Preview
FILED
5/20/2021 4:46 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Matthew Little DEPUTY
CAUSE NO. DC-21-04276
ALFREDO MARTINEZ, § IN THE DISTRICT COURT
Plaintiff, §
§
V. § 134th JUDICIAL DISTRICT
§
JOSHUA FARMER, §
Defendant. § DALLAS COUNTY, TEXAS
PLAINTIFF’S NOTICE OF FILING AFFIDAVITS
Please take notice that pursuant to Rules 803 (6) and 902(10) of the Texas Rules of
Evidence, and pursuant to §18.001 of the Texas Civil Practice and Remedies Code, Plaintiffs file
the following affidavits:
(1) Billing Records Affidavit by the custodian of records for SJ Kechejian, M.D., PA,
to include the itemized billing records attached thereto; and
(2) Medical Records Affidavit by the custodian of records for SJ Kechejian, M.D.,
PA.
The above-listed affidavits, including all records associated thereto, have been served on
all counsel and/or parties of record.
Respectfully submitted,
ALMASRI & MARZWANIAN LAW GROUP PLLC
Notice of Affidavits Page 1
By: /s/ Hazim Mandavia
Sam Almasri
Texas Bar No. 24053071
Email: sam@theamlawgroup.com
Hazim Mandavia
Texas Bar No. 24096984
Email: hazim@theamlawgroup.com
9330 LBJ Freeway, Suite 120
Dallas, Texas 75243
Tel. (214) 227 -2777
Fax. (214) 227-2271
Attorneys for Plaintiff
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing has been served on all counsel of
record in accordance with the Texas Rules of Civil Procedure on this 20th day of May, 2021.
/s/ Hazim Mandavia
Hazim Mandavia
Notice of Affidavits Page 2
Cause No. 9021-94276
ALFREDO MARTINEZ § 1N THE DISTRICT COURT
PLAINTIFF, §
§
§
§ 134‘“ JUDICIAL COUR'I‘
v. §
§
JOSHUA FARMER, § DALLAS COUNTY, TEXAS
BEFENDANT. §
AFFIDAWT OF COST OF SERVICES BY CUSTODIAN
SJ KECHESHAN Mi) PA
'
the nod signed authority, on. this day personally appeared
BEWME7/(Mafia
'
”
who, after being by me first duly sworn, on oath deposed and said:
My gone is I am over 18 years of age, of sound
‘légwgrmgf _.
mind, capabie of making(gafh‘zm
this aft“ avit, and pars nally acquainted with the facts herein. I am the custodian
of billing records for 8.} KEGHEJIAN MD, PA. Attached to this affidavit are ““3“
pages of 'biiiing
record for the service that this facility provided ALFREDO MARTINEZ from .5. [oz/2.912
to "7 2.3120! 52 . These attached records are exact copies of the originals. Regarding these resents, I
state the following:
(1) It is in the rcgular course of business to keep these records.
(2) It is in the regular course of business for an employee, representative, or doctor with persons!
knowledge of the act, event, condition, opinion, or diagnosis recorded to make the memorandunfis) or
l‘éGOl‘d(S} or to transmit information thereof to be included in such memorandunfis) or rccord(s).
(3) 'IThe entries in the records are made at or near the time of the act, event, or condition described by the
records or reasonably soon thcrcaficr.
(4) It is our policy not to release the originals of the records but to make cxact duplicates thereof, which
'
the attached pages represent.
(5} The services provided were rcasonabie, and the services performed were necessary for the proper care
and treatment of the patient.
‘
(6) The total amount paid for the services was $ and the amount cmremiy unpaid but
which SJ Ml) PA has rig t to be paid after any adjustments or credits is
a
$3
'
KECggEJIAN
. .
(7) The record(s) attached hereto are the original(s) or exact copies of the originaKs) and nothing has
berm removed or deleted from the original filo making these copies.
.
hrytforc
m. $7
Signature of ffiant
SUBS AND SWORN to before me, the undersigned a ,hority, on this (gig/day of
REE}: . ,2021.
Nata Publi ta bf
AUGUSTO o. co
$992439, of Texas
Notary Public. State
gf‘kfi‘a
,
Expires 02-06-2023
figw-fi’; Comm. Notary ID 4016469
”~f.3§.ff-“
Notice of Assignment: We have an assugn'ment
of the patients claim for damages and Injunes
to the extent
arising from the accident/incident.
