Preview
FILED
3/17/2023 9:53 AM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Miranda Lynch DEPUTY
CAUSE NO. DC-22-14527
CRYSTAL SKATES § IN THE DISTRICT COURT
Plaintiff, §
§
V. § IOIST JUDICIAL DISTRICT
§
LILIANA PALACIOS §
Defendant. § DALLAS COUNTY, TEXAS
PLAINTIFF 'S NOTICE OF FILING BUSINESS (MEDICAL) RECORDS AND
AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
TO THE HONORABLE JUDGE OF THIS COURT:
I.
Business (Medical) Records Affidavits
Pursuant to Rule 902(10), Texas Rules of Evidence, Plaintiff files herewith the business
records Affidavits identified below, which Plaintiff reserves the right to offer into evidence at the
trial of the instant case:
1. Medical Records of TOUCHSTONE IMAGING ARLINGTON prepared by
Cindy Au as the Custodian of Records for TOUCHSTONE IMAGING
ARLINGTON, which records are attached to the Affidavit being served on the
attorneys of record.
2. Medical Records of MEDICAL CITY ARLINGTON prepared by Glenda Willey
as the Custodian of Records for MEDICAL CITY ARLINGTON, which records
are attached to the Affidavit being served on the attorneys of record;
3. Medical Records of SMITH COUNTY HEALTHCARE SYSTEM prepared by
Alex Kosarow as the Custodian of Records for SMITH COUNTY
HEALTHCARE SYSTEM, which records are attached to the Affidavit being
served on the attorneys of record.
The above-described Affidavits are signed by individuals who are qualified to provide the
prerequisites for admissibility of these records under Rule 803(6) and (7), Texas Rules ofEvidence,
and attest that the records attached were in fact kept as required by Rules 803 (6) and (7), Texas
Rules ofEvidence.
Subject to the local rules applicable to the Court in which this cause is pending, Plaintiff is
PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 1 of 4
filing the above-referenced Affidavits with the Clerk of the Court and serving copies of the
Affidavits on each other party in the case at least fourteen (14) days before the day on which
evidence is first scheduled to be presented at the trial of the case. Further, the above records will
be made available at the offices of Plaintiffs attorney for inspection and copying, upon reasonable
notice, at the expense of the party desiring the copies.
II.
Affidavits of Necessitv of Services and Reasonableness of Charges
Pursuant to Tex. Civ. Prac. & Rem. Code, §18.001, Plaintiff files herewith the following
identified Affidavit Concerning Cost and Necessity of Services, attesting that the services provided
were reasonable at the time and place the service was provided relevant to the claims in the instant
litigation and the services were necessary:
1. Billing Records of TOUCHSTONE IMAGING ARLINGTON, prepared by
Cindy Au as the Custodian of Records for TOUCHSTONE IMAGING
ARLINGTON, which records are attached to the Affidavit Concerning Cost and
Necessity of Services being served to the attorney(s) of record;
2. Billing Records of TEXAS RADIOLOGY ASSOCIATES, LLP prepared by
Amy Glatz as the Custodian of Records for TEXAS RADIOLOGY
ASSOCIATES, LLP, which records are attached to the Affidavit Concerning Cost
and Necessity of Services being served on the attorneys of record;
3. Billing Records of MEDICAL CITY ARLINGTON prepared by Shelly Shaut as
the Custodian of Records for MEDICAL CITY ARLINGTON, which records are
attached to the Affidavit Concerning Cost and Necessity of Services being served
on attorney(s) of record.
4. Billing Records of QUESTCARE MEDICAL SERVICES, PLLC prepared by
Salime Assaf as the Custodian of Records for QUESTCARE MEDICAL
SERVICES,PLLC, which records are attached to the Affidavit Concerning Cost
and Necessity of Services being served on the attorneys of record;
5. Billing Records of SMITH COUNTY HEALTHCARE SYSTEM prepared by
Alex Kosarow as the Custodian of Records for SMITH COUNTY
HEALTHCARE SYSTEM, which records are attached to the Affidavit being
served on the attorneys of record;
PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 2 of 4
The aforementioned Affidavits have been taken before an officer with authority to
administer oaths and made by the person who provided the service or the person in charge of
records, and show the service provided and the charge made. Attached to each Affidavit is the
itemized statement of service and the charges for such service.
