Preview
FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024
EXHIBIT F
FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024
NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024
101 Park Avenue, 17th Floor
New York, NY 10178
Tel 212.878.7900 Fax 212.692.0940
www.foxrothschild.com
BRYN GOODMAN
Direct No: 212.878.7975
Email: BGoodman@FoxRothschild.com
NICOLE E. PRICE
Direct No: 212.878.7979
Email: NPrice@FoxRothschild.com
December 8, 2023
VIA EMAIL
Molly Brachfeld
Assistant Attorney General, Health Care Bureau
New York State Office of the Attorney General
28 Liberty Street
New York, New York 10005
Molly.Brachfeld@ag.ny.gov
Re: Garnet Health Medical Center
Dear Ms. Brachfeld:
As you know, this firm represents Garnet Health Medical Center (“GHMC”). In our
previous letter, dated November 10, 2023, GHMC responded to the New York State Office of the
Attorney General’s (the “Attorney General”) letter, dated October 24, 2023, (the “Letter”) and
objected to the lack of legal basis for its investigation as well as the improper, overbroad requests
for information. We invited the Attorney General to engage in a discussion regarding these
objections and potentially reach a resolution by limiting the scope and breadth of the requests.
However, when we met on December 5, 2023, the Attorney General’s team did not agree
to limit or narrow any of the requests, nor did the team articulate a valid legal basis for the
investigation or the scope and breadth of the requests. Nevertheless, in an effort to show good
faith and resolve this matter without further investigation, GHMC agreed to produce certain
relevant documentation without waiver of or prejudice to any rights, defenses, or objections.
GHMC hereby expressly preserves any and all procedural, jurisdictional, and substantive rights,
defenses, and objections that may exist now or in the future, including without limitation, all
defenses and objections outlined in its letter dated November 10, 2023.
Enclosed please find documents bates-stamped GHMC 000001-000069. The enclosed
documentation is not intended as an exhaustive production of all records, documents, data, or
information that GHMC may have relating this matter, nor is it a direct response to each and every
request for information, allegation, or misstatement of fact set forth in the Letter. As discussed,
GHMC is also reviewing its files for other documents and information related to the requests in
the Letter. As appropriate, GHMC will provide supplemental response(s) in connection with its
152730041.4
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NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024
Ms. Molly Brachfeld
December 8, 2023
Page 2
review on or before January 5, 2023. Accordingly, GHMC expressly reserves the right to present
additional information, defenses, and objections at any time.
Respectfully,
Bryn Goodman
Nicole E. Price
cc:
Sudarsana Srinivasan Galen Sherwin
Bureau Chief, Health Care Bureau Special Counsel for Reproductive Justice
28 Liberty Street 28 Liberty Street
New York, New York 10005 New York, New York 10005
Sudarsana.Srinivasan@ag.ny.gov Galen.Sherwin@ag.ny.gov
152730041.4
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NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024
GarnetHealth patienteadei
Consent forAdmission and h"eatment
I consent to admission and the rendering of care at Gamet Health including one or more of its affiliates: Garnet Health Medical
Garnet Health Medical Center - Garnet Health Garnet Health Urgent Care (collectively "Garnet
Center, Catskills, Doctors,
Health"), that may include routine diagnostic procedures and such medical treatment directed by my attending practitioner
and/or other affiliated practitioner(s) considered to be necessary. I understand that photographs, videotapes, digital or other
images may be recorded to document care for identification purposes.
I realize that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury or
even death. I acknowledge that no guarantees have been made to me as the result of the examination or treatment of this hospital.
I understand that:
a) Unless is an emergency
there or other extraordinary circumstances exist, no invasive procedures are performed upon a
patient and until he/she has had an opportunity
unless to discuss them with the practitioner or other health professional
to the patient's satisfaction.
b) Each patient has the right to consent or to refuse consent to the proposed procedure or therapeutic course.
c) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent.
I understand that many of the practitioners on staff of this hospital, including the attending practitioner(s) named, are not employees
or agents of this hospital, but rather are independent practitioners who have been granted the privilege of using this facility for
the care and treatment of their patients. Furthermore, I realize that among those who attend to patients at this hospital are medical,
nursing and other bealthcare personnel in training who, unless requested otherwise, may be present during patient care as a part
of their education.
I understand that the hospital as well
as the practitioner(s)
staff, who are associated with the hospital, operate under an
organizational code of ethical behavior.
decisions All
related to my health care will be based upon my health needs. I
clinical
understand that I have the right to know the name of my practitioner who has primary responsibility for my care and the identity
and professional status of individuals responsible for authorizing and performing procedures or treatments on me. I know that I
will be informed of any professional relationships that the hospital/practitioner have to another health care provider/institution
involved in my care that might suggest a conflict of interest, including business relationships and relationships with educational
institutions. Any policies and/or procedures related to information on the hospital's organizational code of ethical behavior will
be made available to me upon my request. I understand that I can notify my nurse, the hospital administration, or my practitioner
with questions or concerns that I have regarding the above information.
