Party Statement: Guardianship of ADRIAN FLORES, et al. Print

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                                MC-030
    ATTORNEY 0R PARTY WITHOUT ATTORNEY       (Name, stare Bar number, and address):                                                 FOR COURT use ONLY
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         ATTORNEY FOR
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                           (Name):
                                                                                                                        CEWW 0F SANNeg “NARD, NgM
                                                                                                                                  BEPNARDWO D’STRJCT
    SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F San Bernardino                                                                          OCT 2 6 2022
        STREET ADDRESS: 247 West Third Street
        MAILING ADDRESS: 247 West Third Street

       CITY AND ZIP CODE: San Bernardino
               BRANCH NAME:

         PLAINTIFF/PETITIONERZ
                                     SBJC
                                          924 1 5-02 1 2
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                                                                                                                 CASE NUMBER:

                                                 DECLARATION
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         declare under penalty of perjury under the laws of the State of California that the foregoing
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Form Approved for Opfional Use
Judicial Council of California                                                       DECLARATION                                                               Page   1   of   1

MC-O30 [Rem Jlnuary   1,   2006]
Patienfi:      GONZALES, PRISCILLA DOB: Mar              11,   1965
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                                                                                                  ALLIED PACEFIC OF CALIFORNIA


                                                               Authorization Details

 Auth Number:                         AFC     -
                                                    ‘
                                                                            Status:                                        W“
                                      .2022? 01   1799998700043             Acfion      Date;                        10/11/2022
  Health     FEM   AW N°=                                                   Expiration Date:                        10/1 1/2023
  Request Data:                       ‘1   011 1/2022
                                                                            Ram Date:
 Referral Typo:                       VENTRAK. HERNIA
                                      WITHOUT DESTRUCTION
                                      0R GANGRENE
 Cert Type:



 Patient     Name:                    GONZALES, PRISCILLA                   Date of Birth:                          03/1 1/1 965
                                      4922 FLORENCE AVE APT                 Gender;                                 F
                                      20"
                                                                            Member ID:                              71   9W1 293020
                                      85“” CA‘ 902m
                                                                            Member PCP:                             CASABAR, RUBEN s
 Phone:                                                                                                                                 -




 Health Plan:                         ANTHEM BLUE CROSS
                                     MEDICARE


 Referral By:                         CASABA R‘ RUBEN S
 Phone Number:                        {323)   5608880
 Fax Number:                          (323) 562-0288



 Referral Yo;                         ADVANCE SURG EONs                     Address:                                120   w HELLMAN AVE STE
                                      MEDICAL GROUP,                                                               203
 Specialty:                          (GS)    GEN EBAE. SURG ERY                                                    MONTEREY PARK. CA
 POS:                                (1    ”OFFICE                                                                 91754            r




 Facility;                                                                  Phone Numbar:                          (626) 457-6333
                                                                            Fax Number:                            (626) 457—1 933

                                                                           \Facifity   Address:

                                                                            Facility   Phona Number:



    REFERENCE               DIAG CODE                   DESCRfPTION



    1                       K8020                       CALCULUS GB W/O CHOLECYSTITIS W/O OBSTRUC'HON


    2                       K439                        VENTRAL HERNIA WITHOUT OBSTRUCTIQN OR GANG RENE
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    CPT CODE                DESCRIPTION                                     MODIFIER                   DIAG REF             QUANTITY


   99203
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                            OFFICE/OUTPATI ENT VESH"                                                   K439                 1




Document: 2022-10-10 gs          referrall                                                              Printed:   10-17-2022 03:30:57
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