Preview
FILED
11/6/2020 1:03 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Martin Reyes DEPUTY
CAUSE NO. DC-20-09663 Martin Reyes
SHERRI HODGE, § IN THE DISTRICT COURT
Plaintiff, §
§
vs. § 95TH JUDICIAL DISTRICT
§
BIG LOTS STORES, INC., §
Defendant. § DALLAS COUNTY, TEXAS
PLAINTIFF MARIA GARCIA’S NOTICE OF FILING AFFIDAVITS
FOR BILLING AND MEDICAL RECORDS
TO: Defendant BIG LOTS STORES, INC., by and through its attorney of record, Zach T.
Mayer, Mayer LLP, 750 N. St. Paul Street, Suite 700, Dallas, Texas 75201
Plaintiff MARIA GARCIA hereby gives notice to opposing counsel, pursuant to Texas
Rule of Evidence 902, of her ling and intent to use the below listed business records, and
accompanying self-authenticating afdavits (attached hereto), at the trial and/or any hearing
regarding this matter:
Trusted ER Hillcrest — Billing Afdavit
Trusted ER Hillcrest — Medical Afdavit
99°99‘95>P°.Nt‘
Trusted Health Physicians — Billing Afdavit
Premier Injury Clinic — Billing Afdavit
Premier Injury Clinic — Medical Afdavit
Jaime Ramirez, MD — Billing Afdavit
Jaime Ramirez, MD — Medical Afdavit
MRI Centers of Texas — Billing Afdavit
MRI Centers of Texas — Medical Afdavit
. Uptown Radiology — Billing Afdavit
. Uptown Radiology — Medical Afdavit
. Epic Pain and Orthopedics — Billing Afdavit
. Epic Pain and Orthopedics — Medical Afdavit
. ASP Cares — Billing Afdavit
Respectfully submitted,
J. ALEX. L FI , P.
I
9/,‘
By:
JOSHUA W. ALEXANDER
Texas Bar No. 24086984
Email: josh@jalexlawrm.com
KELSEY E. BRODOCK
Texas Bar No. 24086965
Email: kelsey@jalexlawrm.com
DAVID W. TOWNEND
Texas Bar No. 201 55700
Email: david@jalexlawrm.com
ROBERT B. MOSS
State Bar No. 241 13558
Email: robert@jalexlawrm.com
13601 Preston Road
West Tower, Suite 600W
Dallas, Texas 75240
Phone: (972) 535-5700
Fax: (844) 838-7440
ATTORNEYS FOR PLAINTIFF
CERTIFICATE OF SERVICE
I certify that a true and correct copy of the foregoing has been served on the following in
accordance with the Texas Rules of Civil Procedure on this the 26th day ofNovember, 2020.
Via E-Service:
Zach T. Mayer
Mayer LLP
750 N. St. Paul Street, Suite 700
Dallas, Texas 75201
Attorneyfor Defendant
JOSHJJA W. ALEXANISER
AFFIDAVIT OF COST 0F SERVICES BY CUSTODIAN
STATE OF TEXAS *
a:
COUNTY OF DALLAS *
Before me, the undersigned authority, personally appeared
who, being by me duly sworn, deposed as follows:
WMLH-
My name is Dmnm‘qkw‘K—am of sound mind and capable of making this
afdavit, and personally acquainted with the facts herein stated.
I am a custodian of records for Trusted ER Hillcrest. Attached to this aidavit are
records that provide an itemized statement of the service and the charge for the service that
Trusted ER Hillcrest provided to Sherri Hodge from 07/13/19 through 07/ 13/ 19. The attached
records are a part of this afdavit.
The attached records are kept by Trusted ER I-Iillcrest in the regular course of business,
and it was in the regular course of business of Trusted ER Hillcrest for an employee or
representative of Trusted ER Hillcrest, with knowledge of the services provided, to make the
record or to transmit information to be included in the record. The records were made in the
regular course business at or near the time or reasonably soon after the time the service was
provided. The records are the original or duplicate ofthe original.
The services provided were necessary and the amount charged for the services was
reasonable at the time and place that the services were provided.
The total amount paid for the services was $ 0 and the amount currently
unpaid but which Trusted ER Hillcrest has a right to be paid aer any adjustments or credits is
$ 6,443.44 .
_%ant
A
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SWORN To AND SUB SCRIBED before me on the 9( day of véu S’r' , JG?
