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1 JENNIFER L. DAUER (CA Bar No. ) LAWRENCE B. GARCIA (CA Bar No. 0) DIEPENBROCK A Professional Corporation 00 Capitol Mall, Suite 00 Sacramento, CA Telephone: () -000 Facsimile: () - ELIZABETH C. SAVIANO (CA Bar No. ) LAW OFFICES OF ELIZABETH C. SAVIANO Market Street, "^ Floor San Francisco, CA Telephone: () - Facsimile: () -0 Attorneys for Petitioners and Plaintiffs CALIFORNIA PRIMARY CARE ASSOCIATION, CLINICAS DEL CAMTNO REAL, INC., and SOUTHERN TRINITY HEALTH SERVICES, INC. Cas«IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF SACRAMENTO CALIFORNIA PRIMARY CARE ASSOCIATION, a California non-profit corporation; CLINICAS DEL CAMINO REAL, INC., a California non-profit corporation; and SOUTHERN TRINITY HEALTH SERVICES, INC., a California non-profit corporation, v. Petitioners and Plaintiffs, STATE OF CALIFORNIA^acting by and through the DEPARTMENT OF HEALTH CARE SERVICES, Respondent and Defendant. ) Case No.: Cnurl Of Califon VERIFIED PETITION FOR WRIT OF ) MANDATE; COMPLAINT FOR ) DECLARATORY RELIEF ) Courthouse News Service DIEPENBROCK -0-

2 Petitioners and Plaintiffs California Primary Care Association ("CPCA") and Clinicas del Camino Real, Inc. ("Clinicas"), and Southern Trinity Health Services, Inc. ("STHS"), (collectively, "Petitioners") allege as follows: INTRODUCTION. Pursuant to California Welfare and Institutions Code section. ("Section."), the State of California, Department of Health Care Services ("DHCS") has stated that, effective July, 0, it will no longer pay for certain covered benefits which are currently being reimbursed under California's Medicaid program ("Medi-Cal"). DHCS has indicated its interpretation that Section. applies to Federally Qualified Health Centers ("FQHC") and Rural Health Clinics ("RHCs"), and that, as of July, it will deny reimbursement for Medi-Cal patient visits at which the services identified in Section.(b)(l) are provided. Medi-Cal is a public health insurance program providing needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases.. This Petition seeks a writ of mandate to compel DHCS to comply with its mandatory, ministerial duty to continue to reimburse FQHCs for mandatory FQHC services and RHC services which include face-to-face encounters between FQHC or RHC patients and specified practitioners, including medical doctors, podiatrists, dentists, optometrists, and chiropractors, as well as physician assistants, nurse practitioners, certified nurse midwives,- clinical psychologists, licensed clinical social workers, and certain visiting nurses.. This Complaint also seeks declaratory relief that, as a matter of law, DHCS must continue to reimburse FQHCs and RHCs for the services for which it proposes to stop reimbursing FQHCs and RHCs. PARTIES. Petitioner California Primary Care Association is a California non-profit corporation whose members consist of more than 00 non-profit community clinics and ""

3 health centers in California - including the vast majority of private, non-profit FQHCs in California - which provide comprehensive, quality health care services to primarily low-income, uninsured and underserved Californians. CPCA also represents some private, non-profit RHCs. CPCA and its members have an interest in ensuring that DHCS carries out its obligations under Medi-Cal to compensate clinics for mandatory FQHC and RHC services provided under Medi-Cal, and as required by federal and state law.. Petitioner Clinicas del Camino Real, Inc. ("Clinicas") is a California non- profit corporation with its principal place of business in Ventura, California, serving low- income, uninsured and underserved patients in Ventura County. Clinicas is designated as an FQHC. Clinicas has ten health center locations, thirty school-based mental health sites, and three mobile clinics (including a mobile dental clinic). Clinicas serves over 0,000 users, in over 0,000 patient encounters per year. Clinicas employees include the full time equivalent of physicians, physician assistants/nurse practitioners,. dentists, Psychologists and Marriage Family Therapists, Optometrists,. Chiropractors, and a. Podiatrist. Clinicas has a direct monetary interest in ensuring that it is paid for its services and protecting its status as a federally-designated FQHC entitled to cost-based reimbursement for providing services. Clinicas also has a direct monetary interest in clarifying the "visits" for which it may seek reimbursement so that it can make services and staffing decisions, allocate its limited resources, and determine whether it is necessary and appropriate to apply for a change in its prospective payment system reimbursement rate.. Petitioner Southern Trinity Health Services ("STHS") is a California non- profit corporation with its principal place of business in Mad River, California. It is designated as an FQHC and serves low-income, uninsured and underserved patients in southern Trinity and southeastern Humboldt Counties. STHS is in a Designated Health Professional Shortage Area and Medically Underserved Area, and serves a medically underserved population. The nearest other medical, dental, and behavioral health services are over 0 miles away (. - hours) over harsh mountainous terrain. STHS serves an area with a population of,, of which % live below the federal poverty level. STHS ~^~