Subject to the local rules applicable to the Court in which this action is pending, Plaintiff
is filing the above-referenced Affidavits with the Clerk of the Court and serving copies of the
Affidavits on 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 of Plaintiffs
attorney for inspection, upon reasonable notice, and copying at the expense of the party desiring
such copies. Plaintiff reserves the right to offer into evidence at the trial of the instant cause the
above-referenced Affidavits and itemized statements.
Respectfully submitted,
BAILEY & GALYEN
2777 North Stemmons Frwy
Dallas, TX 75207
(214) 252-9099 - Office
(214) 520-9941 — Facsimile
alee@galyen.com - Email
By: Ana Lee
/s/
Ana Lee
Texas State Bar No.: 24094684
ATTORNEY FOR PLAINTIFF
PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 3 of 4
CERTIFICATE OF SERVICE
I hereby certify that on this the 17th day of March 2023, the above and foregoing instrument
has been forwarded to counsel(s) of record in accordance with the TEXAS RULES 0F CIVIL
PROCEDURE:
VIA: E-Serve and/or Facsimile
Mark A. Teague
The LeCrone Law Firm, PC
123 N. Crockett St. Suite 200
Sherman, TX75090
Attorney for: Liliana Palacios
John W. Breeze
The LeCrone Law Firm, PC
123 North Crockett St. Suite 200
Sherman, TX 75090
Attorney for: Liliana Palacios
Hillary Luckett Clark
123 N. Crockett St. Suite 200
Sherman, TX 75090
Attorney for: Liliana Palacios
Ana Lee
/s/
Ana Lee
PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES
Page 4 of 4
AFFIDAVIT 0F RECORDS BY CUSTODIAN OF
SMITH COUNTY HEALTHCARE SYSTEM
BEFORE ME, the undersigned authority, personally appeared
MK k0$wro at) , who, being duly sworn, deposed as follows:
My name is 44x kflsnrmD I am of sound mind, capable of making
.
this affidavit, and personally acquainted with the facts herein stated.
I am a custodian of records for Smith County Healthcare System. Attached to this
affidavit are records that provide an itemized statement of the service and the charge for the service
4' 27 .2/ -
that Smith County Healthcare System provided to Crystal Skates on 11/5942; . The attached
records are a part of this affidavit.
5/m'44‘ down—65
The attached records are kept by #MMA Mfg, Sz Sfim in the regular course of
business, and it was the regular course of business of Smith County Healthcare System for an
employee or representative of Smith County Healthcare System, 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 afier the time the
service was provided. The records are the original or 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 $ “5/ and the amount currently unpaid
but which Smith County Healthcare System has a right to be pa" after any adjustments or
credits is $ /5; ?7/. 3'9
rant
SWORN TO AND SUBSCRIBED before me, on
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AFFmiwrr or RECORDS CUSTODIAN Page 1 of l
CAUSE N0.
CRYSTAL SKATES § IN THE COURT
PLAINTIFF, §
§
V. §
§
CRYSTAL SKATES §
DEFENDANT. § COUNTY, TEXAS
MEDICAL RECORDS AFFIDAVIT
BEFORE ME, the undersigned authority, on this day personally appeared
M kasmod) , who swore on oath that the following facts are true:
"My name is M [( koswao . I am of sound mind, capable of making
this affidavit, and personally acquainted with the facts herein stated.
"I am the custodian of the records of Smith County Healthcare System. Attached hereto
[is/are] 5L page[s] of medical records from Smith County Healthcare System regarding
treatment provided to Crystal Skates. These said pages of records are kept by Smith
County Healthcare System in the regular c0urse of business, and it was the regular course of
business of Smith County Healthcare System for an employee or representative of Smith County
Healthcare System, 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 the original
or exact duplicates of the original."
fiant
SWORN To AND SUBSCRIBED me on
W 515, 1911/
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MEDICAL RECORDS AFFIDAVIT Page 2 of 2
STATE OF TEXAS
DODGMCO')
COUNTY OF BEXAR
AFFIDAVIT OF RECORDS CUSTODIAN
Before me, the undersigned authority, personally appeared SHELLY SHAUT, who, being by me duly
sworn, deposed as follows:
My name is SHELLY SHAUT. I am of sound mind and capable of making this
affidavit, and personally acquainted with the facts herein stated.
