DeclarationCal. Super. - 6th Dist.August 8, 2019I 2 J 4 5 6 8 9 l0 il t2 t3 14 l5 16 17 l8 19 20 21 22 23 24 25 26 27 28 JAMES R. WILLIAMS, County Counsel (S.8. #271253) SARA J. PONZIO, Deputy County Counsel (5.8. #206774) OFFICE OF THE COLINTY COUNSEL 70 West Hedding Street, East Wing, Ninth Floor San Josd, California 95110-1770 Telephone: (408) 299-5900 Facsimile: (408) 292-7244 Email : sara.ponzio@cco.sccgov.org Attorneys for Plaintiff COLINTY OF SANTA CLARA COLINTY OF SANTA CLARA, Plaintiff, V, LAURA ROSENZWEIG, et al., Defendants. SUPEzuOR COURT OF CALIFORNIA, COTINTY OF SANTA CLARA No. 19CV353155 DECLARATION OF MICHELLE GALGIANI IN SUPPORT OF PLAINTIFF'S REQUEST F'OR DEFAULT JUDGMENT I, MICHELLE GALGIANI, declare: 1. I am a Supervising Patient Business Services Clerk at the Santa Clara Valley Health and Hospital Systern (SCVHHS). 2, I have personal knowledge of all of the matters stated herein, and could truthfully and competently testify to these matters if called as a witness. 3. As a regular part of its business, Santa Clara Valiey Medical Center (SCVMC) maintains a computerized record of all of the medical bills of its patients. 4. The medical bills maintained by SCVMC indicate all debits and credits, and in whose favor those entries are made. The bills are kept in a reasonably permanent manner on computer, and hard copies can be printed as needed. 5. Each entry is recorded at or near the time that a medical procedure is adrninistered and a payrnent is made DECLARATION OF MICHELLE GALGIANI 19CV353155 Electronically Filed by Superior Court of CA, County of Santa Clara, on 10/29/2019 9:37 AM Reviewed By: D Harris Case #19CV353155 Envelope: 3579384 19CV353155 Santa Clara - Civil D Harris I 2 4 5 6 7 8 9 l0 1t t2 13 14 15 16 1'7 18 19 20 2t 22 23 24 25 26 27 28 6. Billing information is electronically transferred from SCVMC's database to the Department of Tax and Collection's database. 7 . The Department of Tax and Collections processes the matter for further collection purposes. 8. tr have reviewed the records in this case at SCVMC and have personal knowledge of them. g. Attached as Exhibit "A" is a true and correct copy of a Conditions of Admission form signed by Laura Rosenzweig, on December 27,2017. 10. Attached as Exhibit "B" is a true and correct copy of a Conditions of Admission form signed by Laura Rosenzweig, on December 21,2017. I l. Attached as Exhibit "C" is a true and correct copy of a Consent to Treatment on Outpatient Basis form signed by Laura Rosenzweig, on Decetn bet 21,2017 . 12. The originals of the attached Exhibits are not kept by SCVMC. I declare, under penalty of perjury under the laws of the State of California, that the ?\ oay or eX:{r,'ih.g ivl 2ote, atforegoing is true and correct. Executed on this San Jos6, California. G 2DECLARATION OF MICHELLE GALGIANI i9cv353155 EXHIBIT AHI I o ;ii'J'f:,::li':i:,'s}'il:::?; n,,,, | -40s-808-61 50 .0F srlfra drna VALLCY lridtlcAl CENT€R Conditlons of Admiss: Page2 ot2 State of Californla Department of Health Services Llcenslng & Certificatlon one Almaden Bl, 9th Fl, San lose, CA 95113 I -S00-554-0348 or l -408'277 -17 84 9EX; I Customer Service DePartment 751 S. Bascom Av', San lose, CA 95128 l-800-351 - l818 or I -408-885-4826 Californla RelaY Services | -800-735-2 9 22t TDD t -800-7 i5'29 29 I lnlerpreter Servlces: lnterpreter Servlces. are available 24 hours a day' 7. days a week',at no cost for non-Engltsh speakini"'nJt.ttrng and speech-impalred patlents and their famllles' lf you need ;; ;;i;rt;;; t"t'us tnJ* *h"in yoricall valley connectlon'(l-888-334-1000) to register, make an ifpoi"rl"*ni,'o1. "ru betng admttied to.the hospllal. Or contact Language Servlces (l-888_334_t000; TDD tl+OS-CZt-.tO68). (Californta Relay servlces ls also avallablc: TDD I -800-735-2929)' lf you have a comPlaint, contact: o 9. Advance Dlrectlves: tr r do t oo no, have an Advance Dtrecttve lF- (inirial) I have been asked to provlde a coPy of my Advance Directive (inltial) O I have recelved the svcMc "Patient lnformatlon" booklet !N.