Preview
FILED
8/3/2023 2:35 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Brandon Keys DEPUTY
Cause No. DC-23-01413
HIWOT MIRACH, Individually and as Next § IN THE DISTRICT COURT OF
Friend of N.S and A.B., minors §
Plaintiffs §
§ 298th JUDICIAL DISTRICT
Vv.
JULIO ANTONIO VICENTE RODAS § DALLAS COUNTY, TEXAS
Defendant
_ _ __
NOTICE OF FILING AFFIDAVIT(S)
TO Defendant Julio Antonio Vicente Rodas, by and through his attorney of record, Javier
Gonzalez, The Law Office of Chrysti Bryant, 8360 LBJ Freeway, Suite 410, Dallas, TX
75243.
Pursuant to the provisions of Tex. R. Evid. 902(10) and Tex. Civ. Pract. & Rem. Code
§18.001, Plaintiffs Hiwot Mirach, Individually and as Next Friend of N.S and A.B., minors in the
above entitled and numbered cause, gives all concerned parties notice of filing with the Clerk of
the Court in which this cause is pending the following affidavit(s):
Affidavit of Aniyia Jones, Custodian of Billing Records for ASP Cares
(re Hiwot Mirach)
Affidavit of Ruby Ibarra, Custodian of Billing Records for First Medical
Group (re Hiwot Mirach)
Affidavit of Ruby Ibarra, Custodian of Medical Records for First Medical
Group (re Hiwot Mirach)
Affidavit of Sara Rios, Custodian of Billing Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re Hiwot Mirach)
Affidavit of Sara Rios, Custodian of Medical Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re Hiwot Mirach)
Affidavit of Amy Glatz, Custodian of Billing Records for Texas
Radiology Associates, LP (re Hiwot Mirach)
NOTICE OF FILING AFFIDAVIT(S) PAGE 1
Affidavit of Sara Rios, Custodian of Billing Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re A.B.)
Affidavit of Sara Rios, Custodian of Medical Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re A.B.)
Affidavit of Sara Rios, Custodian of Billing Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re N.S.)
10. Affidavit of Sara Rios, Custodian of Medical Records for Texas
Healthcare. Neck & Back Clinics, P.A. (re N.S.)
11 Affidavit of Abby Alexander, Custodian of Medical Records for Texas
Health Allen (re A.B.)
12. Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas
Medicine Resources, LLP (re A.B.)
13 Affidavit of Tina Taheri, Custodian of Billing Records for City of Allen
(re Hiwot Mirach)
14 Affidavit of Tina Taheri, Custodian of Medical Records for City of Allen
(re Hiwot Mirach)
1S Affidavit of Za’ Kayla Henderson, Custodian of Billing Records for DFW
MRI (re Hiwot Mirach)
16. Affidavit of Za’Kayla Henderson, Custodian of Medical Records for
DFW MRI (re Hiwot Mirach)
17 Affidavit of Abby Alexander, Custodian of Medical Records for Texas
Health Allen (re Hiwot Mirach)
18 Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas
Medicine Resources, LLP (re Hiwot Mirach)
19 Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas
Medicine Resources, LLP (re N.S.)
20 Certification of Jim Hollis, Custodian of Motor Vehicle Crash Records
for the Texas Department of Transportation
You are further hereby notified that the above-described affidavits may be used by
Plaintiffs as evidence in this cause. Plaintiffs have provided Defendant copies of above records.
NOTICE OF FILING AFFIDAVIT(S) PAGE 2
Respectfully submitted,
By: _C~
> 2
NEJAT AHMED
Texas State Bar No. 24034304
ejat@lalawtx.com
JENNIFER B. LEMASTER
Texas State Bar No. 24041063
jennifer@lalawtx.com
JOEY MALDONADO, JR.
Texas State Bar No. 24039474
joey@lalawtx.com
LEMASTER & AHMED PLLC
5700 Tennyson Parkway, Suite 310A
Plano, TX 75024
Telephone: 972.666.7219
Facsimile: 972.483.0413
ATTORNEYS FOR PLAINTIFFS
HIWOT MIRACH, INDIVIDUALLY AND AS
NEXT FRIEND OF N.S AND A.B., MINORS
CERTIFICATE OF SERVICE:
I hereby certify that I served a true and correct copy of this document on counsel of
record listed below by method specified on the 3"! day of August, 2023:
Javier Gonzalez Via Eserve: KADallasEservice@kemper.com
The Law Office of Chrysti Bryant javier. gonzalez@kemper.com
8360 LBJ Freeway, Suite 410
Dallas, TX 75243
_C~
22 +1
Nejat A. Ahmed
NOTICE OF FILING AFFIDAVIT(S) PAGE 3
Exhibit "A"
BILLING RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM
12/12/2021 to present, pertaining to Hiwot Mirach, DOB:
Before me, the undersigned authority, personally appeared, Anivict Jocoos who being
by me duly sworn, deposedas follows:
Tam the person in charge of the records of ASP Cares. Attached to this affidavit are records that provide an
itemized statement of the service and the charge for the service that ASP Cares provided to Hiwot Mirach from
12/12/2021 to present.
The attached records are kept by the custodian of records in the regular course of business. The information
contained in the records was transmitted to me in the regular course of business by ASP Cares or an employee or
representative of ASP Cares who has personal knowledge of the information. The records were made at or near
reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original.
The service provided was necessary and the amount charged for the service was reasonable at the time and
place that the service was provided.
a, $ Zz Y q ‘ OO > amount charged by ASP Cares
$ © Total amount written off from the total charges, which ASP Cares
agrees it will never seek to collect from any source
O Total amount paid to date on the referenced account by or on behalf of
Hiwot Mirach
2UaoO (Civhe amount presently outstanding on the referenced account or which
ASP Cares is legally entitled to collect
1uUqd0
“Total amount paid” PLUS “amount presently outstanding on the
6 referenced account that ASP Cares has the legal right to collect” (item
a c plus item d)
Anivia
AFFIANT
JacoosS
(Custodian of Records)
Sworn to and subscribed before me on the. 50 day of. YNOAS/ » 22>
NOFARY PUBLIC
My Commission Expires: O ri ~ | ome 2 Y
in, BRENDA ANGELICA JUAREZ
% Notary Public, State of Texas
Comm. Expires 07-13-2024
%, Notary ID 132565437
a
MIRACH000355
BILLING RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM
12/12/2021 to present, pertainingto Hiwot Mirach, DOB
Before me, the undersigned authority, personally appeared. (2uny Ipasvor who being
by me duly swom, deposedas follows:
| am the person in charge of the records of FIRST MEDICAL GROUP. Attached to this affidavit are records
that provide an itemized statement of the service and the charge for the service that First Medical Group provided to
Hiwot Mirach from 12/12/2021
to present.