I am a custodian of records for MEDICAL CITY ARLINGTON (“Hospital”).
Attached to this affidavit are records that provide an itemized statement of the service and the
charge for the service that Hospital provided to CRYSTAL SKATES on 09/22/2021 TO
09/22/2021. The attached records are a part of this affidavit.
The attached records are kept by Hospital in the regular course of business, and it was the
regular course of business of Hospital for an employee or representative of Hospital, 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 original or a
duplicate of the original.
Pursuant to Texas Civil Practice & Remedies Code § 18.002(b—1), 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 but
which Hospital has a right to be paid after any adjustments or credits is $6,797.81.
** The amount paid and the amount the Hospital has a right to be paid may change pending
potential payment from the patient’s health insurance.
Affiant
SWORN To AND SUBSCRIBED before me on this 22ND day of
NOVEMBER 2021.
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,
My commission expires: m
Notary Public, State of Texas
07-18-2023
printed Name MICHAEL RODRIGUEZ
MICHAEL RODRIGUEZ
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CRYSTAL SKATES "101056891 1 15662502
Patlentz Medical Record Number: eRequest ID:
Facility: Mgqiga! £112 Aflmfion Phone Number: 682-509~6446
Address: 332; Magjggk Rg City/State: Arlingon, TX Zip: 7m
AFFIDAVIT PM I L C RDS
Before me. the undersigned authority, personally appeared
who, being by me duly sworn, deposed as follows:
My name Is Qienda Willey , I am of sound mind, capable of making this affidavit and
personally acquainted with the facts herein stated:
I am the custodian of the medical records for Medical gm Mime"
Attached hereto are 62 pages of medical records.
These said Epages of medical records are kept by in the regular course of
business, and it was in the regular course of business of for an employee or
representative of Medical Clg AdingLon with knowledge of the act, event, condition, opinion or
diagnosis. was ordered to make the record into transmit information thereof to be included in such records;
and the records were made at or near the time of reasonably soon thereafter. The records attached hereto are
the original or exact duplicates of the original.
AFFIDAVIT OF NO RECORDS
D A thorough search of requested information carried out under my direction and control revealed that this facility does
not have the records described in the patient authorization or the subpoena dunes tecum.
DECIARATION OF CUSTODIAN OF RECORDS
I,
Glenda “(may , am the duly authorized Custodian of Records of the above named facility. lam familiar with
the mode of preparation of, and have the authority to certify. the facility record. declare under penalty of perjury under
1
the hints of the State of Igxas , County of Torrent that the foregoing is true and correct.
mm gauzou
Signature Date
*‘IFOB¥*I¢#M
Subsc ibed and tary publi dfors hi W0
TONI SAMPLE
Notary Public
MyNoiaryiD 12
My commission expires: Jill! 1. 2023 ExpimJulyLM
in states where a Notary is not required, this form will only include signature and date of the medical record custodian.
AFFIDAVIT OF RECORDS BY CUSTODIAN OF
TOUCHSTONE IIVIAGING ARLINGTON
BEFORE ME, the undersigned authority, personally appeared
Cindy Au , who, being duly sworn, deposed as follows:
My name is Cindy Au . I am of sound mind, capable of making
this afiidavit, and personally acquainted with the facts herein stated.
I am a custodian of records for Touchstone Imaging Arlington. Attached to this affidavit
are records that provide an itemized statement of the service and the charge for the service that
Touchstone Imaging Arlington provided to Crystal Skates on 11/09/2021 The attached records
are a part of this affidavit.
Touchstone Imaging
The attached records are kept by Arlington in the regular course of
of business of Touchstone Imaging Arlington for an
business, and it was the regular course
employee or representative of Touchstone Imaging Arlington, 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 original or 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
but which Touchstone Imaging Arlngton has a right to be paid after any adjustments or credits
is $4 238.00 .
