On January 06, 2023 a
Party Statement
was filed
involving a dispute between
Anselmo, Maria,
and
Rodriguez, Bianca,
Serrano, Oscar,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
Preview
FILED
5/24/2023 5:07 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Steve Brashear DEPUTY
CAUSE NO. DC—23-002 18
MARIA ANSELMO § IN THE DISTRICT COURT 0F
§
§
§
VS. § DALLAS COUNTY, TEXAS
§
§
OSCAR SERRANO AND §
BIANCA RODRIGUEZ § 298TH JUDICIAL DISTRICT
AFFIDAVIT OF COSTS AND NECESSITY OF SERVICES AND REASONABLENESS
OF CHARGES OF DAMACO WELLNESS CENTER
FOR PLAINTIFF MARIA ANSELMO
Please see attached.
AFFIDAVIT OF COSTS AND NECESSITY OF SERVICES AND REASONABLENESS OF CHARGES OF
DAMACO WELLNESS CENTER FOR PLAINTIFF MARIA ANSELMO
STATE OF TEXAS §
COUNTY OF DALLAS §
BEFORE the
IE,\U6L
ME, undersigned authority, personally appeared
LQD.Vi ,who, being by me (ti-11y sworn, deposed as follows:
My name is 1:6\‘UCL Lf’b }(L, I amot’sound mind and capable
of makmg this affidavit, and personally acquainQwith the facts herein stated.
I am a custodian of records for DAMACO Wellhess Cente'r. Attached to this affidavit are records
business, and it was the regular course of business of DAMACO Wellness Center for an employee
or representative of DAMACO Wellness Center 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 ofth‘e ongmajl.
The services provided were necessary and the amount charged for the services was
reasonable at the time and place that the services were pi’OVided.
Tbs total amount paid. .01: esemieeswas z$ andtheammnt curretifly unpaid but
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.
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3M0, 0b
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winchrDQWNMDWUIMSS .
za-nght to he
has any adjus ents ts IS
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SWORN: TO AND SUBSRIBED beibre me
\\“l 1I“, ESMERALDA LEAL
P000,
Notary Public, State 01 Texas
Comm. Expires 08-14-2023
WiO/LCLMUL
Notary ID 10037738
Notary'srrimed Name: .3Wmld. (WM
My Commission Expireswfijw’q/g ,.
_
DAMACO Wellness Center
8035 E RL Thornton va#417
Dallas, TX 75228
gel (214)694-0609 3/29/2022
Patient: Mafia Anselmo Instructions:
Complete the patient information portion of your insurance
claim form. Attach this bill, signed and dated, and all other
Chart #= — bills pertaining to the claim. 11" you have a deductible policy,
Ci” 3: - hold your claim forms until you have met your deductible.
Mail directly to your insurance can'ier.
Date Description Procedure Modifier Dx 1 OX 2 Dx 3 OX 4 Units Charge
6/10/2021 Est Detailed 0v 99213 M5126 813.8XXA $23.3XXA S33.5XXA 1 200.00
6/ 10/2021 Elecmodes A4556 M51 .26 S 13.8XXA 823.3XXA 833.5% 1 40.00
6/ 10/2021 Massage 97124 M5126 S 13.8XXA $23.3XXA $33.5XXA 1 50.00
6/10/2021 Ice/Heat Therapy 97010 M5126 S 13.8XXA SZSSXXA $33.5XXA 1 35.00
6/ 10/2021 Attended Electric Muscle Stim 97032 M5126 Sl3.8XXA $23.3XXA S335XXA 1 70.00
6/ 10/2021 Traction 97012 M5126 $13.8XXA 823.3XXA S33.5XXA 1 65.00
6/ 17/2021 Massage 97124 M5126 813.8XXA S23.3XXA S33.5XXA l 50.00
6/ 17/2021 Ice/Heat Therapy 97010 M5126 $13.8XXA $23.3XXA S33.5XXA l 35.00
6/17/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00
6/ 17/2021 Traction 97012 M5126 S 13.8XXA S23.3XXA S33.5XXA 1 65.00
6/24/2021 Mas sage 97124 M5126 $13.8XXA 823.3XXA S33.5XXA 1 50.00
6/24/2021 lee/Heat Therapy 97010 M5126 Sl3.8XXA $23.3XXA S335XXA 1 35.00
6/24/2021 EMS Unattended 97014 M5126 Sl3.8XXA 823.3XXA 833.5XXA l 65.00
604/2021 Traction 97012 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00
6/28/2021 Mas sage 97124 M5126 $13.8XXA S73.3XXA 833.5XXA 1 50.00
6/28/2021 lee/Heat Therapy 97010 M5126 $13.8XXA 'S23.3XXA S335XXA 1 35.00
6/28/2021 EMS Unattended 97014 M5126 S13.8XXA $23.3XXA $33.5XXA 1 65.00
6/28/2021 Traction 97012 M5126 $13.8XXA 823.3XXA 833.5XXA 1 65.00
7/ 19/2021 Spinal Region 2—3 98941 M5126 S 13.8XXA 823.3XXA S33.SXXA l 75.00
7/ 19/2021 Massage 97124 M5126 813.8XXA 823.3XXA $33.5XXA 1 50.00
7/19/2021 Ice/Heat Therapy 97010 M5126 S 13.8XXA 823.3XXA S33.5XXA 1 35.00
7/ 19/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00
7/ 19/2021 Traction 97012 M5126 $13.8XXA SZ3.3XXA S33.5XXA 1 65.00
7/21/2021 Spinal Region 2-3 98941 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 75.00
7/21/2021 Ice/Heat Therapy 97010 M5126 $13.8XXA $23.3XXA S335XXA 1 35.00
7/21/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA l 65.00
7/21/2021 Traction 97012 M5126 513.8XXA SZ3.3XXA $33.5XXA l 65.00
Provider Information— Total Charges: 3 1635.00
Provider Name: Jess ica Puente D.C. T001] Payments: 3 0‘00
License: Total Adjustments: s 0.00
“"2332 3:: - Total Due This Visit:
Total Account Balance:
3 1635.00
$ 10,1(X).00
Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described
above. I also authorize the release of any inforrmtion necessary to process this claim.
