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ELECTRONICALLY FILED
Faulkner County District Court in Conway - Small Claims & Civil Division
Jaime Hamerlinck - DIV 1 Clerk | Vickie Carter - DIV 2 Clerk
2024-Mar-04 15:12:11
CWCV-24-428
IN THE DISTzuCT COURT OF FAULKNER COUNTY. ARKANSAS
D09D01 : 4 Pages
CIVIL DIVISION
MSCB, INC
PLAINTIFF
VS
Redacted NO
SAMANTHA DAWN GALLAGHER
DEFENDANT(S)
COMPLAINT
Plaintiffs Address: DAVID W. EDWARDS, P.C., P.O. BOX 458, PARIS, TN 38242.
PHONE: (800) 2st-2362.
Defendant's Address: SAMANTHA DAWN GALLAGHER. l7 RAINWATER CY VILONIA, AR
72173.
Nature of Claim: Debt Collection
Nature and Amount of Relief Claimed: Plaintiffis seeking the principal balance of $1596.23, plus
attorney fees of $399.06, pre-judgment interest of $131.98, court costs, and post-judgment interest.
Date Claim Arose: The claim arose on the dates set forth in Schedule A, which is attached to the
Complaint.
Factual Basis of Claim:
I . That Plaintiff, MSCB, INC., an organization incorporated under the laws of Tennessee and
licensed as a collection agency in Arkansas, in good faith and for valuable consideration, accepted
assignment of the accounts referenced in Schedule A from the Creditor, BAPTIST HLTH MED CTR
CONWAY on the date specified in the Assignment and Affidavit of Account attached hereto as Exhibit A.
2.T\aIBAPTIST HLTH MED CTR CONWAY is a hospital corporation authorized to conduct
business in the State of Arkansas with its principal place of business located at I l00l EXECUTIVE CR DR
IOO, LITTLE ROCK , AP.T22IIOOOO .
3. That the defendant may be found at 17 RAINWATER CV, VILONIA, AR 72173, or DIAMOND
PERSONAL CARE LLC, , .
4. That venue is proper in FAULKNER County because the defendant(s) either reside(s) in
FAULKNER County or signed the contract sued upon in FAULKNER County.
5. That BAPTIST HLTH MED CTR CONWAY provided to the Defendant, or Defendant's legal
dependents, medical services and facilities on one or several occasions as shown by the accounts referenced
in Schedule A, and verified by the Affidavit of Account, attached hereto as Exhibit A, for which the
Defendant is now indebted to the Plaintiffin the amount of $1596.23.
6. That itemization of each medical bill is not attached to the Complaint due to the requirements of
the Health Insurance Portability and Accountability Act (HIPAA), which provides that a covered entity may
disclose protected health information only to the extent that such use or disclosure is required by law and
the use or disclosure complies with and is limited to the relevant requirement of the law. 45 C.F.R. '
164.512(a).
7.That Arkansas Code Annotated'l 6-45-104 provides: In any suit on an account in any of the
courts of this state, the affidavit of the plaintiff, duly taken and certified according to law, that the account is
just and correct shall be sufficient to establish the account, unless the defendant denies under oath the
correctness of the account, either in whole or in part, in which case the plaintiff shall be held to prove by
other evidence such part ofhis account as is thus denied.
8. Wherefore, Plaintiff prays for a money judgment against the Defendant, SAMANTHA DAWN
GALLAGHER, in the principal amount of $1596.23, plus attorney fees of $399.06, pre-judgment interest of
$ 131.98 ,court costs, and post-judgment interest and general relief.
Respectfully submitted,
l*, *a
David W. Edwards, #2000055
DAVID W. EDWARDS, P.C.
