Can a urgent care clinic ban you?
August 10, 2013 1:29 AM   Subscribe

I was at urgent care for a ear problem and the doctor only spent less than 2 minutes with me, didnt even look at the other ear, gave me a prescription and left. The nurse came in and wanted me to sign a form saying I was "satisfied with my treatment and had all my questions answered" I told the nurse I had more questions for the doctor before I would sign it. She said the doctor was not going to answer any more questions and I overheard him saying to call the police, I was amazed as I was being very polite. So I left, as I was leaving he said I was banned from the clinic. Can they do that?
posted by john123357 to Law & Government (35 answers total) 6 users marked this as a favorite
Any business can ban any customer for any reason (exception: banning members of a protected class only BECAUSE they are members of that protected class). "Firing" a customer who is more trouble than they're worth is a pretty standard business practice.

Go to a different urgent care clinic in the future.
posted by Jacqueline at 2:43 AM on August 10, 2013

Response by poster: That is the only good one in my area, the other one has very limited hours and dosent have real doctors on staff just PA's . Isint a clinic considered a public place? Also don't they have a obligation to treat you if there are not any good alternatives?
posted by john123357 at 2:49 AM on August 10, 2013

It depends. EMTALA states that any person presenting to the hospital for evaluation of an emergency medical condition must be given a medical screening exam, by law. As far as I can tell, an urgent care center might be considered a 'hospital' for these purposes if it is owned by a hospital (or depending on proximity on hospital grounds). However, for certain patients with very minor complaints, that medical screening exam is allowed to be extremely brief.

I believe that if the urgent care center is freestanding and greater than 2/3 of their patients do not present with emergency medical conditions then it is not considered a type of emergency department or a part of a "hospital" and not subject to EMTALA.
posted by treehorn+bunny at 2:49 AM on August 10, 2013 [3 favorites]

To be clear, I should say that they probably are not obligated by law to treat you if they are a typical commercial urgent care that mainly cares for patients with minor medical issues.

But are you sure this place is really a "good" option for medical care if they would treat you this way?
posted by treehorn+bunny at 2:53 AM on August 10, 2013 [6 favorites]

The questionnaire/form is likely part of some kind of quality assurance mechanism. So, take this up with whatever corporate level of management is overseeing this clinic.
posted by snuffleupagus at 3:23 AM on August 10, 2013 [1 favorite]

One of the reasons that urgent care is becoming such a widespread phenomenon in the states is because they really don't have to put up with any flack, from anyone. That's by design, which is why they're so profitable in comparison to hospitals.

Unlike a hospital, they're not legally obligated to treat you, they don't have to accept your insurance, and they tend to attract staff that are attracted to that philosophy - who have been burned out from those previously mentioned working conditions.

Lots of emergency physicians are becoming very frustrated with the bureaucracy of hospitals, which has increasingly become focused on consumer satisfaction (despite the fact that the consumer in this situation often neither knows what's best for them, and wouldn't agree with it if they did).

Was his reaction completely ridiculous? Yes. Can they get away with it? Probably. I would encourage you to discuss this with the administration, because I'm sure they won't be happy with his behavior, although they probably won't do anything, because physicians hold quite a bit of bargaining power, and he'll be able to successfully argue that your medical care wasn't adversely impacted by his perfunctory examination.

On the other hand, he may be under pressure to see as many patients as possible per hour, and the administration may not care at all that he didn't answer your questions satisfactorily.

In conclusion, this is a systemic issue in American health care that is unlikely to change, as all the economic incentives for poor behavior are in place and are unlikely to change anytime soon. Any physician who is still spending time with patients, performing a thorough history and physical exam, explaining the diagnosis, treatment, side effects as well as alternatives is the exception rather than the rule these days. Furthermore, they're likely taking a considerable financial hit to remain compassionate and render exceptional care, and are likely under considerable administrative pressure to become more "efficient" immediately.

This isn't going to change until we shift to a health care system that is forced to consider primary care and preventative medicine due to economic considerations, single-payer or what have you. Until then, everyone gets paid on how much work they do, not how well they do it.

/rant off
posted by hobo gitano de queretaro at 6:24 AM on August 10, 2013 [39 favorites]

Is it possible that they confused you with someone else? Maybe it would be worthwhile to try finding out what their concern was, perhaps by writing if you aren't sure what put them off, and try to address it or otherwise come to an understanding.
posted by XMLicious at 6:29 AM on August 10, 2013 [2 favorites]

One recourse you have is to make a complaint to their corporate parent.

