[Hpn] Homeless, With a New Loss: Identity

William C. Tinker wtinker@verizon.net
Tue, 08 Jan 2008 05:42:07 -0500


This is a multi-part message in MIME format.

------=_NextPart_000_0007_01C851B9.34D1E670
Content-Type: multipart/alternative;
	boundary="----=_NextPart_001_0008_01C851B9.34D1E670"


------=_NextPart_001_0008_01C851B9.34D1E670
Content-Type: text/plain;
	charset="iso-8859-1"
Content-Transfer-Encoding: quoted-printable

Homeless, With a New Loss: Identity=20
http://www.nytimes.com/2008/01/08/health/views/08case.html?ref=3Dscience

By ELISSA ELY, M.D.

Published: January 8, 2008
There is always plenty to worry about when you are homeless. The most =
pressing concerns have to do with health and finances, of course. But =
occasionally there are other worries - deeper, odder, more unexpected. =
Some are even existential. A while ago, I met a man in a shelter clinic =
who described the worry that preoccupied him.=20

=20
Camilla Engman

The situation was medically straightforward; events should have unfolded =
predictably. He had pulled a muscle in his shoulder. If he had been =
working with a primary-care doctor, he would have gone to see him. But =
he had been homeless for years, floating from city to city and shelter =
to shelter. So he went, uneconomically but expectantly, to the emergency =
room.

He waited in a cubicle with a curtain around it. As usual, a nurse took =
his vital signs, and wrote them in a chart with his name on it. As =
usual, the doctor came in next. This was business as he knew it. She =
looked down at the chart.=20

"I see you were here last October," she said, as he later told me.=20

That surprised him. He had never been in this emergency room before. He =
told her so. She checked the chart, and disagreed.

"No, you were here for an overdose," she said. According to the chart, =
he had been transported in a stupor from a shelter across town.

Well, he had certainly stayed at that shelter, maybe even last October. =
But he was not a drug user, had never overdosed, and had never been to =
this E.R. He said so again.

She suggested that he had been intoxicated and didn't remember. The =
chart had an entry from October with his name, his birth date and an =
accurate Social Security number. She read them out loud to him. These =
were facts, but no longer the business he knew.=20

He asked to see the chart. He wanted to know what he was supposed to =
have overdosed on, and what his physical description was. Someone must =
have taken his identification out of his wallet. It's crazy - especially =
since they didn't take the wallet itself - but anything can happen in a =
shelter.

The doctor wouldn't give him the chart. She was in the sudden surreal =
position of being asked to share privileged information about one =
patient with another patient who might or might not have been the same =
person. If your identity is being used by someone else, then his =
overdose is not your business. You have no right to his medical =
information. This is a violation of Hipaa, the Health Insurance =
Portability and Accountability Act.

He didn't care about Hipaa (many of us don't care much for it), but the =
doctor had no choice. Though the situation was absurd, her license and a =
large fine were potentially at stake. She wrote him a prescription for =
extra-strength ibuprofen and strongly suggested he find a primary-care =
physician. He was discharged without seeing the chart.

Back in the shelter, he started to worry. Suddenly his shoulder was the =
least of his problems. Someone had stolen his name and Social Security =
number. Did the thief have his Medicaid number too, and use it to buy =
prescription drugs? Could he claim Social Security checks? Where else =
would the misdoings of an alternate self turn up?

He had not been sleeping well to begin with, and here was something else =
to keep him awake at night. He came to see us for the insomnia, which =
was easy enough to treat. But he lingered, prescription in hand, to =
reflect on the nature of being. "Before my shoulder started hurting, =
life was easier," he told me.=20

"There was only one of me then."=20

Elissa Ely is a psychiatrist in Boston.

------=_NextPart_001_0008_01C851B9.34D1E670
Content-Type: text/html;
	charset="iso-8859-1"
Content-Transfer-Encoding: quoted-printable

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META http-equiv=3DContent-Type content=3D"text/html; =
charset=3Diso-8859-1">
<META content=3D"MSHTML 6.00.6000.16587" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV>Homeless, With a New Loss: Identity </NYT_HEADLINE>
<SCRIPT language=3DJavaScript type=3Dtext/JavaScript>function =
getSharePasskey() { return =
'ex=3D1357448400&en=3D1e2e1f0dc3e00738&ei=3D5124';}</SCRIPT>

<SCRIPT language=3DJavaScript type=3Dtext/JavaScript>=0A=
function getShareURL() {=0A=
	return =
encodeURIComponent('http://www.nytimes.com/2008/01/08/health/views/08case=
.html');=0A=
}=0A=
function getShareHeadline() {=0A=
	return encodeURIComponent('Homeless, With a New Loss: Identity');=0A=
}=0A=
function getShareDescription() { =0A=
=0A=
	return encodeURIComponent('If your identity is being used by someone =
else, then his overdose is not your business.');=0A=
}=0A=
function getShareKeywords() {=0A=
	return encodeURIComponent('Medicine and Health,Homeless =
Persons,Doctors,Health Insurance and Managed Care,Health Insurance =
Portability and Accountability Act');=0A=
}=0A=
function getShareSection() {=0A=
	return encodeURIComponent('health');=0A=
}=0A=
function getShareSectionDisplay() {=0A=
=0A=
	return encodeURIComponent('Cases');=0A=
}=0A=
function getShareSubSection() {=0A=
	return encodeURIComponent('views');=0A=
}=0A=
function getShareByline() {=0A=
	return encodeURIComponent('By ELISSA ELY, M.D.');=0A=
}=0A=
function getSharePubdate() {=0A=
	return encodeURIComponent('January 8, 2008');=0A=
}=0A=
</SCRIPT>

