On January 15, 2008 a
CREDITOR'S CLAIM/BILL BY EMSA-WESTERN DIVISION
was filed
in the District Court of Oklahoma County.
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3/10/2008 1:59:51 PM PAGE 002/002 Fax Server
pB-2006- 38
FILED IN THE AG fries age ~ 36
OKLAHOMA COUNTY, OKLA.
EMSA-Western Division
P.O, BOX 21228
DEPT. 64
TULSA, OK 74121-1228
(405) 297-7110
Patient name: ABRAMS, DANNY L.
Run number: 07-7139229
Date of call: 11/17/2007
Time of call: 16:31
Caller:
From: 5000 SE 84TH ST
DANNY L. ABRAMS
To: SOUTHWEST INTEGRIS MEDICAL CEN
5000 SE 84TH ST
OKLAHOMA CITY, OK 73135 Primary payor: First Health
446-54-6756
Secondary payor: Gill Patient
Description Check # Quantity Unit price Payment date Amount
Emergency Base Rate 1 719.71 719.71
Mileage 9 9.00 81,00
Payment - Check w080207sw 1 217/2008 653,10
Payment - Check w080221 sw 4 212412008 -247.61
PLEASE PAY THIS AMOUNT: $0.00
DETACH ALONG ABOVELINE AND RETURN STUB WTH YOUR PAYMENT, THANK YOU
Patient name: ABRAMS, DANNY L. Run number: 07-7139229 Amount | $
Current date: 03/10/2008 enclosed:
Due on: 3/20/2008
Remit to: EMSA-Westem Division
P.O, BOX 21228
DEPT. 64
TULSA, OK 74121-1228
Document Filed Date
June 08, 2009
Case Filing Date
January 15, 2008
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3/10/2008 1:59:51 PM PAGE 002/002 Fax Server pB-2006- 38 FILED IN THE AG fries age ~ 36 OKLAHOMA COUNTY, OKLA. EMSA-Western Division P.O, BOX 21228 DEPT. 64 TULSA, OK 74121-1228 (405) 297-7110 Patient name: ABRAMS, DANNY L. Run number: 07-7139229 Date of call: 11/17/2007 Time of call: 16:31 Caller: From: 5000 SE 84TH ST DANNY L. ABRAMS To: SOUTHWEST INTEGRIS MEDICAL CEN 5000 SE 84TH ST OKLAHOMA CITY, OK 73135 Primary payor: First Health 446-54-6756 Secondary payor: Gill Patient Description Check # Quantity Unit price Payment date Amount Emergency Base Rate 1 719.71 719.71 Mileage 9 9.00 81,00 Payment - Check w080207sw 1 217/2008 653,10 Payment - Check w080221 sw 4 212412008 -247.61 PLEASE PAY THIS AMOUNT: $0.00 DETACH ALONG ABOVELINE AND RETURN STUB WTH YOUR PAYMENT, THANK YOU Patient name: ABRAMS, DANNY L. Run number: 07-7139229 Amount | $ Current date: 03/10/2008 enclosed: Due on: 3/20/2008 Remit to: EMSA-Westem Division P.O, BOX 21228 DEPT. 64 TULSA, OK 74121-1228