Patient Signature: Date:
DAMACO Wellness Center
'
8035 E RL Thornton Fwy#417
Dallas. TX 75228
Pagezz (214169443609 3/29/2022
Patient: Maria Anselmo Instructions:
Complete the patient infonmtion portion ofyour insurance
chim form. Attach this bill, signed and dated. and all other
Chart #3 _ bills pertaining to the claim. If you have a deductible policy,
hold your claim fonns until you have met your deductible.
Cl“ #5 - Mail directly to your insurance carrier.
Date Description Procedure Modifier Ox 1 D): 2 D): 3 OX 4 Units Charge
7/21/2021 Ultrasound 97035 M5126 $13.3XXA $23.3XXA $33.5XXA 1 55.00
7/22/2021 Massage 97124 M5126 Sl3.8XXA $23.3XXA $33.5XXA 1 50.00
7/22/2021 106/ Heat Therapy 97010 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 35.00
7/27J2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA S33.5XXA 1 65.00
7/22/2021 Traction 97012 M5 .26
1 S I 3.8XXA $23.3XXA $33.5XXA 1 65.1”
7/28/2021 Massage 97124 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 50.00
7/28/2021 Ice/ Heat Therapy 9701 0 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 35.00
7/28/2021 EMS Unattended 97014 M 51 .26 $13.8XXA S23.3XXA $33.5XXA 1 65.“)
7/28/2021 Traction 97012 M51 .26 $13.3XXA $23.3XXA $33.5XXA 1 65.00
8/5/2021 Massage 97124 M5126 513.8XXA $23.3XXA 333.5XXA 1 50.00
8/5/2021 Ice/Heat Therapy 97010 M 51 .26 $13 .8XXA 523.3XXA $33.5XXA 1 35.“)
8/5/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00
8/5/2021 Traction 97012 M 51 .26 SI 3.8XXA 323.3XXA S33.5XXA 1 65.00
8/9/2021 Massage 97124 M5126 $13.8XXA $23.3XXA $33.5XXA 1 50.00
8/9/2021 lcclHeat Therapy 97010 M5126 $13 .8XXA $23.3XXA S33 5XXA 1 35.00
8/9/2021 EM S Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.1»
3/9/2021 Traction 97012 M5126 $13.8XXA 523.3XXA S33.5XXA 1 65.00
8/ 16/2021 Massage 97124 M5126 S 13.8XXA $23.3XXA 333.5XXA 1 50.00
8/16/2021 lee/Heat Therapy 97010 M5126 $13.8XXA $23 .3XXA S33.5XXA 1 35.00
8/16/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA $33.5XXA 1 65.00
8/ 16/2021 Traction 97012 M51 .26 813.8XXA $23.3XXA $33.5XXA 1 65.00
8/25/2021 Est Detailed CV 9921 3 M51 .26 $13.8XXA S23.3XXA S33.5XXA 1 200.00
8/25/2021 Spinal Region 2-3 98941 M5126 513.8XXA 523.3XXA S33.5XXA 1 75.00
8/25/2021 EMS Unattended 97014 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.00
8/25/2021 Traction 97012 M5126 S 13.8XXA 323.3XXA S33.5XXA 1 65.00
8/25/2021 Ultras ound 97035 M5126 $13.8XXA $23.3XXA $33.5XXA 1 55.00
8/25/2021 Therapeutic Activities 97530 M51 .26 S 13.8XXA S23.3XXA S335XXA 2 160.00
‘r—vaider Information Total Cl'rarges: 3 1750.00
Provider Name: Jessica Puente D.C. T0131 Payments: 3 0-00
License: - Total Adjustments: $ 0.00
“mggtgg‘l _ Total Due This Visit:
Total Account Balance:
3 1750.00
$ 10,100.00
Assign and Release: I hereby authorim payment of medical benefits to this physician for the services described
above. I also authorize the release of any information necessary to process this claim.
Patient Signature: Date:
DAMACO Wellness Center
8035 E RL Thornton Fwy#417
Dallas. TX 75228
Page: 3 (214)694-0609 3/29/2022
Patient: Maria Anselmo Instructions:
Complete the patient information portion of your insurance
clain fen-n. Attach this bill. signed and dated, and all other
Chart#: - bilk pertaining to the claim If you have a deductible policy,
hold your claim forms until you have met your deductble.
Case 1*: - Mail directly to your insurance carrier.
