Preview
NO. 21-DCV-286847
RICARDO MENDOZA, ROLAND § IN THE DISTRICT COURT
PEREZ, ALLAN MAJANO, ROBERTO 8
LIMAS, and EBER CARDONA §
Plaintiff,
V. 240th JUDICIAL DISTRICT
YANIEL LOPEZ GONZALEZ and YLG
TRANSPORT LLC
Defendant. § OF FORT BEND COUNTY, TEXAS
PLAINTIFFS NOTICE OF FILING AFFIDAVITS CONCERNING
COST & NECESSITY OF SERVICES AND AFFIDAVITS WITH
ATTACHED BUSINESS RECORDS
I
Pursuant to TEXAS CIVIL PRACTICE AND REMEDIES CODE § 18.001 and/or
Rule
902(10) of the TEXAS RULES OF CIVIL EVIDENCE, you are hereby notified that Plaintiff
has filed. .
with the clerk of the court, the following affidavits:
Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper
Chiropractic, dated November 22, 2021, with 3 pages of Billing Records of Ricardo
Mendoza;
Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper
Chiropractic, dated November 22, 2021, with 65 pages of Medical Records of Ricardo
Mendoza;
Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper
Chiropractic, dated November 22, 2021, with 1 pages of Billing Records of Roberto
Limas;
Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper
Chiropractic, dated November 22, 2021, with 20 pages of Medical Records of Roberto
Limas;
Il.
Plaintiff intend to offer these affidavits and records into evidence in the trial of the above-
captioned cause. The affidavits and records proved up by way of affidavit have been produced to
counsel of record or are available for inspection and copying at 6611 N. Main, Houston, Texas
77009.
Further, pursuant to Rule 902(10)(a) of the TEXAS RULES OF CIVIL EVIDEN
CE, these
records will be made available by the Clerk of the Court to counsel for all parties
to this litigation for
inspection and copying at the expense of the counsel requesting such copies.
Respectfully submitted,
/s/ Christopher J. Davila
Christopher J. Davila
State Bar No: 24095459
Jesus G, Davila
State Bar No: 05455270
6611 North Main Street
Houston, Texas 77009
(713) 868-8044
(713) 868-9122 Fax
jdavila@thedavilalawfirm.com
cdavila@thedavilalawfirm.com
ATTORNEYS FOR PLAINTIFF
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the attached has been forwarded
to all
known counsel of record by email/e-file and/or facsimile and/or regular
mail and/or certified
mail, return receipt requested, on this 14th day of December, 2021.
Ce: Nick Lanza
LANZA LAW FIRM, P.C,
2502 Algerian Way
Houston, Texas 77098
eservice @lanzalawfirm.com
rvincent@|anzalawfirm.com
/s/ Christopher J. Davila
Christopher J. Davila
NO. 21-DCV-286847
RICARDO MENDOZA, ROLAND § IN THE DISTRICT COURT
PEREZ, ALLAN MAJANO, ROBERTO §
LIMAS, and EBER CARDONA §
Plaintiff,
v. 240th JUDICIAL DISTRICT
YANIEL LOPEZ GONZALEZ
and YLG
TRANSPORT LLC
§ OF FORT BEND COUNTY, TEXAS
Affidavit of Records Custodian of Hooper
STATE OF TEXAS 8
COUNTY OF HARRIS §
BEFORE ME, the undersigned authority, personally appeared Clifford Ryan Hooper who,
being me duly swom, deposed as follows:
“My name is Cliff Ryanord
Hooper I am of sound mind and capable of making this affidavit,
and personally acquainted with the facts herein stated. I am a custodian of records for Hooper
ic. Attached to this affidavit are records that provide an itemized statement of the service
and the charge for service that ;
ic provided to Ricardo Mendoza on 01/12/21 thru
7/15/21. The attached records are a part of this affidavit.
The attached records are kept by Hooper Chiropractic in the regular course of business, and it
was the regular course of business of ic for an employee or representative of Hooper
ic with knowledge of the service provided, to make the record or to transmit information to
be included in the record, The records were made in the regular course of business at or near the time
or reasonably soon after the time the service was provided. The records are the original or a duplicate
of the original.
‘The services provided were necessary and the amount charged for the service was reasonable at
the time and place that the services were provided,
The total amount paid for the services was $ 0.00 and the amount sumenly unpaid but which
Hooper Chiropractic has a right to be paid after any adjus
O-c
lifford Ryan Hooper
SUBSCRIBED AND SWORN to before me this 14 day of Reem, 01,
TANIA S LOPEZ.
NOTARY PUBLIC.
ID# 131644345 Notary Public in and For the State of Texas
te
Comm. E;So OF 182020
Mooper Chiropractic
520 w 15th at
edmond, OK 73023
405-285-7325
ID#: 462770676
Clifford Hooper MPIOr 4215373410
Thursdey July 15, 2021
Patient Ricardo Mendoza #3208
Itemized Statemen: 01/12/2021 = 07/18/2021
B
Onset date
Mail to:
Ricardo Mendosa
9009 Barkiey
Mouston, TX 77017
Insured juranse Cerrier (primary)
DoB:
Policy
Current Di, nosis
M50.01 ervi. disc disorder with
M51.16 Intervertebral disc disordersmyelop
with
athy, high cervical r
M99.02 Segmental and somatic dysfunction ofradic ulopathy, lumba
cervical region
M99.07 Segmental and somatic dysfunction of upper extrem
M99.03 Segmental and somatic dysfunction of lumbar regionity
M99.05 Segmenta. and somatic dysfunction of
$13. 4xxA Sprain of ligaments of cervical spine, pelvic region
initial encounter
$46.912A Strain of unspec. muscle, fasc, tend. shoul
S33. 5xXxA Sprain of ligaments of lumbar spine, initial encounter4 left arm, init. enct.