4 also serves a large population of recreational tourists and other non-residents travelling through the area, and assists the United States Forest Service with fire season response and medical services on the fire line. The inability of STHS to recover for its services would be devastating for the people living in, and visiting, this rural area. STHS has a direct monetary interest in ensuring that it is paid for its services and protecting its status as a federally-designated FQHC entitled to cost-based reimbursement for providing services. STHS also has a direct monetary interest in clarifying the "visits" for which it may seek reimbursement so that it can make services and staffing decisions, allocate its limited resources, and determine whether it is necessary and appropriate to apply for a change in its prospective payment system reimbursement rate.. Respondent California Department of Health Care Services is an agency of the State of California, acting by and through its directors, or duly designated employees and agents. DHCS is the state agency that is responsible for operation of the Medi-Cal program and for making payments to Medi-Cal providers under that program. DHCS has the responsibility to comply with its legal obligations in the management and payment of Medi-Cal funds, and to comply with the Welfare and Institutions Code and the approved State Medicaid plan. STATEMENT OF FACTS. Federal funding for healthcare involves a complicated system run, in substantial part, through the Medicare and Medicaid programs. These programs make healthcare available to elderly, low-income, and disabled individuals, considered medically needy. Medicare is wholly federally funded to provide health benefits to the elderly, blind and disabled. Medicaid focuses on low-income categorically needy and other medically needy individuals, and is implemented at the option of each state within detailed federal requirements. If a state elects to participate in Medicaid, the Federal government funds a portion of the program, as long as the state provides a designated level of matching funds and complies with the Medicaid program requirements. Some patients qualify under both Medicare and Medicaid. "J"

5 . California has elected to participate in Medicaid. To be entitled to Federal Financial Participation, California has prepared its Medicaid State Plan ("State Plan"), a comprehensive written document that describes the nature and scope of California's Medi- Cal program within the limitations of federal Medicaid requirements. The State Plan establishes how California will implement Medi-Cal within federal requirements. The State Plan was approved by the Federal Department of Health and Human Services, Centers for Medicare and Medicaid Services ("CMS"). It is essentially a contractual agreement between California and the Federal government, and must be administered in conformity with federal law and regulations. Failure to administer the State Plan in accordance with its terms may result in the Federal government denying California Federal Financial Participation, i.e., the.% federal share of California's Medi-Cal costs.. FQHC and RHCs services are a mandatory covered benefit in Medicaid and Medi-Cal. U.S.C. a(a)(). Under federal law, states are required to pay for core FQHC and RHCs services and any other ambulatory service offered by an FQHC or RHC which is included in the state's Medicaid plan. See U.S.C. d(a)()(b) and (C). California has expressly adopted this requirement in subdivisions (a) and (b) of California Welfare and Institutions Code section.0. Such services are referred to herein as "FQHC Services" when offered by an FQHC or "RHC Services" when offered by an RHC.. Federally Qualified Health Centers are specifically defined in federal law. FQHCs include entities that receive a grant under Section 0 of the federal Public Health Services Act, entities that formally subcontract with Section 0 grantees, entities that meet the requirement for receiving a grant under Section 0, and Indian Health Services. See U.S.C. d(/)()(b). Most FQHCs are operated by non-profit organizations. Nonprofit FQHCs are primary health care clinics that are certified under federal law and provide a broad and comprehensive range of health care services to underserved patient populations. By law, FQHCs must serve a population that is medically indigent, or a specially underserved population such as migratory and seasonal agricultural workers, the homeless, --