<DIV id=3DtoolsRight>
<SCRIPT language=3Djavascript>=0A=
			<!-- =0A=
			function submitCCCForm(){=0A=
				PopUp =3D window.open('', =
'_Icon','location=3Dno,toolbar=3Dno,status=3Dno,width=3D650,height=3D550,=
scrollbars=3Dyes,resizable=3Dyes');=0A=
				this.document.cccform.submit();=0A=
			}=0A=
			// -->=0A=
			</SCRIPT>

<FORM name=3Dcccform=20
action=3Dhttps://s100.copyright.com/CommonApp/LoadingApplication.jsp=20
target=3D_Icon><FONT face=3DArial size=3D2><A=20
href=3D"http://www.nytimes.com/2008/01/08/health/views/08case.html?ref=3D=
science">http://www.nytimes.com/2008/01/08/health/views/08case.html?ref=3D=
science</A></FONT></FORM>
<DIV class=3DarticleTools>
<DIV class=3Demail><A =
href=3D"javascript:articleShare('permalink');"><FONT=20
color=3D#004276></FONT></A>&nbsp;</DIV>
<SCRIPT language=3DJavaScript =
type=3Dtext/javascript>writePost();</SCRIPT>
</DIV></DIV><NYT_BYLINE version=3D"1.0" type=3D" ">
<DIV class=3Dbyline>By ELISSA ELY, M.D.</DIV>
<DIV class=3Dbyline>&nbsp;</DIV></NYT_BYLINE>
<DIV class=3Dtimestamp>Published: January 8, 2008</DIV>
<DIV id=3DarticleBody><!--NYT_INLINE_IMAGE_POSITION1 --><NYT_TEXT>
<P>There is always plenty to worry about when you are homeless. The most =

pressing concerns have to do with health and finances, of course. But=20
occasionally there are other worries =97 deeper, odder, more unexpected. =
Some are=20
even existential. A while ago, I met a man in a shelter clinic who =
described the=20
worry that preoccupied him. </P>
<DIV id=3DarticleInline>
<DIV id=3DinlineBox>
<DIV class=3Dimage>
<DIV class=3DenlargeThis><A=20
href=3D"javascript:pop_me_up2('http://www.nytimes.com/imagepages/2008/01/=
08/health/08casesCA01readdy.html', '08casesCA01readdy', =
'width=3D424,height=3D600,scrollbars=3Dyes,toolbars=3Dno,resizable=3Dyes'=
)"><FONT=20
face=3DArial></FONT></A></DIV><A=20
href=3D"javascript:pop_me_up2('http://www.nytimes.com/imagepages/2008/01/=
08/health/08casesCA01readdy.html', '08casesCA01readdy', =
'width=3D424,height=3D600,scrollbars=3Dyes,toolbars=3Dno,resizable=3Dyes'=
)"><FONT=20
face=3DArial><IMG height=3D242 alt=3D""=20
src=3D"http://graphics8.nytimes.com/images/2008/01/08/health/08cases.1901=
.jpg"=20
width=3D190 border=3D0></FONT> </A>
<DIV class=3Dcredit>Camilla Engman</DIV>
<P class=3Dcaption></P></DIV></DIV></DIV><A name=3DsecondParagraph></A>
<P>The situation was medically straightforward; events should have =
unfolded=20
predictably. He had pulled a muscle in his shoulder. If he had been =
working with=20
a primary-care doctor, he would have gone to see him. But he had been =
homeless=20
for years, floating from city to city and shelter to shelter. So he =
went,=20
uneconomically but expectantly, to the emergency room.</P>
<P>He waited in a cubicle with a curtain around it. As usual, a nurse =
took his=20
vital signs, and wrote them in a chart with his name on it. As usual, =
the doctor=20
came in next. This was business as he knew it. She looked down at the =
chart.=20
</P>
<P>=93I see you were here last October,=94 she said, as he later told =
me. </P>
<P>That surprised him. He had never been in this emergency room before. =
He told=20
her so. She checked the chart, and disagreed.</P>
<P>=93No, you were here for an overdose,=94 she said. According to the =
chart, he had=20
been transported in a stupor from a shelter across town.</P>
<P>Well, he had certainly stayed at that shelter, maybe even last =
October. But=20
he was not a drug user, had never overdosed, and had never been to this =
E.R. He=20
said so again.</P>
<P>She suggested that he had been intoxicated and didn=92t remember. The =
chart had=20
an entry from October with his name, his birth date and an accurate =
Social=20
Security number. She read them out loud to him. These were facts, but no =
longer=20
the business he knew. </P>
<P>He asked to see the chart. He wanted to know what he was supposed to =
have=20
overdosed on, and what his physical description was. Someone must have =
taken his=20
identification out of his wallet. It=92s crazy =97 especially since they =
didn=92t take=20
the wallet itself =97 but anything can happen in a shelter.</P>
<P>The doctor wouldn=92t give him the chart. She was in the sudden =
surreal=20
position of being asked to share privileged information about one =
patient with=20
another patient who might or might not have been the same person. If =
your=20
identity is being used by someone else, then <SPAN =
class=3Ditalic><EM>his=20
</EM></SPAN>overdose is not <SPAN class=3Ditalic><EM>your =
</EM></SPAN>business.=20
You have no right to his medical information. This is a violation of =
Hipaa, the=20
Health Insurance Portability and Accountability Act.</P>
<P>He didn=92t care about Hipaa (many of us don=92t care much for it), =
but the=20
doctor had no choice. Though the situation was absurd, her license and a =
large=20
fine were potentially at stake. She wrote him a prescription for =
extra-strength=20
ibuprofen and strongly suggested he find a primary-care physician. He =
was=20
discharged without seeing the chart.</P>
<P>Back in the shelter, he started to worry. Suddenly his shoulder was =
the least=20
of his problems. Someone had stolen his name and Social Security number. =
Did the=20
thief have his <A title=3D"Recent and archival health news about =
Medicaid."=20
href=3D"http://topics.nytimes.com/top/news/health/diseasesconditionsandhe=
althtopics/medicaid/index.html?inline=3Dnyt-classifier">Medicaid</A>=20
number too, and use it to buy prescription drugs? Could he claim Social =
Security=20
checks? Where else would the misdoings of an alternate self turn up?</P>
<P>He had not been sleeping well to begin with, and here was something =
else to=20
keep him awake at night. He came to see us for the <A=20
title=3D"In-depth reference and news articles about Insomnia concerns."=20
href=3D"http://health.nytimes.com/health/guides/specialtopic/insomnia-con=
cerns/overview.html?inline=3Dnyt-classifier">insomnia</A>,=20
which was easy enough to treat. But he lingered, prescription in hand, =
to=20
reflect on the nature of being. =93Before my shoulder started hurting, =
life was=20
easier,=94 he told me. </P>
<P>=93There was only one of me then.=94 </P><NYT_AUTHOR_ID>
<DIV id=3DauthorId>
<P>Elissa Ely is a psychiatrist in=20
Boston.</P></DIV></NYT_AUTHOR_ID><NYT_UPDATE_BOTTOM></NYT_UPDATE_BOTTOM><=
/NYT_TEXT></DIV></DIV></BODY></HTML>

