Jackson County Memorial Hospital Authority v. Michael J. Rocha

IN THE DISTRICT COURT IN AND FOR JACKSON COUNTY STATE OF OKLAHOMA JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY, Plaintiff, vs. MICHAEL J. ROCHA, Defendant. PETITION Plaintiff, JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY by and through its attorneys, Timothy A. Fisher and Kristin Blue Fisher of the firm of Fisher & Fisher, for its Petition against the Defendant, Michael J. Rocha, alleges and states as follows: 1. Defendant is an individual residing in Jackson County, Oklahoma or received services from Plaintiff in Jackson County, Oklahoma. 2. This court has jurisdiction over the subject matter hereof and the parties hereto. 3. Defendant is indebted to Plaintiff for services rendered and for an account stated in the sum of $10,181.42. See Exhibit A. 4. After all due and just credits have been applied and after demand, there remains due, owing, and unpaid the sum of $10,181.42, together with pre-judgment interest at the statutory rate of 6% per annum from the date of services rendered until the date of judgment, and thereafter at the statutory rate for judgments. 5. Plaintiff is in compliance with the Transparency In Health Care Prices Act. See Exhibit B. Wherefore, Plaintiff prays for judgment against Defendant in the sum of $10,181.42, together with pre-judgment interest thereon at the statutory rate of 6% per annum from the date of services rendered until the date of judgment and thereafter at the statutory rate for judgments, plus the costs of this action accrued and accruing and a reasonable attorney's fee. Respectfully submitted, Kristin Blue Fisher, OBA # 15898 Timothy A. Fisher, OBA #15899 FISHER & FISHER PO Box 700870 Tulsa, Oklahoma 74170 918-488-9191 [email protected]/[email protected] Attorneys for Plaintiff NOTICE: THIS PLEADING (INCLUDING ANY ATTACHMENTS) IS A COMMUNICATION FROM A DEBT COLLECTOR ATTEMPTING TO COLLECT A DEBT. ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE. VERIFICATION OF ACCOUNT PLAINTIFF/CREDITOR: JACKSON COUNTY MEMORIAL HOSPITAL* DEFENDANT(S)/DEBTOR(S) MICHAEL J ROCHA STATE OF OKLAHOMA COUNTY OF JACKSON THE UNDERSIGNED, BEING FIRST DULY SWORN UPON OATH, STATES: 1. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE PLANTIFF IN THE POSITION OF Account Specialist 2. THE UNDERSIGNED IS FAMILIAR WITH THE ACCOUNT RECORDS OF PLAINTIFF. TO THE BEST OF THE UNDERSIGNED'S KNOWLEDGE AND BELIEF THERE IS PRESENTLY DUE AND OWING AND UNPAID TO PLANTIFF FROM THE DEFENDANT(S) THE SUM OF $10181.42 AFTER CREDIT HAS BEEN GIVEN FOR ALL PAYMENTS AND OFFSETS TO WHICH THE DEFENDANT(S) IS/ARE ENTITLED. (IF APPLICABLE) THE MENTIONED DEFENDANT(S) HAS NOT REQUESTED A FAP/FAP WAS REQUESTED AND DENIED AFTER REVIEW CLIENT FURTHER CONFIRMS COMPLIANCE WITH ALL 501(r) REQUIREMENTS SUBSCRIBED AND SWORN TO BEFORE ME THIS 26 DAY OF DECEMBER, 2022. CRYSTAL PAYNE Notary Public State of Oklahoma Commission #19002626 Exp: 03/12/23 MY COMMISSION EXPIRES: 3/12/23 NOTARY PUBLIC **PLEASE VERIFY THE ABOVE BALANCE(S), SIGN, NOTORIZE AND RETURN WITH THE ITEMIZED STATEMENT(S) FOR THE CHARGE(S) INCLUDED IN THE TOTAL. ACCOUNT# BALANCE # J00011794475 $933.08 ✓ # J00011816321 $6448.57✓ # J00011856055 $1917.02✓ # J00020501731 $882.75✓ EXHIBIT "A" JACKSON COUNTY Memorial Hospital P.O. BOX 8190 1200 E. PECAN ALTUS, OK 73522 OUTPATIENT REGISTRATION PATIENT NAME/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO. 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) GUARANTOR/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO. 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) FINANCIAL CLASS SP INSURANCE NAME SELF PAY POLICY NUMBER COVERAGE NUMBER SUBSCRIBER NAME/INSURED NAME ADMISSION DATE/TIME 01/16/20 ACCOUNT NUMBER J00011794475 ROOM/BED ER UNIT NO./MED RECORD NO. M087071 DATE OF BIRTH 092598 AGE 21 SEX M MRTL STAT. S RELIGION NRP ETINICITY H RACE H SMOKER H PERSON TO NOTIFY/ADDRESS FIGUEROA, MARIA 1601 JUPITER ALTUS, OK 73521 HOME PHONE 580-695-3664 RELATIONSHIP GRANDMOTHER LAST ADMISSION DATE/TIME LW DNR POA SERVICE CODE VA? NEXT OF KIN/ADDRESS ROCHA, YADIRA 1112 EULA ST ALTUS, OK 73521 HOME PHONE 580-301-9033 WORK PHONE ACCIDENT INFORMATION ONSET OF SYMPTOMS REASON FOR VISIT N/V/D COMMENTS ADMITTING/FAMILY PHYSICIAN NONE ATTENDING PHYSICIAN FITZGERALD SR., JAMES M, D REFERRED BY USER OLI0449 RELEASE OR RESPONSIBILITY FOR PATIENT VALUABLES: I assume responsibility for retaining articles in my possession and any others brought to me while a