6 or residents of public housing. They must provide preventative services, and offer services at a reduced fee schedule, based on the patient's income.. To be designated as an FQHC, an organization must meet the requirements of U.S.C. section b and its implementing regulations, and undergo a rigorous application process through the federal Health Services Resources Administration ("HRSA") as approved by CMS.. RHCs are specifically defined in federal law. See U.S.C. d(/)(l). RHCs must meet certain conditions of participation and certification requirements under federal law.. Most FQHCs and a few RHCs also are licensed "community clinics" under State law. Cal. Health & Safety Code (a). In California, they must be operated by a non-profit corporation, and must base any patient charges on the patient's ability to pay, utilizing a sliding fee scale.. Both FQHCs and RHCs are entitled to receive reimbursement for the provision of services to Medicare and Medicaid patients on the basis of reasonable cost. See U.S.C. a(bb). To comply with the requirement that FQHCs and RHCs be reimbursed for their reasonable costs of providing services, California has adopted a prospective payment system ("PPS"). See Cal. Welf. & Inst. Code.0.. Clinics designated as FQHCs are required to have a "Scope of Project" approved by HRSA. The Scope of Project defines the services that the FQHC must provide or arrange for, to include "required primary health services" and additional health services "appropriate to meet the health needs of the population served" by the FQHC. See U.S.C b(b), subsections () and (). The Scope of Project also defines the approved service sites and services necessary for state Medicaid agencies to calculate PPS payment rates. The Scope of Project is an agreement between the FQHC and HRSA that supports the FQHC designation. --

7 . HRSA may terminate an FQHC's designation if it finds that the FQHC is not in substantial compliance with its Scope of Project, Section 0 grant terms, or other federal requirements applicable to FQHCs.. FQHC and RHC "core providers," as defined by federal law and State law, include physicians, nurse practitioners, physician assistants, clinical social workers, clinical psychologists, and services and supplies incident to the services of these providers and, in limited circumstances, visiting nurses.. FQHCs and RHCs are reimbursed for patient "visits" at the FQHC's or RHC's PPS rate. In general, the PPS rate is established by dividing allowable clinic costs for a base year by the number of "visits" that year (generally, a face-to-face encounter between an FQHC or RHC patient and an FQHC or RHC core provider, including a physician). The FQHC costs are those permitted by federal law, in accordance with Medicare reasonable cost principles, to include costs associated with providing required primary health services and additional approved services.. Under California Welfare and Institutions Code section.0(g) and California's State Plan, both FQHC Services and RHC Services are reimbursed on a "pervisit basis." A visit includes a "face-to-face encounter" between a patient and a "physician, physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse." "Physician" includes a "medical doctor, / osteopath, podiatrist, dentist, optometrist, and chiropractor." Cal. Welf. & Inst. Code.0(g). This definition is consistent with federal law. U.S.C x(r). A visit specifically includes a face-to-face encounter between a patient and a dental hygienist. A visit may include other face-to-face contacts not relevant to this dispute.. By statute, California defines FQHC Services and RHC Services more broadly than required by federal law by expanding the scope of the services to include all services provided by physicians or the other specified medical professionals within their license and scope of practice. These broad definitions also are included in California's State Plan as approved by CMS. --

8 . Other Medi-Cal providers are reimbursed varying amounts depending on the type of service provided. In comparison, FQHCs and RHCs are reimbursed at the flat PPS rate based on the fact that the patient had a face-to-face encounter with a FQHC or RHC core provider, i.e., "physicians" and the other specified professionals.. During its Third Extraordinary Session of 0-, the Legislature adopted California Welfare and Institutions Code section., which was effective upon filing with the Secretary of State in March 0. Section. was added by amendment on February, 0, passed in the Senate the same day, and passed in the Assembly the following day. It was only one part of the Legislature's extensive attempt to address California's budget crisis. Given the extremely short time period between the addition of Section. to Assembly Bill X_ and its adoption, there is no legislative history which reasonably can assist in interpreting its provisions.. Section. provides, in relevant part, as follows: (a) Notwithstanding any other provision of this chapter,... in order to implement changes in the level of funding for health care services, specific optional benefits are excluded from coverage under the Medi-Cal program. (b) () The following optional benefits are excluded from coverage under the Medi-Cal program: (A) Adult dental services, except as specified in paragraph (). (B) Acupuncture services. (C) Audiology services and speech therapy services. (D) Chiropractic services. (E) Optometric and optician services, including services provided by a fabricating optical laboratory. (F) Podiatric services. (G) Psychology services. (H) Incontinence creams and washes. --