Date Description Procedure Modifier D): 1 Ox 2 Dx 3 DJ: 4 Unlts Charge
9/2/2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA S33.5XXA 1 65.00
9/2/2021 Traction 97012 M51 .26 $13.8XXA S23.3XXA $33.5XXA 1 65.00
9/212021 Trigger Point/ Manual Traction 97140 M5126 513.8XXA $23.3XXA 533.5XXA 1 65.00
9/2/2021 TP exercises 971 10 M5126 $13.8XXA $23.3XXA 533.5XXA 2 150.00
9/9/2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA 533.5XXA 1 65.00
9/9/2021 Traction 97012 M5126 $13.8XXA S23.3XXA $33.5XXA 1 65.00
9/9/2021 Trigger Point/ Manual Traction 97140 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.1”
9/9/2021 Ultrasound 97035 M51 .26 S 13.8XXA $23.3XXA 533.5XXA 1 55.00
9/15/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA 533.5XXA 1 65.00
9/ 15/2021 Traction 97012 M5126 813.8XXA $23 .3XXA S33.5XXA 1 65.“)
9/15/2021 Trigger Point/ Manual Traction 97140 M5126 313.8XXA S23.3XXA $33.5XXA 1 65.1”
9/ 15/2021 TP exercises 97110 M5126 S13.8XXA $23.3XXA $33.5XXA 2 150.00
9/22/2021 EMS Unattended 97014 M5126 813.8XXA $23.3XXA S335XXA 1 65.00
9/22/2021 Traction 97012 M5126 S 13.8XXA S233XXA S33.5XXA 1 65.00
9/22/2021 Trigger Point/ Manual Traction 97140 M5126 Sl3.8XXA $23.3XXA S33.5XXA 1 65.00
9/22/2021 TP exercises 971 10 M5126 S13.8XXA $23.3XXA $33.5XXA 2 150.1”
9/30/2021 EM S Unattended 97014 M51 .26 $13.8XXA S23.3XXA S33.5XXA 1 65.1”
9/ 30/2021 Traction 9701 2 M51 .26 $13.8XXA $23.3XXA S33.5XXA 1 65.00
9/30/2021 Trigger Point/ Manual Traction 97140 M5126 S 13.8XXA 823.3XXA $33.5XXA 1 65.00
9/30/2021 TP exercises 971 10 M5126 513.8XXA $23.3XXA S33.5XXA 2 150.00
10/4/2021 Spinal Region 2-3 98941 M5126 $13.8XXA 523.3XXA S33.5XXA I 75.00
10/4/2021 EMS Unattended 97014 M5126 Sl3.8XXA 523.3XXA S33.5XXA 1 65.00
10/4/2021 Traction 97012 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.“)
10/4/2021 Trigger P0 int! Manual Traction 97140 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00
10/4/2021 Ultrasound 97035 M 51.26 S 13.8XXA $23.3XXA S33.5XXA 1 55.00
10/12/2021 EM S Unattended 97014 M5126 313.8XXA $23.3XXA S33.5XXA 1 65.111
10/ 12/2021 Traction 97012 M5126 $13.8XXA 523.3XXA S33.5XXA 1 65.00
——vaider Information Total Charges: 3 2085.00
Provider Name: Jessica Pu ente D.C. Total payments: 3 0.00
License: - Total Adjustments: S 0.00
Cmgf: $11: _ Total Due This Visit:
Total Account Balance:
3 2085.00
$ 10,100.00
Assign and Release: [hereby authorize payment of medical benefits to this physician for the services described
above. [also authorize the release of any information necessary to process this Chaim.
Patient Signature: Date:
DAMACO Wellness Center
8035 E RL Thomton Fwy#417
Dallas. TX 75228
Page:4 (214)694-0609 3/29/2022
Patient: Maria Anselmo
Conplete the patient information portion of your insurance
claim form. Attach this bill, signed and dated, and all other
Chart 1*: — bills pertaining to the claim. Ifyou have a deductible policy,
hold your claim fonts until you have met your deductible.
case #= - Mail directly to your insurance can'ier.
Date Description Procedure Modifier D): 1 DJ: 2 OX 3 OX 4 Units Charge
10/ 12/2021 Ultrasound 97035 M5126 Sl3.8XXA $23.3XXA S33.5XXA I 55.00
10/12/2021 TP exercises 971 10 M5126 813.8XXA S23.3XXA S33.5XXA 2 150.00
10/19/2021 FNIS Unattended 97014 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00
10/ 19/2021 Traction 97012 M5126 813.8XXA 523.3XXA $33.5XXA l 65.00
10/19/2021 Ultrasound 97035 M5126 $13.8)OCA S23.3XXA S33.5XXA 1 55.00
10/19/2021 TP exercises 971 10 M5126 $13.8XXA S23.3XXA S33.5XXA 2 150.00
10/26/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00
10/26/2021 Traction 97012 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00
10/26/2021 Trigger Point/ Manual Traction 97140 M5126 $13.8XXA $23.3XXA $33.5XXA l 65.00
10/26/2021 TP exercises 971 10 M5126 S 13.8XXA S23.3XXA S33.5XXA 2 150.00
11/3/2021 EMS Unattended 97014 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00
11/3/2021 Traction 97012 M51 .26 $13.8XXA 823.3XXA S33.5XXA 1 65M)
11/3/2021 Ultrasound 97035 M5126 $13.8XXA S23.3XXA 833.5XXA l 55.00
1 1/3/2021 TP exercises 97110 M5126 S 13.8XXA S233XXA S33.SXXA 2 150.00
11/9/2021 Ell/IS Unatten decl 97014 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 65.00
1 1/9/ 2021 Traction 97012 M5126 S 13.8XXA $23.3XXA 533.5)(XA 1 65.“)
11/9/2m1 Trigger Point! Manual Tract'nn 97140 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00
11/9/2021 TP exercises 971 10 M5126 Sl3.8XXA $23.3XXA S33.5XXA 2 150.1!)
11/16/2021 Est Detailed 0V 99213 M5126 Sl3.8XXA $23.3XXA 533.5XXA 1 200.00
11/16/2021 Spinal Ragion 2-3 98941 M5126 $13.8XXA $23.3XXA S33.5XXA 1 75.00
11/16/2121 EMS Unattended 97014 M5126 813.8XXA S23.3XXA S33.5XXA 1 65.00
11/ 16/2021 Traction 970 i2 M5126 813.8XXA 823.3XXA S33.5XXA 1 65.00
1 1/ 16/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.1”
11/ 16/2021 TP exercises 97110 M5126 Sl3.8XXA $23.3XXA S33.5XXA 2 150.00
11/22/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00
11/2212021 Traction 97012 M5126 513.8XXA $23.3XXA S33.5XXA l 65.00
11/22/2021 Trigger Point/ Manual Traction 97140 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00
Provider Information———-———‘ Total Charges: 3 2370.00
Provider Name: Jessica Puente D.C. Total Payrnents: $ 0.00
License: - Total Adjustments: $ 0.00
PM
SSN or EN. _ ‘
Total Due This Visit:
Total Account Balance:
0 2370.00
3 10,100.00
Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described
above. I also authon’ze the release of any information necessary to process this claim.