- (initlal) I wanr addittonal informatlon about Advance Dlrectlves I Yes /*" y lh (inltlal) The underslgned certlfies that helshe has read the foregolng' recelved prrl.nt, thelatlent's legal representatlve, or ls duly autl'lorlzed by the agent to execute the above and accept its terms' a copy thereof, and is the patlent as the Patlent's general ,PW{r pl Patient Date/Time of Signing Witne Patient's Agent or Representative RelationshlP to Patient DISTFIBUTIoN:oFlGlNAL.MEDICALREcoRDs'YELLow"ADMITTINGoEPT'.PINK"PATIENTcoPY o 6923 05/?009 EXHIBIT A -c- 9lf7^ Uu VALL€Y i,€ONCAL CCNT€R Conditions of Admissiot Page 1 of 2 Name of Patlen sexrl a l. conscnt to tr{edlcal and surglcal procedurcs: The undcrslgned consenls to the Procedures whlch may hc Lrerf*rmed during thts hosiptrallzatlon or on an outPatlcnt basls, tncludlng emcrgencY treahent or servlccs and whrchlnay tnclu'de but are not llmlted to laboratory prrrcedurei, x-ray t'xamlnatlon, medlcal ancl surglcal ,r**r,o.n, f, procec{ures, anesthesla,.or hospltal servlces rcndered for the-patlent,under thc generalind specrailnsrrui:rtons ol the patlent's physlclanor surgeon, l{ 1!:Y:i:l lnfant rvhlle a palient if rnt. hospltal, I agree rhat these same Conditlons of Partlclpation apply to the intant' L Nursing Carc: The hospital provlctc.s general duty nurslng care unless,,upon orders of the parient,s physictan, the iatfcht is provitled more lntensiveiursing care..lt is agreed tllt sfolH $i ;,;ii;;i oi rtisztrer lcgal iepresentaiive request lhe services of a speclal eluty trurst", tvllhr'rttt an orclt'r from the patient,s pfiystciin, rhar such servlces ntusr bc arranged.fr}r by thc patlent or hls/her legal ,."pr.r.nr'rtru*. rhJnispiiulsr.trrl tn no way be responslble foifatlurc tei provlde the s.rme and is hJreby released f;;;;;y ind alt liabllrty uriring from rhe fact that sald patlent i5 nol provldcd rvlth such addltional care, L Teaching lnstitUtion; ScvMc is a teaching facilitlr tralnlng physlcians, surgeons. nursc$ and othcr health cire personnel. At rhc request, ancl-under ihe supeivtslon, of the attendlng physlcian' I agree that risidenti, interns, medical students, post-gradrrate fc'llows, visiting faftrlty members .rnd other health care personnel in training *ny paitt.ipie tn the carc of tlre patlent, certain mcdlcal servtces may be pirriJ.o L1, inaivlauits *h'd ao nor have a physlclan's certlflcnte but are quallfled to particlpaie in i spcclal program as a vlslting faculty member. t. Financial Agreement: Tlre underslgned agrees to pay for services rendered, in accordance with the regular iates and terms establisFed forluch seivlces at the hospltal, atrd agree that, pursuant to Cal'i'forrria Civil Code section 288t, et seq., the hospltal has a contractual first llen against any subsequent ludgment or compromise regarding the inf urles or condition for which the patient receives medlcal servlces. .i. personal Valuables: Patients are encouraged to leave personal items at home. lt is understood and agrced that the hospital maintalns a iireproof safe for the safekeeplng of money and valuablc.s, and rhe hosplial sIall not bc llable'ferr the loss or damagc.to any moncy, lcwclry, glasses, clentures, docrlnrents, furs, fur coats ancl