CWLUA/LaM—x,
Notary Public, State of Texas
Notary’s printed name: W W 519D. My commission expires; $ 'CL 'm l
MELINDA ALLISON SHOKLER
I],’1
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:§.-' Notary
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09-06-2021 9
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AFFIDAVIT 0F MEDICAL RECORDS
STATE OF TEXAS *
a:
COUNTY OF DALLAS *
BEFORE ME; the undersigned authority, personally appeared
who, being by me duly sworn deposed as follows:
MOW “Ml”
I, the undersigned, am over 21 years of age, of sound mind, capable of making this
afdavit, and personally acquainted with the, facts herein stated; and
I
I am the Custodian of Records for Trusted ER Hillcrest. Attached hereto are medical
records pertaining to .Sherri Hodge. These said records are kept in the regular course of
business, and it was in the regular course for an employee or representative of Trusted ER
Hillcrest with personal knowledge of the act, event, condition, or diagnosis, recorded to make
the record or to transmit information thereof to be included in such memorandum er record; and
the memorandum or record was made at or near the time of the act, event or condition recorded
or reasonably soon thereafter.
The records attached hereto are originals or exact duplicates of originals, and nothing has
been removed om the original les before making copies.
mew-4%
SWORN TO AND SUBSCRIBED before me on the 2l day of [11.565 ’i , .2010?
Notary Public, State of Texas
Notary’s printed name: v kl! LAW Obit: My commission
‘ t a"
expires:J’U“—
\“unm” ’1
MELmDA ALLISON SHOKLER
gay'qga
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'81
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AFFIDAVIT 0F COST OF SERVICES BY CUSTODIAN
STATE OF TEXAS *
a:
COUNTY OF DALLAS *
Before me, the undersigned authority, personally appeared
who, being by me duly sworn, deposed as follows:
Emmw
My name is S 3Q hm g mgglL-Iyam of sound mind and capable of making this
afdavit, and personally acquainted with the facts herein stated.
I am a custodian of records for Trusted Health Physicians. Attached to this afdavit are
records that provide an itemized statement of the service and the charge for the service that
Trusted Health Physicians provided to Sherri Hodge from 07/13/19 through 07/13/19. The
attached records are a part of this afdavit.
The attached records are kept by Trusted Health Physicians in the regular course of
business, and it was the regular course of business of Trustejd Health Phvsieiar_1_s for an
employee or representative of Trusted Health Physicial with knowledge of the services
provided, to make the record or to transmit information to be included in the record. The records
were made in the regular course business at or near the time or reasonably soon after the time the
service was provided. The records are the original or duplicate of the original.
The services provided were necessary and the amount charged for the services was
reasonable at the time and place that the services were provided.
The total amount paid for the services was $ 0 and the amount currently
unpaid but which Trusted Health Physicians has a right to be paid after any adjustments or
credits is $ $575.00 .
m:
‘
SWORN TO AND SUBSCRIBED before me on the al day of A’URU 34’ , ml
Notary Public, State of Texas
Notary’s printed name: YWMOU‘ SWI’V My commission expires: 7’“
AFFIDAVIT OF COST OF
SERVICES BY CUSTODIAN
STATE 0F TEXAS
§
COUNTY OF DALLAS §
§
'Before me, the undersig
ned authority, on this da
a person whose y personally appeared
his/her oath, he/she said: identity is known to me. Aer I
administered an oath to
. him/her, upon
\ K
l. My name is/qg
afdavit. Ihave personam mmg :mnm . lam ofsound mind and
l know ledge of the facts stated in this afdavit capable ofmaking this
and they are true and cor
rect.
2. I am the Custodian of
records that pro ' Billing Records for PREMIER INJURY CLINIC. Attached to this
vide lze ent of the se i e d the a‘idavit are
CLINIC provided to ch the service that PRE
The attached records are a fro m to I
part of thi afdavit. 'HB gig , in the amount of $ WY . .
3. The attached records are
was the regula course of kept by PREMIER INJURY CLINIC
in the
PREMIER INJURY CL
r business of PREMIER
INJURY CLINIC for anregular course of business, and it
INIC; with knowledge of the service employee or representativ of
e
information to be included provided, to make the record or
in the record. The record to transmit
time or reasonabl soon aer s were made in the
y the time the service was regular course of business at or nea
provided. The records are the r the
original. original or a duplicate ofthe
4. The services pro
vided were necessary and the amount
and place that the servic charged for the services was reason
es were provided able at the time
.
