HCA hospital staff steal boy for Medicaid reimbursements

8/12/2019 HCA hospital staff steal boy for Medicaid reimbursements

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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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Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 2 of 18


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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

coNorTloN$FADMrS.stoNsENGLT$|-|) ,F

rffiA[-x h,bi* |

15 n5e",)

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

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15/18

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


16/18

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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17/18

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$taffic therc wiU be a separalc hargc u profossionolsryicss endergd y phyricianc o nre or on my behalf, d thar will rocoive a bill for there professiornlrcrviel thet e separnte rom hc bill fm hosflnl serviccc-Padsrt V&ltrffm Rtlhh. I urderrhnd that I have h right to rcaiw. the vigitore whom or my rupPottprson dcelgnercs, rlrhou rtgsrd to nry reluionrhip to thors vi$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

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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



18/18

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_

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HCA hospital staff steal boy for Medicaid reimbursements