fur garntents, or L"tthc'r articles that are not placed in the s.rfe. J'he liatriltry of the hospit.rl for loss of any.personal property deposlted with the hospital for safe t..prng is ltmited by law to five hundred dollars ($50o.00) unless a written receipt for a grearer amouni has been obtalned from the hospltal by the Patlent' 6. Asslgnmcnt of lnsurance/Medlcal Beneflts to thc Hospltal: Thc' unclcrslgncd authorlzcs, *,hethcr helshe signs as an agent or as patlent, direct payrncnt to the htrspital,of any,lnsu.rance{ rnec.lical beneflts oihe rwlsr. palable to oi on beh.rlf of the underslgrred for thls hospltallzatlon or tor rlrcse outparienr iervices, tnclirding emergency services lf rendered, at a rate not to exceed the t.,oipttnt's regular charges, tt is agieed tliat payment to the hospltal, Pursuant to thls authorizatlorr, by an insurance company shill rtischarge sald lnsurance company of any and.all obligatiorrs undJr a pclicy ro rhe exient'of such paymint. lt ls understood by thc underslgned that hc/ihc ts financially'rr'sponslble for charges not covered by this asslgnment. t . t,hotography: I consent to the taking of plcturcs, vldcotapes or other eleclronic reproductlons of the porieni's r*ii.rt oirurgical conditlin or treatment, and the use of thc' pictures, vidcotapes or eieclronic rc?.,rocluctir.rrrs, for treatment or lnternal or external actlvltles conslstenl rvith the l-los.pital's mission, such .1s eclucation and r.'search, conductcd in accordance wlth Hospital pollclcs and applicable law. {)rvned f,nd opcrllrld |tl the County of Srnl& Chr[ o o o I EXHIBIT BHI I Conditlons of Admlssio Page 2 ol 2 mnrl cs# REG OA Goes AOOR: customer service DePartment 751 S. Bascom Av,, San lose, CA 95128 I -800-351 - I 8l 8 0r I -408-885-4826 California RelaY Services I -800-73s-2 922; TDD t -800-7 35-2929 Seen ln ED ABZ4 Glven LOC o o o "( .9 ll$fta clRA VALL€Y itr@lcAL C€NTCR o PLAI{CODE: GUAR: 8. lnterPreter Services: lnterpreter Scrvlces arc avalla REF MD: for non*Engllsh speaklng and hea rlng and speech-in an lnterPreter, let us knorv when You call Vallcy Con necllon tl-EBE-334-1000) to register, make an appolntment, or are belng admitted to the hosPltal Or contact Language Services { l-888-334- 1000; ]'DD l-'108-971 -4068). (Callforn la Rclay Services ls also avallable: TDD I -800-735-2929)' lf you have a comPlaint, contactl Language Servlces Coordinator 751 S. Bascom Av., San lose, CA 951 28 r -408-808-61 50 State of California Department of Health Servlces Llcenslng & Certlflcation One Almaden Bl, 9th Fl, San Jose, CA 95113 I -80O-5s4-0348 or I -408'277 - 1784 9, Advance Dlrectlves: tr I do prao not have an Advance otrective@. (lnitlal) \ I have been asked to provlde a copy of my Advance Dfirectlve /dl'( (lnltlal) I have recelved the SVCMC "Patlent Informatlon" booklet -1!t (lnitlal) I wanr addittonal tnformatton about Advance Dlrectlves p tes n ruoAE (lnltlal) The underslgned certlfles that helshe has read the foregolng, recel ou,i*,, the"patient's legal representatlve, or ls duly authorlzed by agent to execute the above and accept lts terms' ved a copy thereof, and ls the the patlent as the Patlent's general te of Slgnlng Wltness Patient's Agent or Representatlve RelarlonshlP to Patient olsTHlEUTloN:oRIGINAL.MEoIoALREcoFDs.YELLow.ADMITTINGDEPI.PINK-PATIENTcoPY o 6S23 05t2009 EXHIBIT B 'O.sfftl caFA VALL€Y IJT€DICAL C€NT€R Condltions of Admission Page 1 of 2 Name ' osexl l. conscnr ro Mcdlcal and surgical proccdurcs: l'he underslgned consents to the procedures whlch may lre pcrformeel cluring thts hoJpttalizatlon or on an outPatlenl basls, includlng emergency treatment