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.
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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
BILLING RECORDS AFFIDAVIT OF MEMORIAL CARE PHARMACY
FOR PLAINTIFF MARIA ANSELMO
Please see attached.
BILLING RECORDS AFFIDAVIT OF MEMORIAL CARE PHARMACY FOR PLAINTIFF MARIA AN SELMO
BILLING RECORDS AFFIDAVIT
(Pursuant to Tex. R. Evid. 902)
MARIA ANSELMO ALVAREZ
6/20/1978
STATE OF TEXAS §
COUNTY OF HARRIS §
Before me, the undersigned authority, personally appeared Alex Vazguez, who, being
by me duly sworn, deposed as follows:
My name is Alex Vazguez. 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 MEMORIAL CARE PHARMACY. 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 _1_ pages of billing records from
MEMORIAL CARE PHARMACY. 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
MEMORIAL CARE PHARMACY, 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
thereafier. The billing records attached hereto are the original or exact duplicates of the original.
1.Total charges for the services rendered: $555.00
2. The amount actually paid by the patient or on the patient’s behalf: $0.00
3. Amount, if any, adjusted or written off: $0.00
4. Any amount currently unpaid but which the facility has a right to be paid afier any
adjustments or credits: $555.00
V
Affiant
SWORN TO AND SUBSCRIBED before me on the 9 day of May , 2022.
KYLE ALLEN YEC‘SOH
is“:
New Public. State at Tom
{E Comm. Expires 03-29-2021
m ammss
"magi: norm
Q—aryéiic, State of Texas
Memorial Cam Phanmcy
STATEMENT
PO. Box 66602
TX 77266 Statement Date: Paynnnt Date: Statement #:
Houston,
Phone: (346) 262—03 10
05/09/2022 -
Check #2 Payment Due:
Fax: (832) 476-1970
$555.00
ANSELMO ALVAREZ MARIA
MEMORIAL CARE PHARMACY
P.O. Box 66602
Houston, TX 77266
Bill of Summary
Date of Slipn'em Descfipt'wn Chaos (Emits Patient Balance
:
01/03/2022 Cycloberrzaprinc 10mg 0301 $141.70 $141.70
‘
01/03/2022 Voltaxen Gel 1%0100.1 $279.70 $279.70
01/03/2022 Naproxen 500mg (260.1 $133.60 $133.60
Accomt Caren Balance: $555.00
Delivery Charge: $0.00
Total: $555.00
Thank you for your business!
Should you have any inquiries concerning this statement, please contact (346) 262-0310.
Please nuke all checks payable to Mermn'al Care Phanmcy.
P.0. Box 66602, Houston, TX 77266
T: (346) 262-0310 F: (832) 476-1970
|
E—Imil: Billing@MennrialCarePhanmcy.com
Tax ID: -
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 BILLING RECORDS AFFIDAVIT OF MEMORIAL CARE PHARMACY FOR PLAINTIFF MARIA ANSELMO Please see attached. BILLING RECORDS AFFIDAVIT OF MEMORIAL CARE PHARMACY FOR PLAINTIFF MARIA AN SELMO BILLING RECORDS AFFIDAVIT (Pursuant to Tex. R. Evid. 902) MARIA ANSELMO ALVAREZ 6/20/1978 STATE OF TEXAS § COUNTY OF HARRIS § Before me, the undersigned authority, personally appeared Alex Vazguez, who, being by me duly sworn, deposed as follows: My name is Alex Vazguez. 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 MEMORIAL CARE PHARMACY. 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 _1_ pages of billing records from MEMORIAL CARE PHARMACY. 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 MEMORIAL CARE PHARMACY, 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 thereafier. The billing records attached hereto are the original or exact duplicates of the original. 1.Total charges for the services rendered: $555.00 2. The amount actually paid by the patient or on the patient’s behalf: $0.00 3. Amount, if any, adjusted or written off: $0.00 4. Any amount currently unpaid but which the facility has a right to be paid afier any adjustments or credits: $555.00 V Affiant SWORN TO AND SUBSCRIBED before me on the 9 day of May , 2022. KYLE ALLEN YEC‘SOH is“: New Public. State at Tom {E Comm. Expires 03-29-2021 m ammss "magi: norm Q—aryéiic, State of Texas Memorial Cam Phanmcy STATEMENT PO. Box 66602 TX 77266 Statement Date: Paynnnt Date: Statement #: Houston, Phone: (346) 262—03 10 05/09/2022 - Check #2 Payment Due: Fax: (832) 476-1970 $555.00 ANSELMO ALVAREZ MARIA MEMORIAL CARE PHARMACY P.O. Box 66602 Houston, TX 77266 Bill of Summary Date of Slipn'em Descfipt'wn Chaos (Emits Patient Balance : 01/03/2022 Cycloberrzaprinc 10mg 0301 $141.70 $141.70 ‘ 01/03/2022 Voltaxen Gel 1%0100.1 $279.70 $279.70 01/03/2022 Naproxen 500mg (260.1 $133.60 $133.60 Accomt Caren Balance: $555.00 Delivery Charge: $0.00 Total: $555.00 Thank you for your business! Should you have any inquiries concerning this statement, please contact (346) 262-0310. Please nuke all checks payable to Mermn'al Care Phanmcy. P.0. Box 66602, Houston, TX 77266 T: (346) 262-0310 F: (832) 476-1970 | E—Imil: Billing@MennrialCarePhanmcy.com Tax ID: - 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