Preview
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