On November 30, 2022 a
Party Statement
was filed
involving a dispute between
Becerra-Montes, Antony,
and
Chavez, Angel,
Chavez, Jose M.,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
Preview
FILED ‘
3/22/2023 10:59 AM
1
FELICIA PITRE ;
DISTRICT CLERK
DALLAS CO., TEXAS
Dorothy Strogen DEPUTY
CAUSE N0. DC-22-l6409
ANTONY BECERRA-MONTES,
Plaintiff IN THE DISTRICT COURT
VS.
DALLAS COUNTY, TEXAS
ANGEL CHAVEZ AND JOSE M. 1.92”" JUDICIAL DISTRICT
CHAVEZ,
Defendant
PLAINTIFF ANTONY BECERRA-MONTES’S NOTICE OF FILING AFFIDAVITS
TO: Defendants, Angel Chavez and Jose M. Chavez, by and trough his attorney of record; W.
Todd Parker and John. Roddy Pace, The Parker Firm, P.C., 6115 New Copeland Rd., Suite
320, Tyler, Texas 75703.
You are hereby notified that Plaintiff, Antony Becerra-Montes, has filed in the above
entitled and numbered cause, the following records, pursuant to Chapter 18 of the Texas Civil
Practice & Remedies Code and Rule 902 of the Texas Rules of Evidence:
]. Momentum Spine & Joint (Billing)
These records (or portions thereof) will be offered as evidence at the trial on the merits of this
case.
Plaintiff's Notice of Filing Affidavits Page 1
DATE: March 22 , 20 23
Respectfllii su dmitted.
By
DElvi
I Sikohm
State Bar NO. 11658563
DAVID S. KOHM & ASSOCIATES
1414 W. Randol Mill Road, Suite 118
Arlington, Texas 76012
Tel: (817) 226—8100 Fax: (817) 200-0111
Email: lit-efile@attorneykohm.com
ATTORNEYS FOR PLAINTIFFS
CERTIFICATE OF SERVICE
I hereby cefiify that on this 22nd day of March , 20 23 a true and correct
copy of the above and foregoing document was served via (as indicated below):
Via E-Filer Sergicla
W. Todd Parker
John Roddy Pace
61 15 New Copeland Rd, Suite 320
Tyler, Texas 75703
Tel: 903-595-4541
Fax: 903-595«2864
mark eflnfit‘markerfi111111030111
i rpace@parkerfi.rmnc.com
ATTORNEY FOR DEFENDANT
ATTORNEY FOR PLAINTIFFS
r 1'
Dav id S- Kohm
BILLING RECORDS AFFIDAVIT
(Pursuant to Tex. R. Evid. 902)
PATIENT’S NAME: ANTONY BECERRA MONTES
PATIENT’S DATE OF BIRTH: 09/27/2001
STATE or TEXAS §
COUNTY OF DALLAS §
Before me, the undersigned authority, personally appeared Marissa Palacios, being by
me duly sworn, deposed as follows:
My name is Marissa Palacios. I am of sound mind and capable of making this affidavit,
and personally acquainted with the facts herein stated:
I am the custodian of billing records for MOMENTUM SPINE AND JOINT. I am
familiar with the manner in which the facility’s billing records are created and maintained by virtue
of my duties and responsibilities. Attached hereto are g pages of billing records from
MOMENTUM SPINE AND JOINT. These billing records are kept in the regular course of
business, and it was the regular course of business for an employee or representative of
MOMENTUM SPINE AND JOINT, with knowledge of the act, event, condition, opinion, or
diagnosis, recorded to make the billing records or to transmit information thereof to be included
in such records; and the billing records were made at or near the time or reasonably soon thereafter.
The billing records attached hereto are the original or exact duplicates of the original.
Total charges for the services rendered: $975.00
1.2.3.4.
The amount actually paid by the patient or on the patient’s behalf: $_0.9fl
Amount, if any, adjusted or written off: M
Any amount currently unpaid but which the facility has a right to be paid after any
adjustments or credits: $975.00
_.MZ// Affi'ant /'
SWORN TO AND SUBSCRIBED before me on t th day oprril, 2022.
sxgt‘v'u'w,
....° 4 comm mos
1,,
)
Notary Public. State of Texas
tlry Pu iate of Texas
23%;; ~%3’a'= Comm. Expires 03.244025 1c
"angst? Notary ID 133290188
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.