Your other recourse is to find a primary care physician or ENT that you visit and cultivate a relationship with who is available to answer your questions about your conditions and treats you like you want to be treated. Those practitioners will be more interested in maintaining and ongoing relationship with you as a patient rather than managing flow through the system, as an urgent care doctor is.
posted by deanc at 6:50 AM on August 10, 2013 [1 favorite]

Are you sure the doctor was talking about you? Did he come right up to you and say you were banned? I second XMLicious' idea - find out why the heck they banned you, because from your version of events it seems completely ridiculous.
posted by Autumn at 7:00 AM on August 10, 2013 [5 favorites]

It sounds like you're looking for concierge medicine in an urgent care setting, which is like me going to Payless Shoes and asking for a comprehensive fitting for running shoes.

I took a look at your Ask history, and in most of your questions you ask multiple followup questions. A visit to a doctor doesn't mean that you have a lock on their time for as long as you want. I don't even get that from my primary care physician, who is very much Dr. "You have (XXX) here is a prescription for (YYY) come back in 3 weeks if you're still (ZZZ). Feel better, bye!" If I have a question about what makes the medicine work, I'll ask the pharmacist, but I still make sure I only as a question, MAYBE two, and I don't go into details such as questioning how acidic/basic the medicine is.

As for police/banning, if you refuse to take the necessary actions (fill out the customer service form) so that they can process you out, they can call the cops. Like if I was in a restaurant and refused to pay my check so they could turn the table over, they could call the police and refuse to service me again. Even if I was the politest person in the world, I'm being a troublemaker.

Good luck - I hope you find a PCP that you can develop a friendly-banter relationship with.
posted by kimberussell at 7:26 AM on August 10, 2013 [6 favorites]

As for police/banning, if you refuse to take the necessary actions (fill out the customer service form) so that they can process you out, they can call the cops. Like if I was in a restaurant and refused to pay my check so they could turn the table over, they could call the police and refuse to service me again. Even if I was the politest person in the world, I'm being a troublemaker.

That is actually not at the same thing as asking the customer to sign a legal release saying their service was satisfactory. If you get served in a restaurant, you have to pay, but you don't have to sign any releases.

OP, anyone can call the police for anything, but the police do not have to respond or arrest anyone. Crazy cranks do this all the time. Your best course of action is probably to revisit your assumption that this store is the only good one in the area.
posted by ignignokt at 7:35 AM on August 10, 2013 [4 favorites]

You do realize that any doctor can practice in an urgent care. The one I occasionally used years ago had as their physician -a psychiatrist. Yup.

Do yourself a favor and find a primary care doc and leave these urgent cares alone.
posted by St. Alia of the Bunnies at 8:36 AM on August 10, 2013 [3 favorites]

An urgent care clinic is probably not legally obligated to treat you on an ongoing basis since the whole model of the practice is based on one-off visits rather than continuing care, although lthey probably do have an obligation to refer you to appropriate follow up care (they will tell you to see your primary care doctor or go to the ED, so don't get your hopes up there).

It's a much bigger deal to discharge a patient from a primary care practice. I've only discharged three patients from our practice in the last 5 years--one for stealing from a doctor, one for attempting to hit a doctor, and one for flagrant narcotics fraud.

Your best bet for having some consequence to this incident is to figure out who is in charge of customer complaints and file a complaint. This will obviously work better if the doctor in question is an employee of the practice and not the owner.
posted by The Elusive Architeuthis at 8:43 AM on August 10, 2013 [2 favorites]

To me it's not clear why you would refuse to sign the paper. You left out the details that would explain the other half of the story.
From what I gather:
You had an urgent care matter - your ear- , the doctor quickly identified the problem and gave you a prescription, you didn't immediately present him with any questions while he was in the room with you and then he left the room and went on to another patient.
The nurse presented you with release papers and that's when you refused to sign them unless the doctor came back -interrupting the care of the next patients in line- and answered some more of your questions that you hadn't thought of and examined your other ear, which wasn't presenting a problem?
Despite whether you believe you were being polite in your manner, you were perceived to be causing a problem in the clinic.
Urgent care is for treating matters that can not wait until you get to your family doctor. If you need follow up or something more extensive, then you need to go to your family doctor.
You also didn't mention how often you are using this care facility and whether or not you have caused an issue in the past.
posted by tenaciousmoon at 8:57 AM on August 10, 2013 [20 favorites]

I believe that if the urgent care center is freestanding and greater than 2/3 of their patients do not present with emergency medical conditions then it is not considered a type of emergency department or a part of a "hospital" and not subject to EMTALA.