S. The total amount for the services was $
PREMIER INJURY CLINpa id
IC has Q and the amount curre
a right to be
paid after any adj
t1 id but which
tments or credits is $
AFFIANT
NOEMY OLIVAS
232° 9%.”: Notary Public, State of Texas
‘
a. g;
'53”?
Comm. Expires 05-27-2022
.Notary m 129330646
BUSINESS RECORDS AF
FIDAVIT
STATE 0F TEXAS
§
COUNTY 0F DALLAS §
§
Before me, the
undersigled authority, on th
a person whose is day pe
identity is lmown to me. Aer rsonally appeared
his/her oath, he/she sa I administered an oath
id: to him/her,
upon
aidavit. Ihave personal knowle . Iam of sound mind and
ge of the acts stated in this afdav capable of ma king this
it and they are true and
2. I am the correct.
person in charge of the records
for PR EMIER INJURY CLINIC.
3.
afdavit are
ched E52 pages of records 'om PREMIER INJURY CL
E
1
ais INIC relating to
4. These records are
kept by PREMIER INJURY CL
regular course of business of INIC in the regular course
of business, and it was in
PREMIER INJURY CLINIC PREMIER INJURY CLINIC for an the
with knowled of the employee or represen
recorded, to make this re ge act, event, condition, tative of,
cord or to transmit the inf
made at or near the ormation to be included opinion or diagnosis that was
time, or reasonably soon alter in this record. The rec
recorded. The records the act, event, ord was
are the condition, opini or
or
originals an exact dupli on diagnosis that was
cate of the originals.
»,
AFFIANT $6
SWORN AND SUBSCR
IB ED before me on this the
‘30 day
2019.
RE EIVED
V
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01/151’2020 1%:39 T—08:OD TO: +1214553618 FRUI‘E. 8448387440
AFFIDAVIT OF COST 0F SERVICES BY CUSTOIDTA.N
STATE 0F mms §
§
COUNTY 01': DALLAS §
Before me, the undersigned authority, on this day Jh LUCIE“
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.- :v 151—5665;. nix-.5 n5 1".“ '111.1'1"1 1: 1' 111_1w1_1 11'_1 1_1___11_.
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2. I am the: Custodian 0f Billing Records for DR. MIME RAMIREZ, MD. Attached to this aidavit an:
records that provide an itmizcd statement of the service and the: charge fnr the Hen-vice that: DR. JAIME
RAMIREZ. MD provided
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infommtion to be: includcd'1n the 1114:0111. The records were made'm thr. mgulm course of business at 01
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STATE F TEXAS §
§
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am pages
SHERRI. HO‘DGE.
These mmrds are kept by DR. JAIME RAMIREZ, MD in the regular course of businass, an‘d lit wa's-in
the: mgular course of businms (EUR. JAIME RAM'I'R HZ, MD for an employee: m‘ t‘epr§sentat}vc of,
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AFFIDAVIT OF COST OF SERVICES BY CUSTODIAN
STATE OF TEXAS §
§
COUNTY OF DALLAS §
Before
the undersigned authority, on this day personally appeared
me, gm D|NA
SALDANA a person whose identity is known to me. Aer I administered an oath to him/her, upon
his/her oath, he/she said:
1. My name is GALDINA SALDANA . I am of sound mind and capable of making this
afdavit. I have personal knowledge of the facts stated in this afdavit and they are true and correct.
2. I am the Custodian of Billing Records for MRI CENTERS OF TEXAS. Attached to this afdavit are
records that provide an itemized statement of the service and the charge for the service that MRI CENTERS OF
TEXAS provided to SHERRI HODGE , from 08/1 6/19 to 08/1 6/19 , in the amountof$ 2 554.00 . The
attached records are a part of this afdavit.
3. The attached records are kept by MRI CENTERS OF TEXAS in the regular course of business, and it was
the regular courseof business of MRI CENTERS OF TEXAS for an employee or representative of MRI
CENTERS OF TEXAS, 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 aer the time the service was provided. The records are the original or a duplicate ofthe original.
4. The services provided were necessary and the amount charged for the services was reasonable at the time
and place that the services were provided.