------=_NextPart_001_0008_01C851B9.34D1E670--

------=_NextPart_000_0007_01C851B9.34D1E670
Content-Type: image/jpeg;
	name="08cases.1901.jpg"
Content-Transfer-Encoding: base64
Content-Location: http://graphics8.nytimes.com/images/2008/01/08/health/08cases.1901.jpg

/9j/4AAQSkZJRgABAgAAZABkAAD/7AARRHVja3kAAQAEAAAAMgAA/+4ADkFkb2JlAGTAAAAAAf/b
AIQACAYGBgYGCAYGCAwIBwgMDgoICAoOEA0NDg0NEBEMDg0NDgwRDxITFBMSDxgYGhoYGCMiIiIj
JycnJycnJycnJwEJCAgJCgkLCQkLDgsNCw4RDg4ODhETDQ0ODQ0TGBEPDw8PERgWFxQUFBcWGhoY
GBoaISEgISEnJycnJycnJycn/8AAEQgA8gC+AwEiAAIRAQMRAf/EAaIAAAAHAQEBAQEAAAAAAAAA
AAQFAwIGAQAHCAkKCwEAAgIDAQEBAQEAAAAAAAAAAQACAwQFBgcICQoLEAACAQMDAgQCBgcDBAIG
AnMBAgMRBAAFIRIxQVEGE2EicYEUMpGhBxWxQiPBUtHhMxZi8CRygvElQzRTkqKyY3PCNUQnk6Oz
NhdUZHTD0uIIJoMJChgZhJRFRqS0VtNVKBry4/PE1OT0ZXWFlaW1xdXl9WZ2hpamtsbW5vY3R1dn
d4eXp7fH1+f3OEhYaHiImKi4yNjo+Ck5SVlpeYmZqbnJ2en5KjpKWmp6ipqqusra6voRAAICAQID
BQUEBQYECAMDbQEAAhEDBCESMUEFURNhIgZxgZEyobHwFMHR4SNCFVJicvEzJDRDghaSUyWiY7LC
B3PSNeJEgxdUkwgJChgZJjZFGidkdFU38qOzwygp0+PzhJSktMTU5PRldYWVpbXF1eX1RlZmdoaW
prbG1ub2R1dnd4eXp7fH1+f3OEhYaHiImKi4yNjo+DlJWWl5iZmpucnZ6fkqOkpaanqKmqq6ytrq
+v/aAAwDAQACEQMRAD8A6zNBLLGiRkKrD941BUAgUptiiQKiLGtAqAKBQHYbdcY1zBEUjlmVHYAq
rEAkbD9bDFEYSIHjcMp6MtCDQ06jMAk97kfBa0KspRgCrCh27H3GOSFEUKtAo7Ur+JzMQiszvRFB
LE0oABUk4hBdR3DOsJakdKkrQfFuKE9/bGz3qiOK+1P9UZliRVCoAFHRQopga5vILJUeeQr6jcEC
qXZmpUKFQEkntiMGqJcV9KKdiKiSkYorD9hmLBeXjStMd1R3oqwowUjwKjAUNYgkk6kPQrHAFBdm
J5OeNfkB4DBcMplUtxeMg0KyLxbb6TtjhGgcyCgcjiWpvQb0wiVIIQc1vcTxkyyCCP8A33CPiO/7
UvX/AIGnzy49LghikijqBIal6ksO9A5JNMT1O01O5KrZXa20VKP8NWZidqHtiB8tiev1q+urhgKs
C/Ebddhk7PDXFQPQBjW/K/eVlydNjmMMt6bdlMZIDcV4qSQnv03rucqHV9KtlaIXH1iUlpHMaNIW
LHoD06UFMMIPKunrEZUtQzgjj6lWJH7R+M4It9Kv419QLb29SypAo6CoEZZ1HU71Aw8BrYSPXuW/
cPtSiDVriVALfS5pKk/E4WNeu27HEo5NZN00Tx28M8i8md2MgQK4URhU2H2vp61yYR6ZGqoHdiFW
jKNgWqSW8e/jjLjS9PR5b0QL670LN4sNg3zyXhyomgFMhfMliosb+VS016wVd2ECKgAO32jyOOGj
24UTSvNNyJAMkrdqdlIHfJnbxQrGyJGqjkQyqAAaGgwt1oKpgVQAAG2G3hglCUYmXF8tmNgnkkkd
rbxGqRgEd9z+s4tmzZTZ72TqDNQZs2CyrqDNQZs2NlXUGVtl5sIJVa9vYXVfUlPPkIRU8KMy1CLy
HxHfl8/ljYY9LtpBOLoK1BbbyALyQFgKCi8lU7eAxSCztbqOGdXd1RnKVoAW5gljtv8AEmx7/LA1
0ba1mhtppGlWWb1Z1ULT1DwWMPSiom4ah60w9WaYXlp9ZtZbcykB0KFm3FCKEsAUrt74DtrO0+BI
b2VmTitOYHL0ftfDQClTVqbYtJexyXUlksckiRUFxOBWNXNGWOorVvEdvpxyafYwfvCPsqAzSNUU
61bltv1NcCqV1a2VDdSXBjIHpCcsCFLmhJPj267DESbWFYZTdSQ2fD91CkZjQhT9r4FrQ8hTxxRr