The attached records are kept by the custodian of records in the regular course of business. The information
contained in the records was transmitted to me in the regular course of business by First Medical Group
or an employee
or representative of First Medical Group who has personal knowledge of the information. The records were made at
or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of
the original
The service provided was necessary and the amount charged for the service was reasonable at the time and
place that the service was provided.
a. $ L,225,00 Total amount charged by First Medical Group
s_ DB Total amount written off from the total charges, which First Medical
Group agrees it will never seek to collect from any source
D Total amount paid to date on the referenced account
Hiwot Mirach
by or on behalfof
The amount presently outstanding on the referenced account or which
225.00 First Medical Group is legally entitled to collect
“Total amount paid” PLUS “amount presently outstanding on the
referenced account that First Medical Group has the legal right to
\1225,00 ”
collect” (it item d)
FI IT (Cust an ofRi
Swom to and subscribed before me on the. 13 day of. Joly 29 23
NOTARY PUBLIC
My Commission Expires: 3 laoas
Me, ContaogeAlcorta
C,§ Snr "E re
OF bmNO. 126578504
es
MIRACH000357
MEDICAL RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all medical records FROM 12/12/2021 to preseat, including but not limited to, any and
all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records, therapy records, notes and
(Corey perro.
correspondence relating to Hiwot Mirach, DOB:
Before me, the undersigned authority, personally appeared,
by me duly swom, deposed
My name is
of sound mind and capable
ae
of making this affidavit,
. | am over eighteen (18) years of age,
and personally acquainted with the fact herein stated.
I am aCustodian of Records for:
FIRST MEDICAL GROUP
This is a regularly conducted business activity. Attached hereto are | | pages of records from this facility, and it
was regular practice to make and maintain these records, These records are kept in regular course of business and it
was the regular course of business for an employee or representative of this facility with knowledge, or one who had
been furnished such knowledge of the act, event, condition, opinion, or diagnoses recorded to make the record or to
transmit information
thereof to be included in such record; and the record was made at or near the time of the act,
event or condition recorded or reasonably soon thereafter. The method of preparation of the records was trustworthy.
The records attached hereto are the original or e: icates of the original
AFFIANT ( stodian of Records)
Sworn to and subscribed before
me on the. 13 day of. Dolu 2023
ark Yo AQ
NOTARY PUBLIC
My Commission Expires: 3lalacas
at
i,
Cenlda Alcorta
My Commission Expres
10 No 128878504
Peta
MIRACHO00361
BILLING RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all billing records
including but limited to an: 'y and all itemized billing
2/12/2021 to present, pertaining to Hiwot Mirac statements FROM
h, DOB:
Before me, the undersigned authority, Perso
nally appeared, co w aod
by me duly sworn, deposed as follows: who being
Tam the person in charge of the records of Texas
Healthcare Neck & Back Clinics, P.A.. Attac
affidavit are records that provide an itemized hed to this
statement o} f the service and the charge for
Healthcare Neck & Back Clinics, P.A. provided the service that Texas
to Hiwot t Mirach from 12/12/2021 to present,
The attached records are kept by the cust odian
of records in the regular course of business.
contained in the records was transmitted 1 ‘0 The information
me in the regular course of business by Texas
Clinics, P.A. or an employce or represent Healthcare Neck & Back
tative of Texas Healthcare Neck & Back Clini
knowledge of the information. The recor ‘ds cs, P.A. who has personal
were made at or near reasonably soon after
provided. The records are the original or th © time that service was
e: ‘xact duplicates of the original.
The service provided was necessai ry and the amoun
t charged for the service was reasonable at
place that the service was provided. the time and
a. $ _S,4D8.°? Total amount charged by Texas Healthcare Neck & Back Clinics, P.A,
Total amount written off from the total charges,
which Texas
Healthcare Neck & Back Clinics, P.A. agrees
db collect from any source
it will never seek to
&
Total amount paid to date on the referenced
account by or on behalf of
Hiwot Mirach
The amount presently outstanding on the refer
enced account or which
Texas Healthcare Neck & Back Clinics, P.
s$4qo8.” collect
A. is legaily entitled to
“Total amount paid” PLUS “amount presently
outstanding on the
referenced account that Texas Healthcar ¢ Neck
$ S499." has the legal right to collect” (item c plus item d)
& Back Clinics, P.A.
Seen -
AFFIANT (Custodian of Records)
Swom to and subscribed before me on the 7 day of
DE
Notary Pul
IR. NOTARY PUBLIC
Myn/A3
Comm. &:
M 70; < } My Commission Expires:
MIRACHO000373
MEDICAL RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all medical records FROM
12/12//22021 to Present
pres , including but not limited to, any and
all reports, notes, tests, test results, diagnoses, Progno
ses, office records, clinic records, therapy records,
correspondence relating to Hiwot Mirach, notes and
DOB: 7
Before me, the undersigned authority, Personal
ly appeared, Soca As
by me duly sworn, deposed as follows: who being
My name is Sere Tas - Lam over eighteen (18) years of age,
of sound mind and capable of making this affidavit,
and Personally acquainte d with the fact herein stated
,
Tam a Custodian of Records for:
Texas Healthcare Neck & Back Clinics, P.A.