patient. I understand that the hospital maintains a safe for safekeeping of such items, which is available for my use and when depositing or withdrawing valuables from the safe, I will sign the valuables envelope. FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS: For services rendered the patient named above, I assign and authorize payment directly to Jackson County Memorial Hospital of any hospital benefits, including major medical benefits. I agree to pay that part covered by insurance if the hospital has not received payment from the insurance within 30 days after discharge. I fully understand that this bill is subject to any charges and/or credits not available at dismissal, as well as charges in the estimated insurance benefit payment (if any). I further understand and agree to pay all collection fees, and court costs related to collection of this account. I assign and authorize payment for fees for in hospital services provided independently and separately billed by my attending physician and consulting physicians such as pathologist, anesthesiologist and radiologist. DISCLOSURE OF INFORMATION: I understand that my medical records and billing information are made and retained by Jackson County Memorial Hospital and are accessible to hospital personnel, medical staff, medical staff nurses, medical staff office managers and any covering provider. Hospital personnel, treating physicians and their affiliates may use and disclose medical information for treatment, payment or health care operations to any other physician(s) or health care personnel involved in my continuum of care for this admission. Safeguards are in place to discourage improper access. JCMH, its medical staff and their affiliates are authorized to disclose all or part of my medical record to any insurance carrier, workers compensation carrier, or self-insured employer group liable for any part of JCMH's charges and to any health care provider who is or may become involved with my care. Oklahoma law requires that JCMH advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). By signing this agreement, you are consenting to such disclosure. CONSENT FOR MEDICAL TREATMENT: JCMH and its Medical Staff are hereby authorized to administer any medical, diagnostic or therapeutic treatment, including blood transfusions, as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances. I understand that emergency professional services shall be provided by a specifically requested private physician or by a JCMH emergency room physician engaged in the practice of emergency medicine. GENERAL DUTY NURSING: I understand that the Hospital provides general duty nursing care whereby nurses are called to the bedside by a signal system. If a patient is in such a condition as to require continuous nursing care, it is agreed that private duty nursing care must be arranged by the patient or his/her representative and his/her physician. Since the hospital cannot be responsible for providing such care, it is hereby released from any and all liability arising from the fact that the patient does not receive special duty nursing care. SPECIAL CONSENT FOR HIV TESTING: The undersigned specifically consents to the testing of the patient's blood for human immunodeficiency virus (also known as AIDS) if determined by the patient's attending physician to be necessary (I) for determining the appropriate treatment and/or treatment procedures for the patient or (II) for the protection of the attending physician and/or employee or agent of the hospital or the attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. The undersigned has been informed about the nature of the blood test, its expected benefit, and has been given the opportunity to ask questions about the blood test. It is the Policy of JCMH, JCMH Swing Bed Program, and JCMH Home Health Agency to prohibit discrimination based on age, race, color, ethnicity, religion, culture, language, physical or mental impairment, socioeconomic status, sex, sexual orientation and gender identity or expression. JCMH is committed to providing reasonable and impartial access to available, medically indicated care, treatment and services. Information about Patient Rights, Patient Care, Medicare Benefits, Billing and other important information is located in the Patient Handbook. Your signature on this form certifies you have received or been offered a copy of the Patient Handbook. PRECERTIFICATION POLICY: I understand that JCMH will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician, but will not assume responsibility for precertification or any impact which it may have on insurance payment. