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HomeMy WebLinkAboutMINUTES - 11152005 - C25 CLAIM BQARD OF UP'E VISt� S OF,CONTRA COSTA COUNTY •sl� BOA" ACTIUNt-*. Claim Against the County, or District Governed by the Board of Supervisors,Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section references are to }' The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code'Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN 3 CLAIMANT: JOSEPH LUIS NIEVES AND SANDRA..NIEVES ATTORNEY: RICHARD HOBIN DATE RECEIVED: OCTOBER' 05, "2005 HOBIN, SHINGLER & SIMON OCTOBER 05 2045 ADDRESS: 1011 A STREET, BY DELIVERY TO CLERK,ON: , ANTIOCH, CA 94509-2.323 BY MAIL POSTMARKED: OCTOBER 03, 2005 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-mated claim. JOHN SWEET fid Dated: OCIQB 0 , 2QO5 By: Deputy II. FIC3Ivt: County Counsel.. T"+0► Clerk of th6 Board of Supp sors (4"This claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { } Claim is not;timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to;apply for leave to present a late claim (Section 911.3). ( ), Other: Dated: 'i7'G 'S` By: WC&=6= Deputy County Couns III. FROM: Clerk of the Board TO. County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911.3): I€V OAF,D►ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. O Other: a I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:/ ' ,r1" ' " JOiN SNEETEN, CLERK, Hy , Deputy Clerk §� WARNING(Gov. code section 913) Subject to certain exceptions,'you have only six (6)months from the date this notice was personally served or deposits in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with,this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING' I declare under penalty of perjury that I am now,and at all times herein mentioned,have been a citizen of the United States, over age l8; and that today I deposited in the United States Postal Service in Martinez, California,postage full, prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 6" 40 0 JOHN SWEETEN, CLERK By Deputy Cleri a3€3rc`_' 05 12:41 CONTRA COSTA COUNTY CLERK OF THE 97570153 tJ0.361 902 < h BOA"OF SUPERVISORS OF COMA COSTA COUNTY I?NSTRUCTIt NS TO CLAIM NNT A. A claire relating to a cause of action for death or for injury to person or to personal-property or growing crops shall be presenters not later than six months after the accrual of the cause of action. A clam relating to any other cause of actionshall be presented not later than one year after the accrual of the cause of action. {Gov. Cade f3 911.2.} B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 fine Street, Martinez, SCA 94553_ C, if claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fr_ See penalty for fraudulent claims,penal Code Sec. 72 at the end of this form,* R.E. Claim By; Reserved for Clerk's filing stamp JOSEPH LUIS NIEVES and SANDRA NIEVES ' ' IV Against the County of Contra Costa w OCT 0 20 The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the surra of$ * and in suort of this claim represents as follows; PARI' '1"S CLAIM FOR WRONGFUL DEA MT B CA ESMERALD NIEV'ES°-HUERTA, BORN JANUARY 29, 1988, AGE 17ART FROM A FATAL, CAR. C'T� 1. "then Ole damage car injury occur. Dive exact date and hour) APRIL 15, 2005 2. Where did the damage or injury occur? include city and county) MAIN STREETr APPROXIMATELY 100 YARDS WEST OF LIVE OAK AVENUE, 0,AKLEY, CA J: Now did the damage or injury occur? (give full;details;use extra paper if required) SEE CONTRA COSTA SHERDS ACCIDENT REPORT REPORTING FACTS OF THE CAR CRASH REPORT HAS NOT BEEN RELEASED TO DATE. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? SEE. ATTACHMENT ##4 5 What are the names Of'couraty or district officers, servants, or employees causing the damage or injury? UNKNOWN AT THIS TIME _09/30/2005 12:41 CONTRA COSTR COUNTY CLERK OF THE � 9757015-7 t-40.391 907 n. What damage or injuries do your claim resulted? (Give full extent of injuries Kir damages claimed. Attach.Mo estimates for auto damage,) SEE ATTACHMENT #6 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or darnage.) ` SEE ATTACHMENT #7 8. Names and addresses of vritnesses, doctors,and hospitals. CONTRA COSTA COUNTY, OFFICE OF SH=F—CORONER 9. List the expenditures you made on account of this accident or injury, BATE TTIwIE AMOUNT SEE ATTACHMENT #9 sssssrsssrssssssrssss•sssss■•rssssssrsrsssessrssssssssrs�rsrsrsarssssosaIN Von s-ssesrss1 Gov. Cede Sec. 910.2 zroay vide-.?!Te claim shall be signed by t t` erson on his behalf.,, -- SEl�1l NC7TICES TO: (Attorney) l ROBIN SHI LER & SIMON, LLP Name and address of Attorney ) RICHARD HOBIN } (Claimant's Signature) 1011 "Art STREET } (Address) ANTIOC H, CA 94509 ) Telephone 10. }Telephone No. ( 925) 757-7585 ®J r s i 10r peony*votes s i s r r R r ss s s E r s s.M M s s`s s ss.1-11s s s s s s• s r f r s r s-s•s s r r r r s r•s w Y s r sr f s•s s i PUBLIC RECORDS NOTICE: Please be advised that this claim farm, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachirents, addendurns, or supplements attached to the claim form, including medical records, are also subiectto public disclosure; is*080save 60600.9Is0:•0s99s'.ssilPs•s•sorsrss ss 0saassr see 40#61180609800664 rs•las moss ssasT NOTICE: Section 12 of the Penal Code provides: Every person who. with intent to defraud presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay tate same if genuine, any false or fraudulent claim. bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year; by a fine of not exceeding°one thousand dollars'($1,000,00), or by both sach imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding telt thousand dollars (S 10,000), or by both such imprisonment and fine. ATTACHMENT TO CLAIM PRESENTED TO THE COUNTY OF CONTRA COSTA Claimants' Names: JOSEPH LUIS NIEVES and SANDRA NIEVES Paragraph 4 What particular act or omission on the part of county or district officers, servants, or employee caused the injury or damage? Answer: On information and belief, it is alleged that the City of Oakley is liable for the dangerous condition of the roadway which it had actual andlor constructive notice and for which the City of Oakley failed to provide:safeguards. Further, the City of Oakley failed to maintain and/or repair the roadway which resulted in a dangerous condition for which the City is liable Para-graph 6. What damage or injury occurred? Answer: The parents claim for the wrongful death of their daughter, BLANCA ES'MERALD NIEVES-HUERTA; born January 29, 1988, age 17, arising out of`a fatal car crash on a public street within the city limits of Oakley, California on April 15, 2005. The damages include,but are not limited to, compensation for the loss of love,companionship, comfort, affection,society,moral support, and loss of financial support, services and other pecuniary losses according to proof at trial: Paragraph 7 & 9. Damage Calculation Answer: The parents claim for the wrongful death of their daughter, BLANCA ESMERALD NIEVES-HUERTA, born January 29, 1988, age 17, arising out of`.a fatal car crash on a public street within the city limits of Oakley, California on April 15, 2005. The damages include, but are not limited to, compensation forthe loss of love, companionship, comfort, affection, society,moral support, and loss of financial support, services and other pecuniary losses according to proof at trial.'` ................. ................. Hobin, Shingler & Simon, LLP Attorneys at Law Richard Hobin 1011 A Street Of Counsel Ronald J. Shingler Antioch, California 94509-2323 Bryce C. Anderson Aaron H. Simon (925) 757-7020 Susan S. Ochi fax: (925) 757-0153 e-mail: info@deltalawyer.com www.deltalawyer.com xh........... October 3, 2005 Clerk of the Board of Supervisors County Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 Re: Blanca Nieves Date of Death: April 15, 2005 Dear Sir/Madam: Enclosed please find original and one copy of your government claim form. Please file and return endorsed-filed copy to our office in the self-addressed stamped envelope provided. If you have any questions, please contact our office. Yours very truly, HOBIN, SHINGLER & SIMON, LLP Margie Reis Office Manager Enc. CLAIM fiOARD OF SUEE&VISORS OF CONTM COSTA COUNTY BDArRIi►ACTIt N: 200 Claim Against the County,or District Governed by )'' the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references i are to } The copy of this document mailed to you is your California Govertunent Codes. ) notice of the action taken on your claim by the Beard of Supervisors. (Paragraph IV below), given Pursuant to'Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $673.50 CLAIMANT: BRITI'IE PATION ATTORI EY: UNKNOWN DATE RECEIVED: OCTOBER' 06, 2005 ADDRESS: 41.0 WtHI EY AVENUE BY DELIVERY TO CLERK ON: OCT08ER 06, 2005 CIAI.LE.O CA 945$9 BY MAIL POSTMARKED: OCTOBER 05, 2005 FROM: Clerk of the Board of Supervisors TCI: County Counsel Attached is a copy 0fthe above•noted claim. OCTOBER 06 2005 JOHI�t S WEE Dated: 1y: Deputy II. FkOIv : County Counsel. TQ!,Clorkz ofth6 Board of Supe isors ( This claim complies substantially with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.The Board cannot act for 15 nays(Section 910.8). ( ) Claim is not timely filled. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: '" By: Deputy County iCouns III. FROM: Clerk of the Board TO County Counsel (1) ;,County Administrator(2) ( ) Crim was returned as untimely with notice to claimant(Section 911.3). IV. AI2.D ORDER:' By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: '" t1' . JOHN SWEETEN, CLERK;,By I V I Deputy Clerk WARNING(Gov. code sectio 913) Subject to certain exceptions,;you have only six(6)months from the date this notice was personally served or deposit, in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. ,*For Additional'Warrung See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States,over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage full' prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 11 JOHN SWEETEN, CLEF By Deputy Cler BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A Maim relating to a cause of action for death or for injury to person or to personal property'or growing craps shall be presented not later than six months'after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room'106, County Administration Building,651 Pine Street, Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors,,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form, wows.w s■ss rssall!'o■n a•aaw'raa sows Mason sawas sswr■aa soma malls wa tsJwa■s■I:wa■1 RE: Claim By: Reserved for Clerk's filing stamp } )} R F C Against the County of Contra Costa or } 0 € € } District} (Fill in the name) } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 6;7' and in support of this claim represents as follows: 1. When did the damage or injury occur? Give exact date and hour) cul _m rtl in-ilk 2. Where did the damage or injury occur? (Include city and county) / r J 3. How did the damage or injury occur? (Give full details;'use extra paper if require } e owfe- tea. 4. What particular act or omission a thep of county or distri t officers, servants, or employees caused the injury or damage? � ? ' 5 What are the names of county or district officers, servants,or employees causing the damage or injury? -D q pl ih I/,Q; P10 6. that damage or injuries do your claire resulted? (Give fullexte/nt o f injuries or damages claimed. Attach two estimates for.auto damage,) ;ev 1!5 ' ' i t f 7. How was the amount claimed above computed? (Include the estimated atnount of any prospective ijijury or damage.) 771e, #7-a 8. Dames and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you mole on account of this accident or injury: DATE TIME AMOUNT i ■srsss a srrrrrrssrsrassssrsssago some rBass'sssor■ssrr■ssrsrssrsorrmammon rsrrrssrsrss'rNo ) Gov. Code Sec. 910.2 provides "The claim shall be )signed by the claimant or by some person on his behalf." SEND NOTICES TO: (.Attorney) ) Name and address of Attorney ) r f , (Claimant's Signature) ) f ){ (Address) o Telephone No. )Telephone No. '2 — ssrrs:srssssrs•srsrrrosrssrsssssrssra'sassasasrrrsrrsrrssarsrraeonsrsrssss'ssssnnusesOnoI PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public 'disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form,including medical records, are also subject to public disclosure. ■rsssrrsssrr■rarsssrr'■sass'ssRowena memo srssssssrrsrsmsrsones Now ssar�srrr>>�srr�ssrrrrrsN NOTICE: Section 72 of the.Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any;county, city,'or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.40), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. �' €vis c�dPl"' Qww 4 A 47 lc� le ��r .-bomoo S Aar r�er� �a 7�Vs 77� r�lur--" Wa� uk dtn Work Receipt �€ �_ � Datc fa=n d0r"Co4.1t act phonc, t_ibor Part< Total Cost Cost Cast �■YO��YI®Y�II�®■�1�11��� ■IY�IY�/�®�� . i • e.: Landscape Concret -free Service & Hau in tµ U/ -645-7492 f ✓ �wrr+bv tw.wYY_. r.... �'l yb'`F i£ .. .... . wn ^ THE HOME QEPC?T 0633 1175 AaMIRA'. CALLAGHAN LN. ALLEJOI CALIFORNIA 707 552-9600 0633 WOOS 43953 08/06/05 SALE 61' RS7924 06:10 PM f r2�x 613499070029 SEVIN 64 DST 5.44 078291310825 CLR REMOVER 5.58 049793098870 BOOK LOCK. 4 8 1.97 7.88 043156989041 MAXSEC aBOLT 48.97 8994496102350 3"WHTBRSBRSH 1.27 042224000954 6-PC KIT »6.98 086584427983 36X80 PREHNG <S> 127.00 731677812367 36" PACIFIC 88.00 168187 MOF CASING 21 8 0.40 ' 10.08 SUBTOTAL 301.28 SALES TAX 22.22 TOTAL $323.50 CHECK 323.50 XXXXXX8058 1. AUTH CODE 623303 TA 1' 063308 43953 08/06/2005 7261 FIT HIRING SPECIALTY SALES ASSOCIATES. APPLY TODAY IBJ-STORE OR ON-LINE AT: CAREERS.HOMEaEPOT.COM/SPECIALISTS t ENTER FOR A CHANCE TO WIN R S5,000 HOMEDEPOT GIFT CARI3I Your Opinion Countsl We would like to hear about your shopping experience. Enter to win a $5,000' Home Depot Gift Card by completinv a brief survey about Your store visit ats r i www.Home0apotOpinion.com You will need the following to enter on-lines usrsav lot 813828 88203 f �" �ewcs+srcl�- Entrios 'must be entered by 09/05/2005. Entrants roust be 18 or older to enter. See complete rules an website. No purchase necessary. (Esta encuesta tambi6n sa encuentra en esparhol an la ;�4ei na del Internet.) CLAIM UQARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD AC1I0N: 1Ca�LR 15105 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references'are to ) The copy of this document mailed to you is your California Government Codes. notice of the action taken on your claim by the Hoard of Supervisors. (Paragraph IV below), given Pursuant to Government Code'Section 913 and 915.4. Please nate all"Warnings". AMOUNT: CLAIMANT: LAMAS W. STURGIS #2005018962 #Q-MOD #S ATTORNEY UNKNOWN DATE RECEIVED: OCTOBER LI, 2005 MA6N D I'MION FACILITY OCTOBER 11, 2005 ADDRESS: lO 0 CARD STREET, BY DELIVERY TO CLERK ON: MARTINEZ, CA 94553 BY MAIL POSTMARKED. OCTOBER_07, 2005' FROM: Clerk of they Board of supervisors TO: County Counsel Attached is a copy of the above-noted claim. JC)I-IN SVtTEE E erk'" Dated: OCTOBER 11, 2(7.05 By: Deputy II. F96M: County Counsel.: - TO:Clerk of th6 Board of Su iervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant:The Board cannot act for 15 days(Section 910.8). ( ) Claim is not;.timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply'for leave to present a late claim'(Section 911.3). )' Other: Dated: /0-0/ „k- By: Deputy County Couns III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER:°° By unanimous vote of the Supervisors present: (%4 This Claim is rejected'in full. O Cather: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN SWEETEN,CLERK, By ,Deputy Clerk WARNING(Gov. code s' ion 913T V Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposit, in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional'Warning See;Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,,and at all times herein mentioned, have been a citizen of the United States,over age 1'8; and that today I'deposited in the United States Postal Service in Martinez, California,postage full prepaid a certified copy of this Board Carder and Notice to Claimant,addressed to the claimant as shown above. Dated: JOHN SWEETEN, CLERIC By Deputy Cler, Claim to: BOARD.8F SUPERVISORS OF CONTRA COSTA COUNTY ,� ��j,�1CTICtNS�C! LAi�rL,�NT A Claims relating to causes afaction for death or for injury to person or to personal property or growing crops and which ague on or before December 1, 1987,must be presented not later than the 10&day after the accrual of the cause of action. Claims relating to uses of action for death or f©r injury to person or to persoriatl property or growing crops and:which accrue on or after January 1, 1988,must be presented not later than six:months afar the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual ofthe cause-'of action. (Gov't Code 911.2.) its B. Claims must be filed with the Clerk ofthe Board of Supervisors at its office in Room 106, County Administration Building, 651 Pixie Street, Martinez,CA 94553. C. If claimis against a district governed by the Board of Supervisors,rather than the County,the name of the District should be filled in. D. If the claim is against more than one public entity, separate'claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp } RE } Against the County of Contra Costa or ) '' OCT 1 12005 District) OLE K BOARD Z}i�SUPERVISORS (Fill in name) CONTRA COSTA CO. The undersigned claimant hereby snakes claim against the County of Contra Costa or the above-named district in the sunt of$ I and in support of this claim represents as follows. 