Patient Signature: Date:
DAMACO Wellness Center
8035 E RL Thornton Fwy #417
Dallas. TX 75228
Page: 5 (214)694-0609 3/29/2022
Patient: Maria Amelmo 111M
Complete the patient information portion of your insurance
claim form. Attach this bill, signed and dated, and all other
Chart#:
C339 1*:
-- bills ertainin to the claim. If ou have adeductible oli ,
holdlimur claifn ferns until youyhave met your deductilrlr-fy
Mail directly to your insurance carrier.
Date Description Procedure Modifier Dar 1 D! 2 Dx 3 D): 4 Units Charge
11/22/2021 TP exercises 97110 M5126 813.8XXA S233XXA S33.5XXA 2 150.00
11/30/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00
11/30/2021 Traction 97012 M5126 $13.8XXA S233XXA $33.5XXA 1 65.1!)
11/30/2021 Ultrasound 97035 M5126 Sl3.8XXA $23.3XXA S33.5XXA 1 55.00
11/30/2021 TP exercises 97110 M5126 Sl3.8XXA $23.3XXA 533.5XXA 2 150.“)
12/8/2021 Spinal Region 2-3 98941 M5126 $13.8XXA $23.3XXA S33.5XXA l 75.00
12/8/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00
12/8/2021 Traction 9701.2 M5126 Sl3.8XXA S23.3XXA S33.5XXA 1 65.00
12/8/2021 Trigger Point/ Manual Traction 97140 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00
12/8/2021 TP eremises 97110 M5126 $13.8XXA $23.3XXA $33.5XXA 2 150.00
12/16/2021 EMS Unattended 97014 M5126 813.8XXA 523.3XXA S33.5XXA l 65.00
12/16/2021 Traction 97012 M5126 513.8XXA 823.3XXA 833.5XXA 1 65.00
12/16/2021 Trigger Point/ Manual Traction 97140 M5126 513.8XXA $23.3XXA S33.5XXA l 65.00
12/16/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.00
12/20/2021 EMS Unattended 97014 M5126 S13.8XXA S23.3XXA S33.5XXA 1 65.00
12120/2021 Traction 97012 M5126 Sl3.8XXA $23.3XXA 833.5XXA 1 65.00
12/20/2021 Trigger Point! Manual Traction 97140 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00
1220/2021 TP exercises 97110 M5126 813.8XXA 823.3XXA S33.5XXA 2 150.00
12/30/2021 FINAL EXAM 99214 M5126 S13.8XXA $23.3XXA S33.5XXA 1 250.00
12/30/2021 Spinal Region 2-3 98941 M5126 Sl3.8XXA $23.3XXA 833.5XXA 1 75.00
12/30/2021 EMS Unattended 97014 M5126 Sl3.8XXA 523.3XXA $33.5XXA 1 65.00
12/30/2021 Traction 97012 M5126 S13.8XXA 823.3XXA S33.5XXA 1 65.00
12/30/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.1!)
12/30/2021 Narrative Report 99199 M5126 smxx». 823.3XXA S33.SXXA 1 250.00
r——Provider Information Total Charges: $ 2260.00
Provider Name: Jessica Puente D.C. Total Payments: 3 0.00
License: - Total Adjustments: $ 0.00
“$33: :3: _ Total Due This Visit:
Total Account Balance:
5 2260.00
$ 10,100.00
Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described
above. I also authorize the release of any information necessary to process this claim
Patient Signature: Date:
~
DAMACO Wellness Center
8035 E RL Thornton FM #417
Dallas. TX 75228
Page: 1 (214)694-0609 3/29/2022
Patient: Maria Anselmo Instructing:
Conplete the patient information portion of your insurance
claim form. Attach the bill, signed and dated, and all other
Chart #: '
_ bills pertaining to the claim. If you have a deductible policy.
hold your claim forms until you have met your deductible.
C9“ #3 - Mai] directly to your insurance carrier.
Date Deccrlptlon Procedure Modifier Ox 1 OX 2 OX 3 Dr: 4 Units Charge
Supplemental Codes 00000 $73.109A $83.90XA S43.409A M54.i6 1 0.00
Supp lermn tal Codes 00000 M603 M62.40 M511 1 0.00
5’0
60%]
60"-
——Provider Information Total Charges: 3 0.00
Provider-Name: Jessica Puente D.C. Total Payments: 3 0.00
License:
Commercial PIN:
- Total Adjustments:
. . .
3 0.00
Total Due This Visit: S 0.00
SSN or EIN: _ Total Account Bahnce: $ 10,100.00
Assign and Release: [hereby authorize payment of medical benefits to this physician for the services described
above. [also authorize the release of any infomiation necessary to process this claim
Patient Signature: Date:
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.
