In the United States District Court

,
for the Middle District of Georgia
Macon Di vi si on
Dann
et al i a
Sl ayden Cross l l l , MBA, Dr. Sharon
plaintiffs in propria persona
Cross,
V.
DOCTORS HOSPITAL OFAUGUSTA, LLC.,
et alia
defendants
Ci vi l acti on fi l e number:
5:14-cv-00006-CAR
.Jury Tri al Demanded
Plaintiffs' rebuttal to defendants' document #82
Defendants oft employ the word "conclusory" in describing the plaintiffs' assertions, Conclusory
is defined as "consisf ing of or relating to a conclusion or assertion for which no supporting evidence is
offered' . That defendants are claiming to fault plaintitfs for conclusory positions is ironic given that
defendants participated,
under color of law, in the seizing of F.C, and his parents for reasons
unsupported by any reasonable evidence whatsoever. Furthermore, no evidence to demonstrate
"reasonable" suspicion of abuse or neglect have been proposed or shown, The fabricated
"kidnappers" suspicion was shown to be untrue. At no tirne was the issue of F.C,' s accident brought
up as suspicious, and the circumstances of his accident were barely acknowledged by the hospital
and staff. As it stands, the only issue on which the "reporting" was initiated was the lack of consent for
a vaccination, hardly a "reasonable" suspicion of neglect or abuse. In point of fact, defendants have
yet to provide
this Court with any evidence to support their accusations toward plaintiffs.
Come to
think of it, there is no evidence before this Court that defendants have ever accused plaintiff
Dann
Cross or Sharon Cross of doing or not doing some act that would put
their son' s life in imminent
danger or in any danger at all. In further point
of fact, two year
old and uninsured F.C. was
unreasonably seized, after which time he was, by mandate, insured by Medicaid after which time the
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only alleged "accuser" of record, defendant Cartie, began billing and receiving Medicaid
reimbursements. Upon discoveiing that defendant Cartie and others within the Doctors Hospitalwere
now sharing private medical information with Medicaid (in order to receive federal remuneration)
plaintiffs immediately proceeded
to call and write the doctors hospital and Medicaid to demand that all
attempts to share private medical information regarding the matter cease. Shortly thereafter all billing
of Medicaid halted.
As the current record stands, this Court is without evidence demonstrating that plaintiffs
are
culpable of any wrongdoing of any kind at anytime, Yet plaintiffs and their son, F.C., were
unreasonably seized, vi et armis, at around 8PM on December 51h,2012.
Plaintiffs (beneficiaries) have commanded State actors (Trustees) to produce both the
"accuser" and his or her Oathed or affirmed statement evidencing that plaintiffs have committed some
wrong to
justify
their' seizure. Those commands were met with tacit response or "it' s confidential" from
state actors. Counsel for defendant DOCTORS HOSPITAL OF AUGUSTA in addition to defendants
Heyward Wells, Thomas Dorn, Trisha Foster, Chris Haga, Donna Masters, Terrell Yelverton, and Julie
Lewis have asserted that they are accusing plaintiffs of some wrongdoing yet are pointedly refusing to
articulate what acts plaintiffs did or did not do which put the life of F.C. in imminent or probable
danger.
Defendants Haga, Foster, and the DOCTORS HOSPITAL OF AUGUSTA, LLC
tampered with and falsified plaintiffs' medical records.
ln reviewing documents to support this rebuttal on April 9th,2014 plaintiffs
discovered new
evidence highly suggestive of misrepresentation on the part of defendants.
Soon after plaintiff Dann Cross arrived with his son, F.C., to the doctors hospital in Augusta
Georgia late in the evening/night on December 4th, 2012, plaintiff
Cross was presented with and did
sign a "Conditions of Admissions" contract verisimilar to the document annexed to this rebuttal at
exhibit A. Prior to signing said document, plaintiff Dann Cross did strike any and all terms and
conditions he deemed unacceptable at that time.
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On March 8th, 2013 plaintiffs authorized the release, from the DOCTORS HOSPITAL OF
AUGUSTA, LLC., of their entire medical record generated on Decemb er 4, 5, and 6 of 2012.
Plaintiffs received the "entire medical record" to discover, within it, that the "Conditions of Admissions"
document, within which plaintiff Dann Cross had struck several terms and conditions prior to signing,
was mi ssi ng, The document at exhi bi t A sat i n i ts stead.
As has earlier been revealed, plaintiff Dann Cross was at all times willing to let hospital staff
examine his lD but was not agreeable to allowing that lD to be copied. Sometime shortly after
defendant Cartie left plaintiffs' room in the morning of December 5th, 2012 detendant Haga entered
plaintiffs' room and requested that plaintiff Dann Cross accompany him to another room wherein he
could ask plaintiff
a few questions. Plaintiffs believe defendant Haga to be the DOCTORS HOSPITAL
admissions dir6ctor at that time. Plaintiff Dann Cross and defendant Haga exited plaintiffs' room (617)
and entered an empty and adjacent room, At this time plaintiff Dann Cross, defendant Chris Haga,
and defendant and patient advocate Trisha Foster were the only ones attending to this meeting,
Defendant Haga requested to see Dann Cross' s lD. Plaintiff Cross presented his lD to Haga for
examination. Haga very briefly examined Cross' s lD and returned it back to Cross with no
expressions of concern regarding the lD, Next, defendant Haga brought forth a "Conditions of
Admi ssi on" document si mi l ar to the one at exhi bi t A, Haga, whi l e cal m, was very fi rm and i nsi stent
that plaintiff Dann Cross sign page
5 of said document at exhibit A. Equally calm and firm was plaintiff
Cross in refusing to sign another "Conditions of Admissions" document. While defendant and patient
advocate Foster stood (no more than three feet away) observing Haga and Cross, Defendant Haga
said, "You made many strikethroughs to the form (Conditions of Admission) you
signed", To which
Cross responds, "l did not agree with all the terms and conditions on the form so I struck through
them", Then, defendant Haga (to plaintiff
Cross' s surprise) again requests that plaintiff Dann Cross
sign page 5 of said document, To this repeated request to sign said document Cross responds, "No".
