Preview
FILED
DALLAS COUNTY
11/26/2019 4:11 PM
FELICIA PITRE
DISTRICT CLERK
Margaret Thomas
CAUSE N0. DC-18-16118
MICHAEL P. BURCH § IN THE DISTRICT COURT
Plaintiff, §
§
V. § 134TH JUDICIAL DISTRICT
§
ELVIRA ZUBIRI ALCANTAR §
Defendant. § DALLAS COUNTY, TEXAS
PLAINTIFF'S NOTICE OF FILING BUSINESS (MEDICAL) RECORDS AND
AFFIDAVITS CONCERNING COST AND NECESSITY OF SERVICES
TO THE HONORABLE JUDGE OF THIS COURT:
I.
Business (Medical) Records Affidavits
Pursuant t0 Rule 902(10), Texas Rules ovaz'dence, Plaintiff files herewith the business
records Affidavits identified below, which Plaintiff reserves the right t0 offer into evidence at the
trial of the instant case:
1. Medical Records ofAccident & Injury Chiropractic Irving, prepared by Dr. Lou
Saucedo as the Custodian 0f Records for Accident &
Injury Chiropractic Irving,
which records are attached t0 the Affidavit being served 0n the attorneys 0f record;
2. Medical Records 0f Lone Star Radiology, prepared by Dr. Lou Saucedo as the
Custodian 0f Records for Lone Star Radiology, which records are attached t0 the
Affidavit being served 0n the attorneys 0f record;
The above-described Affidavits are signed by individuals who are qualified t0 provide the
prerequisites for admissibility 0f these records under Rule 803(6) and (7), Texas Rules ovaidence,
and attest that the records attached were in fact kept as required by Rules 803 (6) and (7), Texas
Rules ovaidence.
Subject t0 the local rules applicable t0 the Court in which this cause is pending, Plaintiff is
filing the above-referenced Affidavits with the Clerk 0f the Court and serving copies 0f the
Affidavits 0n each other party in the case at least fourteen (14) days before the day 0n which
PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 1 of 3
evidence is first scheduled t0 be presented at the trial 0f the case. Further, the above records will
be made available at the offices 0f Plaintiff‘s attorney for inspection and copying, upon reasonable
notice, at the expense 0f the party desiring the copies.
II.
Affidavits 0f Necessitv 0f Services and Reasonableness 0f Charges
Pursuant t0 Tex. Civ. Prac. & Rem. Code, §18.001, Plaintiff files herewith the following
identified Affidavit Concerning Cost and Necessity 0f Services, attesting that the services provided
were reasonable at the time and place the service was provided relevant t0 the claims in the instant
litigation and the services were necessary:
1. Billing Records of Accident & Injury Chiropractic Irving, prepared by Dr. Lou
Saucedo as the Custodian 0f Records for Accident & Injury Chiropractic Irving,
which records are attached t0 the Affidavit Concerning Cost and Necessity 0f
Services being served t0 the attorney(s) 0f record;
2. Billing Records of Lone Star Radiology prepared by Dr. Lou Saucedo as the
Custodian 0f Records for Lone Star Radiology which records are attached t0 the
Affidavit Concerning Cost and Necessity 0f Services being served 0n the attorneys
0f record;
3. Billing Records of Parkland Health &
Hospital System, prepared by Tracy
Williams as the Custodian 0f Records for Parkland Health Hospital System,&
which records are attached t0 the Affidavit Concerning Cost and Necessity 0f
Services being served 0n attorney(s) 0f record.
The aforementioned Affidavits have been taken before an officer with authority t0
administer oaths and made by the person who provided the service 0r the person in charge 0f
records, and show the service provided and the charge made. Attached t0 each Affidavit is the
itemized statement 0f service and the charges for such service.
Subject t0 the local rules applicable t0 the Court in which this action is pending, Plaintiff
is filing the above-referenced Affidavits with the Clerk 0f the Court and serving copies 0f the
Affidavits 0n each other party in the case Tex. CiV. Prac. & Rem. Code § 18.001 [Vernon Supp.