This is a regularly conducted business activity. Attached
hereto are G0 Pages of records from this facility,
was regular practice to make and maintain these and it
records, These records are kept in regular course of
was the regular course of business for an emplo business and it
yee or rep resentative of this facility with knowledge,
been furnished such knowledge of the act, event, or one who had
conditi ion, opinion, or diagnoses recorded to make
transmit information thereof to be included in such the record or to
re cord > and the record was made at or near the time
event or condition recorded or reasonably soon thereat of the act,
fter. The method of preparation of the recor:
The records attached hereto are the original or exact ‘ds was trustworthy
di luplicates of the original.
Soro“ Luo
AFFIANT (Custodian of Records)
Swom to and subscribed before me on the
day of. 23
rn entiation KALA Z hint Ye Lh
DEBRA H. KENDRIX NOTARY PUBLIC
Was a
lotary Public, State of Texas
Comim, Exwires 69-20-2023
ea
ty1D 11690700
PR a
My Commission Expires:
eo
MIRACH000376
BILLING RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM
12/12/2021 to present, pertaining to Hiwot Mirach, DOB
Before me, the undersigned authority, personally appeared, Amy Glatz who being
by me duly sworn, deposed as follows:
Iam the person in charge of the records of Texas Radiology Associates, LP. Attached to this affidavit are
records that provide an itemized statement of the service and the charge for the service that Texas Radiology
Associates, LP provided to Hiwot Mirach from 12/12/2021 to present.
The attached records are kept by the custodian of records in the regular course of business. The information
contained in the records was transmitted to me in the regular course of business by Texas Radiology Associates, LP
or an employee or representative of Texas Radiology Associates, LP who has personal knowledge of the information.
The records were made at or near reasonably soon after the time that service was provided. The records are the original
or exact duplicates of the original.
The service provided was necessary and the amount charged for the service was reasonable at the time and
place that the service was provided.
a. $ 915.00 Total amount charged by Texas Radiology Associates, LP
Total amount written off from the total charges, which Texas
Radiology Associates, LP agrees it will never seek to collect from any
$ 0.00 source
Total amount paid to date on the referenced account by or on behalf of
$s 0.00 Hiwot Mirach
The amount presently outstanding on the referenced account or which
$ 915.00 Texas Radiology Associates, LP is legally entitled to collect
“Total amount paid” PLUS “amount presently outstanding on the
referenced account that Texas Radiology Associates, LP has the legal
$ 915.00 right to collect” (item c plus item d)
fh
a =
te
AFF! [AND (Custodian o: cod)
Sworn to and subscribed before me on the 318t day, of May 2023
‘BRIDGET SHAY HAYNES
hy Marypt?
NGPARY PUBLIC
tery Public, St
mn. E 28
Notary ID 131089085 My Commission Expires: 04-11-2025
MIRACHO000467
BILLING RECORD AFFIDAVIT
Records Pertaining To: A B
Type of Records: Any and all billing records includin; g but limited
to any and all itemized billing statements FROM.
2/12/2021 to present, pertaining to A DOB:
Before me, the undersigned authority, personally appeared, Se a Aas who being
by me duly sworn, deposed as follows:
Tam the person in charge of the records of Texas He: althcare Neck
& Back Clinics, P.A., Attached to this
affidavit are records that provide an itemized statement of the service and
the charge for the service that Texas Healthcare
Neck & Back Clinics, P.A. provided to A
from 12/12/2021 to present,
The attached records are kept by the custodian of records in the
regular course of business. The information
contained in the records was transmitted to me in the regular course
of business by Texas Healthcare Neck & Back
Clinics, P.A. or an employee or representative of Texas Healthc
are Neck & Back Clinics, P.A. who has personal
knowledge of the information. The records we re made at or near
reasonably soon after the time that service was
provided. The records are the original or exact di luplicates of the original.
The service provided was necessai ry and the amount charged for the service
was reasonable at the time and
place that the service was provided,
a $ x S53 7 cae Total amount charged by Texas Healthcare Neck & Back Clinics,
P.A.
Total amount written off from the total charges, which Texas
Healthcare Neck & Back Clinics, P.A. agrees it will never seek to
$ Y collect from any source
: / Ta amount paid to date on the referenced account by or on behalf of
The amount presently outstanding on the referenced account or which
Texas Healthcare Neck & Back Clinics, P.A. is legally entitled
s BSY,°° collect
to
“Total amount paid” PLUS “amount presently outstanding on the
referenced account that Texas Healthcare Neck & Back Clinics, P.A.
s_ 9S¥” has the legal right to collect” (item c plus item d)
Sern (dros
AFFIANT (Custodian of Records)
Swor
ey, ZH day (Ayy-
a
Sora H. HENDRIX
otary Public, Stato of Texas
Comm. Expires 09-20-2023
Gag 1D 11690700 NOTARY PUBLIC
ae ae a
My Commission Expires: BLYAB
MIRACH000469
MEDICAL RECORD AFFIDAVIT
Records Pertaining To: A B
Type of Records: Any and all medical records FROM 12/12/2021 to present, including but not limited to, any and
all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records,
therapy records, notes and
correspondence relating to DOB:
Before me, the undersigned authority, personally appeared, Seca. hist who being
by me duly sworn, deposed as follows:
My name is __ ore (Ye S . Lam over eighteen (18) years of age,
of sound mind and capable of making this affidavit, and personally acquainte d with the fact hereinstated.
Tam a Custodian of Records for:
Texas Healthcare Neck & Back Clinics, P.A.
This is a regularly conducted business activity. Attached hereto are 3 pages of records from this facility, and it
was regular practice to make and maintain these records, These records are kept in regular
course of business and it
was the regular course of business for an employee or representative of this facility with knowledge,
or one who had
been furnished such knowledge of the act, event, condition, opinion, or diagnoses
recorded to make the record or to
transmit information thereof to be included in such record; and the record was made at or near the
time of the act,
event or condition recorded or reasonably soon thereafter. The method of preparation of the records
was trustworthy.
The records attached hereto are the original or exact duplicates of the original.