1. When did the damage or injury L occur?(Give enact date Land hour) 2. W here did the damage ori occur'?(Include city and county) t? Ala e 3. How did the damage or injury occur?(Give full details; use extra paper if required) 0Ve- �m��y 91s', 4. 'What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damaged c ? / ' fr uer Cly' /st' Aps !F 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claimresulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) -floe��ty A' ' 7. H64 was the amount clam above computed?(Include thees �eed ,:gounirtof/ainfj Prospective injury or damage.) 8. Names and addresses of witnesses, doctors, and hospitals. . 4 9. =List the expenditures you made on account of this accident or injury. DATE TINtE MOUNT ec/� ) 'Gov. Code Sec. 910.2 provides"The claim must be SEND NOTICES TO: fA=m,ey ) signed by the claimant or by some person on his behalf:" Name and Address of Attorney ) ... � } (Claimant's ignatureX } (Address) :. Telephone No, )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent.to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board o€officer,authorized to allow or pay the same if genuine,any Use or fraudulent claim,bill,mount, voucher,or writing,is punishable either by imprisonment in the:.county jail for a period of not more than one year,by a fine of not exceeding one thousand t s 1004 or by boat such U npnSonnWnt and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars 010,000),or by bath such imprisonment and fine. CLAIM BOARS OF SUPE WISOEW OF CONTRA COSTA COUNTY BCI ACTION 1ME1 . 2 Claire Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Beard Action. All Section references are to j The copy of this document mailed to you is your California Government Codes. j notice of'the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), givt Pursuant to Government Code Section 9`13 and 915.4. Please nate all"Warnings" AMOUNT: $35,500.00 CLAIMANT JOSEPH Q. MC.4 MAS ATTORNEY': MARLU S CASTILLO'': DATE RECEIVED: OCTOBER 14, 2005' LAW OFFICES OF MA= S. CASTILLO ADDRESS: 1625 THE AIA'EDA #622 BY DELIVERY TO CLERK ON: OCTOBER 14 2005 SAN JOSE, CA 95126 BY MAIL POSTMARKED. HAND DELIVERED FROM: Clerk of the Hoard ofSupervisors TO: County Counsel Attached is a copy of the above-noted claim. OCTOBER 141, 2005 JOHN S W E E erk Dated: By: Deputy IT C?M: County Counsel. TO: Clerk of they Beard of Sup isors (.4,111is claim complies substantially with Sections 910 and 910.2. This Claim FAILS to comply substantially with Sections 910 and 10.2,and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). Other: Dated: /� ®"l %' 1' By: Deputy County Con I1I. FROM: Clerk-ofthe:Board TO: County Counsel (M) County Administrator(2)' ( ) Claim was returned as untimely with notice to claimant(Section 911.3). 1V. 40ARD ORDER: By unanimous vote of the Supervisors present; This Claim is rejected in full. ( } Other: I certify that this is a true and correct'copy of the Board's Order entered in its minutes for this date. Dated: JOHN SWEETEN,CLERK,By Deputy Clerk WARNING(Gori. code section 91 3) Subject to certain exceptions, you have only six (6)months from the date this notice was personally served or dep€ ill'the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of eYa attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse'Side of This Notice. ' AFFIDAVIT OF MAILING I declare'under,penalty of perjury that I an now, and at all times herein Have been a citizen of the Unite States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage f prepaid a`certified copy of this Board Order artd Notice to Claimant, addressed to the claimant as>>shown above. Dated: +t1=ZV 2g�j ""JOHN SWEETEN, CLERK By _—Deputy C: B"J.c41'2D OF S LlRYISORS OF CONMU CO TA CC TY TS`I RUCTIONS TO CUAIII4LA�'l� A. A claim relating to a cause of actioa for death or for u jtry ti4 person or to pwanal property or grousing c-Tops shall be 'presented not later than six months after the accrual of the:cause of action A claim relating to any other oeme of ac on shall be presorted not later than,one'ye* after'rlte;accnml of the cause of action. (Gov. Cade§ 911.2.) B. Claims must be filed with the Clark of the Boe r. of Supervisors at its office in Raom 106. Cas!ncy A stratian Building,651.'Pine Street,Ma tine:z,CA 94553. C. If claim is against a.dis� grvemed by the Board of Supenrisors, rattier thm the County= tate naris ofthe District should be filled iu. D. If the claim is against more than one public entity, soparate claims mus. be filed against each public entity. E. >artiud. Seepenalty for fraudulent claims, Panel Crile Sec.72 at the end of this form. •r rrrf dKMwIrl rrrr:aE:moYrsrKrrrask out rrrrr•Y rrar wrrrr�:■rrr•r■rr7:r rrrr'k t'rr�'rar ae4 t. RE Claim By: Reserved for Clark's filing stem; JOSEPH Q. MACARANAS RECEIVED .Agan the County of Contra Costa or ) OCT 14 2005 East Contra Costa Fire c�.EwcaonriosUPFiv�soRS Protection District District) c©Nr�Acos�rAcc (Fiji if,the named )' 1 The undemigned claimant hereby makes Clam against the County of Contra Costa or t're above named district in the;sum of S 3 5,5 Q.-0 0 and in support oftfis clams represents as fntluws: 1. When did the damage or ir4jr.rry ocour? (Give exact date and hove) June 5, 2005 at 2:45 P.M', �. Where dirt the damage or injury occur? (Includ;city and oounty) Vasco Road and Camino Diablo Road in Contra Costa County 3. HOW did the darricge or injury occur?' (Cruse frill details;use extra paper ifraquirel) See Annex "A" and made part hereof 4. What pardeular act an, o rcisslon on the part Df coumy or district officers, sarvats, or Mn!)loyeves caused the inury or damage? See 'Annex "B" and made part hereof S "Lrrhat are:the narnes of cou&Y or distdot officers,searvamts,or employees causaig the damages or ijury7 Joseph Patrick Pelot 6. '%17,at gage or injuriesdo your can resulted? '(Give 'full eaten: of Lniux% o, c1atnmd. Attnh two estimates for auto dawage) w See Annex "C" and made part hereof 7, l.•sav; was the am+juat c13;.med above -omputed t-la !tide tEe escunared amount of -ally pzrsspecfiive �,ter d'�aae.i Based on the nature of the injuries, current medical bills, and pain and suffering. ' g. ,amen and eche-3ses of Mtnesses,doctor-,and baspita ; See Annex "D" and made part hereof 9. List thw exr.,m6 s you=ad--ori account oft is accida nt or nrjury: DUE, r +tam wart%aarrtaarrxasrarrr•aanasmas %rasasmrrrsexarrswwasr*saw aa trswerrsi..rrr, ► Gov. Code Sec;. 910.2 moviti*s"The clam, shali ate signed'„by'le claimant or by saint person on his behaT Name and addrem of Attorney MARLU S CASTILLO Law 'Offices of Marlu S. l' ;Cla t's:Sia aiurej Castillo` ; 1625 The Alameda #622 i 2825 Pendleton Drive, San Jose, CA 95148 San "JOse CA 95126 p (add ss) 3 ,l Telepho:�eNL ( 408)293-850'8 )T'eiephaneNa. ( 408) 528-7415 ttMwxt1V;R*M'.rtt%9101taY rr:farrr.'srafsrr rarssr■tatrrra•.srraa-.r crtar tM ar rsr#trllaa rllrw.wswx'two - PUBLIC RECORDS NOTICIr. 113e..ase be advised tree*th s el aim farm,or any c1mm filed with the Coutty under the Tort Gt;:cams Act. is RUbJ N 'T c, a atlic 'disclosure u der the CaUfrndia.Public 1--orris Act. (Gm, Code, --�§ 6500 et.seq.) Furthermore, a_r} at hzhrhe=1ts,a?=jMdHrr,s.Or Secpplernenrs attached to the clam firm,iarludiag�medical recmts, Ore aisc sub;ec r. 1. putstic disclostire. Wkwr ERt Nrwrra rt Lrara aa..rr Ya Noses owl**r hea*Ytrr■•rrai'YOsrrar 3aaaY:rs ar,.aa.a ort Meet i.ax NOTICE: Saction 7-:1 of the Penal Code provides, EN,ery parson who,wits, inn at to defraud,presents for ailoma.nce 3r for pa;mentto anny'state bcar� Or officar, o- tc any county, -.iv. or district board or officer, authorized to allow or pay the same'if Senuineury Nss e; iiaudalent clairsa,bill, ac:com•t voucher,car werltirsg, is punishable either by imprison-m diet in the i�o'unt�”Jpii fc~•:n period of not more than one yt r, by a fuss of not exceeding one thousnhd delltiirs ;Si,{ItIC.t�tli, rr .y.y noxi. sucl, impTisom east anti fine, or by imprisonment it the state prison, by a fine ofDot exceeding-er*1acusand d,i`:a s: l510,00C"?,or't y both such imprisonment and fine. Annex "Ar, 3 .HOW DID THE DAMAGE OCCUR? On June 5, 2005 at or about 2 :45 P.M. , I claimant Joseph Q. Macaranas was driving my 1994 White Dodge Ram 250 with California' License No. 3KCU931 . At that time I was stopped` on Camino Diablo Road(Contra Costa County) westbound intending to make a left turn unto southbound Vasco Road(Contra Costa County) . Together with me at that time was my wife, Maria Cristelita M. Macaranas who was the front seat ' passenger and my children Kristine Macaranas and Jessica Macaranas, and my niece Jasmine Laureta,, who were the rear passengers. While