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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 OF
§§§§§§§§§
VS. DALLAS COUNTY, TEXAS
OSCAR SERRANO AND
BIANCA RODRIGUEZ 298TH JUDICIAL DISTRICT
BILLING RECORDS AFFIDAVIT OF MOMENTUM SPINE AND JOINT
FOR PLAINTIFF MARIA ANSELMO
Please see attached.
BILLING RECORDS AFFIDAVIT OF MOMENTUM SPINE AND JOINT FOR PLAINTIFF MARIA
AN SELMO
BILLING RECORDS AFFIDAVIT
(Pursuant to Tex. R. Evid. 902)
PATIENT’S NAlWE: MARIA AN SELMO ALVAREZ
PATIENT’S DATE OF BIRTH: 06/20/1978
STATE 0F TEXAS
COUNTY OF DALLAS
Before me, the undersigned authority, personally appeared Marissa Palacios, being by
me duly sworn, deposed as follows:
My name is Marissa Palacios. I am of sound mind and capable of making this affidavit,
and personally acquainted with the facts herein stated:
I am the custodian of billing records for MOMENTUM SPINE AND JOINT. I am
familiar with the manner in which the facility’s billing records are created and maintained by virtue
of my duties and responsibilities. Attached hereto are g pages of billing records from
MOMENTUM SPINE AND JOINT. These billing records are kept in the regular course of
business, and it was the regular course of business for an employee or representative of
MOMENTUM SPINE AND JOINT, with knowledge of the act, event, condition, opinion, or
diagnosis, recorded to make the billing records or to transmit information thereof to be included
in such records; and the billing records were made at or near the time or reasonably soon thereafter.
The billing records attached hereto are the original or exact duplicates of the original.
Total charges for the services rendered: $2 400.00
PP’NF‘
The amount actually paid by the patient or on the patient’s behalf: §0.00
Amount, if any, adjusted or written off: $0.00
Any amount currently unpaid but which the facility has a right to be paid after any
adjustments or credits: $2,400.00
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Affiant/
SWORN TO AND SUBSCRIBED before me on the _4_th da of May, 2022.
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9. ;_:a,-r'ig momma-libsisfiessfla PATIENT NAME
North Dallas Momentum ANSELMO ALVAREZ, MARIA L
9441 LYNDON BJOHNSON FWY
BILL DATE ACCOUNT NO. AMOUNT PAID. , .
STE 114
DALLAS, TX 75243-4635 Jan I7, 2022
214-557—4111
ANSELMO ALVAREZ, MARIA L
This is a statement for professional services rendered by your
physician. You may receive a separate bill from the hospital for
its services.
PMT/ADJ/
DATE OF SERVICE DESCRIPTION OF SERVICE CHARGES AMOUNT
WITHHELD
:
Dec 17, 2021 Claim:110893, Provider: Raj V. Kakarlapudi M.D.
Dec 17, 2021 99204 Office Visit, New Pt. Level 4 5125030
Jan 17, 2022 Your Balance Due On These Services
Your Balance Due 0n These Services... $1,250.00
Jan 03. 2022 SYDNEY PARDINO, MD
Claim:1:12054Y Provider:
Jan 03. 2022 99212 Office Visit, Est Pt., Level 2 557500
Jan 17. 2022 Your Balance Due On These Services
Your Balance Due 0n These Services... 557500
Ian 07, 2022 Claim:112418. Provider: Raj V. Kakarlapudi MD.
Jan 07, 2022 99212 Office Visit. Est Pt., Level 2 $575.00
Jan 17, 2022 Your Balance Due 0n These Services
Your Balance Due On These Services... 5 57 5.00
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ACCOUNTNGB‘E PAY THIS .
Jan 17, 2022 ANSELMO ALVAREZ. MARIA L AMOUNT $2,400.00
MAKE CHECK PAYABLE To : Momentum Spine and Joint
“ " " " '
my {iMPORTANT MESSAGE REGARDING YOURACCOUNT'1E
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We are pleased to offer you the option of credit card payment. Please indicate your method below.
