Preview
FILED
8/26/2020 11:54 AM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Lafonda Sims DEPUTY
Cause No. DC-19-13584
ALFONSO LARA § IN THE DISTRICT COURT
Plaintiff, §
§
vs. § DALLAS COUNTY, TEXAS
§
§
DAYAKAR PINDI §
Defendant. § 160th JUDICIAL DISTRICT
PLAINTIFF ALFONSO LARA’S NOTICE
OF FILING RECORD AFFIDAVITS
COMES NOW, ALFONSO LARA, and hereby files with the Court the following
affidavits:
Billing record affidavit of AMPM
Medical Centers
Medical record affidavit of AMPM
Medical Centers
Billing record affidavit of Cano Health & Rehab
Medical record affidavit 0f Cano Health & Rehab
Billing record affidavit of DFW MRI
Medical record affidavit of DFW MRI
Billing record affidavit of Epic Pain & Orthopedics
Medical record affidavit of Epic Pain & Orthopedics
Billing record affidavit of Lakewood Anesthesia
Medical record affidavit 0f Lakewood Anesthesia
Billing record affidavit 0f Radiology Consultants North Texas
Medical record affidavit of Radiology Consultants North Texas
Billing record affidavit of Singleton Associates, PA
By copy of this Notice, opposing counsel are notified that these affidavits are being filed
with the Court pursuant to TRE 902. The records corresponding to the enclosed affidavits will be
kept in our office for use at trial. Copies 0f these affidavits and certified records were served on
opposing counsel simultaneously on a CD containing Plaintiff s Rule 194 Disclosures Via certified
mail return receipt requested, article number 91 7199 9991 7036 7648 5729.
PLAINTIFF ALFONSO LARA’S NOTICE OF FILING RECORD AFFIDAVITS - Page 1 0f 2
Respectfully submitted,
/s/ Sabrina L. Galvan
Sabrina L. Galvan
Texas Bar Number 24096871
Juan C. Hernandez
Texas Bar Number 24002270
16850 Dallas Parkway
Dallas, Texas 75248
sabrina@juanlaw.com
(972) 235-4444 Telephone
(972) 235-4454 Telecopy
Attorneysfor Plaintifl
CERTIFICATE OF SERVICE
Ihereby certify that a true and correct copy 0f the foregoing instrument was forwarded to
all attorneys of record in accordance with the Texas Rules 0f Civil Procedure, on this 26th day of
August 2020.
Via E-Service
Scott A. Whitcomb
Susan L. Florence & Associates
1201 Elm Street, Suite 5050
Dallas, Texas 75270
T: 214-659-4325
F: 877-678-4763
swhim@allstate.com
Attorneyfor Defendant
/s/ Sabrina L. Galvan
SABRINA L. GALVAN
PLAINTIFF ALFONSO LARA’S NOTICE OF FILING RECORD AFFIDAVITS - Page 2 0f 2
Cause No. DC-19-13584
ALFONSO LARA § IN THE DISTRICT COURT
Plaintiff, §
§
vs. § DALLAS COUNTY, TEXAS
§
§
DAYAKAR PINDI §
Defendant. § 160th JUDICIAL DISTRICT
AFFIDAVIT BY THTHE PERSON WHO IS IS IN CHARGE OF BILLING RECORDS
(Affidavit
(Affidavit per 18.001 et
p r §§ 18.001, et seq.
seq. of
of the
,
the Civil
Civil Practices
Practices and
and Remedies
Remedies
Code and ule 902(10)
and lRule 902(10) b
b of
of the
the Texas
Texas Rules
Rules of
of Civil
Civil Evidence)
Evidence)
BEFORE ME, the
the imdersigned
ndersigned authority,
authority, personally
personally appeared
appeared g km “AV) @ruos
<...XJ6o..3; [é mofi
(name
(name of
of affiant), who, bei
affiant), who, bei gg by
by me duly
duly sworn,
sworn, deposed
deposed as
as follows:
follows:
My name is \b ‘.|/\ QmeDS (name of affiant). I am of sound mind and
capable
capable of making this
this affi avit, and
affijlavit, and am personally
personally acquainted
acquainted with the facts
with the facts herein
herein stated:
stated:
II am the
the person
person in
in charge
charge and
and the
the custodian
custodian of
of records of AMPM Medical
records of Medical Centers.
