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                                                                                                            ~
    Stone, Renzy (MR # 045058727)                                                                                                                                                               Page 227 of 241



          provider:         1936
          Performed:        06/28/13 2013 - 06/28/13 2037                                                                Rest.Jing Lab:                   SMS
          Specimen Information
             Type                      Source                                                                       Collected On
                                                                                                                    06/211/13 2038
               -----Eommen·t·:-With 1\Tcontra-sCwithout p(J:To                                          call results: BT:32658 or 32675; LB.J:65!320. No LMP for male
                    patient.

    CT PELVIS W CONTRAST [146288568]                                           R£;sulted: OO·JO. F~·3sul1 Status: In process
                         Harring, Theresa   R, MD 06/28/13       RE~sLJ_e_d-by-:- Horn, ·Gary L Jr., Resident (MD
      Ordering
      provider:          1936
       Performed:        06/28/13 2013 - 06/28/13 2037           Rest.:l.ing Lab: SMS
       Specimen Information
          Type                       Source                       Collscted On
                                                                  06/213/13 203!3
         -- -·.              -·        .. -                               .
             Comment: With IV contrast, without PO.To call results: BT:32658 or 32675; LB.J:65!320. No LMP for male
             patient.              '

-.., .=C..:..T_:.C:..:.H..:..:E::..:S=-T:....W.:..:_C=-0=-:..:N...:.T.:..:R.:..:A:=S..:..T.J.[...:...14.:...:6=2:.:.9...:.17.:..:9::..::8:...~.J-:--::-:-=---=-::-:-:-~=---       Re suI ted. 00•J 0. F\ e s u11 Status: In Process
                Ordering                                                            Harring, Theresa R, MD 06/28/13                                                   ResLT-ed-by-:- l'~uban, Joshua, Resident
                provider:                                                           2131
                 Performed:                                                         06/28/13 2209 - 06/28/13 2224                                                     ResLI ing Lab: SMS
                Specimen Information
                            Type                                                                                            Source                                     CollEcted On
                                                                                                                                                                       06/28/13 2225
                -·-··   ..   --··--·-        ---···-· ·-·   - ----·- .. -· ....
                         Comment: No LMP for male patient.

     Testing Performed By
        Lab -Abbreviation                                       Name                          Director                             ,.'4ddres::;                                 \!;:did Dale Range
        6-SMS                                                   SMS                           Unknown                              Unknown                                      04/28/04 0000 - Present
        105- MISYS                                              MISYS ···-·                   Unknown                              Unknown                                      04/28/04 0000 - Present
        505- BM1                                                BT MAIN-                      Unknown                              Unknown                                      10/09/04 0000 - Present
                                ·-···   ..                      STATION 1
           507- 8M3                                             BTMAIN-                       Unknown                              IJnknown                                     10/09/04 0000 - Present
          -------------- _________ST6TLQH_:3_
           508- BM4                                             BT MAIN-                      Unknown                               Unknown                                     10/09/04 0000 - Present
                                                                STATION 4


     Custom History
     Progress Notes
                                                                                                                                           -----·· -----
        Shaji, Shani, RN at 6/30/2013 4:47PM
                                                                                                                                    ------------··---
          Author Type: Registered Nurse      Status: Signed
                 AVS, and prescription given to the officer Kunkel, C with the patient. Patient verbalized
                 understanding of all the information given. IV removed, no complications. Patient going to
                 jail with officer Kunkel, C. Patient alert, oriented, in no apparent distress, denied any f)ain.
                 Patient taken downstairs on wheel chair.
           Xue, Amy S, Resident at 6/29/2013 9:27 PM
             Author Type: Resident              Status: Signed



                                                             is~1y.o. male Hospitalized 612812013 7:1 ~~ k:--- Acl4kl
                                                                                                                                                      1



                   Renzy Stone
                                        :.'' • ..,,..        · ·<>-        ,_,-~lviecnanisii'i'"'orTraiu'i1i1a                              ..
                                                                                                                                      ~----~---------------~




      Printed by 133853 at 7/8/15 3:50PM
                                                                                               Page 3 of241
Stone, Renzy (MR # 045058727)


     No murmur heard.
     Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no
     wheezes. He has no rales.                                                                  .
     Abdominal: Soft. He exhibits no distension. 1\lo tenderness. He has no rebound and no guardmg.
     Musculoskeletal: Normal range of motion. He exhibits no edema and no tenderness.