P.O. Box 458
Paris, TN 38242
I -800-25 l-2362
Attorney for Plaintiff
#2043061r
;
SCHEDULE A
SCHEDULE OF ACCOT]NTS
Responsible Party: SAMANTHA DAWN GALLAGHER
Account Patient Date of Date of Last Balance
Number Service Pavment
GALLAGHER,SAMANTHA, 8I2OI2O22 $1s96.23
Total Account Balance: $1596.23
REDACTED COPY
#204306n
Affidavit as to Correctness of Account
I, the undersigned, an employee in the business office of the creditor, having the authority to execute this
affidavit on behalf of the creditor, and being familiar with the books and records of the creditor and the
referenced account, state that the following information is true and correct to the best of my knowledge,
information and belief:
The creditor to whom the account is owed BAPTIST HLTH MED CTR CONWAY
The creditor pursuing the collection ofthe account MSCB, INC
The debtor obligated to pay the account I savnNrHA DAwN GALLAGHER
The name of the original creditor BAPTIST HLTH MED CTR CONWAY
The owner of the account (Assigned or Held by the Original Creditor) ASSIGNMENT: MSCB,INC
Interest Rate; Source of Interest Rate 60/o; Ark. Code Sec.4-57-l0l(d)
Patient Respplq_D.il.r-ty_ Account Number Balance
I GALLAGHER,SAMANTFIA, SAMANTHA DAWN GALLAGHER $ 1596.23
TOTAL $ 1596.23
For good and valuable consideration, the receipt whereof is hereby acknowledged, the Creditor (Assignor) hereby, and in
accordance with and subject to the contract between Creditor and MSCB, lnc., hereby assigns to MSCB, Inc. (Assignee), the
referenced account(s) for the purpose of billing, collecting, or filing suit in the Assignee's own name, as the real party in interest.
CREDITOR: BAPTIST HLTH MED CTR CONWAY
ADDRESS: 1 1001 EXECUTIVE CR DR 100
LITTLE ROCK , AR722I1OOOO
BY x
Keni Smith
STATE OF ARKANSAS
COUNTY OF
SWORN TO AND SUBSCRIBED BEFORE ME THIS THE
DAY OF 20-
Notary Public
MY COMMISSION EXPIRES
EXHIBIT A
REDACTED COPY
#204306ll
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ELECTRONICALLY FILED Faulkner County District Court in Conway - Small Claims & Civil Division Jaime Hamerlinck - DIV 1 Clerk | Vickie Carter - DIV 2 Clerk 2024-Mar-04 15:12:11 CWCV-24-428 IN THE DISTzuCT COURT OF FAULKNER COUNTY. ARKANSAS D09D01 : 4 Pages CIVIL DIVISION MSCB, INC PLAINTIFF VS Redacted NO SAMANTHA DAWN GALLAGHER DEFENDANT(S) COMPLAINT Plaintiffs Address: DAVID W. EDWARDS, P.C., P.O. BOX 458, PARIS, TN 38242. PHONE: (800) 2st-2362. Defendant's Address: SAMANTHA DAWN GALLAGHER. l7 RAINWATER CY VILONIA, AR 72173. Nature of Claim: Debt Collection Nature and Amount of Relief Claimed: Plaintiffis seeking the principal balance of $1596.23, plus attorney fees of $399.06, pre-judgment interest of $131.98, court costs, and post-judgment interest. Date Claim Arose: The claim arose on the dates set forth in Schedule A, which is attached to the Complaint. Factual Basis of Claim: I . That Plaintiff, MSCB, INC., an organization incorporated under the laws of Tennessee and licensed as a collection agency in Arkansas, in good faith and for valuable consideration, accepted assignment of the accounts referenced in Schedule A from the Creditor, BAPTIST HLTH MED CTR CONWAY on the date specified in the Assignment and Affidavit of Account attached hereto as Exhibit A. 2.T\aIBAPTIST HLTH MED CTR CONWAY is a hospital corporation authorized to conduct business in the State of Arkansas with its principal place of business located at I l00l EXECUTIVE CR DR IOO, LITTLE ROCK , AP.T22IIOOOO . 3. That the defendant may be found at 17 RAINWATER CV, VILONIA, AR 72173, or DIAMOND PERSONAL CARE LLC, , . 