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: A complete description of how your medical information will be used and disclosed by this facility is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this agreement. A copy is included in your admissions packet and is posted in the hospital. I have been offered a copy of Jackson County Memorial Hospital's Notice of Privacy Practices. Directory Restrictions? ☐ Yes ☐ No The undersigned certifies that he/she has read the foregoing, and is the patient, or is duly authorized as the guarantor and on behalf of the patient accepts all of the above. PATIENT DATE GUARANTOR RELATIONSHIP DATE WITNESS JACKSON COUNTY Memorial Hospital P.O. BOX 8190 1200 E PECAN ALTUS, OK 73522 OUTPATIENT REGISTRATION PATIENT NAME/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) GUARANTOR/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) FINANCIAL CLASS SP ADMISSION DATE/TIME 012320 1357 ACCOUNT NUMBER J00011816321 ROOM/BED TYPE ER UNIT NO./MED RECORD NO M087071 DATE OF BIRTH 092598 21 SEX M RACERACE H MARITAL STAT S SMOKER RELIGION NRP ETHNICITY H PERSON TO NOTIFY/ADDRESS FIGUEROA, MARIA 1601 JUPITER ALTUS, OK 73521 HOME PHONE 580-695-3664 WORK PHONE LAST ADMISSION DATE/TIME LW DNR POA SERVICE CODE VA? NEXT OF KIN/ADDRESS ROCHA, YADIRA 1112 HULA ST ALTUS, OK 73521 HOME PHONE 580-301-9033 WORK PHONE INSURANCE NAME SELF PAY POLICY NUMBER COVERAGE NUMBER SUBSCRIBER INSURED NAME ACCIDENT INFORMATION ONSET OF SYMPTOM N/V, ABD PAIN FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS: For services rendered the patient named above, I assign and authorize payment directly to Jackson County Memorial Hospital of any hospital benefits, including major medical benefits. I agree to pay that part covered by insurance if the hospital has not received payment from the insurance within 30 days after discharge. I fully understand that this bill is subject to any charges and/or credits not available at dismissal, as well as charges in the estimated insurance benefits payment (if any). I further understand and agree to pay all collection fees, and court costs related to collection of this account. I assign and authorize payment for fees for in hospital services provided independently and separately billed by my attending physician and consulting physicians such as pathologist, anesthesiologist and radiologist. DISCLOSURE OF INFORMATION: I understand that my medical records and billing information are made and retained by Jackson County Memorial Hospital and are accessible to hospital personnel, medical staff, medical staff nurses, medical staff office managers and any covering provider. Hospital personnel, treating physicians and their affiliates may use and disclose medical information for treatment, payment or health care operations to any other physician(s) or health care personnel involved in my continuum of care for this admission. Safeguards are in place to discourage improper access. JCMH, its medical staff and their affiliates are authorized to disclose all or part of my medical record to any insurance carrier, workers compensation carrier, or self-insured employer group liable for any part of JCMH's charges and to any health care provider who is or may become involved with my care. Oklahoma law requires that JCMH advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). By signing this agreement, you are consenting to such disclosure. CONSENT FOR MEDICAL TREATMENT: JCMH and its Medical Staff are hereby authorized to administer any medical, diagnostic or therapeutic treatment, including blood transfusions, as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances. I understand that emergency professional services shall be provided by a specifically requested private physician or by a JCMH emergency room physician engaged in the practice of emergency medicine. GENERAL DUTY NURSING: I understand that the Hospital provides general duty nursing care whereby nurses are called to the bedside by a signal system. If a patient is in such a condition as to require continuous nursing care, it is agreed that private duty nursing care must be arranged by the patient or his/her representative and his/her physician. Since the hospital cannot be responsible for providing such care, it is hereby released from any and all liability arising from the fact that the patient does