Gaa 209 Tension-type headache, unspecified, not intractable
MS4.2 Cervicalgia
25.512 Pain in left shoulder
Date Description
Amount
01/12/21 99203 25 New Patient Exam Expanded
01/12/21 72040 X-Ray Cervical 2/3 view 150.00
01/12/21 72070 X-Ray Thoracic 2 View 200.00
01/12/21 72100 X-Ray Lumbar 2 View 200.00
01/12/21 98941 Adjustment 3-4 Areas 200.00
01/12/21 98943 Adjustment Extremity 80.00
02/12/21 97110 59 Thera: utic Exercises $5.00
01/12/21 97012 Mechanical Traction 55.00
01/14/21 96941 Adjustment 3-4 Areas 35.00
01/14/21 98943 Adjustment Extremity 80.00
01/14/21 97012 Mechanical Traction $5.00
01/14/22 97140 59 Manual Therapy 35,00
01/19/21 98941 Adjustment 3-4 Areas 80.00
01/19/21 98943 Adjustment Extremity 80.00
01/19/22 97012 Mechanical Traction 55.00
01/19/21 97110 $9 Therapeutic Exercises 35.00
91/21/21 96942 Adjustment 3-4 Ar: a 55.00
91/21/21 98943 Adjustment Extremity 80.00
91/21/21 97012 Mechanical Traction 55.00
21/21/23 97110 59 Therapeutic Exercises 35.00
91/26/21 98941 Adjustment 3-4 Areas $5.00
91/26/21 98943 Adjustment Extremi 80.00
91/26/21 97012 Mechanical Traction 55.00
22/26/21 97140 $9 Manual Therapy 35.00
23/02/21 Adjustment 3-4 Areas 40.00
93/02/21 peda Adjustment Extremity 80.00
23/02/21 97012 Mechanical Traction 55.00
93/02/21 97110 59 Therapeutic Exercis: 35.00
33/04/21 geoa1 Adjustment 3- Areas 55.00
23/04/21 989. Adjustment Extremity 80.00
93/04/72 97012 Mechanical Traction 55.00
23/04/21 97110 59 Therapeutic Exercises 35.00
55.00
oe 2 Patient: Ricardo Mendoza
Date Description
Amount
03/06/21 98941 Adjustment 3-4 Areas
03/06/21 98943 Adjustment Extremity 80.00
03/06/21 97012 Mechanical Traction 55.00
03/06/21 97110 S9 Therapeutic Exercises 35.00
03/26/21 96941 Adjustment 3-4 areas 55.00
03/26/21 98943 Adjustment Extremity 80.00
03/26/21 97012 Mechanical Traction 55.00
03/26/21 97110 59 Therapeutic Exercises 35.00
03/29/21 98943 Adjustment 3-4 Areas 55.00
03/29/21 98943 Adjustment Extremity 80.00
03/29/22 97022 Mechanical Traction 55.00
03/29/21 97110 59 Therapeutic Exercises 35,00
04/01/21 99941 Adjustment 3-4 Ari $5.00
04/01/21 96943 Adjustment Extremity 80,00
0 01/21 97012 Mechanical Traction 55.00
04/01/21 97110 S9 Therapeutic Exercises 35.00
O4/12/21 98941 Adjustment 3-4 Areas 55.00
04/12/21 98943 Adjustment Extremity 80.00
04/12/21 97012 Mechanical Traction 55.00
04/12/21 97110 59 Therapeutic Exercises 35.00
04/19/21 98941 Adjustment 3-4 Areas $5.00
04/19/21 98943 Adjustment Extremity 60.00
04/19/21 97012 Mechanical Traction 55.00
04/19/21 97110 59 Therapeutic Exercises 35.00
04/22/21 98941 Adjustment 3-4 Areas $5.00
24/22/21 98943 Adjustment Extremity 80.00
94/22/21 97012 Mechanical Traction 55.00
04/22/21 97110 S39 Therapeutic Exercises 35.00
25/18/21 96941 Adjustment 3-4 Areas 55.00
95/18/21 98943 Adjustment Extremity 80.00
95/18/21 97012 Mechanical Traction 55.00
35/18/21 97110 59 Therapeutic Exercises 35.00
98/24/21 98941 Adjustment 3-4 Areas 55.00
95/24/21 98943 Adjustm t Extremity 80.00
95/24/22 97012 Mechanical Traction 55.00
98/24/21 97110 59 Therapeutic Exercises 35.00
26/01/21 98941 Adjustment 3-4 Areas 55.00
26/01/21 98943 Adjustment Extremity 80.00
36/01/21 97012 Mechanical Traction $5.00
26/01/21 97110 59 Therapeutic Ex cises 35.00
26/07/21 98941 Adjustment 3-4 Areas 55.00
26/07/21 98943 Adjustment Extremity 80.00
26/07/21 97012 Mechanical Traction 55,00
36/07/21 97110 $9 Therapeutic Exercises 35.00
26/09/21 98941 Adjustment 3-4 areas 55.00
26/09/21 98943 Adjustment Extremity 80.00
26/09/21 97012 Mechanical Traction $5.00
96/09/21 97110 59 Therapeutic Exercises 35.00
26/15/21 99941 Adjustment 3-4 Areas $5.00
26/15/21 98943 Adjustment Extremity 80.00
26/15/21 97012 Mechanical Traction $5.00
26/15/21 97110 S9 Therapeutic Exercises 35.00
26/29/21 96941 Adjustment 3-4 Areas 55.00
26/29/21 98943 Adjustment Extremity 80.00
26/29/21 97012 Mechanical Traction 55.00
26/29/21 97110 59 Therapeutic Exercises 35.00
27/01/21 98941 Adjustment 3-4 Areas 55.00
37/01/21 90943 Adjustment Extremity 80.00
27/01/21 97012 Mechanical Traction 55.00
27/01/22 97110 $9 Therapeutic Exercises 35.00
27/07/21 96941 Adjustment 3-4 Areas 55.00
27/07/21 98943 Adjustment Extremity 80.00
27/07/21 97012 Mechanical Traction 55.00
27/07/21 97110 59 Therapeutic Exercises 35.00
27/18/21 96941 Adjustment 3-4 Ar 55.00
27/15/21 98943 Adjustment Extremity 80,00
27/15/21 97012 Mechanical Traction $5.00
d7/15/21 97110 59 Therapeutic Exercises 35,00
55.00
total Sales Tax 0.00
total Late Charges 0.00
Sotal Interest Charges 9.00
vatients-Cash Reva 0.00
vatients-Chks Revd c.00
je 3 Patient: Ricardo Mendoza
Patients-Crdt Crd 0.00
Payer Payments 0.00
Total Charges 6160.00
Total Received 0.00
Total Adjustment 0.00
Balance (based on search) :! 6160.00
NO. 21-DCV-286847
RICARDO MENDOZA, ROLAND § INTHE DISTRICT COURT
PEREZ, ALLAN MAJANO, ROBERTO
LIMAS, and EBER CARDONA
v. 240th JUDICIAL DISTRICT
YANIEL LOPEZ GONZALEZ
and YLG
TRANSPORT LLC
; OF FORT BEND COUNTY, TEXAS
AFFIDAVIT
BEFORE ME, the undersigned
authority, personally appeared C' Head being
by me
duly sworn, deposed as follows:
My name i WC fal pec am of soon ind ad capable of making this vi, nd
personally acquainted with
Tam the custodian of records of Hooper Chiropractic, Attached hereto are © pages of records
treatmentfor Ricardo Mendoza. These said OS” pagesof
records are kept by Hooper Chiropractic in the regular course of business, and it was the regular course
of businessof for an employee or representativeof with
knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record orto transmit
information thereof to be included in such record; and the record was made at or near the time or
Teasona soon thereafter.
ble The records attached hereto are the original or exact duplicates of the
ge
original
SUBSCRIBED
AND SWORNto before me this__ 2°-2~"day of Noreonh-2001,
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and For the State of Towam_ GAM Aan
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2010061# { # 19001023
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10% EXP, 01/29/23
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PATIENT INTAKE
numer caro £7 Z2 Age_3
7 Gender: @ F Today's Date:
‘Home Address: Home Phone: ( )
City, State, Zip: Work Phone: ( )
Email Address: Cell Phone: (FF
Birth Date: Social
Security: SE Marital suus: SM b/w
Occupation: Se /E Cun trae for Employer Name:
Spouse’sName: {77 da /7 Jye2 Spouse's Birthdate: SN Do you have any children?(Yeg No
How were you referred to this office? Law ce
i I give my consent to be contacted by text and/or email regarding information including but not limited two insurance coverage, diagnostic tests
(Le. MRI), receipts, and eppointment scheduling. I understand that my protected heelth information may not be securely protected by this office’s
‘email provider or my personal email carrier.