If registered as an inpatient
I have received the Patient's Bill of Rights, information on the Self Determination Act under New York State Law, a copy of the
Medicare/Champus"
New York State Health Care Proxy, the "Important Message from (if a Medicare patient), information on
DNR(do not resuscitate) order, the letter from the New York State Department of Health explaining the SPARCS data collection
system, maternity (if a maternity
information patient), with information about how I can exercise the rights explained in these
materials. If I have any concerns regarding any care, including ethical issues, I can request a consultation with the hospitals Case
Consults/Ethics Committee. I can ask my practitioners or nurses for more information,
If registered as an outpatient observation pptient
Observation status allows your practitioner to perform medical tests and provide medical care in a hospital setting while trying to
determine if there is a need for more extensive in-hospital services (inpatient
status) or if you can be discharged with further care
provided as an outpatient. This means the decision regarding discharge for outpatient care or admission for inpatient status can
be made within approximately 24 hours. At this time, you are considered an outpatient even though you are in a regular hospital
room receiving some of the same services as an inpatient. Guidelines and regulations are mandated by your insurance company
to determine if you are billed as an outpatient or inpatient.
Observation status may affect your Medicare, Medicaid, and/or private insurance coverage for the current hospital setvices,
including medications and other pharmaceutical supplies, as well as coverage for any subsequent discharge to a skilled nursing
facility or home and community-based care.
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GH MC 000001
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t Garnet Health eatienttabel
You are responsible to know your insurance plan and coverage. Many plans have deductibles or co-payments. You are to contact
your insurance plan to better understand the implications of being placed in observation status.
If regis tered as an extended Ambulatory Surgery outpatient
Outpatient status is required for certain surgical procedures when the practitioner expects youtt) be ready for discharge in 24 hours
or less. If it is determined that you need more extensive services in the hospital your status will be changed to an inpatient. The need
for outpatient status rather than inpatient status is a determination made by your practitioner based on your diagnosis, the planned
surgical procedure and the expected length of time you will need to be in the hospital.
MedicareBeneficiaries
Payment for Outpatient and/or Observation status is covered under Medica're Part B. You will be responsible for co-
payments for the services provided instead of an inpatient deductible. Understand that as an Outpatien t and/or Observation
patient you are responsible for the cost of your prescriptions and over the counter medications that you have been taking at home
prior to your hospitalization. Medicare will pay for any medications given to treat your current condition while in the hospital.
Observation and/or Outpatient Services mean this timein the hospital cannot count toward the three (3) day inpatient hospital
stay needed for Medicate to cover a Skilled Nursing Facility stay.
The hospital provides a Case Manager who reviews your chart to ensure that the appropriate status has been ordered by the
practitioner and is billed
correctly, The Case Manager will continue to review your medical records as necessary and discuss your
case with your practitioner to facilitate the appropriate status under Medicare regulations.
I understand that the charges ofall practitioners and physicians involved in the diagnosis and treatment of my care are separate
from the hospital charges, I understand that I am financially responsible to the hospital and those practitioners/physicians for
charges not covend or paid by my insurer and that some of those practitioners/physicians may not participate in my insurance
P_l_a&
Personal Belongings
Garnet Health will not assume responsibility for money, personal property items or prosthetic devices kept at the bedside or on
my person. I understand that arrangements can be made for safekeepmg for any articles of value including medication. Other
articles, with the exception of toiletries and appropriate clothing, should be sent homé.
Assignment of Benefits
In consideration of services rendered, I hereby assign and transfer over to Garnet Health and affiliated
and treatment physicians
and affiliated practitioners all health
insurance, worker's compensation, and automobile benefits of any nature whatsoever now
due, and due to become due, and payable to me, including personal injury protection, medical payments, underinsured/uninsured
benefits, any benefits of any other coverage which becomes available to me for hospital and practitioner services. I hereby direct
all above third party payers to pay such benefits directly to Gamet Health and affiliated physicians and affiliated practitioners in
consideration of services furnished and to be furnished
by Garnet Health. I hereby appoint the hospital, affiliated practitioners,
and any agent acting on their
as my behalf
authorized representative to pursue any claims, penalties and administrative and/or
legal remedies on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due
me for the payment of charges associated with my treatment. I hereby appoint the hospital, affiliated physicians, and any agent
acting on their behalf, as my authorized representative to pursue any claims, penalties, and administrative and/or legal remedies
on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due me for the
payment of charges associated with my treatment.
I understand that the charges of all practitioners involved in the diagnosis and treatment of my care are separate from the hospital
charges.
Release of Information
Authorization is hereby granted to release such information as may be necessary for my care and for the completion of my
hospitalization claims via mail, electmnic or facsimile transmission. I understand that medical information, while adhering to
rules and regulations, will be disclosed to any organization responsible for reimbursement or provision of care or services.