Sane %
AFFIANT
+
(Custodian of Records)
Swom to and subscribed before me on the 3 } day of, 204 ZB
i, DEBRA H. HENDRIX NOTARY PUBLIC
“a s
% Notary Public, State of Texas
Comm. Expires 09-20-2023
Notary ue 11690700
My Commission Expires: YhiVAB
Wn
- ram
MIRACH000471
BILLING RECORD AFFIDAVIT
Ly
Records Pertaining To: N 5
Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM
12/12/2021 to present, pertaining to DOB:
Before me, the undersigned authority, personally appeared, ce Qos who being
by me duly sworn, deposed as follows:
lam the person in charge of the records of Texas Healthcare Neck & Back Clinics, P.A.. Attached to this
affidavit are records that provide an itemized statement of the service and the charge for the service that Texas
Healthcare Neck & Back Clinics, P.A. provided to from 1 2. /12/2021 to presen it.
The attached records are kept by the custodian of records in the regular course of business. The information
contained in the records was transmitted to me in the regular course of business by Texas Healthcare Neck & Back
Clinics, P.A. or an employee or representative of Texas Healthcare Neck & Back Clinics, P.A. who has personal
knowledge of the information. The records were made at or near reasonably soon after the time that service was
provided. The records are the original or exact duplicates of the original.
The service provided was necessary and the amount charged for the service was reasonable at the time and
place that the service was provided.
a. $ 3S g an Total amount charged by Texas Healthcare Neck & Back Clinics, P.A.
Total amount written off from the total charges, which Texas
Healthcare Neck & Back Clinics, P.A. agrees it will never seek to
collect from any source
Total amount paid to date on the referenced account by or on behalf of
The amount presently outstanding on the referenced account or which
Texas Healthcare Neck & Back Clinics, P.A. is legally entitled to
Stoned collect
“Total amount paid” PLUS “amount presently outstanding on the
Zsy.°? referenced account that Texas Healthcare Neck & Back Clinics, P.A.
has the legal right to collect” (item c plus item d)
Soe
AFFIANT (Custodian of Records)
Swo to and subscribed before me on we Fay ofMy.
is
13417)
Ve
NOTARY PUBLIC
Wo
%
“WW
Neng be My Commission Expires:
emp &y 7
Noy, Ng
Weng Stary Oye
SS
Fog Oa, Stag
MIRACH000504
MEDICAL RECORD AFFIDAVIT
Records Pertaining To: N 33
Type of Records: Any and all medical records FROM 12/12/2021 to present, including but not limited to, any and
all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records, therapy records, notes and
correspondence relating to DOB:
Before me, the undersigned authority, personally appeared, So vi A> gC who being
by me duly sworn, deposed as follows:
My name is Soren (Lins . Tam over eighteen ( 18) years of age,
of sound mind and capable of making this affidavit, and personally acquainted with the fact hereinstated.
1am a Custodian of Records for:
Texas Healthcare Neck & Back Clinics, P.A.
This is a regularly conducted business activity. Attached hereto are 30 pages of records from this facility, and it
was regular practice to make and maintain these records, These records are kept in regular course of business and it
was the regular course of business for an employee or representative of this facility with knowledge, or one who had
been furnished such knowledge of the act, event, condition, opinion, or diagnoses recorded to make the record or to
transmit information thereof to be included in such record; and the record was made at or near the time of the act,
event or condition recorded or reasonably soon thereafter. The method of preparation of the records was trustworthy.
The records attached hereto are the original or exact duplicates of the original.
Swom to and subscribed before me on the 3) day of, DNF »A3
aI
0b3
ac NOTARY PUBLIC
it,
ves %, _ DEBRAH. HENDRIX
Notary Public, State Of My Commission Expires:
Texas
Comm. Expires 09-20-
“a ss 2023
eT Notary 10 11890709
St Le PEDITTS
MIRACH000506
STATE OF TEXAS
COUNTY OF TARRANT
AFFIDAVIT
Relating to Medical Records of Texas Health Allen (“Hospital”).
Before me, the undersigned authority, personally appeared _ ABBY ALEXANDER ms
who by me being duly sworn, deposed as follows:
“My name is ABBY ALEXANDER . Tam of sound mind, capable of making this Affidavit, and
personally acquainted with the facts herein stated.”
“I am a medical records custodian of the Hospital and as such am a custodian of the patient care
records of said hospital. These records may also include documents received from other health care providers.
Attached hereto are 31 page(s), being exact copies of records from the Hospital concerning
B A for date(s) of service 12/12/2021 kept by the Health
Information Management Services Department. These records are kept by the Hospital in the regular course
of business, and it was the regular course of business of the Hospital for an employee or representative or a
member of the medical staff of the Hospital with knowledge of the act, event, condition, opinion, or diagnosis
recorded to make the record or to transmit information thereof to be included in such record; and the record
was made at or near the time or reasonably soon thereafter. The records attached hereto are exact duplicates
of the original.”
The bates numbering represents the actual page count on this record.
AFFIANT
SWORN TO AND SUBSCRIBED before me on the ZL day of_. Og, wB
JENNIFER FRITZ
lL. Notary ID #130187322
4K My Commission Expires
April 10, 2027
Notary Publi 1c Spite of T
My Commi ion Expires: 16-77
‘Texas Health Resources Records Affidavit June 2023
MIRACHO000541
AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF
TEXAS MEDICINE RESOURCES, LLP
STATE OF TEXAS
COUNTY OF TARRANT
Before me, the undersigned authority, personally appeared Jasmine Gonzales, who, being
by me duly swom, deposed as follows:
My name is Jasmine Gonzales. I am of sound mind and capable of making this affidavit,
and personally acquainted with the facts herein stated.
1am custodian of billing records for Texas Medicine Resources, LLP (“Provider Group”).
Attached to this affidavit are billing records that provide an itemized statement of the service and
the charge for the service that Provider Group rendered to A B on 12/12/2021. The
attached billing records are a part of this affidavit.
The attached billing records are kept by Provider Group in the regular course of business,
and it was the regular course of business of Provider Group for a representative of Provider Group
with knowledge of the billing service provided, to make the record or to transmit information to
be included in the billing record. The billing 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 a
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 $0.00 and the amount currently unpaid which
Provider Group has the right to be paid after any adjustments or credits is $588.00(@ collections).
