On February 06, 2020 a
Party Statement
was filed
involving a dispute between
Mobley, Jacqueline,
and
Ortiz, Maria,
for MOTOR VEHICLE ACCIDENT
in the District Court of Dallas County.
Preview
FILED
6/12/2020 12:29 PM
FELICIA PITRE
DISTRICT CLERK
DALLAS CO., TEXAS
Treva Parker—Ayodele DEPUTY
DC-20-02088
JACQUELINE MOBLEY § IN THE DISTRICT COURT
vs. g 14TH JUDICIAL DISTRICT
MARIA ORTIz g DALLAS COUNTY, TEXAS
Affidavit ofMedicaI Charges
from
Baylor Medical Cen ter at Irving
FM£94253
0F 1* =1>iti4
STATE OF §
§ AFFIDAVIT
AFFIDAVIT OF
0F MEDICAL
MEDICAL CHARGES
CHARGES
m: 6
COUNTY OF r,-
m}
111.11111. w §
me duly
Before me,
Befnre me, the
the undersigned
undersigned authority,
sworn, deposed and said:
duly sworn, said:
authority, personally
persnnally appeare appearedn, 1 1F"—
k;filivho, being
being by
by
-—.
,tviLL-4..lexth_
"t
"My name is
"My name is . 1 am
Iamofnfsound
soundmind
mindand
andcapable
capable of
flfmaking
making this
this
affidavit, and
affidavit, and personally
personally acquainted
acquainted withwith the
the facts herein stated.
facts herein stated.
I am
I am the
the custndian
custodian ofof records
records fur
forBaylor
Baylor Medical
Medical Center
Center at
at Irving.
Irving. Attached
Attached toto this
this affidavit
affidavit are
are
records that provide
records that provide an an itemized
itemized statement of uf the service and
the service the charge
and the for the
charge fur the service that Baylor
service that
Medical Center
Medical Center at at Irving
Irving provided
prnvided to tn Jacqueline
Jacqueline Mobley
Mnbley from 34- (aq to
frnm fiflgifi E‘QS (r.
tn _I‘;,1 Lg. The
The *~
attached records
attached records are
are aa part
part of
0f this
this affidavit.
affidavit.
The attached
attached records
records are
are kept
keptbybyBaylor
Baylor Medical
Medical Center
Center at
at Irving
Irving in
in the
the regular
regular course of its
uf its
business,
business, and it
it was
was the
the regular
regularcnurse
course nfbusiness
of businessnfBaylnr
of Baylor Medical
Medical Center
Center at
at Irving
Irving for
fur an employee
or representative of
Dr representative Baylor Medical
nf Baylnr Medical Center
Centerat atIrving
Irving, with
with knowledge
, knowledge of the service
nfthe service provided,
provided, to
tn make
the record
the recnrd or to transmit
Dr tn information to
transmit infurmatinn tn be
he included in the
included in the recnrd.
record. The records
records were
were made
made inin the
the regular
regular
course
course of
uf business
business atat or
or near the time
near the time or reasonably scum
Dr reasnnahly soon after
after the
the time
time the
the service
service was
was provided.
provided. The
The
records are
records are the
the original
nriginal or
Dr a
a duplicate
duplicate of
uf the
the original.
original.
The services
services provided
prflvided were necessary
necessary and
and the
the amount
amnunt charged for the services
fur the reasonable
services was reasunable
at the time
at the time and
and place
place that
that the
the services
services were provided.
provided.