PURPOSE OF THIS VISIT
at
Is this purpose related to un auto accident / work No Ifs0, when: _AVo Qe 1020
Describe: Ht by Semi behind
Please describe the pain & its location: A/éck , backe Shovicls
Indicate your current level of pain from @ (No Pain) to 10 (Exeruciating): 0 1 23 41596 7.89 10
When did this condition
begin? 1 / 27/220 Whendid
you rt noticeitr Jake hot vvgltt
Is this condition
getting worse? Yes No
Does complaini(s)
In this condition: Constant’, Comes & goes Activity related Plea t+
inverfere with: “Work iSleep “Hobbies :-Deily Routine Explain: LFting
F4, bensling ec ning deery
‘What activities aggravate your symptoms? _€ ve Lrwks -2-7t* pr
Ia there anything that has relieved your symptoms? Yes(No ) Deveribe._ Ty lero) — Aeff/e OT Cony” gh ,
Have you experienced this condition before? Yes(N9 If 30, please explain:
Have you had treatment anywhere else for this condition? Yes (Np! What type of treatment?
6,6l bi ks
HEALTH LIFESTYLE
Do you exercise? (gi No How often?(i32X 3X 4X 5X per week other: __
What sctivities?Running Jogging Weight Training
Cycling Yogn Pilates Swimming Other: _W/../king
Do you smoke? Yes (ip) How much?
Do you drink sicohol? Yes ® How ameh
/ week?
Do you drink coffee? (Ye) No How many cups/day? Ore par Ag
Do you take any supplements (i.¢. vitamins, minerals, herbs)? L, be.
‘Have you seen a Chiropractor before? YeaQ Approximately
last visit to Chiropractor?
‘How did you respond?
Please use the diagram to indicate where
the type of pain or discomfort
following
the key below:
A~ DulVache
N- Numbness
T— Tingling
S ~ Sharp or Stabbing
B—Burning
‘St—Stiffness
Th- Throbbing
D-—Deep
C- Cramping
HEALTH CONDITIONS
Please indicate if you currently have or have a history of any of the following injuries or ilinesses.
© Headaches ® Neck Pain © Allergies/Sinusitis © Dizziness
© Migraines © Pain into shoulders/Arms © Numbness/Tingling in Arms/Hands © Grip Weakness
© TMJ Pain/clicking © Low Energy/Fatigue ©Visual or Hearing Trouble Mid Back Pain
© Pain around ribs/chest © Indigestion/Heartbum © Nausea © Asthma/Wheezing
© Shortness
of Breath © Heart Conditions © Diabetes © Uleers/Gastritis
© Low Back Pain ‘© Numbness/Tingling
in Legs/Feet © Pain into Hips/legs/feet © Weakness
in legs/feet
© Constipation/Diarrhes ©Cramping in legs/feet © Cold hands/feet © Frequent urination
2 Scoliosis © Thyroid Conditions © Dislocations/Fractures 0 Cancer
© “Hump” at base
of neck ©Hives/Eczerma © Arthritis © Varicose Veins
‘Women Only: © Menstrual Irregularities Currently Pregnant? Yes No
Please litany medications
mugeria: (2.) x ety ae Cyst [bach nh
Have you ever bad aay injuries to your spine? Yes (No)
FAMILY HEALTH HISTORY
Have any of your family members ever been diagnosed with the following?
© Diabetes © Cancer © Stroke © Heart Disease/Heart Attack © Measles
© Varicose Veins © Polio © Mumps © Neurological Conditions o Kidney Discase
© Liver Disease © Eczema © Depression © Infectious Diseases © Tuberculosis
© Bleeding Disorders © Osteoporosis o Arthritis © Dementia/Alzheimers © Lung Conditions
INSURANCE INFORMATION
T clearly understand thet all insurance coverage, whether accident, work related, or general coverage is an arrangement between my
insura carrier nce
and myself. If this office chooses to bill any services to my insurance carrier that they are performing these
services are strictly as a convenience to me. The Doctors office will provide any necessary reports of required information to aid in
insurance reimbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately
responsible for any unpaid balances. Any monies received will be credited to my account.
understandthere could. some services that my insurance company does not cover, if this is the case are you willing to pey for
these services?YES (please circle)
Patients Signature. KK catde Merndsaz Date
/ - ) 2 — 20 2/
Guardian or Spouse's Signature Authorizing Gare. Date.
“Iheceby authorize Dr. Kevin Morford, Dr. Brenda Hooper, Dr. April Morford and/or Dr. Ryan: Hooper to administer care as deemed necessary to my child, a minor
under the age of 18 years old.
Please only fill out the following information if we have not received a copy of your insurance card
‘Name of Insurance
Co. Policy#.
Phone #
Insured’s Name.
Relationship
to Insured. Subscriber's Birthdate acl acts
Who should receive charges on vour account?
©Patient © Spouse © Parent/Guardian © Workers Comp © Auto Insurance © Personal
Health Insurance
IN CASE OF EMERGENCY
Name 7 dela hoz
Relationship J 7g 25
Work Phone.
Home Phone.
Cell Phone_J 3 2 640 3025
AUTHORIZATION OF CARE and INFORMED CONSENT
T authorize and agree to allow the doctor(s) and/or physical therapist to work with my spine through the use of spinal
adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal biomechanical
and neurological function. I acknowledge and understand that even though negative results are rarely experienced, as with
any form of treatment they are possible. Some of the potential risks may include but are not limited to: fractures, worsening
of symptoms, muscle injury, joint irritation/dislocation. I recognize it is my responsibility to inform of the doctor of any
and all conditions that may affect my care.
Although no significant data shows a correlation between chiropractic adjustments and the cause of stroke, I understand
that there is concem in certain situations and if I have questions | agree to consult with my doctor. In the uncommon case
that negative results from treatment occur at any time, I will notify the doctor immediately so that proper treatment can be
administered and the result noted for future reference.
It is with full understanding and acknowledgment that | authorize and agree to the recommended course of treatment for
conditions related to my spine and joints as prescribed by my doctor in this office.
T understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all
charges.
‘The Doctor and/or physical therapist will not be held responsible for any health conditions or diagnoses which are pre-
nes even ly eens alin care cies, ac: atid foe pln structs Conon agooved at ts
T also clearly understand that if I do not follow the doctors and/or physical therapist specific recommendations at this
clinic that I will not receive the full benefit from these programs, and that if I terminate my care prematurely that all foes
incurred will be due and payable at that time.
[authorize the assignment of all insurance benefits be directed to the doctor and/or chiropractic office(s) for all services
a Keele Ponders
Patient’s Name Printed Patient's signature eee
Minors Name Guardian/Spouse’s
Signature of Authorizing care for minor Date
RADIOGRAPH CONSENT
Ido hereby give my consent to allow this office and its representatives, as deemed by the examining physician
to take radiographsof my spine and/or extremities.