5. The total amount paid for the services was $ Q and the amount currently unpaid but which MRI
CENTERS OF TEXAS has a right to be paid aer any adjustments or credits is $ 2.554-00 .
SWORN AND SUBSCRIBED before me on this the 1A day of RB]
4%
m gi , 2019.
\ .
DONNA D_ EWING
,
“Wm/,1
“R ‘30
:‘<}$..'.’Yo,\
’1
Notary Public m and or the Sta Texas
’1]I Imu‘
\“NIH”,
N013”, public, State of Texas
,_”(,
O
:ik} “z” Comm. Expires 11-24-2022
'+
2.03.23“ Notary no 125717143
BUSINESS RECORDS AFFIDAVIT
STATE OF TEXAS §
§
COUNTY 0F DALLAS §
Before the undersigned authority, on this day personally appeared
me, GALDINA
SALDANA a person whose
, identity is known to me. Aer I administered an oath to him/her, upon
his/her oath, he/she said:
1. My name is GALDINA SALDANA . lam of sound mind and capable of making this
aidavit. I have personal knowledge of the facts stated in this afdavit and they are true and correct.
2. I am the person in charge of the records for MRI CENTERS 0F TEXAS.
3. Attached to this affidavit are 6 pages of records from MRI CENTERS OF TEXAS relating to
SHERRI HOD E .
4. These records are kept by MRI CENTERS OF TEXAS in the regular course ofbusiness, and it was in the
regular course of business of MRI CENTERS OF TEXAS for an employee or representative of, MRI
CENTERS OF TEXAS with knowledge of the act, event, condition, opinion or diagnosis that was
recorded, to make this record or to transmit the information to be included in this record. The record was
made at or near the time, or reasonably soon aer the act, event, condition, opinion or diagnosis that was
recorded. The records are the originals or an exact duplicate of the originals.
-’WI" 121;AMA
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may./_/l.
SWORN AND SUBSCRIBED before me on this theZl day of Fl W1 u s l— , 2019.
Notary Public in and for the Sge of Texas
DONNA D EWING
\‘,ls‘{f}'é,’;,,
‘
°,- Notary Public. State of Texas
H"
a ‘5'. (:35Comm Ex ires 11- 24-
Preview
FILED 11/6/2020 1:03 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Martin Reyes DEPUTY CAUSE NO. DC-20-09663 Martin Reyes SHERRI HODGE, § IN THE DISTRICT COURT Plaintiff, § § vs. § 95TH JUDICIAL DISTRICT § BIG LOTS STORES, INC., § Defendant. § DALLAS COUNTY, TEXAS PLAINTIFF MARIA GARCIA’S NOTICE OF FILING AFFIDAVITS FOR BILLING AND MEDICAL RECORDS TO: Defendant BIG LOTS STORES, INC., by and through its attorney of record, Zach T. Mayer, Mayer LLP, 750 N. St. Paul Street, Suite 700, Dallas, Texas 75201 Plaintiff MARIA GARCIA hereby gives notice to opposing counsel, pursuant to Texas Rule of Evidence 902, of her ling and intent to use the below listed business records, and accompanying self-authenticating afdavits (attached hereto), at the trial and/or any hearing regarding this matter: Trusted ER Hillcrest — Billing Afdavit Trusted ER Hillcrest — Medical Afdavit 99°99‘95>P°.Nt‘ Trusted Health Physicians — Billing Afdavit Premier Injury Clinic — Billing Afdavit Premier Injury Clinic — Medical Afdavit Jaime Ramirez, MD — Billing Afdavit Jaime Ramirez, MD — Medical Afdavit MRI Centers of Texas — Billing Afdavit MRI Centers of Texas — Medical Afdavit . Uptown Radiology — Billing Afdavit . Uptown Radiology — Medical Afdavit . Epic Pain and Orthopedics — Billing Afdavit . Epic Pain and Orthopedics — Medical Afdavit . ASP Cares — Billing Afdavit Respectfully submitted, J. ALEX. L FI , P. I 9/,‘ By: JOSHUA W. ALEXANDER Texas Bar No. 24086984 Email: josh@jalexlawrm.com KELSEY E. BRODOCK Texas Bar No. 24086965 Email: kelsey@jalexlawrm.com DAVID W. TOWNEND Texas Bar No. 201 55700 Email: david@jalexlawrm.com ROBERT B. MOSS State Bar No. 241 13558 Email: robert@jalexlawrm.com 13601 Preston Road West Tower, Suite 600W Dallas, Texas 75240 Phone: (972) 535-5700 Fax: (844) 838-7440 ATTORNEYS FOR PLAINTIFF