Patient History - Summary that we have provided medical services In treating By Date of Service
the injuries, therefore. we are entitled. to payment.
-
5 J KECHEJIAN MD PA It does not Date ranges 05/07/2019 to 04fl6/2021
If payment is made to patient,
200 W Colorado Blvd constitute payment to us. All Provides
Dallas, TX 75208 Show last billed date
2 1 4—946- 1 177
Open Items Only
Chart #: 34763 Home Phone: _ ‘I
Patient Name: MARTINEZ,ALFREDO Office Phone:
Address: .- Resp. Party: MARTINEZ,ALFREDO
City, State, Zip: DALLAS, TX 75228 Resp. Acct# -
U Code Source I B Service Prov Visit#l Charge Paid/ Patient Insurance Total Last Billed Date Billed ..
Resp Party
. Date check# Amount Applied Balance Balance Balance‘ Carrier This Charge
99213 Y N 7/24/2019 JT75 1540048 $187.00 $0.00 $0.00 $187.00 $187.00 290042
992 13 Y N 7/ 1/20 19 F7 5 1537294 $187.00 $0.00 $0 .00 $187 .00 $187 .00 290042
97010 ‘1’ N 7/1/2019 I175 1537294 $51.00 $0.00 $0.00 $51.00 $51.00 290042
' ‘
97014 Y N 7/1/2019 1175 1537294 $67.00 $0.00 $0.00 $67.00 $67.00
‘
290042
97035 Y N 7/1/2019 1175 1537294 $70.00 $0.00 $0.00 $70.00 $70.00 290042
97010 Y N 6/28/2019 JT75 1539827 $51.00 $0.00, $0.00 $51.00 $51.00 290042
97014 Y N 6/28/2019 J'l75 1539827 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 6/28/2019 JT75 1539827 $70.00 $0.00 $0.00 $70.00 $70.00 290042
97010 Y N 6/26/2019 JT75 1537296 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 ‘1’ N 6/26/2019 1175 1537296 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 6/26/2019 1175 1537296 $70.00 $0.00 $0.00 $70.00 $70.00 290042
I
97010 Y N 6/ 17/2019 JT75 1537297 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 Y N 6/17/2019 3175 1537297 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 6/17/2019 JT75 1537297 $70.00 $0.00 $0.00 $70.00 $70.00 . 290042
97010 Y N 6/14/2019 3175 1537583 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 Y N 6/14/2019 JT75 1537583 $67.00 $0.00 $0.00 $67.00 $67.00 4
290042
1
97035 Y N 6/14/2019 J175 1537583 $70.00 $0.00 $0.00 $70 .00 $70. 00 290042
* U = Unapplied
* I = 3:]? Insurance * B = Insurance Billed
Generated 4/26/2021 01:26:32 PM ”WWAdvancedm Page 1 of 3
Notice of Assignment: We have an assignment
of the patients claim for damages and injuries
Patient History - Summary
,
arising from the accident/incident/to the extent By Date of Service
that we have provided medical services treating
In
5 J KECHEiIAN MD PA we are Date ranges 05/07/2019 to 04/26/2021
the injuries, therefore, entitledtc payment.
200 W Colorado Blvd If payment is made to patient. it does not All Providers
constitute payment to us.
Dallas, TX75208 Show last billed date
214-945-1177 Open Items Only
Chart #: 34763 Home Phone: _
Patient Name: MARTINEALFREDO Office Phone:
Address: — Resp. Party: MARTENEZ,ALFREDO
City, State, Zip: DALLAS, TX 75228 Resp. Acct# - _
U Code Source I B Service Prov Visit#/ Charge Paid] Patient Insurance Total Last Billed Date Billed -.