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AFFIDAVIT or RECORDS CUSTODIAN Page 1 of 1
AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF
Texas Radiology Associates, LLP
(Pursuant to Texas Civil Practice & Remedies Code § 18.002 (b-1))
STATE OF TEXAS §
COUNTY 0F COLLIN g
BEFORE ME, the undersigned authority, personally appeared
Amy G'atz , who, being by me duly sworn, deposed as follows:
My name is Amy G'atz . I am of sound mind and capable of making
this affidavit, and personally acquainted with the facts of herein stated.
I am a custodian of records for Texas Radiology Associates, LLP. Attached to this affidavit are records
that provide an itemized statement of the service and the charge for the service that Texas Radiology Associates,
LLP provided to Crystal Skates on 09/22/2021
(dates). The attached records are a part of this
affidavit.
The attached records are kept by me 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, LLP or an
employee or representative of Texas Radiology Associates, LLP who had personal knowledge of the
information. The records were made at or near the time or reasonably soon after the time that 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 were 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 but
which Texas Radiology Associates, LLP has a right to be paid is $ 91-80
Affi ant
SWORN TO AND SUBSCRIBED before me on the 5 day of AUQUSt , 20 22 .
Nota lic, State o
cedmo 8/28/2024
Notary’s printed name: ChriStOPher My commission expires:
cumsromen canine—l
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Noun ID "NOW“ Yes-j
AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF
Questcare Medical Services, PLLC
(Pursuant to Texas Civil Practice & Remedies Code § 18.002 (b—l))
STATE OF WAS PENNSYLVANIA §
§
COUNTY OF MONTGOMERY §
BEFORE ME, the undersigned authority, personally appeared
Salime Assaf , who, being by me duly sworn, deposed as follows:
My name is Salime Assaf . I am of sound mind and capable of making
this affidavit, and personally vauainted with the facts of herein stated.
I am a custodian of records for Questcare Medical
Services, PLLC. Attached to this affidavit are records
that provide an itemized statement of the service and the
charge for the service that Questcare Medical Services,
PLLC provided to Crystal Skates on 09122i2‘t and 11120121 (dates). The attached records are a
part of
this affidavit.
The attached records are kept by me in the regular course of business. The information
contained in the
records was transmitted to me in the regular course of business
by Questcare Medical Services, PLLC or an
employee or representative of Questcare Medical Services, PLLC who had personal
knowledge of the
information. The records were made at or near the time or
reasonably soon after the time that the service was
provided. The records are the originai or a duplicate of the original.
The services provided were necessary and the amount
charged for the services were 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 but
which Questcare Medical Services, PLLC has a right to be paid is $ 1744.20 .
Sat/am flm
Affiant V
SWORN TO AND SUBSCRIBED before me on the /‘-§% day (fin—Lu. , ZOQQ .
No/tarflm State oféPexas~ FR
Notary‘s printed name: ébG/H . Kcmi My commission expires:
JUN 0 8 2024
Commonwealth of Pennsylvania -
Notary Seat
Ebony Reid, Notary Public
Montgomery County
My commission expires June 8, 2024
Commission number 1362352
Member. Pennsytvrmia Association of Nth-arias
REQ—1284131'F-QED290977712314-AFFD
Automated Certificate of eService
This automated certificate of service was created by the efiling system.
The filer served this document via email generated by the efiling system
on the date and to the persons listed below. The rules governing
certificates of service have not changed. Filers must still provide a
certificate of service that complies with all applicable rules.
