On March 15, 2022 a
Judgment
was filed
involving a dispute between
California Business Bureau Inc.,
and
Banuelos, Jacinto Hernandez,
Banuelos, Maria,
Does 1-10,
for Rule 3.740 Collections $10,000 or Less Limited
in the District Court of San Bernardino County.
Preview
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DocuSign Envelope ID: BBBS7D81—7ZB3-4602-9457-244977DF7BBZ SUPERIOR CO‘U'F-QIT 56F
CALIFORNIA
COUNTY OF SAN BERNA
SAN BERNARDINO DISTRR9g1J'O
'JAN l 9 2023
Calvin F. Love, Bar #307493
800 South Barranca Avenue, Suite 100
Covina,Ca.91723 mrl .m ”a o
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(626) 653-0455
Attorney for Plaintiff
senaida ‘da Mosa
SUPERIOR COURT OF THE STATE OF CALIFORNIA
CENTRAL DISTRICT, COUNTY OF SAN BERNARDINO-LIMITED
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CALIFORNIA BUSINESS BUREAU, ) CASE NOC \“SE’WO-j 2.—
INC
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DECLARATION 1N SUPPORT OF JUDGMENT
Plaintiff
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VS.
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JACINTO HERNANDEZ BANUELOS, )
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16 Defendant
vvvv
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18 Danithy Green
I, , do say and declare:
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If cahed as a witness I would competently testify to all of the following facts which are within
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my personal knowledge. I am the Office Manager for Plaintiff s Assignor, San Antonio
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Regional Hospital. In such capacity I have custody and control of patient financial records and
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accounts. These records are kept and maintained in the ordinary and regular course and scope of
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24 the business 0f Plaintiff’s Assignor. All entries are made at or near the time of the actual event or
25 transaction. I am also familiar with the hospital’s billing practices, and the application of a patient’s
26 insurance benefits.
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San Antonio Regional Hospital is required to file its Chargemaster with the State of
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-1-
DECLARATION IN SUPPORT OF JUDGMENT
DocuSign Envelope ID: BBBB7D81 -7283-4602-9457-244977DF7BBZ
£
California Office of Statewide Health Planning and'Development on a bi-annual basis. The
Chargematers is consistent With the Chargemaster for other hospitals located in the Los Angeles area
The Chaigemaster is based upon the hospital’s experience including the very high percentage of
patients that receive uncompensated care. The uncompensated care is the result of a combination of
mandatory financial assistance, reimbursement from governmental programs below the actual costt
deliver the services, or uncollectible due to bankruptcy or the patient has no resources to pay.
"
Attached as Exhibit “l is the agreement signed by Defendant, Jacinto Hernandez Banuelos, in
which he agreed to pay for hospital services as incurred.
10 At the time the hospital services were incurred, it was indicated that Defendant, Jacinto
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Hernandez Banuelos, was married to Defendant, Maria Banuelos. Defendants provided Blue Shield
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insurance which the hospital billed. The Demographic information is attached as Exhibit “2".
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Attached as Exhibit “3" is the itemized statement for hospital services incurred by the Defendant.
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After applying the Defendant’s insurance benefits an aggregate balance 0f $6,810.18 remains owing.
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16 Defendants were advised that they could apply for financial assistance. The Defendants did not appl <.
17 for financial assistance.
18 Regular and periodic statements 0f the balance were mailed to Defendants. When they failed tc
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pay, the sum of $6,810. 1 8 was assigned to Plaintiff. Attached as Exhibit “4" is the ass'ignment.
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I declare under penalty of perjury that the foregoing is true and correct. Executed at Rancho
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1/3/2023
cucamonga, califomia 0n :DocuSlgned by:
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-2-
DECLARATION IN SUPPORT OF JUDGMENT
Document Filed Date
January 19, 2023
Case Filing Date
March 15, 2022
Category
Rule 3.740 Collections $10,000 or Less Limited
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Preview
F ‘ "D ".. DocuSign Envelope ID: BBBS7D81—7ZB3-4602-9457-244977DF7BBZ SUPERIOR CO‘U'F-QIT 56F CALIFORNIA COUNTY OF SAN BERNA SAN BERNARDINO DISTRR9g1J'O 'JAN l 9 2023 Calvin F. Love, Bar #307493 800 South Barranca Avenue, Suite 100 Covina,Ca.91723 mrl .m ”a o 2 (626) 653-0455 Attorney for Plaintiff senaida ‘da Mosa SUPERIOR COURT OF THE STATE OF CALIFORNIA CENTRAL DISTRICT, COUNTY OF SAN BERNARDINO-LIMITED 10 11 CALIFORNIA BUSINESS BUREAU, ) CASE NOC \“SE’WO-j 2.— INC 12 DECLARATION 1N SUPPORT OF JUDGMENT Plaintiff 13 VS. 14 JACINTO HERNANDEZ BANUELOS, ) 15 16 Defendant vvvv 17 18 Danithy Green I, , do say and declare: 19 If cahed as a witness I would competently testify to all of the following facts which are within 20 my personal knowledge. I am the Office Manager for Plaintiff s Assignor, San Antonio 21 Regional Hospital. In such capacity I have custody and control of patient financial records and 22 accounts. These records are kept and maintained in the ordinary and regular course and scope of 23 24 the business 0f Plaintiff’s Assignor. All entries are made at or near the time of the actual event or 25 transaction. I am also familiar with the hospital’s billing practices, and the application of a patient’s 26 insurance benefits. 27 San Antonio Regional Hospital is required to file its Chargemaster with the State of 28 -1- DECLARATION IN SUPPORT OF JUDGMENT DocuSign Envelope ID: BBBB7D81 -7283-4602-9457-244977DF7BBZ £ California Office of Statewide Health Planning and'Development on a bi-annual basis. The Chargematers is consistent With the Chargemaster for other hospitals located in the Los Angeles area The Chaigemaster is based upon the hospital’s experience including the very high percentage of patients that receive uncompensated care. The uncompensated care is the result of a combination of mandatory financial assistance, reimbursement from governmental programs below the actual costt deliver the services, or uncollectible due to bankruptcy or the patient has no resources to pay. " Attached as Exhibit “l is the agreement signed by Defendant, Jacinto Hernandez Banuelos, in which he agreed to pay for hospital services as incurred. 10 At the time the hospital services were incurred, it was indicated that Defendant, Jacinto 11 Hernandez Banuelos, was married to Defendant, Maria Banuelos. Defendants provided Blue Shield 12 insurance which the hospital billed. The Demographic information is attached as Exhibit “2". 13 Attached as Exhibit “3" is the itemized statement for hospital services incurred by the Defendant. 14 After applying the Defendant’s insurance benefits an aggregate balance 0f $6,810.18 remains owing. 15 16 Defendants were advised that they could apply for financial assistance. The Defendants did not appl <. 17 for financial assistance. 18 Regular and periodic statements 0f the balance were mailed to Defendants. When they failed tc 19 pay, the sum of $6,810. 1 8 was assigned to Plaintiff. Attached as Exhibit “4" is the ass'ignment. 20 I declare under penalty of perjury that the foregoing is true and correct. Executed at Rancho 21 1/3/2023 cucamonga, califomia 0n :DocuSlgned by: 22 23 24 25 26 27 28 -2- DECLARATION IN SUPPORT OF JUDGMENT