         Arms: 1: Superficial abrasion
      Neurological: He is alert.
      Skin: Skin .is warm and dry. No rash noted. He is not di<:·phoretic:. No erythema. No pallor.




      MOM


      31 yo M BIB EMS after MVA, withAMS, combative.

      - Trauma surgery at bedside
      - CXR
      - tdap
      - chemical restraints
      - CT H/CS
      - CT AlP

      Staff present during evaluation.

      Theresa Harring, M.D.
      Emergency Medicine, R2
      Provider ID: 36445
      1951

      NON-VIOLENT RESTRAINTS PROVIDER NOTE
      The patient Renzy Stone is severely agitated and_co u;e . Verbal de-escalation and redirection
      were unsuccessful and it is my medical opinion that es.s restrictive interventions are/were
      ineffective. I am cancer          the atient's be avior is caused b a medical condition, that he
      might pull out tubes, lines or dressings, is interfering with the provisions o care and is attempting
      to ambulate or get out of bed without assistance whE!n c1ssistance is required for safety and that




 PrintP.r! hv 1iiRq ::1t 7/R/1 S i:SO PM
Stone, Renzy (MR # 045058727)                                                                 Page 4 of241



     his behavior jeopardizes his immediate physical safety. The patient will be placed in restraints in
     order to keep him safe and in order to facilitate further medical evaluation and care.

     Theresa R Harring, MD
     June 28, 2013 7:51 PM




     CT AlP shows an inferior sternal fracture. Will proceed with CT chest. Discussed this
     with the Radiology resident and despite risks of double dye load, risl< of possible injury
     outweighs risk of not finding possible other injuries. Will give 2L NS now for hydration and
     proceed with CT chest, trap, and EKG.

      Discussed with Dr. Morris of GS- will await CT chest for final disposition.

     Theresa Harring, M.D.
     Emergency Medicine, R2
     Provider ID: 36445
     2157

      TEACHING PHYSICIAN NOTE

      I personally examined Renzy Stone, performed the key portions of the history and physical
      examination and was directly involved in his care.
      Trauma Code 1 patient. I was present on arrival of the patient and began my assessment at that .
      moment.                        .                                                     . 5-<._~~ws


      I reviewed the laboratory results, radiology results, radic•logy images and resident's note and
      agree with the findings as documented in thE~ resident's note .. _ _
      Pati nt altered, reported! on c . Sitting up, refusinq exam. fter ativ
                                                                                                      7 .
                                                                                   nd versed, coaxed into
     .allowin exam. Re etitive uestionin .
      CT head and neck negative, CT abd negative but show~; sternal injury. Sent back for CT chest.
      During this time complaining of chest pain (before even leaving CT abel/pelvis). No respiratory
      difficulty.

      CT chest result pending, but no obvious vascular injury and sternal fracture noted.

      Surgery aware, and will likely admit the patient.

      I discussed the case with the resident and agree with tile diagnosis of:
      1. Altered mental status (780.97)           ·
      2. MVA (motor vehicle accident) (E819.9Z)
      3. Abrasion of left shoulder (912.0AA)
      4. Chest pain (786.50F)


      and plan:
      Surgery team present on arrival.
      Evaluation continuing, likely admit.


      Gregory E Rumph, MD
      June 28,2013 10:35 PM




Printed hv 1TiR<;i ::~t   7/9../J.c; 1-.c;n PM
Stone, Renzy (MR # 045058727)                                                                                                   Page 16 of241


            2. Small hematoma overlying the left lateral abdominal wall musculature.


            A/P:
            31yo M s/p MVC, combative with +LOC




            Stephanie Morris, MD
            General Surgery PGY2
                    48388
             /28/2013, 9:23 PM
            Pager 713 404 287

            Teaching Physician Attestation Statement:

            I personally examined Renzy Stone with the resident trauma team Drs Saucedo
            and Morris. I was present in the shock room upon thE! patient's arrival.
            I agree with the history and all the components of the exam as delineated in the
            resident's note above. I have personally revi,~wed the current lab results and
            radiology results. Will add CT chest to workup given mechanism and chest xray
            findings. Overnight observation.