qty Dodge` Ram completely stopped, a Fire Truck of the East Contra Costa Fire Protection District and driven by Joseph Patrick Pelot appeared in the distance traveling eastbound on Camino Diablo Road at a very high rate of speed. The traffic light was red at that time The Fire Truck' continued to approach the intersection at 'a high rate of speed I carefully watched the movement of the fire truck as it entered the intersection'. The traffic" light was still red. As the Fire Truck sped through the intersection, I heard breaking glass and metal and saw a Toyota Corolla who was traveling northbound on Vasco Road collide with the Fire Truck. Upon collision ......... ..... with the Fire Truck, the Toyota Corolla then hit the light pole on the median strip. I The Fire Truck veered to the left heading towards my Dodge Ram. As it approached our vehicle,, all I could do was turn my head to the right and glance quickly at any wife and kids . Then the Fire Truck struck our vehicle violently. The impact of being hit by the Fire Truck was so powerful that my Dodge Van was tossed at least 90 degrees to the right . Upon impact, I blacked out for a moment and as I regained my vision, I saw the Fire Truck stopped on the hilly roadside to any right . My Dodge Van suffered major damage. I got out of the Dodge Van and moved the kids to a safe distance away and hurried back to check on my wife, Maria Cristelita M. Macaranas who was injured and in pain. I remained beside my wife until Paramedics came . While checking on Kristine Macaranas, Jessica Macaranas and Jasmine Laureta, the driver Joseph Patrick Pelot apologized to me with the statement that he was sorry he hit us . Joseph Patrick Pelot was negligent in driving the fire truck because he failed to slow down before entering the intersection and ensuring that traffic in all directions were clear. He failed to exercise the duty to drive with due' regard for the safety of all persons using the highway. As a result of the collision caused by the 'negligence of 'Joseph Patrick Pelot, I suffered personal injuries, Annex "B" 4 . WHAT' PARTICULAR ACT OR OMISSION ON THE PART OF COUNTY' OR DISTRICT OFFICERS, SERVANTS, OR EMPLOYEES CAUSED THE INJURIES? JOSEPH PATRICK 'PELOT, an employee of East Contra Costa Fire Protection District and while driving the Fire Truck of ' East Contra Costa Fire Protection District negligently crossed the intersection on Vasco Read without slowing down and making sure that traffic in all directions were clear and safe for him to do so;. As a result of Joseph Patrick Pelot' s negligence he collided with a Toyota Corolla who was northbound on Vasco 'Road and he (Pelot) struck: the Dodge Ram of claimant Joseph Q. Macaranas, causing personal injuries to the latter. SEX "C" 6 . WHAT DAMAGES OR INJURIES DO YOUR CLAIM RESULTED? (Cive full extent of injuries or: damages`' claimed. Attached two estimates for auto damage) Claimant Joseph Q. Macaranas suffered personal injuries as: a result of the accident and his injuries are neck sprain/strain, right hip pain, left foot pain, pain in both knees, upper back sprain/strain, lower back sprain./strain, aright chest wall contusion, right foot pain. Claimant is still undergoing treatment as of presentation of this claim with Dr. Jose Reyes for his knees and with Dr'. Hung T. Lam for his chiropractic treatment, hence does not know yet the total of his medical bills. Medical bills todate are as follows: 1 .Dr. Jose Reyes $ 354 . 00 2 .Dr. Hung Lam 3, 645 . 00. 3 .John Muir Medical Center 2, 677 .65 4 .Bay Area Imaging Consultants Med Group 81 . 00 5 .CA Emergency Physicians 268 . 00 Total Iodate $7, 025 . 65 The Dodge Ram of claimant Joseph Q Macaranas was declared a 'total wreck. Claimant attaches a copy of the estimate and picture of the vehicle Annex „D,r 8 . NAMES AND ADDRESSES OF WITNESSES, DOCTORS AND HOSPITALS; Witnesses 1 .Maria% Macaranas-2825 Pendleton Drive, San Jose, CA 951.48 2 .Kristne Macaranas:-2825 Pendleton Drive,San Jose,CA 95148 3 .Jessica Macaranas-2825 Pendleton Drive, San Jose, CA 95148 Doctors" and Hospitals 1 . John Muir Medical Center-1.601 Ygncio Valley Read, Walnut Creek, CA 945198 2 . Katie Hurd, M.D. -John Muir Medical Center, 1601 Ygnac o Valley Read, Walnut Creek, CA 94598 3 . Dr. Hung T. Lam(Pain. and Injury Care Center) -730 Story Road, CA 95122, San Jose, CA 95122 4 . Dr. Jose K. Reyes-1625 Tully ;Road ##A, San Jose, CA 95122 5 . Bay Area Imaging Consultants Medical Group-P.O. Box 31455, Walnut Creek, ; CA 94598 6 . CA Emergency Physicians-P.O. Box582663 ##D-03 , Modesto, C.A. 95358 U.;S S.A.A. WESTERN REGIONAL OFFICE s P.o. BOX 659462 SAN ANTONIO, TX 78265 ('800) 531-8222 (916) 921--9060 CD LOG NO 6953 -0 ESTIMATE 06-24-05 3:58 PM LrA.IM INFORMATION CLAIM' # 000000004 POLICY # 016870628 COMPANY USAA, BASE = CA, CLOSE CD = NF CLAIM REP 08260/00035 INSURED MSG JOSEPH Q MACARANAS LOSS DATE 06-05-05 CLAIMANT LOSS TYPE COLLISION'; LOSS PAYEE ACCT # 001 I'SPECTION COMPANY US.AA TYPE FIELD PRIMARY POI FRONT END CENTER SECOND POI APPRAISER NAIVE DONALD NOHAI GORE PHONE (800) 705-7432 FAX (408) 377-6149 ADDRESS PO BOX 28405 INSP DATE 06-24-05 CITY ''STATE SAN JOSE CA LOCATION VIC ZIP 95159- CITY STATE SAN JOSE C1: MER MACARANAS, JOSEPH' Q WORK#:.(925) 875-478$ 2825' PENDLETON DR HOME#'(40$) 528,-7415 SAN JOSE CA 95148-3016 EPAIR TOTAL LOSS CAR IN' CA REPAIR DAYS EHICLE 1994' DODGE B250 STD 2 DR PASS. VAN' EXTENDED- $CYL GASOLINE 5.2: 1PTIONS TWO-STAGE - EXTERIOR SURFACES TWO--STAGE - INTERIOR SURFACES PRIVACY GLASS TILT STEERING WHEEL FRT AND REAR AIR CONDITIONING AUTOMATIC TRANS CRUISE CONTROL BODY ,COLOR WHITE/GREEN' MILEAGE' 135,785 CONDITION' GOOD WIN 2B6HB21Y9RK17101$ LICENSE # LtmgoWN CODE N615 1MARE : iR 6-15 DC: 6--16DI':6-24 DS ETR: DRV- N _1_ 1994 DODGE 'B250 STD 2 DR 1 ;S. VAN EXTENDED CtAIA # 000000004 LOG 6953 -0 06-24-05 3:58 PM ROD DATE:N/A. DDITIONAL COMAENTS:TOTAL LOSS SETTLED IN THE FIELD.ADP#1544149 #4 *4-4, P CODES: * = USER-ENTERED VALUE E = REPLACE OEM NG = REPLACE NAGS EC = ALTERNATE REPL PART UC = RECONDITIONED PRT UM = REMAN/REBUILT PRT EU = RECYCLED PART EP = ALTERNATE REPL PART PC = PXN RECONDITIONED PM = PXN RENAN/REBUILT TE = PARTL REPL PRICE ET = PARTL REPL LABOR IT = PARTIAL REPAIR I = REPAIR L = REFINISH BR '- BLEND REFINISH TT = TWO-TONE CG = CHIPGUARD SB = SUBLET N = ADDITIONAL LABOR RI = R&I ASSEMBLY P = CHECK AA = APPEAR ALLOWANCE RP = RELATED PRIOR UP = UNRELATED PRIOR P GDE MC DESCRIPTION MFR.PART NO. PRICE AJ% B% HOURS R - --- -- ----------- ------------ ----- --- -- ----- - 0028 GRILLE ASSEMBLY 55054635 145.00 INC 1 0028 GRILLE ASSEMBLY REFINISH 1 .2 4 1.2 Surface 0041 HE ADLDMP ASSYIHALOG IT 55055277AB 240.00 0.5 1 0042 HEADLAMP ASSY,HALOG, RT 55055276AB 240.00 0.5 1 0973 HEADLAMPS AIM ADDITIONAL LABOR 0.4 1 0083 PANELIHOOD 55344901AB 437.00 0.8 1 0083 PANELHOOD REFINISH 4 .4 4 2.3 Surface 0.8 Edge 0: 6 Two-stage setup 0.7 Two-stage 0088 LATCHHOOD PANEL 5207088 40.70 0.1 1 0089 SUPT,HOOD LOCH VERT' 55344934 41 . 60 INC 1 0084 HINGE.HOOD, PANEL LT 55347107AB 17. 60 0.5 1 0084 HINGE,HOOD, PANEL LT REFINISH 0. 4 4 0.3 Surface 0.1 Two-stage 0085 HINGEHOOD PANEL RT 55347106AB 17. 60 0.2 1 0085 HINGE,HOOD PANEL RT REFINISH 0.4 4 0.3 Surface 0.1 Two-stage 0076 PANEL,RADIATORSIDE IT 55344957 69. 60 1 . 6 1 0076 PANEL,RADIATOR SIDE LT REFINISH 0.2 4 0.2 Surface 0077 FANELIRADIATOR SIDE RT 55344956 69. 60 1.4 1 0077 PANEL,RADIATOR SIDE RT REFINISH 0.2 4 0.2 Surface 0075 CRSMBR,,RAD PANEL UPR 55346530 84 .25 1 . 6 1 0075 CRSHBR,,RAD PANEL UPR REFINISH 0.2 4 0.2 Surface 1 0074 CRSMBR,,RAD PNL LOWER 55234742 163.00 4 .8 1 0074 CRStBR,,RAD PNL LOWER REFINISH 0.5 4 -2- 1994 , ,DODGEB250 STD 2 DR jS. VAN EXTENDED CLAIM, # 000000004 LOG 6953 -0 06-24-05 3:58 PM 0. 4 Surface 0.1 Two-stage P 0755 RADIATOR ALTERNATE REPI, PA 247.50 1.2 1 0062 DEFLECTORIRADIATOR 55036341 11 .85 0.2 1 0764 TANK,COOLANT RECOVERY 52027787 18.35 INC 1 0759 BIADEENGINE FAN 52027999AB 37.60 0.4 2 0767 01 CLUTCHENGINE FAN 52027883AB 150.00 INC 2 0758 SHROUD,,RADIATOR 52027864 62.85 INC 1 0756 HOSE,RADIATOR UPPER 52005814 14 .30 0.3 1 0757 HOSEIRADIATOR LOWER 52027649 14 .30 0.3 1 0762 PUMPIENGINE COOLANT 53021018AB 94 .50 1.4 2 0761 PULLEYCOOLANT PUMP 53010221 23.50 0.5 2 0970 A/C EVAC RECHRG & RCV ADDITIONAL LABOR 1.8 2 P 0731 CONDENSERIA/C ALTERNATE REPL PA 156.00 0.7 2 P 0103 SER,FRONT IT ALTERNATE REPL PA 102. 19 4 .5 1 0103 FENDERrFRONT IT REFINISH 2. 6 4 1.7 Surface 0.5 Edge 0. 4 Two-stage P 0104 FENDERFRONT RT ALTERNATE REPL PA 117 .35 5.0 1 0104 FENDERrFRONT RT REFINISH 2. 6 4 1.7 Surface 10.5 Edge 0.4 Two-stage 0790 COOLER,ENGINE OIL 52028302 156.00 0.5 2 0751 DUCT,,A.IR INTAKE 53030508 41.50 0.2 2 1741 BELTfDRIVE 53010281 41.70 0.3 2 G 0143 WINDSHIELD,TINTED NAGS DW1167-GT 187.05 -50 2.0 1 0149 01 RESERVOIR,W/S WASHER 55154858 52. 