or,, , services and whtchlnay inclut{e but are not limlted to laboratory proceduret, {-luy examinatlon, medlcal and surglcal treatmentbr procedures, anesthesia, or hospltal services rendered for the.patlentunder the generalind special instructions of the patlent's physlclan or surgeon. lf I deliver an lnfant while a patlent if tnir hospital, I agree rhat these same Conditions of Participatlon apply to the infant' 2. Nurslng Carc: The hospital provides general dttty nurslng care unless, upon orders of the patlenti physician, the'parient is provl-ded more lntenslve nurslng care..lt is agreed that should the patient oi his/her legal iepresentuiiv* request the services of a special duty nurse, without an order irom rhe pagenr's pfr'ysictan, rhat such servtces must be arranged.for by the patient or his/her legal ,"pr*r"nt'utive. The hlspital shall ln no way be responslblc for failure lo provlde the same artd ts 6ereby released from any and all liability aiistng from the fact that said patlent ls not provlded with such addttional care. L Teaching lnsrlmtlon: scvMc is a teaching facillty, tralnlng physicians, surgeons. nurses and other health cfre personnel. At the request, and under lhe supervlsion, of the attend1ng physician' I igree rhat rlstdents, interns, medlcal students, post-graduate fellrrws, vlslting faculty memhers and oiher health care personnel in tralntng may partlclpale ln the,care of the patlent. certaln medlcal servtccs may bc provtded by indtvlduits wh6 do not have a physlclan's cettiflcate but are quallfled to parricipate in i special program as a visiling faculty member. 4, Financlat Agreementl The undersigned agrees to pay for servlces rendered, in accordatrce with the regular r"ates and terms establlshed for-such services at the hospltal, and_ agree that, pursuant to California Civil Code section 2BBl, et seq., the hospital has a contractual first llen against any subscquent iudgment or compromise regarding the lnfurles or conditlon for which the patient receives medlcal services, 5. personal Valuables: Fatients are encouraged ro leave personal items at home. ll Is understood rr,J igreed thar rhe hospttal maintalns a fireproof safe for the safekeeplng of money an.d valuables, and tlrc hosplial shall not be liable for the loss or damage.to any money, iewelry, glasses, dentures, documents, furs, fur coats and fur garments, or other artlcles that are not placed In the safe. The liability of the hospital for loss of any personal Property deposlted with the hospital for safe keeping is limited by law to flve hundred dollars ($500.00) unless a written receipt for a greater amouni hai been obtained from the hospital by the patient' 6. Assignment of lnsurance/Medlcal Benefits to the Hospital: The underslgncd authorizes, whei-her he/she slgns as an agent or as patient, d.lrect payment to the hospital of any.insurance/. medical bencftts oiherwise payalrle to oi on behalf of the undersigned for this hospitalization or for these outpatient services, including emergency servlces lf rendered, at a rate not to exceed the hospiral'i regular charges. lt ls agieecl thlt payment to the hospltal, pursuant to thls .rurhorlzatloil, by un lnsurance company shill dtscharge salcl lnsurance company of any and.all obllgartons unddr a pollcy ro rhe exienr'of such payment. lt ls understood by the underslgned that he/sihe is financially'responsible for charges not covercd by thls asslgnment. 