Free Complaint - District Court of Delaware - Delaware

Case 1:06-cv-00428-SLR

Document 2

Filed 07/11/2006

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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE

(Name of Plaintiff or plaintiffs)
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CIVIL ACTION NO.
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(Name of Defendant or Defendants)

1.

This action is brought pursuant to -

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jurisdiction exists by%tue for discrimination related to (In what area did discrimination occur? e.g. race, sex, religion) (Federal statute on which jurisdiction is based)

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2.

Plaintiff resides at (Sheet Address) (city) (County) (State)

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(Zip Code)

(Area Code) (Phone Number)

3.

Defendant resides at, or its business is located at

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(State) (Zip Code) (Day)

(Street Address)

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(Year)

(city)

(County)

4.

The alleged discriminatory acts occurred on
(Month)

5.

The alleged discriminatory practice

i continuing. s

Case 1:06-cv-00428-SLR

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6.

Plaintiff@)filed charges with the (Agency) (Street Address) (city) (County) (State) (Zip)

regarding defendant@)alleged discriminatory conduct on:
7.
8.

@ate) Attach decision of the agency which investigated the charges referred in paragraph 6 above. Was an appeal taken from the agency's decision7 Yes

No

If yes, to whom was the appeal taken?
9.

The discriminatory acts alleged in this suit concern: (Describe facts on additional sheets if
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necessary)

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Defendant's conduct is discriminatory with respect to the following:
A.

Plaintiffs race Plaintiffs color Plaintiffs sex Plaintiffs religion Plaintiffs national origin

B.
C.

D. E.

Case 1:06-cv-00428-SLR

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11.

Plaintiff prays for the follouiing relief: (Indicate the exact relief requested)

Dated:

J.

Case 1:06-cv-00428-SLR

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3

C H R I HEALTH SERVICESR E S ~ C ~

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CONDITIONS FOR TREATMENT

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CONSENT FOR TREATMENT (Patient Information and ~onkent)

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I consent to and authorize Christiana Care Health Services, physicians, professionals and employees to render care and furnish the necessary treatments, surgical or laboratory procedures, anesthesia, x-ray examinations or, tests or, drugs and supplies as ordered or requested by my physicians. I understand Christiana Care Health Services is a community teaching hospital and medical students interns, resident physicians, nursing students and other health professional trainees may participate in my care. I further understand that Christiana care maintains medical records and other information pertaining to my care, billing and payment in electronic form. I acknowledge that no guarantee or assurance has been made as to the results of treatment, surgery, or examinations in the hospital. I understand that if I required medical treatment by the Trauma Team in the Emergency Department, my treatment may have been videotaped for performance improvement. I understand that these tapes may be reviewed by the Trauma Team but will not become part of my medical record and will be erased after review. RELEASE FROM LIABILITY FOR VALUABLES I hereby assume responsibility for all items of personal property brought to the hospital, excepting articles placed in the hospital's safe, and release the hospital, its agents, servants or employees from all claims in regard to lost, stolen or damaged articles. The maximum liability of the hospital for loss of any personal property which is deposited with the hospital for safe keeping is limited to $300 unless a written receipt for a greater amount has been obtained from the hospital by the patient. FINANCIAL RESPONSIBILITY, ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION
I am responsible to Christiana Care Health Services and to physicians providing hospital-based services (e.g. Emergency Department physicians, Anesthesiologists, Radiologists, Pathologists, etc) for any and all charges (or amounts based on payment arrangements agreed to by them) that are incurred during my admission and/or treatment and not paid or otherwise satisfied by insurance or other third party benefits. I assign and request payment of benefits to Christiana Care Health Services and to physicians providing hospital-based services (e.g. Emergency Department physicians, Anesthesiologists, Radiologists, Pathologists, etc.) for which I am entitled under the terms of any and all policies under which I have coverage. This assignment applies to all services related to my current admission or, for outpatient services, until revoked. NOTIFICATION AND ACKNOWLEDGEMENT OF PATIENT RIGHTS AND PRlVlLEDGES

l hav had the opportunity to receive and review Christiana Care Health Services Notice of Privacy Practices
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Relationsh~p Date