Centers.
Attached
Attached to this affidavit
to this affidavit a e - - + - - pages
ane pages of
I
billing records
of billing records that provide an
that provide an itemized
itemized statement
statement
of
of the
the service
service and
and the
the c arge for
charge for the
the service that AMPM Medical
service that Medical Centers
Centers provided
provided to
to
A\Q’)fl®©
....!........l....!....L.!....L1-_i_,,_"' LEVI)
-'-"'----==-"'---""'-+----- - --(name
(name of patient) from
ofpatient) //'J
I
ZQ’1 /J q
q
Z I
[FIRST
[FIRST DATE OF
0F SERVI E] through
SERVICE] through JI(éh
r ,Z /-J, / JMq [LAST DATE OF
0F SERVICE].
SERVICE]. The
The
attached
attached billing
billing records
records ar
are a part of
a part of this
this affidavit.
affidavit. The total
total charge
charge for
for the
the services
services provided
provided is
is
/\DO S:2-
00
0
:gfio
$ _ ____,-~" ' - - - - - - - - - + - - - - -
l . The total
total of
of these charges that
these charges that has
has been
been paid
paid IS
is
$_ _
$
\S\
c9-
~------- . The total
total of
of these
these charges
charges that
that are
are still
still owed IS
is
So oO
oo
$
$ ll.
960
The attached billi
attached billing records
records are kept by
are kept by me in the regular
in the regular course
course of
of business.
business. The
The
information contained in th¢ billing records was transmitted to me in the regular course ofbusincss
by AMPM Medical Centers or an employee or representative of AMPM Medical Centers who
had personal knowledge of the information. The billing records were made at or near the time or
reasonably soon afier the time that the service was provided. The billing records are the originals
0r an exact duplicate of the originals.
The service providefi was necessary and the amount charged for the service was reasonable
at the time and place that the service was provided.
All statements made herein by me are within m a1 kno dge.
SWORN TO AND SUBSC RIBED before me on the IQ day of KJL) l
g
2019.
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Cause No. DC-19-13584
ALFONSO LARA § IN THE DISTRICT COURT
Plaintiff, §
§
vs. § DALLAS COUNTY, TEXAS
§
§
DAYAKAR PINDI §
Defendant. § 160th JUDICIAL DISTRICT
AFFIDAVIT BY TH 4 PERSON WHO IS IS IN CHARGE OF MEDICAL RECORDS
(Affidavit
(Affidavit aa sper 18.001,, et
per§§ 18.001 et seq.
seq. of
of the
the Civil
Civil Practice
Practice & Remedies
Remedies
Code aa 1dd Rule
Rule 902(10)
902(1 0) bb of
of the
the Texas
Texas Rules
Rules ofEvidence)
of Evidence)
BEFORE ME, the ndersigned authority,
the mdersigned authority, personally appeared 1, )Clf)rv); n
personally appeared rl JWI ~ OS
park oS
(name
(name of
of affiant),
affiant), who,
who, bei g by
bei1 1g by me duly
duly sworn,
sworn, deposed
deposed as
as follows:
follows:
My name is 603 rwlm IZCm/uos (name of affiant). I am of sound mind and
capable of
capable of making this
this affi avit, and
affi+avit, and personally
personally acquainted
acquainted with the facts
with the facts herein
herein stated:
stated:
II am the
the custodian
custodian of
of records
records and
and the
the person
person in
in charge
charge of
of records of AMPM Medical
records of Medical
Centers.