Haga then asks Cross if F,C. has Medicaid. Cross indicates that F.C. does not have Medicaid. Haga
then tells Cross that F.C. may be eligible for Medicaid. Cross indicates to Haga the he (Cross) is
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responsible for F,C. and that Medicaid was not an option. This meeting involving Haga, Cross, and
Foster then concluded.
It has been over a year since plaintiff
Cross struck certain of the provisions from the Doctors
Hospital "Conditions of Admissions" document. Since the DOCTORS HOSPITAL OF AUGUSA, LLC
and its agents saw fit to omit or destroy the actual document signed by plaintiff Cross, there is no
precise record of what was "struck" from said document. However, plaintiff can disclose to this Court
those provisions he most likely struck from said contract: on page 1 of exhibit A, all of paragraph 2
"FinancialAgreement" and all of paragraph five on page 1 and leading into page 2. On page two of
exhibit A "release of information" provisions would not be agreeable nor would be provisions
regarding "Assignment of Benefits". Please note the bottom right hand corner of page two does not
contain the hafrd written expression of F,C. above "Patient Label" as does page one, Plaintiff Cross
woul d al so be di sagreeabl e to al l of the l anguage i n the top paragraph on page three, i n addi ti on to
provisions within "IVledicare Patient Certification and Assignment of Benefit on page three. Plaintiff
Cross most likely did initial the "acknowledge" section of page four, Note again that the hand written
patient label is mysteriously absent on page 4 as it is missing on page 2. On page five of exhibit A
plaintiff Cross would not be agreeable to open ended language such as "agrees to pay all charges"
and di d si gn hi s name to the ri ght of the "X" on page fi ve of the ori gi nal document. Onl y the
DOCTORS HOSPITAL OF AUGUSTA, LLC., by way of its human representatives, can explain why
plaintiff Dann Cross' s signed contract with the DOCTORS HOSPITAL OF AUGUSTA styled as
"Conditions of Admissions" was eliminated from his "entire medical record" request and was replaced
with the one as evidenced at exhibit A, Please note that defendants Haga and Foster were well aware
that Dann Cross had struck provisions from and signed the "Conditions of Admission" contract yet
proceeded to fashion a new contract (without Dann Cross as a signatory) which expresses on page
five, "required for patients unable to sign without a representative or patients who refuse fo sign".
Discovery is required for plaintiffs to have any chance to determine if this particular falsified record had
something to do with F.C. being put into the care and keeping of the Trust wherein he was enabled to
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receive Medicaid. Plaintiff Dann Cross' s original "Conditions of Admission" would have prohibited the
sharing of any and all information with Medicaid. In fact, the original contract would have made it
legally impossible for defendants to bill anyone except Dann Cross and would also have made it
legally impossible for defendants to assign or transfer any alleged debt incurred during the instant
case. Put another way, DOCTORS HOSPITAL OF AUGUSTA, LLC would not be able to simply
convey "accounts receivable", germane to this matter, to a factor or debt collector for quick, albeit,
discounted remuneration. Did defendants, including DOCTORS HOSPITAL, tamper with and falsify
the "Conditions of Admissions" in order to share F.C,' s medical information with Medicaid? Discovery
and depositions are required to determine if the plaintiffs' inalienable rights were violated for the mere
remunerative benefits to these defendants.
After this meeting with Haga and Foster (and after being subjected to Cartie' s terroristic
threats) Dann Cross, Sharon Cross, and her father asked nurse Kathy Ecks to call defendant and
nurse manager, Donna Masters, so that they could complain to defendant Masters about the abuses
thus far suffered. Plaintiffs were quite shaken by what was occurring to them when defendant Masters
entered the room. Defendant Masters at 10:30 AM December 5th, 2012 expresses within her notes
that plaintiffs are not only upset with how they have been treated but that plaintiffs may not be F.C.' s
parents. In these same notes defendant Masters reveals that she "reassured the father that surgery
was delayed due to the fact that Dr, Hassan was in the operating room with another patient". Nurse
notes made by defendant Yelverton earlier that morning at7 10 AM clearly indicated the following,
"Per Dr. Cartie, Patient is not cleared for this AM until he receives tetanus vacqination or otheruuise
cleared by Dr. Cartie". Defendant Masters supervises defendant Yelverton thus defendant Masters is
here caught deceiving patients when at 10:30AM she asserts in her notes, "reassured the father that
surgery was delayed due to the fact that Dr. Hassan was in the operating room with another patient".
After deceiving the plaintiffs
as to why surgery was delayed for F.C, she then continues on with the
deception by manufacturing an elaborate five point ruse implying that the recently terrorized plaintiffs
may not be F,C.' s parents. Defendant Masters' s notes, at 10:30AM, strongly suggest fabrications to
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support defendant Cartie' s notes made earlier at 8:30 AM wherein Cartie writes, "dad remains
unwitting to provide copy of ID for admittnpu4ooses
-
| have sig concerns
@
fhis point that we have no
way to verify who parents actually are much /ess rT fhls is even their child
-have
to have lD of child or
parent'.
The evidence thus shown can lead one to reasonably conclude that defendant Masters lied to
the plaintiffs about why F.C.' s surgery was delayed and then went on to manufacture concerns
consistent with Cartie' s earlier manufactured (false)
concerns. All of these concerns fabricated by
Masters, Cartie, and Haga (he reported Cross' s lD to be tampered with) culminated with defendants
Wren, Cole, Jane Doe, Janet Doe, and Masters coming together with plaintiffs at noon in the surgical
waiting room wherein it was discovered by all present that said fabrications were abject deceptions.
No matter beciuse the defendants were going to press on using the only ammo they had left against
the plaintiffs
-
plaintiffs'
absolute and unequivocal refusal of the tetanus toxoid vaccine. At 8PM
defendant Lewis with the assistance of defendant Yelverton and State actor defendant Wren seized
F.C. and his parents vi et armis to force administer a 100o/o non-essential medical procedure (tetanus
toxoid) with side-effects inclusive of death, Said defendants then proceeded
to force administer, ultra
vires, additional dangerous, untested, and experimental substances into F,C.' s body.