45 0.2 1 0207 DOOR SHELL, FRONT LT 55347411 1, 480.00 3.8 1 0207 DOOR SHELL,FRONT LT REFINISH 4.2 4 2.0 Surface 1 5 Edge 0:7 Two-stage ;R 0208 DOOR SHELL,FRONT RT BLEND REFINISH 1.2 4 0.8 Blend 0.4 Two-stage .1 0260 W/STRIPIBELT OUTER RT R&I ASSE1,4BLY 0.2 1 .1 0232 PNLIINNER DOOR TRIM RT R&I ASSENSLY INC 1 .1 0056 HANDLE,FRONT DOOR 0 RT R&I ASSEMBLY 0. 6 1 48 ITEMS MC I-ESSAGE 01 CALL DEALER FOR EXACT PART # / PRICE 'INAL CALCULATIONS & ENTRIES 'ARTS GROSS PARTS $ 3f764 .85 -3- 1994. DODGE IB250 STD' 2 DR ')S. VAN EXTENDED ,tLAIM # 000000004 LOG 6953 -0 06-24-05 3:58 PM OTHER PARTS $ 810.09 PAINT MATERIAL 500.00 DJUSTMFMS DISCOUNT MARKUP LINE ITEMS $ 93.53 PARTS & MATERIAL TOTAL $ 41981.41 TAX ON PARTS & MATERIAL @ 8.250% $ 410. 97 LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL $ 70.00 30.3 0.4 $ 2f149.00 2 MECH/'ELECT $110.00 4 .0 1 .8 $ 638. 00 3-F?,AlvM 4-REFINISH $ 70.00 18 .1 $ 11267.00 5-PAINT $ 30.00 ABOR TOTAL $ 4f054 .00 SUBLET REPAIRS TOWING STORAGE ROSS TOTAL $ 9f446.38 LESS: DEDUCTIBLE $ 250.00- ET TOTAL $ 9, 196.38 TOTAL LOSS XN Y/05/04/00/01/00 CUM 05/04/00/01/00 Geocode: 94002 PENINSULA XS Na DP PENPRO W0412 ES LOG6953 -0 07-13-05 12:03:49 REL 4 .12.1 DT05/05 (C) 1993 - 2005 ADP CLAIMS SOLUTIONS GROUP, INC. USER-ESTABLISHED THRESHOLD FOR PAINT MATERIAL HAS BEEN REACHED AND CALCULATED IN THIS ESTIMATE. ANY ADDITIONAL MATERIALS MAY REQUIRE FURTHER APPROVAL. 'k+ 3.5 HRS WERE ADDED TO THIS EST. BASED ON ADP'S TKO-STAGE REFINISH FORMULA. STIMATE CAI=TED USING THE 2.5 HOUR MAXIMUM ALLOWANCE FOR TWO-STAGE EFINISH OF NON-FLEX, EXTERIOR SURFACES. ALIFORNIA LAW PROVIDES THAT YOU HAVE THE RIGHT TO SELECT THE REPAIR FACILITY lF YOUR CHOICE. 'HIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A OURCE, OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES PPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR EHICLE. -4- ................. 1994 DODGE 'B250 STD 2 ISR ': „' VPN EXTENDED CLAIM # 000000004 LOG 6953 -0 06-24-05 3:58 PM HIS IS NOT A REPAIR AUTHORIZATION. .NO SUPPLEMENTS WITHOUT PRIOR APPROVAL LEASE GINE THIS REPAIR ESTIMATE TO YOUR GARAGEMAN. DISCLAIMER: "FAILING TO RESENT THIS ESTIMATE TO THE REPAIRING GARAGE BEFORE REPAIR MAY RESULT IN DDITIONAL EXPENSE TO YOU. ANY SUPPLEMENT TO THIS ESTIMATE MUST BE AUTHORIZED Y A'USAA APPRAISER. " NOTICE: "REPAIRS TO THIS VEHICLE MAY REQUIRESPECIFIC' ELDING EQUIPMENT AS RECOMAENDED BY THE MANUFACTURER.'" CALIFORNIA LAW PROVIDES HAT YOU HAVE THE 'RIGHT TO SELECT THE REPAIR.' FACILITY' OF YOUR CHOICE. 5_ 19.94,DODGE B250 STD 2 DR 3S. VAST EXTENDED CLAIM # 000000004 LOG 6953 -0 06-24-05 3:58 PM Estimate Suma.ry Page DONALD NOHAI ROSS TOTAL $ 91446.38 LESS: DEDUCTIBLE $ 250.00- ET TOTAL $ 91196.38 DP PENPRO W0412 ES LOG6953 --0 07-13-05 12:03:49 REL 4 .12. 1 DT05/05 (C) 1993 2005 ADP CLAIMS SOLUTIONS GROUP, INC. F ALTERNATIVE QUALITY' REPLACE1,ENT PARTS HAVE BEEN INCLUDED IN THIS APPRAISAL, HE SOURCE FOR THESE PARTS HAS ALSO BEEN DISCLOSED. IF ALTERNATIVE QUALITY. EPLACEMENT PARTS AS LISTED ON THIS APPRAISAL, ARE ULTIMATELY USED IN THE EPAIR OF YOUR VEHICLE, THE WARRANTY ON SUCH PARTS WILL BE EQUAL TO, OR REATER THAN, THE PARTS BEING REPLACED, AS STATED IN USAA'S LIMITED PARTS ARRANTY. USAA WARRANTS THAT THE PARTS USED ON YOUR VEHICLE WILL BE OF LIKE IND AND QUALITY, FUNCTION, FIT, AND CORROSION PROTECTION AS THE PART R PARTS THEY REPLACE. USAA. REQUIRES THE USE OF CAPA-'CERTIFIED PARTS FOR ANY HEET METAL REPLACEMENT PART SUBJECT TO CAPA-CERTIFICATION, -6- CD LOG NO 6953 -0 DATE 07-13-05 EHICLE 1994 DODGE B250 STD 2 DR PASS. VAN EXTENDED 8CYL GASOLINE 5,2 PTIONS TWO-STAGE ., EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES PRIVACY GLASS TILT 'STEERING ;WHEEL FRT AND REAR AIR CONDITIONING AUTOMATICTRANS CRUISE CONTROL SUBSTITUTED FOR SUPPLIER PART OEM PART SUPPLIER CLS SRC ART DESCRIPTION NUMBER NUMBER CODE OOLING AND AIR CONDITIONING Radiator 1707 52029115 005 1 M961 52029115 >003 1 Condenser,A/C 3634 416392'.0 003 1 3634 4163924 >005 1 RONT BODY AND WINDSHIELD Fender,Front LT CH1240198 5012601AC 004 C 1 CH1240198C 5012601AC 002 C 1 D0124 5012601AC >001 C 1 DGFD7697 5012601AC >006 C 1 Fender,Front RT CH1241197` 55344910 004 C 1 CH1241197C 55344910 >002 C 1 DGFD7696 55344910 >006 C 1 > = ESTIMATE TOTAL IS BASED ON PRICE QUOTED BY THIS 'SUPPLIER EY TO CLASSIFICATION/SOURCE CODES LS = CLASSIFICATION CODE C CAPA CERTIFIED PART QUOTED BY LISTED SUPPLIER M REMANUFACTURED/REBUILT PART R RECONDITIONED PART S OEM SURPLUS PART RC SOURCE CODE: 1 NON ORIGINAL EQUIPMENT MANUFACTURER PART 3 "- ORIGINAL EQUIPMENT MANUFACTURER (OEM) PART jETAILED DISTRIBUTOR LIST .1_ PXN17 8 5 SAN )SE TRADING CRT 2038 CONCOURSE DRIVE ST B SAN JOSE, CA 95131 (800) 932-9222 _ (408) 434 9222 02 = PXN1790KEYSTONE AUTO CERT 632 SOUTH EL DORADO STREET STOCKTON, CA. 95203 (800) 263-9727 (209) 948-1101 03 - PXN2185 AIR-CON AUTOMOTIVE 8227 REMt= AVENUE CANOGA. PARK, CA 91304 (800) 287-3273 (818) 716-8866 04 PXN6308' COLLISION PARTS CERT 196 BARNARD AVEC SAN JOSE, CA 95125 (800) 427-5659 (408) 291-0950 05 - PXN6692' 1-800 RADIATOR 32 LOCATIONS NATIONWIDE COAST TO COAST, CA. 00000 (800) 723-4286 (707`) 747-7400 DP PENPRO W0412 ES LOG6953 -0 07-13-05 12:03:50 REL 4 .12.1 DT05/05 EOCODE: '94002 SA: PENINSULA (C) 1993 - 2005 ADP CLAIMS SOLUTIONS GROUP, INC. =2_ DATE CREATED: 2004-01-01 00:00:00 DESCRIPTION: Field Assgnnent Attachment Note Version '1.0 CREATED: 2004-01-01 00.00;00 ORIGIN: FILE' ........... DATE CREATED- 2004-01-01 00:00:00 DESCRIPTION: Field AssigmentAttachment NoteVersion 1.0 CREATED: 2004-01-01 0G-00:00, ORICIN: FILE ............. .......... op DATE CREATED: 2004-01-01 00.00:00 DESCRIP'T'ION: Field Assignment Attachment Note Version 1,0 CREATED: 2€04 -01-01 OO:00;00 ORIGIN: Fl? 3LEASE #�AC1'YC1UR'PAYMENTTO. lo[m M R{MT,DIABLO HEALTH SYSTEM P,O.'S 39000 DEPA ENT 3331.0 D - 6 0 0 SAID i5Gi3�.CA94"�39'3370 t94T•3338. PATIENT NAME T—PAIfENTNUMBER 1 SEX AGE ADMISSION DISCHARGE DAYS OSEPH MALAR IAS 05777779177149Y 06 05 05 06 Ora O fNSURANCECOMIPANY NAWE GROUP NUMBER POLICY NUMBER 005303 GREAT WEST LIFE. 35'9606 575390649 CHARGE TO MY: 0 VISA n MASTERCARD '© AMEX 0 DISCOVER JOSEPH MACARANAS CARL?# 2825 PENDLETON 'DRIVE SAN JOSE CA 95148 EXP,DATE L - SIGNATURE: AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE 06/05/05 270 HYDROCODON 5-500MG*ER*,5 TABL 253 1 1 17.65 17.65 TOTAL DRUGS/TAKEFOME 17.65 06/05/05 104C-SPINE;LTD IP (2'-3 VWS) (72040) 320 1 1 616.75 616..75 TOTAL DX X-RAY 616.75 06/05/05 102 , CHEST 2;VIEWS TP '(71.020) 324 2 1 605.75 605.75 TOTAL DX X-RAY/CHEST 605.75 06/05/05 633 ER PUL H J4 1-1i 'T Smolt LE°�J47 1 *,- 45b .. 2 ` ' 0.00 0..00 06/05/05 6404 ER -EMERGENCY qRVICE£� Q04' int/ AM . 450„ y4 1 1437.50 1,437`.50 TO'T'AL EMERMSNCY'`Tt�ial�I�SE1�V 1'CES " 1,437.50 TO'T'AL CHARGES 2,677.65 07/18/05 10015' 012 HMO DISCOUNT PAYMENT 2, 306.33 07/18/05 A.0004 012 HMO PPO CONTRACT ALLOWANCE 321`.32 TOTAL PAYMENTS/ADJUSTMENTS -2,627.65 PATIENT NUMBER A 50.00 05156-00191 THE HOSPITAL DILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR!MT.DIABLO HEALTH SYSTEM ETAIN T141S DETAIL STATEMENT PHYSICIANS.YOUR SURGEON,ASST SURGEON, PO.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST;RADIOL601ST,ETC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO►,CA 94139-3370' FORWARD ONLY. FEDERAL TAX I.D.NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL(925)947-3336 2251L(12t1I10� Page 3 of 7 John Muir Medical Center _ Walnut Creed , CA 94598 PftMACARANAS,JOSEPH DOB: 12/30/1955 Age/Gender:49 M 21:33 MUC X :082'7062 Acct#: 0515600191 Private Phys: 90761-SIAO,DONALD,MD ED Phys: Katie Hurt,MD PAT. NAME: MACARANAS, JOSEPH ADM. DATE: 06/05/2005 PHYS.: CATHERINE HURT, MD MR#:082 70-62 DOB: 12/30/1955 Doc ID#: 624316 Acct#: 0515600191 DD: 06/06/2005 DT: 2:14 P .Job # 000981526 cc: BILLING COPY ER COPY ER DIAGNOSIS NECK PAIN CHEST WALL CONTUSION <KH:Ketie Hurt,MD 06105M 2T36> DISPOSITION PHYSICIAN Pertinent physical findings:bruising and ttp::over tower chest wall, ttp over midline in c spine',KH 06/05/05 23:37> Condition: Good<KH 06100106 23:37> Disposition-Discharged from ED: Fallow-up with:''**Your Regular MD,in 3-4 day(s)<KH 06/05/05 23:37> Discharged home.<KH os/06105 23:37 RX<KH 06/05105 23:37> General discharge instructions given to patient in English.<KH 06/05/05 23:37> MSS#EM4<KH 06/06/05 14:1 MBSI PDX<KH 06106105 14:14y' Printed by Robin Enos,MEDRC on Friday,Tune 17,2005 3:44::03 PMComplete Chart MACARANA3 ,JOSEPH MR 0927062 49y DOB 12/30/1955 M 6 FIN 0315600191 Medical Chart with Audits Pi NAMF E`:NlL'k�PIN CY :rEY5 ATUI'R JpSE?T v4ACN '34 P0 8CX 542563 Stir l-+ Ctit.:K.CAMI[5:3tNG=�R PA'(1.7�Ti" modw rt XODESTO, CA 953 a-0046 MA^S EIMAKD 'dam' 4 IJE5IE SiS r[taES lRicrili�f�A`C T8 rtA{. STA—TEVIVIEN Akt ++tlY"i'3 0-o fQ—T-T ST si iIRE i3 Tw3 OILt is as fl�bm Youvit tiGtSWAL BIL 18462 MAK•ECKE- CA ' I"I ;C9ENLY i'X�Sw'.. .825 PE"NDLI:TON qR PAYABLE fiC3 CA EX ENCY.4 S�� S-�� SAN LOSE. CA, 9514E XODESTC, CA- G5356-0046 �- ia� >r M.Y r ar##/It y x r� x a al at■I r r■ai w al®�":al li al s��!!! ■i wars al w al at lilii�-YI1'al al'�al'.