Centers. Attached
Attached hereto
hereto a e
3er
k;
(a pages
pages of from AMPM Medical
records from
ofrecords Medical Centers
Centers for
for services
services
provided to
t0 :. . . ; \. c:;.::,-::;:::= -.. .~oma
.A
A\£m$c I ----=-:...ri
_V\
____;__ (name
(name of
of patient)
patient) from
from l j;). \ /
l~
I /Q\ ['0‘ to
to
_1_/~~~t. ./_. J_'i___ _ ( ates of services).
let/I‘i
r I
(d ates of services). These
These said
said records
records are
are kept by AMPM Medical
kept by Medical
Centers
Centers in
in the regular cou
the regular coul se
se of business, and
of business, and it
it was the
the regular
regular course
course of of AMPM
business of
of business
Medical
Medical Centers
Centers for
for an
an em loyee or
em] )loyee or representative of AMPM Medical
representative of Medical Centers,
Centers, with knowledge
with knowledge
of the act,
of the act, event,
event, conditio
condition opinion,
opinion, or
or diagnosis,
diagnosis, recorded
,
recorded to
to make the
the record
record or to transmit
or to transmit
information
information thereof to be
thereof to be in luded in
in :luded in such
such record;
record; and
and the
the record
record was made at
at or
or near the time
near the time of
of
the
the act,
act, event,
event, condition,
condition, opi ion, or
opi aion, or diagnosis
diagnosis recorded
recorded or
or reasonably
reasonably soon
soon thereafter.
thereafter. The records
records
attached
attached hereto
hereto are
are the
the origi al or
origi 1a] or exact
exact duplicates
duplicates of
of the
the original
011' ginal and
and are part of
are pan of this
this affidavit.
affidavit.
The service provide was
service provided necessary and
was necessary and the
the amount charged
charged for
for the
the service
service was reasonable
reasonable
at the time and place that e service was provided.
A11 statements ma e herein by me are within my personal knowledge.
AF
.;v~
SWORN T0 AND SUBS RJBED before me on the /
q day of u ,
2019.
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From:
From: SLG Tum
SL6 Team Fax:
Fax: 12144425801
12144425801 To
To:: 4695471404(!!)RCFaK.C0m
46954714040chxmom Fax:
Fax: (469)
(469) 547-1404
541-1404 Page:
Pugo: 6
6 ol
of 9
9 07/18/2019
D7I18I2019 9:37
9:37 AM
Cause No. DC-19-13584
ALFONSO LARA § IN THE DISTRICT COURT
Plaintiff, §
§
vs. § DALLAS COUNTY, TEXAS
§
§
DAYAKAR PINDI §
Defendant. § 160th JUDICIAL DISTRICT
AFFIDAVIT BY THE PERSON WHO IS IS IN CHARGE OF 0F BILLING RECORDS
(Affidavit
(Affidavit per§
per § 18.00 1, et
18.001, et seq.
seq. of the Civil
ofthe Civil Practices
Practices and Remedies
Code
Code and
and Rule
Rule 902(10)
902(10) b b of
of the
the Texas
Texas Rules
Rules of Civil Evidence)
ofCivil Evidence)
BEFORE ME,
ME, the
the undersigned
undersigned authority,
authority, personally
personally appeared
L1
na')i
fl S“w Y ~{A IiW1“
Bs\1\~ 5R0! ‘
(name
(name of
of affiant),
affiant), who,
who, being by m
being by mee duly
duly sworn,
swom, deposed as
as follows:
follows:
My name is
My is fu\11 \t~ sS:a \lflm‘:
Afihmg Ovt..5(?flfl 1· (name
(name of affiant).
afliant). r am
I of sound mind and
capable
capable of
of making
making this
this affidavit,
affidavit, and
and am personally
personally acquainted
acquainted with
with the
the facts
facts herein stated
stated::
II am the
the person in charge
person in charge and
and the
the custodian
custodian of records of Cano Health & Rehab.
of records
Attached to this
Attached to this affidavit
affidavit are
are j_!!J__
1i pages of billing records that provide an itemized statement
pages ofbilling records that provide an itemized statement
of
of the
the service
service and
and the
the charge
charge for
for the
the service
service that Health & Rehab provided to
that Cano Health to
'[\ %h%o lut
Y)“\ \'Ot\SO m (0\
(m (name
(name of patient) from
ofpatient) from Ii} ‘
Q k!\ $?
if- · '):J-.- g
[FIRST
[FIRST DATE OF SERVICE)
SERVICE] through
through 4-tL.