Unreasonabl e Sei zure
Said seizure occurred without a warrant, without probable cause, without any exigent
circumstance, and without parental
consent.
Sai d sei zure was unreasonabl e because no one i ncl udi ng a
j uveni l e j udge
was wi l l i ng to
produce a warrant supported by Oath or affirmation (as is required by Law for all seizures of human
bei ngs) to have F.C. sei zed, Too, no one was wi l l i ng or has been wi l l i ng to arti cul ate probabl e
cause
or exigent circumstances which would
justify
the seizure of F,C. and his parents,
Natural persons and defendants Heyward Wells, Thomas Dorn, Trisha Foster, Chris Haga,
Donna Masters, Terrell Yelverton, and Julie Lewis conspired with defendant Richard Cartie and
defendants Cole and state actor defendants Wren, Albritton, Barr, Jane Doe, and Janet Doe to deprive
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plaintiffs of their fundamental parental rights to refuse the overtly unnecessary medical procedure
known as a tetanus toxoid vaccination. Having no probable or reasonable cause to seize F.C.
themselves, the defendants conspired together to utilize State actors to unreasonably seize F.C. and
his parents
on December 5th, 2012 at approximately 8PM via misrepresented and purely
manufactured information.
The legal person and defendant DOCTORS HOSPITAL OF AUGUSTA, LLC. is named in this
action because plaintiffs were told by Donna Masters that hospital meetings were in process in which
plaintiffs concerns were being discussed. lt is plaintitfs'
belief that those meetings included legal
representatives of the DOCTORS HOSPITAL OF AUGUSTA, LLC, There was also, allegedly, a
meeting between members of DOCTORS HOSPITAL OF AUGUSTA, LLC which included State actor
defendants Jariet and Jane Doe. Furthermore, exhibitA is a five page DOCTORS HOSPITAL OF
AUGUSTA "Conditions of Admission" document which was created by Haga and Foster to replace the
contract struck and signed by plaintiff
Cross. Plaintiffs do not for one moment believe that defendant
Haga and Foster committed this misrepresentation without the full blessings of the legal
representatives of the DOCTORS HOSPITAL OF AUGUSTA, LLC. Defendant Masters' s notes reveal
that she kept defendant Heyward Wells fully informed at each step in the process to leading up to the
point at which plaintiffs were deprived of their rights.
Rights Deprived
Working in concert with State actors, defendants deprived plaintiffs
of at least their Fourth, Fifth
("nor be deprived of life, liberty, or property, without due process of lav/'), and Ninth Amendment rights
in addition to their fundamental parental rights,
Relevant Judicial Conversations
A parent' s right to the care and companionship of his or her children are so fundamental, as to
be guaranteed protection
under the First, Ninth, and Fourteenth Amendments of the United States
Constitution. In re: J.S. and C., 324 A 2d
g0;
supra 129 NJ Super; at 4gg.
The rights of parents
to the care, custody and nurture of their children is of such character that
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it cannot be denied without violating those fundamental principles of liberty and
justice
which lie at the
base of all our civil and political institutions, and such right is a fundamental right protected by this
amendment (First) and Amendments 5, 9, and 14. Doe v. lrwin, 441 F Supp 1247; u.S. D.C. of
Michigan, (1985).
The liberty interest of the family encompasses an interest in retaining custody of one' s children
and, thus, a state may not interfere with a parent' s
custodial rights absent due process protections,
Langton v. Maloney, 527 F Supp 538, D.C. Conn. (1981).
Parent' s interest in custody of her children is a liberty interest which has received considerable
constitutional protection;
a parent who is deprived of custody of his or her child, even though
temporarily, suffers thereby grievous loss and such loss deserves extensive due process protection. /n
the lnterest of Coopen 621 P 2d 437;5 Kansas App Div 2d 594, (1990).
The Due Process Clause of the Fourteenth Amendment requires that severance in the parent-
child relationship caused by the state occur only with rigorous protections for individual liberty interests
at stake, Bell v. city of Milwaukee, 746 F 2d 1205; uS Ct App 7th Cir wt, (1994).
The Court stressed, "the parent-child relationship is an important interest that undeniably
warrants deference and, absent a powerful countervailing interest, protection." A parent' s interest in
the compani onshi p, care, custody and management of hi s or her chi l dren ri ses to a consti tuti onal l y
secured right, given the centrality of family life as the focus for personal
meaning and responsibility.
Stanley v. I[Iinois, 405 US 645, 651;92 S Ct 1208, (1972).
Parent' s rights have been recognized as being "essential to the orderly pursuit
of happiness by
free man." Meyerv. Nebraska,262 US 390;43 S Ct625, (192J).
The U.S. Court of Appeals for the 9th Circuit (California) held that the parent-child
relationship
is a constitutionally protected liberty interest. (See; Declaration of Independence
-life,
liberty and the
pursuit of happiness and the 14th Amendment of the United States Constitution
--
No state can
deprive any person of life, liberty or property without due process of law nor deny any person
the
equal protection
of the laws.) Kelson v. Springfield, 767 F 2d 651; US Ct App 9th Cir, (lgSS).
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The parent-child relationship is a liberty interest protected
by the Due Process Clause of the
14th Amendment. Bett v. City o,f mitwaukee, 746 f 2d 1205, 1242^Q45; US Ct App 7th Cir WI,
(1e85).
No bond is more precious and none should be more zealously protected by the law as the
bond between parent
and child." Carson v. Elrod, 411 F Supp 645, 649; Dc E.D. vA (1976).
A parent' s right to the custody of his or her children is an element of "liberty" guaranteed
by
the5th Amendment and the 14th Amendment of the United States Constitution. Matter of Gentry, 369
NW 2d 889, Ml App Div (1983).
The right of a parent not to be deprived of parental rights without a showing of fitness,
abandonment or substantial neglect is so fundamental and basic as to rank among the rights
contained in this Amendment (Ninth) and Utah' s Constitution, Afticle t
$
t. In re lJ.P., 648 P 2d 1J64;
Utah, (1982).
"The right to the custody and control of one' s child is a fiercely guarded right in our society and
i n our l aw. l t i s a ri ght that shoul d be i nfri nged upon onl y under the most compel l i ng ci rcumstances."