not receive special duty nursing care. SPECIAL CONSENT FOR HIV TESTING: The undersigned specifically consents to the testing of the patient's blood for human immunodeficiency virus (also known as AIDS) if determined by the patient's attending physician to be necessary (i) for determining the appropriate treatment and/or treatment procedures for the patient or (ii) for the protection of the attending physician and/or employee or agent of the hospital or the attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. The undersigned has been informed about the nature of the blood test, its expected benefit, and has been given the opportunity to ask questions about the blood test. It is the Policy of JCMH, JCMH Swing Bed Program, and JCMH Home Health Agency to prohibit discrimination based on age, race, color, color, ethnicity, religion, culture, language, physical or mental impairment, socioeconomic status, sex, sexual orientation and gender identity or expression. JCMH is committed to providing reasonable and impartial access to available, medically indicated care, treatment and services. Information about Patient Rights, Patient Care, Medicare Benefits, Billing and other important information is located in the Patient Handbook. Your signature on this form certifies you have received or been offered a copy of the Patient Handbook. PRECERTIFICATION POLICY: I understand that JCMH will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician, but will not assume responsibility for precertification or any impact which it may have on insurance payment. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: A complete description of how your medical information will be used and disclosed by this facility is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this agreement. A copy is included in your admissions packet and is posted in the hospital. I have been offered a copy of Jackson County Memorial Hospital's Notice of Privacy Practices. Directory Restrictions? ☐ Yes ☐ No The undersigned certifies that he/she has read the foregoing, and is the patient, or is duly authorized as the guarantor and on behalf of the patient accepts all of the above. PATIENT __MICHAEL J ROCHA__ GUARANTOR __MARIA FIGUEROA__ RELATIONSHIP GRANDMOTHER DATE 01/23/20 WITNESS __OW__ FACE SHEET JACKSON COUNTY Memorial Hospital P.O. BOX 8190 1200 E. PECAN ALTUS, OK 73522 OUTPATIENT REGISTRATION PATIENT NAME/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO. 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) GUARANTOR/ADDRESS ROCHA, MICHAEL J 912 E SUTHERLAND ST ALTUS, OK 73521 PHONE NO. 580-649-8090 EMPLOYER BRAUM'S ICE CREAM (MAIN) FINANCIAL CLASS SP INSURANCE NAME SELF PAY POLICY NUMBER COVERAGE NUMBER SUBSCRIBER INSURED NAME ADMISSION DATE/TIME 020420 0759 ACCOUNT NUMBER J00011856055 ROOM/RED TYPE ER UNIT NO/MED RECORD NO M087071 DATE OF BIRTH 092598 AGE 21 SEX M MRTL STAT S RELIGION NRP ETHNICITY H RACE H SMOKER PERSON TO NOTIFY/ADDRESS FIGUEROA, MARIA 1601 JUPITER ALTUS, OK 73521 HOME PHONE 580-695-3664 WORK PHONE LAST ADMISSION DATE/TIME LW DNR POA SERVICE CODE VA? NEXT OF KIN/ADDRESS ROCHA, YADIRA 1112 EULA ST ALTUS, OK 73521 HOME PHONE 580-301-9033 WORK PHONE ACCIDENT INFORMATION ONSET OF SYMPTO N/V, ABD PAIN REASON FOR VISIT ACCIDENT DATE/TIME 02/04/20 COMMENTS ADMITTING/FAMILY PHYSICIAN NONE ATTENDING PHYSICIAN SPEAR, DAVE, MD REFERRING PHYSICIAN USER LOR6106 1. RELEASE OR RESPONSIBILITY FOR PATIENT VALUABLES: I assume responsibility for retaining articles in my possession and any others brought to me while a patient. I understand that the hospital maintains a safe for safekeeping of such items, which is available for my use and when depositing or withdrawing valuables from the safe, I will sign the valuables envelope. 2. FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS: For services rendered the patient named above, I assign and authorize payment directly to Jackson County Memorial Hospital of any hospital benefits, including major medical benefits. I agree to pay that part covered by insurance if the hospital has not received payment from the insurance within 30 days after discharge. I fully understand that this bill is subject to any charges and/or credits not available at dismissal, as well as charges in the estimated insurance benefits payment (if any). I further understand and agree to pay all collection fees, and court costs related to collection of this account. I assign and authorize payment for fees for in-hospital services provided independently and separately billed by my attending physician and consulting physicians such as pathologist, anesthesiologist and radiologist. 