CERTIFICATE OF SERVICE I certify that a true and correct copy of the foregoing has been served on the following in accordance with the Texas Rules of Civil Procedure on this the 26th day ofNovember, 2020. Via E-Service: Zach T. Mayer Mayer LLP 750 N. St. Paul Street, Suite 700 Dallas, Texas 75201 Attorneyfor Defendant JOSHJJA W. ALEXANISER AFFIDAVIT OF COST 0F SERVICES BY CUSTODIAN STATE OF TEXAS * a: COUNTY OF DALLAS * Before me, the undersigned authority, personally appeared who, being by me duly sworn, deposed as follows: WMLH- My name is Dmnm‘qkw‘K—am of sound mind and capable of making this afdavit, and personally acquainted with the facts herein stated. I am a custodian of records for Trusted ER Hillcrest. Attached to this aidavit are records that provide an itemized statement of the service and the charge for the service that Trusted ER Hillcrest provided to Sherri Hodge from 07/13/19 through 07/ 13/ 19. The attached records are a part of this afdavit. The attached records are kept by Trusted ER I-Iillcrest in the regular course of business, and it was in the regular course of business of Trusted ER Hillcrest for an employee or representative of Trusted ER Hillcrest, with knowledge of the services provided, to make the record or to transmit information to be included in the record. The records were made in the regular course business at or near the time or reasonably soon after the time the service was provided. The records are the original or duplicate ofthe original. The services provided were necessary and the amount charged for the services was reasonable at the time and place that the services were provided. The total amount paid for the services was $ 0 and the amount currently unpaid but which Trusted ER Hillcrest has a right to be paid aer any adjustments or credits is $ 6,443.44 . _%ant A m ,1 w Qx SWORN To AND SUB SCRIBED before me on the 9( day of véu S’r' , JG? CWLUA/LaM—x, Notary Public, State of Texas Notary’s printed name: W W 519D. My commission expires; $ 'CL 'm l MELINDA ALLISON SHOKLER I],’1 “$9230, r, """ Public. State of Texas :§.-' Notary 190;”: 26*??? I o é Comm. Expires 09-06-2021 9 0‘ «*‘s I 3%??? Notary ID 131270202 AFFIDAVIT 0F MEDICAL RECORDS STATE OF TEXAS * a: COUNTY OF DALLAS * BEFORE ME; the undersigned authority, personally appeared who, being by me duly sworn deposed as follows: MOW “Ml” I, the undersigned, am over 21 years of age, of sound mind, capable of making this afdavit, and personally acquainted with the, facts herein stated; and I I am the Custodian of Records for Trusted ER Hillcrest. Attached hereto are medical records pertaining to .Sherri Hodge. These said records are kept in the regular course of business, and it was in the regular course for an employee or representative of Trusted ER Hillcrest with personal knowledge of the act, event, condition, or diagnosis, recorded to make the record or to transmit information thereof to be included in such memorandum er record; and the memorandum or record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter. The records attached hereto are originals or exact duplicates of originals, and nothing has been removed om the original les before making copies. mew-4% SWORN TO AND SUBSCRIBED before me on the 2l day of [11.565 ’i , .2010? Notary Public, State of Texas Notary’s printed name: v kl! LAW Obit: My commission ‘ t a" expires:J’U“— \“unm” ’1 MELmDA ALLISON SHOKLER gay'qga 3%: Notary Public. State of Texas r étof’ I? ,‘v: Comm. Expires 09--06-2021 '81 ’I(,,°,f.