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MEDICARE ASSIGNMENT OF INSURANCE BENEFITS

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'Where Medicare denefits are applicable. I certify that the information given by me in applying for payment under Title Vlll of the Social Security Act is correct. I request payment of authorized Medicare benefits to Christiana Care Health Services, Doctors for Emergency Services and other physicians on my behalf for any services furnished me including physician services. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine the benefits for related services. AN IMPORTANT MESSAGE FROM MEDICARE

I have had the opportunity to receive and review the Important Message From Medicare
Signature Relationship

(initial).

Date

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I have decided that I do NOT wish to be listed in the hospital directory. I understand Christiana Care will not tell visitors, callers or clergy my room or telephone number and 1 will not receive any deliveries to my room (such as flowers, (initial). packages, or cards and letters).

Case 1:06-cv-00428-SLR

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CHRISTIANA CARE HEALTH SERVICES EMERGENCY DEPARTMENT: CHRISTIANA HOSPITAL 4755 Ogletown-Stanton Rd Newark, DE 19718 (302) 733-1000 Patient:Nana Y. Agyeman Date:Jul 06, 2006
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REFERRAL: Ophthalmology Stephen Franklin, M.D. 1207 N Scott Street, Wilmington, DE Office Phone: 652-3353

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You are being referred to the doctor listed above. Call the office to arrange a follow-up visit. Let the office know that you were referred from the Emergency Department. SIGNATURE:
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Anita Hodson, M.D.

Case 1:06-cv-00428-SLR

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Nana Y. Agyeman

T ~ U ~ 1 02006 Page 1 ~ 6, 1:51 PM Discharge Instructions from Anita Hodson, M.D. Christiana Care Health Services - Wilmington Hospital
-

Christiana Hospital, 4755 0 letown-Stanton Rd,Newark,DE 302-733-1000 Wilmington Hospital, 14th Washington St, Wilmington,DE 302-733-1000

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Any Concern,. ..Return! DIAGNOSIS: Paresthesias; abnormal EKG OTHER INSTRUCTIONS: Make an appointment with Dr. Agard for follow up care.

PARESTHESIA: Paresthesia means a feeling of numbness, tingling, or strange sensation on your body. This is a common symptom seen in the Emergency Department because it is often very frightening to experience.
There are many possible causes of paresthesias. Bruises or muscular strains may causes some irritation of nearby nerves. Pinching of a nerve in the neck or back may also cause this sensation in the extremities. Unless there are other signs of physical disease, it is most often related to hyperventilation or stress. Your examination today does not show evidence of a stroke, blood clot, or tumor. You will not need other tests unless your symptoms do not clear up soon or unless you develop other symptoms.

NOTIFY YOUR DOCTOR or return here in case of the followin : - Weakness or difficulty with movement of the face, an arm or eg. - Difficulty with s eech or vision. - Prolonged or hig fever. - Severe or worsening headache. - Chan e in mental status - too sleepy, confused, short of breath, more irritable or fussy, slurred speec , difficulty walking.

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REFERRAL: Internal Medicine - Reynold Agard, M .D . Reynold Agard, M.D. Premiere Ph sicians 3 14 E. Main Street, Suite 103, Newark DE 410 Foulk Road, Suite 200B, Wilmington, 30 -762-6675 Office phone: 302-366-0550

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You are bein referred to the doctor listed above. Call the office to arrange a follow-up visit. Let the office know t at you were referred from the Emergency Department. OTHER INSTRUCTIONS: If there is any change in your condition, please return.