7. phutography: I consent to the taking of pictures, vldeotapes or other electronlc reproductlons of the l p.riooi't meiical or surgical conditi6n o; trratment, and the use of the plctures, vldeotapes or electronic leproductions, for treatlient or internal or external activltles consistent wlth the Hospital's mission, such as education and research, conducted in accordance with Hospital policies and applic.rble law. Owncd snd operated by thc County ofSento Clsra a o a a EXH IBIT CI I Printed on 412212Q19 09:03 AM Hernandez, Alvlno H Page I ol 2 l ilrilr illl lllll lll lt llllil lll llll aint! ilr r^rri,j;'nt., r,.:,r,'i ^l^ C -a+- MEnl I L.rndersiand my ilayrrent be made to (-lu,rler and ar-rthot irrliir rnation necessa lrc.allh insr:rance" is i:llrim lorms or eiect :;!qnature ar-tthot'ized trr {lg insurer or ag ,.r::,itgned cases, th il{-li{:es to accept lr:l;l.rorrsible only {.;OirlSLlrance {.2Ao/" +: r.:h:,irge). iire undersigned ca the foregoing anci aLrthorized as the CONSENT ON OUTP NO sexl il lt Lil,,lt4 Posum. Yo, doy tlre administral ', ri,,ilical treatment a1t Cli,',rl1er on an outpati wrrLrld include, but n irr()cedures inclucling adrninistration of rtr inlection. This torm valid lor onlY year from dat' stgned. (Esle fonnutarlo tlene valldez por un afto desde la fecha de ld flrma.) P.rtlcnt 3iln;ltu.* (Firma del Sionalure ot Policyholdor (Firnra del Asegurado) l, l,i- . r 1, Rapresentanie del Pacientoi fi;rl fFccha l BENEFICIARIOS DE''MEDICAFIE" [-ntiarnejo qtre+ ttti ftrtlm est;i piciiendo qll{) '!j'i pnqLre i;1 ganl;r Clara Villley Medieal Cenler 1' auli:ri:a pti'ir qLx] si: r1c a eolloc{:rr la inltrrmact'irt riierjica rreccsaria 1:ilr:i el reclamo rlc pago. Si se indica "otro seguro m€dico" en los formLrlarios de reclamo aprobados o en los reclamos enviados electronicamente, mi firma auloriza para que se proprocione la inforrnacion necesaria al aseglirador o agencia inclic;lrlos' En los caso$ asig;nados de "Medi*ilrr-'". el rtreciico ct prr:v*eclor esta de aQr"retdo en acclJlirr asiglnrrci6n, Fl par:icttte 6s rr:sponsabLl sulamente pr:r el pago ele la carttirlael der-lltciblt: y cle eonseguro {ZlJo'i, ejel cr:bro aprobacio rlr'r "Medicare"). El suscrito ce(ifica que ha leido lo anterior y qlre 6l es el paciente o esta debidamente autorizado como eil agente general del paciente. CONSENTIMIENTCI PAHA TFATAMIENTO COMO PACIENTE EXTERNO mi consentime;ntopara que se rne adminisler el tratamiento m6dico no quir0rgico ordinario en "Santa Clara Valley Medical Centel" comc paciente externo. Este tratamiento incluiria. pero no se limitaria a, procedimienlos de laboratorio incluyendo andlisis de sangre y administraci6n de medicinas inyectadas. {ir- f;. i,,lti :t l:.1 , lhan rrtl llelacion con el pacietlte (Si no es el paciente mismo) Witn€ss {T€sligo) UIION; ORIGINAL - MEDICAL RECCIIID OPD PEOGBESS NOIES COFY - PATIENT VJitness {Testiqo) ;: :x;i,i C;ONI,riioNs 0F ADM|SilarN .1 , jAF rtle.i 0ll/23tii ll,ln Of,{a Clara ValleY lt/edical re lease o{ nredical li pay the clairrr. lf "other ii{-xln.l on all aPProved 'ally submitted claim, mY t.asing of the information shown. ln Medicare merrt The patient is lhe deductible and the Medicare aPProved that he/she has read the l"ratient or dulY nt's gener;rl agent TREATMENT TIENT BA$IS rdinary non-surgical rirrta Clara ValleY Medlcal rl basis. Such lreatmenl be limited to. laboratory tvrllrdrawal of blood and i.rlions eith0r orallY or bY thatuests,,1 l1a physician or supplier consent BENEFITS r'ratLrre loq Q tcl ()1 0 EXHIBIT C Printed on 412212019 09:03 AM Hernandez, Alvlno H Page 2ot 2 Chatl Ni4* [r4M ,,r'' ll iL! L_rir- Islt T€l; -.S- 5ANTA CLAFIA VALI'€Y Santa Clara Valley Health & Hospital $ystem cs# REG Goes By: ADDR: E REF MD pagu EX:l PLANCODE: ASSIGNMENT OF BENEFITS I he undersigned authorized direct payment to Sanla Clara Valley