Garnet Health shall provide my medical records, including but not limited to diagnostic information and test results (including
Revised 7/2020 Page 2 of 3
GH MC 000002
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4 Gamet Health patient Label
legally protected data related to sexually transmitted disease(s), HIV communicable disease(s), psychiatric care, substance
abuse care and social services), to any practitioner or facility for the purpose of facilitating the transfer, referral and/or
continuity of my care. This information may also be reported when required, to organizations such as the NY S Department of
Health and/or the Centers for Disease Control for Disease Control and Prevention. I hereby release the above named facility
from any and all legal liability that may arise from the disclosure of this information. If you wish to opt out of the electronic
sharing of your medical records, please call 845-333-1600.
I grant permission for the use of my blood, tissues and/or organs to be used for the purposes of the advancement of medical
science and education, and their disposal, at this Hospital or at such other institution as this Hospital may designate.
Notice of Privacy Practices
By signing below, I acknowledge receipt of the Notice of Privacy Practices, which outlines how health information about me
may be used or disclosed. (Excludes referred outpatient non-invasive procedures, for example lab tests or diagnostic imaging
tests ordered by your practitioner.)
Guarantee of Payment for Non-Covered Charges
For, and in consideration of, services rendered or to be rendered to the above named patient by Garnet Health and/or its Hospital
Based Practitioners during the admission commencing on or the visit on the above referenced date. I/we hereby guarantee
payment, jointly and severally, of any and all charges incurred by the above named patient for which the hospital and atliliated
physician(s) has not been reimbursed by an insurance company or government agency. I/we understand that all bills are due upon
presentation and that in the event I/we default in fulfilling the terms of this agreement, I/we agree to pay, in addition to the amount
owing on this account, any reasonable attorney's fees incurred in the collection of the account. In the event that the above named
patient is admitted on the above referenced admission date for delivery of a new born child(ren), this guarantee of payment shall
also apply to any charges incurred by said newborn(s).
This form has been explained to me, and I am satisfied that I understand its contents and significance. I permit a copy of this
consent to be used in place of the original.
Dateffime
Patient Signature Representative*
Garnet Health Staff Representative's Relationship to Patient
*If the patient is incapable of signing and another person signs in his/her stead, please complete why the patient is unable to
give consent personally or acknowledge receipt ofNotice of Privacy Practice and unable to sign this form:
O Minor (any unmarried male or female who has not reached his/her 18th birthday)
O Unconscious
O Physical condition
¡ Mentally incapacitated
¡ Other
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GHMC000003
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CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL
_....
GHVHS
= Orange Regional Medical Center
P..e
GREATER HUDSON VALLEY HEALTH SYSTEM
Catskill Regional Medical Center
APPLIES TO:
Grover M. Hermann Hospital, Callicoon
“ System
GHVHS Medical DOCUMENT
Group
Organization CONTROL
CATEGORY: NUMBER:
F Department (specify)
f"
GHVHS Medical Group
Title:
Patient Abuse: Recognizing and Reporting Suspected Child Ab'use/ Neglect or Exploitation
Attachments: C. Protective Services Resource List E. State of N.Y. DOH letter, May 1S, 2008,
A. Work Instructions D. Consent to Take Photograph DPACS;08-03 re: Mandated Reporters for
B. DSS-221A Form Suspected Child Abuse or Maitreatment
Purpose:
To ensure that there is a consistent procedure for recognizing and reporting suspected child abuse/neglect or
exploitation throughout Orange Regional Medical Center.
Definitions:
Physical Abuse is infliction of physical injury by punching, beating, kicking, biting, burning, shaking, or
Otherwise harming a child.
Child Neglect is failure to provide for a chil s basic needs, and the neglect can be physical, educational, or
emotional. Neglect includes withholding of medically indicated treatment.
Sexual Abuse is fondling a child's genitals, intercourse, incest, rape, sodomy, exhibitionism, and commercial
exploitation through prostitution or the production of pornographic materials.
Emotional Abuse (psychological/verbal abuse, mental injury) is acts or failures to act on the part of parents or
other caregivers thatrhave caused or could cause serious behavioral, cognitive, emotional, or mental disorders.
Exploitation is to take unjust advantage of a patient for one's own advantage or benefit.
Policy:
Orange Regional Medical Center is committed to protecting children who are suspected victims of abuse, neglect
or exploitation, to the best of its ability. Under the Child Protective Services Act, Orange Regional Medical Center is
considered a mandatory reporting source for suspected child abuse and/or maltreatment, for all children under the
age of 18. This policy delineates the following:
1. Provides information to help patient care staff identify conditions and behaviors that might be
indicators of child abuse, neglect, or maltreatment.
2. Ensures per social service law, that a mandated reporter at Orange Regional Medical Center is
required to personally report to the Statewide Central Register of Child Abuse and Maltreatment
(SCR) any case of suspected abuse or maltreatment.
GHMC 000004
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CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL
3. Ensures if there are multiple mandated reporters with direct knowledge or reasonable cause to
suspect child abuse or maltreatment it is allowable for mmandated reporter to notify
Statewide Centralized Register of Child Abuse and Maitreatment (SCR). The mandated reporter
may advise the other mandated reporters that the call was made to the SCR and whether a
report was accepted or not.
4. ·Provides a procedure to follow when child abuse or neglect is alleged or suspected.