�as�`��a►�►ot,•11F�411 THEMIS..'11�l#.CV SMP7CE CJYARt+f iJ--F`FJRALI REyVRMED C1LEC1 9- BILLING OFFICE HOURS 9A..5 PM PrP one b-L 800 340-1260 Tax It).**- G424940+00 Para triol',- 1.800-952.435' iel PhysicIars b- x 2, c sTk , *NE r:.n- Referring Doctor k HURT, 'AT" 1�. A=unt Numbw- - orjo1^ 494 Service Provider b. car JoF__N rt�_� VEM CSTR Patient Name JoSsrH XA,7ARANAS Statement Date • ?�.?5 i t�5 L»IM PPM DIAGNOSIS DESCR1P`1710 I OF$,ERVICLS AMOUNT 7929-1 LEVEL 3 El+t C DCV, FH-7.9 CRIMR-M ( SEs/05,r'`EIb f 1-1221 I 99054 SUNDAY/HOLIDAY 06/0w'/03 t 4 5221 "=';:20!26 kw Y INTSR? Cl;E'ST ?4"p' flSlflSr'C5 i "4272, -,3Q40/25 X-RAY IN-_V.Fp C-3p NE' 26.0- Total for Clam. 269.-X ' I i I ' i 1 i I x is CIi3T t "- 'Y L71i 1G ILEI 1A CLAIM WITH XOUR I hlSURANCE CARRIER;; C IYTA..."' '::alf ?Y' '"#t T", i 1�7I1 REKAI21u`t+?R` 8SSEr yM ACCOUNT IS PAST DDE. FLEA-15E REMIT PAV'rEXT TcnAl%'d. f .cmc r r yia tri esu iado ut recl.amc a Su slag pro Inedi1G?r 3 s r+r nts aux n rocesado. Gr&: aa. I allaaaaaar •- # s PRMLARY I +LpY t INS E' INJURY IDATi` ADVIwow DATE 'DISCK&RGE DATE ; BALANCE DUE ' CIE ARXY FESEc VES GREAT WZST G613SJfl5 ^CCh - V 1 a.iJ'LSalry�- f IPiace o''tetvict codes) �1 1 - kl Ctlt 1iO i $ outpaltio't H—pul 3 - Dactues Epic, 4 - !s[lergertcy Rggii DAT -962 46 Zai OS CARD JH61-01EA CREW CARD TYPE Fit 741 5 I2 30S;S 0 CARD NUMBER EXP.DATE x CAPE PAY SIGNATURE AMOUNT PAID PHONE(925)296-7156 ;.KE CHECK PAYAOU TO: BILL TO. BAY' IMAGING CONSULTANTS MED GROUP PO BOX 31.455 MACARANAS , JOSEPH WALNUT CREEK CA 94598 2825 PENDLETONDRIVE 1111111 11111111all 6111111 11.111ti.11 fit]If itllit11111111tilli SAN JOSE CA 95148 DETACH HERE AND RETURN TOP PORTION.WITH YOUR PAYMENT USING THE RETURN ENVELOPE ENCLOSED. r 0 PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHMES ABOVE. I Emig =11N 0111-101100M ROOM e 11620 '26 CHEST2 'VIEWS 786.50 41.00 06/05/05 E 72040 26 CERVICAL SPINE (2 OR 3 VIEWS) 723.1 40.00 PENDING INSU NCE PAYMENT: .00 For questions, to update your insurance informaion, or for a * N(tice of Privacy Practices, phone us at (925). 96-7156, fax * u! at (925) 296-71.74 or email us at billing@bMm net. Please * i r chide your account number in the email or on� ihe check. Dsi 700132 MACARANA5. 3 EPH: 0132-827062 81.00 LOCATION OF SERVICE JOHN MUIR HOSPITAL 1601 NUWid VkLL ROAD TU, M 06/28/05 HURT, C INCOMPLETE INS INFO. PLEASE SEND SAY IMAGING CONSULTANTS MED GROUP Copy OF YOUR INS CARD FRONT AND BACK PO Box 31456 OR REMIT BALANCE. WALNUT CREEK CA 94598 IRS#94-2966646 PHONE'925/296.7166 PHONE HOURS:8:00 ain.to 4:00 prn. _--=PLACE Of SERVICE: I-INPATIENT HospiTAL 0=0VtPA'nSNT HOSPITAL F-2F—RaS e-EMEAGENCY ROOM 1.if you wish our assistance infiling atialim for Yourftsaith insum,to welb,Please Complete this form and return It to our office.Failure to return the form automatically makes you responsible for payment In full. 2. R you need another claim fled for 1 second insurance company,please make 9 pliatocopy,of this statement,then complete one form for each insurance carrier.Return all iorms to out office. 3.Bd sure to sign the Appropriate authorbation(s)below for each form submilled. I HEREBY AUTHORIZE THE PROVIDER SHOWN ON THIS FORM TO RELEASE TO Insurance Company: AUTHORIZATION. MY INSURANCE COMPANY ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. ClaimOffice Address: x Policy No.: Gtoup,No.; AUTHMUTION:I HEREBY AUTHORIZE AND DIRECT MY INSURANCE ODMPA14Y CARRIER TO PAY DIRECTLY TO THE PROVIDER SHOWN ON THIS FORM ANY BENEFITS DUE ME UNDER MY Name of Insured: Soc,Sec.No,: INSURANCE PLAN.I:AGREE TO PAY THE BALANCE OF EXPENSES NOT PAID UNDER THIS PLAN. Employer Relation,of of Insured: Pot"to Insured, x �jgjggi;granallmal 111 Mill 0121:110111iIII1910�Pzp 1110[ago N"I a a if Ink,N 1z Imagnamaggy. agglai'! STMT-1110(1104) DR3 OFFICE � t Jose K. Reyes, M.D.,Inc. 1625 Tully Rd. San Jose,CA 95122 (408)929-0606 Patient, W oscvh Macaca Ids b 1. T ispl e s is DBTehtl 2825 PeidlawnDr. ?. Diagnasis DBTe�,-: San Jose,CA 95149 3. Diagnosis DBText, 4. Diagncsls DBTex4' D.0,1 0,512005 0.01 t1 i/2005 Te)c4 Date DoWeiption Procedure Modify Glx 1 Dx 2 Ox a Dx 4 Units C14arge 8!51X[)5 111111a outpatient Once V's?r 99,201 300.00 '780.4 &7O 847.1 215.010 8�Sf2005 Motrin 600ing*30 37143 300.00 780.4 647.0 847.1 i 7`,00 Fi'.9>2005 �� Outpatient Office Visk 9Q14 $47,1 $47.' 845.0 W4 9 115.00- 1911-7005 =1911-70?5 M�trz:n 600mg&30 17140 8471 347.2 8-5.0 840.3 1_'.()t P 3r'id rL ter tion regi Chareps S 534000 --- —Provider'NaTm- Jose K.Reyes WD. Totii Vaymettt; License; A53379 1otalAdjustments; �Ctri� Medicare)PIN- i3(} 53790 "Total Due This Visit: $354.00 S N or FIN, 91.2051579 TsuIACeaunt Balance: , S.3`4DO i e¢'21 Tex 22 Text i Teas?t t� �4 ain Injury Care Center 1111 .C. ax Icy. 77-154" 1 x:«x+.erxa .x..x ..... ..r.........ro«a.... ue.... ... ... »r ...: ....... Dear Attorney Castillo, Here are the diagnos ses you requested far the Ma,caranaas'f=iiy, Jessi; Left foot pain,right hip contusion.left,§hculder pain,neck, s pram}r sau1n,upper back sprain/sftin,myofascitis. Kristine:*peck spnin/st-ai%upper back sprainlstrain„right ankle Sprai ' train,knees contusion.. taw bask sprain/straim. JOLSeph.,Neck sprauvstrair4 upper back spramistraih,lower track sprainfstrrdn. right crest wall contusion,right foot pain. RAIN INJURY CARE CENTER 730 STOIRY RD.#2 SAN JOSE; ,-,A 95122 10/1212006 l Joseph lMacaranas 2825 Pendle Ton br MA ,1000'; Ean Joss-,CA 9514 { 7111$2005 98940 Chiropractic Manual Therapy 9011 50,00 711112005 9T1Q-€ Myofascial Release 901 25.00 E 711112' 05 97D1,4 Electrical Stimulation Q1 2D.00 71 Ell Ql L1x612 Wehanical Traction 4[l1 20.00 711=200" 94)21 Re-examimation 9Ci150.00 Y 13/200: O$W" Chimpractic Manual Th6r°apy 900 5000 111312005 97140-59 myowdw Ri�qsase 9011 25.00 71312005 97014 Electrical Stimulation, 1.401 1410.00' "r1 /20 0 16 97 P"1i Medhanical Traction 901 X00 7f7Aw2G 9ta4.a(,, Chimpreek,Manual Therapy 901 "Ti S2 05 9.1 :Q-59 Mcsf wtlal Release 3011 25-00 '! 0;;. 1;7 D I ectri,;al St.: Muiatlon 9U1 2D 00 711 12G04 91012; %Ieclianical Traction 901 20,00 "fllerlaOcs OPAO CrOm;)ractic Manua!Therapy 9101 I 50,00 Myofascial release W1 25,00 C1 T;.83'20+wt's i 14 Electrical Stimulation 901 2V,0 i 5;2lw z r. C'7 MachaNcal Traction 20,00 .1 94 C C l xircipm tip Manual I hera y X01 �O.DC� 7,'2l ,20-,z. 97�4Q-P!� Myofacial Release 001 25.00 7120,12005 Clectricai Stimulation 101 20.0c, "7t" ^r+liu 7(112 li1leohaT13 of Traction Zl i 20,00 V22005 RK940 niropractic Manuel Tterapy; 53 1 50.00 1'22#51)n 971.40-59 MyofaaCial Ft cage 3 2Fi.t t1 ( Continued 3,845.30 „r>r- nupG ;r PAIN &INJURY CARE CENTF.R '30 TORY RD, #2 SAN JOSE,` 4 95122 110.112t200' (408)287-5540 Joseph macaranas 2.825 f�endle ion IAC LMACJ00017 � Sart Jose, Cid 9514$ w 7122/20.0$ 47014Electricals Sttimulation. ' 9011 7122/2005 971712 Mechanical Traction 901 20,610 7;25,'2005 46940 Chiropractic Manual Therapy 901 50.00 712512005 9714Or5'9 Myof spial Raieass 9011 25.00 712512006- 97014' Electrii,al$timulatlon 90- 20,01 712.5/2005 970j2 Mechanical Tractlnn 90 20 ttQ' 7P2`12005 96040, Chiroprac#lc Manual Therapy 901 60X 7V,12105 97140.59 Myofascial Release 901 25,4E V271200,65 97014 Electrical Stimulation 001 20.00 72 i 7'2005 97012 Mechanical Traction 901 20-DO 712912005 98940 Cniropractic Manual Therapy 901 50,00 7129,"2005 97110-59 Myofascial Release 901 2&00 70912005 97014. F-lectrical Stimulation 901 20,00 7:2912005 97012 Mechanical Traction 909 20,00 811:2009 98040 Chiropractic(l Masai Therapy` 901 50,00 8/112005 97140-59 Myofascial Release 909 25.30 81112005 970214 Electrical Stimuiation' 919 20,00 si.V2005 97012 Mechanical Traction 901 20,00 81'FW2C0S Rew, Chiropractic Manual Therapy 901 50.00 ,N2005 47 214 Electrical Stimulawn 901 20.00 815112005 97012 Mechanical Traction 901 2U.00 8ferzx,5 98940' Chiropractic Manual Therapy 9131 50-00 18120 :5 97014 Electrical Stimulation 901 29.09 c;rar r'uaci QonfirutsC trattfncted 3," .003 i . .................. PAIN & INJURY CARE CENTER 730 STORY RD,#2 SAN JOSE, CA 96122 10/12/2005 5 `408)28-7Z540 L Joseph Macararvas JACJC�7 2825 Pendle Ton Dr pan Jose, CA 95148 8/8/2W5 97012 Mechanical Traction 901 20.00 811212005 98940 Chiropractic Manual Therapy 901 50,00 8112/200b 97014 Electrical Stimulation 901 20-00 8/1242006 97012 Mechanical Traction 0-01 20.00 8111-7/2005 98940 Chiropractic Manual Therapy 901 50.011 811712005 97014 Electrical Stimulation 901 20,00 8,11712005 07012 Mechanical Traction 001 20.00 811912005 96940 Chtropradie Manual Therapy 901 50.00 6110912005 9701A Fledrical Stimulation 90, 20,00 811912X16 97012 Mechanical Traction 1901 20.00 3122,12005 98940 Chiropractic Manual Therapy 901 50.00 812212005 97014 Eled.rical Stimulation 901 20.00 512212005 97012 Mechanical Traction Ro 1 20.00 8126120Ct 98940 Chiropractic Wnual Therapy 9011 50.00 5!26i200f� 97014 Electrical Stimulation 901 20.00 812612006 97012 Mechanical Traction 901 20.00 5+131/2005 99212 Re-examination 901 60.00 e131/2005 98940 rhiropracfto Manual Therapy 901 WOO 013112401;197014 Electrical StirniAltiOn 901 20.00 Mechanical Traction 901 20.00 8131/201G5 97012 901 50,00 91212006 98940 Chiropractic Iftnual Therapy qf)1 20.00 91212005 97014 Electrical SUMUlatiOn 901 20.00 q/2121305 67012 Mechanical Traction C ontinued Continued PAIN IWURY CARE CENTER 730 STORY FPr7. SANT JOSE, CA 0z'12210/1212006 � (40-3)287,Z540 -- 825'Pendl ;Ton Or MAS J04 G' Sail Jose. CA 05148 91712005 98940 Chiroprictic Manual Therapy 504 50.00 9t7,12405 37014 Electrirsi Stimulation901 240.00 9171 005 137012 Nlact anical Tradon 901 20.