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CAUSE NO. C-0474-21-D
§
NOEL ARTURO ZAMORA, JR. § IN THE DISTRICT COURT
§
VS § HIDALGO COUNTY, TEXAS
§
REYNALDO SALINAS-REYNA, §
INDIVIDUALLY AND REYNALDO R. § 206TH JUDICIAL DISTRICT
SALINAS §
DIRECT QUESTIONS TO BE PROPOUNDED TO THE WITNESS
Custodian of Records for: FAMILY MEDICAL & SPECIALTY CLINIC
Records Pertaining to: NOEL ARTURO ZAMORA, JR.
1. Please state your full name.
Answer:
2. Please state your position and/or job title.
Answer:
3. Please state your employer's name, business address and telephone number:
Answer:
4. Are you authorized by FAMILY MEDICAL & SPECIALTY CLINIC to produce and testify as to
the patient billing and accounting records of NOEL ARTURO ZAMORA, JR.?
Answer:
5. If your answer to the preceding questions is "yes," please hand a copy of such records to the
notary public taking your deposition. Have you done as requested? If not, why?
Answer:
6. Has FAMILY MEDICAL & SPECIALTY CLINIC made or caused to be made any billing and
accounting records for services rendered to NOEL ARTURO ZAMORA, JR. FROM 12/07/2020
TO PRESENT which set out the complete billing history, including, but not limited to, the amount
that FAMILY MEDICAL & SPECIALTY CLINIC has adjusted, discounted, and/or written off, any
third-party payments, and any payments made by NOEL ARTURO ZAMORA, JR.?
Answer:
7. What is the total dollar amount of the charges for the services rendered to NOEL ARTURO
ZAMORA, JR. for the period FROM 12/07/2020 TO PRESENT, as reflected in the billing and
accounting records?
Answer:
222319.2 NEW File #: 27000.1761 ADO
8. What is the total dollar amount of the charges for the services rendered, for the period FROM
12/07/2020 TO PRESENT, as reflected in the billing records, which have been paid by NOEL
ARTURO ZAMORA, JR. (and not by private insurance or some other person or entity)?
Answer:
9. Has any amount of the charges for services rendered for the time period from 12/07/2020 TO
PRESENT to NOEL ARTURO ZAMORA, JR. been paid by private insurance, or by any person
or entity other than NOEL ARTURO ZAMORA, JR.?
Answer:
10. If your answer to the preceding question was "yes," please write the name of the private
insurer, person, or entity, and the total amount paid by each for services rendered to NOEL
ARTURO ZAMORA, JR. during the time period asked.
Answer:
11. If you provided a name or names and amount(s) in response to the preceding questions,
please state whether or not FAMILY MEDICAL & SPECIALTY CLINIC has a managed care or
contractual arrangement as to each private insurance, person or entity listed which requires an
adjustment, discount, or write-off of any portion or amount of the billed charges.
Answer:
12. If your answer to the preceding question was "yes" as to any private insurer, person, or
entity listed, please state the total amount of the charges for services rendered to NOEL
ARTURO ZAMORA, JR. during the period FROM 12/07/2020 TO PRESENT as reflected in the
billing and accounting records, which has been adjusted, discounted, written off by FAMILY
MEDICAL & SPECIALTY CLINIC as a result of the managed care or contractual arrangement
with each private insurer, person or entity listed.
Answer:
13. For each entity listed in the preceding three questions, please state whether or not FAMILY
MEDICAL & SPECIALTY CLINIC has a managed care or contractual arrangement with the
listed private insurer, person, or entity which prohibits FAMILY MEDICAL & SPECIALTY CLINIC
from seeking reimbursement from NOEL ARTURO ZAMORA, JR. for any of the amounts which
have been adjusted, discounted, or written off as a result of that managed care or contractual
arrangement.
Answer:
14. Has any amount of the charges for services rendered for the time period from 12/07/2020
TO PRESENT to NOEL ARTURO ZAMORA, JR. been purchased or assigned by a third party?
Answer:
15. If your answer to the preceding question was "yes," please write the name of the
purchasing third party, and the total amount paid for the account for services rendered to NOEL
ARTURO ZAMORA, JR. during the time period asked.
Answer:
222319.2 File #: 27000.1761 ADO
16. Do any contracts or agreements exist with any party that concern NOEL ARTURO
ZAMORA, JR.’s treatment (including but not limited to attorney, other providers concerning rent
or use of their facilities, provision of services, billing or collection of medical fees, or referral of
patients)?
Answer:
17. For each party listed in the preceding questions, please provide a copy of any contract(s)
(sale, service, etc) they have with the FAMILY MEDICAL & SPECIALTY CLINIC that are
applicable to NOEL ARTURO ZAMORA, JR.. Also provide copies of any documents between
the third party and FAMILY MEDICAL & SPECIALTY CLINIC and/or NOEL ARTURO ZAMORA,
JR. or their attorney.