2019]. These Affidavits and itemized statements are also available at the offices 0f Plaintiff‘s
PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 2 of 3
attorney for inspection, upon reasonable notice, and copying at the expense 0f the party desiring
such copies. Plaintiff reserves the right t0 offer into evidence at the trial 0f the instant cause the
above-referenced Affidavits and itemized statements.
Respectfully submitted,
BAILEY & GALYEN
4131 N. Central Exp 860
Dallas, TX 75204
(214) 252-9099 - Office
(214) 520-9941 — Facsimile
bforteith@galyen.com - Email
By: /s/William A. Forteith
William A. Forteith
Texas State Bar N0.: 07267500
ATTORNEY FOR PLAINTIFF
CERTIFICATE OF SERVICE
I hereby certify that 0n this the 26th day 0f November, 2019, the above and foregoing
instrument has been forwarded t0 counsel(s) 0f record in accordance with the TEXAS RULES OF
CIVIL PROCEDURE:
VIA: E-Serve and/or Facsimile
Chad Kimble
Law Office 0f Chad Kimble, PC
1204 S. White Chapel Blvd.
Southlake, TX 76092
Attorney for: Elvira Zubiri Alcantar
/s/William A. Forteith
William A. Forteith
PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 3 of 3
)
)
)
Plaintiff, ) IN THE DISTRICT IN AND FOR COUNTY,
) TEXAS
VS .
)
)
)
)
Defendant, )
AFFIDAVIT OF NECESSITY OF SERVICES/REASONABLENESS OF CHARGES
Before me, the undersigned authority, on this day personally appeared DR. LOU
SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows:
My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making
this affidavit, and personally acquainted with the facts herein stated:
10
I am the custodian of billing records for ACCIDENT & INJURY CHIROPRACTIC.
Attached hereto are billing records from 09/28/2017 THRU 12/01/2017,
ll pertaining to MIKE BURCH, DOB: 09/21/1971, SSN: N/A. These pages of billing
records are kept by ACCIDENT & INJURY CHIROPRACTIC, in the regular course of
12 business, and it was the regular course of business of ACCIDENT & INJURY
CHIROPRACTIC, for an employee or representative of ACCIDENT & INJURY
13 CHIROPRACTIC, with 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 or
l4
reasonably after the time that the service was provided.
15 The total cost of services for MIKE BURCH received at this facility is
$10,226.00 (which may include a Records Summary Report fee of $150.00). The
l6 total amount adjusted, payments, and write off is $0.00. The adjusted total
cost reflects billing and adjustment as of the date of this affidavit. With
17 the sole exception of fees related to the Records Summary Report fee of
$150.00, these services and charges were both reasonable and necessary in
connection with MIKE BURCH treatment. The amount currently unpaid but which
l8
ACCIDENT & INJURY CHIROPRACTIC has a right to be paid after any adjustments
or credits is $10,226.00.
19
I am familiar with the charges rendered in the vicinity in which they were
2O incurred. I consider these charges to be reasonable and customary for all
like or similar services. The records attached hereto are the original or
21 exact duplicates of the original.
22
Affiant
23 SWORN TO AND SUBSCRIBED before me on the t day of .
,
2019.
24 *XB’MM
\ J
zwmm
Notary Pubiic, State of Texas
“
25 Notary’s printed name and
commission expires:05—13—2023
LKYSAUNAS
My Notary ID # 130225380
Expires May 13, 2023
) Cause No.:
)
Plaintiff, )
) IN THE DISTRICT COURT
vs. )
) DALLAS COUNTY, TEXAS
)
)
Defendant, )
)
AFFIDAVIT FOR THE AUTHENTICATION OF BUSINESS RECORDS
Before me, the undersigned authority, on this day personally appeared DR. LOU
SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows:
My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making
this affidavit, and personally acquainted with the facts herein stated:
lO
I am the custodian of healthcare treatment records for ACCIDENT & INJURY
ll CHIROPRACTIC. Attached hereto are records from 09/28/2017 THRU 12/01/2017,
pertaining to MIKE BURCH, DOB: 09/21/1971, SSN: N/A. These records are kept
12 by ACCIDENT & INJURY CHIROPRACTIC in the regular course of business, and it
was the regular course of business of ACCIDENT & INJURY CHIROPRACTIC for an
13 employee or representative of ACCIDENT & INJURY CHIROPRACTIC, with knowledge
of the act, event, condition, opinion, or diagnoses recorded to make the
l4
records or to transmit information thereof to be included in such records;
and the records were made at or near the time or reasonably after the time
that the service was provided. The records attached hereto are the original
15 or exact duplicates of the original.
l6
l7 Affiant
l8 SWORN To AND SUBSCRIBED before me on the lg day of A Lfigggflg k] gfl, 2019.
