On July 07, 2021 a
Party Discovery
was filed
involving a dispute between
Rose, Daniel,
and
Hall, Bridgette,
for Personal Injury
in the District Court of Goodhue County.
Preview
25-CV-21-1345
Filed in District Court
MAYO 4500 San Pablo Road Patient Online Services
State of Minnesota
6/27/2022 4:56 PM
CLINIC JaCksonvmeI FL 322244865 Go to www.mayoclinic.0rglonlineservices to
make payments and manage your account.
If you have any questions about your Guarantor Guarantor ID
account, please call: 844-217-9591
Dan Rose 911 1551
Date Requested: 07/21/20
Dan Rose This is not a bill and may not reflect your total
545 N WINTER ST balance due. This is an itemization of services
RIVER FALLS WI 54022-1267 provided between 6/25/2019 and 6/9/2020.
Hospital Services
Patient: ROSEARYAH
Vislt #: 1031335369 Place at Sawtca: MCI-IS Cannon Falls
Data at Pranadure Pranaclura Dasafiptian Rev my Charge Amt
Serving Coda Castle
06/25/2019 12011 12011 REPAIR OF WOUND (2.5 CENTIMETERS OR 0450 1 $596.00
LESS) OF THE FACE, EARS, EYELIDS, NOSE, LIPS,
AND/OR MUCOUS MEMBRANES FACILITY
06/25/2019 12011 12011 REPAIR OF WOUND (2.5 CENTIMETERS OR 0981 1 $521.00
LESS) OF THE FACE, EARS, EYELIDS, NOSE, LIPS,
AND/OR MUCOUS MEMBRANES PROFESSIONAL
06/25/2019 250000007 LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05—0.5 % 0250 1 $71.30
GEL 3 ML SYRINGE
06/25/2019 99283 99283 EMERGENCY DEPARTMENT VISIT LEVEL 3 0450 1 $495.00
FACILITY
06/25/2019 99284 99284 EMERGENCY DEPARTMENT VISIT LEVEL 4 0981 1 $617.00
PROFESSIONAL
07/19/2019 Contractual Write-Off 1 -$980.26
07/19/2019 Insurance Payment 1 -$157.74
07/30/2019 Contractual Write-Off 1 -$1,019.63
07/30/2019 Insurance Payment 1 -$142.57
Total $0.00
©2019 Mayo Foundation for Medical Education and Research Page 1 of1
Document Filed Date
June 27, 2022
Case Filing Date
July 07, 2021
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25-CV-21-1345 Filed in District Court MAYO 4500 San Pablo Road Patient Online Services State of Minnesota 6/27/2022 4:56 PM CLINIC JaCksonvmeI FL 322244865 Go to www.mayoclinic.0rglonlineservices to make payments and manage your account. If you have any questions about your Guarantor Guarantor ID account, please call: 844-217-9591 Dan Rose 911 1551 Date Requested: 07/21/20 Dan Rose This is not a bill and may not reflect your total 545 N WINTER ST balance due. This is an itemization of services RIVER FALLS WI 54022-1267 provided between 6/25/2019 and 6/9/2020. Hospital Services Patient: ROSEARYAH Vislt #: 1031335369 Place at Sawtca: MCI-IS Cannon Falls Data at Pranadure Pranaclura Dasafiptian Rev my Charge Amt Serving Coda Castle 06/25/2019 12011 12011 REPAIR OF WOUND (2.5 CENTIMETERS OR 0450 1 $596.00 LESS) OF THE FACE, EARS, EYELIDS, NOSE, LIPS, AND/OR MUCOUS MEMBRANES FACILITY 06/25/2019 12011 12011 REPAIR OF WOUND (2.5 CENTIMETERS OR 0981 1 $521.00 LESS) OF THE FACE, EARS, EYELIDS, NOSE, LIPS, AND/OR MUCOUS MEMBRANES PROFESSIONAL 06/25/2019 250000007 LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05—0.5 % 0250 1 $71.30 GEL 3 ML SYRINGE 06/25/2019 99283 99283 EMERGENCY DEPARTMENT VISIT LEVEL 3 0450 1 $495.00 FACILITY 06/25/2019 99284 99284 EMERGENCY DEPARTMENT VISIT LEVEL 4 0981 1 $617.00 PROFESSIONAL 07/19/2019 Contractual Write-Off 1 -$980.26 07/19/2019 Insurance Payment 1 -$157.74 07/30/2019 Contractual Write-Off 1 -$1,019.63 07/30/2019 Insurance Payment 1 -$142.57 Total $0.00 ©2019 Mayo Foundation for Medical Education and Research Page 1 of1