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---- Instructions are continued on next page. ----

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Case 1:06-cv-00428-SLR
APPOINTMEN?
Date : 07/1012006 Time : 10:30AM Seen BY: Stephen H.Fran Encounter: 85153 Message : NEW EX PER CHRISTIANA E

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PRACTICE

Page 4 of 9

Eye Physicians and Surgeons PA
SSN: Onset Date: Onset Type: ILL

PATIENT
NANA AJYEMAN ~ c c#t : 89461
Diagnosis: Sex: M DOB: \ Primary Provider: ReE Prov.:
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1207 North Scott St Wilmington, DE 19806
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RESPONSIBLE PARTY
NANA AJYEMAN 802 WEST 8TH STREET Wilmington, DE 19801
Home: (302) 472-5497 Work: (302) Case: 99909 - NRM Patient Status: 1 Financial Status:

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INSURANCE
#

PATIENT FINANCIAL
Activation Expiration

Code

Policy #

CoPay

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Patient Due:
Insurance Due: Last Payment:

0.00 Credit Balance: 0.00 Total Balance: 0.00 on

1 UNITE

0.00 0.00

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Case 1:06-cv-00428-SLR

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Case 1:06-cv-00428-SLR

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Nana Y. Agyeman

T ~ U ~ 1 02006 ~ 6, 1:51 PM

Page 2

.................................................... .................................................... STARTER PACKSISAMPLE MEDICATIONS: I understand and acknowled e that I may have received medication in a NON-CHILD PROOF container I understand if a child is in t e presence of this container the container could be opened.

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I understand that this and all medications should be kept out of the reach of children. .................................................... .................................................... I understand that the treatment I have received was rendered on an emergency basis only and that further treatment may be necessary. I have been given a copy of the above instructions. I understand these instructions; and I will arrange for follow-u care as outlined above. If my condition worsens, I will call my doctor or return to the Emergency epartment.

8

(Signature) Circle One: PATIENT PARENT SPOUSE RELATIVE FRIEND GUARDIAN NOTE: Your insurance company may require you to contact them or your primary care physician as soon as possible after your Emergency Room visit.

*** PHYSICIAN REFERRAL:If you need assistance obtaining a local physician or *** LAB RESULTS/MEDICAL RECORDS: You may call at 302-428-6852.

dentist you may call the "Christiana Care Referral Service" help line at 302-428-4100.

.................................................... .................................................... *** FLU SEASON HAS ARRIVED, AND THE CDC EXPECTS THIS YEAR TO BE A BAD ONE! PLEASE CONTACT YOUR FAMILY PHYSICIAN AND ARRANGE TO HAVE THIS SEASON'S VACCINE. PEOPLE THAT ARE ELDERLY, VERY YOUNG, OR SUFFER FROM ASTHMA OR RESPIRATORY ILLNESSES ARE PARTICULARLY AT RISK *** ....................................................

Case 1:06-cv-00428-SLR

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1.neBrooklyn Hospital Center
U121 DeKalb Avenue

Bmklyn, NY 11201

0 1 0 0 arks side Avenue

Bmoklyn. NY 11226

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Request for Consultation for:
Physician or Service

Date:

Time:
Cl Studies or Therapy Indicated

AM PM

E STAT l
ROUTINE

C Consultation ONLY l
Consultation and Follow Up

O Opinion and Recommendations

a Transfer of Patient to YOUR SERVICE

REASON FOR CONSULTATION:

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M.D.

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Signam of Attending Physician

REPORT OF CONSULTATION:

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DATE:

TIME:

SERVICE1 DEPT.