Sulema Navarro on behalf of Andrew Rohe
Bar No. 24085562
snavarro@guerrerolaw.com
Envelope ID: 75979528
Filing Code Description: Correspondence - Letter To File
Filing Description: REGARDING FILING AFFIDAVITS
Status as of 5/25/2023 8:45 AM CST
Associated Case Party: OSCAR SERRANO
Name BarNumber Email TimestampSubmitted Status
Vincent Lorento DallasLegal@allstate.com 5/24/2023 5:07:57 PM SENT
Associated Case Party: BIANCA RODRIGUEZ
Name BarNumber Email TimestampSubmitted Status
Vincent Lorento DallasLegal@allstate.com 5/24/2023 5:07:57 PM SENT
Associated Case Party: MARIA ANSELMO
Name BarNumber Email TimestampSubmitted Status
ANDREW D.ROHE AROHE@GUERREROLAW.COM 5/24/2023 5:07:57 PM SENT
Sulema Navarro snavarro@guerrerolaw.com 5/24/2023 5:07:57 PM SENT
Document Filed Date
May 24, 2023
Case Filing Date
January 06, 2023
Category
MOTOR VEHICLE ACCIDENT
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FILED 5/24/2023 5:07 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Steve Brashear DEPUTY CAUSE NO. DC—23-002 18 MARIA ANSELMO § IN THE DISTRICT COURT 0F § § § VS. § DALLAS COUNTY, TEXAS § § OSCAR SERRANO AND § BIANCA RODRIGUEZ § 298TH JUDICIAL DISTRICT AFFIDAVIT OF COSTS AND NECESSITY OF SERVICES AND REASONABLENESS OF CHARGES OF DAMACO WELLNESS CENTER FOR PLAINTIFF MARIA ANSELMO Please see attached. AFFIDAVIT OF COSTS AND NECESSITY OF SERVICES AND REASONABLENESS OF CHARGES OF DAMACO WELLNESS CENTER FOR PLAINTIFF MARIA ANSELMO STATE OF TEXAS § COUNTY OF DALLAS § BEFORE the IE,\U6L ME, undersigned authority, personally appeared LQD.Vi ,who, being by me (ti-11y sworn, deposed as follows: My name is 1:6\‘UCL Lf’b }(L, I amot’sound mind and capable of makmg this affidavit, and personally acquainQwith the facts herein stated. I am a custodian of records for DAMACO Wellhess Cente'r. Attached to this affidavit are records business, and it was the regular course of business of DAMACO Wellness Center for an employee or representative of DAMACO Wellness Center 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 ofth‘e ongmajl. The services provided were necessary and the amount charged for the services was reasonable at the time and place that the services were pi’OVided. Tbs total amount paid. .01: esemieeswas z$ andtheammnt curretifly unpaid but I: “e U V . - . . 3M0, 0b ' . . ,. , winchrDQWNMDWUIMSS . za-nght to he has any adjus ents ts IS // SWORN: TO AND SUBSRIBED beibre me \\“l 1I“, ESMERALDA LEAL P000, Notary Public, State 01 Texas Comm. Expires 08-14-2023 WiO/LCLMUL Notary ID 10037738 Notary'srrimed Name: .3Wmld. (WM My Commission Expireswfijw’q/g ,. _ DAMACO Wellness Center 8035 E RL Thornton va#417 Dallas, TX 75228 gel (214)694-0609 3/29/2022 Patient: Mafia Anselmo Instructions: Complete the patient information portion of your insurance claim form. Attach this bill, signed and dated, and all other Chart #= — bills pertaining to the claim. 11" you have a deductible policy, Ci” 3: - hold your claim forms until you have met your deductible. Mail directly to your insurance can'ier. Date Description Procedure Modifier Dx 1 OX 2 Dx 3 OX 4 Units Charge 6/10/2021 Est Detailed 0v 99213 M5126 813.8XXA $23.3XXA S33.5XXA 1 200.00 6/ 10/2021 Elecmodes A4556 M51 .26 S 13.8XXA 823.3XXA 833.5% 1 40.00 6/ 10/2021 Massage 97124 M5126 S 13.8XXA $23.3XXA $33.5XXA 1 50.00 6/10/2021 Ice/Heat Therapy 97010 M5126 S 13.8XXA SZSSXXA $33.5XXA 1 35.00 6/ 10/2021 Attended Electric Muscle Stim 97032 M5126 Sl3.8XXA $23.3XXA S335XXA 1 70.00 6/ 10/2021 Traction 97012 M5126 $13.8XXA 823.3XXA S33.5XXA 1 65.00 6/ 17/2021 Massage 97124 M5126 813.8XXA S23.3XXA S33.5XXA l 50.00 6/ 17/2021 Ice/Heat Therapy 97010 M5126 $13.8XXA $23.3XXA S33.5XXA l 35.00 6/17/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00 6/ 17/2021 Traction 97012 M5126 S 13.8XXA S23.3XXA S33.5XXA 1 65.00 6/24/2021 Mas sage 97124 M5126 $13.8XXA 823.3XXA S33.5XXA 1 50.00 6/24/2021 lee/Heat Therapy 97010 M5126 Sl3.8XXA $23.3XXA S335XXA 1 35.00 6/24/2021 EMS Unattended 97014 M5126 Sl3.8XXA 823.3XXA 833.5XXA l 65.00 604/2021 Traction 97012 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00 6/28/2021 Mas sage 97124 M5126 $13.8XXA S73.3XXA 833.5XXA 1 50.00 6/28/2021 lee/Heat Therapy 97010 M5126 $13.8XXA 'S23.3XXA S335XXA 1 35.00 6/28/2021 EMS Unattended 97014 M5126 S13.8XXA $23.3XXA $33.5XXA 1 65.00 6/28/2021 Traction 97012 M5126 $13.8XXA 823.3XXA 833.5XXA 1 65.00 7/ 19/2021 Spinal Region 2—3 98941 M5126 S 13.8XXA 823.3XXA S33.SXXA l 75.00 7/ 19/2021 Massage 97124 M5126 813.8XXA 823.3XXA $33.5XXA 1 50.00 7/19/2021 Ice/Heat Therapy 97010 M5126 S 13.8XXA 823.3XXA S33.5XXA 1 35.00 7/ 19/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00 7/ 19/2021 Traction 97012 M5126 $13.8XXA SZ3.3XXA S33.5XXA 1 65.00 