3. DISCLOSURE OF INFORMATION: I understand that my medical records and billing information are made and retained by Jackson County Memorial Hospital and are accessible to hospital personnel, medical staff, medical staff nurses, medical staff office managers and any covering provider. Hospital personnel, treating physicians and their affiliates may use and disclose medical information for treatment, payment or health care operations to any other physician(s) or health care personnel involved in my continuum of care for this admission. Safeguards are in place to discourage improper access. JCMH, its medical staff and their affiliates are authorized to disclose all or part of my medical record to any insurance carrier, workers compensation carrier, or self-insured employer group liable for any part of JCMH's charges and to any health care provider who is or may become involved with my care. Oklahoma law requires that JCMH advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). By signing this agreement, you are consenting to such disclosure. 4. CONSENT FOR MEDICAL TREATMENT: JCMH and its Medical Staff are hereby authorized to administer any medical, diagnostic or therapeutic treatment, including blood transfusions, as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances. I understand that emergency professional services shall be provided by a specifically requested private physician or by a JCMH emergency room physician engaged in the practice of emergency medicine. 5. GENERAL DUTY NURSING: I understand that the Hospital provides general duty nursing care whereby nurses are called to the bedside by a signal system. If a patient is in such a condition as to require continuous nursing care, it is agreed that private duty nursing care must be arranged by the patient or his/her representative and his/her physician. Since the hospital cannot be responsible for providing such care, it is hereby released from any and all liability arising from the fact that the patient does not receive special duty nursing care. 6. SPECIAL CONSENT FOR HIV TESTING: The undersigned specifically consents to the testing of the patient's blood for human immunodeficiency virus (also known as AIDS) if determined by the patient's attending physician to be necessary (I) for determining the appropriate treatment and/or treatment procedures for the patient or (II) for the protection of the attending physician and/or employee or agent of the hospital or the attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. The undersigned has been informed about the nature of the blood test, its expected benefit, and has been given the opportunity to ask questions about the blood test. 7. It is the Policy of JCMH, JCMH Swing Bed Program, and JCMH Home Health Agency to prohibit discrimination based on age, race, color, ethnicity, religion, culture, language, physical or mental impairment, socioeconomic status, sex, sexual orientation and gender identity or expression. JCMH is committed to providing reasonable and impartial access to available, medically indicated care, treatment and services. Information about Patient Rights, Patient Care, Medicare Benefits, Billing and other important information is located in the Patient Handbook. Your signature on this form certifies you have received or been offered a copy of the Patient Handbook. 8. PRECERTIFICATION POLICY: I understand that JCMH will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician, but will not assume responsibility for precertification or any impact which it may have on insurance payment. 9. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: A complete description of how your medical information will be used and disclosed by this facility is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this agreement. A copy is included in your admissions packet and is posted in the hospital. I have been offered a copy of Jackson County Memorial Hospital's Notice of Privacy Practices. Directory Restrictions? ☐ Yes ☐ No PATIENT ___WRITTEN___ DATE 24/10/04 WITNESS ___ GUARANTOR ___ _____ RELATIONSHIP ___ DATE ___ WITNESS ___ PATIENT NAME/ADDRESS Rocha, Michael J 912 E Sutherland St Altus, OK 73521 PHONE NO. 580-649-8090 EMPLOYER WhataBurger GUARANTOR/ADDRESS Rocha, Michael J 912 E Sutherland St ALTUS, OK 73521 PHONE NO. 580-649-8090 EMPLOYER WhataBurger FINANCIAL CLASS SP