9 DIEPENBROCK (d) This section shall only be implemented to the extent permitted by federal law. (Emphasis added.) The services encompassed in Section.(b)(l) are referred to herein as "Excluded Optional Benefits.". The Excluded Optional Benefits specifically at issue herein are the following services: dental, chiropractic, optometric, and podiatric. Each of these types of service also is a mandatory FQHC Service or RHC Service. Petitioners are informed and believe and thereon allege that DHCS is not contending that FQHCs and RHCs may not be reimbursed for visits with clinical psychologists and licensed clinical social workers, notwithstanding the fact that "psychology services" are specifically identified as "excluded" in Section... Section. becomes effective on July, 0.. On or about April, 0, Carmela Castellano-Garcia (by telephone), Elia Gallardo, and Marty Lynch (President of the CPCA Board of Directors) from Petitioner CPCA met with officials at DHCS to discuss the implementation of Section.. At that meeting, DHCS informed CPCA that, because the Excluded Optional Benefits were adopted "[notwithstanding any other provision of this chapter," Section. applied to FQHCs. By implication, CPCA understood that position to apply to RHCs as well. In effect, DHCS informed CPCA that Section. precludes the State from reimbursing FQHCs and RHCs for face-to-face visits with core providers where FQHC Services or RHC Services which would also fall within the definition of Excluded Optional Benefits are provided. DHCS indicated that Section. supersedes or overrides any contrary statutory language, effectively stating that the broad and general language of the "notwithstanding" clause of Section. implicitly or explicitly repealed every single contrary statutory provision governing FQHCs and RHCs.. Section. does not expressly address statutory authority applicable to FQHCs and RHCs and/or their reimbursement mechanism, which is heavily impacted by federal law. In particular, Section. does not explicitly amend Welfare and --

10 Institutions Code section.0 to disallow FQHC Services or RHC Services provided by a clinical psychologist, licensed clinical social worker, podiatrist, dentist, optometrist, and chiropractor. Section. does not provide any other authority to DHCS to change the reimbursement mechanism for FQHCs and RHCs.. Interpreting Section. to apply to FQHCs would require implicit amendment or repeal of other statutory provisions, including the definition of "FQHC Services," "RHC Services," and the definitions of "visit" and "physician" in Welfare and Institutions Code section.0(g). Because implicit repeal or amendment of statutes is disfavored, Section. does not apply to FQHCs or RHCs. 0. By its terms, Section. does not apply if implementing it is not permitted by federal law. Thus, Section. does not apply to exclude reimbursement for FQHC Services and RHC Services in general, adult dental services, psychological services, or other services provided by FQHCs if those services are within the scope of the approved federal Scope of Project.. Interpreting Section. to apply to FQHCs would significantly undermine the FQHCs' ability to comply with their federal obligations in that FQHCs are required to have a Scope of Project, approved by the Federal government, and are required by law to provide (or provide for) the services encompassed in that Scope of Project. Petitioner STHS includes within its approved Scope of Project both adult dental services and clinical psychology services. Petitioner Clinicas includes within its approved Scope of Project adult dental services, clinical psychology services, podiatry services, optometry services, and chiropractic services. Other members of Petitioner CPCA have within their approved scopes of project one or more of the following services: adult dental, chiropractic, optometric, podiatric, and/or clinical psychology. If Section. were applied to FQHCs, it would deny them the financial resources necessary to provide services which they are obligated to provide, likely forcing them to violate their approved federal Scope of Project and potentially to lose recognition as an FQHC. --