Brooks v. Parkerson, 265 Ga. 189,454 S.E.2.d 769 (1gg5).
O.C.G.A. 19-7-5 is not relevant to this instant action
Georgia statute 19-7-5 appears to encourage yet does not expressly permit (as defendants
assert) defendants to subject, or cause to be subjected, any citizen of the United States or other
person within the
jurisdiction
thereof to be deprived of any rights, privileges, or immunities secured by
the Constitution.
In any event, plaintiffs have well evidenced punishment, malice, and bad faith efforts on the
parts
of defendants DOCTORS HOSPITAL OF AUGUSTA, Heyward Wells, Thomas Dorn, Trisha
Foster, Chris Haga, Donna Masters, TerrellYelverton, and Julie Lewis given their demonstrable
subjugation of plaintiffs.
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Novak v. Cobb County Kennestone Hospi tal Authori ty
Defendants' assert at page four of document #82 by way of their citing Novak v. Cobb County
Kennestone HospitalAuthority, "Plaintiffs would have this Court find...[a]
'conspiracy'
anytime a doctor
renders his medical opinion to a state actor who in turn seeks
judicial
retief on an ex parfe
basis
because the doctor's assessmenf of the emergency might be incorrect or exaggerated." This could
not be further from the truth. The plaintiffs in this instant matter would nof have the court believe that
"a conspiracy occurs any time a doctor renders a medical opinion to a state actor who in turn seeks
judicial
relief...." The plaintiffs
would have the court believe that a conspiracy exists wherein the doctor
in question maligns the patient' s parents (the plaintiffs) to state actors, fabricates information/evidence
to state actors, and intentionally misrepresents the situation to state actors (all in conjunction with
other hospital defendants) in order to facilitate the removal of plaintiffs'
son from his parent' s
care.
Novak is as interesting as it is different in circumstance from the instant action, Defendants,for
the first time, appear to be asserting that the the absence of the tetanus toxoid vaccine (for F.C.)
would have elevated F,C,' s medical condition to that of an "emergency". lf said assertion is the actual
position
of defendants then their bad faith and malice toward plaintiffs
is further revealed and
galvanized,
Within the emergency medical context the patient must be immediately stabilized lest that
pati ent i mmedi atel y di e. l f the medi cal defendants are now cl ai mi ng the vacci ne to be an emergency
medical procedure
then said claim is revealed as bad faith given
their delay and participation
in the
delay (to the point
of deceiving the patients
about the delay of the very procedure
which would most
mitigate if not eliminate a potential
tetanus infection) of surgery. Fudhermore, one does not have to
be a nurse or doctor, as many of the defendants are, to realize how perfidious is the assertion that the
tetanus toxoid vaccine is an emergency medical procedure, Plaintiffs' research has not yielded
a
single instance in which tetanus toxoid vaccination has ever been considered an emergency
procedure. Would the defendants have this Court believe that F.C.' s life was in imminent danger if he
did not receive the tetanus vaccine on December 5th, 2012? lf so. then claim so.
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Going back to Novak, "The hearing began at
g:35
a.m. in the hospital's intensive care unit
where Gregory Novak was confined. Judge Hines handted the hearing himself in that he, alone,
examined the witnesses: Drs. Henderson and Tucker, Novak's primary treating physicians,
and
members of the hospital's staff. The hospital's attorneys, Pedrick and Landers, simply sfood by. The
physicians
testified that Novak's condition was continuing to deteriorate and that, without a btood
transfusion, he would probably die." Plaintiffs have not studied Novak extensively, however upon
quick perusal it does appear that multiple medical professionals (doctors)were personally
claiming
(not hearsay), in person,
to a Judge that they themselves thought the patient would probablydie,
as
in death was imminenf, without the medical procedure known as "blood transfusion". Furthermore,
medical doctors asserted directly to the Judge that Novak' s condition was worsenrng as time
progressed. There is no evidence before this Court that defendants (including a medical doctor) ever
once asserted to anyone that F.C,' s l i fe was i n i mmi nent danger and that he woul d probabl y
di e i f he
did not receive the tetanus toxoid vaccine.
Defendants' medical and professional
opinions were superseded by their desire to punish
plaintiffs for plaintiffs' refusal to consent to a a medically unjustified and non-exigent procedure, for
pl ai nti ffs' fi ri ng
of defendant Carti e, and for pl ai nti ffs bei ng uni nsured and not appl yi ng for Medi cai d. l t
is possible that other motivations exist (i.e.
such as an attempt to punish plaintiffs
for personal
choices
to which the defendants strongly objected). However, this would be a matter to determine in
discovery.
Of more relevance in this instant matter than Novak is Bendiburg v. Dempsey 909 F.2d 469
(11th Cir. 1 990) in which this Court ruled that if " private defendants intentionatly exaggerated the
emergency nature of
[plaintiff's]
medical problems,
and indeed did this for the purpose
of supptying the
state officials with fhe necessary facts to obtain ex parte temporary custody on a court order with the
implied approvalfor a consent to the surgical procedures, they have acted in concert with the state
actors in such a way as fo subT'ect them to liability for a Sec. 1983 cause of action, under fhe cases
that have been decided since Dennis v. Sparks 449 U.5.24, 101 S.Cf. 783, 66 L.Ed.2d 1AS (1990).
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r yr #* - - - .
See Rende//-Baker v. Kohn,457 U.S. 830, 838 n. 6, 102 S.Ct. 2764, 2769, T3 L. Ed. 2d 41A (1991)
(acts of private party attributable to state when private party
acts in concert with state actors); Strength
v. Hubert, 854 F.2d 421 (11th
Cir. 1988) (conspiratorial
acts must impinge upon federat right). "
For the foregoing reasons and all the others revealed in the plaintiffs'
complaint, defendants'
motion to dismiss this instant action should be denied.
Respectfully submitted this 1Oth day of April
plaintiffs in propria persona
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Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 12 of 18
Certificate of Service
I hereby certify that I have electronically filed plaintiffs' rebuttal to defendant' s Motion to dismiss
brief (doc. 82) with the Clerk of Court using the CM/ECF system.