“\‘$ Notary lD 131270202 AFFIDAVIT 0F COST OF SERVICES BY CUSTODIAN STATE OF TEXAS * a: COUNTY OF DALLAS * Before me, the undersigned authority, personally appeared who, being by me duly sworn, deposed as follows: Emmw My name is S 3Q hm g mgglL-Iyam of sound mind and capable of making this afdavit, and personally acquainted with the facts herein stated. I am a custodian of records for Trusted Health Physicians. Attached to this afdavit are records that provide an itemized statement of the service and the charge for the service that Trusted Health Physicians provided to Sherri Hodge from 07/13/19 through 07/13/19. The attached records are a part of this afdavit. The attached records are kept by Trusted Health Physicians in the regular course of business, and it was the regular course of business of Trustejd Health Phvsieiar_1_s for an employee or representative of Trusted Health Physicial with knowledge of the services provided, to make the record or to transmit information to be included in the record. The records were made in the regular course business at or near the time or reasonably soon after the time the service was provided. The records are the original or duplicate of the original. The services provided were necessary and the amount charged for the services was reasonable at the time and place that the services were provided. The total amount paid for the services was $ 0 and the amount currently unpaid but which Trusted Health Physicians has a right to be paid after any adjustments or credits is $ $575.00 . m: ‘ SWORN TO AND SUBSCRIBED before me on the al day of A’URU 34’ , ml Notary Public, State of Texas Notary’s printed name: YWMOU‘ SWI’V My commission expires: 7’“ AFFIDAVIT OF COST OF SERVICES BY CUSTODIAN STATE 0F TEXAS § COUNTY OF DALLAS § § 'Before me, the undersig ned authority, on this da a person whose y personally appeared his/her oath, he/she said: identity is known to me. Aer I administered an oath to . him/her, upon \ K l. My name is/qg afdavit. Ihave personam mmg :mnm . lam ofsound mind and l know ledge of the facts stated in this afdavit capable ofmaking this and they are true and cor rect. 2. I am the Custodian of records that pro ' Billing Records for PREMIER INJURY CLINIC. Attached to this vide lze ent of the se i e d the a‘idavit are CLINIC provided to ch the service that PRE The attached records are a fro m to I part of thi afdavit. 'HB gig , in the amount of $ WY . . 3. The attached records are was the regula course of kept by PREMIER INJURY CLINIC in the PREMIER INJURY CL r business of PREMIER INJURY CLINIC for anregular course of business, and it INIC; with knowledge of the service employee or representativ of e information to be included provided, to make the record or in the record. The record to transmit time or reasonabl soon aer s were made in the y the time the service was regular course of business at or nea provided. The records are the r the original. original or a duplicate ofthe 4. The services pro vided were necessary and the amount and place that the servic charged for the services was reason es were provided able at the time . S. The total amount for the services was $ PREMIER INJURY CLINpa id IC has Q and the amount curre a right to be paid after any adj t1 id but which tments or credits is $ AFFIANT NOEMY OLIVAS 232° 9%.”: Notary Public, State of Texas ‘ a. g; '53”? Comm. Expires 05-27-2022 .Notary m 129330646 BUSINESS RECORDS AF FIDAVIT STATE 0F TEXAS § COUNTY 0F DALLAS § § Before me, the undersigled authority, on th a person whose is day pe identity is lmown to me. Aer rsonally appeared his/her oath, he/she sa I administered an oath id: to him/her, upon aidavit. Ihave personal knowle . Iam of sound mind and ge of the acts stated in this afdav capable of ma king this it and they are true and 2. I am the correct. person in charge of the records for PR EMIER INJURY CLINIC. 