Standard(s):
Reference(s):
NYS Social Law, Chapter 193 of the Laws of 2007 amended section 413
NY Family Court Act, Section 1012
JCAHO Standard RI.2.150, PC .01.02.09
NYS Mandated Child Abuse Recognition and Reporting
Letters"
"Information http://OCFS.StateNyenet/policies/external/OCFS2008/#lNF.
Cross Reference(s):
Taking and Uploading Digital Images to the Electronic Medical Record
Patient Abuse: Domestic Violence Policy
Laboratory Manual: Newborn Drug Screen Policy
Patient Abuse: Recognizing and Reporting Suspected Adult and Elder Abuse, Neglect or Exploitation.
Author/Title:
Patricia Metzger, Director of Case Management Services
Approver/Title:
Scott Batulis, President'& CEO
Concurrences
VP Outpatient Services VP of Patient Care Services/CNO
Chief Medical Officer Nursing Administration (Med Surg)
Nursing Admi,nistration (ICU/PCU/ED) Director, Risk Management
Document Control
Status Key: A = New B = Reviewed + # C = Revised + # D = Archived
Status Description of Change Date Author/Tith
Patricia Metzger,
Dkedor oRase
C 1 Revised to reflect DNV ISO 1/7/20
Management
Services
GHMC 000005
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CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL
Patient Abuse: Recognizing and Reporting
Work Instruction Template / Applies to:
Document Control Number:
150049 Page 1 of 6
Title:
Work instructions: Patient Abuse: Recognizing and Reporting Suspected Child Abuse/Neglect or Exploitation
SUSPECTED ABUSE/NEGLECT/EXPLOITATION:
I. Physical or Behavioral Indicators Of Abuse, Neglect or Exploitation in
Children:
The following physical and behavioral indicators raise the possibility of child abuse or neglect. Their
presence warrants further inquiry and possible reporting to Statewide Central Register of Child
Abuse and Maltreatment (SCR) as specified in the PROCEDURE, below.
A. Physical Indicators of Abuse:
1. Unexplained bruises and welts in different stages of healing:
" On face, lips, mouth
" On torso, back, buttocks, thighs
" Reflecting a shape of an article (for example: a belt buckle or electrical cord)
2. Unexplained burns:
" cigarette burns- on soles, back or buttocks
Cigar, especially palms,
" Rope burns on arms, legs, neck or torso
" Immersion burns (sock-like, glove-like, doughnut shaped on buttocks or genitalia)
" Burns with a distinctive pattem, i.e. from an iron or radiator
3. Unexplained fractures:
" To skull, nose, facial structure
" In various stages of healing
" Multiple or spinal fractures
"accidentally"
" Fractures discovered during an exam
4. Unexplained lacerations or abrasions:
" To mouth, lips, gums, eyes
" To external genitalia
" On backs of arms, legs or torso
" Bite marks
5. Flead Injuries
" Absence of hair and/or hemorrhage beneath the outer covering of the brain due to
severe hitting or shaking
" Retinal hemorrhage or detachment, due to shaking
" Eye Injury
" Jaw and nasal fractures
GHMC 000006
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CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL
" Tooth or frenulum (of the tongue or lips) injury
" Shaken Baby Syndrome: Less Serious injury: Lethargy/decreased muscle tone,
extreme irritability, poor sucking or swallowing, rigidity or posturing. Serious Brain
lniury: Difficulty breathing, seizures, head or forehead appears larger than usual or
soft-spot on head appears to be bulging, inability to lift head, inability of eye to focus
or tack movement or equal size of pupils.
B. Physical Indicators of Neglect:
1. Poor hygiene, inappropriate clothing
2. Fatigue, listlessness, consistent hunger
3. Lack 'of supervision, unattended, obvious medical/physical problems
4. Ingestion of noxious substances
5. Abandonment
C. Behavioral Indicators of Abuse and Neglect:
1. lnappropriate wariness of adult contacts
2. Fear of parents, report of being injured by parents, fear of returning home.
3. Behavioral extremes (aggressiveness or withdrawal)
4. Report of no supervision or no caretaker
5. Antisocial behavior
6. Wears long sleeves or other concealing clothing (even in hot weather) to hide physical
injuries.