            I have discussed his case with the resident cmd agree with th13 medical decision
            making and plan documented in the resident's note above.

            James Suliburk, MD
            HCHD 10 # 27163


            Electronically signed by Suliburk. Jarnes W, MD on 61281<'013 ·10:30 Pr-n

         H&P by Morris, Stephanie U, Resident at 6/28/2013 9:23PM                                                                 Version 1 of 2
            Autl1or: Morris, Stephanie U, Resident      Service: BT Surgery Blue                      ~,utfror Type: Resident
            Filed: 6/28/2013 9:34 PM                    Note Time: 6/28/2013 9:23 PM                  ::;talus Signed
            Editor: Morris, Stephanie U, Resident (Resident)                                             1

            Related Notes:        Addendum by Suliburk, James W, MD (Physician) filed at 6/28/20'13 ·1 0:30PM

                                                             GENERAL SUHGERY
                                                               TRAUMA CODE 1


           HPI: 31yo M with past medical history .as. below IPn~sents following high-
           speed MVA. He was the driver and hit a couple of cars in front of him. Per
           EMS, he was extricated from the vehicle, +LOC, thten combative with EMS
           and in SR. Vehicle was totaled.

           PMH:
           Past Medical History
           Diagnosis                                                                                      Date
Stone, Renzy (MR # 045058727)                                                                                                                        Page 40 of 241


   Ordering provider:           Harring, Theresa R, MD 06/28/13 1936
   Performed:                   06/28/13 2013 - 06/28/13 2037
   Specimen Information
   __:_I:Y_Ec::e_ _ _ _ _ _ _ _ _ _ _ _.=S-=o.::u:.:rc'-'e'--------------C=-<JIIected'-0=:'-'n,--_ _
                                                                                         OE;/28/13 2038
            ·c~-~~e~-t: Wth.IV contrast, without PO.To call results: BT:32658 or 32675; LBJ:65620. No LMP for male patient.


CT CHEST W CONTRAST                                                                                                          Resulted: 0000, Result Status: In process

   Ordering provider:          Harring, Theresa R, MD 06/28/13 2131                   Re~•ultH    by:       ---Kuban, Josh"U;,·R~;iCie-~t
   Performed:                  06/28/13 2209 - 06/28/13 2224                         Re~;ulth!l   Lab:         SMS
   Specimen Information
      T~~-----------------~S~o~u~rc~e~----------
   ____                                                                                C<JIIecied On
                                                                                       OEii28/i 3-2225 ----------------- - - - - - ---··------------·
           Comment No LMP for male patient.


Testing Performed By
   Lab - Abbreviation             Name                          Director                    ,~ddress       __:_ _____ ·---~J.!~Dat~~Jl_!l9_e_ _ _ _ _ _ __
   6-SMS                          SMS                           Unknown                     Unknown                          04/28/04 0000 - Present



All RADIOLOGY Results

BASIC METABOLIC PANEL                                                                                              Resulted: 06/29/13 0336, Result Status: In process
   Ordering provider:          Morris, Stephanie U, Resident 06/29/13 0235           Re~:ulthq    l. ab:
   Specimen Information
       T e                                                                             C<JIIecl.ed On
       Blood
                                                                            ·-------oEi729i1·3-a-3·36----------~--------- ----·----~-   ·--------- ------ -------·------·   ·---------~--




CBC/DIFF                                                                                                           Resulted: 06/29/13 0336, Result Status: In process
   Ordering provider:   Morris, Stephanie U,-Resident 06/29/13 023S                  Rewlti'l!, Lab:           MISYS
   Specimen Information
   ___ Ty_E~e____________________.=S.=o.urce:.___________
                                                                                       C<Jii~C::!~- On----·-·------·---------------·---------------
       Blood                                                                           OE;/29/13 0336


                                                                                                                   Resulted: 06/29/13 0253, Result Status: In process
                               Harring, Theresa R, MD

                                               Source



TROPONIN I POC                                                                                                     Resulted: 06/28/13 2150, Result Status: In process
   Resulting Lab:              MISYS
   Specimen Information

                                               Source,_________ ·----oiii28ii    32135
                                                                        C<JIIec'led On ________                  -----   ···------- ______ --------- -·----------------