4’27 --\
’| °)
I
[LAST DATE OF SERVICE]. The
attached
attached billing
billing records
records are
are a
a part
part of
of thi
thiss affidavit.
affidavit. The total
total charge
charge for
for the
the services
services provided is
is
oD
$_
$ 1 ngu ~'----9___,,\_p__o
7.. .:. . .;,'---= _v_ _ _ .
The
The total
total of
of these
these charges
charges that
that has
has been
been paid
paid 1s
is
$_ ______,_,
OO
Q_oo _· _ _ _
$ O .
The
The total
total of these charges
of these that are
charges that are still
still owed 1s
is
$_
s mgmfm
1-+--
1S~ 9.. J. . l.>-""..
octD_ _ _
The
The attached
attached billing
billing records
records are
are kept
kept by
by me in
in the
the regular
regular course
course of
of business.
business. The
From: SLG Team Fax: 12144425301 To: 46954714D4@RCF3K.c0m Fax: (469) 547-1404 Pago: T of 9 0711812019 9:37 RM
information contained in the billing records was transmitted to me in the regular course of
business by Cano Health & Rehab or an employee or representative of Cano Health & Rehab
who had personal knowledge of the information. The billing records were made at or near the
time or reasonably soon afier the time that the service was provided. The billing records are‘the
originals or an exact duplicate of the originals.
The service provided was necessmy and the amount charged for the service was
reasonable at the time and place that the service was provided.
A11 statements made herein by me are within my ersonal knowledge
AFFIANT
SWORN TO AND SUBSCRIBED before me on the l 3 l g day of A (J
fi 0 3 Z
2019.
'
Notary Pub tate of Texas
4
Notary’s printed name'
fiyugg chéa flatly
HERNAN ROCHA PADILLA
Notary ID #1 30006759
My Commission Expires
October 28, 2022
To: Page:
Pago: 8
I of
of 9 07/18/2019 9:37 AM
Preview
FILED 8/26/2020 11:54 AM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Lafonda Sims DEPUTY Cause No. DC-19-13584 ALFONSO LARA § IN THE DISTRICT COURT Plaintiff, § § vs. § DALLAS COUNTY, TEXAS § § DAYAKAR PINDI § Defendant. § 160th JUDICIAL DISTRICT PLAINTIFF ALFONSO LARA’S NOTICE OF FILING RECORD AFFIDAVITS COMES NOW, ALFONSO LARA, and hereby files with the Court the following affidavits: Billing record affidavit of AMPM Medical Centers Medical record affidavit of AMPM Medical Centers Billing record affidavit of Cano Health & Rehab Medical record affidavit 0f Cano Health & Rehab Billing record affidavit of DFW MRI Medical record affidavit of DFW MRI Billing record affidavit of Epic Pain & Orthopedics Medical record affidavit of Epic Pain & Orthopedics Billing record affidavit of Lakewood Anesthesia Medical record affidavit 0f Lakewood Anesthesia Billing record affidavit 0f Radiology Consultants North Texas Medical record affidavit of Radiology Consultants North Texas Billing record affidavit of Singleton Associates, PA By copy of this Notice, opposing counsel are notified that these affidavits are being filed with the Court pursuant to TRE 902. The records corresponding to the enclosed affidavits will be kept in our office for use at trial. Copies 0f these affidavits and certified records were served on opposing counsel simultaneously on a CD containing Plaintiff s Rule 194 Disclosures Via certified mail return receipt requested, article number 91 7199 9991 7036 7648 5729. PLAINTIFF ALFONSO LARA’S NOTICE OF FILING RECORD AFFIDAVITS - Page 1 0f 2 Respectfully submitted, /s/ Sabrina L. Galvan Sabrina L. Galvan Texas Bar Number 24096871 Juan C. Hernandez Texas Bar Number 24002270 16850 Dallas Parkway Dallas, Texas 75248 sabrina@juanlaw.com (972) 235-4444 Telephone (972) 235-4454 Telecopy Attorneysfor Plaintifl CERTIFICATE OF SERVICE Ihereby