{00' 9114/200 08940 Chlropract Manual Therapy 901 50.00 V14120!4' 97014 Electrical Stimulation 901 20.011 9/`lPf1-GQ 989401' Chiropractic Manual Thempy: 901 50.00 1S/l912GO5 910114 Elaotrical Stimulation 901 20,00 1/23,'2005 989411' Chiropractic Manual Therapy 90 $0.00 912312005 97014 Electrical Stimulation 901 21100 k' k .a1� ( so.na CLAIM HQARD OF UPE,RVISORS OF CON I .A !QOSTA COUNTY � • BOARD ACTIONtN Claim Against the County,;or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT'' and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Cade Section 913 and 915.4. Please note all"Warnings". AMOUNT: $500,000.00 CLAIMANT: MARIA CRISTELITA M MACARAI AS ATTORNEY: MARLU S. CASTTLLO DATE RECEIVED: OCTOBER 14,: 2005 LAW OFFICES OF MARLU S. CASTILLO ADDRESS: 1625 THE AIAM DA #622 BY DELIVERY TO CLERK, ON: OCTOBER 14, 2005 SAN JOSE, CA 95126 . BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Hoard of Supervisors TO, County'Counsel Attached is a copy of the above-noted claim. OCTOBER 14, 2005 3OIIN SWEET , Dated: Fay: Deputy F Fit m—: County CouneelF.. TO: Cldrk of then Board of Super4isors (44his claim complies substantially with Sections 910 and 910.2, G ( ) This Claim FAILS to comply substantially with Sections 910'and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8), { ) Claim is not timely filed. The;Clerk,should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3): O Other: Dated: By: Deputy County Cour III'. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section'911.3). IV. 13DARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( )` tither: f_ I certify that this is a true and correct'copy of die Board's Order entered in its minutes for this date, r Dated:44 - JOHN SWEETEN,CLERK.,By Deputy Clerk WARNING(Gov. code se ion 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposi in the mail to file a court action on,this claim. See Crov+ernment Cade Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so irn�rtediately. *For Additional Warning See Reverse Side of This Notice. ' AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned, have been a citizen of the United States, overage 18 and that today I deposited in the United States Postal'Service in Martinez, California,postage fiii prepaid a certi>ted copy ofthis Board Order and Notice to Clainiatit, addressed to the claimant as shown above. Dated: ' p4 /(0.cA i 1O `SWEETEN, CLERK By Deputy Cie BOARD OF''S E.RVMPS5 OF CC►NTRA.COSTA CC 'TY LNSTI UCTIONS TO,CLrAMANT A.. A claim relating to a cause of action for death or for Wu.ry tb pe�s0 Or to personal property cr gmw7 ercps shall be 'presented not later than six months after the ROM I of the cause of action. A. claim relating to any other cause of action shall be presented not later t-11=one-ye"a.r after`tt�e accnad of the cause of action, (0m.,. Code §911.2.) R Claims mist be filed with the Clerk of the Board. of Supervisors at its office in: Room 106, Cour*Administration Building,651Pine Stre-at,Martinez,CA.94553. C. if claim is,against a district govemed by the Bogrd of SupenAi ors, rather than the County, the nares of the District should be filled in. D. If tht claim is against more than. one public entitisep , arate claims'mus: be filed against each public Entity. E. f 1. See penalty for fraudulent claims,Pewl Code Sec. 72 at the end oftbis form. sago*rrrrtertrsrrisrrrarrKsrr one rtssrrrrrrrfrr■rrrxa�rrrrrrrrsrsrrrrtretarrrsei'rA RE: Claim By: Reserved for Clerk's filing stanyp ABTA C'RIETELITA M. &ACARANAS ) JyE# VED I� Against the County of Contra Costa or 7 OCT 1 4 2005 East Contra Costa Fire Protect'ioA D strict District) C1.5KBOARD3FSUPERVISORS ' (" ill in the name) ) CONTRA COSTA Co. l The undersigned claimant here=by makes claim against the County of Contra Costa or the above-named d3 S#Iict iii tilt sutra.of$5 0 0 0 0 0•0 0 and in support of this elli=represer"as folloutS': L When slid th-damage cr is�jsuy occur? (give exact dente and hour) June 5, 2005 t}T iptA , I %ere did the damage or injury occur? C',nclude,offy and county) Vasco Road and. Camino Diablo Road in Contra Costa County 3. How did the damage or Wm,occur? (Give fit deteMs;use extra paper is re-quiet-d See Annex "A" and made` part' hereof. 4. What pwdcuta act or Mission on the Par:of Gourrtv ar district Officers, senm=.,=., or cmployoes caused the injure or damage? See Annex "B" and made part hereof'. 5 %at are the names of county or district officers,servassta, or employee,causing the damage or injiury7 JOSEPH PATRICK PELOT 0. Wlat damage or injuries do your claim resulted? (Cruse full extent of iniuries or ciemag;? claii-ad. Atta-,two estimates for auto damage.; � See Annex "C" anal made part hereof. 7. How 9,u the amount ''claimed above eoi�nputed?, (Includetete estimated arnottnt of my, Pros esti inlurY or(iamaP.) Based on the nature' of the injuries, current medical bills, Pain and suffering, lost wages. 8. :amen and addresses cif'Aitnes.3es,doctons,and haspitalss, See Annex "D" and made part hereof. 9. List tb,--,ex sutures you=ad on account of Ons accident or injtuy. t MiMM fAii M K Mf..aif as aMa*MA Ana a**M#faaAar rYi#riiiA#i r r1td.m M•a ata a aillY sMe#r.f am%ar Aat:a a**Y t l .1 .Gots.Carle,gest. 910.2 provides"Me clwim sball be . signed by claimant or by some prison on his j belml. 't}T3Cl*S 14}" (ftirrntr} Nam and address'of 4ttoruey � MARLU S. CASTILLO Law Offices' of Marlu S, (Claitzut's S" i Castillo Ma a Cristelita Macaranas 1625 The Alameda #622 San ,Jose, CA 95126 1 2825 Pendleton Drive, San Jose, CA 95148 Te epho e,No.(408)293 8508 Telephone No. (408) 528 741 5 aYr'JKrr4lsoaaYY*Y■rq rr rrY a1Y rltrrarM:arYrrfri ait t lYa Ytt�arrr#t•rrinafi-i r..Ma tr Y.ifrAa KIY tt is YNf Yidt: FUBLZC RECORDS NCITTM 1*)em be advised to ar this cit m,form.or any claim filed with the Coumt7 under the Tort Clainis Act,is Gubjac:Tri. x�blic disclosure undue de Csli ria Public Records Act:. (Gov. Code, ,95 6500 et seq.) I#urthermore, any attachauents,raddea duds;or supplements attached to the claim fo m.,including medical r ords,am also subiect:c put3lie disclost". an*raraatruraar•Yaarrno*Yraenraaaartis#erar,rr'rrArr'arrrrYxrYarllrYrllMxYYsrsarraaeatia�rsatrrx� Section 72 of`t44 Penal Code provides. B%rery Verson who, with intent to defmud,pmts for aflo-wrante or fbr ps ment to Wy state board or of r, a to any county, city, or district bDard or offic.,er, authorized to sallow or pay the same if Seauine,-unv falsa or f'raudulm-it claim, bili,aorta„trot voucher.or+writing, is punishable either by imximmem iq the County*I for a period of not macre the carie yosr, by ar.fine of Writ cot ding one thousand dollars i$1,00C,00), cr bbmh sucl, Imprisonment and lame, or by irnprisomneut in the sty O prison, b}, a fine Of no exeseding`an.thousand doi'.a:E (,10 000),or by bath such impriscnm att and 11m. u, at ;1a a e o:` i iuties do %,Our riairn resulted? (;Gaive full extent 'of niuri� or ,1ern isa ry., daftracd. Att -,l",,to n v-,;6m.ates for auto damage.) " See Annex "C", and.'' made pari hereof;, 7. ljow vvas the ,.)uat clamed above eompuutud,' t1aclude the edimmd amotcnt -of MY prijspe0tiVeiAJUrY0tdaraa9eJ Based on the nature' of the injuries, current medical bills, pain and suffering, lost wages. 4. sxneM� addte,3ses cf ftesx,do ttrrs,and epi?; See Annex "D" and made part hereof. 9. List tlte expend%t s yc.ru'raa&on account of this a. cident or injtny: ME lYaY:tiffMMt t�R RRRl':R1ClLl.:!!!!!!'