D. Physical Indicators of Sexual Abuse:
1. Underclothing that is torn, blood stained, or shows signs of semen
2. The presence of semen in oral, anal, or vaginal areas
3. The presence of foreign objects in rectal or vaginal cavities
4. Vaginas that are torn, lacerated, infected, or bloody (as well as broken hymens)
5. Penises or scrotums that are swollen, inflamed, infected, or show signs of internal bleeding
6. Bite marks on or around the genitals
7. Anal areas that are swollen, torn, lacerated, or infected or that have lax muscle tone
suggestive of internal stretching I
8. S.carred or mutilated sexual organs or other parts of the body .
9. Venereal disease in oral, anal, and urogenital areas (especially in prepubescent children)
10. Unusual vaginal or urethral Irritations or discharges unless they are the apparent result of
excessive rubbing (during cleaning) or self-stimulation
11. Repeated cystitis, especially in prepubescent girls
12. Pregnancy, especially in young adolescent girls
E. Behavioral Indicators of Sexual Abuse:
1. Sexual behavior inappropriate for age
2. Report of sexual assault by caretaker
Preview
FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 EXHIBIT F FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 101 Park Avenue, 17th Floor New York, NY 10178 Tel 212.878.7900 Fax 212.692.0940 www.foxrothschild.com BRYN GOODMAN Direct No: 212.878.7975 Email: BGoodman@FoxRothschild.com NICOLE E. PRICE Direct No: 212.878.7979 Email: NPrice@FoxRothschild.com December 8, 2023 VIA EMAIL Molly Brachfeld Assistant Attorney General, Health Care Bureau New York State Office of the Attorney General 28 Liberty Street New York, New York 10005 Molly.Brachfeld@ag.ny.gov Re: Garnet Health Medical Center Dear Ms. Brachfeld: As you know, this firm represents Garnet Health Medical Center (“GHMC”). In our previous letter, dated November 10, 2023, GHMC responded to the New York State Office of the Attorney General’s (the “Attorney General”) letter, dated October 24, 2023, (the “Letter”) and objected to the lack of legal basis for its investigation as well as the improper, overbroad requests for information. We invited the Attorney General to engage in a discussion regarding these objections and potentially reach a resolution by limiting the scope and breadth of the requests. However, when we met on December 5, 2023, the Attorney General’s team did not agree to limit or narrow any of the requests, nor did the team articulate a valid legal basis for the investigation or the scope and breadth of the requests. Nevertheless, in an effort to show good faith and resolve this matter without further investigation, GHMC agreed to produce certain relevant documentation without waiver of or prejudice to any rights, defenses, or objections. GHMC hereby expressly preserves any and all procedural, jurisdictional, and substantive rights, defenses, and objections that may exist now or in the future, including without limitation, all defenses and objections outlined in its letter dated November 10, 2023. Enclosed please find documents bates-stamped GHMC 000001-000069. The enclosed documentation is not intended as an exhaustive production of all records, documents, data, or information that GHMC may have relating this matter, nor is it a direct response to each and every request for information, allegation, or misstatement of fact set forth in the Letter. As discussed, GHMC is also reviewing its files for other documents and information related to the requests in the Letter. As appropriate, GHMC will provide supplemental response(s) in connection with its 152730041.4 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 Ms. Molly Brachfeld December 8, 2023 Page 2 review on or before January 5, 2023. Accordingly, GHMC expressly reserves the right to present additional information, defenses, and objections at any time. Respectfully, Bryn Goodman Nicole E. Price cc: Sudarsana Srinivasan Galen Sherwin Bureau Chief, Health Care Bureau Special Counsel for Reproductive Justice 28 Liberty Street 28 Liberty Street New York, New York 10005 New York, New York 10005 Sudarsana.Srinivasan@ag.ny.gov Galen.Sherwin@ag.ny.gov 152730041.4 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 GarnetHealth patienteadei Consent forAdmission and h"eatment I consent to admission and the rendering of care at Gamet Health including one or more of its affiliates: Garnet Health Medical Garnet Health Medical Center - Garnet Health Garnet Health Urgent Care (collectively "Garnet Center, Catskills, Doctors, Health"), that may include routine diagnostic procedures and such medical treatment directed by my attending practitioner and/or other affiliated practitioner(s) considered to be necessary. I understand that photographs, videotapes, digital or other images may be recorded to document care for identification purposes. I realize that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury or even death. I acknowledge that no guarantees have been made to me as the result of the examination or treatment of this hospital. I understand that: a) Unless is an emergency there or other extraordinary circumstances exist, no invasive procedures are performed upon a patient and until he/she has had an opportunity unless to discuss them with the practitioner or other health professional to the patient's satisfaction. b) Each patient has the right to consent or to refuse consent to the proposed procedure or therapeutic course. c) No patient will be involved in any research or experimental procedure without his or her full knowledge and consent. I understand that many of the practitioners on staff of this hospital, including the attending practitioner(s) named, are not employees or agents of this hospital, but rather are independent practitioners who have been granted the privilege of using this facility for the care and treatment of their patients. Furthermore, I realize that among those who attend to patients at this hospital are medical, nursing and other bealthcare personnel in training who, unless requested otherwise, may be present during patient care as a part of their education. I understand that the hospital as well as the practitioner(s) staff, who are associated with the hospital, operate under an organizational