The amount paid
paid far
for the
the services $mm
services was $ 3an, jckand the the amount
amnunt currently
currently unpaid but which
mm
Baylor
Baylnr Medical
16R
Center at
Medical Center at Irving
Irving has
has aaright
rightto
tnbe
bepaid
paidafter
afterany
an}?adjustments
adjustments or
or credits
credits is
is S-
$-
SWDRN TO
SWORN
AFFIA
AFFIA /CUSTODIAN
SUBSCRIBED before
TU AND SUBSCRIBED befnre
{EUSTGDIANOF
me on
fin the
the
0FRECORDS
RECDRDS
ICI_ day
l I of Pk
day of m . 2002°
201320
NOTARY PUBLIC, STATE OF
mirm•••••••
DE1DRE COWART
My Notary ID # '125989616
Expires February 2, 2023
‘BAELOR
BAYLOR MED CTR AT IRVINGEBAYLOR
Al IRVING BAYLOR DIED MED CTR CTR ATATIRVINGI rt.; 117664172
IRyINGEfifl11J664172 OF
1901 N MACARTHUR BLVD PO Box 841590
E0 BOX 841590 Uni1000939493000001
£Eng0939493000001
STAfEMENT COVERS PERM— 17
137
137
-IRVING ?50612220
IRVING TX 750612220 DALLAS TX
DALLAS TX 752841590
?52341590 fifimmml
5 FED TAX NO
Fm”
FROM mmma
THROUGH
?
2148203151 2148208515
214820851§_ 752586857 032818 032918
75258635? 032813
”WMWHWE
8 PATIENT NAME
MOBLEY ,JAC
h MORLEY UELINEHMMWMMfifi
JACQUELINE 9 PATIENT ADDRESS a'2200 WILLIAM BREWS
2200 WILLlam_Bg§MS I
h
IRVING ;,i¥L TX“ 75062
TXj? b = a
-
01
01
'W
10
1° BIRTHDATE
B’RTHMTE
05061965
31 OCCURRENCE
COPE
CIDDE DATE
032818 Al
R1 050865
050865
11
‘1 SEX
3E“
CODE-:'.‘.-:
:-L:IE
_
12
12 DATE
•1::C.URRENC.t.
u.::I::I::'.r.::.::E:-1jl:_t
EM:
DATE
ADMISSION
millélfigmfl
13 HR 14 TYPE
m'lficl-LMLME—
33 OCCURRENCE
EDDE
CODE
SRC 1E
HPE 15155m: DH” 17
16 DHR
34 OCCLARENCE
5T”
1’ STAT.
QEE
DATE CODE
01
O1
n
18
DATE
1i tn
35
CODE
DUDE
.21
:1
mu
cgnmflflmfian
CONDITION CODES
22
OCCURRENCE
FROM
FRDH
23
EHEE SPAN
EPAH
24
THRGUGH
THROUGH
36
3a
EDDE
Is CODE
25 a
:5 27
1? 2S
23 fisfig
sum
GLGUHREHBETEEEH
OCCURRENCE
FROM
FRDM
SPAN
2a ACOT
TX
THROUGH
THHfiLIGH
37
37
"11
11 032818
383mm
tiGNA CHILDRENS MED CTR M 35%.“ “fl?
VALUE CODES
AMOUNT
40
CODE
1.0U€ CODES
AMOUNT
41
Ema
CODE
WIVE CODES
WEE?
AMOUNT
PO Box
BOX 182223
132223 aa 45 11600
6 01
b
n :
=
CHATTANOOGA,
CHATTANGOGA, TN 37422
3T422
d
7
42 REV ED.
41HEI£ CD 43 DESCRI PT! ON
DEECFIJF'Tlm HHEFGEFRNE!
HCPC SI RATE 1HIPPBEGBE
HI PPSCODE 45 sew
#5 554'. WE
mm 116
IE Emu! UN as
UH'ITE fl
47 TOTAL CHARGES
TflflL CHARGES 48 NON-COVERED CHARGE?“
HHDH-CflVEHED CHARGE 49
PHARMACY
0250 PHARMACY
'
032818
03281a 3 0 61
0561
.n.
PHARMACY
0250 PHARMACY
2
=
032918 4 22 55
22:53
u-
=
0259
0259LDRUGs/0THER
DRUGS/OTHER 032818
032318 3L 99 47
99_4? u
*
0259 DRUGS/OTHER 032918
032918 1L 0-
0§5151 p
'
0259 DRUGS/OTHER
DRUGs/OTHER J2785 032918
032913 4 1065
106536363 I
‘
0300 LABORATORY
LRBORATORY 36415 032918
03291 L 34 - 67
34367 i
0301 LAB/CHEMISTRY
?