AIMEE P SANDERS ai meesanders@frai l swi j sonl awcom
BRETT A Wl LLIAMS bwill iams@insleyrace. com, ehowa rd@ insleyrace. com
BRYAN M GRANTHAM bgrantham@hptylaw.com
DAVI D V JOH NSON dj
@insleyrace.
com, cdeel@ i nsleyrace. com, ehoward@insleyrace. com
JOHN SLADE EDWARDS
jsedwards@martinsnow.com
Joseph Charles Timothy Lewis timlewis@thetimlewisfirm.com
KEVIN P RACE krace@insleyrace.com, klatos@insleyrace.com
KIM M JACKSON kjackson@hptylawcom, measton@hptylaw,com, mhyde@hptvlaw,com
ROGER E HARRIS roger.harris@swiftcurrie.com, sharon.noble@swiftcurrie.com
SHANNON S HINSON shannon.hi nson@swi ftcurri e.cgm
SUSAN ELIZABETH TEASTER steaster@law.ga.gov, O4crmail@law.ga.gov, dorland@law.ga,gov
WILLIAM DALLAS NESMITH
,
l l l wnesmi th@sumtercountyga.us
I further Certify that I have this day served a copy of this document via U.S. Mail to:
Randol ph Frai l s
211 Peasant Home Road
Suite A-1
Augusta, GA 30907
This 1Oth day of April, 2014.
'//r*"rr
Page 13 of 13
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 13 of 18
of Admigim
l. Cuuent to Trerlmeut, I consent to ille which rny be performed dudqg thie horyitalizatiotr or on an
oulpatienl basis, including emergeocy hatmenl or and shich rrny include but are nd limited to laboatory
prooedrle$! x.ray exrmination, diagno*lic nrdical. mrning or curgical bratrrcnt or pnrocduret. ancrthcsia.
mhorpital eervioesrrdered to rrc a$ orfued by or otlrq hesltbcarr professional on the ho'spitat'e mediral
staff. I undantsrd that ss
Fert
of ilreh trnining, stu in hesltb csrc Dducntion muy pm'ticipote in lhe delivcry of my
rnedical care ild trgalnnt or be obeervern while I nrcdicrl crue and ftatrrnnt at ths Hocpital, nnd that these
6tudeDt$ will be zupervired by inenucrcrs and he maff. I funher consenr F rh hoepiul cfirducrhg blood-borup
infc*tiour dimre tesdn& iuclrrding but not to testhg for heprtitis, Acquird lrunune Deficiacy Syndmrne
(AIDS),
nnd Hurnan Inunwndrficirncy Virue if a
Sryuician
olders sush test6 or if arden;d by prutwol. I
underulaud rhat tho poteilial side effece nnd compl of this testing ale gencrally minor and arc oomparable ro fte
routlrF collsctioo of blood specirrm, including fmm the needle stick md/tr sliSfit burning, blseding or
sorErrsrs 8r thG purchlls sine- Ths rcsulte of this tost bocomo part of my confidefiial rndical romrd.
l. .Flnedd Agructnmt. Ia coosideratisn of services to b rcrdtred to rtEr or to th patient for *hom I am
Regmdless, I agree that excep wlrcre prohibitcd
B
me fte undatignod. I a$ce !o psy sr:y scrvlcce
the pdient'r account at ft ratc8 statsd in tlrc hospiul"s prim li*
the charge is prmsred for the serriic provided, which rates arc
lemr ofthir agreement to
Fy
thc potirnt'r account. $oms spccial
may bill my iuoinance compury, but is mt obligatcd to do ro,
0re financial msponsibility for the services rendered belongs to
ane nor covered and covered chnrges not patd ln full by my
Patient Label
Pr$ I cf5
Pag 1 of 5
insuanm compmry. Thir includeq hut is not limi to, coinnunnm, deductibks, non-covercd benefitn due lo polky
witr Insrnnncc plan rquiremeots. I aleo agroe tht if the hospinl timiu r policy exclurlons ar well as ftllurt to
mu* initirtc colloction cfforts io rsoollcr fimounts by rnc, thsn in addition to smorrGts insured lbr the tenrices
DOSI-ORS HOSPITAL OF AUGUSTA
coNorTloN$ oF ADMrS.stoNs
(ENGLT$|-|)
,F
rffiA
[-x
h,bi *
|
15
an5e",)
eccerptitrg reryoncihility, I individually pmmisc lo
(hrown a* tlre
*Charge
lvh*terJ eff*tive on the
hcrrfry txp'errly iucorporaed by rcftmocc ar the
items will be pdceil sEptrfltely if there is no
priae
or rhc Chtrgr Mr$tsr. u if rhc cborgc is tistcd aa uero. An
csdmac of ffc anddpatrd clurges fc rcr"clccs to to tbe psrieflt is available upon rc$rest fmn the hospital.
htirnter mey vary slgnificantly from tlre final ba,red on n variay of fwtors, including bot not limind to th
and $c noce$sity of providing additional good$ and servioc$. ofirr$c of ualmedl lileilsity of care physlclan
Ttn hospital will provide e rnedical screoning
deerrrine if therc is an emergency mrdicel
ar roquirod to all paticn$ who rr making modical *rvima to
witbout regard to the patient'e rbility to poy. If tlrerc is an
snergcDcy nrdical coditiur, thc hosFitil wiil stabilizing treatrnent wittrirt its capacity. ttrowcvcr, paticnts who
do not qualify undcr thc hcftpitrl's charity erc
for iltese servioes.
or otb* applicahlc policy arc oot rclicycd of thcir oblQation to
I6y
If supplicr and eerrices are pmvided to a p*tient
privstc bcalth insurmcc plans, the hospital may
hat coverage f,to,rCh s gpvemmental pogran r througb certain
eycnt lny p[ymnt rqurd from thc undcreigncd
a di$unted
Fayrmnt
for thoge supplies and rerricoe. h this
bc detffmincd by the tenrn of the govcmmcntal program or
ad not covcred by a gorrernmenhl progranL the prient mey be
givae heslft insurmcc plan. If the patient is uni
eltgible to have hls or her sccounl disoounted or rmder the hospital"r uninsured discount m charity care
progrflls in etbct at ihe lim sf trEafrrFnl I
hoepiul.