code of ethical behavior. decisions All related to my health care will be based upon my health needs. I clinical understand that I have the right to know the name of my practitioner who has primary responsibility for my care and the identity and professional status of individuals responsible for authorizing and performing procedures or treatments on me. I know that I will be informed of any professional relationships that the hospital/practitioner have to another health care provider/institution involved in my care that might suggest a conflict of interest, including business relationships and relationships with educational institutions. Any policies and/or procedures related to information on the hospital's organizational code of ethical behavior will be made available to me upon my request. I understand that I can notify my nurse, the hospital administration, or my practitioner with questions or concerns that I have regarding the above information. If registered as an inpatient I have received the Patient's Bill of Rights, information on the Self Determination Act under New York State Law, a copy of the Medicare/Champus" New York State Health Care Proxy, the "Important Message from (if a Medicare patient), information on DNR(do not resuscitate) order, the letter from the New York State Department of Health explaining the SPARCS data collection system, maternity (if a maternity information patient), with information about how I can exercise the rights explained in these materials. If I have any concerns regarding any care, including ethical issues, I can request a consultation with the hospitals Case Consults/Ethics Committee. I can ask my practitioners or nurses for more information, If registered as an outpatient observation pptient Observation status allows your practitioner to perform medical tests and provide medical care in a hospital setting while trying to determine if there is a need for more extensive in-hospital services (inpatient status) or if you can be discharged with further care provided as an outpatient. This means the decision regarding discharge for outpatient care or admission for inpatient status can be made within approximately 24 hours. At this time, you are considered an outpatient even though you are in a regular hospital room receiving some of the same services as an inpatient. Guidelines and regulations are mandated by your insurance company to determine if you are billed as an outpatient or inpatient. Observation status may affect your Medicare, Medicaid, and/or private insurance coverage for the current hospital setvices, including medications and other pharmaceutical supplies, as well as coverage for any subsequent discharge to a skilled nursing facility or home and community-based care. Revised 7/2020 Page 1 of 3 GH MC 000001 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 t Garnet Health eatienttabel You are responsible to know your insurance plan and coverage. Many plans have deductibles or co-payments. You are to contact your insurance plan to better understand the implications of being placed in observation status. If regis tered as an extended Ambulatory Surgery outpatient Outpatient status is required for certain surgical procedures when the practitioner expects youtt) be ready for discharge in 24 hours or less. If it is determined that you need more extensive services in the hospital your status will be changed to an inpatient. The need for outpatient status rather than inpatient status is a determination made by your practitioner based on your diagnosis, the planned surgical procedure and the expected length of time you will need to be in the hospital. MedicareBeneficiaries Payment for Outpatient and/or Observation status is covered under Medica're Part B. You will be responsible for co- payments for the services provided instead of an inpatient deductible. Understand that as an Outpatien t and/or Observation patient you are responsible for the cost of your prescriptions and over the counter medications that you have been taking at home prior to your hospitalization. Medicare will pay for any medications given to treat your current condition while in the hospital. Observation and/or Outpatient Services mean this timein the hospital cannot count toward the three (3) day inpatient hospital stay needed for Medicate to cover a Skilled Nursing Facility stay. The hospital provides a Case Manager who reviews your chart to ensure that the appropriate status has been ordered by the practitioner and is billed correctly, The Case Manager will continue to review your medical records as necessary and discuss your case with your practitioner to facilitate the appropriate status under Medicare regulations. I understand that the charges ofall practitioners and physicians involved in the diagnosis and treatment of my care are separate from the hospital charges, I understand that I am financially responsible to the hospital and those practitioners/physicians for charges not covend or paid by my insurer and that some of those practitioners/physicians may not participate in my insurance P_l_a& Personal Belongings Garnet Health will not assume responsibility for money, personal property items or prosthetic devices kept at the bedside or on my person. I understand that arrangements can be made for safekeepmg for any articles of value including medication. Other articles, with the exception of toiletries and appropriate clothing, should be sent homé. Assignment of Benefits In consideration of services rendered, I hereby assign and transfer over to Garnet Health and affiliated and treatment physicians and affiliated practitioners all health insurance, worker's compensation, and automobile benefits of any nature whatsoever now due, and due to become due, and payable to me, including personal injury protection, medical payments, underinsured/uninsured benefits, any benefits of any other coverage which becomes available to me for hospital and practitioner services. I hereby direct all above third party payers to pay such benefits directly to Gamet Health and affiliated physicians and affiliated practitioners in consideration of services furnished and to be furnished by Garnet Health. I hereby appoint the hospital, affiliated