Resp Party
Date
. Check# Amount Applied Balance Balance Balance Carrier This Charge
97010 Y N 6/13/2019 3175 1537298 $51.00
-
$0.00 $0.00 $51.00 $51.00 290042
97014 Y N 6/13/2019 J175 1537298 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 6/13/2019 3175 1537298 $70.00 $0.00 $0.00 $70.00 $70.00 290042
‘ Y
97010 N 6/11/2019 3175 1537344 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 Y N 6/11/2019 JT75 1537344 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 6/11/2019 J'l75 1537344 $70.00 $0.00 $0.00 $70.00 $70.00 290042
99214 Y N 6/10/2019 3175 1533490 $237.00 $0.00 $0.00 $237.00 $237.00 290042
97010 Y N 5/22/2019 3175 1533487 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 Y N 5/22/2019 J'l75 1533487 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 5/22/2019 J'I75 1533487 $70.00 $0.00 $0.00 $70.00 $70.00 290042
97010 Y N 5/20/2019 3175 1533486 $51.00 $0.00 $0.00 $51.00 $51.00 290042
97014 Y N 5/20/2019 3175 1533486 $67.00 $0.00 $0.00 $67.00 $67.00 290042
97035 Y N 5/20/2019 J'l75 1533486 $70.00 $0.00 $0.00 $70.00 $70.00 290042
99213 Y N 5/16/2019 J'l75 1531684 $187.00 $0.00 $0.00 $187.00 $187.00 290042
RX096 Y N 5/10/2019 J'l75 1534144 $39.66 $0.00 $0.00 $39.66 $39.66 290042
RX096 Y N 5/10/2019 J'I75 1534144 $56.82 $0.00 $0.00 $56.82 $56.82 290042
h
72040 Y N 5/9/2019 3175 1531681 $30.00 $0.00 $0.00 $250.00 $250.00 290042
* U = Unapplied * I = Bill Insurance * B = Insurance Billed
Generated 4/26/2021 01:26:32 PM W W Advancedm Page 2 of 3
Notice of Assignment: We have an assignment
of the patients ctaim for damages and InjUI'IES
Patient History - Summary
5
arising from the accidentfrncident. to the extent
'
BY Date of Service
.
that we have provided medical services in treating
5 J KECHEIIAN MD PA =
lme injurieS, therefore, Date ranges 05/07/2019 to
’
wcteoar:agr‘;tli1ttleditto(guess/arming:é 04/26/2021
Nd
gunfigt‘: fiafinefligeus.
€331: C'Il‘géogaggilg Show lee:I i3:::l:::
214-946-1177 Open Items Only
Chart #: 34763 Home Phone: _
Patient Name: MAR‘I'INEZ,ALFREDO Office Phone:
Address: _ Resp. Party: MARTINEALFREDO
-
'
City, Slate, Zip: DALLAS, TX 75228 Resp. Acct#
U Code Source I B Service Prov Visit#/ Charge Paid I Patient Insurance Total Last Billed Date Billed Resp Party
Date Check# Amount Applied Balance Balance Balance Carrier This Charge
72100 Y N 5/9/2019 1175 1531681 $265.00 $0.00 $0.00 $265.00 $265.00 290042
99203 Y N 5/7/2019 N75 1531629 $325.00 $0.00 $0.00 $325.00 $325.00 290042
E0190* Y N 5/7/2019 J'i75 1531629 $72.00 $0.00 $0.00 $72.00 $72.00 290042
£1200 Y N 5/7/2019 J'I75 1531629 $72.00 $0.00 $0.00 $72.00 $72.00 290042
Grand Total: $3,570.48 $0.00 $0.00 $3,570.48 $3,570.48
* U = Unapplied * I = Bill Insurance * B = Insurance Billed
Generated 4/26/2021 01:26:32 PM ’WwW/idvancedm Page 3 of 3
Cause No. DC-Zi-M276
ALFREDO MARTINEZ § IN THE DISTRICT COURT
PLAINTIFF, §
§
§
§ I34!h JUDIClAL COURT
v. §
§
JOSHUA FARMER, § DALLAS COUNTY, TEXAS
DEFENDANT. §
MEDICAL NECLSSITY REC RDS AFFIDAVIT
SJ KECHEJiAN MD PA
BEFOL:
cfi;
undersi authority, on this day persenaliy appeared
76/. MWAIEeé‘ZZ Pay film, after being by me first duly sworn, on oath deposed and
said:
vamclemm/
‘
.
My name is C;a‘H’W , I am ever ]8 years of age, of
sound mind, capable ofmaking {his affidavit arid personally acquainted with the facts herein. .1 am the
custodian ef medical records for SJ KECHEJIAN Ml) PA Attached :0 this affidavit are m;
pages of medical records for the service that this facility provided to ALFREDO MARTINEZ om f
e “I I to "I (as; ('20 i Q The service provided was necessary and the amount charged for
the service was reasonable'at the time and place that the service was provided. These attached records
exact copies of the originals. Regarding these recerds, I state the following:
: are
(i) It is in {he regular course ofhusiness to keep these records.