yxugqyB/q/MCIMnwTtUbolOToppvTj88WeKJJeR5FYz8KouysR+yEH2z/N2GEKVA20sfH6rPK8sP
PlJM9IlDnkQ9VavHtQVHjiSaq6CNZU5tJGjl+aqod2KhWLABeVKjHSTRvDESjMkvFktidyrH4fU2
ag/yRgLUmimb6tciQCYL66mnqCNXJRI0T4VLHbfffxpkuHbkGN79U5ju4rnl9XYyojAGdKenyDAF
Fb9ojvTJLKqqjsoAY0qRsTvkPNzpVncppUC+nMio3owJtGpICBgnQnsPpyYz/wB0fmv/ABIZbhHp
ka9zCf1KmISsaPTqpT9eL4Gk/wB3HwKfhQ5dLkwCIY8QSe2J3X+88vspP3Y6X+7b5ZU4rBIP8lv1
Ynkfcq2M8RKfBifvAOFmtkFofbkP1HDIbxOf5qH71GFesn94g8Kn7wuVZf7s/D72UeaWZs2bMVm7
A0uo2EJIluY1I6jkCfwwTmstJsnLiOGOMihqEB6nfDEAmt1KXfpzTa0SRpD/AJCM38M36W5mkFnc
yV2rw4j72yRfo+BAeJIAXoKDcd8VFlb77E1FNz+OWcHl8yxvz+xjAvtSfaPTHB7c5FGYT6yasbOI
AfZT1fiJr08OmSlbWBWVlTdRQYUU+OnbliY0QKG/vX4lGrGGQDkw2B2JHb2wLLpdpNJyYMldpUjb
iJaEMolpu3EjbHC9s1QFplXjUNyJH2aBuvucXV4pK8HDUNDRq0I6jY5X1bUO2mWhUqOQHqesoDbK
9Q3JR0G4xNNJsUWZChf6zX1ndizNyrtyO464OoP8zgeWYi4S2iXkxHNySQAoPFt/EY2qhdadbMks
rPIshi9Iur/Fx7KpIPGpP7OJvp0IWC1id1kjQqXVj8EbDi+3T4ugwXdPBFAzzuRGPAmpNdgvixPQ
YXW9zc3BlhjtOKhgZJHmIpX9l5EDcpPELsvSuEckG0epgif0oecsqgDgprQDYB2Pwj6cCNo6zFjL
K8SM3N4rdiCxrzHOZvj2O9F44Kt5eFUkEMca0CmKWo5E04lSq0J7eOCqCtN8b7lpBJpdjCgSFGRT
IJKKzD4mNGJ3qfpyUz/3R+Y/WMIiq/DuftL3/wAoYezmkTkdhXL8P0ya58wqYHccvXH+Uo/BcEYk
o/eTDxKn8B/TLiwbn/um3p03+kY5xVGHscbOOURB7lf+JDHnocep9yoeJgbYHtwQ/wDCjC7WR+8Q
+ODIGP1WhGwiQ/fXAut9Yf8AZfwyrJvjPwZDmlObNmzFZuwdpvWT5D+OAcH6b/u0/L+OSh9QQeSL
c/bHbh/XFMY25cf5I/jjiaLXwGXsW8I/92/7P+OHmElP39P8vr9ORlzj70jqosulCsckQqqKSCrG
oLVHEdSS4wUps7eOSZUUcQXlKLU7LQ/ZHWi0xr+l9XNw0BIqoJZaVpsHau/EYg10jogKqkEvFS8j
FVapoQnHdh79MpPNuV2vLWSIzITJGH9Mun2Qab/FUAgdCelcv6pYy0neOhcBviLKexHw1FOgyj9Q
dkKuhMX92iuAtfsj4QaEilB4Y8vaTmWFmViABKAdxXszA7V+eBUDJc6RC6LIqrBE5VJpPsLIoYlU
5VO29T07Y0pYTW3q+iz20Z5xc2I5E16LWtDX9ob4YrbWhjRViTjGaxgAUDCu4998Lrq0uBH9X+s/
vbpuIESKgoftt+2dl98I96Pg2sMMzOTphBYoGLACoShUrvtwPhgmMyqSYraoDFficqxA/a+Mfxxg
soI4DyuLl0WgFZGDU2HH4eOJfUkjki+rzOsnKQj1Ob1od6VelFrh2VWW9nkmSM2cgHrBDJUcQFYH
lXb5ZKpj+7evhkIPFLi2aS5mMgm50ULx5FqUY8a/EB8IyaXMkccUrysEjROTuxoABWpJOX4fpLVP
6lYHdvY/wxNP76X/AGP6sjrefPLEUzobwuCR8aRuy9AOoXBVn5p8vXkr+hqENWKBVkb0iTWmwk41
yziia3HNHDLuPyTmb7KjxZf1jHt0PyxkvRKd2H9ce32T8sl3sUBDX6q3tFGPwr/HENcG0B92H6sF
otLVz4hfuCrgbW/sQn/Kb9WVTH7s+4feyHNJs2bNmKzdg/Tf92/R/HC8mgJ8N8FaJK8ouPUABUx0
41/aTn38K5PGPV7kHkmX7bj2H8cc/wBhvkcr/dh/1R+s4heX1laLS6uYoCw+ESOqk/IMcu6MUT0G
EVfj5f5VcNYr2yulY2tzFPQE0jdWNPkpwoyEvqikdURJDEZLW5LfEA0BhO6FZBXkRTrtijQQ0FY1
+HpsNvljHKcYa0+2uXKWICxgCo3kNKL9Hc5UTfwbQg7kyOfqtpGkb9TIVU8R/MBvT6cZBa22krIh