Stacey Arellano on behalf of Ana Lee
Bar No. 24094684
sarellano@galyen.com
Envelope ID: 73756357
Filing Code Description: Affidavit
Filing Description: NOTICE OF FILING AFFIDAVITS
Status as of 3/17/2023 10:07 AM CST
Associated Case Party: CRYSTAL SKATES
Name BarNumber Email TimestampSubmitted Status
Melanie Kulp dallaslit@galyen.com 3/17/2023 9:53:41 AM SENT
Ana K.Lee alee@galyen.com 3/17/2023 9:53:41 AM SENT
Associated Case Party: LlLlANA PALACIOS
Name BarNumber Email TimestampSubmitted Status
Mark A.Teague eservice@lecronelaw.com 3/17/2023 9:53:41 AM SENT
Preview
FILED 3/17/2023 9:53 AM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Miranda Lynch DEPUTY CAUSE NO. DC-22-14527 CRYSTAL SKATES § IN THE DISTRICT COURT Plaintiff, § § V. § IOIST JUDICIAL DISTRICT § LILIANA PALACIOS § Defendant. § DALLAS COUNTY, TEXAS PLAINTIFF 'S NOTICE OF FILING BUSINESS (MEDICAL) RECORDS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES TO THE HONORABLE JUDGE OF THIS COURT: I. Business (Medical) Records Affidavits Pursuant to Rule 902(10), Texas Rules of Evidence, Plaintiff files herewith the business records Affidavits identified below, which Plaintiff reserves the right to offer into evidence at the trial of the instant case: 1. Medical Records of TOUCHSTONE IMAGING ARLINGTON prepared by Cindy Au as the Custodian of Records for TOUCHSTONE IMAGING ARLINGTON, which records are attached to the Affidavit being served on the attorneys of record. 2. Medical Records of MEDICAL CITY ARLINGTON prepared by Glenda Willey as the Custodian of Records for MEDICAL CITY ARLINGTON, which records are attached to the Affidavit being served on the attorneys of record; 3. Medical Records of SMITH COUNTY HEALTHCARE SYSTEM prepared by Alex Kosarow as the Custodian of Records for SMITH COUNTY HEALTHCARE SYSTEM, which records are attached to the Affidavit being served on the attorneys of record. The above-described Affidavits are signed by individuals who are qualified to provide the prerequisites for admissibility of these records under Rule 803(6) and (7), Texas Rules ofEvidence, and attest that the records attached were in fact kept as required by Rules 803 (6) and (7), Texas Rules ofEvidence. Subject to the local rules applicable to the Court in which this cause is pending, Plaintiff is PLAINTIFF'SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 1 of 4 filing the above-referenced Affidavits with the Clerk of the Court and serving copies of the Affidavits on each other party in the case at least fourteen (14) days before the day on which evidence is first scheduled to be presented at the trial of the case. Further, the above records will be made available at the offices of Plaintiffs attorney for inspection and copying, upon reasonable notice, at the expense of the party desiring the copies. II. Affidavits of Necessitv of Services and Reasonableness of Charges Pursuant to Tex. Civ. Prac. & Rem. Code, §18.001, Plaintiff files herewith the following identified Affidavit Concerning Cost and Necessity of Services, attesting that the services provided were reasonable at the time and place the service was provided relevant to the claims in the instant litigation and the services were necessary: 1. Billing Records of TOUCHSTONE IMAGING ARLINGTON, prepared by Cindy Au as the Custodian of Records for TOUCHSTONE IMAGING ARLINGTON, which records are attached to the Affidavit Concerning Cost and Necessity of Services being served to the attorney(s) of record; 2. Billing Records of TEXAS RADIOLOGY ASSOCIATES, LLP prepared by Amy Glatz as the Custodian of Records for TEXAS RADIOLOGY ASSOCIATES, LLP, which records are attached to the Affidavit Concerning Cost and Necessity of Services being served on the attorneys of record; 3. Billing Records of MEDICAL CITY ARLINGTON prepared by Shelly Shaut as the Custodian of Records for MEDICAL CITY ARLINGTON, which records are attached to the Affidavit Concerning Cost and Necessity of Services being served on attorney(s) of record. 