80053
80053 032818 11 321
32156262 -l
=
0301 LAB/CHEMISTRY 84484
84484 032818
032818 1L 245
24536 63 lr
9
0301 LAB/CHEMISTRY
10301 8448491
3448491 032818
032813 2 491
491;2 24 III-
14
1
0301 LAB/CHEMISTRY 80061 032918 11 263
263;0000 r.-
Document Filed Date
June 12, 2020
Case Filing Date
February 06, 2020
Category
MOTOR VEHICLE ACCIDENT
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FILED 6/12/2020 12:29 PM FELICIA PITRE DISTRICT CLERK DALLAS CO., TEXAS Treva Parker—Ayodele DEPUTY DC-20-02088 JACQUELINE MOBLEY § IN THE DISTRICT COURT vs. g 14TH JUDICIAL DISTRICT MARIA ORTIz g DALLAS COUNTY, TEXAS Affidavit ofMedicaI Charges from Baylor Medical Cen ter at Irving FM£94253 0F 1* =1>iti4 STATE OF § § AFFIDAVIT AFFIDAVIT OF 0F MEDICAL MEDICAL CHARGES CHARGES m: 6 COUNTY OF r,- m} 111.11111. w § me duly Before me, Befnre me, the the undersigned undersigned authority, sworn, deposed and said: duly sworn, said: authority, personally persnnally appeare appearedn, 1 1F"— k;filivho, being being by by -—. ,tviLL-4..lexth_ "t "My name is "My name is . 1 am Iamofnfsound soundmind mindand andcapable capable of flfmaking making this this affidavit, and affidavit, and personally personally acquainted acquainted withwith the the facts herein stated. facts herein stated. I am I am the the custndian custodian ofof records records fur forBaylor Baylor Medical Medical Center Center at at Irving. Irving. Attached Attached toto this this affidavit affidavit are are records that provide records that provide an an itemized itemized statement of uf the service and the service the charge and the for the charge fur the service that Baylor service that Medical Center Medical Center at at Irving Irving provided prnvided to tn Jacqueline Jacqueline Mobley Mnbley from 34- (aq to frnm fiflgifi E‘QS (r. tn _I‘;,1 Lg. The The *~ attached records attached records are are aa part part of 0f this this affidavit. affidavit. The attached attached records records are are kept keptbybyBaylor Baylor Medical Medical Center Center at at Irving Irving in in the the regular regular course of its uf its business, business, and it it was was the the regular regularcnurse course nfbusiness of businessnfBaylnr of Baylor Medical Medical Center Center at at Irving Irving for fur an employee or representative of Dr representative Baylor Medical nf Baylnr Medical Center Centerat atIrving Irving, with with knowledge , knowledge of the service nfthe service provided, provided, to tn make the record the recnrd or to transmit Dr tn information to transmit infurmatinn tn be he included in the included in the recnrd. record. The records records were were made made inin the the regular regular course course of uf business business atat or or near the time near the time or reasonably scum Dr reasnnahly soon after after the the time time the the service service was was provided. provided. The The records are records are the the original nriginal or Dr a a duplicate duplicate of uf the the original. original. The services services provided prflvided were necessary necessary and and the the