Wzflm .J trim
x ‘
J A
l9
Notary Pfiblic, State of Texaa
20
Notary's printed name and
commission expires:05-13-23
21
22 LILY SALINAS
My Notary ID # 130225380
23 Expires May 13, 2023
24
25
J Cause No.:
)
)
Plaintiff, 1 IN THE DISTRICT IN AND FOR COUNTY,
) TEXAS
VS. J
J
)
)
Defendant, J
AFFIDAVIT OF NECESSITY OF SERVICES/REASONABLENESS OF CHARGES
Before me, the undersigned authority, on this day personally appeared DR. LOU
SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows:
My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making
this affidavit, and personally acquainted with the facts herein stated:
lO
I am the custodian of billing records for LONE STAR RADIOLOGY. Attached
hereto are billing records from 09/29/2017, pertaining to MIKE BURCH, DOB:
11 09/21/1971, SSN: N/A. These pages of billing records are kept by LONE STAR
RADIOLOGY, in the regular course of business, and it was the regular course
12 of business of LONE STAR RADIOLOGY, for an employee or representative of LONE
STAR RADIOLOGY, with knowledge of the act, event, condition, opinion, or
13 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 or
reasonably after the time that the service was provided.
l4
The total cost of services for MIKE BURCH received at this facility is
15 $346.00 (which may include a Records Summary Report fee of $150.00). The
total amount adjusted, payments, and write off is $0.00. The adjusted total
l6 cost reflects billing and adjustment as of the date of this affidavit. With
the sole exception of fees related to the Records Summary Report fee of
l7 $150.00, these services and charges were both reasonable and necessary in
connection with MIKE BURCH treatment. The amount currently unpaid but which
LONE STAR RADIOLOGY has a right to be paid after any adjustments or credits
18
is $346.00.
l9 I am familiar with the charges rendered in the vicinity in which they were
incurred. I consider these charges to be reasonable and customary for all
20 like or similar services. The records attached hereto are the original or
exact duplicates of the original.
21
22
Affiant
23
swam mo mm SUBSCRIBED before me on the {fl day o£ A120 _. _, L .
/
, 2019-
" \
'
(?flém fa éMM/D
.3 \
-.
24 Notary Pfiblic, State of Texas
Notary’s printed name and
25 commission expires:05—13—2023
fi.
LILY SALINAS
My Notary ID # 1 30225380
Expires May 13. 2023
) Cause No.:
)
Plaintiff, )
) IN THE DISTRICT COURT
VS. )
) DALLAS COUNTY, TEXAS
)
)
Defendant, )
)
AFFIDAVIT FOR THE AUTHENTICATION 0F BUSINESS RECORDS
Before me, the undersigned authority, on this day personally appeared DR. LOU
SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows:
My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making
this affidavit, and personally acquainted with the facts herein stated:
lO
I am the custodian of healthcare treatment records for LONE STAR RADIOLOGY.
ll Attached hereto are records from 09/29/2017, pertaining to MIKE BURCH, DOB:
09/21/1971, SSN: N/A. These records are kept by LONE STAR RADIOLOGY in the
12 regular course of business, and it was the regular course of business of LONE
STAR RADIOLOGY for an employee or representative of LONE STAR RADIOLOGY, with
13 knowledge of the act, event, condition, opinion, or diagnoses recorded to
make the records or to transmit information thereof to be included in such
l4
records; and the records were made at or near the time or reasonably after
the time that the service was provided. The records attached hereto are the
original or exact duplicates of the original.