Cycw03NxWV5K9CaktX2xc+hbDZgGJqzEgsx8T445ro7CK3aRuzHii/e+/wCGKrop/wBxH6gVrh1r
6UdD/Wg8TiAHG6Y7SXXEKq9gW+I/JVFPnj0jvW+ykNsG3biOTfT0GWtiOReaeQs1AxUiOoHYlAD+
ON+a15IcW9yFmCckPqF5JTRWkoQAqFtgOI6/RlSyJ6gunnhin3URlwRHG3Ubfaau+C0tbBm4+gHN
OQaQF6itOrk5bfU4HWFY1Ej/AGURBWnjt0GPEO9PCeVIStgXtykocRScqAFi0jELzZgOvXCvz/5l
WRpvL9qKhSn1uatBVfj9ID6Ryw2GpIkjpIrckkXhEi8qhW/mHc5GdRstCsdZuI9Tivby4nleUtGg
EVZGZ6IOavJT/JrhGUcBAPMp8IidyHSww6m+JXFuk5UPXipr886Le6b5WtIY2mtH4zLyja3jnlal
K8qxBqdf2sjmoaZpJtZb/SLqR0gKCa2njdHHqGikc1Q0+jIiYLYzL8utQuLnS5LKdzItnMghZjVg
jqTw332KmmTiTaNz/kn9Wcq/LiaVdZmt1NIpIubrTqUPwn6ORzqk391J/qn9WZeI3D3OLlFTPnuo
kUtX+X6qDAmt/wB1F/rH9WD5gBCw8aficL9bPwQr4sT9wxybQl7gxHMJNmzZsxGbsMNLiSKF/TUK
GbegpWgAwvw1sRS2X3JP45PH9XwQeTV/eRafbXF9NvHbxGRgOppXYfM7Zx27N/rN7PqBgkkeZy54
qzhQeig06AbZ1rXHt0025F0eMcqCHlQN8UjBE2aqmjGu+RK3ikjtpdLn1GWW6QjjIlY3XnUIo4U+
H6exw5JUQGzENiWFRPPYXUc8YaGaJg6mnFtvn450765B9TF/X9x6frV/yePLIv5hsXt9Gtw80ly8
MvxzSks55gjqe1aYYGSP/B4ap4/VeNfehX9eRvqykN4+9k0rARxN4PH29wP44sCBt2PtgS9eX6t+
62YGM1O42Ze2Kxm5R25qGjCjjQ1ckA1r9keGD9bFUWKGMUjjCDwVaZZRKj23pTwwJq93La2LyQAm
ZmVIwASxLEfCoUN8RHTtidq91CzI9vM4eQkyM4YABewJNATt19640qKmll5CO3Vq1HJ+PwgeFT1+
jLJnZaMq1J3C1oB8zhdqCahO9AJI7dV4lImK+o0n7LstWCr3KgHtXxfZxyQSFFiubmaNRymcskVK
bLGlSAB0ApXBw+bLi5bDZEfVZnLhrhkjcmiIu9D2LtU4rHa28T8qMWIpyZiTT/MZoJ7tynrWcsCO
gfnJQ8XPWNqdCMXZwoLMaKu7HsB3ODgAPL5qckiOfy2S/WbxdO0u5u0UcoQDGKftEgL+JwK1zEdJ
ttRuI/XnS3FwDQFgeI5yCtNxWuK35sdc0+4tDJIkasnqsVaNkpR1YiQDYjfADx6Df2UWmrcq6WoR
Y5Jl4k+mKV4kqCMZjYe9MCLPeUxWSC+t0tljcRzRhykg4lY/2Sy+56D54XeYbOC28uXMFpGIo0Ky
8FqBXmCx+nDG2+oWFsESaJEUAMwcUNK+LMe/SuFGo+YY5Fe2tIllRwUeSQVUg7Gid/pyA5th25qX
5ZhTqF4SPjEcdD7Vev8ADOnP9g0FdumQzyFDpsdq5t4Ql6JONy9SWZOLGM/ETQdRtk1zPw/R73Dy
m5lTn/uj9H6xhZrf+6R2+L+GGc3903+ffCjW5VW4toijtzrUotQoqBVj0GOX6T8PvYx5pesTuKqM
aQVJB6jY4us6xkBRyHckU28FGBrlriQK8Hpq1SGLhjt2oFIzGod7Y3hvZiltH8q/ecjavfPNNCJI
+USowHAhW5g7E8qjpkg0y5S7sopEBUrVJIz1R12ZT8snjFE+5iSg/MlrZ3emSR31wbWFCkolWhPK
NuSqFbqT4ZDl1XQbW5lvquk8v21am3vudq/PFvON69xq5teX7q1VVVf8pwGY/iBkSukV7qAgLzTk
/T4qAbfjkMhs+5yNNDiNHlVp7qGsNqMfpRrwt23IO5bwr7YbJqaSaDIyqnqwqInioKbkIH49Kb1y
MDoK9ab4pH9mb/U/43TAEEgz8uL7LZw4v2FWoIi6EqSCQAyhRsO/U0wY/wBdaH4fgnc0UUHBaH7T
GtaEDGXImisuMaGVlAcu7AU4kPVvu7DLhhvYQOHAs5Bl5kkUFSSvHua0FfDfB+soWO2oI8EUbF2L
Vnk4UTiQffah/ZGPkvvSlFlCrXNyFDOqgFgP5n3VRX54Fvmu7RWupnc8iUCwnfcj0441OwLnqxqc
GWVtLaoXkUPdTn1LmUmg5noo/wAlRsMNbWUHnQS62n1e8V5bQLGDK8crXD/GAp+yiKGVSOld8N7T