Answer:
18. Is FAMILY MEDICAL & SPECIALTY CLINIC a provider under Medicare and/or Medicaid?
Answer:
19. If the answer to the previous question is "yes," is it true that FAMILY MEDICAL &
SPECIALTY CLINIC contract with Medicare and/or Medicaid requires that a patient not be held
legally responsible for the payment of any portion of the charges for treatment or services not
covered by Medicare and/or Medicaid?
Answer:
20. If the answer to the preceding question is "no," state all terms of NOEL ARTURO ZAMORA,
JR.'s insurance coverage of the healthcare expenses reflected on FAMILY MEDICAL &
SPECIALTY CLINIC’s billing records which allow FAMILY MEDICAL & SPECIALTY CLINIC to
bill NOEL ARTURO ZAMORA, JR. for amounts not covered by Medicare/Medicaid.
Answer:
21. What is the amount of charges for treatment or services rendered for the time period FROM
12/07/2020 TO PRESENT to NOEL ARTURO ZAMORA, JR. which have been paid by
Medicare and/or Medicaid?
Answer:
22. What is the current balance, if any, owed on NOEL ARTURO ZAMORA, JR.'s bill for the
specific period of time requested?
Answer:
23. What amount, if any, of the said current balance does FAMILY MEDICAL & SPECIALTY
CLINIC continue to seek as payment from NOEL ARTURO ZAMORA, JR. as his/her legal
obligation to pay beyond what Medicare/Medicaid, private insurance, or other person or entity
has already paid?
Answer:
222319.2 File #: 27000.1761 ADO
24. Please fill in the following blanks with the requested information concerning medical
treatment provided to NOEL ARTURO ZAMORA, JR. FROM 12/07/2020 TO PRESENT:
A. TOTAL AMOUNT FOR ALL MEDICAL BILLED:
Answer:
B. TOTAL AMOUNT PAID BY PRIVATE INSURER:
Answer:
C. TOTAL AMOUNT PAID BY MEDICARE/MEDICAID:
Answer:
D. TOTAL AMOUNT PAID BY NOEL ARTURO ZAMORA, JR.:
Answer:
E. TOTAL AMOUNT WRITTEN OR CHARGED OFF:
Answer:
F. TOTAL AMOUNT OF CONTRACTUAL AGREEMENT ADJUSTMENTS:
Answer:
G. TOTAL AMOUNT STILL OWED AND BY WHOM:
Answer:
______________________________________________
WITNESS CUSTODIAN OF RECORDS
I,______________________________,A Notary Public in and for the State of Texas do hereby
certify that the foregoing answers of the witness were made by the said witness and sworn to and
subscribed before me. The records attached hereto are exact duplicates of the original records.
GIVEN UNDER MY HAND AND SEAL on this the ________ day of____________________20
.
______________________________________________
Notary Public in and for the State of Texas
222319.2 File #: 27000.1761 ADO
CAUSE NO. C-0474-21-D
§
NOEL ARTURO ZAMORA, JR. § IN THE DISTRICT COURT
§
§
VS HIDALGO COUNTY, TEXAS
§
REYNALDO SALINAS-REYNA, §
INDIVIDUALLY AND REYNALDO R. § 206TH JUDICIAL DISTRICT
SALINAS §
AFFIDAVIT
RECORDS PERTAINING TO: NOEL ARTURO ZAMORA, JR.
Before me, the undersigned authority, personally appeared___________________________________,
who being duly sworn, deposed as follows:
My name is _________________________________. I am over 18 years of age, of sound mind, capable
of making this affidavit, and personally acquainted with the facts herein stated:
I am the CUSTODIAN OF BILLING RECORDS OF FAMILY MEDICAL & SPECIALTY CLINIC and am
familiar with the manner in which its records are created and maintained by virtue of my duties and
responsibilities. Attached hereto are _______ pages of records which are maintained in either paper
copies and/or digital electronic format from FAMILY MEDICAL & SPECIALTY CLINIC. These said
records are kept by FAMILY MEDICAL & SPECIALTY CLINIC in the regular course of business and it
was the regular course of business of FAMILY MEDICAL & SPECIALTY CLINIC for an employee or
representative of FAMILY MEDICAL & SPECIALTY CLINIC, or other individual, with knowledge of the
act, event, condition, opinion, or diagnosis, recorded to make the record or to transmit information thereof
to be included in such record; and the record was made at or near the time or reasonably soon thereafter.
The records attached hereto are the originals or exact duplicates of the originals.