Signature of Patient/or Guardian of said Minor adds Pendens Date 2/12 -ZOZ/
Females Only: Lalso hereby declare that to my knowledge that I am not pregnant ( Initial )
Tre Chiropractic Offices of
Or. Brenda Hooper, Dr. Kevin Morford, Dr. Apri! Morford & Dr. Ryan Hooper
520 W. 15" St Edmond, OK 73013
(p) 405.844.4492 (f) 406.341.8294
CKNOWLEDGMENT OF RECEIPT OF HIPAA
PRIVACY NOTICE
I Reta Meudarz have been made aware of and/or received a copy of
this office's Notice of Privacy Practices. | understand that | have certain rights to privacy regarding
my protected health information. | understand that this information can and will be used to:
. Conduct, plan and direct my treatment and follow-up among the health care providers who may
be directly and indirectly involved in providing my treatment.
° Obtain payment from third-party payers.
° Conduct normal health care operations such as quality assessments and accreditation.
Signature: Keer edo Klndors Date: 2@)- /7- Z2OZ/
Please list anyone you give permission to view your private health records in the case of emergency or
if we are unable to contact or communicate with you.
Name: LG de [2 bur Relationship: _S_go vse
Name: Relationship:
ic
ikiie a ua Sa
We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but
Acknowledgment could not be obtained because:
C1 Individual refused to sign
Communications barriers prohibited obtaining the Acknowledgment
O An emergency situation prevented us from obtaining Acknowledgment
0 Other (Please Specify)
Staff signature
Form Copyright © 2013 by InstaCode institute.
Form may only be copied and/or customized by the owner of this book for use in his/her own office.
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Attention: Allied Health Orthop
edics
From: Dr. Ryan Hooper, D.C.
About: Referral for Ortho Cons
ult.
Patient Name: Ricardo Mendoz
a
Patient phone# 832-212-1748
008:
PATIENT INTAKE
C. atde Fleng 23 Age_s Gender:MF Today 'sDate:_f
Home Address: Home Phone: ( _.
City, State, Zip Work Phone: (
‘Email Address: Cell Phone: (SFJ_Q
2 iZ
sy
Birth Deco: SocialSocurity # ER eitsue:
s Mw
Occupation: Se /f Cy ty Employer Name:
YeNeme: fT de fa Jn Spouse's Birthdate: MMM Do you have any children?(Yes
‘How were you referred to this office? x
@ 1 give my consent to be contacted by text and/or email regarding information inchading bur not limited to insurance coverage, diagnostic tests
(Le. MRD, receipts, and appointment scheduling. I understand that my protected health information may not be securely protected by this office’s
email provider or axy perscaal email carrier.
PURPOSE OF THIS VISIT
Reason
for this visit: Borde vit
+ + i
1s this purpose related to an wuto sccident / wark injury? (Pes No Ifso, 4e em
Describe: Hit by Steins tenn foela
Please describe the pain & its location: ck Dac ic s stichie
beara inci on a ed 01234 s 6 7 8910
‘When did this condition begin? 4flz¢ When did you St notice it? desig bby ght t
Is this condition
getting worse? Yes No Is this condition: ( Constant” Comes
& goes Activity relased Brenthr deer
Does complaint(s) interfere with: Work «Sleep.-Hobbies --Deily Routine Explain:/,—~ “ Nene sins turning
‘What activities aggravate your symptoms? bhang Thangs (eR faite vl? = 2-2t'p.
5
Js there anything thet has relieved your symptoms? Yes“No Desoibe: “Ty Le col — ft. OT Cenk”
Have you experienced
this condition before? Yes(Ny af so, please explain:
Have you had treatment enywhere else for this condition? Yes (No What type of trestment?
6D, liuhgs
HEALTH LIFESTYLE
Do you exercise? Cou No How often? 1% 2X 3X 4X 5X per week other:
What vid? Ramsing eng ‘Weight Training
Cycling Yoga Pilates Swimming Other: kung
Do you smoke? Yes (Nip How auch?
Do you drink alvobet? You ® How much / week?
Do you drink coffee? (Ye) No How many cups / day? 2.7 a dey
‘Do you take any supplements (i.¢. vitamins, minerals, herbs)? te
‘Have you seen a Chiropractor before? Yee Ng Approximately
last visit to Chiropractor? ———
How did you respond?
To whom it may con cern,
Ricardo presented to my offi
ce after an Auto Accident.
After | examined and treate
d him
he showed little to no improv
ement in his left shoulder.
We sent him for an MRI of
his Neck,
Low Back and Left Shoulder whi
ch showed a Partial thickness
tear in his left Shoulder and a
couple of mild to Severe bul
ges in his Cervical and Lumbar
areas. I would like you to hav
e to
consult with him and see if
there is anything you might
be able to do in order to give
him some
longer lasting relief. | have also
attached the MRI report to
this referral. | will also send
the MRI
with the patient so you will be
able to view it as well.
Sincerely,
De
Dr. C. Ryan Hooper, D.C.
Dee rouse X-Ray
Phoae: (713) orn
411W. Packer Ra., SuiteA
Houston, Texas 77091 Fax: (713) 602-2299
Final Radiology Report
Name: MENDOZA, RICARD
O
MRN: 77452NHX Age: 59y Date: 05/28/2021 2:38 PM
Study: MRI CERVICAL sp. DOs: 7
INE W/O CONRAST Requesting Physician: HO
ion: 6210528144. 7 OPER, CLIFFORD
Location code: H5
MRI Cernical Spine
Indication: Neck pain post trauma
Comparison: None.
Tectrical factors: Long and short
as ft- and water-welgtted sequence
s were Obtained. Findings:
Alignmentia saisfactory
Vertebral are of normalhe’
C7. Mild Arterior spondyiosis ight: se eae itera Moderate algnal toss
at the of intervertebral diaks. Mild loss of
height fram C4 to
The Craniocenical junction, atla
ntodental interval, Visualized post
erior fossa and Position af the
cerebellar tonsils appear normal,
Preand Paraspinal soft tissues are normal in
appearance.
The spinal cond is of normal calib
er and signal.
2-3: Unremarkabie.
C3-4: Unremarkable,
C4-5: Broad. based right paracert
ral 2.3
C5-6: Right Paracentral 3.5 mm disc hami mm hemiation iindents the right anterior spinal cord,
C6-7: Broed-besed Hight para ation indents the ventral dural sac
central ind right and spinal cord,
Sntertor spinal cord. Narrowing disc hemiation is more prominent to
of the fight neural Wilh displacement of the right C7
the Fight at 2.8 mm into this right
foramen may be Nerve root. Narrow
C7-T1: Unremarkable. of the
inneura
gl
Neural foramina are patent.
Impression:
1. C4 -5 right paracantral2..3
mm hemiation with cord indentat
2. C5-Ci 6 right paracentral 3.5 mm ion
disc hemiation with cord indentat
3. C8V7 right paracentrata:
tre ceplncee ea ion
foramen moderate or severe eratn indents the ght arkror pina
Cord. Narrowing of the right neural
Electronicaity signed by: Daniel
Backias MD 5/28/2021 4:38 PM
CDT Workstation: 109-0124673
orth Houston X-Ray
www.
Phone: (713) 692-1133 Socthhowstomesy@yahoo
411. Packer Rd, SuiteA com
Fax: (713) 692-2299
‘Texas 77091
Final Radiology Report
Name: MENDOZA, RICA
RDO
MRN: 77452! Age:
Study: MRI LUMBAR SPIN
E W/O CONTRAST
G210528143231725
DOB. —
Requesting Phy
Date: 05/28/2021 2:10 PM
sictan: HOOPER, CLIFFO
RD
Location code: R16
MRI Lumbar Spine
Indication: POST MVA, RADI
CULOPATHYLUMBAR REGION.