3. afdavit are ched E52 pages of records 'om PREMIER INJURY CL E 1 ais INIC relating to 4. These records are kept by PREMIER INJURY CL regular course of business of INIC in the regular course of business, and it was in PREMIER INJURY CLINIC PREMIER INJURY CLINIC for an the with knowled of the employee or represen recorded, to make this re ge act, event, condition, tative of, cord or to transmit the inf made at or near the ormation to be included opinion or diagnosis that was time, or reasonably soon alter in this record. The rec recorded. The records the act, event, ord was are the condition, opini or or originals an exact dupli on diagnosis that was cate of the originals. », AFFIANT $6 SWORN AND SUBSCR IB ED before me on this the ‘30 day 2019. RE EIVED V 12/“85f2015 B4: 394W 01/151’2020 1%:39 T—08:OD TO: +1214553618 FRUI‘E. 8448387440 AFFIDAVIT OF COST 0F SERVICES BY CUSTOIDTA.N STATE 0F mms § § COUNTY 01': DALLAS § Before me, the undersigned authority, on this day Jh LUCIE“ paragnaily appealed .- :v 151—5665;. nix-.5 n5 1".“ '111.1'1"1 1: 1' 111_1w1_1 11'_1 1_1___11_. "11111 _1_ n111111111nr11-n 1:11'1 1_'1' -——— -— 1r —r-..--...--.-.-.—.., 111mm hisfher oath, hel$hc said: 1- ' MI flarf'l_ is thn Lumen .1 am of sound mind and capable of making this axnuvu I. nerve pBTSOilJ K IEgB OI. If“) iact statstd In thi‘. :3.deva and they 311:: true: and cnri‘cl. 2. I am the: Custodian 0f Billing Records for DR. MIME RAMIREZ, MD. Attached to this aidavit an: records that provide an itmizcd statement of the service and the: charge fnr the Hen-vice that: DR. JAIME RAMIREZ. MD provided S Lj . "1_., The attached to SHERRI HDDGE, from res-cords are a pan of this afdavit. M _N/FZA‘ZM to jig/(i, in the amount of ..—. —. - . ‘ . T __Lj . ' "l Ht: I}! LEE; [lrJl'l If“: l_H_ m’ __". II”! was Luv Ingmar WHYSG D]. UUSinuSS UI'Lih. inn Ipl'i—lyWU U1 liylusllld VET Ul- DR. JAIME RAMIREZ, MD with lmowledga of the serum: _providcd to makt the rccord m to transmit infommtion to be: includcd'1n the 1114:0111. The records were made'm thr. mgulm course of business at 01 near the time 01' reasonably $0011 after [he Lime the sari/1‘05 was pruvidcd. The mmrds are the—urigim or ., 1. , 11- .11 ' ' 4 -- --—" 'u. uupnuwm 1.11. un‘rmuglnm. “'4. Iha services provided W611: tnessary and the amount Charged for the Services was usuwnuu'u: n'L in: .1..." ...... 1..- ....1 “uu ..I.-.1.L it. ...-nu..— “1.1L:- way-'1...‘.i ‘../.-....w...u.1.1undul 5_ ”All“, ”Juji'ljclllnl 1'1““: w'rI Hfw vvuapu ”Ax j 11111.] .'_-'I_'1_'_II_] mulls {Dig}m: lug? —- f.“":"'.n?!j ' F“ d! .. n.- 14.13:" ‘ swam AND SUBSCRIBED before me on this. the; da. gm..__, 2020. ' a c1 Jay ExpirIIas IEGI'mmuasmn "hwy" l 111 .. IIIhIIfly 02.12022 r:- . 13165Q73'7» $.03,“ PFI‘TF‘TUF“W TafmhJ'JI-d'l ."1 Md! I'JIUAM 14:35:! 'I‘mH-HH ’I'I'J‘ +121Ghhl'-SIHH rLJM: dEQSU'I’EQU E- I 112.83 .L' AF, mml STATE F TEXAS § § COUNTY OF DALLAS § “5f“; mg, the: undersigned muhority: on this day personally appemd .......-J.h_LMGvien I 9 pawn“ whnor:__h’¥_t-xr1tjf§f it‘Llgrm'imnj'rj ma Al‘ T af‘ln‘linitmd at! Bath t0 himafhl', upon his/her oath, hé/she Said: MY 11313116 i3 30h n Hui-Wm“ . I am of sound mind and capabla of making this .N“. .1. .'.a. ' V I. .. .. ....... . ... .1 1.- .....1 ...J.-.. ...II‘ L1,”. {“n. a.J..-. “animd I“ Hahn nI-T-L-lnn-H- and “luau I)“: h-nn- iII'Ir’“ YEAH-n? MLIJU'i-l'v'l'u. 'l. .uVD lJUlDuuaL axuuvr [ugh-’5'. Vi um Jan-Ln oLaLL-u 1.I..I Hum um “an v.” Lug... um; vnv w. wv “Hw- —u..._-.. person in charge ofthc rtcords for DR. JAIME RAMIREZ, MD E‘J I' am le Attachcd to this afdavit __Q_ of recards from DR. JAIME RAMIREZ, MD relating to '5'” am pages SHERRI. HO‘DGE. These mmrds are kept by DR. JAIME RAMIREZ, MD in the regular course of businass, an‘d lit wa's-in the: mgular course of businms (EUR. JAIME RAM'I'R HZ, MD for an employee: m‘ t‘epr§sentat}vc of, DR. of condition, or that was JAIME RAMIREZ, MD with knowledge the act, cvent, opiniou dxagnosxs v 1 .. .1.. ..1.'.- Luib icLUlu. ..