certify that a true and correct copy 0f the foregoing instrument was forwarded to all attorneys of record in accordance with the Texas Rules 0f Civil Procedure, on this 26th day of August 2020. Via E-Service Scott A. Whitcomb Susan L. Florence & Associates 1201 Elm Street, Suite 5050 Dallas, Texas 75270 T: 214-659-4325 F: 877-678-4763 swhim@allstate.com Attorneyfor Defendant /s/ Sabrina L. Galvan SABRINA L. GALVAN PLAINTIFF ALFONSO LARA’S NOTICE OF FILING RECORD AFFIDAVITS - Page 2 0f 2 Cause No. DC-19-13584 ALFONSO LARA § IN THE DISTRICT COURT Plaintiff, § § vs. § DALLAS COUNTY, TEXAS § § DAYAKAR PINDI § Defendant. § 160th JUDICIAL DISTRICT AFFIDAVIT BY THTHE PERSON WHO IS IS IN CHARGE OF BILLING RECORDS (Affidavit (Affidavit per 18.001 et p r §§ 18.001, et seq. seq. of of the , the Civil Civil Practices Practices and and Remedies Remedies Code and ule 902(10) and lRule 902(10) b b of of the the Texas Texas Rules Rules of of Civil Civil Evidence) Evidence) BEFORE ME, the the imdersigned ndersigned authority, authority, personally personally appeared appeared g km “AV) @ruos <...XJ6o..3; [é mofi (name (name of of affiant), who, bei affiant), who, bei gg by by me duly duly sworn, sworn, deposed deposed as as follows: follows: My name is \b ‘.|/\ QmeDS (name of affiant). I am of sound mind and capable capable of making this this affi avit, and affijlavit, and am personally personally acquainted acquainted with the facts with the facts herein herein stated: stated: II am the the person person in in charge charge and and the the custodian custodian of of records of AMPM Medical records of Medical Centers. Centers. Attached Attached to this affidavit to this affidavit a e - - + - - pages ane pages of I billing records of billing records that provide an that provide an itemized itemized statement statement of of the the service service and and the the c arge for charge for the the service that AMPM Medical service that Medical Centers Centers provided provided to to A\Q’)fl®© ....!........l....!....L.!....L1-_i_,,_"' LEVI) -'-"'----==-"'---""'-+----- - --(name (name of patient) from ofpatient) //'J I ZQ’1 /J q q Z I [FIRST [FIRST DATE OF 0F SERVI E] through SERVICE] through JI(éh r ,Z /-J, / JMq [LAST DATE OF 0F SERVICE]. SERVICE]. The The attached attached billing billing records records ar are a part of a part of this this affidavit. affidavit. The total total charge charge for for the the services services provided provided is is /\DO S:2- 00 0 :gfio $ _ ____,-~" ' - - - - - - - - - + - - - - - l . The total total of of these charges that these charges that has has been been paid paid IS is $_ _ $ \S\ c9- ~------- . The total total of of these these charges charges that that are are still still owed IS is So oO oo $ $ ll. 960 The attached billi attached billing records records are kept by are kept by me in the regular in the regular course course of of business. business. The The information contained in th¢ billing records was transmitted to me in the regular course ofbusincss by AMPM Medical Centers or an employee or representative of AMPM Medical Centers who had personal knowledge of the information. The billing records were made at or near the time or reasonably soon afier the time that the service was provided. The billing records are the originals 0r an exact duplicate of the originals. The service providefi was necessary and the amount charged for the service was reasonable at the time and place that the service was provided. All statements made herein by me are within m a1 kno dge. SWORN TO AND SUBSC RIBED before me on the IQ day of KJL) l g 2019. \\\\\\H' IHl/l/II ‘ Ill, ’zt/ \\‘3“;%B§Afigrl4 (<24, S \RY Pg 2 sag. 2w 49;??? E m (5 ( m {a . Notary Publlc, State of Texas g z U“ W r”: é {gN E (>7. E w (T\-~ a 3, ?