Comparison: None.
Techrical factors: Long and
short ends, fat- and water-weight
ed ‘Sequences ware obtained
.
Findings:
Alignment ia satisfactory
Vertabral bodies are of norm
al height and Signal. Mild si
Preview
NO. 21-DCV-286847 RICARDO MENDOZA, ROLAND § IN THE DISTRICT COURT PEREZ, ALLAN MAJANO, ROBERTO 8 LIMAS, and EBER CARDONA § Plaintiff, V. 240th JUDICIAL DISTRICT YANIEL LOPEZ GONZALEZ and YLG TRANSPORT LLC Defendant. § OF FORT BEND COUNTY, TEXAS PLAINTIFFS NOTICE OF FILING AFFIDAVITS CONCERNING COST & NECESSITY OF SERVICES AND AFFIDAVITS WITH ATTACHED BUSINESS RECORDS I Pursuant to TEXAS CIVIL PRACTICE AND REMEDIES CODE § 18.001 and/or Rule 902(10) of the TEXAS RULES OF CIVIL EVIDENCE, you are hereby notified that Plaintiff has filed. . with the clerk of the court, the following affidavits: Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper Chiropractic, dated November 22, 2021, with 3 pages of Billing Records of Ricardo Mendoza; Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper Chiropractic, dated November 22, 2021, with 65 pages of Medical Records of Ricardo Mendoza; Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper Chiropractic, dated November 22, 2021, with 1 pages of Billing Records of Roberto Limas; Affidavit of Clifford Ryan Hooper the Custodian of Billing Records for Hooper Chiropractic, dated November 22, 2021, with 20 pages of Medical Records of Roberto Limas; Il. Plaintiff intend to offer these affidavits and records into evidence in the trial of the above- captioned cause. The affidavits and records proved up by way of affidavit have been produced to counsel of record or are available for inspection and copying at 6611 N. Main, Houston, Texas 77009. Further, pursuant to Rule 902(10)(a) of the TEXAS RULES OF CIVIL EVIDEN CE, these records will be made available by the Clerk of the Court to counsel for all parties to this litigation for inspection and copying at the expense of the counsel requesting such copies. Respectfully submitted, /s/ Christopher J. Davila Christopher J. Davila State Bar No: 24095459 Jesus G, Davila State Bar No: 05455270 6611 North Main Street Houston, Texas 77009 (713) 868-8044 (713) 868-9122 Fax jdavila@thedavilalawfirm.com cdavila@thedavilalawfirm.com ATTORNEYS FOR PLAINTIFF CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the attached has been forwarded to all known counsel of record by email/e-file and/or facsimile and/or regular mail and/or certified mail, return receipt requested, on this 14th day of December, 2021. Ce: Nick Lanza LANZA LAW FIRM, P.C, 2502 Algerian Way Houston, Texas 77098 eservice @lanzalawfirm.com rvincent@|anzalawfirm.com /s/ Christopher J. Davila Christopher J. Davila NO. 21-DCV-286847 RICARDO MENDOZA, ROLAND § IN THE DISTRICT COURT PEREZ, ALLAN MAJANO, ROBERTO § LIMAS, and EBER CARDONA § Plaintiff, v. 240th JUDICIAL DISTRICT YANIEL LOPEZ GONZALEZ and YLG TRANSPORT LLC § OF FORT BEND COUNTY, TEXAS Affidavit of Records Custodian of Hooper STATE OF TEXAS 8 COUNTY OF HARRIS § BEFORE ME, the undersigned authority, personally appeared Clifford Ryan Hooper who, being me duly swom, deposed as follows: “My name is Cliff Ryanord Hooper I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated. I am a custodian of records for Hooper ic. Attached to this affidavit are records that provide an itemized statement of the service and the charge for service that ; ic provided to Ricardo Mendoza on 01/12/21 thru 7/15/21. The attached records are a part of this affidavit. The attached records are kept by Hooper Chiropractic in the regular course of business, and it was the regular course of business of ic for an employee or representative of Hooper ic with knowledge of the service provided, to make the record or to transmit information to be included in the record, The records were made in the regular course of business at or near the time or reasonably soon after the time the service was provided. The records are the original or a duplicate of the original. ‘The services provided were necessary and the amount charged for the service was reasonable at the time and place that the services were provided, The total amount paid for the services was $ 0.00 and the amount sumenly unpaid but which Hooper Chiropractic has a right to be paid after any adjus O-c lifford Ryan Hooper SUBSCRIBED AND SWORN to before me this 14 day of Reem, 01, TANIA S LOPEZ. NOTARY PUBLIC. ID# 131644345 Notary Public in and For the State of Texas te Comm. E;So OF 182020 Mooper Chiropractic 520 w 15th at edmond, OK 73023 405-285-7325 ID#: 462770676 Clifford Hooper MPIOr 4215373410 Thursdey July 15, 2021 Patient Ricardo Mendoza #3208 Itemized Statemen: 01/12/2021 = 07/18/2021 B Onset date Mail to: Ricardo Mendosa 9009 Barkiey Mouston, TX 77017 Insured juranse Cerrier (primary) DoB: Policy Current Di, nosis M50.01 ervi. disc disorder with M51.16 Intervertebral disc disordersmyelop with athy, high cervical r M99.02 Segmental and somatic dysfunction ofradic ulopathy, lumba cervical region M99.07 Segmental and somatic dysfunction of upper extrem M99.03 Segmental and somatic dysfunction of lumbar regionity M99.05 Segmenta. and somatic dysfunction of $13. 4xxA Sprain of ligaments of cervical spine, pelvic region initial encounter $46.912A Strain of unspec. muscle, fasc, tend. shoul S33. 5xXxA Sprain of ligaments of lumbar spine, initial encounter4 left arm, init. enct. Gaa 209 Tension-type headache, unspecified, not intractable MS4.2 Cervicalgia 25.512 Pain in left shoulder Date Description Amount 01/12/21 99203 25 New Patient Exam Expanded 01/12/21 72040 X-Ray Cervical 2/3 view 150.00 01/12/21 72070 X-Ray Thoracic 2 View 200.00 01/12/21 72100 X-Ray Lumbar 2 View 200.00 01/12/21 98941 Adjustment 3-4 Areas 200.00 01/12/21 98943 Adjustment Extremity 80.00 02/12/21 97110 59 Thera: utic Exercises $5.00 01/12/21 97012 Mechanical Traction 55.00 01/14/21 96941 Adjustment 3-4 Areas 35.00 01/14/21 98943 Adjustment Extremity 80.00 01/14/21 97012 Mechanical Traction $5.00 01/14/22 97140 59 Manual Therapy 35,00 01/19/21 98941 Adjustment 3-4 Areas 80.00 01/19/21 98943 Adjustment Extremity 80.00 01/19/22 97012 Mechanical Traction 55.00 01/19/21 97110 $9 Therapeutic Exercises 35.00 91/21/21 96942 Adjustment 3-4 Ar: a 55.00 91/21/21 98943 Adjustment Extremity 80.00 91/21/21 97012 Mechanical Traction 55.00 21/21/23 97110 59 Therapeutic Exercises 35.00 91/26/21 98941 Adjustment 3-4 Areas $5.00 91/26/21 98943 Adjustment Extremi 80.00 91/26/21 97012 Mechanical