On October 01, 2019 a
Party Statement
was filed
involving a dispute between
Martinez, Sarah,
and
Sanchez, Rudy,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
Preview
FILED
DALLAS COUNTY
12/12/2019 11:33 AM
FELICIA PITRE
DISTRICT CLERK
Rosa Delacerda
DC-19-16024
SARAH MARTINEZ §
§ IN THE DISTRICT
DISTRICT COURT
§
§
VS.
vs. §
§ 298m JUDICIAL
298TH DISTRICT
JUDICIAL DISTRICT
§
§
RUDY SANCHEZ
RUDY SANCHEZ §
§ DALLAS COUNTY, TEXAS
Affidavit of
Afiidavit Medical Charges
ofMedicaI
from
from
American Radiology Consultants
STATE OF
0F GORGIA
GORGIA I557
.
coumv OF
COUNTY muscerE
0F MUSCOGEE ?&fifiJ
4se-t,Livrom tiVlutrictis
“H.
L
AFFIDAVIT FOR AMERICAN RADIOLOGY
RADIOLOGY CONSULTANTS
RE:
RE: SARAH
SARAH N MARTINEZ
BEFOREME,
BEFORE ME,the
theundersigned
undersignedauthority,
authority,personally
personally appeared
appeared CHERYL GRANGER
CHERYL GRANGER
Who, by me duly
Who, being by sworn, deposed
duly sworn, deposed as follows:
asfoflows:
My name is
is CHERYL GRANGER
GRANGER; Il am of sound mind, capable of
ofsound making this
ofmaking this Affidavit
Afl'idavit and
and personally
personally
Acquainted with
Acquainted with thefacts
the facts herein stated:
stated: I am the
l the custodian
custodian of
of the
thebilling
billing records for
for
AMERICAN RADIOLOGY
AMERICAN RADIOLOGY CONSULTANTS
CONSULTANTS who
who providedthe
provided theservice.
service.
These
These said
saidpages
pagesofof
bills areare
bills kept by by
kept AMERICAN
AMERICANRADIOLOGY CONSULTANTS
RADIOLOGY CONSULTANTS in in theregular
the regularcourse
course of
of
business, and it in the
it was in the regular course of
of business
business for
for our legal representative with
legal representative with knowledge of the
knowledge ofthe
act,
act, event,
event, condition,
condition, opinion
opinion or
or diagnosis
diagnosis recorded
recorded to
to make
make the
the billing
billing record
record or to transmit
or to transmit information
information
to be included in
thereof to such bill:
in such bill: and
and the
the bill
billwas
wasmade
made at
at or
or near
near the
the time or
or reasonably
reasonably soon
thereafter.
thereafter. The
Thebill
bill attached
attachedisisthe
theoriginal
original or
or exact
exact duplicates
duplicates of
of the
the original.
original.
The total amount paid
The total for the
paid for the service
service was
was $$ 0-00
0.00 (amount
{amount paid)
paid) and
and the
the amount
amount currently
currently unpaid
unpaid but
but
which AMERICAN
AMERICAN RADIOLOGY CONSULTANTS
RADIOLOGY CONSULTANTS has the
has the right
right to be
to be paid
paid after
after any
any adjustmentsor
adjustments orcredits
credits
is $ 252-00
is 5 252.00 (Remaining
(Remaining Balance).
Balance).
I
fo • f,
----- GER
AL & BILLING
BILLINGspchIST
SPEC AIST
swoaN TO
SWORN AND SUBSCRIBED
To AND BEFORE ME
SUBSCRIBED BEFORE ME THIS
THIS _5 DAYOF
5 DAY 0F NOV.
NOV‘ XO19
g019
AMERICAN RADIOLOGY
AMERICAN RADIOLOGY CONSULTANTS,
CONSULTANTS, PLLC
PLLC
717 20TH ST
ST
COLUMBUS, GA
COLUMBUS, GA 31904-8920
31904-8920
Phone: (800)841-4236
Phone: (800)841 -4236
Fax: (706)653-1162
Fax: (706)653-1 162
Tax ID:
ID:
Patient:
Patient: 852969 -- MARTINEZ, SARAH N
MARTINEZ. SARAH
Date Created:
Created: Tuesday,
Tuesday, November
November5,
5, 2019
2019 2:30
2:30 PM
PM
E—
DATE REF. Doctor!"