68sci3JjCAKEEbOzVB6uz0rhfpP1j07pUKKouZqs1SQSa0Cim304aReohPqMHBH2QvEDf5k4mgSN
go3AO7bq8sMiJK0TEA+ooBIow6cgRke1CHUfXlgt79z6USygTUCklqbmML8+hyRn41aNVK8hQlSe
VK12yO66ktkLubjJxkgSCN3qRzdjXduvwVwxO3fQ7kHn8WNT311ctJ6s7SK7Bm7BioCKxG37K98B
XJmCAwlag1YOCQQB4gimKBl2r9GBr+RRA6g8WdTGhFftEH7srJcjTQvJfSIv9SjZy3VyFkf0o02J
VQzE7VIqxHfatMMFO5B+WB7aEQbLsqLxUf2YI7f598AZaqR8Thu+ED5lNNA1j9Dagt06F4WBSVV6
8T+0PcZ1W3uIbqFLi3cSRSAMjr0IOcVOTb8vr6Rvremu1UjAmiB/Z5Eq4Ht0zI086PAeR5OHkje7
NZf7tvlhTrKubi3ZGAAV+S0qTToAa7YbS/3bYUa/DHIIGIIdeQWRdmHTocvy/Sfh97XHmlnB+nE/
dmfmkZ+AtuNgRXv0rgOOe6YFCeZVmUsqGh4mlaswX7sd6U7/AGjt/lMf+Ixhf15i1TYshcNqFyNw
THFQMCp2512PhXDrS6epfdlE61/5ExVwJpduqXbBuLAxNsEAH2l8anNr15b6JptxLD8FxdErGgP2
pGUIWoa7KoyyOwMulfcxPc8/1G5N7f3N01D6sjMvyrRfwwvIDXi0f7ETfu/dmX4j91MWGwxEMPrh
qSP3IopG32tyMpJc7S/xHupXGKR9Jf8AjH/xumJmgx8Z+GY/5H/G6YQ4r0uc0tJP9Qj6SKDF+nzw
Pcf7xyeyV+7fBFa1yJ/SWSXay4jtopj/ALruIGPsOYH8cOorCaX4mIVe3c/dhHrjRrp0nNgDyjKA
ndiHU0A75LRxk/ewsKnr4GniMuxQjIb70Ts1ykQdktsdCjs1lVpmk9WV5tgBTmenfphhHaW8e4QE
+Lb/AK8VVq7EcWHb+Ix2ZAhAbgBr4jytoADoKZz7z5fmbUINPjb4bZOcg/y5On3L+vJ7c3ENpBJc
3DiOGJSzuegAzjmoXr6hfXF6+xndnA60B2UfQKZXqJVER7/uZYxvfco1H7Q37/RgS7EzS2kEQ+B5
C1w3hHGOdB/rNQYLFa7bdvu9sDKSb10WTksUYZkp0MhNN/fjmEXZ6SPoke+QHyRAHUeJ3y9/9rNT
w+Xgcr/b3wjk42aV5Jnz+5ze3yw/8mx6hJqNwdNmjilSCreshZGBcAKeJBHzyPn36ZMvy5iLS6jc
dgIowf8AgmP8Mtwi8kWmf0lPLfzFdrbtNqenuII2kjlurYiSMGJijMyGjgVX3yr3VdP1MR/UrhJi
pPJAaMK+KtQjEYWL+T7+U9ZBeP8A8FJJiXmu0t3sLKcxKs7SRK0ygB6MVBHMb5lZBcSPc0jmgo7p
/jjit3cq7jkdlJ5Hod8fyv36IkfzIP8AzV+rALx3tldQ2tncmRJRIyx3PxAcKGnNfi3ri0eqlJHh
voTA0ZUPKp5xAsKrVh9mvvmMR1AB6+bO+9M9KE0V3I9zKGUQkmlAFAYVPbIH5l125v8AWZormB7f
6uONvA5Un0zuHYKTxLdx1HTBXnLzFdWUcum6U/C4mi4zzqaMgqHCof5m8cg9uHD+pK5eVx8ZY1qT
1Ncy8OmM4xM7AO/vDVPLw3w7nkjTPchy/MgnYqfs0+Ry1uwpq8UZJ2JAoaeHfEgjzyBIw0jHoqgs
dtz0wLKxSJ2WtaHjx3P0ZmSwYZD1QGw6bH7GmGfNA+iZFn3j7U3gvxPM0QUDgN9+56DJJBpDLoF1
rM3RuMdsg/l9Rebn7qDIBZRyTTQNHGRcbRxCnxOzEAVB9+mdufy+f8Lx+XvU/eiH0/U/4to0lflz
zDnp4xnGW3DIio73XW26OWRiR/EBuduaM4h4+B6MtD9IpjbZudvEx6lFr86YouyAnYUGAY9RsLWE
JPcxxlSwALCtAxA2GYNXdd7lJZ5tHG3tJRsUnqD2rStfwyU2GrLM4t7pVtrwiq0NYph/Mjd/1jIn
rGq6FfW/oSTPIVbkhhU7N0r8VAcKrXV7eBjaOjzabUNEsh/ewn+ZGX+GXw4hEUDtfNpkY8R3G71W
olUq1UenbqPdTlpWNVSRixApzNATTxpQVyNWGuelHGL6QTWhH7m/Xqv/ABlp0/1unjTCnz15mvrK
xMFjA81qSEvNQjHwKXpwhUitGPVm6AfPa3xBwmXOkCNmkH5u8w/pSc6fZvWygajMP92SDqf9Ve2R