(2) It is in fire regular course 'of business for an employee, representative, or doctor with
personal lchowledge of the act, event, condition, opinion, or diegnesis recorded to make
the memorandum(s) 0r record(s) or to transmit information thereof to be included in
such memorandurn(s) or record(s).
(3) The entries in the records are made at or near the time of the act, event, or condition
described bythe records 0r reasonably soon thereafter.
(4) It is our policy not'to release the originals of the records but to make exact duplicates
{hereofl whish the attached pages represent.
Km,
Signature Wfiffiam l/Wm/
AND SWORl‘J to before me, the undersigned authoi'ty, on this thebgfl
/day Of
202 1
SUBS-(“$1318
P“ 0’ “tum—14%,.
‘ AUGUSTO o. co Distal}!
- .........
«988311,, Public, State of Texas
. ,
Notary .
38%|:
1'8 ‘3
fog:Comm. Expires 02-06-2023
5293'
NotarylD 4016460
'1 .
Automated Certificate of eService
This automated certificate of service was created by the efiling system.
The filer served this document via email generated by the efiling system
on the date and to the persons listed below. The rules governing
certificates of service have not changed. Filers must still provide a
certificate of service that complies with all applicable rules.
Nida Rafi on behalf of Hazim Mandavia
Bar No. 24096984
Nida@theamslawgroup.com
Envelope ID: 53662481
Status as of 5/24/2021 11:16 AM CST
Associated Case Party: ALFREDO MARTINEZ
Name BarNumber Email TimestampSubmitted Status
Sam Almasri sam@theamlawgroup.com 5/20/2021 4:46:47 PM SENT
Hazim Mandavia hazim@theamlawgroup.com 5/20/2021 4:46:47 PM SENT
Carolina Alzate carolina@theamlawgroup.com 5/20/2021 4:46:47 PM SENT
Hashem Saad Hashem@theamlawgroup.com 5/20/2021 4:46:47 PM SENT
Manuela Morales manuela@theamlawgroup.com 5/20/2021 4:46:47 PM SENT
Associated Case Party: JOSHUA FARMER
Name BarNumber Email TimestampSubmitted Status
J. Robert Miller rmiller@miller-brown.com 5/20/2021 4:46:47 PM SENT
Rebecca Stogner rstogner@miller—brown.com 5/20/2021 4:46:47 PM SENT
Preview
FILED 5/20/2021 4:46 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Matthew Little DEPUTY CAUSE NO. DC-21-04276 ALFREDO MARTINEZ, § IN THE DISTRICT COURT Plaintiff, § § V. § 134th JUDICIAL DISTRICT § JOSHUA FARMER, § Defendant. § DALLAS COUNTY, TEXAS PLAINTIFF’S NOTICE OF FILING AFFIDAVITS Please take notice that pursuant to Rules 803 (6) and 902(10) of the Texas Rules of Evidence, and pursuant to §18.001 of the Texas Civil Practice and Remedies Code, Plaintiffs file the following affidavits: (1) Billing Records Affidavit by the custodian of records for SJ Kechejian, M.D., PA, to include the itemized billing records attached thereto; and (2) Medical Records Affidavit by the custodian of records for SJ Kechejian, M.D., PA. The above-listed affidavits, including all records associated thereto, have been served on all counsel and/or parties of record. Respectfully submitted, ALMASRI & MARZWANIAN LAW GROUP PLLC Notice of Affidavits Page 1 By: /s/ Hazim Mandavia Sam Almasri Texas Bar No. 24053071 Email: sam@theamlawgroup.com Hazim Mandavia Texas Bar No. 24096984 Email: hazim@theamlawgroup.com 9330 LBJ Freeway, Suite 120 Dallas, Texas 75243 Tel. (214) 227 -2777 Fax. (214) 227-2271 Attorneys for Plaintiff CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing has been served on all counsel of record in accordance with the Texas Rules of Civil Procedure on this 20th day of May, 2021. /s/ Hazim Mandavia Hazim Mandavia Notice of Affidavits Page 2 Cause No. 9021-94276 ALFREDO MARTINEZ § 1N THE DISTRICT COURT PLAINTIFF, § § § § 134‘“ JUDICIAL COUR'I‘ v. § § JOSHUA FARMER, § DALLAS COUNTY, TEXAS BEFENDANT. § AFFIDAWT OF COST OF SERVICES BY CUSTODIAN SJ KECHESHAN Mi) PA ' the nod signed authority, on. this day personally appeared BEWME7/(Mafia ' ” who, after being by me first duly sworn, on oath deposed and said: My gone is I am over 18 years of age, of sound ‘légwgrmgf _. mind, capabie of making(gafh‘zm this aft“ avit, and pars nally acquainted with the facts herein. I am the custodian of billing records for 8.