%Eor 3:593; ‘5 N t ’s printed name: ”’1’ " 8983'?“ s? OLVMM («67% ‘ '2’ 0’0,K): ' '21 \\\\\ ”’1' Imuun‘“ Cause No. DC-19-13584 ALFONSO LARA § IN THE DISTRICT COURT Plaintiff, § § vs. § DALLAS COUNTY, TEXAS § § DAYAKAR PINDI § Defendant. § 160th JUDICIAL DISTRICT AFFIDAVIT BY TH 4 PERSON WHO IS IS IN CHARGE OF MEDICAL RECORDS (Affidavit (Affidavit aa sper 18.001,, et per§§ 18.001 et seq. seq. of of the the Civil Civil Practice Practice & Remedies Remedies Code aa 1dd Rule Rule 902(10) 902(1 0) bb of of the the Texas Texas Rules Rules ofEvidence) of Evidence) BEFORE ME, the ndersigned authority, the mdersigned authority, personally appeared 1, )Clf)rv); n personally appeared rl JWI ~ OS park oS (name (name of of affiant), affiant), who, who, bei g by bei1 1g by me duly duly sworn, sworn, deposed deposed as as follows: follows: My name is 603 rwlm IZCm/uos (name of affiant). I am of sound mind and capable of capable of making this this affi avit, and affi+avit, and personally personally acquainted acquainted with the facts with the facts herein herein stated: stated: II am the the custodian custodian of of records records and and the the person person in in charge charge of of records of AMPM Medical records of Medical Centers. Centers. Attached Attached hereto hereto a e 3er k; (a pages pages of from AMPM Medical records from ofrecords Medical Centers Centers for for services services provided to t0 :. . . ; \. c:;.::,-::;:::= -.. .~oma .A A\£m$c I ----=-:...ri _V\ ____;__ (name (name of of patient) patient) from from l j;). \ / l~ I /Q\ ['0‘ to to _1_/~~~t. ./_. J_'i___ _ ( ates of services). let/I‘i r I (d ates of services). These These said said records records are are kept by AMPM Medical kept by Medical Centers Centers in in the regular cou the regular coul se se of business, and of business, and it it was the the regular regular course course of of AMPM business of of business Medical Medical Centers Centers for for an an em loyee or em] )loyee or representative of AMPM Medical representative of Medical Centers, Centers, with knowledge with knowledge of the act, of the act, event, event, conditio condition opinion, opinion, or or diagnosis, diagnosis, recorded , recorded to to make the the record record or to transmit or to transmit information information thereof to be thereof to be in luded in in :luded in such such record; record; and and the the record record was made at at or or near the time near the time of of the the act, act, event, event, condition, condition, opi ion, or opi aion, or diagnosis diagnosis recorded recorded or or reasonably reasonably soon soon thereafter. thereafter. The records records attached attached hereto hereto are are the the origi al or origi 1a] or exact exact duplicates duplicates of of the the original 011' ginal and and are part of are pan of this this affidavit. affidavit. The service provide was service provided necessary and was necessary and the the amount charged charged for for the the service service was reasonable reasonable at the time and place that e service was provided. A11 statements ma e herein by me are within my personal knowledge. AF .;v~ SWORN T0 AND SUBS RJBED before me on the / q day of u , 2019. 'll'! *tf: ”*3 \1‘ Q3?“ (1/! R J $$$$- -E. 74. 45% 3.3 i} 3 ".ng {$- ?gi 53‘ ‘5 ‘ ' ’56 vfiw ?— 7 L 3:: U 3 fir 3 Notary Public, State ofTexas Z : fig; .\K{E%; ‘ " ¥?