Signature of M.D.
601 7/02

Case 1:06-cv-00428-SLR
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Professional Medical Recovery P. 0. 6488 BOX Woodland Hills, CA 91365 (818) 702-0669 (800) 541-5125 Fax: (818) 593-3421

BROTMAN MEDICAL CENTER 60052016

APRIL 12.2006 638266-6 NANA AGYEMAN 574 E. 163RD ST. BRONX NY 10456

Patient: Date o f Service: File No.: Principal Amount: Interest Due: Other Charges: TOTAL NOW DUE

AGYEMAN, NANA 10123105

638266-6 1,386.17 64.55
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I$

1.450.72

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TEAR ON PERFORATION AND RETURN THlS PORTION WITH YOUR PAYMENT TO ASSURE PROPER CREDIT TO YOUR ACCOUNT

This unpaid and delinquent obligation has been assigned to us for collection. It is important that you contact this office regarding this debt. Contacting the original creditor will not satisfy the requirement to contact this office. Make all payments to and arrangements with this office to preserve your rights and avoid miscommunications or delays which could result in the reporting of this delinquent debt against your credit record with the national credit reporting agencies. Interest charges are added to this account from the date of first delinquency and are payable in accordance with California Civil Code, Sec. 3289. lnterest charges will continue to be added until the account is paid in full. Read the important information on the reverse side of this letter carefully. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office within 30 days after receiving this notice, this office will obtain verification of the debt or obtain a copy of the judgement and mail you a copy of such judgement or verification. If you request of this office within 30 days after receiving this notice, this office will provide you with the name and address of the original creditor, if different from the current creditor. As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligation. But we will not submit a credit report to a credit reporting agency until the expiration of the time period described above. The state Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act require that, except under unusual circumstances, collectors may not contact you before 8am or after 9pm. They may not harass you by using threats of violence or arrest or by using obscene language. Collectors may not use false or misleading statements or call you at work if they know or have reason to know that you may not receive personal calls at work. For the most part, collectors may not tell another person, other than your attorney or spouse, about your debt. Collectors may contact another person to confirm your location or enforce a judgement. For more information about debt collection activities, you may contact the Federal Trade Commission at 1-877-FTC-HELPor www.ftc.gov. MR. HILL Account Representative Monday thru Friday - 8am to 5pm (818)-702-0669 1Ext. 2060 Si usted prefiere avisos futuros en espatiol, llamar o volver por favor este aviso con su peticion

FOR YOUR CONVENIENCE YOU MAY PAY THIS ACCOUNT BY TELEPHONE USING YOUR CHECKING ACCOUNT OR YOUR MASTERCARD OR VISA CREDIT CARD CERTAIN RESTRICTIONS MAY APPLY.

