On March 15, 2019 a
Party Statement
was filed
involving a dispute between
Herrera, Imelda,
and
Carrillo, Omar,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
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FILED
DALLAS COUNTY
9/24/2019 1:39 PM
FELICIA PITRE
DISTRICT CLERK
CAROLYN SELLERS
CAUSE NO. DC-1 9-03790
IMELDA HERRERA, IN THE DISTRICT COURT
Plaintiff,
V. 162ND JUDICIAL DISTRICT
OMAR CARRILLO,
Defendant. DALLAS COUNTY, TEXAS
COST OF SERVICES AFFIDAVIT OF BAYLOR SCOTT & WHITE MEDICAL CENTER
- IRVING
TO THE HONORABLE JUDGE OF SAID COURT:
Plaintiff Imelda Herrera files the attached Cost of Services Affidavit of Baylor
Scott & White Medical Center -
Irving in accordance with section 18.001, et seq. of the
Texas Civil Practices & Remedies Code.
Respectfully submitted,
/s/ David Maldonado
David Maldonado
State Bar No.24084914
Ben Abbott & Associates, PLLC
1934 Pendleton Drive
Garland, TX 75041
(972) 263-5555
(81 7) 263-5555
(972) 682-7586 Facsimile
eService@benabbott.com
ATTORNEYS FOR PLAINTIFF
CERTIFICATE OF SERVICE
This is to certify that a true and correct copy of the foregoing document was
served on all counsel of record and/or pro se parties in accordance with Rules 21 and
21 a of the Texas Rules of Civil Procedure on this 24th day of September, 201 9.
/s/ David Maldonado
David Maldonado
663T 6F SERVICES AFFIDAVIT 6F BAYLGR §CGTT & WHITE MEDICAL CENTER - IRVING Page 4
AFFIDAVIT 0F COST 0F SERVICES BY CUSTODIAN OF
BAYLOR SCOTT & WHITE MEDICAL CENTER-IRVING
STATE OF TEXAS §
COUNTY 0F S 2Q\\0\ 1 g
~ I
Before me, the undersigned authority, personally appeared 3h Q\bul Shaddox
who, being by me duly sworn deposed as follows:
"My name is Iam of sound mind and capable of making this
affidavit, and personally acquain ted with the facts herein stated.
&
Iam a custodian of records of Baylor Scott White Medical Center-Irving. Attached to
thisaffidavit are records that provide an itemized statement of the service and the charge for that
servic; that Eager Scott &
White Medical Center-Irving provided to Imelda Herrera on
(0 L\ / l The attached records are a part of this affidavit.
.
&
The attached records are kept by Baylor Scott White Medical Center-Irving in the
regular course of business, and it was the regular course of business of Baylor Scott White &
Medical. Center-Irving for an employee or representative of Baylor Scott White Medical. &
Center—Irving, with knowledge of the service provided, to make the record or to transmit
information to be included in the record. The records were made in the regular course of business
at or near the time or reasonably soon after the time the service was provided. The records are the
orig'nal 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 $_Q______ and the amount currently
unpaid but which Baylor
8%“ & Whitf Medical Center-Irving has a right to be paid after any
adjustments or credits is $
-
é/s’rdayof m
SWORN TO and SUBSCRIBED before
A
.2073
b m MW
Signature of
y.
I
fifiant
4444'?» £975
a
On [h.S
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x-“‘vfi£go, ’SUSAN cox
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:‘ENotary Public, State of Texas imggtpughf
.
m and for
.
Comm.Expires12-3o-2019
e ‘ e 0 6an
OF
g
-‘
mu“ Notary ID 130482324
My Commission expires: /2 w 30 'f 7
COST OF SERVlCE AFFIDAVIT (259898)
BAYLOR SCOTT & WHITE MEDICAL CENTER-IRVING
Document Filed Date
September 24, 2019
Case Filing Date
March 15, 2019
Category
MOTOR VEHICLE ACCIDENT
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FILED DALLAS COUNTY 9/24/2019 1:39 PM FELICIA PITRE DISTRICT CLERK CAROLYN SELLERS CAUSE NO. DC-1 9-03790 IMELDA HERRERA, IN THE DISTRICT COURT Plaintiff, V. 162ND JUDICIAL DISTRICT OMAR CARRILLO, Defendant. DALLAS COUNTY, TEXAS COST OF SERVICES AFFIDAVIT OF BAYLOR SCOTT & WHITE MEDICAL CENTER - IRVING TO THE HONORABLE JUDGE OF SAID COURT: Plaintiff Imelda Herrera files the attached Cost of Services Affidavit of Baylor Scott & White Medical Center - Irving in accordance with section 18.001, et seq. of the Texas Civil Practices & Remedies Code. Respectfully submitted, /s/ David Maldonado David Maldonado State Bar No.24084914 Ben Abbott & Associates, PLLC 1934 Pendleton Drive Garland, TX 75041 (972) 263-5555 (81 7) 263-5555 (972) 682-7586 Facsimile eService@benabbott.com ATTORNEYS FOR PLAINTIFF CERTIFICATE OF SERVICE This is to certify that a true and correct copy of the foregoing document was served on all counsel of record and/or pro se parties in accordance with Rules 21 and 21 a of the Texas Rules of Civil Procedure on this 24th day of September, 201 9. /s/ David Maldonado David Maldonado 663T 6F SERVICES AFFIDAVIT 6F BAYLGR §CGTT & WHITE MEDICAL CENTER - IRVING Page 4 AFFIDAVIT 0F COST 0F SERVICES BY CUSTODIAN OF BAYLOR SCOTT & WHITE MEDICAL CENTER-IRVING STATE OF TEXAS § COUNTY 0F S 2Q\\0\ 1 g ~ I Before me, the undersigned authority, personally appeared 3h Q\bul Shaddox who, being by me duly sworn deposed as follows: "My name is Iam of sound mind and capable of making this affidavit, and personally acquain ted with the facts herein stated. & Iam a custodian of records of Baylor Scott White Medical Center-Irving. Attached to thisaffidavit are records that provide an itemized statement of the service and the charge for that servic; that Eager Scott & White Medical Center-Irving provided to Imelda Herrera on (0 L\ / l The attached records are a part of this affidavit. . & The attached records are kept by Baylor Scott White Medical Center-Irving in the regular course of business, and it was the regular course of business of Baylor Scott White & Medical. Center-Irving for an employee or representative of Baylor Scott White Medical. & Center—Irving, with knowledge of the service provided, to make the record or to transmit information to be included in the record. The records were made in the regular course of business at or near the time or reasonably soon after the time the service was provided. The records are the orig'nal 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 $_Q______ and the amount currently unpaid but which Baylor 8%“ & Whitf Medical Center-Irving has a right to be paid after any adjustments or credits is $ - é/s’rdayof m SWORN TO and SUBSCRIBED before A .2073 b m MW Signature of y. I fifiant 4444'?» £975 a On [h.S l x-“‘vfi£go, ’SUSAN cox *‘gwm‘s :‘ENotary Public, State of Texas imggtpughf . m and for . Comm.Expires12-3o-2019 e ‘ e 0 6an OF g -‘ mu“ Notary ID 130482324 My Commission expires: /2 w 30 'f 7 COST OF SERVlCE AFFIDAVIT (259898) BAYLOR SCOTT & WHITE MEDICAL CENTER-IRVING