BMP POC                                                                                                            Resulted: 06/28/13 2010, Result Status: In process
   Resulling Lab:              MISYS
   Specimen Information
   -~T~y""p""e______________S:::.o=-u=:rc::cc::e______________
                                                             c!~~C?:~_cl__Q!! _________________                                    .. _ ____ _ ______ ------------ _
                                                                                       OEi/28/13 2001


HIV-1/HIV-2 DIAGNOSTIC/SYMPTOMATIC                                                                                 Resulted: 06/28/13 2005, Result Slatus: In process
   Ordering provider:          Harring, Theresa R, MD 06/28/13 1936
                                                                                                                                                                    ·-   ----~------·-··-·
                                                                                                               MISYS
   Specimen Information
   __!y_E.::.e_ _ __                           Source
        Blood


                                                                                                                   Resulted: 06/28/13 2005, Result Status: In                   roc~

                               Harring, Theresa R, MD 06/28/13 1936                                        ·--~·lisvs-   ·------ ·----- -·-- -- ------------------
                                               Source



Testing Performed By




PrintPti hv 1 iiRlii       M   7/R/1 .-:; i·lin PM
Stone, Renzy (MR # 045058727)                                                                         !-"age LLIS or   L4t




     I·< ' .......•.. >' (_, ; ,,,,<.
                            c<;-;;Hi~tcjry:c)f.J?resehfJIIri~·":-·$_5-:-:-•---:-·
     31yo M with h/o hypertension and unclear psychiat:ic disorder was admitted after high-
     speed MVA, in which he hit several cars in front of :1im. (+)loss of consci'ous.ness, and
     was very combative with EMS and in the shock room. He was found to have a non-
     displaced sternal fracture and was admitted for monitor. He is currently under police~
     custody. UDS (+) benzodiazepine, cannabinoid, opiate and PCP ~                         ''\.
                                                                                                                -~'          ~
     'Eye    ~~e~ing: S-pontaneously -·                             'l·ni.
                                                                               5
                                                                                    -                           ~ 0L~
   · Verbal Response: Confused but converses                                                                            /
     Motor Response: Obeys simple commands
      otal Score: 14]

     1-·i' i-/:t;.y,~;:. · ;;.~.i)>.• .,_._._. ; ;c:, .. : .i>PaseMedicalH:i<:
     HTN and unclear psychiatric disorder (on risperdal and depakote)

     I ·-: ':' >:.:;-:;> · · '- ': -:.~ _-. -. ·- - -_ · •·- . -:    'So.ci.aLHx·
     H/o drug use

     1>·,.-,·:,;:i·',.;~_:·;;,?•.-,.· .- ~·-··-·-·-· .·.·•·· ::e'·Pfe..-lhjury•Medicatioh_._s_~~-----------'
     Outpatient prescriptions marked as ta1king for tiH~ 6/28/1:::: EmtCounter
     (Hospital Encounter)
     Medication                  Sig                             Dispense     Ref!!!
      • buPROPion (WELLBUTRIN Take 150 mg by mouth
        XL) 150 mg extended      every morning. Was taking
        release tablet           twice daily




     Allergies as of 06/28/2013- Fully AsSE!SS•ed 015/23/~':013
     Allergen                             Reaction                                      Noted
     • No known allergies                                                               06/06/2011




     Headache: no
     Neck Pain: no
     Visual Changes: no
     Change in Hearing: no
     Difficulty Speaking or Swallowing: no
     Other HEENT: no
     Chest Pain: yes - mid-chest, consistent with sternal fracture
     Shortness of Breath: no
     Other Cardiovascular/Respiratory Complaints: no
     Abdominal Pain: rio
     NauseaNomitting: no
     Spine or Flank Pain: no
     Other Gl or GU complaints: no
     Female Patient: No LMP for male patient.