lledical Center of any irrsurancclnredical benefits on behall of the urrdersigned or patient for services rendered. it is understoad by tlre undersrgned that he1$he is iinancially responsible for charges not covered by tiris assignmenl, Center de cualquier beneficio mecJico o pago de seguro hech: a nombre del suscrito o del paciente por servicios proporcionados. El suscrito enliende que dl o ella es responsable financieramente por los cobros que no sean cubierlos por esta asignacidn. L,l I rturv INTERPRETER SERVICES lnterpreter Servlces are available 24 hours a day, 7 days a week, at no cost for non-English speaning and hearing and speech impaired patienls and their families lf you need an intcrpreter, let us know when you call Valley Connection {1-BBB-334-1000) to register, make an appointment, or are being admitted to the liospital. Or contact Language Seruices i1 BSB-334-t 000; TDD 1-408-971-4068) LCalrfornia Relay Services is also available: TDD 1 -800-735-292s). SERVICIOS DE INTERPRETES Los Servicios de lntdrpretes estiin disponibles las 24 horas Cel dia, 7 dias a la semana, para personas que no hablan ingl6s y sordomudas y sus familias. Si necesita un inttirprete, avfsenos cuancio llame a Valley Connection (1-888-334-'1000) para registrarse o hacer una cita, o cuando vaya a ser internado en el hospital. O llame a Language Services (l -BBB-334-1000; TDD 1-408-97'l -4068). Tambi6n disp,:nible el servicio de comunicacion por transcripcion: (California Relay $ervices, TDD '1-800-735-2929.) Si tiene algur'a queja. llame o escriba a.ii y,:rt have a cornplainl, contact Language $ervices Coordinator (Coordinador del Serviclos de Int6rpretes) 751 S. Bascom Ave,, San Jose, CA 95128 . '1-408-808-6150 Customer Service Departmenl (Departamento de Servicios al Cliente) 751 S. Bascom Ave., $an Jsse, CA 95128 . 1-800-351-1818 or (o) 1-408-885'4826 $tate of California Departrnent of Health Services Licensing & Certilication {$cpartamento de Servicios del Estado de California Licer:sing & Certificalion} L''rre Alrnaclerr Blvd., g'nFlocr, San Juse, CA giil I3 . 1-80C-554-0348 or (o) 1-4t18-277^1784 California Relay Services 1 -800-735-2922: TDD 1 "800-735-2929 DISTHIBUTION:White-Chart Pink-PatientCopy 1 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA PROOF OF SERVICE BY MAIL County of Santa Clara v. Laura Rosennveig, et al. 19CV353155 I, Angela Garcia, say: I am now and at all times herein mentioned have been over the age of eighteen years, employed in Santa Clara County, Califomia, and not aparty to the within action or cause; that my business address is 70 West Hedding Street, East Wing, 9th Floor, San Jose, California 95110-1770. I am readily familiar with the County's business practice for collection and processing of correspondence for mailing with the United States Postal Service. I served a copy of the DECLARATION OF MICHELLE GALGIAIII IN SUPPORT OF PLAINTIFF'S REQUEST FOR DEFAULT JUDGMENT by placing said copy in an envelope addressed to Laura Rosenzweig 8200 Kern Ave. #K205 Gilrov" California 95020 which envelope was then sealed, with postage fully prepaid thereon, on OCT 2 I 20lg , and placed for collection and mailing at my place of business following ordinary business practices. Said correspondence will be deposited with the United States Postal Service at San Jose, California, on the above-referenced date in the ordinary course of business; there is delivery service by United States mail at the place so addressed. I declare under penalty of perjury true and correct, and that this declaration under the laws of was executed on tef?'g 2100437 1 Proof of Service by Mail 19cv353155