Taylor Brown on behalf of David Kohm
Bar No. 11658563
taylorb@attorneykohm.com
Envelope ID: 73895936
Filing Code Description: Affidavit
Filing Description: - MOMENTUM SPINE & JOINT (BILLING)
Status as of 3/22/2023 11:56 AM CST
Associated Case Party: ANGEL CHAVEZ
Name BarNumber Email TimestampSubmitted Status
W. Todd Parker tparker@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT
John RoddyPace Jrpace@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT
Krystal Cleveland kcleveland@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT
Document Filed Date
March 22, 2023
Case Filing Date
November 30, 2022
Category
MOTOR VEHICLE ACCIDENT
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FILED ‘ 3/22/2023 10:59 AM 1 FELICIA PITRE ; DISTRICT CLERK DALLAS CO., TEXAS Dorothy Strogen DEPUTY CAUSE N0. DC-22-l6409 ANTONY BECERRA-MONTES, Plaintiff IN THE DISTRICT COURT VS. DALLAS COUNTY, TEXAS ANGEL CHAVEZ AND JOSE M. 1.92”" JUDICIAL DISTRICT CHAVEZ, Defendant PLAINTIFF ANTONY BECERRA-MONTES’S NOTICE OF FILING AFFIDAVITS TO: Defendants, Angel Chavez and Jose M. Chavez, by and trough his attorney of record; W. Todd Parker and John. Roddy Pace, The Parker Firm, P.C., 6115 New Copeland Rd., Suite 320, Tyler, Texas 75703. You are hereby notified that Plaintiff, Antony Becerra-Montes, has filed in the above entitled and numbered cause, the following records, pursuant to Chapter 18 of the Texas Civil Practice & Remedies Code and Rule 902 of the Texas Rules of Evidence: ]. Momentum Spine & Joint (Billing) These records (or portions thereof) will be offered as evidence at the trial on the merits of this case. Plaintiff's Notice of Filing Affidavits Page 1 DATE: March 22 , 20 23 Respectfllii su dmitted. By DElvi I Sikohm State Bar NO. 11658563 DAVID S. KOHM & ASSOCIATES 1414 W. Randol Mill Road, Suite 118 Arlington, Texas 76012 Tel: (817) 226—8100 Fax: (817) 200-0111 Email: lit-efile@attorneykohm.com ATTORNEYS FOR PLAINTIFFS CERTIFICATE OF SERVICE I hereby cefiify that on this 22nd day of March , 20 23 a true and correct copy of the above and foregoing document was served via (as indicated below): Via E-Filer Sergicla W. Todd Parker John Roddy Pace 61 15 New Copeland Rd, Suite 320 Tyler, Texas 75703 Tel: 903-595-4541 Fax: 903-595«2864 mark eflnfit‘markerfi111111030111 i rpace@parkerfi.rmnc.com ATTORNEY FOR DEFENDANT ATTORNEY FOR PLAINTIFFS r 1' Dav id S- Kohm BILLING RECORDS AFFIDAVIT (Pursuant to Tex. R. Evid. 902) PATIENT’S NAME: ANTONY BECERRA MONTES PATIENT’S DATE OF BIRTH: 09/27/2001 STATE or TEXAS § COUNTY OF DALLAS § Before me, the undersigned authority, personally appeared Marissa Palacios, being by me duly sworn, deposed as follows: My name is Marissa Palacios. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated: I am the custodian of billing records for MOMENTUM SPINE AND JOINT. I am familiar with the manner in which the facility’s billing records are created and maintained by virtue of my duties and responsibilities. Attached hereto are g pages of billing records from MOMENTUM SPINE AND JOINT. These billing records are kept in the regular course of business, and it was the regular course of business for an employee or representative of MOMENTUM SPINE AND JOINT, with knowledge of the act, event, condition, opinion, or diagnosis, recorded to make the billing records or to transmit information thereof to be included in such records; and the billing records were made at or near the time or reasonably soon thereafter. The billing records attached hereto are the original or exact duplicates of the original. Total charges for the services rendered: $975.00 1.2.3.4. The amount actually paid by the patient or on the patient’s behalf: $_0.9fl Amount, if any, adjusted or written off: M Any amount currently unpaid but which the facility has a right to be paid after any adjustments or credits: $975.00 _.MZ// Affi'ant /' SWORN TO AND SUBSCRIBED before me on t th day oprril, 2022. sxgt‘v'u'w, ....° 4 comm mos 1,, ) Notary Public. State of Texas tlry Pu iate of Texas 23%;; ~%3’a'= Comm. Expires 03.244025 1c "angst? Notary ID 133290188 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. Taylor Brown on behalf of David Kohm Bar No. 11658563 taylorb@attorneykohm.com Envelope ID: 73895936 Filing Code Description: Affidavit Filing Description: - MOMENTUM SPINE & JOINT (BILLING) Status as of 3/22/2023 11:56 AM CST Associated Case Party: ANGEL CHAVEZ Name BarNumber Email TimestampSubmitted Status W. Todd Parker tparker@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT John RoddyPace Jrpace@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT Krystal Cleveland kcleveland@parkerfirmpc.com 3/22/2023 10:59:28 AM SENT