éj‘ ii; a a ' 9;: Notary prmted name a ugfiks a s 4' ”ixzifigfl {lillii yEE‘3‘\\§ Mkfé ,N’e+fl [L5" w From: From: SLG Tum SL6 Team Fax: Fax: 12144425801 12144425801 To To:: 4695471404(!!)RCFaK.C0m 46954714040chxmom Fax: Fax: (469) (469) 547-1404 541-1404 Page: Pugo: 6 6 ol of 9 9 07/18/2019 D7I18I2019 9:37 9:37 AM Cause No. DC-19-13584 ALFONSO LARA § IN THE DISTRICT COURT Plaintiff, § § vs. § DALLAS COUNTY, TEXAS § § DAYAKAR PINDI § Defendant. § 160th JUDICIAL DISTRICT AFFIDAVIT BY THE PERSON WHO IS IS IN CHARGE OF 0F BILLING RECORDS (Affidavit (Affidavit per§ per § 18.00 1, et 18.001, et seq. seq. of the Civil ofthe Civil Practices Practices and Remedies Code Code and and Rule Rule 902(10) 902(10) b b of of the the Texas Texas Rules Rules of Civil Evidence) ofCivil Evidence) BEFORE ME, ME, the the undersigned undersigned authority, authority, personally personally appeared L1 na')i fl S“w Y ~{A IiW1“ Bs\1\~ 5R0! ‘ (name (name of of affiant), affiant), who, who, being by m being by mee duly duly sworn, swom, deposed as as follows: follows: My name is My is fu\11 \t~ sS:a \lflm‘: Afihmg Ovt..5(?flfl 1· (name (name of affiant). afliant). r am I of sound mind and capable capable of of making making this this affidavit, affidavit, and and am personally personally acquainted acquainted with with the the facts facts herein stated stated:: II am the the person in charge person in charge and and the the custodian custodian of records of Cano Health & Rehab. of records Attached to this Attached to this affidavit affidavit are are j_!!J__ 1i pages of billing records that provide an itemized statement pages ofbilling records that provide an itemized statement of of the the service service and and the the charge charge for for the the service service that Health & Rehab provided to that Cano Health to '[\ %h%o lut Y)“\ \'Ot\SO m (0\ (m (name (name of patient) from ofpatient) from Ii} ‘ Q k!\ $? if- · '):J-.- g [FIRST [FIRST DATE OF SERVICE) SERVICE] through through 4-tL. 4’27 --\ ’| °) I [LAST DATE OF SERVICE]. The attached attached billing billing records records are are a a part part of of thi thiss affidavit. affidavit. The total total charge charge for for the the services services provided is is oD $_ $ 1 ngu ~'----9___,,\_p__o 7.. .:. . .;,'---= _v_ _ _ . The The total total of of these these charges charges that that has has been been paid paid 1s is $_ ______,_, OO Q_oo _· _ _ _ $ O . The The total total of these charges of these that are charges that are still still owed 1s is $_ s mgmfm 1-+-- 1S~ 9.. J. . l.>-"".. octD_ _ _ The The attached attached billing billing records records are are kept kept by by me in in the the regular regular course course of of business. business. The From: SLG Team Fax: 12144425301 To: 46954714D4@RCF3K.c0m Fax: (469) 547-1404 Pago: T of 9 0711812019 9:37 RM information contained in the billing records was transmitted to me in the regular course of business by Cano Health & Rehab or an employee or representative of Cano Health & Rehab who had personal knowledge of the information. The billing records were made at or near the time or reasonably soon afier the time that the service was provided. The billing records are‘the originals or an exact duplicate of the originals. The service provided was necessmy and the amount charged for the service was reasonable at the time and place that the service was provided. A11 statements made herein by me are within my ersonal knowledge AFFIANT SWORN TO AND SUBSCRIBED before me on the l 3 l g day of A (J fi 0 3 Z 2019. ' Notary Pub tate of Texas 4 Notary’s printed name' fiyugg chéa flatly HERNAN ROCHA PADILLA Notary ID #1 30006759 My Commission Expires October 28, 2022 To: Page: Pago: 8 I of of 9 07/18/2019 9:37 AM