Printed by 133853 at 7/8/15 3:50PM
Stone, Renzy (MR # 045058727)                                                                             Page 27 of241


           •   Platelet                                           196                       150- 400 (1\/uL)
           •   Neutrophil                                         69                        50- 70 (%)
           •   Lymphocyte                                         24                        :20- 40 (%)
           •   Monocyte                                           7                         :2- I 0 (%)
           •   Eosinophil
               Basophil
                                                                  on
                                                                  0 ('')
                                                                                            :2- 4 (%)
                                                                                            :2- 5 (%)
           •   Neutrophil, Abs                                    7.!3                      (KiuL)
           •   Lymphocyte, Abs                                    2.13                      (KiuL)
           •   Monocyte, Abs                                      0.8                       (KiuL)
           •   Eosinophil, Abs                                    0.04 (*)                  0.05 - 0.40 (KiuL)
           •   Basophil, Abs                                      0.0                       (KiuL)

           or BMP:
           Results for orders placed during the hospital encounter of 06/28/13 (from the pr.1st 24 h(;w·(:';))
           BASIC METABOLIC PANEL
           Component                                              Value                     l"<ange
               C02                                                24                        :21 - 32 (rnmoi/L)
           •   Chloride                                           1oe (*)                   98 - I 07 (mmoi/L)
           •   Potassium                                          3.13                      3.50 - 5.10 (mmoi/L)
           •   Sodium                                             142                       136 - 145 (mmoi/L)
           •   Glucose                                            88                        70 - 99 (mg/dL)
           •   Urea Nitrogen                                      12                        7- 18 (mg/dL)
           •   Creatinine                                         1.2                       0.6 - 1.3 (mg/dL)
           •   Anion Gap                                          10
           •   Calcium                                            8.4 (*)                   8.50 - 10.20 (mg/dL)
           •   GFR, Estimated                                     >60                       (ml/rnin/1.73 m2)
           •   GFR, Estim, Afr-Am                                 >60                       (ml/rnin/1.73 m2)


           Current Inpatient Medications
         ' Current facility-administered medications
           Medication                     Dose       Route   Frequm1ProvidE~r                  Last       l_(jjSJ:
                                                             cy                                           Dose
           • saline flush 1 0                 10 mL lntraven as            Stephanie lJ
             mL                                     ous      needed        Morris, Resident
           • 0.9% NaCI                              lntraven continu       Stephanie U      100
             infusion                               ous      ous           Morris, Resident rnLihr
                                                                                            (06/2SI/1
                                                                                               3 030'7)
           • morphine 4        4 mg                  IV      q3h prn Stephanie U                          Last
             mg/mL injection 4                       Push            Morris, Resident                     Dose: 4
             mg                                                                                           mg at
                                                                                                          06/29/1
                                                                                                          3 1158
           • HYDROcodone-        1                   Oral    q6h prn Stephanie lJ                         Last
             acetaminophen      tablet                               Morris, Resident                     Dose: 1
             (NORCO) 5-325                                                                                tablet
                tablet 1 tablet


           • ondansetron                  4 mg       IV      q6h prn Stephanie LJ
             (ZOFRAN)                                Push            Morris, Resident
             injection 4 mg




Printed hv 1iiRq   l'lt 7/'X/1.::; 1·<;n PM
     0   _,




     Stone, Renzy (MR # 045058727)                                                                                                 Page 28 of 241



                         • LORazepam                         1 mg         IV             q6h prn Amy S Xue,                         Last
                           (ATIVAN)                                       Push                   Resident                           Dose: ·1
                           injection 1 mg                                                                                           mg at
                                                                                                                                    06/29/1
                                                                                                                                    3 0819
                                                             2 mg         lntramu q6h prn Amy S Xue,
                                                                          scular          Resident                    ·~cv-tJ~ Al~~-
                                                                          IV
                                                                          Push
                                                                                         q6h prn Amy S Xue,
                                                                                                 Resident                  . ifWJ=H3
                                                                                         4x daily Amy S Xue,
                                                                                                                           ··rtct l ~C:A~j/)~
                                                            mg                           prn      Resident                 .}_~ ~~.<(J)~
                                                             25 mg Oral                  daily
                             e
                            (HYDRODIURIL)
                            tablet 25 mg
                          • saline flush 10   10 ml lntraven as     Theresa R
                            ml                      ous      needed Harring, MD
                          • IOHEXOL 300
                            MG IODINE/ML
                            IV Pyxis Override
                          • IOHEXOL 350
                            MG IODINE/ML
                            IV Pyxis Override




                         Amy S. Xue, MD 41797
                         PGY-1 Surgery
                         713-404-1767 (pager)
                         Electronically signed by Xue, Amy S, Resident on 6/2912013 4:20PM