Traction 55.00 22/26/21 97140 $9 Manual Therapy 35.00 23/02/21 Adjustment 3-4 Areas 40.00 93/02/21 peda Adjustment Extremity 80.00 23/02/21 97012 Mechanical Traction 55.00 93/02/21 97110 59 Therapeutic Exercis: 35.00 33/04/21 geoa1 Adjustment 3- Areas 55.00 23/04/21 989. Adjustment Extremity 80.00 93/04/72 97012 Mechanical Traction 55.00 23/04/21 97110 59 Therapeutic Exercises 35.00 55.00 oe 2 Patient: Ricardo Mendoza Date Description Amount 03/06/21 98941 Adjustment 3-4 Areas 03/06/21 98943 Adjustment Extremity 80.00 03/06/21 97012 Mechanical Traction 55.00 03/06/21 97110 S9 Therapeutic Exercises 35.00 03/26/21 96941 Adjustment 3-4 areas 55.00 03/26/21 98943 Adjustment Extremity 80.00 03/26/21 97012 Mechanical Traction 55.00 03/26/21 97110 59 Therapeutic Exercises 35.00 03/29/21 98943 Adjustment 3-4 Areas 55.00 03/29/21 98943 Adjustment Extremity 80.00 03/29/22 97022 Mechanical Traction 55.00 03/29/21 97110 59 Therapeutic Exercises 35,00 04/01/21 99941 Adjustment 3-4 Ari $5.00 04/01/21 96943 Adjustment Extremity 80,00 0 01/21 97012 Mechanical Traction 55.00 04/01/21 97110 S9 Therapeutic Exercises 35.00 O4/12/21 98941 Adjustment 3-4 Areas 55.00 04/12/21 98943 Adjustment Extremity 80.00 04/12/21 97012 Mechanical Traction 55.00 04/12/21 97110 59 Therapeutic Exercises 35.00 04/19/21 98941 Adjustment 3-4 Areas $5.00 04/19/21 98943 Adjustment Extremity 60.00 04/19/21 97012 Mechanical Traction 55.00 04/19/21 97110 59 Therapeutic Exercises 35.00 04/22/21 98941 Adjustment 3-4 Areas $5.00 24/22/21 98943 Adjustment Extremity 80.00 94/22/21 97012 Mechanical Traction 55.00 04/22/21 97110 S39 Therapeutic Exercises 35.00 25/18/21 96941 Adjustment 3-4 Areas 55.00 95/18/21 98943 Adjustment Extremity 80.00 95/18/21 97012 Mechanical Traction 55.00 35/18/21 97110 59 Therapeutic Exercises 35.00 98/24/21 98941 Adjustment 3-4 Areas 55.00 95/24/21 98943 Adjustm t Extremity 80.00 95/24/22 97012 Mechanical Traction 55.00 98/24/21 97110 59 Therapeutic Exercises 35.00 26/01/21 98941 Adjustment 3-4 Areas 55.00 26/01/21 98943 Adjustment Extremity 80.00 36/01/21 97012 Mechanical Traction $5.00 26/01/21 97110 59 Therapeutic Ex cises 35.00 26/07/21 98941 Adjustment 3-4 Areas 55.00 26/07/21 98943 Adjustment Extremity 80.00 26/07/21 97012 Mechanical Traction 55,00 36/07/21 97110 $9 Therapeutic Exercises 35.00 26/09/21 98941 Adjustment 3-4 areas 55.00 26/09/21 98943 Adjustment Extremity 80.00 26/09/21 97012 Mechanical Traction $5.00 96/09/21 97110 59 Therapeutic Exercises 35.00 26/15/21 99941 Adjustment 3-4 Areas $5.00 26/15/21 98943 Adjustment Extremity 80.00 26/15/21 97012 Mechanical Traction $5.00 26/15/21 97110 S9 Therapeutic Exercises 35.00 26/29/21 96941 Adjustment 3-4 Areas 55.00 26/29/21 98943 Adjustment Extremity 80.00 26/29/21 97012 Mechanical Traction 55.00 26/29/21 97110 59 Therapeutic Exercises 35.00 27/01/21 98941 Adjustment 3-4 Areas 55.00 37/01/21 90943 Adjustment Extremity 80.00 27/01/21 97012 Mechanical Traction 55.00 27/01/22 97110 $9 Therapeutic Exercises 35.00 27/07/21 96941 Adjustment 3-4 Areas 55.00 27/07/21 98943 Adjustment Extremity 80.00 27/07/21 97012 Mechanical Traction 55.00 27/07/21 97110 59 Therapeutic Exercises 35.00 27/18/21 96941 Adjustment 3-4 Ar 55.00 27/15/21 98943 Adjustment Extremity 80,00 27/15/21 97012 Mechanical Traction $5.00 d7/15/21 97110 59 Therapeutic Exercises 35,00 55.00 total Sales Tax 0.00 total Late Charges 0.00 Sotal Interest Charges 9.00 vatients-Cash Reva 0.00 vatients-Chks Revd c.00 je 3 Patient: Ricardo Mendoza Patients-Crdt Crd 0.00 Payer Payments 0.00 Total Charges 6160.00 Total Received 0.00 Total Adjustment 0.00 Balance (based on search) :! 6160.00 NO. 21-DCV-286847 RICARDO MENDOZA, ROLAND § INTHE DISTRICT COURT PEREZ, ALLAN MAJANO, ROBERTO LIMAS, and EBER CARDONA v. 240th JUDICIAL DISTRICT YANIEL LOPEZ GONZALEZ and YLG TRANSPORT LLC ; OF FORT BEND COUNTY, TEXAS AFFIDAVIT BEFORE ME, the undersigned authority, personally appeared C' Head being by me duly sworn, deposed as follows: My name i WC fal pec am of soon ind ad capable of making this vi, nd personally acquainted with Tam the custodian of records of Hooper Chiropractic, Attached hereto are © pages of records treatmentfor Ricardo Mendoza. These said OS” pagesof records are kept by Hooper Chiropractic in the regular course of business, and it was the regular course of businessof for an employee or representativeof with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record orto transmit information thereof to be included in such record; and the record was made at or near the time or Teasona soon thereafter. ble The records attached hereto are the original or exact duplicates of the ge original SUBSCRIBED AND SWORNto before me this__ 2°-2~"day of Noreonh-2001, a plot fp iy, s anit Nay, Public’n $ yey %, My % » ny M. ea and For the State of Towam_ GAM Aan s 2 eUsTILO dX F PROTAR, pa 2010061# { # 19001023 ~daywYa 10% EXP, 01/29/23 = “My, s ww % Ys,Fp PUBLIC, rNeee ge “tiny rien “My, “arin PATIENT INTAKE numer caro £7 Z2 Age_3 7 Gender: @ F Today's Date: ‘Home Address: Home Phone: ( ) City, State, Zip: Work Phone: ( ) Email Address: Cell Phone: (FF Birth Date: Social Security: SE Marital suus: SM b/w Occupation: Se /E Cun trae for Employer Name: Spouse’sName: {77 da /7 Jye2 Spouse's Birthdate: SN Do you have any children?(Yeg No How were you referred to this office? Law ce i I give my consent to be contacted by text and/or email regarding information including but not limited two insurance coverage, diagnostic tests (Le. MRI), receipts, and eppointment scheduling. I understand that my protected heelth information may not be securely protected by this office’s ‘email provider or my personal email carrier. PURPOSE OF THIS VISIT at Is this purpose related to un auto accident / work No Ifs0, when: _AVo Qe 1020 Describe: Ht by Semi behind Please describe the pain & its location: A/éck , backe Shovicls Indicate your current level of pain from @ (No Pain) to 10 (Exeruciating): 0 1 23 41596 7.89 10 When did this condition begin? 1 / 27/220 Whendid you rt noticeitr Jake hot vvgltt Is this condition getting worse? Yes No Does complaini(s) In this condition: Constant’, Comes & goes Activity related Plea t+ inverfere with: “Work iSleep “Hobbies :-Deily Routine Explain: LFting F4, bensling ec ning deery ‘What activities aggravate your symptoms? _€ ve Lrwks -2-7t* pr Ia there anything that has relieved your symptoms? Yes(No ) Deveribe._ Ty lero) — Aeff/e OT Cony” gh , Have you experienced this condition before? Yes(N9 If 30, please explain: Have you had treatment anywhere else for this condition? Yes (Np! What type of treatment? 