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IMPORTANT INFORMATION ABOUT COLLECTIONS AND THIS NOTIFICATION
Your Riqhts and Obliaations Read the letters or notices which we send you carefully. They contain important informationabout your rights and obligations. Communicationssent to you may contain time sensitive limitations. Read notices carefully to be aware of such limitations. California Civil Code Sec. 1788.21 requires that you notify your creditor of your change of name, address, or employment for any existing consumer credit. This notice has been sent to you by a debt collection agency regarding an unpaid and delinquent obligation which you owe to the creditor named on the front of lhis letter. Debts are due and payable in full. A collection agency is not a billing service and holds no obligation to submit a claim for payment to any thiid party on your behalf. This debt was placed for collection by your creditor because it was unresolved after a reasonable period of time, including having been submitted to any third party which you requested at time of service. If you believe this bill should be paid by your insurance, we will obtain and provide you a copy of the billing which you can submit to your insurance for reimbursement, if you so request, but such will not effect a delay in our right to request full payment of this delinquent debt. Your original creditor has attempted to encourage your payment or response previous to assignment of this debt for collection and has received inadequate response. If you believe this claim is covered by Medicare, Medi-Cal or Workers' Compensation insurance, you must contact us immediately and provide the necessary information in order that we can investigate your coverage and take appropriate action. Delaying in contacting us may void your right to be covered due to time limits which exist for the submission of claims for payment by Medicare, Medi-Cal and Workers' Compensation. Validation of Debt You have the right to request proof of this debt. Our obligation to prove this debt in response to your request or dispute is limited to providing you with the name and address of the original creditor, an itemization of charges and credits which equal the principal amount due, and a statement that the amount remains due. If this debt pertains to a judgement, proof of lhis debt is accomplished by providing a copy of the judgement. If you dispute this debt claiming that you are a victim of identity theft, you will be required to prove your daim including providing a copy of the police report which you filed at the time the theft of your identity originally occurred. Filing a false claim of identity theft is a criminal offense. Special Fees and Charqes Should any check or bank instrument be retumed to us, unpaid, we will impose a charge of $25.00 to your account for handling and to cover the charges made to us by our bank. This fee will be charged for each and every retumed check or bank instrument. Submittins Pavment of this Debt You may pay this debt by mailing a check, money order or bank instrument made payable to Professional Medical Recovery at Post Office Box 6488, Woodland Hills, CA 91365-6488. YOU may pay by telephone using your checking account or Mastercard or Visa Credit Card. To pay this debt in full, you must pay the amount shown in the box TOTAL NOW DUE on the face of this letter. Payment of any amount which is less than the TOTAL NOW DUE will not constitute payment in full and will not close this account. Any remaining balance due will continue to be reported to the national credit reporting agencies as an unpaid collection account. We reserve the right to process checks electronically, at first presentment and any re-presentments,by transmitting the amount of the check, routing number and check serial number to your financial institution. Your checking account may be debited as soon as the same day we receive your payment. If you have more than one unpaid account with us, we will apply any payment which you make to the oldest account first unless you specify the account number which you desire the payment to be posted to by writing our account number on the face of your check. Monthlv Payments We have no obligation, legal or otherwise, to approve monthly payments to pay this delinquent debt. All debts are considered due and payable in full. Any payments which are received will be credited to-your account and the account balance reduced accordingly but receipt or acceptance of such payment will not constitute an approved monthly payment agreement nor will it stop any .other actions which we may legally pursue in collection of lhis debt. If we establish an approved monthly payment agreement to assist you with resolving this debt, it will be your obligation to make such payments as and when due and for the amount agreed upon. If you miss a payment or submit payment of a lesser amount, the payment agreement will be deemed void without further notice. Interest charges will continue to be added to your account during any monthly payment agreement. While any amount will be accepted in payment, we will only approve a payment anangementfor larger balances and for a limited amount of time. Your account representativecan provide you with further information. National Credit Repottinq Agencies The National Credit Reporting Agencies (CRA's) such as Experian (formerly TRW) and Equifax, maintain a record of obligations and information about how consumers pay their obligations.-This information is provided to any' business that'seeks to determine your credit status for the provision of any credit (home loans, credit cards, bank loans, car loans, etc.). We report to the CRA's monthly for each unpaid account if the responsible party for that account has not responded with payment following nolltcation. Once a debt is reported, ~tremains on your credit record for up to seven (7) years or more from the date of original delinquency and cannot be deleted except for special and unusual circumstances. If you dispute this debt, along with reporting the unpaid collection account we will report that you have disputed it. If you dispute the debt directly with the CRA's, they will notify us of your dispute. We will then investigate your dispute, review your account, and respond to the CRA advising them that the account is either correct as reported or by submitting updated or corrected information. The making of a dispute does not automatically remove the reported debt from your credit record Monitoring of Calls When calling our office, your call may be monitored or recorded for training and quality assurance purposes. If at any time you feel you have not been treated courteously and provided assistance in resolving this unpaid obligation, you may address your complaint, in writing, to Complaint Services, Professional Medical Recovery, Post Office Box 6488, Woodland Hills, CA 91365-6488 for a response from management.

F O R Y O U R CONVENIENCE Y O U M A Y P A Y THIS ACCOUNT B Y T E L E P H O N E U S I N G Y O U R CHECKING A C C O U N T O R Y O U R MASTERCARD O R V I S A CREDIT C A R D CERTAIN RESTRICTIONS M A Y APPLY.

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