7/21/2021 Spinal Region 2-3 98941 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 75.00 7/21/2021 Ice/Heat Therapy 97010 M5126 $13.8XXA $23.3XXA S335XXA 1 35.00 7/21/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA l 65.00 7/21/2021 Traction 97012 M5126 513.8XXA SZ3.3XXA $33.5XXA l 65.00 Provider Information— Total Charges: 3 1635.00 Provider Name: Jess ica Puente D.C. T001] Payments: 3 0‘00 License: Total Adjustments: s 0.00 “"2332 3:: - Total Due This Visit: Total Account Balance: 3 1635.00 $ 10,1(X).00 Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described above. I also authorize the release of any inforrmtion necessary to process this claim. Patient Signature: Date: DAMACO Wellness Center ' 8035 E RL Thornton Fwy#417 Dallas. TX 75228 Pagezz (214169443609 3/29/2022 Patient: Maria Anselmo Instructions: Complete the patient infonmtion portion ofyour insurance chim form. Attach this bill, signed and dated. and all other Chart #3 _ bills pertaining to the claim. If you have a deductible policy, hold your claim fonns until you have met your deductible. Cl“ #5 - Mail directly to your insurance carrier. Date Description Procedure Modifier Ox 1 D): 2 D): 3 OX 4 Units Charge 7/21/2021 Ultrasound 97035 M5126 $13.3XXA $23.3XXA $33.5XXA 1 55.00 7/22/2021 Massage 97124 M5126 Sl3.8XXA $23.3XXA $33.5XXA 1 50.00 7/22/2021 106/ Heat Therapy 97010 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 35.00 7/27J2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA S33.5XXA 1 65.00 7/22/2021 Traction 97012 M5 .26 1 S I 3.8XXA $23.3XXA $33.5XXA 1 65.1” 7/28/2021 Massage 97124 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 50.00 7/28/2021 Ice/ Heat Therapy 9701 0 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 35.00 7/28/2021 EMS Unattended 97014 M 51 .26 $13.8XXA S23.3XXA $33.5XXA 1 65.“) 7/28/2021 Traction 97012 M51 .26 $13.3XXA $23.3XXA $33.5XXA 1 65.00 8/5/2021 Massage 97124 M5126 513.8XXA $23.3XXA 333.5XXA 1 50.00 8/5/2021 Ice/Heat Therapy 97010 M 51 .26 $13 .8XXA 523.3XXA $33.5XXA 1 35.“) 8/5/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00 8/5/2021 Traction 97012 M 51 .26 SI 3.8XXA 323.3XXA S33.5XXA 1 65.00 8/9/2021 Massage 97124 M5126 $13.8XXA $23.3XXA $33.5XXA 1 50.00 8/9/2021 lcclHeat Therapy 97010 M5126 $13 .8XXA $23.3XXA S33 5XXA 1 35.00 8/9/2021 EM S Unattended 97014 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.1» 3/9/2021 Traction 97012 M5126 $13.8XXA 523.3XXA S33.5XXA 1 65.00 8/ 16/2021 Massage 97124 M5126 S 13.8XXA $23.3XXA 333.5XXA 1 50.00 8/16/2021 lee/Heat Therapy 97010 M5126 $13.8XXA $23 .3XXA S33.5XXA 1 35.00 8/16/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA $33.5XXA 1 65.00 8/ 16/2021 Traction 97012 M51 .26 813.8XXA $23.3XXA $33.5XXA 1 65.00 8/25/2021 Est Detailed CV 9921 3 M51 .26 $13.8XXA S23.3XXA S33.5XXA 1 200.00 8/25/2021 Spinal Region 2-3 98941 M5126 513.8XXA 523.3XXA S33.5XXA 1 75.00 8/25/2021 EMS Unattended 97014 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.00 8/25/2021 Traction 97012 M5126 S 13.8XXA 323.3XXA S33.5XXA 1 65.00 8/25/2021 Ultras ound 97035 M5126 $13.8XXA $23.3XXA $33.5XXA 1 55.00 8/25/2021 Therapeutic Activities 97530 M51 .26 S 13.8XXA S23.3XXA S335XXA 2 160.00 ‘r—vaider Information Total Cl'rarges: 3 1750.00 Provider Name: Jessica Puente D.C. T0131 Payments: 3 0-00 License: - Total Adjustments: $ 0.00 “mggtgg‘l _ Total Due This Visit: Total Account Balance: 3 1750.00 $ 10,100.00 Assign and Release: I hereby authorim payment of medical benefits to this physician for the services described above. I also authorize the release of any information necessary to process this claim. Patient Signature: Date: DAMACO Wellness Center 8035 E RL Thornton Fwy#417 Dallas. TX 75228 Page: 3 (214)694-0609 3/29/2022 Patient: Maria Anselmo Instructions: Complete the patient information portion of your insurance clain fen-n. Attach this bill. signed and dated, and all other Chart#: - bilk pertaining to the claim If you have a deductible policy, hold your claim forms until you have met your deductble. Case 1*: - Mail directly to your insurance carrier. Date Description Procedure Modifier D): 1 Ox 2 Dx 3 DJ: 4 Unlts Charge 9/2/2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA S33.5XXA 1 65.00 9/2/2021 Traction 97012 M51 .26 $13.8XXA S23.3XXA $33.5XXA 1 65.00 9/212021 Trigger Point/ Manual Traction 97140 M5126 513.8XXA $23.3XXA 533.5XXA 1 65.00 9/2/2021 TP exercises 971 10 M5126 $13.8XXA $23.3XXA 533.5XXA 2 150.00 9/9/2021 EMS Unattended 97014 M51 .26 S 13.8XXA $23.3XXA 533.5XXA 1 65.00 9/9/2021 Traction 97012 M5126 $13.8XXA S23.3XXA $33.5XXA 1 65.00 9/9/2021 Trigger Point/ Manual Traction 97140 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.1” 9/9/2021 Ultrasound 97035 M51 .26 S 13.8XXA $23.3XXA 533.5XXA 1 55.00 9/15/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA 533.5XXA 1 65.00 9/ 15/2021 Traction 97012 M5126 813.8XXA $23 .3XXA S33.5XXA 1 65.