15
l6
Affiant
l7
SWORN To AND SUBSCRIBED before me on the /Eg day of A IOLLE [L1 éfigfl , 2019.
l8
('Wcém P/Mu/wzo
l9 Notary Public, State of Taxaa
Notary’s printed name and
20
commission expires:05-13-23
21
22 LILY SALINAS
My Notary ID # 130225380
Expires May 13, 2023
23
24
25
Cause No. DC-l8-161 18
MICHAEL P. BURCH, In the District Court
Plaintiff(s),
v. 134T“ Judicial District
ELVIRA ZUBIRI ALCANTAR, Dallas County, Texas
Defendant(s).
AFFIDAVIT CONCERNING COST AND NECESSITY OF SERVICES
(PURSUANT TO Tex. Civ. Prac. & Rem Code §18.001)
DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL
SYSTEM
STATE OF TEXAS
Wm
COUNTY OF DALLAS §
Before me, the undersigned authority, personally appeared Tracy Williams, who, being
by me duly sworn, deposed as follows:
My name is Tracy Williams. I am of sound mind and capable of making this affidavit,
and personally acquainted with the facts herein stated.
l am a custodian of records for Dallas County Hospital District d/b/a Parkland Health &
Hospital System. Attached to this affidavit are records that provide an itemized statement of the
service and the charge for the service that Dallas County Hospital District d/b/a Parkland Health
& Hospital System provided to Michael Burch on/from 09/15/17 to 09/16/1 7. The attached
records are a part of this affidavit.
The attached records are kept by Dallas County Hospital District d/b/a Parkland Health &
Hospital System in the regular course of business, and it was the regular course of business of
Dallas County Hospital District d/b/a Parkland Health & Hospital System for an employee or
representative of Dallas County Hospital District d/b/a Parkland Health & Hospital System with
knowledge 0f 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 after the time the service was provided. The records are the original or 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 $ 10,610.54 and the amount currently unpaid
but which Dallas County Hospital District d/b/a Parkland Health & Hospital System has a right
to be paid after any adjustments or credits is $ 0.00. ‘
X1 a
Affié’nt: Tra
L D 09¢
Williams
m
Title: Custodian of Billing Records
Dallas County Hospital District d/b/a
Parkland Health & Hospital System
20H.
SWORD To AND SUBSCRIBED before me on the Jim” oft fl kgmém ,
SHARON BUSBY
'
My Notary ID # 124422561 ta Publ'c, State o Texas
. Expires December 21. 2027.
Namezgflé Z’h LLS/é‘/ ,
My Commislsion Expires: lfigq 2:3—
Preview
FILED DALLAS COUNTY 11/26/2019 4:11 PM FELICIA PITRE DISTRICT CLERK Margaret Thomas CAUSE N0. DC-18-16118 MICHAEL P. BURCH § IN THE DISTRICT COURT Plaintiff, § § V. § 134TH JUDICIAL DISTRICT § ELVIRA ZUBIRI ALCANTAR § Defendant. § DALLAS COUNTY, TEXAS PLAINTIFF'S NOTICE OF FILING BUSINESS (MEDICAL) RECORDS AND AFFIDAVITS CONCERNING COST AND NECESSITY OF SERVICES TO THE HONORABLE JUDGE OF THIS COURT: I. Business (Medical) Records Affidavits Pursuant t0 Rule 902(10), Texas Rules ovaz'dence, Plaintiff files herewith the business records Affidavits identified below, which Plaintiff reserves the right t0 offer into evidence at the trial of the instant case: 1. Medical Records ofAccident & Injury Chiropractic Irving, prepared by Dr. Lou Saucedo as the Custodian 0f Records for Accident & Injury Chiropractic Irving, which records are attached t0 the Affidavit being served 0n the attorneys 0f record; 2. Medical Records 0f Lone Star Radiology, prepared by Dr. Lou Saucedo as the Custodian 0f Records for Lone Star Radiology, which records are attached t0 the Affidavit being served 0n the attorneys 0f record; The above-described Affidavits are signed by individuals who are qualified t0 provide the prerequisites for admissibility 0f these records under Rule 803(6) and (7), Texas Rules ovaidence, and attest that the records attached were in fact kept as required by Rules 803 (6) and (7), Texas Rules ovaidence. Subject t0 the local rules applicable t0 the Court in which this cause is pending, Plaintiff is filing the above-referenced Affidavits with the Clerk 0f the Court and serving copies 0f the Affidavits 0n each other party in the case at least fourteen (14) days