} KEGHEJIAN MD, PA. Attached to this affidavit are ““3“ pages of 'biiiing record for the service that this facility provided ALFREDO MARTINEZ from .5. [oz/2.912 to "7 2.3120! 52 . These attached records are exact copies of the originals. Regarding these resents, I state the following: (1) It is in the rcgular course of business to keep these records. (2) It is in the regular course of business for an employee, representative, or doctor with persons! knowledge of the act, event, condition, opinion, or diagnosis recorded to make the memorandunfis) or l‘éGOl‘d(S} or to transmit information thereof to be included in such memorandunfis) or rccord(s). (3) 'IThe entries in the records are made at or near the time of the act, event, or condition described by the records or reasonably soon thcrcaficr. (4) It is our policy not to release the originals of the records but to make cxact duplicates thereof, which ' the attached pages represent. (5} The services provided were rcasonabie, and the services performed were necessary for the proper care and treatment of the patient. ‘ (6) The total amount paid for the services was $ and the amount cmremiy unpaid but which SJ Ml) PA has rig t to be paid after any adjustments or credits is a $3 ' KECggEJIAN . . (7) The record(s) attached hereto are the original(s) or exact copies of the originaKs) and nothing has berm removed or deleted from the original filo making these copies. . hrytforc m. $7 Signature of ffiant SUBS AND SWORN to before me, the undersigned a ,hority, on this (gig/day of REE}: . ,2021. Nata Publi ta bf AUGUSTO o. co $992439, of Texas Notary Public. State gf‘kfi‘a , Expires 02-06-2023 figw-fi’; Comm. Notary ID 4016469 ”~f.3§.ff-“ Notice of Assignment: We have an assugn'ment of the patients claim for damages and Injunes to the extent arising from the accident/incident. Patient History - Summary that we have provided medical services In treating By Date of Service the injuries, therefore. we are entitled. to payment. - 5 J KECHEJIAN MD PA It does not Date ranges 05/07/2019 to 04fl6/2021 If payment is made to patient, 200 W Colorado Blvd constitute payment to us. All Provides Dallas, TX 75208 Show last billed date 2 1 4—946- 1 177 Open Items Only Chart #: 34763 Home Phone: _ ‘I Patient Name: MARTINEZ,ALFREDO Office Phone: Address: .- Resp. Party: MARTINEZ,ALFREDO City, State, Zip: DALLAS, TX 75228 Resp. Acct# - U Code Source I B Service Prov Visit#l Charge Paid/ Patient Insurance Total Last Billed Date Billed .. Resp Party . Date check# Amount Applied Balance Balance Balance‘ Carrier This Charge 99213 Y N 7/24/2019 JT75 1540048 $187.00 $0.00 $0.00 $187.00 $187.00 290042 992 13 Y N 7/ 1/20 19 F7 5 1537294 $187.00 $0.00 $0 .00 $187 .00 $187 .00 290042 97010 ‘1’ N 7/1/2019 I175 1537294 $51.00 $0.00 $0.00 $51.00 $51.00 290042 ' ‘ 97014 Y N 7/1/2019 1175 1537294 $67.00 $0.00 $0.00 $67.00 $67.00 ‘ 290042 97035 Y N 7/1/2019 1175 1537294 $70.00 $0.00 $0.00 $70.00 $70.00 290042 97010 Y N 6/28/2019 JT75 1539827 $51.00 $0.00, $0.00 $51.00 $51.00 290042 97014 Y N 6/28/2019 J'l75 1539827 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 6/28/2019 JT75 1539827 $70.00 $0.00 $0.00 $70.00 $70.00 290042 97010 Y N 6/26/2019 JT75 1537296 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 ‘1’ N 6/26/2019 1175 1537296 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 6/26/2019 1175 1537296 $70.00 $0.00 $0.00 $70.00 $70.00 290042 I 97010 Y N 6/ 17/2019 JT75 1537297 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 6/17/2019 3175 1537297 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 6/17/2019 JT75 1537297 $70.00 $0.00 $0.00 $70.00 $70.00 . 