On September 06, 2017 a
Party Statement
was filed
involving a dispute between
Hubbard, Patricia,
and
Luna, Leonardo,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
Preview
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DALLAS COUNTY
12/7/2017 5:25 PM
FELICIA PITRE
DISTRICT CLERK
CAUSE NO. DC-17-11588
PATRICIA HUBBARD IN THE DISTRICT COURT
Plaintiff,
Vv. DALLAS COUNTY, TEXAS
LEONARDO LUNA
Defendant. 116™ JUDICIAL DISTRICT
AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF
TEXAS HEALTH [HOSPITAL]
State of T
County of f Ballas
Before me, the undersigned authority, personally appeared the undersigned Affiant,who, being
first duly sworn, deposed as follows:
"My name is 1 am of sound mind and capable of making
this affidavit, and I am personally é¢quainted with the facts stated herein.
"I am a custodian of.records for Texas Health [Hospital], which is referred to hereinafter as "the
|
Provider", and I am authorized to execute this affidavit on behalf of the Provider.
"Attached to this affidavit are records that provide an it ite statement ofthe services and the
charge & igeach ezice that the Provider provided to on
(dates). The attached records are a part of this
The attached records are kept by me in the regular course ofbusiness. In the regular course of
business, the information contained in the records was transmitted to me by the Provider or by an employee
or representative of the Provider who had personal knowledge of the information. The records were made
at or near the time the service was provided or reasonably soon thereafter and accurately reflect the event
recorded. The records are the original or a duplicate of the original éxcept for any redactions required by
law.”
The services were necessary and the amounts charged forthe services were reasonable at the time
and place that the services were provided.
To date, the total amount paid for the services is $. Ys LO -O7 and taking into
account sy adjustment due to payer adjudication, ie Provider has a balance due of
. Such balance may be revised due to coordination of benefits and/or by
future payments and/or by future credits, adjustments or discounts or by reversal(s) thereof. Once a
contracted payer makes payment, contractual adjustments may apply. Accordingly, Provider
pre-determined adjustments may not be reflected herein.
SWORN TO AND SUBSCRIBED before me on Ab
Es uly bite
Public, State of Texas
Notary Seal:
LYNDIA CONLEY-WHITE
Notary 'D # 10677369
Affidavit - 1E7
‘My Commission Expires
2 eee November 13, 2020
Document Filed Date
December 07, 2017
Case Filing Date
September 06, 2017
Category
MOTOR VEHICLE ACCIDENT
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| DALLAS COUNTY 12/7/2017 5:25 PM FELICIA PITRE DISTRICT CLERK CAUSE NO. DC-17-11588 PATRICIA HUBBARD IN THE DISTRICT COURT Plaintiff, Vv. DALLAS COUNTY, TEXAS LEONARDO LUNA Defendant. 116™ JUDICIAL DISTRICT AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF TEXAS HEALTH [HOSPITAL] State of T County of f Ballas Before me, the undersigned authority, personally appeared the undersigned Affiant,who, being first duly sworn, deposed as follows: "My name is 1 am of sound mind and capable of making this affidavit, and I am personally é¢quainted with the facts stated herein. "I am a custodian of.records for Texas Health [Hospital], which is referred to hereinafter as "the | Provider", and I am authorized to execute this affidavit on behalf of the Provider. "Attached to this affidavit are records that provide an it ite statement ofthe services and the charge & igeach ezice that the Provider provided to on (dates). The attached records are a part of this The attached records are kept by me in the regular course ofbusiness. In the regular course of business, the information contained in the records was transmitted to me by the Provider or by an employee or representative of the Provider who had personal knowledge of the information. The records were made at or near the time the service was provided or reasonably soon thereafter and accurately reflect the event recorded. The records are the original or a duplicate of the original éxcept for any redactions required by law.” The services were necessary and the amounts charged forthe services were reasonable at the time and place that the services were provided. To date, the total amount paid for the services is $. Ys LO -O7 and taking into account sy adjustment due to payer adjudication, ie Provider has a balance due of . Such balance may be revised due to coordination of benefits and/or by future payments and/or by future credits, adjustments or discounts or by reversal(s) thereof. Once a contracted payer makes payment, contractual adjustments may apply. Accordingly, Provider pre-determined adjustments may not be reflected herein. SWORN TO AND SUBSCRIBED before me on Ab Es uly bite Public, State of Texas Notary Seal: LYNDIA CONLEY-WHITE Notary 'D # 10677369 Affidavit - 1E7 ‘My Commission Expires 2 eee November 13, 2020