My reading of the guidance in the Final Rule you linked is that it is really only applicable to locations that are already credentialed as hospital-based clinics - that is, they bill for technical component charges on a UB using a hospital's Medicare provider number, are included on the hospital's Medicare Cost Report, etc.

In my experience, urgent care clinics are virtually never credentialed this way, even if they're part of an integrated health system that also operates hospitals and are immediately adjacent to a hospital campus. The whole urgent care business model pretty much depends on them not being subject to EMTALA so they can turn away frequent fliers who don't pay their bills, and for this reason they are almost always credentialed as non-provider-based physician practices that have much wider latitude to discharge patients.
posted by strangely stunted trees at 9:05 AM on August 10, 2013

They probably have a website, and maybe a statement of patient's rights. I'd make a complaint, because asking questions about treatment is reasonable behavior. Requiring you to sign a form saying I was "satisfied with my treatment and had all my questions answered" isn't part of your care and you don't have to sign it, especially if it's not true. Threatening to call the police is overkill, and banning you sounds like bitchiness. It's unlikely they keep a list of patients banned for asking questions. They might have such a list for people who have behaved in a drug-seeking or violent manner. Maybe that doctor has been complained about, and they're keeping stats on him. Contacting to owner of the clinic is likely to get you in-banned, if you were ever banned at all.
posted by theora55 at 10:14 AM on August 10, 2013 [1 favorite]

sounds like the doctor is a dick. i've dealt with one pretty rude doctor before.
the difference between a doctor and someone else in the service sector is the doctor is too important (or thinks he is) to be disciplined for rude behavior. not indefinitely, though. i would certainly complain, if the corporate parent gets a slew of complaints, and comes down on him, maybe it will give him incentive to rethink his bedside manner.
posted by camdan at 11:57 AM on August 10, 2013

Yeah, I really hope you're not leaving anything out, as that seems to be a real leap to me.

There was one time we erred in bringing my dad, early in his dementia, to an urgent care when he had pneumonia. He was perfectly ambulatory when we picked him up at the nursing home, but at the urgent care he became a sack of potatoes and seemed to be seizing. We brought him inside with the help of a staff member and a wheelchair and they began assessing him, but almost immediately told us they could not treat him there and we needed to call 911.

I was a little non-plussed. We had to call 911? Apparently that's their policy. So we called 911 and they sent a paramedic unit who transported him to the other side of the medical campus a quarter of a mile away, and later charged us $500 for the line-of-sight trip. (The urgent care was a clinic operated by a physicians group that leased from the hospital, but was not operated by the same entity.) It was weird and the only time I've ever been angry with them. But yeah, they're not hospitals and don't have an obligation to treat beyond the Hippocratic Oath, and that's weak sauce compared to things like the EMTALA.

Anyway, even when I went to the ER last month for a deep cut to my palm, they basically said they would undo my stitches if I came back and I should call them for any signs of infection, but follow-up was a matter for my primary care physician. They are only there for "emergent" care. If you were expecting going to urgent care to be the same as having a comprehensive relationship with a PCP you're going to be disappointed.

I have also found, in general, that "the doctor" is not the one who is the main point of contact. There are intake nurses, prep nurses, and so forth who do a lot of the grunt work, and someone will give you a takeaway pamphlet for your drugs or your aftercare and explain it to you who is not the physician. So again, maybe your expectations here were being placed on the wrong personnel.

I've been treated by PAs, by residents, by interns, and I don't really think it's affected my care overall. So maybe that other urgent care isn't as bad as you're making it out to be. In fact as a Medicaid-insured patient (probably part of it) I am assigned to a PA-C as my PCP. I'm pretty happy with her overall. I would really reconsider whether you're just focused on the more and more obsolete hierarchical physician-nurse model, rather than the team model that is more prevalent depending on organization and state regulatory regime.