290042 97010 Y N 6/14/2019 3175 1537583 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 6/14/2019 JT75 1537583 $67.00 $0.00 $0.00 $67.00 $67.00 4 290042 1 97035 Y N 6/14/2019 J175 1537583 $70.00 $0.00 $0.00 $70 .00 $70. 00 290042 * U = Unapplied * I = 3:]? Insurance * B = Insurance Billed Generated 4/26/2021 01:26:32 PM ”WWAdvancedm Page 1 of 3 Notice of Assignment: We have an assignment of the patients claim for damages and injuries Patient History - Summary , arising from the accident/incident/to the extent By Date of Service that we have provided medical services treating In 5 J KECHEiIAN MD PA we are Date ranges 05/07/2019 to 04/26/2021 the injuries, therefore, entitledtc payment. 200 W Colorado Blvd If payment is made to patient. it does not All Providers constitute payment to us. Dallas, TX75208 Show last billed date 214-945-1177 Open Items Only Chart #: 34763 Home Phone: _ Patient Name: MARTINEALFREDO Office Phone: Address: — Resp. Party: MARTENEZ,ALFREDO City, State, Zip: DALLAS, TX 75228 Resp. Acct# - _ U Code Source I B Service Prov Visit#/ Charge Paid] Patient Insurance Total Last Billed Date Billed -. Resp Party Date . Check# Amount Applied Balance Balance Balance Carrier This Charge 97010 Y N 6/13/2019 3175 1537298 $51.00 - $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 6/13/2019 J175 1537298 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 6/13/2019 3175 1537298 $70.00 $0.00 $0.00 $70.00 $70.00 290042 ‘ Y 97010 N 6/11/2019 3175 1537344 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 6/11/2019 JT75 1537344 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 6/11/2019 J'l75 1537344 $70.00 $0.00 $0.00 $70.00 $70.00 290042 99214 Y N 6/10/2019 3175 1533490 $237.00 $0.00 $0.00 $237.00 $237.00 290042 97010 Y N 5/22/2019 3175 1533487 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 5/22/2019 J'l75 1533487 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 5/22/2019 J'I75 1533487 $70.00 $0.00 $0.00 $70.00 $70.00 290042 97010 Y N 5/20/2019 3175 1533486 $51.00 $0.00 $0.00 $51.00 $51.00 290042 97014 Y N 5/20/2019 3175 1533486 $67.00 $0.00 $0.00 $67.00 $67.00 290042 97035 Y N 5/20/2019 J'l75 1533486 $70.00 $0.00 $0.00 $70.00 $70.00 290042 99213 Y N 5/16/2019 J'l75 1531684 $187.00 $0.00 $0.00 $187.00 $187.00 290042 RX096 Y N 5/10/2019 J'l75 1534144 $39.66 $0.00 $0.00 $39.66 $39.66 290042 RX096 Y N 5/10/2019 J'I75 1534144 $56.82 $0.00 $0.00 $56.82 $56.82 290042 h 72040 Y N 5/9/2019 3175 1531681 $30.00 $0.00 $0.00 $250.00 $250.00 290042 * U = Unapplied * I = Bill Insurance * B = Insurance Billed Generated 4/26/2021 01:26:32 PM W W Advancedm Page 2 of 3 Notice of Assignment: We have an assignment of the patients ctaim for damages and InjUI'IES Patient History - Summary 5 arising from the accidentfrncident. to the extent ' BY Date of Service . that we have provided medical services in treating 5 J KECHEIIAN MD PA = lme injurieS, therefore, Date ranges 05/07/2019 to ’ wcteoar:agr‘;tli1ttleditto(guess/arming:é 04/26/2021 Nd gunfigt‘: fiafinefligeus. €331: C'Il‘géogaggilg Show lee:I i3:::l::: 214-946-1177 Open Items Only Chart #: 34763 Home Phone: _ Patient Name: MAR‘I'INEZ,ALFREDO Office Phone: Address: _ Resp. Party: MARTINEALFREDO - ' City, Slate, Zip: DALLAS, TX 75228 Resp. Acct# U Code Source I B Service Prov Visit#/ Charge Paid I