practitioners, and any agent acting on their as my behalf authorized representative to pursue any claims, penalties and administrative and/or legal remedies on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due me for the payment of charges associated with my treatment. I hereby appoint the hospital, affiliated physicians, and any agent acting on their behalf, as my authorized representative to pursue any claims, penalties, and administrative and/or legal remedies on my behalf for collection against any responsible payer or third party liability carrier of any and all benefits due me for the payment of charges associated with my treatment. I understand that the charges of all practitioners involved in the diagnosis and treatment of my care are separate from the hospital charges. Release of Information Authorization is hereby granted to release such information as may be necessary for my care and for the completion of my hospitalization claims via mail, electmnic or facsimile transmission. I understand that medical information, while adhering to rules and regulations, will be disclosed to any organization responsible for reimbursement or provision of care or services. Garnet Health shall provide my medical records, including but not limited to diagnostic information and test results (including Revised 7/2020 Page 2 of 3 GH MC 000002 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 4 Gamet Health patient Label legally protected data related to sexually transmitted disease(s), HIV communicable disease(s), psychiatric care, substance abuse care and social services), to any practitioner or facility for the purpose of facilitating the transfer, referral and/or continuity of my care. This information may also be reported when required, to organizations such as the NY S Department of Health and/or the Centers for Disease Control for Disease Control and Prevention. I hereby release the above named facility from any and all legal liability that may arise from the disclosure of this information. If you wish to opt out of the electronic sharing of your medical records, please call 845-333-1600. I grant permission for the use of my blood, tissues and/or organs to be used for the purposes of the advancement of medical science and education, and their disposal, at this Hospital or at such other institution as this Hospital may designate. Notice of Privacy Practices By signing below, I acknowledge receipt of the Notice of Privacy Practices, which outlines how health information about me may be used or disclosed. (Excludes referred outpatient non-invasive procedures, for example lab tests or diagnostic imaging tests ordered by your practitioner.) Guarantee of Payment for Non-Covered Charges For, and in consideration of, services rendered or to be rendered to the above named patient by Garnet Health and/or its Hospital Based Practitioners during the admission commencing on or the visit on the above referenced date. I/we hereby guarantee payment, jointly and severally, of any and all charges incurred by the above named patient for which the hospital and atliliated physician(s) has not been reimbursed by an insurance company or government agency. I/we understand that all bills are due upon presentation and that in the event I/we default in fulfilling the terms of this agreement, I/we agree to pay, in addition to the amount owing on this account, any reasonable attorney's fees incurred in the collection of the account. In the event that the above named patient is admitted on the above referenced admission date for delivery of a new born child(ren), this guarantee of payment shall also apply to any charges incurred by said newborn(s). This form has been explained to me, and I am satisfied that I understand its contents and significance. I permit a copy of this consent to be used in place of the original. Dateffime Patient Signature Representative* Garnet Health Staff Representative's Relationship to Patient *If the patient is incapable of signing and another person signs in his/her stead, please complete why the patient is unable to give consent personally or acknowledge receipt ofNotice of Privacy Practice and unable to sign this form: O Minor (any unmarried male or female who has not reached his/her 18th birthday) O Unconscious O Physical condition ¡ Mentally incapacitated ¡ Other Revised 7/2020 Page 3 of 3 GHMC000003 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL _.... GHVHS = Orange Regional Medical Center P..e GREATER HUDSON VALLEY HEALTH SYSTEM Catskill Regional Medical Center APPLIES TO: Grover M. Hermann Hospital, Callicoon “ System GHVHS Medical DOCUMENT Group Organization CONTROL CATEGORY: NUMBER: F Department (specify) f" GHVHS Medical Group Title: Patient Abuse: Recognizing and Reporting Suspected Child Ab'use/ Neglect or Exploitation Attachments: C. Protective Services Resource List E. State of N.Y. DOH letter, May 1S, 2008, A. Work Instructions D. Consent to Take Photograph DPACS;08-03 re: Mandated Reporters for B. DSS-221A Form Suspected Child Abuse or Maitreatment Purpose: To ensure that there is a consistent procedure for recognizing and reporting suspected child abuse/neglect or exploitation throughout Orange Regional Medical Center. Definitions: Physical Abuse is infliction of physical injury by punching, beating, kicking, biting, burning, shaking, or Otherwise harming a child. Child Neglect is failure to provide for a chil s basic needs, and the neglect can be physical, educational, or emotional. Neglect includes withholding of medically indicated treatment. Sexual Abuse is fondling a child's genitals, intercourse, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. Emotional Abuse (psychological/verbal abuse, mental injury) is acts or failures to act on the part of parents or other caregivers thatrhave caused or could cause serious behavioral, cognitive, emotional, or mental disorders. Exploitation is to take unjust advantage of a patient for one's own advantage or benefit. Policy: Orange Regional Medical Center is committed to protecting children who are suspected victims of abuse, neglect or exploitation, to the best of its ability. Under the Child Protective Services Act, Orange Regional Medical Center is considered a mandatory reporting source for suspected child abuse and/or maltreatment, for all children under the age of 18. This policy delineates the following: 1. Provides information to help patient care staff identify conditions and behaviors that might be indicators of child abuse, neglect, or maltreatment. 