Also, doesn't have real doctors on staff just PAs is probably wrong. You may be seen by a PA, but a PA almost as a matter of course is overseen by an attending physician with full credentials.
posted by dhartung at 4:22 PM on August 10, 2013

You do realize that any doctor can practice in an urgent care. The one I occasionally used years ago had as their physician -a psychiatrist. Yup.

Psychiatrists are physicians.

OP, I get the impression you are leaving out significant details because your story doesn't add up. Do you go to this clinic often? I've definitely had ER staff become frustrated with me for being a frequent customer (through no fault of my own).
posted by Librarypt at 5:27 PM on August 10, 2013

Response by poster: I had not been to this clinic in almost 2 years and that doctor I had not seen before in about 3-4 years, back then I looked different as well with a beard and different hair style. When I went there in the past it was for normal reasons and did not have any strange interactions with them. The update is I got a call from the police saying the doctor said I had threatened to drive my car through the building as I was leaving and they had 3 witnesses (medical staff that were near him) , which is a absolute lie. I left very politely and didn't say a word. I am amazed that a doctor would lie like this and that his staff would cover for him like that. I asked the cop if I could call and make a polite complaint about him to his boss and at first he said yes then changed his mind quickly and said if I did I might be arrested for aggravated harassment. I thought you had to make 3 calls in a row and that had to be harassing, rude ect to be charged with harassment.? They also have a "patient feedback" form on their site but at this point I am afraid to fill it out because they could modify what I wrote to include some threat and give it to the police, they have already shown they are not afraid to make up outright lies to cover themselves. However what they did to me is wrong and I need to let his boss know my side of the story somehow. I am also concerned they will send the notes on my visit to my primary care doctor, and he might believe them and damage my relationship with him. What should I do?
posted by john123357 at 9:14 PM on August 10, 2013

Something about this scenario just didn't add up to me, so I looked at your question history, and looking at that I noticed you've asked a number of questions about ears and eyes, as well as about various chemicals, etc. Is it possible there's more going on here, i.e. you have some non-medical issues related to ear and eye health, and the doctor was reacting to that? I don't mean to be dismissive in any way by saying this, rather I'm trying to be helpful by pointing out the possibility of there being other factors involved in the matter.
posted by Dansaman at 11:00 PM on August 10, 2013 [2 favorites]

Response by poster: He diagnosed me with a middle ear infection with fluid behind the ear. I didn't go in with anything strange.
posted by john123357 at 11:11 PM on August 10, 2013

I suggest you follow up with your primary care doctor on this and ask them what they feel is the best course of action. They will be familiar with you and your current medical situation as well as the local urgent care milieu.

I definitely appreciate the fact that so many here are sticking up for busy urgent care providers and emergency physicians, however, I maintain that physicians should endeavor to make time to answer the questions of their patients, even if the patient is being a bit odd or difficult about it. That is the nature of being a healthcare provider. People are allowed to think of questions after their encounter with the physician, it's a common issue that people have trouble with asking appropriate questions when they are put on the spot and they think of what they meant to ask afterwards. Any place that cannot ensure that a patient understands their diagnosis and discharge instructions is providing poor healthcare (even though providing poor healthcare may be common under our current system, see hobo gitano de queretaro's rant for an accurate assessment, that doesn't make it OK).
posted by treehorn+bunny at 12:24 AM on August 11, 2013

Response by poster: I plan to get a copy of the police report to find out their side of the story but I would rather my primary doctor not know about this becasue doctors tend to stick together. Do urgent cares usually send a copy of the report to the primary doctor?
posted by john123357 at 12:27 AM on August 11, 2013

Maybe it would be better to approach your primary doctor asking whether you're nuts - as though you're entertaining the possibility that you actually said these things due to some sort of mental health event despite the fact that it would be totally uncharacteristic, but somehow have no memory of it and instead remember the entire experience at the clinic completely differently from your accusers. And also relay the warning you got from the police about the possible legal hazards of approaching the clinic directly to find out more about what happened.

I would think that while your primary doctor might be inclined to defend a brother of the cloth if you just go in with accusations (maybe thinking that you're fishing for support for a malpractice lawsuit or something), she (or he) might much more seriously investigate the matter if she thinks the question being answered is whether or not you have mental health issues, which directly pertains to her care of you as a professional.
posted by XMLicious at 6:13 AM on August 11, 2013

In my experience, it is not remotely anywhere near that easy to be diagnosed with a mental health problem, even with symptoms that are recurrent over the course of years instead of a one-time event. And accurately describing what you have actually experienced and how you have actually been treated by medical professionals is not faking a symptom.