before the day 0n which PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 1 of 3 evidence is first scheduled t0 be presented at the trial 0f the case. Further, the above records will be made available at the offices 0f Plaintiff‘s attorney for inspection and copying, upon reasonable notice, at the expense 0f the party desiring the copies. II. Affidavits 0f Necessitv 0f Services and Reasonableness 0f Charges Pursuant t0 Tex. Civ. Prac. & Rem. Code, §18.001, Plaintiff files herewith the following identified Affidavit Concerning Cost and Necessity 0f Services, attesting that the services provided were reasonable at the time and place the service was provided relevant t0 the claims in the instant litigation and the services were necessary: 1. Billing Records of Accident & Injury Chiropractic Irving, prepared by Dr. Lou Saucedo as the Custodian 0f Records for Accident & Injury Chiropractic Irving, which records are attached t0 the Affidavit Concerning Cost and Necessity 0f Services being served t0 the attorney(s) 0f record; 2. Billing Records of Lone Star Radiology prepared by Dr. Lou Saucedo as the Custodian 0f Records for Lone Star Radiology which records are attached t0 the Affidavit Concerning Cost and Necessity 0f Services being served 0n the attorneys 0f record; 3. Billing Records of Parkland Health & Hospital System, prepared by Tracy Williams as the Custodian 0f Records for Parkland Health Hospital System,& which records are attached t0 the Affidavit Concerning Cost and Necessity 0f Services being served 0n attorney(s) 0f record. The aforementioned Affidavits have been taken before an officer with authority t0 administer oaths and made by the person who provided the service 0r the person in charge 0f records, and show the service provided and the charge made. Attached t0 each Affidavit is the itemized statement 0f service and the charges for such service. Subject t0 the local rules applicable t0 the Court in which this action is pending, Plaintiff is filing the above-referenced Affidavits with the Clerk 0f the Court and serving copies 0f the Affidavits 0n each other party in the case Tex. CiV. Prac. & Rem. Code § 18.001 [Vernon Supp. 2019]. These Affidavits and itemized statements are also available at the offices 0f Plaintiff‘s PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 2 of 3 attorney for inspection, upon reasonable notice, and copying at the expense 0f the party desiring such copies. Plaintiff reserves the right t0 offer into evidence at the trial 0f the instant cause the above-referenced Affidavits and itemized statements. Respectfully submitted, BAILEY & GALYEN 4131 N. Central Exp 860 Dallas, TX 75204 (214) 252-9099 - Office (214) 520-9941 — Facsimile bforteith@galyen.com - Email By: /s/William A. Forteith William A. Forteith Texas State Bar N0.: 07267500 ATTORNEY FOR PLAINTIFF CERTIFICATE OF SERVICE I hereby certify that 0n this the 26th day 0f November, 2019, the above and foregoing instrument has been forwarded t0 counsel(s) 0f record in accordance with the TEXAS RULES OF CIVIL PROCEDURE: VIA: E-Serve and/or Facsimile Chad Kimble Law Office 0f Chad Kimble, PC 1204 S. White Chapel Blvd. Southlake, TX 76092 Attorney for: Elvira Zubiri Alcantar /s/William A. Forteith William A. Forteith PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 3 of 3 ) ) ) Plaintiff, ) IN THE DISTRICT IN AND FOR COUNTY, ) TEXAS VS . ) ) ) ) Defendant, ) AFFIDAVIT OF NECESSITY OF SERVICES/REASONABLENESS OF CHARGES Before me, the undersigned authority, on this day personally appeared DR. LOU SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows: My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: 10 I am the custodian of billing records for ACCIDENT & INJURY CHIROPRACTIC. Attached hereto are billing records from 09/28/2017 THRU 12/01/2017, ll pertaining to MIKE BURCH, DOB: 09/21/1971, SSN: N/A. These pages of billing records are kept by ACCIDENT & INJURY CHIROPRACTIC, in the regular course of 12 business, and it was the regular course of business of ACCIDENT & INJURY CHIROPRACTIC, for an employee or representative of ACCIDENT & INJURY 13 CHIROPRACTIC, with 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 or l4 reasonably after the time that the service was provided. 