-__...-.: Ln. Lu w. Mama-mu “an Jawtl-‘no-nnnnn u amount, Luv “Mun-Hummin— ”m. 1m: u-u ww hurvlnfharl nun-uuvu in -.-- Thin -----v T" - -- - - u Th Y'ECI'd I'LNJUI'UELEE l_.U_l_J,j::u.$ " ' . In.» aim was made at 0r near the time, or reasonabiy soon ai’cur the act, cvet'xt, uuumfm, awnion an ._ Jig. ' ' was recmdcd. The records are the originals er an exact duplicate of the engmaie. gwgmxt AND SUBSP'R [HRH het‘nre me cm thie the R. a. w dev of .rx v 1/" h returrpwn .I MJI 'A Avn 11-h“. ghee. g-FTexas: A A .L “t W; H- 4%. .. :1 .Rant'ttr‘day Cook m. . CI M... (nmrnzp AFFIDAVIT OF COST OF SERVICES BY CUSTODIAN STATE OF TEXAS § § COUNTY OF DALLAS § Before the undersigned authority, on this day personally appeared me, gm D|NA SALDANA a person whose identity is known to me. Aer I administered an oath to him/her, upon his/her oath, he/she said: 1. My name is GALDINA SALDANA . I am of sound mind and capable of making this afdavit. I have personal knowledge of the facts stated in this afdavit and they are true and correct. 2. I am the Custodian of Billing Records for MRI CENTERS OF TEXAS. Attached to this afdavit are records that provide an itemized statement of the service and the charge for the service that MRI CENTERS OF TEXAS provided to SHERRI HODGE , from 08/1 6/19 to 08/1 6/19 , in the amountof$ 2 554.00 . The attached records are a part of this afdavit. 3. The attached records are kept by MRI CENTERS OF TEXAS in the regular course of business, and it was the regular courseof business of MRI CENTERS OF TEXAS for an employee or representative of MRI CENTERS OF TEXAS, 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 aer the time the service was provided. The records are the original or a duplicate ofthe original. 4. The services provided were necessary and the amount charged for the services was reasonable at the time and place that the services were provided. 5. The total amount paid for the services was $ Q and the amount currently unpaid but which MRI CENTERS OF TEXAS has a right to be paid aer any adjustments or credits is $ 2.554-00 . SWORN AND SUBSCRIBED before me on this the 1A day of RB] 4% m gi , 2019. \ . DONNA D_ EWING , “Wm/,1 “R ‘30 :‘<}$..'.’Yo,\ ’1 Notary Public m and or the Sta Texas ’1]I Imu‘ \“NIH”, N013”, public, State of Texas ,_”(, O :ik} “z” Comm. Expires 11-24-2022 '+ 2.03.23“ Notary no 125717143 BUSINESS RECORDS AFFIDAVIT STATE OF TEXAS § § COUNTY 0F DALLAS § Before the undersigned authority, on this day personally appeared me, GALDINA SALDANA a person whose , identity is known to me. Aer I administered an oath to him/her, upon his/her oath, he/she said: 1. My name is GALDINA SALDANA . lam of sound mind and capable of making this aidavit. I have personal knowledge of the facts stated in this afdavit and they are true and correct. 2. I am the person in charge of the records for MRI CENTERS 0F TEXAS. 3. Attached to this affidavit are 6 pages of records from MRI CENTERS OF TEXAS relating to SHERRI HOD E . 4. These records are kept by MRI CENTERS OF TEXAS in the regular course ofbusiness, and it was in the regular course of business of MRI CENTERS OF TEXAS for an employee or representative of, MRI CENTERS OF TEXAS with knowledge of the act, event, condition, opinion or diagnosis that was recorded, to make this record or to transmit the information to be included in this record. The record was made at or near the time, or reasonably soon aer the act, event, condition, opinion or diagnosis that was recorded. The records are the originals or an exact duplicate of the originals. -’WI" 121;AMA ' may./_/l. SWORN AND SUBSCRIBED before me on this theZl day of Fl W1 u s l— , 2019. Notary Public in and for the Sge of Texas DONNA D EWING \‘,ls‘{f}'é,’;,, ‘ °,- Notary Public. State of Texas H" a ‘5'. (:35Comm Ex ires 11- 24-