2. Ensures per social service law, that a mandated reporter at Orange Regional Medical Center is required to personally report to the Statewide Central Register of Child Abuse and Maltreatment (SCR) any case of suspected abuse or maltreatment. GHMC 000004 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL 3. Ensures if there are multiple mandated reporters with direct knowledge or reasonable cause to suspect child abuse or maltreatment it is allowable for mmandated reporter to notify Statewide Centralized Register of Child Abuse and Maitreatment (SCR). The mandated reporter may advise the other mandated reporters that the call was made to the SCR and whether a report was accepted or not. 4. ·Provides a procedure to follow when child abuse or neglect is alleged or suspected. Standard(s): Reference(s): NYS Social Law, Chapter 193 of the Laws of 2007 amended section 413 NY Family Court Act, Section 1012 JCAHO Standard RI.2.150, PC .01.02.09 NYS Mandated Child Abuse Recognition and Reporting Letters" "Information http://OCFS.StateNyenet/policies/external/OCFS2008/#lNF. Cross Reference(s): Taking and Uploading Digital Images to the Electronic Medical Record Patient Abuse: Domestic Violence Policy Laboratory Manual: Newborn Drug Screen Policy Patient Abuse: Recognizing and Reporting Suspected Adult and Elder Abuse, Neglect or Exploitation. Author/Title: Patricia Metzger, Director of Case Management Services Approver/Title: Scott Batulis, President'& CEO Concurrences VP Outpatient Services VP of Patient Care Services/CNO Chief Medical Officer Nursing Administration (Med Surg) Nursing Admi,nistration (ICU/PCU/ED) Director, Risk Management Document Control Status Key: A = New B = Reviewed + # C = Revised + # D = Archived Status Description of Change Date Author/Tith Patricia Metzger, Dkedor oRase C 1 Revised to reflect DNV ISO 1/7/20 Management Services GHMC 000005 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL Patient Abuse: Recognizing and Reporting Work Instruction Template / Applies to: Document Control Number: 150049 Page 1 of 6 Title: Work instructions: Patient Abuse: Recognizing and Reporting Suspected Child Abuse/Neglect or Exploitation SUSPECTED ABUSE/NEGLECT/EXPLOITATION: I. Physical or Behavioral Indicators Of Abuse, Neglect or Exploitation in Children: The following physical and behavioral indicators raise the possibility of child abuse or neglect. Their presence warrants further inquiry and possible reporting to Statewide Central Register of Child Abuse and Maltreatment (SCR) as specified in the PROCEDURE, below. A. Physical Indicators of Abuse: 1. Unexplained bruises and welts in different stages of healing: " On face, lips, mouth " On torso, back, buttocks, thighs " Reflecting a shape of an article (for example: a belt buckle or electrical cord) 2. Unexplained burns: " cigarette burns- on soles, back or buttocks Cigar, especially palms, " Rope burns on arms, legs, neck or torso " Immersion burns (sock-like, glove-like, doughnut shaped on buttocks or genitalia) " Burns with a distinctive pattem, i.e. from an iron or radiator 3. Unexplained fractures: " To skull, nose, facial structure " In various stages of healing " Multiple or spinal fractures "accidentally" " Fractures discovered during an exam 4. Unexplained lacerations or abrasions: " To mouth, lips, gums, eyes " To external genitalia " On backs of arms, legs or torso " Bite marks 5. Flead Injuries " Absence of hair and/or hemorrhage beneath the outer covering of the brain due to severe hitting or shaking " Retinal hemorrhage or detachment, due to shaking " Eye Injury " Jaw and nasal fractures GHMC 000006 FILED: ORANGE COUNTY CLERK 03/19/2024 10:11 AM INDEX NO. EF002246-2024 NYSCEF DOC. NO. 13 RECEIVED NYSCEF: 03/19/2024 CONFIDENTIAL - NOT SUBJECT TO FOlA/FOlL " Tooth or frenulum (of the tongue or lips) injury " Shaken Baby Syndrome: Less Serious injury: Lethargy/decreased muscle tone, extreme irritability, poor sucking or swallowing, rigidity or posturing. Serious Brain lniury: Difficulty breathing, seizures, head or forehead appears larger than usual or soft-spot on head appears to be bulging, inability to lift head, inability of eye to focus or tack movement or equal size of pupils. B. Physical Indicators of Neglect: 1. Poor hygiene, inappropriate clothing 2. Fatigue, listlessness, consistent hunger 3. Lack 'of supervision, unattended, obvious medical/physical problems 4. Ingestion of noxious substances 5. Abandonment C. Behavioral Indicators of Abuse and Neglect: 1. lnappropriate wariness of adult contacts 2. Fear of parents, report of being injured by parents, fear of returning home. 3. Behavioral extremes (aggressiveness or withdrawal) 4. Report of no supervision or no caretaker 5. Antisocial behavior 6. Wears long sleeves or other concealing clothing (even in hot weather) to hide physical injuries. D. Physical Indicators of Sexual Abuse: 1. Underclothing that is torn, blood stained, or shows signs of semen 2. The presence of semen in oral, anal, or vaginal areas 3. The presence of foreign objects in rectal or vaginal cavities 4. Vaginas that are torn, lacerated, infected, or bloody (as well as broken hymens) 5. Penises or scrotums that are swollen, inflamed, infected, or show signs of internal bleeding 6. Bite marks on or around the genitals 7. Anal areas that are swollen, torn, lacerated, or infected or that have lax muscle tone suggestive of internal stretching I 8. S.carred or mutilated sexual organs or other parts of the body . 9. Venereal disease in oral, anal, and urogenital areas (especially in prepubescent children) 10. Unusual vaginal or urethral Irritations or discharges unless they are the apparent result of excessive rubbing (during cleaning) or self-stimulation 11. Repeated cystitis, especially in prepubescent girls 12. Pregnancy, especially in young adolescent girls E. Behavioral Indicators of Sexual Abuse: 1. Sexual behavior inappropriate for age 2. Report of sexual assault by caretaker