Vv
SWORN TO AND SUBSCRIBED before me on the LS. day of Solyy , 2023.
ROXANNE CORTEZ
My Notary ID # 134032107
Expires October 25, 2026 Notary Public, State of Texas
4
Notary’s printed name: Roxanne Cortez
My commission expires: October 25, 2026
MIRACH000579
63
BILLING RECORD AFFIDAVIT
Records Pertaining To: Hiwot Mirach
Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM
12/12/2021 to present, pertaining to Hiwot Mirach, DOB:
Before me, the undersigned authority, personally appeared, Tina Taheri who being
by me duly sworn, deposed as follows:
Tam the person in charge of the records of CITY OF ALLEN. Attached to this affidavit are records that provide
an itemized statement of the service and the charge for the service that City of Allen provided to Hiwot Mirach from
12/12/2021
to present,
The attached records are kept by the custodian of records in the regular course of business. The information
contained in the records was transmitted to me in the regular course of business by City of Allen or an employee or
Tepresentative of City of Allen who has personal knowledge of the information. The records were made at or near
reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original.
The service provided was necessary and the amount charged for the service was reasonable at the time and
place that the service was provided.
a. $ 1042.00 Total amount charged by City of Allen
Total amoun
Preview
FILED 8/3/2023 2:35 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Brandon Keys DEPUTY Cause No. DC-23-01413 HIWOT MIRACH, Individually and as Next § IN THE DISTRICT COURT OF Friend of N.S and A.B., minors § Plaintiffs § § 298th JUDICIAL DISTRICT Vv. JULIO ANTONIO VICENTE RODAS § DALLAS COUNTY, TEXAS Defendant _ _ __ NOTICE OF FILING AFFIDAVIT(S) TO Defendant Julio Antonio Vicente Rodas, by and through his attorney of record, Javier Gonzalez, The Law Office of Chrysti Bryant, 8360 LBJ Freeway, Suite 410, Dallas, TX 75243. Pursuant to the provisions of Tex. R. Evid. 902(10) and Tex. Civ. Pract. & Rem. Code §18.001, Plaintiffs Hiwot Mirach, Individually and as Next Friend of N.S and A.B., minors in the above entitled and numbered cause, gives all concerned parties notice of filing with the Clerk of the Court in which this cause is pending the following affidavit(s): Affidavit of Aniyia Jones, Custodian of Billing Records for ASP Cares (re Hiwot Mirach) Affidavit of Ruby Ibarra, Custodian of Billing Records for First Medical Group (re Hiwot Mirach) Affidavit of Ruby Ibarra, Custodian of Medical Records for First Medical Group (re Hiwot Mirach) Affidavit of Sara Rios, Custodian of Billing Records for Texas Healthcare. Neck & Back Clinics, P.A. (re Hiwot Mirach) Affidavit of Sara Rios, Custodian of Medical Records for Texas Healthcare. Neck & Back Clinics, P.A. (re Hiwot Mirach) Affidavit of Amy Glatz, Custodian of Billing Records for Texas Radiology Associates, LP (re Hiwot Mirach) NOTICE OF FILING AFFIDAVIT(S) PAGE 1 Affidavit of Sara Rios, Custodian of Billing Records for Texas Healthcare. Neck & Back Clinics, P.A. (re A.B.) Affidavit of Sara Rios, Custodian of Medical Records for Texas Healthcare. Neck & Back Clinics, P.A. (re A.B.) Affidavit of Sara Rios, Custodian of Billing Records for Texas Healthcare. Neck & Back Clinics, P.A. (re N.S.) 10. Affidavit of Sara Rios, Custodian of Medical Records for Texas Healthcare. Neck & Back Clinics, P.A. (re N.S.) 11 Affidavit of Abby Alexander, Custodian of Medical Records for Texas Health Allen (re A.B.) 12. Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas Medicine Resources, LLP (re A.B.) 13 Affidavit of Tina Taheri, Custodian of Billing Records for City of Allen (re Hiwot Mirach) 14 Affidavit of Tina Taheri, Custodian of Medical Records for City of Allen (re Hiwot Mirach) 1S Affidavit of Za’ Kayla Henderson, Custodian of Billing Records for DFW MRI (re Hiwot Mirach) 16. Affidavit of Za’Kayla Henderson, Custodian of Medical Records for DFW MRI (re Hiwot Mirach) 17 Affidavit of Abby Alexander, Custodian of Medical Records for Texas Health Allen (re Hiwot Mirach) 18 Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas Medicine Resources, LLP (re Hiwot Mirach) 19 Affidavit of Jasmine Gonzales, Custodian of Billing Records for Texas Medicine Resources, LLP (re N.S.) 20 Certification of Jim Hollis, Custodian of Motor Vehicle Crash Records for the Texas Department of Transportation You are further hereby notified that the above-described affidavits may be used by Plaintiffs as evidence in this cause. Plaintiffs have provided Defendant copies of above records. NOTICE OF FILING AFFIDAVIT(S) PAGE 2 Respectfully submitted, By: _C~ > 2 NEJAT AHMED Texas State Bar No. 24034304 ejat@lalawtx.com JENNIFER B. LEMASTER Texas State Bar No. 24041063 jennifer@lalawtx.com JOEY MALDONADO, JR. Texas State Bar No. 24039474 joey@lalawtx.com LEMASTER & AHMED PLLC 5700 Tennyson Parkway, Suite 310A Plano, TX 75024 Telephone: 972.666.7219 Facsimile: 972.483.0413 ATTORNEYS FOR PLAINTIFFS HIWOT MIRACH, INDIVIDUALLY AND AS NEXT FRIEND OF N.S AND A.B., MINORS CERTIFICATE OF SERVICE: I hereby certify that I served a true and correct copy of this document on counsel of record listed below by method specified on the 3"! day of August, 2023: Javier Gonzalez Via Eserve: KADallasEservice@kemper.com The Law Office of Chrysti Bryant javier. gonzalez@kemper.com 8360 LBJ Freeway, Suite 410 Dallas, TX 75243 _C~ 22 +1 Nejat A. Ahmed NOTICE OF FILING AFFIDAVIT(S) PAGE 3 Exhibit "A" BILLING RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM 12/12/2021 to present, pertaining to Hiwot Mirach, DOB: Before me, the undersigned authority, personally appeared, Anivict Jocoos who being by me duly sworn, deposedas follows: Tam the person in charge of the records of ASP Cares. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that ASP Cares provided to Hiwot Mirach from 12/12/2021 to present. The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by ASP Cares or an employee or representative of ASP Cares who has personal knowledge of the information. The records were made at or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original. The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. a, $ Zz Y q ‘ OO > amount charged by ASP Cares $ © Total amount written off from the total charges, which ASP Cares agrees it will never seek to collect from any source O Total amount paid to date on the referenced account by or on behalf of Hiwot Mirach 2UaoO (Civhe amount presently outstanding on the referenced account or which ASP Cares is legally entitled to collect 1uUqd0 “Total amount paid” PLUS “amount presently outstanding on the 6 referenced account that ASP Cares has the legal right to collect” (item a c plus item d) Anivia AFFIANT JacoosS (Custodian of Records) Sworn to and subscribed before me on the. 50 day of. YNOAS/ » 22> NOFARY PUBLIC My Commission Expires: O ri ~ | ome 2 Y in, BRENDA ANGELICA JUAREZ % Notary Public, State of Texas Comm. Expires 07-13-2024 %, Notary ID 132565437 a MIRACH000355 BILLING RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM 12/12/2021 to present, pertainingto Hiwot Mirach, DOB Before me, the undersigned authority, personally appeared. (2uny Ipasvor who being by me duly swom, deposedas follows: | am the person in charge of the records of FIRST MEDICAL GROUP. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that First Medical Group provided to Hiwot Mirach from 12/12/2021 to present. The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by First Medical Group or an employee or representative of First Medical Group who has personal knowledge of the information. The records were made at or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. a. $ L,225,00 Total amount charged by First Medical Group s_ DB Total amount written off from the total charges, which First Medical Group agrees it will never seek to collect from any source D Total amount paid to date on the referenced account Hiwot Mirach by or on behalfof The amount presently outstanding on the referenced account or which 225.00 First Medical Group is legally entitled to collect “Total amount paid” PLUS “amount presently outstanding on the referenced account that First Medical Group has the legal right to \1225,00 ” collect” (it item d) FI IT (Cust an ofRi Swom to and subscribed before me on the. 13 day of. Joly 29 23 NOTARY PUBLIC My Commission Expires: 3 laoas Me, ContaogeAlcorta C,§ Snr "E re OF bmNO. 126578504 es MIRACH000357 MEDICAL RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all medical records FROM 12/12/2021 to preseat, including but not limited to, any and all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records, therapy records, notes and (Corey perro. correspondence relating to Hiwot Mirach, DOB: Before me, the undersigned authority, personally appeared, by me duly swom, deposed My name is of sound mind and capable ae of making this affidavit, . | am over eighteen (18) years of age, and personally acquainted with the fact herein stated. I am aCustodian of Records for: FIRST MEDICAL GROUP This is a regularly conducted business activity. Attached hereto are | | pages of records from this facility, and it was regular practice to make and maintain these records, These records are kept in regular course of business and it was the regular course of business for an employee or representative of this facility with knowledge, or one who had been furnished such knowledge of the act, event, condition, opinion, or diagnoses recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter. The method of preparation of the records was trustworthy. The records attached hereto are the original or e: icates of the original AFFIANT ( stodian of Records) Sworn to and subscribed before me on the. 13 day of. Dolu 2023 ark Yo AQ NOTARY PUBLIC My Commission Expires: 3lalacas at i, Cenlda Alcorta My Commission Expres 10 No 128878504 Peta MIRACHO00361 BILLING RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all billing records including but limited to an: 'y and all itemized billing 2/12/2021 to present, pertaining to Hiwot Mirac statements FROM h, DOB: Before me, the undersigned authority, Perso nally appeared, co w aod by me duly sworn, deposed as follows: who being Tam the person in charge of the records of Texas Healthcare Neck & Back Clinics, P.A.. Attac affidavit are records that provide an itemized hed to this statement o} f the service and the charge for Healthcare Neck & Back Clinics, P.A. provided the service that Texas to Hiwot t Mirach from 12/12/2021 to present, The attached records are kept by the cust odian of records in the regular course of business. contained in the records was transmitted 1 ‘0 The information me in the regular course of business by Texas Clinics, P.A. or an employce or represent Healthcare Neck & Back tative of Texas Healthcare Neck & Back Clini knowledge of the information. The recor ‘ds cs, P.A. who has personal were made at or near reasonably soon after provided. The records are the original or th © time that service was e: ‘xact duplicates of the original. The service provided was necessai ry and the amoun t charged for the service was reasonable at place that the service was provided. the time and a. $ _S,4D8.°? Total amount charged by Texas Healthcare Neck & Back Clinics, P.A, Total amount written off from the total charges, which Texas Healthcare Neck & Back Clinics, P.A. agrees db collect from any source it will never seek to & Total amount paid to date on the referenced account by or on behalf of Hiwot Mirach The amount presently outstanding on the refer enced account or which Texas Healthcare Neck & Back Clinics, P. s$4qo8.” collect A. is legaily entitled to “Total amount paid” PLUS “amount presently outstanding on the referenced account that Texas Healthcar ¢ Neck $ S499." has the legal right to collect” (item c plus item d) & Back Clinics, P.A. Seen - AFFIANT (Custodian of Records) Swom to and subscribed before me on the 7 day of DE Notary Pul IR. NOTARY PUBLIC Myn/A3 Comm. &: M 70; < } My Commission Expires: MIRACHO000373 MEDICAL RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all medical records FROM 12/12//22021 to Present pres , including but not limited to, any and all reports, notes, tests, test results, diagnoses, Progno ses, office records, clinic records, therapy records, correspondence relating to Hiwot Mirach, notes and DOB: 7 Before me, the undersigned authority, Personal ly appeared, Soca As by me duly sworn, deposed as follows: who being My name is Sere Tas - Lam over eighteen (18) years of age, of sound mind and capable of making this affidavit, and Personally acquainte d with the fact herein stated , Tam a Custodian of Records for: Texas Healthcare Neck & Back Clinics, P.A. This is a regularly conducted business activity. Attached hereto are G0 Pages of records from this facility, was regular practice to make and maintain these and it records, These records are kept in regular course of was the regular course of business for an emplo business and it yee or rep resentative of this facility with knowledge, been furnished such knowledge of the act, event, or one who had conditi ion, opinion, or diagnoses recorded to make transmit information thereof to be included in such the record or to re cord > and the record was made at or near the time event or condition recorded or reasonably soon thereat of the act, fter. The method of preparation of the recor: The records attached hereto are the original or exact ‘ds was trustworthy di luplicates of the original. Soro“ Luo AFFIANT (Custodian of Records) Swom to and subscribed before me on the day of. 23 rn entiation KALA Z hint Ye Lh DEBRA H. KENDRIX NOTARY PUBLIC Was a lotary Public, State of Texas Comim, Exwires 69-20-2023 ea ty1D 11690700 PR a My Commission Expires: eo MIRACH000376 BILLING RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM 12/12/2021 to present, pertaining to Hiwot Mirach, DOB Before me, the undersigned authority, personally appeared, Amy Glatz who being by me duly sworn, deposed as follows: Iam the person in charge of the records of Texas Radiology Associates, LP. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Texas Radiology Associates, LP provided to Hiwot Mirach from 12/12/2021 to present. The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by Texas Radiology Associates, LP or an employee or representative of Texas Radiology Associates, LP who has personal knowledge of the information. The records were made at or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original. The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. a. $ 915.00 Total amount charged by Texas Radiology Associates, LP Total amount written off from the total charges, which Texas Radiology Associates, LP agrees it will never seek to collect from any $ 0.00 source Total amount paid to date on the referenced account by or on behalf of $s 0.00 Hiwot Mirach The amount presently outstanding on the referenced account or which $ 915.00 Texas Radiology Associates, LP is legally entitled to collect “Total amount paid” PLUS “amount presently outstanding on the referenced account that Texas Radiology Associates, LP has the legal $ 915.00 right to collect” (item c plus item d) fh a = te AFF! [AND (Custodian o: cod) Sworn to and subscribed before me on the 318t day, of May 2023 ‘BRIDGET SHAY HAYNES hy Marypt? NGPARY PUBLIC tery Public, St mn. E 28 Notary ID 131089085 My Commission Expires: 04-11-2025 MIRACHO000467 BILLING RECORD AFFIDAVIT Records Pertaining To: A B Type of Records: Any and all billing records includin; g but limited to any and all itemized billing statements FROM. 2/12/2021 to present, pertaining to A DOB: Before me, the undersigned authority, personally appeared, Se a Aas who being by me duly sworn, deposed as follows: Tam the person in charge of the records of Texas He: althcare Neck & Back Clinics, P.A., Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Texas Healthcare Neck & Back Clinics, P.A. provided to A from 12/12/2021 to present, The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by Texas Healthcare Neck & Back Clinics, P.A. or an employee or representative of Texas Healthc are Neck & Back Clinics, P.A. who has personal knowledge of the information. The records we re made at or near reasonably soon after the time that service was provided. The records are the original or exact di luplicates of the original. The service provided was necessai ry and the amount charged for the service was reasonable at the time and place that the service was provided, a $ x S53 7 cae Total amount charged by Texas Healthcare Neck & Back Clinics, P.A. Total amount written off from the total charges, which Texas Healthcare Neck & Back Clinics, P.A. agrees it will never seek to $ Y collect from any source : / Ta amount paid to date on the referenced account by or on behalf of The amount presently outstanding on the referenced account or which Texas Healthcare Neck & Back Clinics, P.A. is legally entitled s BSY,°° collect to “Total amount paid” PLUS “amount presently outstanding on the referenced account that Texas Healthcare Neck & Back Clinics, P.A. s_ 9S¥” has the legal right to collect” (item c plus item d) Sern (dros AFFIANT (Custodian of Records) Swor ey, ZH day (Ayy- a Sora H. HENDRIX otary Public, Stato of Texas Comm. Expires 09-20-2023 Gag 1D 11690700 NOTARY PUBLIC ae ae a My Commission Expires: BLYAB MIRACH000469 MEDICAL RECORD AFFIDAVIT Records Pertaining To: A B Type of Records: Any and all medical records FROM 12/12/2021 to present, including but not limited to, any and all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records, therapy records, notes and correspondence relating to DOB: Before me, the undersigned authority, personally appeared, Seca. hist who being by me duly sworn, deposed as follows: My name is __ ore (Ye S . Lam over eighteen (18) years of age, of sound mind and capable of making this affidavit, and personally acquainte d with the fact hereinstated. Tam a Custodian of Records for: Texas Healthcare Neck & Back Clinics, P.A. This is a regularly conducted business activity. Attached hereto are 3 pages of records from this facility, and it was regular practice to make and maintain these records, These records are kept in regular course of business and it was the regular course of business for an employee or representative of this facility with knowledge, or one who had been furnished such knowledge of the act, event, condition, opinion, or diagnoses recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter. The method of preparation of the records was trustworthy. The records attached hereto are the original or exact duplicates of the original. Sane % AFFIANT + (Custodian of Records) Swom to and subscribed before me on the 3 } day of, 204 ZB i, DEBRA H. HENDRIX NOTARY PUBLIC “a s % Notary Public, State of Texas Comm. Expires 09-20-2023 Notary ue 11690700 My Commission Expires: YhiVAB Wn - ram MIRACH000471 BILLING RECORD AFFIDAVIT Ly Records Pertaining To: N 5 Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM 12/12/2021 to present, pertaining to DOB: Before me, the undersigned authority, personally appeared, ce Qos who being by me duly sworn, deposed as follows: lam the person in charge of the records of Texas Healthcare Neck & Back Clinics, P.A.. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Texas Healthcare Neck & Back Clinics, P.A. provided to from 1 2. /12/2021 to presen it. The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by Texas Healthcare Neck & Back Clinics, P.A. or an employee or representative of Texas Healthcare Neck & Back Clinics, P.A. who has personal knowledge of the information. The records were made at or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original. The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. a. $ 3S g an Total amount charged by Texas Healthcare Neck & Back Clinics, P.A. Total amount written off from the total charges, which Texas Healthcare Neck & Back Clinics, P.A. agrees it will never seek to collect from any source Total amount paid to date on the referenced account by or on behalf of The amount presently outstanding on the referenced account or which Texas Healthcare Neck & Back Clinics, P.A. is legally entitled to Stoned collect “Total amount paid” PLUS “amount presently outstanding on the Zsy.°? referenced account that Texas Healthcare Neck & Back Clinics, P.A. has the legal right to collect” (item c plus item d) Soe AFFIANT (Custodian of Records) Swo to and subscribed before me on we Fay ofMy. is 13417) Ve NOTARY PUBLIC Wo % “WW Neng be My Commission Expires: emp &y 7 Noy, Ng Weng Stary Oye SS Fog Oa, Stag MIRACH000504 MEDICAL RECORD AFFIDAVIT Records Pertaining To: N 33 Type of Records: Any and all medical records FROM 12/12/2021 to present, including but not limited to, any and all reports, notes, tests, test results, diagnoses, prognoses, office records, clinic records, therapy records, notes and correspondence relating to DOB: Before me, the undersigned authority, personally appeared, So vi A> gC who being by me duly sworn, deposed as follows: My name is Soren (Lins . Tam over eighteen ( 18) years of age, of sound mind and capable of making this affidavit, and personally acquainted with the fact hereinstated. 1am a Custodian of Records for: Texas Healthcare Neck & Back Clinics, P.A. This is a regularly conducted business activity. Attached hereto are 30 pages of records from this facility, and it was regular practice to make and maintain these records, These records are kept in regular course of business and it was the regular course of business for an employee or representative of this facility with knowledge, or one who had been furnished such knowledge of the act, event, condition, opinion, or diagnoses recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event or condition recorded or reasonably soon thereafter. The method of preparation of the records was trustworthy. The records attached hereto are the original or exact duplicates of the original. Swom to and subscribed before me on the 3) day of, DNF »A3 aI 0b3 ac NOTARY PUBLIC it, ves %, _ DEBRAH. HENDRIX Notary Public, State Of My Commission Expires: Texas Comm. Expires 09-20- “a ss 2023 eT Notary 10 11890709 St Le PEDITTS MIRACH000506 STATE OF TEXAS COUNTY OF TARRANT AFFIDAVIT Relating to Medical Records of Texas Health Allen (“Hospital”). Before me, the undersigned authority, personally appeared _ ABBY ALEXANDER ms who by me being duly sworn, deposed as follows: “My name is ABBY ALEXANDER . Tam of sound mind, capable of making this Affidavit, and personally acquainted with the facts herein stated.” “I am a medical records custodian of the Hospital and as such am a custodian of the patient care records of said hospital. These records may also include documents received from other health care providers. Attached hereto are 31 page(s), being exact copies of records from the Hospital concerning B A for date(s) of service 12/12/2021 kept by the Health Information Management Services Department. These records are kept by the Hospital in the regular course of business, and it was the regular course of business of the Hospital for an employee or representative or a member of the medical staff of the Hospital with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time or reasonably soon thereafter. The records attached hereto are exact duplicates of the original.” The bates numbering represents the actual page count on this record. AFFIANT SWORN TO AND SUBSCRIBED before me on the ZL day of_. Og, wB JENNIFER FRITZ lL. Notary ID #130187322 4K My Commission Expires April 10, 2027 Notary Publi 1c Spite of T My Commi ion Expires: 16-77 ‘Texas Health Resources Records Affidavit June 2023 MIRACHO000541 AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF TEXAS MEDICINE RESOURCES, LLP STATE OF TEXAS COUNTY OF TARRANT Before me, the undersigned authority, personally appeared Jasmine Gonzales, who, being by me duly swom, deposed as follows: My name is Jasmine Gonzales. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated. 1am custodian of billing records for Texas Medicine Resources, LLP (“Provider Group”). Attached to this affidavit are billing records that provide an itemized statement of the service and the charge for the service that Provider Group rendered to A B on 12/12/2021. The attached billing records are a part of this affidavit. The attached billing records are kept by Provider Group in the regular course of business, and it was the regular course of business of Provider Group for a representative of Provider Group with knowledge of the billing service provided, to make the record or to transmit information to be included in the billing record. The billing 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 a 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 $0.00 and the amount currently unpaid which Provider Group has the right to be paid after any adjustments or credits is $588.00(@ collections). Vv SWORN TO AND SUBSCRIBED before me on the LS. day of Solyy , 2023. ROXANNE CORTEZ My Notary ID # 134032107 Expires October 25, 2026 Notary Public, State of Texas 4 Notary’s printed name: Roxanne Cortez My commission expires: October 25, 2026 MIRACH000579 63 BILLING RECORD AFFIDAVIT Records Pertaining To: Hiwot Mirach Type of Records: Any and all billing records including but limited to any and all itemized billing statements FROM 12/12/2021 to present, pertaining to Hiwot Mirach, DOB: Before me, the undersigned authority, personally appeared, Tina Taheri who being by me duly sworn, deposed as follows: Tam the person in charge of the records of CITY OF ALLEN. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that City of Allen provided to Hiwot Mirach from 12/12/2021 to present, The attached records are kept by the custodian of records in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by City of Allen or an employee or Tepresentative of City of Allen who has personal knowledge of the information. The records were made at or near reasonably soon after the time that service was provided. The records are the original or exact duplicates of the original. The service provided was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. a. $ 1042.00 Total amount charged by City of Allen Total amoun