4. Billing Records of QUESTCARE MEDICAL SERVICES, PLLC prepared by Salime Assaf as the Custodian of Records for QUESTCARE MEDICAL SERVICES,PLLC, which records are attached to the Affidavit Concerning Cost and Necessity of Services being served on the attorneys of record; 5. Billing Records of SMITH COUNTY HEALTHCARE SYSTEM prepared by Alex Kosarow as the Custodian of Records for SMITH COUNTY HEALTHCARE SYSTEM, which records are attached to the Affidavit being served on the attorneys of record; PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 2 of 4 The aforementioned Affidavits have been taken before an officer with authority to administer oaths and made by the person who provided the service or the person in charge of records, and show the service provided and the charge made. Attached to each Affidavit is the itemized statement of service and the charges for such service. Subject to the local rules applicable to the Court in which this action is pending, Plaintiff is filing the above-referenced Affidavits with the Clerk of the Court and serving copies of the Affidavits on 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 of Plaintiffs attorney for inspection, upon reasonable notice, and copying at the expense of the party desiring such copies. Plaintiff reserves the right to offer into evidence at the trial of the instant cause the above-referenced Affidavits and itemized statements. Respectfully submitted, BAILEY & GALYEN 2777 North Stemmons Frwy Dallas, TX 75207 (214) 252-9099 - Office (214) 520-9941 — Facsimile alee@galyen.com - Email By: Ana Lee /s/ Ana Lee Texas State Bar No.: 24094684 ATTORNEY FOR PLAINTIFF PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 3 of 4 CERTIFICATE OF SERVICE I hereby certify that on this the 17th day of March 2023, the above and foregoing instrument has been forwarded to counsel(s) of record in accordance with the TEXAS RULES 0F CIVIL PROCEDURE: VIA: E-Serve and/or Facsimile Mark A. Teague The LeCrone Law Firm, PC 123 N. Crockett St. Suite 200 Sherman, TX75090 Attorney for: Liliana Palacios John W. Breeze The LeCrone Law Firm, PC 123 North Crockett St. Suite 200 Sherman, TX 75090 Attorney for: Liliana Palacios Hillary Luckett Clark 123 N. Crockett St. Suite 200 Sherman, TX 75090 Attorney for: Liliana Palacios Ana Lee /s/ Ana Lee PLAINTIFF‘SNOTICE 0F FILING BUSINESS RECORDS AFFIDAVITS AND AFFIDAVITS CONCERNING COST AND NECESSITY 0F SERVICES Page 4 of 4 AFFIDAVIT 0F RECORDS BY CUSTODIAN OF SMITH COUNTY HEALTHCARE SYSTEM BEFORE ME, the undersigned authority, personally appeared MK k0$wro at) , who, being duly sworn, deposed as follows: My name is 44x kflsnrmD I am of sound mind, capable of making . this affidavit, and personally acquainted with the facts herein stated. I am a custodian of records for Smith County Healthcare System. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service 4' 27 .2/ - that Smith County Healthcare System provided to Crystal Skates on 11/5942; . The attached records are a part of this affidavit. 5/m'44‘ down—65 The attached records are kept by #MMA Mfg, Sz Sfim in the regular course of business, and it was the regular course of business of Smith County Healthcare System for an employee or representative of Smith County Healthcare System, 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 afier the time the service was provided. The records are the original or 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 $ “5/ and the amount currently unpaid but which Smith County Healthcare System has a right to be pa" after any adjustments or credits is $ /5; ?7/. 3'9 rant SWORN TO AND SUBSCRIBED before me, on MM 4 5/ 7,0210 so": \\\ \‘ “mP ‘r’v M" LISA M EARRIZALES 0Q”, NotafY pumic Stat a of T035 [a ma?» Notary Public,” State of Texas :2: 'res 2'23-2026 _ . comm EXP‘ Notes! p 7895655 1 AFFmiwrr or RECORDS CUSTODIAN Page 1 of l CAUSE N0. CRYSTAL SKATES § IN THE COURT PLAINTIFF, § § V. § § CRYSTAL SKATES § DEFENDANT. § COUNTY, TEXAS MEDICAL RECORDS AFFIDAVIT BEFORE ME, the undersigned authority, on this day personally appeared M kasmod) , who swore on oath that the following facts are true: "My name is M [( koswao . I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated. "I am the custodian of the records of Smith County Healthcare System. Attached hereto [is/are] 5L page[s] of medical records from Smith County Healthcare System regarding treatment provided to Crystal Skates. These said pages of records are kept by Smith County Healthcare System in the regular c0urse of business, and it was the regular course of business of Smith County Healthcare System for an employee or representative of Smith County Healthcare System, 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 the original or exact duplicates of the original." fiant SWORN To AND SUBSCRIBED me on W 515, 1911/ \“ \lllln,’I LISA M. CARRIZALES [Vito W141?) ‘03:“: 0", 3°: 2%: Notary Public, State of Texas Notary Public, State of Texas “MM-:3: Comm. Expires 02-23-2026 "Inmu‘\‘ OF Notary FD 7895655 MEDICAL RECORDS AFFIDAVIT Page 2 of 2 STATE OF TEXAS DODGMCO') COUNTY OF BEXAR AFFIDAVIT OF RECORDS CUSTODIAN Before me, the undersigned authority, personally appeared SHELLY SHAUT, who, being by me duly sworn, deposed as follows: My name is SHELLY SHAUT. I am of sound mind and capable of making this affidavit, and personally acquainted with the facts herein stated. I am a custodian of records for MEDICAL CITY ARLINGTON (“Hospital”). Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Hospital provided to CRYSTAL SKATES on 09/22/2021 TO 09/22/2021. The attached records are a part of this affidavit. The attached records are kept by Hospital in the regular course of business, and it was the regular course of business of Hospital for an employee or representative of Hospital, 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 original or a duplicate of the original. Pursuant to Texas Civil Practice & Remedies Code § 18.002(b—1), 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 but which Hospital has a right to be paid after any adjustments or credits is $6,797.81. ** The amount paid and the amount the Hospital has a right to be paid may change pending potential payment from the patient’s health insurance. Affiant SWORN To AND SUBSCRIBED before me on this 22ND day of NOVEMBER 2021. % , My commission expires: m Notary Public, State of Texas 07-18-2023 printed Name MICHAEL RODRIGUEZ MICHAEL RODRIGUEZ ‘to _Mnm PuIII-II: State of Tom =.Eamm Expires DT- n-znzs 5h. "u. “a Notify ID 12!“?525 CRYSTAL SKATES "101056891 1 15662502 Patlentz Medical Record Number: eRequest ID: Facility: Mgqiga! £112 Aflmfion Phone Number: 682-509~6446 Address: 332; Magjggk Rg City/State: Arlingon, TX Zip: 7m AFFIDAVIT PM I L C RDS Before me. the undersigned authority, personally appeared who, being by me duly sworn, deposed as follows: My name Is Qienda Willey , I am of sound mind, capable of making this affidavit and personally acquainted with the facts herein stated: I am the custodian of the medical records for Medical gm Mime" Attached hereto are 62 pages of medical records. These said Epages of medical records are kept by in the regular course of business, and it was in the regular course of business of for an employee or representative of Medical Clg AdingLon with knowledge of the act, event, condition, opinion or diagnosis. was ordered to make the record into transmit information thereof to be included in such records; and the records were made at or near the time of reasonably soon thereafter. The records attached hereto are the original or exact duplicates of the original. AFFIDAVIT OF NO RECORDS D A thorough search of requested information carried out under my direction and control revealed that this facility does not have the records described in the patient authorization or the subpoena dunes tecum. DECIARATION OF CUSTODIAN OF RECORDS I, Glenda “(may , am the duly authorized Custodian of Records of the above named facility. lam familiar with the mode of preparation of, and have the authority to certify. the facility record. declare under penalty of perjury under 1 the hints of the State of Igxas , County of Torrent that the foregoing is true and correct. mm gauzou Signature Date *‘IFOB¥*I¢#M Subsc ibed and tary publi dfors hi W0 TONI SAMPLE Notary Public MyNoiaryiD 12 My commission expires: Jill! 1. 2023 ExpimJulyLM in states where a Notary is not required, this form will only include signature and date of the medical record custodian. AFFIDAVIT OF RECORDS BY CUSTODIAN OF TOUCHSTONE IIVIAGING ARLINGTON BEFORE ME, the undersigned authority, personally appeared Cindy Au , who, being duly sworn, deposed as follows: My name is Cindy Au . I am of sound mind, capable of making this afiidavit, and personally acquainted with the facts herein stated. I am a custodian of records for Touchstone Imaging Arlington. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Touchstone Imaging Arlington provided to Crystal Skates on 11/09/2021 The attached records are a part of this affidavit. Touchstone Imaging The attached records are kept by Arlington in the regular course of of business of Touchstone Imaging Arlington for an business, and it was the regular course employee or representative of Touchstone Imaging Arlington, 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 original or 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 but which Touchstone Imaging Arlngton has a right to be paid after any adjustments or credits is $4 238.00 . 