11 . Interpreting Section. to apply to FQHCs and RHCs would violate the State Plan, effectively violating federal law requiring states to provide services approved in their state plan and California law requiring the State to comply with its State Plan.. Absent a writ compelling DHCS to comply with its payment obligations, on and after July, 0, Petitioners are informed and believe and thereon allege that DHCS will cease reimbursing FQHCs for those mandatory FQHC Services, and RHCs for mandatory RHC Services, which DHCS has mischaracterized as Excluded Optional Benefits.. Although DHCS purports to be prohibited from reimbursing FQHCs and RHCs, as of July, 0, for FQHC Services and RHC Services which DHCS has mischaracterized as Excluded Optional Benefits, before DHCS lawfully could do so, it would have to take the following actions: a. Change the, definition of a "visit" and a "physician," as set forth in Welfare and Institutions Code section.0(g); and b. Obtain approval from CMS for an amended State Plan to change the definition of "visit" for the purpose of FQHC and RHC reimbursement.. Petitioners have a beneficial interest in the issuance of the writ as FQHCs and an association of providers of FQHC Services and RHC Services.. Petitioner Clinicas has a beneficial interest in the issuance of the writ because it anticipates that it will lose between $ million and $ million in revenues per year if DHCS is not required to continue reimbursing Clinicas for visits for the types of services listed in Section.(b)(l), particularly dental services. At one of its locations, dental services comprise approximately % of its business; absent a writ, that clinic will be forced to close, denying residents access to affordable preventative dental services.. Petitioner STHS has a beneficial interest in the issuance of the writ because \ denial of reimbursement for the types of services listed in Section.(b)(l) will deny --

12 STHS over one-quarter of its annual revenue, largely from adult dental services, and likely would make it impossible to keep the dental department open. If STHS is forced to close its dental department, it would not be able to sustain its other services, as dental services comprise over % of STHS' total revenue. Closure of STHS will eliminate all health care services in this remote community.. Petitioners have exhausted all administrative remedies, or are excused from exhausting any such remedies.. Petitioners have no plain, speedy and adequate remedy in the ordinary course of the law. 0. There is an actual controversy relating to the legal rights of FQHCs and RHCs to be paid for those mandatory FQHC Services and RHC Services which DHCS has mischaracterized as Excluded Optional Benefits, and DHCS' purported prohibition on paying for such services. FIRST CAUSE OF ACTION WRIT OF MANDATE (Code Of Civil Procedure ). Petitioners hereby incorporate by reference the allegations set forth in paragraphs through 0 above, and reallege the same as if set forth in full herein.. Under California Welfare and Institutions Code section.0, DHCS has a mandatory, ministerial duty to reimburse FQHCs for face-to-face encounters between an FQHC core provider providing FQHC Services, and to reimburse RHCs for face-to-face encounters between an RHC core provider providing RHC Services. Petitioners are informed and believe and thereon allege that, as of July, 0, DHCS will refuse to compensate FQHCs and RHCs for such "visits," as defined in Welfare and Institutions Code section.0. By denying reimbursement for FQHC Services and RHC Services, DHCS violates its mandatory, ministerial duty to reimburse FQHCs or RHCs for visits, as defined in Section.0.. DHCS has a duty under California law to administer the Medi-Cal program in accordance with the State Plan, applicable State law, and California's Medi-Cal ""

13 regulations. Cal. Code Regs California's State Plan requires that DHCS reimburse FQHCs for face-to-face encounters between an FQHC core provider providing FQHC Services and to reimburse RHCs for face-to-face encounters between an RHC core provider providing RHCs Services, as these are defined in the State Plan. Failing to do so before obtaining approval of a change to the State Plan or obtaining a waiver of mandatory requirements violates both the State Plan and the regulation requiring compliance with the State Plan.. DHCS has a mandatory, ministerial duty to implement Section. and deny reimbursement only to the extent the benefits referenced were "optional benefits." FQHC Services and RHC Services are mandatory, not optional benefits. Any attempt by DHCS to apply Section. to FQHC Services and RHC Services exceeds the statutory language and, thus, violates its mandatory, ministerial duty.. DHCS has a mandatory, ministerial duty to implement Section. only to the extent permitted by federal law. By refusing to reimburse FQHCs and RHCs for the FQHC Services and RHC Services described in U.S.C. sections a(bb) and d(a)()(b) and (C), including dental services, DHCS violates this mandatory, ministerial duty.. Petitioners are informed and believe and thereon allege that, as of July, 0, and absent issuance of a writ of mandate, DHCS will stop paying FQHCs and RHCs for visits in which patients obtain those mandatory FQHC Services or RHC Services which DHCS has mischaracterized as Excluded Optional Benefits. FQHCs and RHCs must now make funding, services, and personnel decisions based on DHCS' position, and some may need to begin winding down their operations and preparing to close.. A writ of mandate should issue prohibiting DHCS from denying payment to FQHCs and RHCs for visits in which patients obtain those mandatory FQHC Services or RHC Services which DHCS has mischaracterized as Excluded Optional Benefits. --