Simply saying that you found the way you were treated incomprehensible but that you can entertain some small possibility that the medical professionals at the clinic were behaving professionally for good reasons you don't perceive is far short of anything that would result in the expenditure of money necessary to diagnose and treat a mental illness. You'll either make progress understanding what happened, or it will be quickly forgotten. Asking the question this way does not involve any risk of ending up getting treated for any condition you don't have; our medical system is just not that attentive to mental health issues.
posted by XMLicious at 8:46 AM on August 11, 2013

Mod note: Ok, we've had the pro- and con- points about mental health suggestion, OP can decide for himself whether that's a good idea. Please don't get into a further debate with other commenters. Thanks.
posted by LobsterMitten (staff) at 8:55 AM on August 11, 2013

Response by poster: I think the doctor was afraid I was going to report him for his substandard care and decided he had to make something up to cover his butt. I was the last patient of the day and he must have been angry about something else and decided to take it out on me. I was really appalled because you would think a doctor had a ethic code he had to follow. For those asking for the full story its this: About 8 o'clock on a Friday night I lost hearing in my right ear and it was ringing, I went to urgent care about 9 and it closed at 10. They were not busy only 3 people ahead of me. The nurse looked in my ear and said it was full of wax, but my eardrum looked fine. When the doctor comes in he only looked in the right ear not both. (they are supposed to look at both )He says he thinks it's a ear infection with fluid behind my ear. And says he will write a prescription for an nasal spray and a antibiotic. I tell him what the nurse says about the wax and ask if it needs to be removed and he said he doesn't think so. He says he will be back to give me the prescription so I figure I can ask him any other questions then and he leaves the room. He had spend less than 2 minutes with me and I felt very rushed. I wait patiently for a half an hour and then a nurse comes in and gives me the prescription and I asked to speak to the doctor again because I have more questions that didn't get to ask him, one being that I had this exact same problem two months ago in the very same ear and the problem was wax which, when they removed it fixed the problem instantly. I wanted to tell him that and ask him to look at my other ear, which he never did. The nurse says she will ask him those questions and get back to me. At this point he must've been standing right outside the door because I can hear them talking and the nurse didn't ask him all the questions I had and just said "he wants you to take the wax out of his ear" to which he said. "I told him he doesn't need it out" she comes back and wants me to sign a form saying I was satisfied with the care I received, and had all my questions answered. I told her that my questions were not answered, and that he had not looked at my left ear, she says she will look at my left ear, and does so and says it looks all right. I tell her I would like to ask my questions so Dr. before I sign the form. She says they are closed now and asked me to come back tomorrow if I want the wax taken out of my ear. I tell her it's not just the wax I had a couple questions for The Dr. At this point it's strange, because it's obvious that I'm the only patient left the doctor is not busy and is standing outside the door and can easily speak to me. My questions would have been answered in less than 2 min. the nurse goes back and says to him "he doesn't want to sign the form until you talk to him". Then I hear him say "well let him sit longer and we will call the police and have him removed." I am shocked at this point as I had been very polite. I walk out and say "I just have a couple questions" and he says "go sit back down". I am amazed because he now wants to trick me to sit back down so he can call the police (he probably thought I didn't hear him say to call the police) as opposed to me leaving on my own. "You didn't even look at my left ear" and he says "yes I did. I remember you. Why are you in here playing games". I am shocked because I had not been there in years and have not seen that doctor about four years when I looked completely different and none of the interactions I had with him or anyone else in the clinic had been strange and I went for simple things like strep throat. And I had only seen that doctor 2 or 3 times in my life, 4 years ago. I think he may have confused me with someone else. I then said "I don't know what you're talking about but if you want me to leave. I will leave". They said you "walk out" , so I leave as I was exiting the door he comes up behind me and says "you're banned from the clinic. I'll call your insurance company". I had a phone call from the police later that night saying that he told them I threatened to drive my car through the building, which is ridiculous because I have a brand-new $30,000 car that is my pride and joy. He blatantly made that up so he could have a reason to ban me as I had done nothing wrong at the clinic. The irony is the clinic is is a somewhat rural area and it takes the cops 20 minites to show up to even a emergency so they had to stay later to make a report than just spend 2 minutes answering my questions.
posted by john123357 at 10:00 AM on August 13, 2013

Hmm. That makes it sound like he might have wanted to have the kind of leverage that threatening to call the police would give him, but that once the police got there he realized that they'd be pretty annoyed if the only reason they were called was to basically serve as doormen; so he made up a scenario in which you threatened violence, but didn't threaten any specific person.