thrt I nay rquEst information ehut lltse prograns liqri thr
I also wdcrdand that, m a coudc$y to mo, thc
iltililulililutl
coAs 1!16 mll
EatLgnLl ct rqn I e0007tl te66 Encourltr ! 0 0554 0 L724 {
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 14 of 18
I
renderd I will pry, to $re extcnt pcrmiued by law: (a) any and all costs incurrerl by the hmpital in pursuing aollecrim,
including, but ftot liruitsd to. msooablc attorneys fsEE, snd ib) Bny cout costs or othr cosh of litigatbn incunEd by lhs
hmpitd that appticuble rules or statutes
Frndl
*E horpital to recover,
3. Consert to Wrl|rcs Telqhurc Calh. If at rny rinn I provids a wireless telcphom nuurber at which I may be
contactrd, I consctrt to reeirrc cdls (induding autodialcd callr and preremrdd urcssages) Et lhlr $inelese rumbcr from
tbe tnspital, itc cuccocsorr and aseigm, flnd tlc rf[liuor, agcnft and independent conlracfirs, imluding mrvicers and
colleaiur agefis, of cnch of them reguding tre hospialiration, tho servics reodrd. or my relnrul linsncial obliguions.
rL
Relelse d lrtrormafm. I p+rmit tlrc hospital and the phyoicians or other hcalth pnrfessimals involved in thc
inpatieil c outpaticnt cut to relcnse hcalthcan: information for purposes of htatileflq payrcnt or healthcart opemdmc,
Ilcalthcare inforrnalion regarding + prior tdr.iseio.r(s) st other IICA afiiliated facilitics ruay bc madc availablc to
subsatrucnt HCA-affiliatod admining frcitities ts coordinat patient carp for caso milragomcnt purpo$6t- Healthcarc
infmnratian may bo rcloaccd to any puson or ontity tirbb for pflyment m the pntienfs behslf in order to verify coverage
ff prlrnrest qucrlions, o'for any other purporc relatrd to benelit
lnymcnt.
tftalthcart. informetioa mey also he releassl
to my omglqrur'r danipre whem the rrn icaB dElivered ue related to a claim undEr woltsr's compenr,nticn. If I anr
oovmed by Medicore or Medicaid, I authmize the relea$e of healthsme informntion to the Social $ecruity Administreti<,n
m its intrnediarics r cariem fsr payrrcnt of a l,tcdicrc claim or to lhe
ryproOriabc
statc agedcy fa payncnt of a
Medicaid clsinL Thin idomation may include, witlrout limitation. history and physicd, erF{gpncy rccs*, laboratorry
rEpo(tE, opcratirc rcputr, phyrician pogt3r notci, iltf8c'3 noteg, cmultttions, p3ychologlcsl rnilcr psychirEic rcpoilr,
drug ond almhol fietlnetrt rDd dischrgg sunrury, Tbic consent spcifically includes inforrnstiou concerning
p$ychological c$ndiflons. peychiatric conditbns, intellecoa] ditatrilily condi[on*, gcnctic information, chtrricl
dependency csrditiong and/or infectisus diseases including, bm not limitEd to, blood borne disaasos, suoh &r Heptitir,
Human Immunodeficieocy Virus(HIV) andAc+dmdlmmurnDoficimcy Syndrum (AIDS).
5. Asrlgmnt of Bcnctlls. In erecuting this assignment of bencfits, I am dirccting the health insursnce carrjet or other
hcalth bcosf-rl plan pruviding my covra$e (includhgt but not limited lo, .rry erryiloyer, cnplnyer guup or trust
rponeorod or offered plan) to psy tb hoepital and/or bospitrl-b*sed physicians directly for the senices the hospital
arrl/or hocpitnl-hasd physicinns provirled to thc patient dnring this admission. [f the insuroncc curier providing my
wvcragc fcil$ t$ pay the h{rspitd or hospitnl-bercd physicians directly, us thry are hcn$y directsd tu dq I ucknuwtedge
hm rt ie my dutf and rcilpneibilify to imnrcdi*ly pay
any zu.h bpnfite rpcelved by me to tbe lnspital or horpital-
bascd physicianr. In rctum fs tlp rcrvicss rcndc.rcd urd to bcrrqrdcrcd by lhc bospital and/or hospitel-based physicians,
I hercby irrcvocably assign and transfer to the hospital and/r hospital-based physirians all right, Etle, and interest in all
payments fm rle hefrlthcrre rendred which ale paid purrmot to any ard all insuranoc policieu and healtlr benefit plans
fnrm which I rm entitlcd to scrvices or I am crnitled to ncrcoLir- I undcrstand that rny paymenr rcceived ftom these
prlisirx rurl/ar plmr will be qlrlirnJ hl lhs ilrtuunt lhrt I have agrued lo pay tbr rtrvises rsrrhrcd during lltir adrnisnion,
as furttor de$lribed uder tcclion 2. | funher hereby inevocably essign and Ealefsr to the hospiul and/or hospltal based
phpicinu an lndelendent, non+rclusive right of leooyery aglinst my lnrurer or health benefrt plon, but lhis
as*ignmsnt rhalL not bc conetnrcd ar au obligation of the. hocpital and/or hospital bascd phyriicians to pursuc any ruch
riglrt of rocovery. I acknowiedge and uderstrnd tur I maintain rny rigbt of mcovery again$t my insurer s lealrh
berrfir phn ard tha foncgotng asdgnment doee not divest me of sudr right. In no event ryill tlre hospital and/or hospltal-
based pbyri{risrui rclain beoefil$ in exsem of tbe auxrunt oc.ed to the honpital ud/or borpital bmed physiciaru for the
cre and usofirrnt rendered dmlog the adruiesiou. If a thlrd party poyer (such
as an Insuraflco compeny or employer
group or Urrsl sponsored on offctotl plm) may be obligntcd to pay somc m all of thccc c.hrrges" I agrcc to tokc all tcliofi
DOCTORS HOSPITAL OT AUGUSTA
CONDITONg OF ADMISSION
(ENOUSH)
Patient Label
oo,ts 1316 t011
Eatl enL!