              \          Progress Notes by Shaji, Shani, RN at 6129/2013 7:45AM                                                          Version 1 of 1
    ~         C             Author: Shaji, Shani, RN                   Service: (none)                  Authc•r TypE: Registered Nurse



 ~b~~~_) ~~;~~;o~~~;;:~;;:~it~J~d ::·,;~: ;~:::,;:::ment, st;t:: :~~·~'people are trying
~or ~                       to kill him and that there are cameras watching hirn. Patioent is alert and


                  ~
                            oriented X3 . Tried explaining to the patient that I am his nurse and that we are
                            helping him here, patient refused the asse~>sment and repeatedly banging on
                            the rails askjnq for attorne~£. MD Xue notified, came and assessed the patient,
                            and ordered for Ativan 1mg. Officer also at the bedside and explained the
                            situation to the patient.
                            Electronically signed by Shati, Shani, RN on G/29/2013 10:3!3 AM

                         Progress Notes by Shaji, Shani, RN at 6129/2013 7:10AM                                                          Version 1 of 1
                            Author: Shaji, Shani, RN                    Service: (none)                 Author TypE: Registered Nurse
                            Filed: 6/29/2013 7:28 AM                    Note Timo: 6/29/2013 7:10 AM    Slatu:;;: Signed
                            Editor: Shaji, Shani, RN (Registered Nurse)
                            On morning assessment patient did not have C-collar on. Per night I~N. patient
                            removed the C-collar, MD paged.



         PrintP.r! hv   111~'>1 <~t   7/Q/1 <; <-<;n Dl\tf
'   ~-·
                                                                                                                                                                                                                                                   Page 1 of 1


                         CONSENTS. AGREEMENTS. AUTHORIZATIONS. ACKNOWLEDGEMENTS AND IRREVOCABLE ASSIGNMENTS

     I. GENERAL CONSENT FOR MEDICAL TREATMENT p]
     Knowing that (Name of Person or I) Stone, Renzy                   am (is) suffering from a condition requiring diagnosis and medical treatment, I hereby voluntarily
     consent to such diagnostic procedures and hospital care and to such medical treatment as is necessary in the judgment of members of the medical staff of the
     Harris County Hospital District of Harris County, Texas or medical staff contracted with the Harris County Hospital District. I understand that if a healthcare worker Is
     accidentally exposed to my blood or body fluids in such a fashion that the healthcare worker may be at risk for contracting AIDS, I will be required to have my blood
     tested pursuant to Texas Law and hospital protocol to determine if I have Human Immunodeficiency Virus (HIV) or other blood borne infections. Test results will be
     kept confidential to the extent allowed by law and any information concerning my identity in connection with such testing will be destroyed after notification to the
     healthcare worker who was exposed.
     II. PROFESSIONAL SERVICES                                     P.J
      1understand that the Harris County Hospital District (HCHD) partners and/or contracts with other providers to provide my medical care when I am seen at a HCHD
     facility. I understand that the information provided in this document pertains to HCHD as well as associated providers.
     Ill. AUTHORIZATION FOR RELEASE OF INFORMATION J?j
     1 hereby authorize my employer or agent, the Harris County Hospital District (HCHD), any physician/doctor practicing within the HCHD, to use or disclose, to any
     potential or identified payer, my protected health information (medical information and billing records). I acknowledge that my protected health infonmation may
     contajn information about services rendered or products administered to me (or the patient) including references to drug and/or alcohol abuse, psychiatric care,
     sexually transmitted disease, HIV/AIDS, Hepatitis 8 or C testing, and other sensitive Information. I understand that the purpose of the use or disclosure of the
     personal health information described above is to determine eligibility, process claims, and collect payment from any source of payment for care provided to me,
     including, but not limited to, insurance policies, grants, pharmaceutical patient assistance programs, and drug reimbursement programs.
     IV. AUTHORIZATION FOR TEXAS DEPARTMENT OF STATE HEALTH SERVICES E
     1 give permission for authorized employees of Harris County Hospital District to enter or view patienUclient data in the Texas Department of State Health Services
     statewide database.
     V. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESAF
     I have received a copy of the Harris County Hospital District's Notice of Privacy Practices.
     VI.AFINANCIAL RESPONSIBILITY M
     I assume full financial responsibility for payment of all' charges for service rendered to the above patient. I understand that responsibility is based on the percentage
     of the balance left after insurance or third party programs and that this balance !!!ID'. be discounted according to the eligibility classification as determined by HCHD
     and associated providers. I understand that I may be responsible for two co-insurance amounts: A coinsurance liability for the hospital and a coinsurance liability for
     the physician/professional services.
     VII. WAIVER FOR PERSONAL BELONGINGS                                                       ·v
     Patients and Visitors are responsible for all personal belongings. HCHD is not responsible for lost, misplaced, stolen, or damaged personal belongings. I have
     been advised to leave all my personal belongings with friends or relatives and not to bring them to a HCHD facility. Personal belongings Include money, jewelry,
     medications, documents, items of monetary or sentimental value, clothing, dentures, hearing aids, eyeglasses or contacts, watches, credit cards, wallets or purses,
     cameras, cell phones, laptops or computers, and medical equipment.
     VIII. ASSIGNMENT OF INSURANCE BENEFITS) M
     In consideration of services rendered, I hereby irrevocably assign and transfer to the HCHD and associated providers for myself and my dependents, all right, title,
     and interest in the benefits payable for services rendered, provided in any insurance policy(ies) under which I or any of my dependents are insured. Said
     irrevocable assignment and transfer shall be for granting the HCHD and associated providers an Independent right of recovery including but not limited to recovery
     rights as a third partY beneficiary on said policy (ies) of insurance, but shall not be construed to be an obligation of the HCHD or associated providers to pursue any
     such right of recovery. I also assign to the HCHD any and all benefits due and/or received on my behalf by the HCHD, under any pharmaceutical assistance or drug
     reimbursement program.
     IX. ASSIGNMENT OF THIRD PARTY CLAIMS, CRIME VICTIMS COMPENSATION E
     I hereby irrevocably assign to the HCHD and associated providers ail right, title, and interest in benefits payable out of any third party action against any other
     person, entity, insurance company, or out of recovery under the Uninsured Motorist or Medical payment provisions of any automobile insurance policy (ies) or any
     other insurance policy (ies) under which I may be entitled to recover.