6m2¥opéém Affiant a SWORN TO ANn's'pBSCRIBED beforeme on QI/xo/Zll’ - W 9092» \“w“ "I”,II Wee—I. §§QXWN PUG('/'._A ’2 \ My ' Public,\,8'tate of ~£Fexas 1 8002737 EXP - 3/16/2026 IN AND 023mb M 7/9“ FOR _.-'0 ”’o<°oF KLP III/I” II I l l 8il|\“\\\ AFFIDAVIT or RECORDS CUSTODIAN Page 1 of 1 AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF Texas Radiology Associates, LLP (Pursuant to Texas Civil Practice & Remedies Code § 18.002 (b-1)) STATE OF TEXAS § COUNTY 0F COLLIN g BEFORE ME, the undersigned authority, personally appeared Amy G'atz , who, being by me duly sworn, deposed as follows: My name is Amy G'atz . I am of sound mind and capable of making this affidavit, and personally acquainted with the facts of herein stated. I am a custodian of records for Texas Radiology Associates, LLP. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Texas Radiology Associates, LLP provided to Crystal Skates on 09/22/2021 (dates). The attached records are a part of this affidavit. The attached records are kept by me 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, LLP or an employee or representative of Texas Radiology Associates, LLP who had personal knowledge of the information. The records were made at or near the time or reasonably soon after the time that 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 were 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 but which Texas Radiology Associates, LLP has a right to be paid is $ 91-80 Affi ant SWORN TO AND SUBSCRIBED before me on the 5 day of AUQUSt , 20 22 . Nota lic, State o cedmo 8/28/2024 Notary’s printed name: ChriStOPher My commission expires: cumsromen canine—l Not-w PM. Sim cl q! MMIWI Mai-2024 Noun ID "NOW“ Yes-j AFFIDAVIT OF BILLING RECORDS CUSTODIAN OF Questcare Medical Services, PLLC (Pursuant to Texas Civil Practice & Remedies Code § 18.002 (b—l)) STATE OF WAS PENNSYLVANIA § § COUNTY OF MONTGOMERY § BEFORE ME, the undersigned authority, personally appeared Salime Assaf , who, being by me duly sworn, deposed as follows: My name is Salime Assaf . I am of sound mind and capable of making this affidavit, and personally vauainted with the facts of herein stated. I am a custodian of records for Questcare Medical Services, PLLC. Attached to this affidavit are records that provide an itemized statement of the service and the charge for the service that Questcare Medical Services, PLLC provided to Crystal Skates on 09122i2‘t and 11120121 (dates). The attached records are a part of this affidavit. The attached records are kept by me in the regular course of business. The information contained in the records was transmitted to me in the regular course of business by Questcare Medical Services, PLLC or an employee or representative of Questcare Medical Services, PLLC who had personal knowledge of the information. The records were made at or near the time or reasonably soon after the time that the service was provided. The records are the originai or a duplicate of the original. The services provided were necessary and the amount charged for the services were 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 but which Questcare Medical Services, PLLC has a right to be paid is $ 1744.20 . Sat/am flm Affiant V SWORN TO AND SUBSCRIBED before me on the /‘-§% day (fin—Lu. , ZOQQ . No/tarflm State oféPexas~ FR Notary‘s printed name: ébG/H . Kcmi My commission expires: JUN 0 8 2024 Commonwealth of Pennsylvania - Notary Seat Ebony Reid, Notary Public Montgomery County My commission expires June 8, 2024 Commission number 1362352 Member. Pennsytvrmia Association of Nth-arias REQ—1284131'F-QED290977712314-AFFD Automated Certificate of eService This automated certificate of service was created by the efiling system. The filer served this document via email generated by the efiling system on the date and to the persons listed below. The rules governing certificates of service have not changed. Filers must still provide a certificate of service that complies with all applicable rules. Stacey Arellano on behalf of Ana Lee Bar No. 24094684 sarellano@galyen.com Envelope ID: 73756357 Filing Code Description: Affidavit Filing Description: NOTICE OF FILING AFFIDAVITS Status as of 3/17/2023 10:07 AM CST Associated Case Party: CRYSTAL SKATES Name BarNumber Email TimestampSubmitted Status Melanie Kulp dallaslit@galyen.com 3/17/2023 9:53:41 AM SENT Ana K.Lee alee@galyen.com 3/17/2023 9:53:41 AM SENT Associated Case Party: LlLlANA PALACIOS Name BarNumber Email TimestampSubmitted Status Mark A.Teague eservice@lecronelaw.com 3/17/2023 9:53:41 AM SENT