amount amnunt charged for the services fur the reasonable services was reasunable at the time at the time and and place place that that the the services services were provided. provided. The amount paid paid far for the the services $mm services was $ 3an, jckand the the amount amnunt currently currently unpaid but which mm Baylor Baylnr Medical 16R Center at Medical Center at Irving Irving has has aaright rightto tnbe bepaid paidafter afterany an}?adjustments adjustments or or credits credits is is S- $- SWDRN TO SWORN AFFIA AFFIA /CUSTODIAN SUBSCRIBED before TU AND SUBSCRIBED befnre {EUSTGDIANOF me on fin the the 0FRECORDS RECDRDS ICI_ day l I of Pk day of m . 2002° 201320 NOTARY PUBLIC, STATE OF mirm••••••• DE1DRE COWART My Notary ID # '125989616 Expires February 2, 2023 ‘BAELOR BAYLOR MED CTR AT IRVINGEBAYLOR Al IRVING BAYLOR DIED MED CTR CTR ATATIRVINGI rt.; 117664172 IRyINGEfifl11J664172 OF 1901 N MACARTHUR BLVD PO Box 841590 E0 BOX 841590 Uni1000939493000001 £Eng0939493000001 STAfEMENT COVERS PERM— 17 137 137 -IRVING ?50612220 IRVING TX 750612220 DALLAS TX DALLAS TX 752841590 ?52341590 fifimmml 5 FED TAX NO Fm” FROM mmma THROUGH ? 2148203151 2148208515 214820851§_ 752586857 032818 032918 75258635? 032813 ”WMWHWE 8 PATIENT NAME MOBLEY ,JAC h MORLEY UELINEHMMWMMfifi JACQUELINE 9 PATIENT ADDRESS a'2200 WILLIAM BREWS 2200 WILLlam_Bg§MS I h IRVING ;,i¥L TX“ 75062 TXj? b = a - 01 01 'W 10 1° BIRTHDATE B’RTHMTE 05061965 31 OCCURRENCE COPE CIDDE DATE 032818 Al R1 050865 050865 11 ‘1 SEX 3E“ CODE-:'.‘.-: :-L:IE _ 12 12 DATE •1::C.URRENC.t. u.::I::I::'.r.::.::E:-1jl:_t EM: DATE ADMISSION millélfigmfl 13 HR 14 TYPE m'lficl-LMLME— 33 OCCURRENCE EDDE CODE SRC 1E HPE 15155m: DH” 17 16 DHR 34 OCCLARENCE 5T” 1’ STAT. QEE DATE CODE 01 O1 n 18 DATE 1i tn 35 CODE DUDE .21 :1 mu cgnmflflmfian CONDITION CODES 22 OCCURRENCE FROM FRDH 23 EHEE SPAN EPAH 24 THRGUGH THROUGH 36 3a EDDE Is CODE 25 a :5 27 1? 2S 23 fisfig sum GLGUHREHBETEEEH OCCURRENCE FROM FRDM SPAN 2a ACOT TX THROUGH THHfiLIGH 37 37 "11 11 032818 383mm tiGNA CHILDRENS MED CTR M 35%.“ “fl? VALUE CODES AMOUNT 40 CODE 1.0U€ CODES AMOUNT 41 Ema CODE WIVE CODES WEE? AMOUNT PO Box BOX 182223 132223 aa 45 11600 6 01 b n : = CHATTANOOGA, CHATTANGOGA, TN 37422 3T422 d 7 42 REV ED. 41HEI£ CD 43 DESCRI PT! ON DEECFIJF'Tlm HHEFGEFRNE! HCPC SI RATE 1HIPPBEGBE HI PPSCODE 45 sew #5 554'. WE mm 116 IE Emu! UN as UH'ITE fl 47 TOTAL CHARGES TflflL CHARGES 48 NON-COVERED CHARGE?“ HHDH-CflVEHED CHARGE 49 PHARMACY 0250 PHARMACY ' 032818 03281a 3 0 61 0561 .n. PHARMACY 0250 PHARMACY 2 = 032918 4 22 55 22:53 u- = 0259 0259LDRUGs/0THER DRUGS/OTHER 032818 032318 3L 99 47 99_4? u * 0259 DRUGS/OTHER 032918 032918 1L 0- 0§5151 p ' 0259 DRUGS/OTHER DRUGs/OTHER J2785 032918 032913 4 1065 106536363 I ‘ 0300 LABORATORY LRBORATORY 36415 032918 03291 L 34 - 67 34367 i 0301 LAB/CHEMISTRY ? 80053 80053 032818 11 321 32156262 -l = 0301 LAB/CHEMISTRY 84484 84484 032818 032818 1L 245 24536 63 lr 9 0301 LAB/CHEMISTRY 10301 8448491 3448491 032818 032813 2 491 491;2 24 III- 14 1 0301 LAB/CHEMISTRY 80061 032918 11 263 263;0000 r.-