_________________________________________________
AFFIANT
SUBSCRIBED AND SWORN TO BEFORE ME on this, the __________day of ________________, 20_____
_________________________________________________
Notary Public in and for The State of Texas
_________________________________________________
Notary’s Printed Name
_________________________________________________
My Commission Expires
222319.2 File #: 27000.1761 ADO
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CAUSE NO. C-0474-21-D § NOEL ARTURO ZAMORA, JR. § IN THE DISTRICT COURT § VS § HIDALGO COUNTY, TEXAS § REYNALDO SALINAS-REYNA, § INDIVIDUALLY AND REYNALDO R. § 206TH JUDICIAL DISTRICT SALINAS § DIRECT QUESTIONS TO BE PROPOUNDED TO THE WITNESS Custodian of Records for: FAMILY MEDICAL & SPECIALTY CLINIC Records Pertaining to: NOEL ARTURO ZAMORA, JR. 1. Please state your full name. Answer: 2. Please state your position and/or job title. Answer: 3. Please state your employer's name, business address and telephone number: Answer: 4. Are you authorized by FAMILY MEDICAL & SPECIALTY CLINIC to produce and testify as to the patient billing and accounting records of NOEL ARTURO ZAMORA, JR.? Answer: 5. If your answer to the preceding questions is "yes," please hand a copy of such records to the notary public taking your deposition. Have you done as requested? If not, why? Answer: 6. Has FAMILY MEDICAL & SPECIALTY CLINIC made or caused to be made any billing and accounting records for services rendered to NOEL ARTURO ZAMORA, JR. FROM 12/07/2020 TO PRESENT which set out the complete billing history, including, but not limited to, the amount that FAMILY MEDICAL & SPECIALTY CLINIC has adjusted, discounted, and/or written off, any third-party payments, and any payments made by NOEL ARTURO ZAMORA, JR.? Answer: 7. What is the total dollar amount of the charges for the services rendered to NOEL ARTURO ZAMORA, JR. for the period FROM 12/07/2020 TO PRESENT, as reflected in the billing and accounting records? Answer: 222319.2 NEW File #: 27000.1761 ADO 8. What is the total dollar amount of the charges for the services rendered, for the period FROM 12/07/2020 TO PRESENT, as reflected in the billing records, which have been paid by NOEL ARTURO ZAMORA, JR. (and not by private insurance or some other person or entity)? Answer: 9. Has any amount of the charges for services rendered for the time period from 12/07/2020 TO PRESENT to NOEL ARTURO ZAMORA, JR. been paid by private insurance, or by any person or entity other than NOEL ARTURO ZAMORA, JR.? Answer: 10. If your answer to the preceding question was "yes," please write the name of the private insurer, person, or entity, and the total amount paid by each for services rendered to NOEL ARTURO ZAMORA, JR. during the time period asked. Answer: 11. If you provided a name or names and amount(s) in response to the preceding questions, please state whether or not FAMILY MEDICAL & SPECIALTY CLINIC has a managed care or contractual arrangement as to each private insurance, person or entity listed which requires an adjustment, discount, or write-off of any portion or amount of the billed charges. Answer: 12. If your answer to the preceding question was "yes" as to any private insurer, person, or entity listed, please state the total amount of the charges for services rendered to NOEL ARTURO ZAMORA, JR. during the period FROM 12/07/2020 TO PRESENT as reflected in the billing and accounting records, which has been adjusted, discounted, written off by FAMILY MEDICAL & SPECIALTY CLINIC as a result of the managed care or contractual arrangement with each private insurer, person or entity listed. Answer: 13. For each entity listed in the preceding three questions, please state whether or not FAMILY MEDICAL & SPECIALTY CLINIC has a managed care or contractual arrangement with the listed private insurer, person, or entity which prohibits FAMILY MEDICAL & SPECIALTY CLINIC from seeking reimbursement from NOEL ARTURO ZAMORA, JR. for any of the amounts which have been adjusted, discounted, or written off as a result of that managed care or contractual arrangement. Answer: 14. Has any amount of the charges for services rendered for the time period from 12/07/2020 TO PRESENT to NOEL ARTURO ZAMORA, JR. been purchased or assigned by a third party? Answer: 15. If your answer to the preceding question was "yes," please write the name of the purchasing third party, and the total amount paid for the account for services rendered to NOEL ARTURO ZAMORA, JR. during the time period asked. Answer: 222319.2 File #: 27000.1761 ADO 16. Do any contracts or agreements exist with any party that concern NOEL ARTURO ZAMORA, JR.’s treatment (including but not limited to attorney, other providers concerning rent or use of their facilities, provision