14 SECOND CAUSE OF ACTION DECLARATORY RELIEF (Code Of Civil Procedure 0). Petitioners hereby incorporate by reference the allegations set forth in paragraphs through above, and reallege the same as if set forth in full herein.. An actual and present controversy has arisen and exists between DECS and Petitioners with respect to DHCS's right to withhold payment from FQHCs and RHCs for visits in which the patients obtain those mandatory FQHC Services or RHC Services, as applicable, which DECS has mischaracterized as Excluded Optional Benefits. 0. Petitioners contend that Section. was not intended to, and does not, apply to deny them reimbursement for those mandatory FQEC Services or REC Services, as applicable, which DECS has mischaracterized as Excluded Optional Benefits.. Petitioners further contend that denying them reimbursement for FQEC Services or REC Services, as applicable, would violate federal law, such that Section., by its terms, does not apply to FQEC or REC services.. Petitioners are informed and believe and thereon allege that DECS contends that it must deny FQECs and RECs reimbursement for visits in which patients obtain those mandatory FQEC Services and REC Services, as applicable, which DECS has mischaracterized as Excluded Optional Benefits.. A declaration of the Court is necessary and proper at this time under all the circumstances so that Petitioners and DECS can determine whether and to what extent FQECs and RECs have the right to recover for those mandatory FQEC Services and REC Services, as applicable, which DECS has mischaracterized as Excluded Optional Benefits, and, correspondingly, the obligation to provide such services.. A declaration of the Court is necessary and proper at this time under all the circumstances so that Petitioners can determine whether they need to seek approval of a change in their Scope of Project and PPS rate. --

15 PRAYER WHEREFORE, Petitioners pray as follows:. With respect to the First Cause of Action, that this Court issue a writ of mandate directing DHCS to reimburse FQHCs and RHCs at their respective PPS rates for visits in which those mandatory FQHC Services or RHC Services, as applicable, which DHCS has mischaracterized as Excluded Optional Benefits, were provided;. With respect to the Second Cause of Action, that this Court issue a declaration that DHCS must reimburse FQHCs and RHCs for visits in which FQHC Services and RHC Services, as applicable, which DHCS has mischaracterized as Excluded Optional Benefits, were provided;. For attorneys fees, in accordance with Code of Civil Procedure section., and costs; and t,. For such further and other relief as the Court deems just and proper. Dated: April, 0 DIEPENBROCK JENNIFER L.tfAUER Attorneys for Petitioners CALIFORNIA PRIMARY CARE ASS'N, CLINICAS DEL CAMINO REAL, and SOUTHERN TRINITY HEALTH SERVICES DIEPENBROCK --

16 I Q II VERIFICATION, the undersigned, certify and declare that I have read the foregoing I'ciition and Complaint and know ils contents, I am an officer of the California Primary Care Association, a party to this action, and am authorized to make this Verification for and on its behalf. The mutters stated in the Petition above are true of my own knowledge and belief except as to those matters stated on information and belief or those matters in paragraphs,,, and, which others have verified, and, as to those matters, I believe them to be true. T declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at California on April, 0. Elia V- Gfallardo, I'teq. DlEfENBROO. -- VFRIPllil) VK I'l I ION FOR WRIT OF MANDATE; COM PLAIN I

17 - - VERIFICATION I, the undersigned, certify and declare that I have read the foregoing Petition and Complaint and know its contents. I am the Chief Executive Officer of Clinicas del Camino Real, a party to this action; and am authorized to make this Verification for and on its behalf. The matters stated in the Petition above are true of ray own knowledge and belief except as to those matters stated on information and belief or those matters in paragraphs,,, and, which others have verified, and, as to those matters, I believe them to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. //) ' "" M Executed at v y d < v \ c^ /I,//, California pri April, 0. / / //, - /* vl/l JS^T^X ^ Roberto's. Juapdz j ^ ' DlEPENUROCK HARRISOH ATTORNEYS AT UW -- *

18 VERIFICATION, the undersigned, certify and declare that I have read the foregoing Petition and Complaint and know its contents. I am the Executive Director of Southern Trinity Health Services, a party to this action, and am authorized to make this Verification for-and on its behalf. The matters stated in the Petition above are true of my own knowledge and belief except as to those matters stated on information and belief or those matters in paragraphs,,, and, which others have verified, and, as to those matters, I believe them to be true. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed at Wine /<"/ #-. California on April, 0. _ C^ctny L. Larsen J ( --