“) 9/15/2021 Trigger Point/ Manual Traction 97140 M5126 313.8XXA S23.3XXA $33.5XXA 1 65.1” 9/ 15/2021 TP exercises 97110 M5126 S13.8XXA $23.3XXA $33.5XXA 2 150.00 9/22/2021 EMS Unattended 97014 M5126 813.8XXA $23.3XXA S335XXA 1 65.00 9/22/2021 Traction 97012 M5126 S 13.8XXA S233XXA S33.5XXA 1 65.00 9/22/2021 Trigger Point/ Manual Traction 97140 M5126 Sl3.8XXA $23.3XXA S33.5XXA 1 65.00 9/22/2021 TP exercises 971 10 M5126 S13.8XXA $23.3XXA $33.5XXA 2 150.1” 9/30/2021 EM S Unattended 97014 M51 .26 $13.8XXA S23.3XXA S33.5XXA 1 65.1” 9/ 30/2021 Traction 9701 2 M51 .26 $13.8XXA $23.3XXA S33.5XXA 1 65.00 9/30/2021 Trigger Point/ Manual Traction 97140 M5126 S 13.8XXA 823.3XXA $33.5XXA 1 65.00 9/30/2021 TP exercises 971 10 M5126 513.8XXA $23.3XXA S33.5XXA 2 150.00 10/4/2021 Spinal Region 2-3 98941 M5126 $13.8XXA 523.3XXA S33.5XXA I 75.00 10/4/2021 EMS Unattended 97014 M5126 Sl3.8XXA 523.3XXA S33.5XXA 1 65.00 10/4/2021 Traction 97012 M5126 S 13.8XXA $23.3XXA S33.5XXA 1 65.“) 10/4/2021 Trigger P0 int! Manual Traction 97140 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00 10/4/2021 Ultrasound 97035 M 51.26 S 13.8XXA $23.3XXA S33.5XXA 1 55.00 10/12/2021 EM S Unattended 97014 M5126 313.8XXA $23.3XXA S33.5XXA 1 65.111 10/ 12/2021 Traction 97012 M5126 $13.8XXA 523.3XXA S33.5XXA 1 65.00 ——vaider Information Total Charges: 3 2085.00 Provider Name: Jessica Pu ente D.C. Total payments: 3 0.00 License: - Total Adjustments: S 0.00 Cmgf: $11: _ Total Due This Visit: Total Account Balance: 3 2085.00 $ 10,100.00 Assign and Release: [hereby authorize payment of medical benefits to this physician for the services described above. [also authorize the release of any information necessary to process this Chaim. Patient Signature: Date: DAMACO Wellness Center 8035 E RL Thomton Fwy#417 Dallas. TX 75228 Page:4 (214)694-0609 3/29/2022 Patient: Maria Anselmo Conplete the patient information portion of your insurance claim form. Attach this bill, signed and dated, and all other Chart 1*: — bills pertaining to the claim. Ifyou have a deductible policy, hold your claim fonts until you have met your deductible. case #= - Mail directly to your insurance can'ier. Date Description Procedure Modifier D): 1 DJ: 2 OX 3 OX 4 Units Charge 10/ 12/2021 Ultrasound 97035 M5126 Sl3.8XXA $23.3XXA S33.5XXA I 55.00 10/12/2021 TP exercises 971 10 M5126 813.8XXA S23.3XXA S33.5XXA 2 150.00 10/19/2021 FNIS Unattended 97014 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00 10/ 19/2021 Traction 97012 M5126 813.8XXA 523.3XXA $33.5XXA l 65.00 10/19/2021 Ultrasound 97035 M5126 $13.8)OCA S23.3XXA S33.5XXA 1 55.00 10/19/2021 TP exercises 971 10 M5126 $13.8XXA S23.3XXA S33.5XXA 2 150.00 10/26/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00 10/26/2021 Traction 97012 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00 10/26/2021 Trigger Point/ Manual Traction 97140 M5126 $13.8XXA $23.3XXA $33.5XXA l 65.00 10/26/2021 TP exercises 971 10 M5126 S 13.8XXA S23.3XXA S33.5XXA 2 150.00 11/3/2021 EMS Unattended 97014 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00 11/3/2021 Traction 97012 M51 .26 $13.8XXA 823.3XXA S33.5XXA 1 65M) 11/3/2021 Ultrasound 97035 M5126 $13.8XXA S23.3XXA 833.5XXA l 55.00 1 1/3/2021 TP exercises 97110 M5126 S 13.8XXA S233XXA S33.SXXA 2 150.00 11/9/2021 Ell/IS Unatten decl 97014 M51 .26 S 13.8XXA $23.3XXA $33.5XXA 1 65.00 1 1/9/ 2021 Traction 97012 M5126 S 13.8XXA $23.3XXA 533.5)(XA 1 65.“) 11/9/2m1 Trigger Point! Manual Tract'nn 97140 M5126 $13.8XXA $23.3XXA $33.5XXA 1 65.00 11/9/2021 TP exercises 971 10 M5126 Sl3.8XXA $23.3XXA S33.5XXA 2 150.1!) 11/16/2021 Est Detailed 0V 99213 M5126 Sl3.8XXA $23.3XXA 533.5XXA 1 200.00 11/16/2021 Spinal Ragion 2-3 98941 M5126 $13.8XXA $23.3XXA S33.5XXA 1 75.00 11/16/2121 EMS Unattended 97014 M5126 813.8XXA S23.3XXA S33.5XXA 1 65.00 11/ 16/2021 Traction 970 i2 M5126 813.8XXA 823.3XXA S33.5XXA 1 65.00 1 1/ 16/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.1” 11/ 16/2021 TP exercises 97110 M5126 Sl3.8XXA $23.3XXA S33.5XXA 2 150.00 11/22/2021 EMS Unattended 97014 M5126 Sl3.8XXA $23.3XXA S33.5XXA l 65.00 11/2212021 Traction 97012 M5126 513.8XXA $23.3XXA S33.5XXA l 65.00 11/22/2021 Trigger Point/ Manual Traction 97140 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00 Provider Information———-———‘ Total Charges: 3 2370.00 Provider Name: Jessica Puente D.C. Total Payrnents: $ 0.00 License: - Total Adjustments: $ 0.00 PM SSN or EN. _ ‘ Total Due This Visit: Total Account Balance: 0 2370.00 3 10,100.00 Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described