6,6l bi ks HEALTH LIFESTYLE Do you exercise? (gi No How often?(i32X 3X 4X 5X per week other: __ What sctivities?Running Jogging Weight Training Cycling Yogn Pilates Swimming Other: _W/../king Do you smoke? Yes (ip) How much? Do you drink sicohol? Yes ® How ameh / week? Do you drink coffee? (Ye) No How many cups/day? Ore par Ag Do you take any supplements (i.¢. vitamins, minerals, herbs)? L, be. ‘Have you seen a Chiropractor before? YeaQ Approximately last visit to Chiropractor? ‘How did you respond? Please use the diagram to indicate where the type of pain or discomfort following the key below: A~ DulVache N- Numbness T— Tingling S ~ Sharp or Stabbing B—Burning ‘St—Stiffness Th- Throbbing D-—Deep C- Cramping HEALTH CONDITIONS Please indicate if you currently have or have a history of any of the following injuries or ilinesses. © Headaches ® Neck Pain © Allergies/Sinusitis © Dizziness © Migraines © Pain into shoulders/Arms © Numbness/Tingling in Arms/Hands © Grip Weakness © TMJ Pain/clicking © Low Energy/Fatigue ©Visual or Hearing Trouble Mid Back Pain © Pain around ribs/chest © Indigestion/Heartbum © Nausea © Asthma/Wheezing © Shortness of Breath © Heart Conditions © Diabetes © Uleers/Gastritis © Low Back Pain ‘© Numbness/Tingling in Legs/Feet © Pain into Hips/legs/feet © Weakness in legs/feet © Constipation/Diarrhes ©Cramping in legs/feet © Cold hands/feet © Frequent urination 2 Scoliosis © Thyroid Conditions © Dislocations/Fractures 0 Cancer © “Hump” at base of neck ©Hives/Eczerma © Arthritis © Varicose Veins ‘Women Only: © Menstrual Irregularities Currently Pregnant? Yes No Please litany medications mugeria: (2.) x ety ae Cyst [bach nh Have you ever bad aay injuries to your spine? Yes (No) FAMILY HEALTH HISTORY Have any of your family members ever been diagnosed with the following? © Diabetes © Cancer © Stroke © Heart Disease/Heart Attack © Measles © Varicose Veins © Polio © Mumps © Neurological Conditions o Kidney Discase © Liver Disease © Eczema © Depression © Infectious Diseases © Tuberculosis © Bleeding Disorders © Osteoporosis o Arthritis © Dementia/Alzheimers © Lung Conditions INSURANCE INFORMATION T clearly understand thet all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insura carrier nce and myself. If this office chooses to bill any services to my insurance carrier that they are performing these services are strictly as a convenience to me. The Doctors office will provide any necessary reports of required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately responsible for any unpaid balances. Any monies received will be credited to my account. understandthere could. some services that my insurance company does not cover, if this is the case are you willing to pey for these services?YES (please circle) Patients Signature. KK catde Merndsaz Date / - ) 2 — 20 2/ Guardian or Spouse's Signature Authorizing Gare. Date. “Iheceby authorize Dr. Kevin Morford, Dr. Brenda Hooper, Dr. April Morford and/or Dr. Ryan: Hooper to administer care as deemed necessary to my child, a minor under the age of 18 years old. Please only fill out the following information if we have not received a copy of your insurance card ‘Name of Insurance Co. Policy#. Phone # Insured’s Name. Relationship to Insured. Subscriber's Birthdate acl acts Who should receive charges on vour account? ©Patient © Spouse © Parent/Guardian © Workers Comp © Auto Insurance © Personal Health Insurance IN CASE OF EMERGENCY Name 7 dela hoz Relationship J 7g 25 Work Phone. Home Phone. Cell Phone_J 3 2 640 3025 AUTHORIZATION OF CARE and INFORMED CONSENT T authorize and agree to allow the doctor(s) and/or physical therapist to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal biomechanical and neurological function. I acknowledge and understand that even though negative results are rarely experienced, as with any form of treatment they are possible. Some of the potential risks may include but are not limited to: fractures, worsening of symptoms, muscle injury, joint irritation/dislocation. I recognize it is my responsibility to inform of the doctor of any and all conditions that may affect my care. Although no significant data shows a correlation between chiropractic adjustments and the cause of stroke, I understand that there is concem in certain situations and if I have questions | agree to consult with my doctor. In the uncommon case that negative results from treatment occur at any time, I will notify the doctor immediately so that proper treatment can be administered and the result noted for future reference. It is with full understanding and acknowledgment that | authorize and agree to the recommended course of treatment for conditions related to my spine and joints as prescribed by my doctor in this office. T understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. ‘The Doctor and/or physical therapist will not be held responsible for any health conditions or diagnoses which are pre- nes even ly eens alin care cies, ac: atid foe pln structs Conon agooved at ts T also clearly understand that if I do not follow the doctors and/or physical therapist specific recommendations at this clinic that I will not receive the full benefit from these programs, and that if I terminate my care prematurely that all foes incurred will be due and payable at that time. [authorize the assignment of all insurance benefits be directed to the doctor and/or chiropractic office(s) for all services a Keele Ponders Patient’s Name Printed Patient's signature eee Minors Name Guardian/Spouse’s Signature of Authorizing care for minor Date RADIOGRAPH CONSENT Ido hereby give my consent to allow this office and its representatives, as deemed by the examining physician to take radiographsof my spine and/or extremities. Signature of Patient/or Guardian of said Minor adds Pendens Date 2/12 -ZOZ/ Females Only: Lalso hereby declare that to my knowledge that I am not pregnant ( Initial ) Tre Chiropractic Offices of Or. Brenda Hooper, Dr. Kevin Morford, Dr. Apri! Morford & Dr. Ryan Hooper 520 W. 15" St Edmond, OK 73013 (p) 405.844.4492 (f) 406.341.8294 CKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE I Reta Meudarz have been made aware of and/or received a copy of this office's Notice of Privacy Practices. | understand that | have certain rights to privacy regarding my protected health information. | understand that