q
?{ el ol S
Fag 2 of 5 rqu ! o0007{9266 E[cou.otr ! o0 0554 0 L724 {
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 15 of 18
necessry !0 s$$ist 0re horyinl anilor horyftal
should the hospitnl or horpital bosed phyricians
physicians it collccting paynunt frrom any srrch third part, pry*r
to collect such psyrnEnL In thc cwnt ths hoepitel andior hospiUl
bused phyricirns elect to cxercis. its indcpendent, right of recoycry again* the prticnt's insuer or healih
plan, I hereby appofurt thc hospital as my reprcsentrtive b
lf,utue,
any administrative rerudie+ claims
and/m larrysuiE on nry bdralf and at the hospital dection, ngniust rny resp:nsiblc tbird party, medical instuer, or
enployer rponsood nedicnl beoefit plan for of collecdng any and rll hospital bancfits duc rrc for thc paymcnt
of the clurgpl rcftrrcd to in scction 2 eborc, If tbe elects lo
trusuc
a claim or lawsuil apinst a rhird party paycr
as authurizrd reprcscntatirr, I agree to refule n
lswef
of &uome1i, if requected, audrodzing the hospital to ttke
al.nim
or lawsuil induding nllo'nring thE hospital to brmg $uit all acdotts nscesery or
ry'ptopriue
in pusuil of
againrl tlr thtd prty payer in my nsmc. I Egffi ro
or launuit brought on my behatf by the hmpital (up
oyer to thc horpital inrncdiaaly all sums rccsvcrcd in nny clairn
ths amoun
of dro hoepitrl"s charges, plur expenAs rrd attorney'r
foos). I hovo rcod and bcco glvcn lhc opportmity ask qrrcstionr about thir assignmcnt of beuefrts. and I hnire eigncd
tbir drurpnr freely and vritbou iduceimng o$er
phyricims.
tho rendirion of scrvicer by tht hnryitrl sn#or hmpitnl bnsod
+Hwphsl-hased
phyticiaw imlufu bN are limhcd to: hncrgency Depmwn Plryslclaa4 Pailnlog[srs,
Rndialogistt, ofu Aae$lrcsiologists, Pryduil*nstr. or other Behavlnm! kalth Pronldtrs. Thr,lr scrtrr.s
are rcnducd by indqadmt conlroctors and arc
*'porutely hy wh phlr icim's hil I ing conzpany.
prt of your hospitvl bill. TIlesc rcttket will hs hilkd
for
6. hiyrlr foorn. I wlderetsnd srd qgrce (hat
I or party rerponsible fs poyment for ho*pital and mcdical rcrvicc* ir
rerymiblc for any addltionat c*ugee $$oeiated the rcqus$t 4nd/0f ufe of a glvare room
?. Conunnicatlols aburt My ltrealttrcare. I my hcalthcare infsrnation b be drcloscd fu purporcs of
oonununisulng re*ul[r, tindln8s, and cerc rc my family msrnbcrs urd othc,n rcupmsible fu my car6 or
design*ed by me. I will provide those indivtdual$ a pass*ord or othcr veriflcadol mcanr spcclfrcd by thc hospitnl,
L Medimre Fflthnt Certification rnd of Benoft. I ce*ify d-rat any infounation I provide in applying for
FflymBnr
un&r Title xvIII (l{edicEr} ol Title xD( icaid) of the Social Scflrity Act is coffect- I rcqucrt pa]rflEnl
of authmized bef,cfrc to bc rmde m ury bchalf uo horpiral or horpitrltorcd physician by tlrc Mdicsrc 0r MEdicrid
p(o$asr
P. Olher Acknovledgemtt*
a. Pemond Vnlnsblcs. I understand the hospital rnaiorains a safe for the snfekoaping of rnorcy aad
valurbler, md thr. hospital strall not bo fm 0re losc of u rlamage rc any noloy.
ftrwolry,
doflnFnts.
furs. fur coats and fur germents, m uticles of unurual valuc and rmall size' rmless plnmd in tire srfc,
and nlull not bc liablc for the losc or emNge rc any other pcrsonrl prop{rty. unlcss dcpositcd with thc
the hoopital for ls6s of nny preornl propedy that is depoeited wirh
o the geater of flve hrmdrrd do[ors ($5m.00) or thc mnxirnrm
hoepital for safeleeping. The tinbilicy
the hospitnl for safekeeplng is llmind
rtquircd by law, unlcs$ a wrrttcn rccci lor a grcatcr a$punl hru htrn ohaincd fmm thc horpiul by thc
padenc.
b. @I and agrre that if tb hospitat at any tinr believee thee nay be a
w{Frn, erpl,oeive device, illegal or drug or Er[/ almholie beverage in my room or with my
DOCTORS HO5PITAL OF AUGUSTA
coNDrTroN$ oF ADMrsSrON
{ENGLTST-D
C,F
Patlent Label
coAS 1e1E ff] |
Pat l at rci
l *l ef 5
Pag 3 of, 5 l Ga! o0097, i 9e66 Encourta ! 0 05540L724{
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 16 of 18
belolrglngp, the hospitd rmy sqarch my room and my belungiqgr, sonfr*ele any of lhe ahovc. itnms thatart
fourrt, and dirlnre af tlnm as appopriata, including delivery of eny item to law cnforoerncnt authoritier.
llotflmet Prolidon for Admlldon of ltfioors. t the underrigned, ockoowlcdglc flnd vcrify thnt I am fie
legal gugrdian m cuntodian of ttr mincfincapacitated palie.rrt.