Patient Insurance Total Last Billed Date Billed Resp Party Date Check# Amount Applied Balance Balance Balance Carrier This Charge 72100 Y N 5/9/2019 1175 1531681 $265.00 $0.00 $0.00 $265.00 $265.00 290042 99203 Y N 5/7/2019 N75 1531629 $325.00 $0.00 $0.00 $325.00 $325.00 290042 E0190* Y N 5/7/2019 J'i75 1531629 $72.00 $0.00 $0.00 $72.00 $72.00 290042 £1200 Y N 5/7/2019 J'I75 1531629 $72.00 $0.00 $0.00 $72.00 $72.00 290042 Grand Total: $3,570.48 $0.00 $0.00 $3,570.48 $3,570.48 * U = Unapplied * I = Bill Insurance * B = Insurance Billed Generated 4/26/2021 01:26:32 PM ’WwW/idvancedm Page 3 of 3 Cause No. DC-Zi-M276 ALFREDO MARTINEZ § IN THE DISTRICT COURT PLAINTIFF, § § § § I34!h JUDIClAL COURT v. § § JOSHUA FARMER, § DALLAS COUNTY, TEXAS DEFENDANT. § MEDICAL NECLSSITY REC RDS AFFIDAVIT SJ KECHEJiAN MD PA BEFOL: cfi; undersi authority, on this day persenaliy appeared 76/. MWAIEeé‘ZZ Pay film, after being by me first duly sworn, on oath deposed and said: vamclemm/ ‘ . My name is C;a‘H’W , I am ever ]8 years of age, of sound mind, capable ofmaking {his affidavit arid personally acquainted with the facts herein. .1 am the custodian ef medical records for SJ KECHEJIAN Ml) PA Attached :0 this affidavit are m; pages of medical records for the service that this facility provided to ALFREDO MARTINEZ om f e “I I to "I (as; ('20 i Q The service provided was necessary and the amount charged for the service was reasonable'at the time and place that the service was provided. These attached records exact copies of the originals. Regarding these recerds, I state the following: : are (i) It is in {he regular course ofhusiness to keep these records. (2) It is in fire regular course 'of business for an employee, representative, or doctor with personal lchowledge of the act, event, condition, opinion, or diegnesis recorded to make the memorandum(s) 0r record(s) or to transmit information thereof to be included in such memorandurn(s) or record(s). (3) The entries in the records are made at or near the time of the act, event, or condition described bythe records 0r reasonably soon thereafter. (4) It is our policy not'to release the originals of the records but to make exact duplicates {hereofl whish the attached pages represent. Km, Signature Wfiffiam l/Wm/ AND SWORl‘J to before me, the undersigned authoi'ty, on this thebgfl /day Of 202 1 SUBS-(“$1318 P“ 0’ “tum—14%,. ‘ AUGUSTO o. co Distal}! - ......... «988311,, Public, State of Texas . , Notary . 38%|: 1'8 ‘3 fog:Comm. Expires 02-06-2023 5293' NotarylD 4016460 '1 . Automated Certificate of eService This automated certificate of service was created by the efiling system. The filer served this document via email generated by the efiling system on the date and to the persons listed below. The rules governing certificates of service have not changed. Filers must still provide a certificate of service that complies with all applicable rules. Nida Rafi on behalf of Hazim Mandavia Bar No. 24096984 Nida@theamslawgroup.com Envelope ID: 53662481 Status as of 5/24/2021 11:16 AM CST Associated Case Party: ALFREDO MARTINEZ Name BarNumber Email TimestampSubmitted Status Sam Almasri sam@theamlawgroup.com 5/20/2021 4:46:47 PM SENT Hazim Mandavia hazim@theamlawgroup.com 5/20/2021 4:46:47 PM SENT Carolina Alzate carolina@theamlawgroup.com 5/20/2021 4:46:47 PM SENT Hashem Saad Hashem@theamlawgroup.com 5/20/2021 4:46:47 PM SENT Manuela Morales manuela@theamlawgroup.com 5/20/2021 4:46:47 PM SENT Associated Case Party: JOSHUA FARMER Name BarNumber Email TimestampSubmitted Status J. Robert Miller rmiller@miller-brown.com 5/20/2021 4:46:47 PM SENT Rebecca Stogner rstogner@miller—brown.com 5/20/2021 4:46:47 PM SENT