat mny be obtaind y rny medicalinsuaure covsr4gcs nsufficicnt, enicd ltogcthcr, r[e undertigned grees o pay all chargcs ot peiid y thc
PrtlenUAuthorhed eprefftrtntiye
lf you c f,ot hc p6tiint, plcase dentify ourRclatiooshipo lhe patient.(Clrde or mnrk rdrdonrhtp(sl ftom Hstbe$pouso PflrEilt lcgal GuardNcighbortTricnd SrbliugHealthcare ower f AttomeyOrher pleasa pccify)-----------'------...------..---
DOCIORS IOSPITALFAUCUTA
coHDtTtoNS F ADMTSSTONENGUSH)
rrYitttcss$ignnfume nd T tle:
x &st+ afi,-Additional lTihesc Signature end Tifle:
(rcquirud for patients unable to sign without arupresentrlive r patient$ ho cfuse o sigu)
x tflttt#* Ck+'*r-rnavrca*"f'llisha fbrt+rHCA Corymarc nndarrd ondilions f Admissionen$sh_0 0ll_
rPatient abel
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Fatiqrt c
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Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 18 of 18