INSURANCE NAME Self Pay ADMISSION DATE/TIME: 07/05/2021 07:56 ACCOUNT NUMBER: J00020501731 ROOM/BED: - TYPE: ER UNIT NO./MED RECORD NO: M000087071 DATE OF BIRTH: 09/25/1998 AGE: 22Y SEX: M MRTL STAT: S RELIGION: NO ETHNICITY: HI RACE: OR SMOKER: PRIMARY CONTACT/ADDRESS Figueroa, Maria 1601 Jupiter Altus, OK 73521 HOME PHONE: 580-695-3664 Home Ph WORK PHONE SECONDARY CONTACT/ADDRESS Rocha, Yadira 1112 Eula St Altus, OK 73521 HOME PHONE: 580-301-9033 Home Ph WORK PHONE LAST ADMISSION DATE/TIME LW DNR POA SERVICE CODE VA? ACCIDENT INFORMATION REASON FOR VISIT: ABD pain ACCIDENT DATE/TIME COMMENTS ADMITTING/FAMILY PHYSICIAN ATTENDING PHYSICIAN Doc, Er REFERRING PHYSICIAN USER: MEG0071 1. RELEASE OR RESPONSIBILITY FOR PATIENT VALUABLES: I assume responsibility for retaining articles in my possession and any others brought to me while a patient and understand that the hospital maintains a safe for safekeeping of such items, which is available for my use and when depositing or withdrawing valuables from the safe, I will sign the valuables envelope. 2. FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS: For services rendered the patient named above, I assign and authorize payment directly to Harmon County Memorial Hospital of any hospital benefits, including major medical benefits. I agree to pay that part covered by insurance if the hospital has not received payment from the insurance within 30 days after discharge. I fully understand that this bill is subject to any charges and/or credits not available at dismissal, as well as charges in the estimated insurance benefits payment (if any). I further understand and agree to pay all collection fees, and court costs related to collection of this account. I assign and authorize payment for fees for in hospital services provided independently and separately billed by my attending physician and consulting physicians such as pathologist, anesthesiologist and radiologist. 3. DISCLOSURE OF INFORMATION: I understand that my medical records and billing information are made and retained by Jackson County Memorial Hospital and are accessible to hospital personnel, medical staff, medical staff nurses, medical staff office managers and any covering provider. Hospital personnel, treating physicians and their affiliates may use and disclose medical information for treatment, payment or health care operations to any other physician(s) or health care personnel involved in my continuum of care for this admission. Safeguards are in place to discourage improper access. JCMH, its medical staff and their affiliates are authorized to disclose all or part of my medical record to any insurance carrier, workers compensation carrier, or self-insured employer group liable for any part of JCMH's charges and to any health care provider who is or may become involved with my care. Oklahoma law requires that JCMH advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). By signing this agreement, you are consenting to such disclosure. 4. CONSENT FOR MEDICAL TREATMENT: JCMH and its Medical Staff are hereby authorized to administer any medical, diagnostic or therapeutic treatment, including blood transfusions, as may be deemed necessary or advisable. I have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances. I understand that emergency professional services shall be provided by a specifically requested private physician or by a JCMH emergency room physician engaged in the practice of emergency medicine. 5. GENERAL DUTY NURSING: I understand that the Hospital provides general duty nursing care whereby nurses are called to the bedside by a signal system. If a patient is in such a condition as to require continuous nursing care, it is agreed that private duty nursing care must be arranged by the patient or his/her representative and his/her physician. Since the hospital cannot be responsible for providing such care, it is hereby released from any and all liability arising from the fact that the patient does not receive special duty nursing care. 6. SPECIAL CONSENT FOR HIV TESTING: The undersigned specifically consents to the testing of the patient’s blood for human immunodeficiency virus (also known as AIDS) if determined by the patient’s attending physician to be necessary (i) for determining the appropriate treatment and/or treatment procedures for the patient or (ii) for the protection of the attending physician and/or employee or agent of the hospital or the attending physician exposed to the bodily fluids of