of services, billing or collection of medical fees, or referral of patients)? Answer: 17. For each party listed in the preceding questions, please provide a copy of any contract(s) (sale, service, etc) they have with the FAMILY MEDICAL & SPECIALTY CLINIC that are applicable to NOEL ARTURO ZAMORA, JR.. Also provide copies of any documents between the third party and FAMILY MEDICAL & SPECIALTY CLINIC and/or NOEL ARTURO ZAMORA, JR. or their attorney. Answer: 18. Is FAMILY MEDICAL & SPECIALTY CLINIC a provider under Medicare and/or Medicaid? Answer: 19. If the answer to the previous question is "yes," is it true that FAMILY MEDICAL & SPECIALTY CLINIC contract with Medicare and/or Medicaid requires that a patient not be held legally responsible for the payment of any portion of the charges for treatment or services not covered by Medicare and/or Medicaid? Answer: 20. If the answer to the preceding question is "no," state all terms of NOEL ARTURO ZAMORA, JR.'s insurance coverage of the healthcare expenses reflected on FAMILY MEDICAL & SPECIALTY CLINIC’s billing records which allow FAMILY MEDICAL & SPECIALTY CLINIC to bill NOEL ARTURO ZAMORA, JR. for amounts not covered by Medicare/Medicaid. Answer: 21. What is the amount of charges for treatment or services rendered for the time period FROM 12/07/2020 TO PRESENT to NOEL ARTURO ZAMORA, JR. which have been paid by Medicare and/or Medicaid? Answer: 22. What is the current balance, if any, owed on NOEL ARTURO ZAMORA, JR.'s bill for the specific period of time requested? Answer: 23. What amount, if any, of the said current balance does FAMILY MEDICAL & SPECIALTY CLINIC continue to seek as payment from NOEL ARTURO ZAMORA, JR. as his/her legal obligation to pay beyond what Medicare/Medicaid, private insurance, or other person or entity has already paid? Answer: 222319.2 File #: 27000.1761 ADO 24. Please fill in the following blanks with the requested information concerning medical treatment provided to NOEL ARTURO ZAMORA, JR. FROM 12/07/2020 TO PRESENT: A. TOTAL AMOUNT FOR ALL MEDICAL BILLED: Answer: B. TOTAL AMOUNT PAID BY PRIVATE INSURER: Answer: C. TOTAL AMOUNT PAID BY MEDICARE/MEDICAID: Answer: D. TOTAL AMOUNT PAID BY NOEL ARTURO ZAMORA, JR.: Answer: E. TOTAL AMOUNT WRITTEN OR CHARGED OFF: Answer: F. TOTAL AMOUNT OF CONTRACTUAL AGREEMENT ADJUSTMENTS: Answer: G. TOTAL AMOUNT STILL OWED AND BY WHOM: Answer: ______________________________________________ WITNESS CUSTODIAN OF RECORDS I,______________________________,A Notary Public in and for the State of Texas do hereby certify that the foregoing answers of the witness were made by the said witness and sworn to and subscribed before me. The records attached hereto are exact duplicates of the original records. GIVEN UNDER MY HAND AND SEAL on this the ________ day of____________________20 . ______________________________________________ Notary Public in and for the State of Texas 222319.2 File #: 27000.1761 ADO CAUSE NO. C-0474-21-D § NOEL ARTURO ZAMORA, JR. § IN THE DISTRICT COURT § § VS HIDALGO COUNTY, TEXAS § REYNALDO SALINAS-REYNA, § INDIVIDUALLY AND REYNALDO R. § 206TH JUDICIAL DISTRICT SALINAS § AFFIDAVIT RECORDS PERTAINING TO: NOEL ARTURO ZAMORA, JR. Before me, the undersigned authority, personally appeared___________________________________, who being duly sworn, deposed as follows: My name is _________________________________. I am over 18 years of age, of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: I am the CUSTODIAN OF BILLING RECORDS OF FAMILY MEDICAL & SPECIALTY CLINIC and am familiar with the manner in which its records are created and maintained by virtue of my duties and responsibilities. Attached hereto are _______ pages of records which are maintained in either paper copies and/or digital electronic format from FAMILY MEDICAL & SPECIALTY CLINIC. These said records are kept by FAMILY MEDICAL & SPECIALTY CLINIC in the regular course of business and it was the regular course of business of FAMILY MEDICAL & SPECIALTY CLINIC for an employee or representative of FAMILY MEDICAL & SPECIALTY CLINIC, or other individual, with knowledge of the act, event, condition, opinion, or diagnosis, recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time or reasonably soon thereafter. The records attached hereto are the originals or exact duplicates of the originals. _________________________________________________ AFFIANT SUBSCRIBED AND SWORN TO BEFORE ME on this, the __________day of ________________, 20_____ _________________________________________________ Notary Public in and for The State of Texas _________________________________________________ Notary’s Printed Name _________________________________________________ My Commission Expires 222319.2 File #: 27000.1761 ADO