15 The total cost of services for MIKE BURCH received at this facility is $10,226.00 (which may include a Records Summary Report fee of $150.00). The l6 total amount adjusted, payments, and write off is $0.00. The adjusted total cost reflects billing and adjustment as of the date of this affidavit. With 17 the sole exception of fees related to the Records Summary Report fee of $150.00, these services and charges were both reasonable and necessary in connection with MIKE BURCH treatment. The amount currently unpaid but which l8 ACCIDENT & INJURY CHIROPRACTIC has a right to be paid after any adjustments or credits is $10,226.00. 19 I am familiar with the charges rendered in the vicinity in which they were 2O incurred. I consider these charges to be reasonable and customary for all like or similar services. The records attached hereto are the original or 21 exact duplicates of the original. 22 Affiant 23 SWORN TO AND SUBSCRIBED before me on the t day of . , 2019. 24 *XB’MM \ J zwmm Notary Pubiic, State of Texas “ 25 Notary’s printed name and commission expires:05—13—2023 LKYSAUNAS My Notary ID # 130225380 Expires May 13, 2023 ) Cause No.: ) Plaintiff, ) ) IN THE DISTRICT COURT vs. ) ) DALLAS COUNTY, TEXAS ) ) Defendant, ) ) AFFIDAVIT FOR THE AUTHENTICATION OF BUSINESS RECORDS Before me, the undersigned authority, on this day personally appeared DR. LOU SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows: My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: lO I am the custodian of healthcare treatment records for ACCIDENT & INJURY ll CHIROPRACTIC. Attached hereto are records from 09/28/2017 THRU 12/01/2017, pertaining to MIKE BURCH, DOB: 09/21/1971, SSN: N/A. These records are kept 12 by ACCIDENT & INJURY CHIROPRACTIC in the regular course of business, and it was the regular course of business of ACCIDENT & INJURY CHIROPRACTIC for an 13 employee or representative of ACCIDENT & INJURY CHIROPRACTIC, with knowledge of the act, event, condition, opinion, or diagnoses recorded to make the l4 records or to transmit information thereof to be included in such records; and the records were made at or near the time or reasonably after the time that the service was provided. The records attached hereto are the original 15 or exact duplicates of the original. l6 l7 Affiant l8 SWORN To AND SUBSCRIBED before me on the lg day of A Lfigggflg k] gfl, 2019. Wzflm .J trim x ‘ J A l9 Notary Pfiblic, State of Texaa 20 Notary's printed name and commission expires:05-13-23 21 22 LILY SALINAS My Notary ID # 130225380 23 Expires May 13, 2023 24 25 J Cause No.: ) ) Plaintiff, 1 IN THE DISTRICT IN AND FOR COUNTY, ) TEXAS VS. J J ) ) Defendant, J AFFIDAVIT OF NECESSITY OF SERVICES/REASONABLENESS OF CHARGES Before me, the undersigned authority, on this day personally appeared DR. LOU SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows: My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: lO I am the custodian of billing records for LONE STAR RADIOLOGY. Attached hereto are billing records from 09/29/2017, pertaining to MIKE BURCH, DOB: 11 09/21/1971, SSN: N/A. These pages of billing records are kept by LONE STAR RADIOLOGY, in the regular course of business, and it was the regular course 12 of business of LONE STAR RADIOLOGY, for an employee or representative of LONE STAR RADIOLOGY, with knowledge of the act, event, condition, opinion, or 13 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 or reasonably after the time that the service was provided. l4 The total cost of services for MIKE BURCH received at this facility is 15 $346.00 (which may include a Records Summary Report fee of $150.00). The total amount adjusted, payments, and write off is $0.00. The adjusted total l6 cost reflects billing and adjustment as of the date of this affidavit. With the sole exception of fees related to the Records Summary Report fee of l7 $150.00, these services and charges were both reasonable and necessary in connection with MIKE BURCH treatment. The amount currently unpaid but which LONE STAR RADIOLOGY has a right to be paid after any adjustments or credits 18 is $346.00. l9 I am familiar with the charges rendered in the vicinity in which they were incurred. I consider these charges to be reasonable and customary for all 20 like or similar services. The records attached hereto are the original or exact duplicates of the original. 