this information can and will be used to: . Conduct, plan and direct my treatment and follow-up among the health care providers who may be directly and indirectly involved in providing my treatment. ° Obtain payment from third-party payers. ° Conduct normal health care operations such as quality assessments and accreditation. Signature: Keer edo Klndors Date: 2@)- /7- Z2OZ/ Please list anyone you give permission to view your private health records in the case of emergency or if we are unable to contact or communicate with you. Name: LG de [2 bur Relationship: _S_go vse Name: Relationship: ic ikiie a ua Sa We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because: C1 Individual refused to sign Communications barriers prohibited obtaining the Acknowledgment O An emergency situation prevented us from obtaining Acknowledgment 0 Other (Please Specify) Staff signature Form Copyright © 2013 by InstaCode institute. Form may only be copied and/or customized by the owner of this book for use in his/her own office. ii afFE Pty f Z| g. al 8 To\|— 82 2 ARE l i Sie BG ¢ | Qe m ! 7k Bz ae a Attention: Allied Health Orthop edics From: Dr. Ryan Hooper, D.C. About: Referral for Ortho Cons ult. Patient Name: Ricardo Mendoz a Patient phone# 832-212-1748 008: PATIENT INTAKE C. atde Fleng 23 Age_s Gender:MF Today 'sDate:_f Home Address: Home Phone: ( _. City, State, Zip Work Phone: ( ‘Email Address: Cell Phone: (SFJ_Q 2 iZ sy Birth Deco: SocialSocurity # ER eitsue: s Mw Occupation: Se /f Cy ty Employer Name: YeNeme: fT de fa Jn Spouse's Birthdate: MMM Do you have any children?(Yes ‘How were you referred to this office? x @ 1 give my consent to be contacted by text and/or email regarding information inchading bur not limited to insurance coverage, diagnostic tests (Le. MRD, receipts, and appointment scheduling. I understand that my protected health information may not be securely protected by this office’s email provider or axy perscaal email carrier. PURPOSE OF THIS VISIT Reason for this visit: Borde vit + + i 1s this purpose related to an wuto sccident / wark injury? (Pes No Ifso, 4e em Describe: Hit by Steins tenn foela Please describe the pain & its location: ck Dac ic s stichie beara inci on a ed 01234 s 6 7 8910 ‘When did this condition begin? 4flz¢ When did you St notice it? desig bby ght t Is this condition getting worse? Yes No Is this condition: ( Constant” Comes & goes Activity relased Brenthr deer Does complaint(s) interfere with: Work «Sleep.-Hobbies --Deily Routine Explain:/,—~ “ Nene sins turning ‘What activities aggravate your symptoms? bhang Thangs (eR faite vl? = 2-2t'p. 5 Js there anything thet has relieved your symptoms? Yes“No Desoibe: “Ty Le col — ft. OT Cenk” Have you experienced this condition before? Yes(Ny af so, please explain: Have you had treatment enywhere else for this condition? Yes (No What type of trestment? 6D, liuhgs HEALTH LIFESTYLE Do you exercise? Cou No How often? 1% 2X 3X 4X 5X per week other: What vid? Ramsing eng ‘Weight Training Cycling Yoga Pilates Swimming Other: kung Do you smoke? Yes (Nip How auch? Do you drink alvobet? You ® How much / week? Do you drink coffee? (Ye) No How many cups / day? 2.7 a dey ‘Do you take any supplements (i.¢. vitamins, minerals, herbs)? te ‘Have you seen a Chiropractor before? Yee Ng Approximately last visit to Chiropractor? ——— How did you respond? To whom it may con cern, Ricardo presented to my offi ce after an Auto Accident. After | examined and treate d him he showed little to no improv ement in his left shoulder. We sent him for an MRI of his Neck, Low Back and Left Shoulder whi ch showed a Partial thickness tear in his left Shoulder and a couple of mild to Severe bul ges in his Cervical and Lumbar areas. I would like you to hav e to consult with him and see if there is anything you might be able to do in order to give him some longer lasting relief. | have also attached the MRI report to this referral. | will also send the MRI with the patient so you will be able to view it as well. Sincerely, De Dr. C. Ryan Hooper, D.C. Dee rouse X-Ray Phoae: (713) orn 411W. Packer Ra., SuiteA Houston, Texas 77091 Fax: (713) 602-2299 Final Radiology Report Name: MENDOZA, RICARD O MRN: 77452NHX Age: 59y Date: 05/28/2021 2:38 PM Study: MRI CERVICAL sp. DOs: 7 INE W/O CONRAST Requesting Physician: HO ion: 6210528144. 7 OPER, CLIFFORD Location code: H5 MRI Cernical Spine Indication: Neck pain post trauma Comparison: None. Tectrical factors: Long and short as ft- and water-welgtted sequence s were Obtained. Findings: Alignmentia saisfactory Vertebral are of normalhe’ C7. Mild Arterior spondyiosis ight: se eae itera Moderate algnal toss at the of intervertebral diaks. Mild loss of height fram C4 to The Craniocenical junction, atla ntodental interval, Visualized post erior fossa and Position af the cerebellar tonsils appear normal, Preand Paraspinal soft tissues are normal in appearance. The spinal cond is of normal calib er and signal. 2-3: Unremarkabie. C3-4: Unremarkable, C4-5: Broad. based right paracert ral 2.3 C5-6: Right Paracentral 3.5 mm disc hami mm hemiation iindents the right anterior spinal cord, C6-7: Broed-besed Hight para ation indents the ventral dural sac central ind right and spinal cord, Sntertor spinal cord. Narrowing disc hemiation is more prominent to of the fight neural Wilh displacement of the right C7 the Fight at 2.8 mm into this right foramen may be Nerve root. Narrow C7-T1: Unremarkable. of the inneura gl Neural foramina are patent. Impression: 1. C4 -5 right paracantral2..3 mm hemiation with cord indentat 2. C5-Ci 6 right paracentral 3.5 mm ion disc hemiation with cord indentat 3. C8V7 right paracentrata: tre ceplncee ea ion foramen moderate or severe eratn indents the ght arkror pina Cord. Narrowing of the right neural Electronicaity signed by: Daniel Backias MD 5/28/2021 4:38 PM CDT Workstation: 109-0124673 orth Houston X-Ray www. Phone: (713) 692-1133 Socthhowstomesy@yahoo 411. Packer Rd, SuiteA com Fax: (713) 692-2299 ‘Texas 77091 Final Radiology Report Name: MENDOZA, RICA RDO MRN: 77452! Age: Study: MRI LUMBAR SPIN E W/O CONTRAST G210528143231725 DOB. — Requesting Phy Date: 05/28/2021 2:10 PM sictan: HOOPER, CLIFFO RD Location code: R16 MRI Lumbar Spine Indication: POST MVA, RADI CULOPATHYLUMBAR REGION. Comparison: None. Techrical factors: Long and short ends, fat- and water-weight ed ‘Sequences ware obtained . Findings: Alignment ia satisfactory Vertabral bodies are of norm al height and Signal. Mild si