      I further authorize the HCHD and associated providers to pursue on my behalf, any claim I may be entitled to pursue before the Crime Victims Compensation
      Division Of The Texas Industrial Accident Board in the event my hospitalization is necessitated by injuries received as the result of a violent crime, but in no event
      shall this be construed to be an obligation of the HCHD or associated providers. 1 understand that this agreement in no way restricts my or my dependents'
      independent right to pursue any such claim before the Crime Victims Compensation Division of the Texas Industrial Accident Board on my behalf. I understand that
      if the HCHD or associated providers are not paid in full by proceeds of any insurance policies then this assignment does not release my obligation and liability to the
      HCHD and associated providers for payment of the services and items provided. I agree to pay the HCHD and associated providers for all charges incurred or
      alternatively, for all charges in excess of the sums actually paid pursuant to said policies based on my eligibility classification.
      X. MEDICARE PATIENTS J?j
      I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized benefits
      be made on my behalf. I have been advised however, that Medicare may not cover the HCHD or physician charges related to this admission. I understand that I
      will be responsible for all charges should Medicare not pay based on my eligibility classification.
      XI.ADECLARATION
      I have read and understand the above initialed consents, agreements, authorizations, acknowledgements and irrevocable assignments. All questions have been
      fully answered. A photocopy of this document shall be considered as effective and valid as the original.




          Signature:                                                                                                                                                                                                   Date:        6/30/2013


      Printed Name:         j
                       ···········-·······-······-·-····--···· ·····················-···········-···················---·····-·······-····· ······- ········································-····   ·········-··--··1
      (If not signed by the patient indicate the relationship to patient that allows for the signature authority i.e., parent. guardian, etc.)


          Witness:     Deyanira Zepeda                                                                                                                                                                                 Date:        6/30/2013
                                                  . -·· PatientlD

      045058727
                                                                                                                               'HAHRlSHEAlTH
                                                                                                                                . . . SYSTEM
      Stone, Renzy
      M 8 8/14/1981                                                                                                                 CONSENTS, AGREEMENTS, AUTHORIZATIONS, ACKNOWLEDGEMENTS &
                                                                                                                                                    IRREVOCABLE ASSIGNMENTS
                                                                                                                                                                                                                               Retention: HR-4800-04   280061(04112)




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