Unfortunately, whatever the series of events that led to this, if there are three people willing to bear false witness against you then anything you might try to do about it may be an uphill battle. Visiting a hospital emergency room with some regularity due to a relative in poor health in the past several years I have on a couple of occasions seen people just screaming threats, and friends who are EMTs say that sort of thing is pretty common, so what they're claiming isn't out of the realm of possibility from the perspective of the police or other third parties. If you've already told the police your side of the story and you visit the clinic as infrequently as you say, the practical thing to do might be to just wait till next time you need to visit and bet that they aren't willing to resurrect everything and perpetuate the ruse at that point, but also be willing to accept the expense of traveling elsewhere if they do.
posted by XMLicious at 11:22 AM on August 13, 2013

Response by poster: If he just wanted me to leave why did he tell me to sit back down after he said to the nurse to call the police? Also why not just ask me to leave?
posted by john123357 at 3:06 PM on August 13, 2013

Maybe as you proposed above he was angry about something that had happened earlier and took out his anger on you - in some previous situation he hadn't gotten his way and by jove he was going to get his way with you and feel like he'd won. Or maybe he's just one of those people who has poor control of his temper and behaves completely irrationally when he's angry, and would be showing up on World's Dumbest Criminals if some advantage hadn't made it possible for him to graduate from medical school.

Or maybe he had accidentally killed one of his earlier patients who was lying dead around the corner and he was afraid that if you didn't go back to the waiting room you'd see the body, and it was actually because of the murder that one of the other staff members had called the police, but they managed to kill her too but then needed a story to give to the police.

In any case, though, you may never be able to do more than speculate; you might not be able to resolve this in any satisfying way that results in anything more than your complaints being on file. You were certainly mistreated and have every right to feel angry, however.
posted by XMLicious at 6:25 PM on August 13, 2013 [1 favorite]

Response by poster: Do you think it's safe for me to make a complaint about him? The way he lied to save his butt makes me think he might do it again and say I called and threatened him or something.
posted by john123357 at 12:55 AM on August 14, 2013

It seems unlikely that someone would continue taking the risk of fabricating these sorts of claims, especially if it got to the point where he'd need to falsify medical records (which I believe he'll have special legal and professional responsibilities in regards to, though I'm not a lawyer or a medical professional) instead of just making false police reports. And many of the MeFites commenting in the thread above would appear to agree that making a complaint is a reasonable response.

There's some infinitesimal chance that he's a psycho who will have no boundaries in exacting retribution for the slightest perceived harm, of course. But that's so improbable that if writing out a formal complaint more substantial than what you've already told the police and sending it somewhere will give you some measure of peace of mind it seems to me like it would probably be worth it.

I'd think that the greatest concern would be to make sure you stick to the facts in any communications you have about this situation and don't make any allegations beyond what you know to be true: like, don't make any claims about his or anyone else's motivations the way we've done in the course of speculatively discussing your story here in this thread, just describe what people said and did in your presence.
posted by XMLicious at 7:08 AM on August 14, 2013

Purely regarding the mystery surrounding what prompted this:

Was there some sort of memorable confrontation when you last saw this doctor? (or that might have been memorable from his perspective? was he a new-ish doctor then? initial experiences can be more memorable than they would be otherwise) -- after all you remember him from three or four years ago too.

Have there been any incidents with other providers or staff there in the interim? He said "we remember you", going by your report, and it sounds like he did have a little while to huddle with the staff.

This whole situation would make more sense as a wild overreaction to a slanted memory, as versus a pure fabrication.
posted by snuffleupagus at 7:28 AM on August 14, 2013 [1 favorite]

Response by poster: There was no memorable confrontation before this. Also he said "I remember you", not "we remember you".
posted by john123357 at 10:50 AM on August 19, 2013

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