above. I also authon’ze the release of any information necessary to process this claim. Patient Signature: Date: DAMACO Wellness Center 8035 E RL Thornton Fwy #417 Dallas. TX 75228 Page: 5 (214)694-0609 3/29/2022 Patient: Maria Amelmo 111M Complete the patient information portion of your insurance claim form. Attach this bill, signed and dated, and all other Chart#: C339 1*: -- bills ertainin to the claim. If ou have adeductible oli , holdlimur claifn ferns until youyhave met your deductilrlr-fy Mail directly to your insurance carrier. Date Description Procedure Modifier Dar 1 D! 2 Dx 3 D): 4 Units Charge 11/22/2021 TP exercises 97110 M5126 813.8XXA S233XXA S33.5XXA 2 150.00 11/30/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00 11/30/2021 Traction 97012 M5126 $13.8XXA S233XXA $33.5XXA 1 65.1!) 11/30/2021 Ultrasound 97035 M5126 Sl3.8XXA $23.3XXA S33.5XXA 1 55.00 11/30/2021 TP exercises 97110 M5126 Sl3.8XXA $23.3XXA 533.5XXA 2 150.“) 12/8/2021 Spinal Region 2-3 98941 M5126 $13.8XXA $23.3XXA S33.5XXA l 75.00 12/8/2021 EMS Unattended 97014 M5126 $13.8XXA $23.3XXA S33.5XXA 1 65.00 12/8/2021 Traction 9701.2 M5126 Sl3.8XXA S23.3XXA S33.5XXA 1 65.00 12/8/2021 Trigger Point/ Manual Traction 97140 M5126 813.8XXA $23.3XXA S33.5XXA 1 65.00 12/8/2021 TP eremises 97110 M5126 $13.8XXA $23.3XXA $33.5XXA 2 150.00 12/16/2021 EMS Unattended 97014 M5126 813.8XXA 523.3XXA S33.5XXA l 65.00 12/16/2021 Traction 97012 M5126 513.8XXA 823.3XXA 833.5XXA 1 65.00 12/16/2021 Trigger Point/ Manual Traction 97140 M5126 513.8XXA $23.3XXA S33.5XXA l 65.00 12/16/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.00 12/20/2021 EMS Unattended 97014 M5126 S13.8XXA S23.3XXA S33.5XXA 1 65.00 12120/2021 Traction 97012 M5126 Sl3.8XXA $23.3XXA 833.5XXA 1 65.00 12/20/2021 Trigger Point! Manual Traction 97140 M5126 $13.8XXA $23.3XXA 833.5XXA 1 65.00 1220/2021 TP exercises 97110 M5126 813.8XXA 823.3XXA S33.5XXA 2 150.00 12/30/2021 FINAL EXAM 99214 M5126 S13.8XXA $23.3XXA S33.5XXA 1 250.00 12/30/2021 Spinal Region 2-3 98941 M5126 Sl3.8XXA $23.3XXA 833.5XXA 1 75.00 12/30/2021 EMS Unattended 97014 M5126 Sl3.8XXA 523.3XXA $33.5XXA 1 65.00 12/30/2021 Traction 97012 M5126 S13.8XXA 823.3XXA S33.5XXA 1 65.00 12/30/2021 Ultrasound 97035 M5126 $13.8XXA $23.3XXA S33.5XXA 1 55.1!) 12/30/2021 Narrative Report 99199 M5126 smxx». 823.3XXA S33.SXXA 1 250.00 r——Provider Information Total Charges: $ 2260.00 Provider Name: Jessica Puente D.C. Total Payments: 3 0.00 License: - Total Adjustments: $ 0.00 “$33: :3: _ Total Due This Visit: Total Account Balance: 5 2260.00 $ 10,100.00 Assign and Release: I hereby authorize payment of medical benefits to this physician for the services described above. I also authorize the release of any information necessary to process this claim Patient Signature: Date: ~ DAMACO Wellness Center 8035 E RL Thornton FM #417 Dallas. TX 75228 Page: 1 (214)694-0609 3/29/2022 Patient: Maria Anselmo Instructing: Conplete the patient information portion of your insurance claim form. Attach the bill, signed and dated, and all other Chart #: ' _ bills pertaining to the claim. If you have a deductible policy. hold your claim forms until you have met your deductible. C9“ #3 - Mai] directly to your insurance carrier. Date Deccrlptlon Procedure Modifier Ox 1 OX 2 OX 3 Dr: 4 Units Charge Supplemental Codes 00000 $73.109A $83.90XA S43.409A M54.i6 1 0.00 Supp lermn tal Codes 00000 M603 M62.40 M511 1 0.00 5’0 60%] 60"- ——Provider Information Total Charges: 3 0.00 Provider-Name: Jessica Puente D.C. Total Payments: 3 0.00 License: Commercial PIN: - Total Adjustments: . . . 3 0.00 Total Due This Visit: S 0.00 SSN or EIN: _ Total Account Bahnce: $ 10,100.00 Assign and Release: [hereby authorize payment of medical benefits to this physician for the services described above. [also authorize the release of any infomiation necessary to process this claim Patient Signature: Date: 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. Sulema Navarro on behalf of Andrew Rohe Bar No. 24085562 snavarro@guerrerolaw.com Envelope ID: 75979528 Filing Code Description: Correspondence - Letter To File Filing Description: REGARDING FILING AFFIDAVITS Status as of 5/25/2023 8:45 AM CST Associated Case Party: OSCAR SERRANO Name BarNumber Email TimestampSubmitted Status Vincent Lorento DallasLegal@allstate.com 5/24/2023 5:07:57 PM SENT Associated Case Party: BIANCA RODRIGUEZ Name BarNumber Email TimestampSubmitted Status Vincent Lorento DallasLegal@allstate.com 5/24/2023 5:07:57 PM SENT Associated Case Party: MARIA ANSELMO Name BarNumber Email TimestampSubmitted Status ANDREW D.ROHE AROHE@GUERREROLAW.COM 5/24/2023 5:07:57 PM SENT Sulema Navarro snavarro@guerrerolaw.com 5/24/2023 5:07:57 PM SENT