4. That venue is proper in FAULKNER County because the defendant(s) either reside(s) in FAULKNER County or signed the contract sued upon in FAULKNER County. 5. That BAPTIST HLTH MED CTR CONWAY provided to the Defendant, or Defendant's legal dependents, medical services and facilities on one or several occasions as shown by the accounts referenced in Schedule A, and verified by the Affidavit of Account, attached hereto as Exhibit A, for which the Defendant is now indebted to the Plaintiffin the amount of $1596.23. 6. That itemization of each medical bill is not attached to the Complaint due to the requirements of the Health Insurance Portability and Accountability Act (HIPAA), which provides that a covered entity may disclose protected health information only to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirement of the law. 45 C.F.R. ' 164.512(a). 7.That Arkansas Code Annotated'l 6-45-104 provides: In any suit on an account in any of the courts of this state, the affidavit of the plaintiff, duly taken and certified according to law, that the account is just and correct shall be sufficient to establish the account, unless the defendant denies under oath the correctness of the account, either in whole or in part, in which case the plaintiff shall be held to prove by other evidence such part ofhis account as is thus denied. 8. Wherefore, Plaintiff prays for a money judgment against the Defendant, SAMANTHA DAWN GALLAGHER, in the principal amount of $1596.23, plus attorney fees of $399.06, pre-judgment interest of $ 131.98 ,court costs, and post-judgment interest and general relief. Respectfully submitted, l*, *a David W. Edwards, #2000055 DAVID W. EDWARDS, P.C. P.O. Box 458 Paris, TN 38242 I -800-25 l-2362 Attorney for Plaintiff #2043061r ; SCHEDULE A SCHEDULE OF ACCOT]NTS Responsible Party: SAMANTHA DAWN GALLAGHER Account Patient Date of Date of Last Balance Number Service Pavment GALLAGHER,SAMANTHA, 8I2OI2O22 $1s96.23 Total Account Balance: $1596.23 REDACTED COPY #204306n Affidavit as to Correctness of Account I, the undersigned, an employee in the business office of the creditor, having the authority to execute this affidavit on behalf of the creditor, and being familiar with the books and records of the creditor and the referenced account, state that the following information is true and correct to the best of my knowledge, information and belief: The creditor to whom the account is owed BAPTIST HLTH MED CTR CONWAY The creditor pursuing the collection ofthe account MSCB, INC The debtor obligated to pay the account I savnNrHA DAwN GALLAGHER The name of the original creditor BAPTIST HLTH MED CTR CONWAY The owner of the account (Assigned or Held by the Original Creditor) ASSIGNMENT: MSCB,INC Interest Rate; Source of Interest Rate 60/o; Ark. Code Sec.4-57-l0l(d) Patient Respplq_D.il.r-ty_ Account Number Balance I GALLAGHER,SAMANTFIA, SAMANTHA DAWN GALLAGHER $ 1596.23 TOTAL $ 1596.23 For good and valuable consideration, the receipt whereof is hereby acknowledged, the Creditor (Assignor) hereby, and in accordance with and subject to the contract between Creditor and MSCB, lnc., hereby assigns to MSCB, Inc. (Assignee), the referenced account(s) for the purpose of billing, collecting, or filing suit in the Assignee's own name, as the real party in interest. CREDITOR: BAPTIST HLTH MED CTR CONWAY ADDRESS: 1 1001 EXECUTIVE CR DR 100 LITTLE ROCK , AR722I1OOOO BY x Keni Smith STATE OF ARKANSAS COUNTY OF SWORN TO AND SUBSCRIBED BEFORE ME THIS THE DAY OF 20- Notary Public MY COMMISSION EXPIRES EXHIBIT A REDACTED COPY #204306ll