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  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
  • ABELARDO GONZALEZ VS. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANYInjury or Damage - Motor Vehicle (OCA) document preview
						
                                

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Electronically Submitted 10/6/2023 11:52 AM Hidalgo County Clerk Accepted by: Sarah Reyes CAUSE NO. CL-23-3295-I ABELARDO GONZALEZ, § IN THE COUNTY COURT Plaintiff, § § Vv. § AT LAW NO. 9 § § STATE FARM MUTUAL § AUTOMOBILE INSURANCE § COMPANY, § Defendant. § HIDALGO COUNTY, TEXAS AFFIDAVIT FOR ADMISSION OF BUSINESS RECORDS BEFORE ME, the undersigned authority, on this day personally appeared Nicole M Tracey , who, being by me duly sworn, deposed as follows: "My name is Nicole M Tracey , 1am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: "I am the custodian of the records of MED CARE EMS. Attached hereto are 4 pages of records from Medcare EMS pertaining to ABELARDO GONZALEZ. These said 4 pages are kept by MED CARE EMS in the regular course of business, and it was the regular course of business of MED CARE EMS for an employee or representative of MED CARE EMS, with knowledge of the act, event, condition, opinion, or diagnosis, recorded to make the records or to transmit information thereof to be included in such records; and the records were made at or near the time or reasonably soon thereafter. The records attached hereto are either the originals or the exact duplicates of the originals." SIGNED on Seyoteaabae 2 262.3 Wetvhe™ “i eeeee Affiant SWQRN _TO AND SUBSCRIBED BEFORE ME, on this the al day of Commonwealth of Pennsylvania - Notary Seal Pala A Aig NOTARY PUBLIC, STATE OF TEXAS eign PamelaA. Fenyus, Notary Public . C Allegheny County MY COMMISION EXPIRES: Q ty My commission expires July 26, 2026 Commission number 1424091 Member, Pennsylvania Association of Notaries Electronically Submitted 10/6/2023 11:52 AM Patient Record 82036241 Dispatch ID / CMS ET3 ID 23-15251 Patient: Abelardo Gonzalez Hidalgo County Clerk PRID:82036241 Dispatch ID / CMS ET3 ID:23-15251 Hospital MR#: Accepted by: Sarah Reyes Service:Med Care EMS Date:April 1, 2023 (State ID: 300010) Team:ALS - Paramedic Base:Station 8 Crew 1:Primary Caregiver - Unit:M-23 Scene,Primary Caregiver Shift:A-Shift - Transport Tail/Reg:U-158 Munoz, Mark EMD: Yes, Pre-Arrival Instr. EMT-B (#776624) - 29B5 Crew 2:Driver/Pilot - Dispatched As:29.Traffic/Transportation Response,Driver/Pilot - Incidents Transport Mass Casualty:No Castillo, Jacob Vehc. Grid:Edinburg EMT-B (778628) Vehc. Disp. Loc:Monte Cristo Transport Mode:Non-Emergent Vehc. Disp. GPS:26.1903366,-98.1111798 Mode No Lights or Sirens Emergency Response Descriptors: Type of Svc: (Primary Response Area) Moved From:Stretcher Unscheduled Transport Unable to sit without Dispatch Priority:Priority 1 Assessment: assistance Response Mode: Emergent (Immediate Unable to stand without Response) assistance Mode Descriptors:Lights and Sirens Unable to walk without Moved Via:Stretcher assistance Position:Semi-Fowlers Final Acuity:Lower Acuity (Green) Disposition: Treated, EMS Transported by Amb. Transport Code:Initial Trip Ref Other Type:Residence Receiving / Hospital Referring / Scene:E UNIVERSITY DR & S 26TH Destination: South Texas Health AVE System ER Monte Edinburg, TX 78542 Cristo Hidalgo County United States Emergency Department Requester:Patient Hospital (General) Scene Grid:Edinburg 3615 N. Interstate Ref. GPS:26.2989517,-98.14549 69C Edinburg, TX 78539 956-258-2100 Dest. Grid:Edinburg Dest. GPS:26.3343271,- 98.1461659 Destination Basis:Patient Choice Odometer Times TRAC-V Wristband ID: D125434 Last Name: Gonzalez First: Abelardo At Ref: 0.1 Received: 15:58 At Rec: 4.0 Dispatch: 15:58 ST:TX Ld Miles: 3.9 EnRoute: 15:59 Country: United States At Ref: 16:02 DOB: 12/06/1959 SSN: 589-60-0846 At Patient: 16:03 Age: 63y Sex: M Weight: Leave Ref: 16:15 At Rec: 16:25 Height: Transfer Care Dest: 16:38 Subscriber: No Available: 16:40 Billing Information: Consent Signed: No None Given PCS / Medical Necessity Signed: No Scene Information Description: Patient ambulated on scene Num. Patients On Scene: 1 Chief Complaint (Category: 29.Traffic/Transportation Incidents) Mvc Duration: 30 Minutes Anatomic Location: General/Global ALS Assessment: Completed for rule-out diagnosis. History of Present Illness Medic 23 responded priority one to the city Edinburg for a MVC on scene patient was ambulatory patient wanted to be transported to Monte Cristo freestanding. Medical History Current Medications Allergies Obtained From: Not Recorded None Listed None Listed Neurological Exam Page: 1 of 4 Electronically Submitted 10/6/2023 11:52 AM Patient Record 82036241 Dispatch ID / CMS ET3 ID 23-15251 Patient: Abelardo Gonzalez Hidalgo County Clerk Level of Loss of Consciousness: Glasgow Accepted Coma Scale by: Sarah Reyes Consciousness: Alert No E V M Tot Chemically Paralyzed: No Int: 4 5 6 = 15 Mental Present: Oriented-Person,Oriented-Place,Oriented-Time,Oriented- Event Airway Respiratory Status: Patent Effort: Normal Cardiovascular Cap. Refill: Less than 2 Seconds Pulses Left Right Carotid: Radial: Normal Normal Femoral: Injury Details Reason for Encounter: Injury/Trauma Drugs/Alcohol?: None Initial Physical Findings Assessment Left Forearm: Abrasion Mental Status: Oriented-Person,Oriented-Place,Oriented-Time,Oriented-Event Impression / Diagnosis System: Extremities Symptoms: Pain (General) Impression: Acute pain due to trauma, Coronavirus / COVID-19 (concern ruled out) Initial Patient Acuity: Emergent (Yellow) Activity Time H.R. REG B.P. RA SpO2 Resp Rhythm ECG Method H.R. Method B.P. Method Action Comment 16:00 Hosp. Notify alert sent by Mark Munoz via Radio. Response Factors Affecting Care: Traffic Scene Factors Affecting Care: Safety of Crew,Safety of Patient Transportation Factors Affecting Care: None Dispatch Factors: None Turn-Around Factors: None Munoz, Mark: Electronically Signed on 04/01/2023 17:19:41 CST TX ID: #776624 Castillo, Jacob: Electronically Signed on 04/01/2023 17:20:10 CST TX ID: 778628 DISCLAIMER This record, as well as any attached document, contains information from Med Care EMS, INC. that is confidential and privileged. This information is only intended only for the use of the members of the health care organizations (EMS, hospitals, etc) who assist in the care of the patient listed above. If you are not authorized to view this record, DO NOT view or copy this record and/or its attachments in any way. You are hereby notified that any disclosure, copying, distribution or taking any action in reliance of the contents of this record and/or its attachment is strictly prohibited and is unlawful. If you have received this in error, please delete and notify Med Care EMS, INC. at (956)661-4100. Page: 2 of 4 Electronically Submitted 10/6/2023 11:52 AM Patient Record 82036241 Dispatch ID / CMS ET3 ID 23-15251 Patient: Abelardo Gonzalez Hidalgo County Clerk Receiving Facility Accepted Med Care EMSby: Sarah Reyes 1501 South K Center St McAllen, TX 78503 (956) 661-4100 Date: 04-01-23 Patient: Gonzalez, Abelardo Age: 63 y Type: Scene Dispatch ID / CMS ET3 Unit: M-23 Mode: Ground Receiving ID: 23-15251 RN: Referring: E UNIVERSITY DR & S 26TH AVE Receiving: Emergency Edinburg, TX 78542 Department South Texas Health System ER Monte Cristo 3615 N. Interstate 69C Edinburg, TX 78539 956-258- 2100 I certify that this patient was received by this facility. Date: 04/01/2023 17:18:31 Name of Signatory: Alex Garcia RM Reason for signing: Relationship to Patient of Signatory: Phone Number of Signatory: Page: 3 of 4 Electronically Submitted 10/6/2023 11:52 AM Patient Record 82036241 Dispatch ID / CMS ET3 ID 23-15251 Patient: Abelardo Gonzalez Hidalgo County Clerk Standard Ambulance Signature Form Accepted by: Sarah Reyes Patient Name: Abelardo Gonzalez Transport Date: 04/01/2023 15:58 I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by Med Care EMS, Inc., now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by Med Care EMS, Inc., regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Med Care EMS, Inc., any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Med Care EMS, Inc. I authorize Med Care EMS, Inc., to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to Med Care EMS, Inc., and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by Med Care EMS, Inc., now, in the past, or in the future. I also authorize Med Care EMS, Inc., to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information. "The patient is herby given notice under Texas Property Code 55.005 that Med Care EMS, Inc., has an emergency medical service lien against you. This emergency medical services lien does hereby attach to any cause of action or claim you have against another person for injuries but does not attach to your real property." I understand that, in the opinion, of Med Care EMS, Inc., the services or items that I have requested to be provided to me on the date of transport shown above may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the HHSC or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services are determined not to be reasonable and medically necessary for my care. Privacy Practice Acknowledgment:Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Med Care EMS, Inc., provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. SECTION I - PATIENT SIGNATURE The patient must sign here unless the patient is physically or mentally incapable of signing. NOTE: If the patient is a minor, the parent or legal guardian should sign in this section. Patient Signature or Mark Date: 2023-04-01 17:17:00.0 If the patient signs with an "X" or other mark, someone should sign below as a witness. This can be an ambulance crew member. Witness Signature Date: 2023-04-01 17:17:00.0 Witness Name Witness Address Witness Phone SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE Not Applicable SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES Not Applicable Page: 4 of 4 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. Frank Guerra Bar No. 24078601 aida@frankguerralaw.com Envelope ID: 80332814 Filing Code Description: Notice Filing Description: Plaintiff's Notice of Filing Affidavits from Med Care EMS Status as of 10/6/2023 12:03 PM CST Associated Case Party: STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY Name BarNumber Email TimestampSubmitted Status Benjamin AdamNeece aneece@adamsgraham.com 10/6/2023 11:52:01 AM SENT Associated Case Party: ABELARDO GONZALEZ Name BarNumber Email TimestampSubmitted Status AIDA BRIGGS aida@frankguerralaw.com 10/6/2023 11:52:01 AM SENT Frank Guerra frank@frankguerralaw.com 10/6/2023 11:52:01 AM SENT