kbdNj1p+rAT3kaghR+9UlWStaH3IxIysW5E7nrmIeKZ4j1b4w2TIggAeG+BrUp9YupaFXcoJOXii
8R943xJZq9RyP81SGH0jHRNAgbjyQyNzkatSSRSpr7DKzEudp5wjCMSaIJJtHGtKD+uVXag6YmJ4
mFFauO2/hhcE3e7Tmik9KeHvnSvJWmXml6Yz3Kit2yzqgNGUFQAGB75H/KHlw6lMup3qf6FC1Ykb
pK4P/EV/E50jMnBjP1nbuaskugYtJHLZ+Tbm2ulMM6wzBkPizsduxrXH+avhstPUbD14h9zLklZE
dSrqGU9VIqPxwDf6RaajGkc3JQjrIpRqUKnkOtR2y+QJFDyawxO4A/Sdke/Gf9S4ioV5tXVhUFVB
r0p6WSC88uzPd291bTKVhEgaNxQnmABQjbthNPZXdquryzwOkZFVcj4SBFx2PzzGMJDmOn++Z2Pt
/Q8x1iOX667sajilfGvpr/DDLy35TuNeX63NKLXT1cxtMF5uzLQkKOg69TgDWYro6zMbdWcFId1F
Vr6SBvbJ55T1OCx06209ZqXLVaWJgePNjWg7dPDNjkzmGCHDzIHLehXc48YCUyDy3R95pOleW/Le
oyafbhXMDqbrlykcuPTHJzvT4ug2zkbMBsB2zqfne9T/AA7OEQxySyxI/E/CRy5H9WcsJHYb4dIe
KEpk2TLn7mGo2kANqDLfy+0dbrVH1S4qtvYf3bUqPXYfDvQj4V3+7OpszcVPqLx5bSfQfowm8uae
2laVbWcDAS8fVuIXHEmR/icg/hhqzGit6NJuX93XY7HfwzHlm4s4n0iRXuDbGHDiI6kH5l5pM2oX
k8iBppwHaigsw2NPlikWhanJQ+h6YPdyF/tyZjYUGw8BmzGOY9AA28HeWNQ+V5TQz3Cr4hAW/E0z
XVjo2mPHHcCW5lfcRggbdN6U6nJLhLrelTXbpd2xHqRrxdSeOw3BB9sEchMqlKh8kmIA2CV32oro
i3H1CZfUVGEltTmnMLvJudqMaAd6ZD3v9QubWNSPgg/YFWUKx3CJ0UsSSf7cGemsolMnxLLUGvcH
Y75cUUduqxxjiq9NyTv4k7nIGRJboRA96FSERQxpTZBxYAbdMUjRAtQSR1AxVoiWBB2Fdu2DdO0T
UdTnFtZQ8mYcuTEItB1NW609q489gzuueyCVFNaCtOuUeFDyAoBuT0xe5gNncTWrMsjwSNGzofhJ
U0PGvvhbqUsSelEzcXclgK0FFoD+vAdkjkrR3kcdzGhoqP8ADHyBrI25Ppnp8IHfrkk8u2MGsavb
WhPKCQerKy90UcqV9+mRlEF+iM6UhU8iD+0w6U/yR1986l+X+g/VLY6xOvGW4XhbLSnGL+an+VTb
2yWOHFMdR1a8mwJv3MziijgjSGFAkcYCoiigAHQAY8kDc9MLtc1WPRtOlvWHJxRIU6cnboP45HLX
QdX1+1W91rUZY1nHKOzi+FeJ+zyHTf5ZmeTjMhvPMOjWFfrF5HyH7CHm33JXI/defUdvT0qyedz0
aT4R/wACnI/qwj0LTrKa1eSeBZJUkZCWqRQU7dMPlSG3WiKsSeAAUZTLNRIA5MhG90C+r+cb77Jj
skPgFBH/AAXNsDto99eUbVNRln/yASR/w234Ya+qp+wGf/VG33mgzfv2/ljHv8R/Cgys5ZnyTwj3
pDf+XLKdrPToneA3kvpPcBquPhLAgbDqMMdX0SBbT0bcIJbZQ0UkYoTwH2TTepp9+PmATU9IaRi4
+tCtQKfZPQKMONXk/wBL4lDGrRj0yRQHrt7H55LiPhxN2QbRQs7MH1y8a98p+tLvIJo0dvEq3X6c
inl+yN/rNrAR8AcSSD/Jj+M/qpkhvVeXylNHGpd/rSkKoqTSjH7hinkK1NLq8deJXjClevxfGx3+
jMrHkGPT5KIviIA6700TgZZYbWKF/B6Ct8H+G5QN/lDri7SRFFYTExg/EK/ENj364V5swRM/Y5NO
HTNmHTNkDzS7EbwlbS4I6iJ6f8CcWwNqLcdPum/4qb8RTFXmkMriP0n7fZpUA+OGum6bJqU/oRsF
4rzaRgTQVp27nAtxCjirrX7JBr37ZKPKNkLezlujWtw9Fr2SPb9dcJDYTQtVXyvYrCV5uZzQrMab
Ef5HSmaTUTbRtb6qnpXFupktp4/hDFR8LRsPsth5hF5slRNMWMgF5JAEPcAfExH6sINbf2hhRkRu
wuryOXY1ZySx7kk1JzGJGH7xA4BrRwGp8q1y1KilabbZdSzIgB5MwCgb8j2FMDkAJ75a0Rtc1FYS
P9FipJct24jon+z6fLOtK6RIqMnpKo4gAfCAOlCOgwi8qWVtZaTF9SlSSWQ8rl+zSU3TxUp0ocF+