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Amount: Exp. Date:
Credit Card No: Date:
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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 OF §§§§§§§§§ VS. DALLAS COUNTY, TEXAS OSCAR SERRANO AND BIANCA RODRIGUEZ 298TH JUDICIAL DISTRICT BILLING RECORDS AFFIDAVIT OF MOMENTUM SPINE AND JOINT FOR PLAINTIFF MARIA ANSELMO Please see attached. BILLING RECORDS AFFIDAVIT OF MOMENTUM SPINE AND JOINT FOR PLAINTIFF MARIA AN SELMO BILLING RECORDS AFFIDAVIT (Pursuant to Tex. R. Evid. 902) PATIENT’S NAlWE: MARIA AN SELMO ALVAREZ PATIENT’S DATE OF BIRTH: 06/20/1978 STATE 0F TEXAS COUNTY OF DALLAS Before me, the undersigned authority, personally appeared Marissa Palacios, being by me duly sworn, deposed as follows: My name is Marissa Palacios. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated: I am the custodian of billing records for MOMENTUM SPINE AND JOINT. I am familiar with the manner in which the facility’s billing records are created and maintained by virtue of my duties and responsibilities. Attached hereto are g pages of billing records from MOMENTUM SPINE AND JOINT. These billing records are kept in the regular course of business, and it was the regular course of business for an employee or representative of MOMENTUM SPINE AND JOINT, with knowledge of the act, event, condition, opinion, or diagnosis, recorded to make the billing records or to transmit information thereof to be included in such records; and the billing records were made at or near the time or reasonably soon thereafter. The billing records attached hereto are the original or exact duplicates of the original. Total charges for the services rendered: $2 400.00 PP’NF‘ The amount actually paid by the patient or on the patient’s behalf: §0.00 Amount, if any, adjusted or written off: $0.00 Any amount currently unpaid but which the facility has a right to be paid after any adjustments or credits: $2,400.00 owl/(raw Affiant/ SWORN TO AND SUBSCRIBED before me on the _4_th da of May, 2022. swig? comm mos um,I In: no\ Mo Notary Publlc. State of Texas 9‘ ‘*2:." tary Public, State of Texas Comm. Expires 08~2+2025 :2. \‘\ \ Notary l0 13:1230‘188 I n‘ \‘ = I “ 9. ;_:a,-r'ig momma-libsisfiessfla PATIENT NAME North Dallas Momentum ANSELMO ALVAREZ, MARIA L 9441 LYNDON BJOHNSON FWY BILL DATE ACCOUNT NO. AMOUNT PAID. , . STE 114 DALLAS, TX 75243-4635 Jan I7, 2022 214-557—4111 ANSELMO ALVAREZ, MARIA L This is a statement for professional services rendered by your physician. You may receive a separate bill from the hospital for its services. PMT/ADJ/ DATE OF SERVICE DESCRIPTION OF SERVICE CHARGES AMOUNT WITHHELD : Dec 17, 2021 Claim:110893, Provider: Raj V. Kakarlapudi M.D. Dec 17, 2021 99204 Office Visit, New Pt. Level 4 5125030 Jan 17, 2022 Your Balance Due On These Services Your Balance Due 0n These Services... $1,250.00 Jan 03. 2022 SYDNEY PARDINO, MD Claim:1:12054Y Provider: Jan 03. 2022 99212 Office Visit, Est Pt., Level 2 557500 Jan 17. 