21 22 Affiant 23 swam mo mm SUBSCRIBED before me on the {fl day o£ A120 _. _, L . / , 2019- " \ ' (?flém fa éMM/D .3 \ -. 24 Notary Pfiblic, State of Texas Notary’s printed name and 25 commission expires:05—13—2023 fi. LILY SALINAS My Notary ID # 1 30225380 Expires May 13. 2023 ) Cause No.: ) Plaintiff, ) ) IN THE DISTRICT COURT VS. ) ) DALLAS COUNTY, TEXAS ) ) Defendant, ) ) AFFIDAVIT FOR THE AUTHENTICATION 0F BUSINESS RECORDS Before me, the undersigned authority, on this day personally appeared DR. LOU SAUCEDO, JR., D.C., who, being by me duly sworn, deposed as follows: My name is DR. LOU SAUCEDO, JR., D.C., I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: lO I am the custodian of healthcare treatment records for LONE STAR RADIOLOGY. ll Attached hereto are records from 09/29/2017, pertaining to MIKE BURCH, DOB: 09/21/1971, SSN: N/A. These records are kept by LONE STAR RADIOLOGY in the 12 regular course of business, and it was the regular course of business of LONE STAR RADIOLOGY for an employee or representative of LONE STAR RADIOLOGY, with 13 knowledge of the act, event, condition, opinion, or diagnoses recorded to make the records or to transmit information thereof to be included in such l4 records; and the records were made at or near the time or reasonably after the time that the service was provided. The records attached hereto are the original or exact duplicates of the original. 15 l6 Affiant l7 SWORN To AND SUBSCRIBED before me on the /Eg day of A IOLLE [L1 éfigfl , 2019. l8 ('Wcém P/Mu/wzo l9 Notary Public, State of Taxaa Notary’s printed name and 20 commission expires:05-13-23 21 22 LILY SALINAS My Notary ID # 130225380 Expires May 13, 2023 23 24 25 Cause No. DC-l8-161 18 MICHAEL P. BURCH, In the District Court Plaintiff(s), v. 134T“ Judicial District ELVIRA ZUBIRI ALCANTAR, Dallas County, Texas Defendant(s). AFFIDAVIT CONCERNING COST AND NECESSITY OF SERVICES (PURSUANT TO Tex. Civ. Prac. & Rem Code §18.001) DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEM STATE OF TEXAS Wm COUNTY OF DALLAS § Before me, the undersigned authority, personally appeared Tracy Williams, who, being by me duly sworn, deposed as follows: My name is Tracy Williams. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated. l am a custodian of records for Dallas County Hospital District d/b/a Parkland Health & Hospital System. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Dallas County Hospital District d/b/a Parkland Health & Hospital System provided to Michael Burch on/from 09/15/17 to 09/16/1 7. The attached records are a part of this affidavit. The attached records are kept by Dallas County Hospital District d/b/a Parkland Health & Hospital System in the regular course of business, and it was the regular course of business of Dallas County Hospital District d/b/a Parkland Health & Hospital System for an employee or representative of Dallas County Hospital District d/b/a Parkland Health & Hospital System with knowledge 0f 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 after the time the service was provided. The records are the original or 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 $ 10,610.54 and the amount currently unpaid but which Dallas County Hospital District d/b/a Parkland Health & Hospital System has a right to be paid after any adjustments or credits is $ 0.00. ‘ X1 a Affié’nt: Tra L D 09¢ Williams m Title: Custodian of Billing Records Dallas County Hospital District d/b/a Parkland Health & Hospital System 20H. SWORD To AND SUBSCRIBED before me on the Jim” oft fl kgmém , SHARON BUSBY ' My Notary ID # 124422561 ta Publ'c, State o Texas . Expires December 21. 2027. Namezgflé Z’h LLS/é‘/ , My Commislsion Expires: lfigq 2:3—