YNRaz0a8ljqlwsfFVPUFyE5DxpXMnHHhj5lxck+KW3IMeu5h5p8xpZhgdK0485WHR2Gx+fI/CPau
TUSVAEaGg6bcR+OR7ybZwWOjRzFgZrs+s570Oyr9AGSAzE14oQo6u/wr+O+WX5tbANGjIS8TkVC3
Uoou3Q+PXDMRxr8XEV/mO5+84XaSGMupAP8ACLuSlB4nqCcMG9KMcpSPYuf1VzEn9RbI8g2ZV6Cr
H/JFf7M1ZT0AX3bc/cP6431mfaGNnH8x+Bf+G3/DG0kYFpJgij7QjoKfN2r/AAyKUHfOtvqGlTzS
HglxVmJoAKdaKK4L169RoJLmBGeKNACGJjViW60+2evcjEfXs1blBH68if7sUVA9zNJt+OAdZlup
NPlZuKxEqGCio3YfttSv+xX6csiTUY116sT1KUaXBe3bPBbenwG7mYsVTl3CL9smm4JGSTS9LTTI
5AJnnlnYPNK4VQSBQcUQAKPbCvyujA3MhU8GChWpsSCa0OSPI5frKY/SHZs2bIBLh0xa1tzcyiMH
iKVZqVoBiI6Yb6TERBLMo+N/hUn2H9cPVeiGk048gYpA0e/ORui8etaYU6/C9pp9wrEMGQFWHQgk
DDeeGW0sjFIatLJVuO4oB/E4WeZSTocDftMBHTuaMD+oY0oYGUZuIG7MeIHudhk7toFtreK3XpGo
X6R1/HIxo1qZr9CykLD+9IPiPs/jksxZSPIOyK+cHHO0jPZXanzIH8MlWQ3zYxbUokB+xEtfarMc
Ccf1JGV2qRU4ZaMkkE/6U9AzwWvwPTqpYfaH+rgAgUFB8XQfM5PtKshYWEVuR8dOUvu7fa/phB37
2zIajQO5XW06yn9IaTOEmNPUB3R/8mePx9+ozaxr0Wp6Tf2E6/Vb6BVYwOQwcBlJMUm1flSuEWpG
PTtRX9FlkuXp6sSiqHl0Xj7+GFl/dfXblrgpwZgoZetGUUNMyMYPviRtfMOJI/Nn2k6nBbaLp8cl
8kTNEFSGNfUmNK/sip/DHSX4dhwtprnvzupBEn0IvNvwyAaYzx38DxKGkDfCprQmh/lBOSxYtSm3
nmESn9iIcf8Ahvib9WDIaPT47/YmO/7GobUWbTySziP6zK0zIlFALfsqWqxAx/rQxkGGEux/3Y/w
/wDDSfEfoGPjs4kPIklu56H6T9o/ScXVET7CgfLKSbNnf7GVICWG5u25MSqdPTUtw+ZJ4V+44pHp
0aqFcggdFAFB9BHH7lwbmwcR5DZaU1giWhC1I6FtyPlXLkjjmQxyoJEPVWFRtj82C0tKqqoVQFUb
ADYDLzZsVdmzZsQrh2yRwItvbpG23EfF8zucI7OISzLy+wvxN9GGhC8iIyTXD1KCvkuGbZRQe+EX
mN4otMe6u5hBHAwJnIqUD/uzw2J5GtABuemHqw+OXLbLLC0Y6kfCfAjcY2FDzjQJ55b2P6tb3cen
CNwZJ4zFGTtwakjcq7H9nJRlkEEhuo2NfHKwMi7IR5iYSavNUkcAi7eyg/xyb5CdVtxNe3Nyso4O
53ZWAFNhvv4dfDFlDmoeXLc3+qqGWsFsPVkPuDRF+k/qye4UeXbFbTT1lp+8uqTMf8kj4Bvv9nfD
fFZmz7mN6rZ30WoSXlrEZVmUAMo5FDQDam4O2xxO28uTS2rPMxhuCf3aHccaft08clGbLPFkAANq
6tXCLSTTfL4tZUubmTnKh5IibKD7k7nDvNmyEpGRspAA5OzZs2BLs2bNirs2bNirs2bNirs2bNiF
TbSkT0G59ZD+AweIlTYD6cDafFE9pEx8CCPcHBwCqNtslXmxtaEHfH0AxpkUd8YZB2x2HLdd0j1F
Al5IB0NG+8YFwVqJJu3J8F/VgXIskNdGaQC2t24SOKtJsSqV3oD3boPDCa6gimuV0hXDzS/vZF25
xxD4Gd6dBxJC+LEU74ZajpEGoyQzNJJBPBURywkA8SQSrAggior7YvaWFvZGR4+Tzz0M9xKecshU
UXm/t2A2GKUQAFAVRQAUA8AMvNmxQ7NmzYq7NmzYq7NmzYq7NmzYq7NmzYq7NmzYq7NmzYhUXZ3s
lt+76xt28D44MNxyFeYp8xhQOmbDe6KTQ3UY6yD6N8TfUFXZByPj0GF+bG002zM7F3NWO5OVmzYF
dmzZsVdmzZsVdmzZsVdmzZsVdmzZsVdmzZsVdmzZsVdmzZsVdmzZsQrX35vvzZssKHffm+/NmxV3
35vvzZsVd9+b782bFXffm+/NmxV335vvzZsVd9+b782bFXffm+/NmxV335vvzZsVd9+b782bFXff
m+/NmxV335vvzZsVf//Z

------=_NextPart_000_0007_01C851B9.34D1E670--