the patient in a manner which could transmit such disease. The undersigned has been informed about the nature of the blood test, its expected benefit, and has been given the opportunity to ask questions about the blood test. 7. It is the Policy of JCMH, JCMH Swing Bed Program, and JCMH Home Health Agency to prohibit discrimination based on age, race, color, ethnicity, religious, culture, language, physical or mental impairment, socioeconomic status, sex, sexual orientation and gender identity or expression. JCMH is committed to providing reasonable and impartial access to available, medically indicated care, treatment and services. Information about Patient Rights, Patient Care, Medicare Benefits, Billing and other important information is located on the Patient Handbook. Your signature on this form certifies you have received or been offered a copy of the Patient Handbook. 8. PRECERTIFICATION POLICY: I understand that JCMH will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician, but will not assume responsibility for precertification or any impact which it may have on insurance payment. 9. ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: A complete description of how your medical information will be used and disclosed by this facility is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this agreement. A copy is included in your admissions packet and is posted in the hospital. I have been offered a copy of Jackson County Memorial Hospital's Notice of Privacy Practices. Directory Restrictions? ☐ Yes ☐ No The undersigned certifies that he/she has read the foregoing, and is the patient, or is duly authorized as the guarantor and on behalf of the patient accepts all of the above. PATIENT SIGNATURE Date: 7/15/21 WITNESS SIGNATURE OUTPATIENT REGISTRATION JCH Revenue Cycle Report Guarantor: Rocha, Michael J Guarantor Number: GNO0070694 912 E Sutherland St ALTUS, OK 73521 580-970-8647 / CELL Name: Rocha, Michael J Bill Num Rev Code Description Non Chg Date Coda Description Account Number: J00011794475 Visit Date: 01/16/20 Chg Amt Balance Ins Bal Pat Bal Amount 933.08 0.00 933.08 714.00 219.08 Bill Num 1 BD Name: Rocha, Michael J Bill Num Account Number: J00011816321 Visit Date: 01/23/20 Chg Amt Balance Ins Bal Pat Bal Descripti.on Amount 6448.57 0.00 6,448.57 28.15 142.09 435.75 3,328.50 1,761.00 499.00 1.33 312.75 Name: Rocha, Michael J Bill Num 1 BD Account Number: J00011856055 Visit Date: 02/04/20 Chg Amt Balance Ins Bal Pat Bal Description Amount 27.64 1917.02 0.00 1,917.02 435.75 138.60 1,218.00 18.62 78.41 JCH Revenue Cycle Report Name: Rocha, Michael J Bill Num Rev Code Description Non Chg Date Code Description Account Number: J00020501731 Visit Date: 07/05/21 <table> <tr> <th>Chg Amt</th> <th>Balance</th> <th>Ins Bal</th> <th>Pat Bal</th> </tr> <tr> <td>669.93</td> <td></td> <td></td> <td>882.75</td> </tr> <tr> <td>19.05</td> <td></td> <td></td> <td>882.75</td> </tr> <tr> <td>193.77</td> <td></td> <td></td> <td></td> </tr> </table> Total Charges: 10,181.42 Total Balance: 10,181.42 Total Patient Balance: 10,181.42 AFFIDAVIT OF COMPLIANCE WITH THE TRANSPARENCY IN HEALTH CARE PRICES ACT STATE OF OKLAHOMA ) COUNTY OF Jackson ) ss. The undersigned, Natalie Young (name), as Senior VP / CFO (title) of Jackson County Memorial Hospital (provider), having been duly sworn, under oath, alleges and states as follows: 1. I have personal knowledge of the specific items of compliance herein identified. 2. Jackson County Memorial Hospital (provider) has fully complied with the Oklahoma Transparency in Health Care Prices Act by making available to the public, in a single document, electronically or by posting conspicuously on its website, the health care prices for at least: a. The twenty most used diagnosis-related group codes or other codes for inpatient health care services per specialty service line used by the provider for billing; and b. The twenty most used outpatient CPT codes or health care services procedure codes per specialty service line used for billing. c. The document includes, along with the health care prices provided, a plain English description of the services for which the health care prices are provided. d. The document is updated as frequently as appropriate but not less than annually. Natalie Young Signature of Affiant Subscribed and sworn to before me, the undersigned Notary Public in and for the state and county above, on this 12 day of February 2025. Commission No.: 22011946 My Commission Expires: 9-1-2026