Lcrd
nduionshltr Betucen Hosltd snd Ptvqlflm$. Morl or a[ of thE hcilh c*re
prnfeseiorale
prformiry *rvices ir the ho$pitd rr+ lndcpemddt t8ntrcf,br:r erd arc mt fospltal r83n$ tr
$nNfG. Independent tnntrrtfrr rre rurymdble lor lhdr wn actions mrl tfte hotpftel rhsll not hG
lit& lm thc ectr or omislonr of ml' ndr indqcnderl contrac'lm* I understond ilut physicianu or
othcr hcalth cre gofc*sianalc rnay bc cailcd upon to
Frovtdc
ear tr renises to m or on my beholf, but tht
I may not actnally rc! tr be exrmined by, all physicinnr or hcalth cuc professionals participating in my
carc; for ex1rrrple, I may not sce phyricians pmvlling radiologr, patholo4ry, EKO inrcrpuation flnd
ancerhoeiolo6y rcwiccc. t undcrstand thff, in Drort in$taffic therc wiU be a separalc chargc fu profossionol
sryicss rendergd by phyricianc to nre or on my behalf, d thar I will rocoive a bill for there professiornl
rcrviel thet ie separnte from thc bill fm hosflnl serviccc-
Padsrt V&ltrffm Rtlhh. I urderrhnd that I have th right to rcaiw. the vigitore whom I or my rupPott
prson dcelgnercs,
yrlrhou
rtgsrd to nry reluionrhip to thors vi$trrs. I alro lsve the right b witbdraw m
dcny such cmocilt at any tlnc. I wlll mt bc denied visitniur privileges on ths bssis of facg, c01or, natioml
mish. rdigion. rcl.
jpndir idcnity, scxual micotation or disability, AII vigitut I deeignrtc will enjoy full
and equal visirs-tion privisee ftal uE no filore ttstricdvc then thom drat ny
imrpdiatc famity memhers
unrld enjuy, Furthcr, I understand 6at tha hospital may rcd to plrce dtricrlly nece$$ary or rcflsonflble
rccrictionr u liinitaliom on my viaittns to
fotct
my hcrlth and safety in addition !o thr health and saf*y
of other,pmionts. TIF hoapinl will clenrly explalfl rhe rearon for ony Eonictions ffi limitatimg if impored.
ff I bclicvc thaf my
yi$itation
rightl hnrm been violatedn I or my repmrsntstiyo hat $e rlglr m urtlir $e
horpital'r comphint resoluliein syrlcm.
I haw been
giten tbe opportunity to rerd and 6$k qur$tions abour thc infmntion conrained in this form as
wsll ar fiis rcqdon of ths furm, and I aclnowledge tlut I either have no qrstions or thar my guestionr bale
trtn amurcrcd to my ratirfrction
Acknowledge:
(Initial)
10. hicrf Sdf Deiemimtlon Act.
i hsu ben furnished infmmation regarding Advanc Dircctivec (sucb m durablc por,vtr cf anomey for healthcare and
Hrdng wiltr), I hrvc also bocn furnirhcd witl writtcn infumtion egarding patient dglrts and rcsponsibilities and orlrer
infmm*im rclnted tD my ihy. Pleme initirl or plncc a mark nert to one of fte follo*lng spplicoblc $tsEIInoID:
DOCTOES HOSPITAL OF AUGUSTA
coNDlTroN$ oF ADMlssloN (El.lGUsH)
Patienl Labl
d.
coAg 1218 Afil
Eat1st!c
?agr 4 of I
Page 4 of 5
I crautcd an Aduanoc
Diroctive and hnw heo
rcqucstcd tro supply a 6HI
lo thc hmpital
I haw fiot erccuted an Advane
Dirctive wish nereclm oo nnd havc
rcceivcd information on lrour to execnE
an Advance Directive
I hsYE not srccutal on
Advauce Dircmiw rud do not
wlsh ro ef,utc one at ilris
tirrE
l qH! o000T19e66 EDrorurtE ! s0 0554 01?24 {
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 17 of 18
ll, Noticc of hiuacy Prrctipr. I arhrowledgc tl
desuibs ilre wey*'in which dn hocpitel mey nse
healtheoru opa'atioos ald othcr prcccribcd and pc
horpital ftivacy Officer dmignaEd on the notice if I
Acknowledgc:
*=_ __,._._ _ _
(Initinl)
I hsve rcscived tho hospital's Notic.e of hivacy hacrim, which
I dimloue rny healthcare information for its uleatnrcot,
Fayfiffit
ttcd uscs and disclosurcs, I uudsrahnd that I rny contast {hE
re a questim or complaint.
Date: I, fte undersigncd, as t
rea{ and fully end con
Aurhoriznrion for Medr
Admission and Author
and agree to be bound
guaranlees hom anyon
lrreatment of senri{Ds, I
ofterwise unavailable,
insruer,
c patiffit or legal agent of tbe pntient, hereby oertify I have
llclcly undcrstand this Conditions of Adurission and
Tirne: nl trcatmcng and thu I have sfuned this Cooditiorc of
ntioft for Medical Treatmcot knowingly, fieely, voluntffily
y its temrs. I have rcceived no pomises, assurancesi or
as lo thc rcsult$ that mny be obtaind by rny medical
insuaure covsr4gc is insufficicnt, denicd altogcthcr, or
[e undertigned agrees !o pay all chargcs not peiid by thc
PrtlenUAuthorhed Reprefftrtntiye
lf you rc f,ot thc p6tiint, plcase identify
'our
Rclatiooship to lhe patient.
(Clrde
or mnrk rdrdonrhtp(sl ftom Hst be
$pouso PflrEilt lcgal Guard
NcighbortTricnd Srbliug
Healthcare Power of Att omey
Orher (pleasa Bpccify) :-----------'------...------..---
DOCIORS TIOSPITAL O F AUCU TA
coHDtTtoNS oF ADMTSSTON
{ENGUSH)
rrYitttcss
$i gnnfume and T itle:
x &st+
afi,-
Additional lTihesc Signature end Tifle:
(rcquirud for patients unable to sign without a
rupresentrlive or patient$ who rcfuse to sigu)
x
tflttt#*
Ck+'*r-rnavrca*"f -
-
'llisha
fbrt+r
HCA Corymarc $nndarrd Condilions Of Admission
en$sh_0!!!!0ll_
r
c
Patient Label
ooAE 1Er6 2011
Fatiqrt! c
I
l Gsl o000?{ 9266
l *cJcf J
Pag 5 of 5 E$ouatr ! 0 055+ 0172.,i1 {
Case 5:14-cv-00006-CAR Document 88 Filed 04/10/14 Page 18 of 18