Stone, Renzy Lee

Opinion

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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 highspeed 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 highspeed 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 nondisplaced 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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