2022 Your Balance Due On These Services Your Balance Due 0n These Services... 557500 Ian 07, 2022 Claim:112418. Provider: Raj V. Kakarlapudi MD. Jan 07, 2022 99212 Office Visit. Est Pt., Level 2 $575.00 Jan 17, 2022 Your Balance Due 0n These Services Your Balance Due On These Services... 5 57 5.00 TJQDLE; : WWW 'iiifiATIEuT‘NMEiW‘is; :fl =53 7 ACCOUNTNGB‘E PAY THIS . Jan 17, 2022 ANSELMO ALVAREZ. MARIA L AMOUNT $2,400.00 MAKE CHECK PAYABLE To : Momentum Spine and Joint “ " " " ' my {iMPORTANT MESSAGE REGARDING YOURACCOUNT'1E - - mt ‘ ;_. “5 4 I _‘ “ . 3'; W" " ’ , . .7; f1"- fl - . ~ . . .‘ 74:192.- , We are pleased to offer you the option of credit card payment. Please indicate your method below. Payment Method: VISA MASTER CARD DISCOVER AMEX CHECK Amount: Exp. Date: Credit Card No: Date: ¥ SELF PAY m -- y. . . a: HEAD H INSURANCE CLAIM FORM 5. APPROVED MNATIGNAL uNsFonM CLAN commmze (woe) 02212 134mm v W X X)-(I) Maoscms “mom mama CHAMWA 41110110111159 1a. 11151191120510. NUMBER {For Pragmm m uem q T PLAN wE moicar.aw) a PATENTS 1.141151111111151... First Na’ms, M16111. B Madman» D (low/Dom} 111111.11; E] “Sign” (Mammy) Dam a PATIENT s a s [31191113FEKIMS-11m; DATE O 0ooO0O 411151111505 NAME {Lasmame, Fusmam male Inman) J ’T r 1 ANSELMO ALVAREZ , MARIA, m L ANSELMO ALVAREZ , ' MARIA, L ’ Is wx- EMF .r:s—_§" PA'IIENT’QCLATIOKIEWOINSURED _ 4111;11— ‘7’ 7 1111311111312” 4011355511110 sweet} “ wDmflmD ___“1_1_.14 ' mums a RESERVED FOR Mucc USE STATE PATENT AND susunen 11150111114110" . _ Tx ‘ ‘s. _“ I‘HONE (lncludeArea Coda} ‘ I‘ELEFHDNEUncfwfa Area Code} — . 4 V ( ) a z I 9701111551 :wunwsfihma (L53: Name. Firm Name, Mickie Iranian m: ks PAHENT'S CbfiEffidfirTé’XxE’D—ET— 'ITINsiJREU'; JLJCY GROUP OR FECK NUMBER " _ -___*~,_,J H.01HER INSURED' S PO‘UCY 0G GROUP NUMEH a EMPLOYMENT? (6111mm or Pieumus) E Rsuéizfis 1311155; 51am SEX It). RESERVE!) FOR NUCG U35 b. AUTG ACCIDENT? YES NO M [3 PLACE (Sufi) b. OTHER CLAIM m (Designated by Nuns) c. RESERVED FOR NUCC USE c. OTHER ACCIDENT" was [j no TX c. {NSURAMCE PLAN NAME OH PROGRAM MAME d, INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAKM D Yesr22] CODES {Usajgnmeci by NUGG) ~o d. 13 THERE ANOTHER HEALTH BENEFIT PLAN? D YES N0 <——--——-——- ”yes. comdele items 9,941. and 9d, fiEAD BACK 0F FORM BEFORE COMPLE‘RNG a SEGNNG THIS FORM. 13. {NSUREDLS 0R AUTHORSZED PERSON S SIGNATURE [authorize 12 PATFEFN'S 0R AWNGWZEL‘ PERSO'V’S SHSNATUDE authewrzv "w Manse n! any madim! o’ yrvr m‘cmnz'o» nmcnsary I aayrer“ 3' 4‘“ than???" therr‘fnrs gnédc!v9“.1.“ r 1.1:};11' ur '9‘ 1Q {mess {1:13 dam. i ass raqneat payment: {'gmau. mar. thawing a: 21c: c mysc‘ or 1c; '1 1e party are (1:291; an. g'rmml 311mg}; up, 451;,»- below .1.... SignatUEe Enjilem, _ .l 2 l7 ‘ 2l ’ ,_ , .1.... signaturiw Fiie _ 3AE ~ OF lLLNESS. INJURY or PH EGNANC Y ELM?) OT! . [ER DA T UNA B LE To wofl K IN 4 a». 14 1 5 15 DATES NT DgURRENT ‘E MM DD YY PfiTflENTD YY OCClIJPATIQZJ QUALQUAL'4391 CUFLVQR fl 04 21 21 4 FROM _;__ 10 1 ~_ 1 17. 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