REF. ‘Béfigir',’
DOCTOR DOCTOR y PROCEDURE_
CHARGES PAYMENTS ADJUSTMENTS BALANCE PAYSOURCE INS PLAN
12/05/2017
12/05/2017 FARZAD,
FARZADA ALI
ALI WENDY L 76815
WONG, WENDY 76815 --US
l. USPG
PG UTE
UT $117.00
02/12/2018
02/1 2/201 8 10246951
10246951 RMG $0.00
$0.00 $117.00
$1 17.00 Write Off
Write Off 0
0
$117.00
$1 17.00 $0.00 $117.00
$1 17.00 $0.00
12/05/2017
12/05/2017 FARZAD,
FARZAD, ALI
ALI WENDY LL 76817
WONG, WENDY 76817- —US
USPG
PG UTE
UTE $135.00
$135.00
02/12/2018
02/1 2/201 8 10246952
10246952 RMG
RMG $0.00
$0.00 $135.00 Write
Write Off
Off 0
'
$135.00
$1 35.00 $0.00 $135.00
s1 35.00 $0.00
Account Total:
Total: $252.00 $0.00 $252.00 $0.00
Page
Page 1 of 1
1 of 1
Document Filed Date
December 12, 2019
Case Filing Date
October 01, 2019
Category
MOTOR VEHICLE ACCIDENT
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED DALLAS COUNTY 12/12/2019 11:33 AM FELICIA PITRE DISTRICT CLERK Rosa Delacerda DC-19-16024 SARAH MARTINEZ § § IN THE DISTRICT DISTRICT COURT § § VS. vs. § § 298m JUDICIAL 298TH DISTRICT JUDICIAL DISTRICT § § RUDY SANCHEZ RUDY SANCHEZ § § DALLAS COUNTY, TEXAS Affidavit of Afiidavit Medical Charges ofMedicaI from from American Radiology Consultants STATE OF 0F GORGIA GORGIA I557 . coumv OF COUNTY muscerE 0F MUSCOGEE ?&fifiJ 4se-t,Livrom tiVlutrictis “H. L AFFIDAVIT FOR AMERICAN RADIOLOGY RADIOLOGY CONSULTANTS RE: RE: SARAH SARAH N MARTINEZ BEFOREME, BEFORE ME,the theundersigned undersignedauthority, authority,personally personally appeared appeared CHERYL GRANGER CHERYL GRANGER Who, by me duly Who, being by sworn, deposed duly sworn, deposed as follows: asfoflows: My name is is CHERYL GRANGER GRANGER; Il am of sound mind, capable of ofsound making this ofmaking this Affidavit Afl'idavit and and personally personally Acquainted with Acquainted with thefacts the facts herein stated: stated: I am the l the custodian custodian of of the thebilling billing records for for AMERICAN RADIOLOGY AMERICAN RADIOLOGY CONSULTANTS CONSULTANTS who who providedthe provided theservice. service. These These said saidpages pagesofof bills areare bills kept by by kept AMERICAN AMERICANRADIOLOGY CONSULTANTS RADIOLOGY CONSULTANTS in in theregular the regularcourse course of of business, and it in the it was in the regular course of of business business for for our legal representative with legal representative with knowledge of the knowledge ofthe act, act, event, event, condition, condition, opinion opinion or or diagnosis diagnosis recorded recorded to to make make the the billing billing record record or to transmit or to transmit information information to be included in thereof to such bill: in such bill: and and the the bill billwas wasmade made at at or or near near the the time or or reasonably reasonably soon thereafter. thereafter. The Thebill bill attached attachedisisthe theoriginal original or or exact exact duplicates duplicates of of the the original. original. The total amount paid The total for the paid for the service service was was $$ 0-00 0.00 (amount {amount paid) paid) and and the the amount amount currently currently unpaid unpaid but but which AMERICAN AMERICAN RADIOLOGY CONSULTANTS RADIOLOGY CONSULTANTS has the has the right right to be to be paid paid after after any any adjustmentsor adjustments orcredits credits is $ 252-00 is 5 252.00 (Remaining (Remaining Balance). Balance). I fo • f, ----- GER AL & BILLING BILLINGspchIST SPEC AIST swoaN TO SWORN AND SUBSCRIBED To AND BEFORE ME SUBSCRIBED BEFORE ME THIS THIS _5 DAYOF 5 DAY 0F NOV. NOV‘ XO19 g019 AMERICAN RADIOLOGY AMERICAN RADIOLOGY CONSULTANTS, CONSULTANTS, PLLC PLLC 717 20TH ST ST COLUMBUS, GA COLUMBUS, GA 31904-8920 31904-8920 Phone: (800)841-4236 Phone: (800)841 -4236 Fax: (706)653-1162 Fax: (706)653-1 162 Tax ID: ID: Patient: Patient: 852969 -- MARTINEZ, SARAH N MARTINEZ. SARAH Date Created: Created: Tuesday, Tuesday, November November5, 5, 2019 2019 2:30 2:30 PM PM E— DATE REF. Doctor!" REF. ‘Béfigir',’ DOCTOR DOCTOR y PROCEDURE_ CHARGES PAYMENTS ADJUSTMENTS BALANCE PAYSOURCE INS PLAN 12/05/2017 12/05/2017 FARZAD, FARZADA ALI ALI WENDY L 76815 WONG, WENDY 76815 --US l. USPG PG UTE UT $117.00 02/12/2018 02/1 2/201 8 10246951 10246951 RMG $0.00 $0.00 $117.00 $1 17.00 Write Off Write Off 0 0 $117.00 $1 17.00 $0.00 $117.00 $1 17.00 $0.00 12/05/2017 12/05/2017 FARZAD, FARZAD, ALI ALI WENDY LL 76817 WONG, WENDY 76817- —US USPG PG UTE UTE $135.00 $135.00 02/12/2018 02/1 2/201 8 10246952 10246952 RMG RMG $0.00 $0.00 $135.00 Write Write Off Off 0 ' $135.00 $1 35.00 $0.00 $135.00 s1 35.00 $0.00 Account Total: Total: $252.00 $0.00 $252.00 $0.00 Page Page 1 of 1 1 of 1