!!!RlM!!tlltR!!!!!l R11`!t!Y'XlMRtYM.:1 LL119[I[31.Mfi!!lR!lf t!!FY!lk R:RtC ;t .Ciray.Cade Sec. 910.2 prc7vides``rbe claim shat be , :a signed by the claiuuwd or by some person or his }behit-" ,.moi {_ ; ( cr:try? t Name and address of Attorney l 4 MARLU S. CASTILLtJ � Law offices of Marlu' S. ) (CWmant'sS11 Castillo Maria Cristelita Macaranas 1625 The Alameda #622 San' ,lase, CA 95126 } {.F>`ddmss } 2825 Pendleton Drive, San Jose, CA 95148, Totephone,N.(408) 293-8508 )TrlephoneNa. (408) 528-7415 isrM's[sttaaltgot-satmu Owasso ptins#rare'aa$ussswac/RsrlalrwK*Xraasrs: PUBLIC RECORDS NOTICE- P''M-ne be advised that this claim farm,or any claim filed with the Cour_I7 under the Tort Claims Ace,is eubj; t T41 p-rbllc disclosure under the Calif+orrtia Public gals Act. (Gov. Code, 556500 et seq.) furtl ennore, azi e- attacbrue,its,'adr.it iutm:or supplements attached to the claim farm including medical mordA4 are also sub;ecc tt pu.trlic disclosure, is to**to a*V a$W*WS%KK0ft ds am 9 as*NOW*MAN *a am**a so Aaa"!Jss*ads Oda**us It us*l..t I so a 4m a..at wx::4- NOTICE: Section 72 of the Penal Cade pto v de s; Every person who,with intent to daliaud,presents for allowance:or fbr pa�`ta'leot to sky sate board'or offa;,er, o to any county, vitt', o?: district hoard or officer,er, authorized to allow or pay the same if genuine, any fhlst or traudulaut claim►,WL account voucher,or writing, is punishable either by imprisourtlem in the C+ou mi Jill-for n period of not more'thim one yazar, by a fine of not exceeding one thousand dollars DIRK-. 0).cr lb;N boar such Imprisonment and fine,or by huprisoninent In the state prison, by a fine of'not exoseding,•ets,+13ousand doi: s ($10,00,G),or by bath such imprisonment and fine. Annex „A„ 3 .HOW DID THE DAMAGE OR INJURY OCCUR? On June 5, 2005 at or about 2 :45 P.M. , I claimant Maria Cristelita M. Macaranas was the front seat passenger of the 1994 White Dodge Rain 250 with California License No. 3KCU931 driven by my husband, Joseph Q. Macaranas that was struck by aFire Truck owned by the East Contra Costa Fire Protection District and driven by its employee Joseph Patrick'' Pelot. This accident happened at the intersection on Vasco Read and '' Camino Diablo in. the Delta Municipal Judicial District, County of Contra Costa. . At that time we were stopped on Camino _Diablo Road westbound intending to 'make a left turn unto' Southbound Vasco Road. Together with us at that time were my children Kristine Macaranas and Jessica Macaranas, and mfr niece Jasmine Laureta, who were the rear seat passengers. While we were stopped, the Fire Truck appeared in the distance traveling eastbound on Camino Diablo Road at a very high rate of speed. The traffic light was red in his direction at that time . The Fire Truck did not slow down and continued to approach the intersection_ at a high rate of speed. The traffic' light was still :red. As the Fire Truck sped through the intersection it collided with a Toyota Corolla who was northbound on Vasco Road. The Toyota Corolla then hit the Light pale on the median strip. A passenger of the Toyota Corolla died as a result of the collision. The Fire Truck 'veered to the left and struck our Dodge Ram vehicle violently causing major' damage as it was declared. a 'total lose The Fire Truck driver,; Joseph Patrick Pelot was negligent in driving the Fire Truck because he failed to slow down before entering the intersection and when he was crossing the intersection and ensuring that traffic, in all directions were ' clear and safe for him to do so. He failed to exercise the duty to drive with due regard for the safety of all persons using' the highway. As a result of the accident I suffered serious personal injuries and was brought by an American Medical Response ambulance to the John Muir Medical Center in Walnut 'Creek, California for emergency treatment . Surgery was performed the next 'day, June 6, " 2005 for my fractured right shoulder. ' Annex "g„ 4 . WHAT PARTICULAR ACT OR OMISSIONON THE FART OF COUNTY OR DISTRICT OFFICERS, SERVANTS, OR EMPLOYEES CAUSED THE INJURY OR DAMAGE? JOSEPH PATRICK PELOT, an employee of East Contra Costa Fire Protection District and while driving the latter' s Fire Truck negligently crossed the intersection on Vasco Road:: without slowing down and making sure that traffic in all directions were clear and safe for him to do so. As a result of Joseph Patrick Pelot' s negligence he collided with a Toyota Corolla who was northbound on Vasco' Road and then he ('Pelot) struck the Dodge Ram of which claimant Maria Cristelita M. Macaranas was a passenger causing personal injuries to the latter. Annex "C" 6 WHAT DAMAGES OR INJURIES DO YOUR CLAIM RESULTED? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) As a result'' of the accident I incurred a Right Humerus Fracture, Sprained Left Shoulder, Acute Postthemorragic Anemia, Hypopotassema, Hematuria, Sprained Shoulder, Acromioclavicular, Calculus of Kidney, Nospecific Abnormal Findings on Radiological & other 'examinat. on of lung field and Painful Respiration. Todate, I am still undergoing medical treatment with Dr. Donald Lewis of 'John Muir Medical Center and John Muir Trauma Physicians, and physical therapy with the Golden Hills Orthopaedic Sports Physical Therapy, Inc . for the injuries I incurred as a result of the vehicular accident, hence I do not know yet the total of my medical bills as if presentation of this claim. Medical bills I have on hand todate are as follows: 1. .John Muir Medical Center $99, 696 . 34 3 .John Muir Trauma Physicians 7, 456 . 38 4 .John Muir Orthopaedic Specialists 143 . 00 5 .American Medical Response 11986 . 58 Total Todate $109, 282 . 30 Lost' Wages Claimant is a QA Specialist with Maxim Integrated Products, 120 Sana Gabriel Drive, Sunnyvale, CA 94086 with a monthly salary of $4, 077,48 per month. She was unable to work from June 5, 2005 to October 4 , 2005 and ,lost a total of $16,, 309 . 92 in wages , ANNED it Dif 8 . NAMES AND ADDRESSES OF WITNESSES, DOCTORS AND HOSPITALS : Witnesses: 1 .Joseph Q. Macaranas-2825 Pendleton Drive, San Jose, CA 95148 2 .'KristineMacaranas-2825 Pendleton Drive, San Jose, CA 95148 3 .Jessica Macaranas-2825 Pendleton Drive, San Jose, CA 95148 Doctors and Hospitals; 1.Dr. Donald Lewis-John Muir Medical Center-1601 Ygnacio Valley Road, Walnut' Creek, CA 94598 2.Dr. Michael Baker-John Muir Medical Center-1601 Ygnacio Valley Road, Walnut Creek, CA 94598 3 .John 'Muir Medical. Center-1601 Ygnacio Valley Road, Walnut Creek, CA 94598 4 .John Muir Orthopaedic Specialist-P.O. Box 31:396, Walnut Creek, rCA 94598-8396 5 .John Muir Trauma 'Physicians-P.O. Box 9021, Walnut Creek, CA 94596 6 .American Medical Response-P.O. Box 3429, Modesto, CA 95353 67 .Golden Hills Orthopaedic Sports Physical Therapy, Inc- 2680 S. White Road ##200, San Jose, CA 95148 5555516360 MACNAS,MARIA Gender :,Female Age :'48 �� — Disposition Horne; Self Care (1") Medicare DRG 218 LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC CMS wt 1.5762 AtLOS 5.5 G/LOS 4.3 All Patient Refined DAG Information 315 SHOULDER, UPPER ARM & FOREARM PROCEDURES APR wt 1.1974'Low Trim 1 High Trim 9 Status: LOS Inlier 008 DISEASES AND DISORDERS OF THE MUSCULOSKELETAL SYSTEM AND CONN TISSUE 2 Moderate Severity of Illness 1 Minor Risk of Mortality Principal Diagnosis *81200 CLOSED FRACTURE OF UPPER END OF HUMERUS, UNSPECIFIED PART AFFECTS APR-DRG *SOI=P Principal diagnosis used for SOI calculation *ROM=P Principal diagnosis used for ROM'calculation Secondary'Diagnoses *2851 ACUTE POSTHEMORRHAGIC ANEMIA SOI=2 Moderate ROM'=1 Minor 2768 HYPOPOTASSEMIA *SOLS Moderate. *ROM=1 Minor #5997 HEMATURIA SOI=1 Minor ROM=1 Minor E8121 MOTOR VEHICLE TRAFFIC ACCIDENT (COLLISION), PASSENGER(OTHER THAN MOTORCYCLE) SOI=1 Minor ROM'=1 Minor E8495 Injury or Poisoning occurring at/in street and highway SOI=1 Minor ROM=1 Minor 83104 CLOSED DISLOCATION OF SHOULDER, ACROMIOCLAVICULAR SOI=1 Minor ROM=1 Minor 5920 CALCULUS OF KIDNEY SOI=2 Moderate ROM=1 Mirror 7931 NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL&'OTHER EXAMINATION OF LUNG FIELD SOI'=1 Minor ROM=1 Minor 78652 PAINFUL RESPIRATION S0I=1 Minor ROM=1 Minor Principal Procedure *7931 OPEN REDUCTION OF FRACTURE WITH INTERNAL FIXATION OF HUMERUS AFFECTS APR-DRG page 1 EASE REMF YOUR PAYMENT TO:., j "Dl-TR HN MMR')MT,DIABLO HEALTH SYSTEM1.BOX30000PART�ttENT 33370 6 15 05 . 1 N F�ANCiSGO,CA 94139-3370 5�.�47-3336 DISCHARGE PATIENT-NAME PATIENT NUMSE-R- AG R 5 5 3 6-0-1--F-7 9Y 6 05 aINSURANCE COMPANY NAME GROUP NUMBER El 5. a6 '1a a POLICY NUMBER 005301 ''GREAT WEST LIFE 359606 575390649 026503 USAA DOI06 05 -.;05 16870628 CHARGE TO MY: 0 VISA ❑ MASTERCARD 0 AMEX © DISCOVER MARIA MACARANAS CARD#', 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE C_ J SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE ERVICE DATE ITEM NO 1 DESCRIPTION P QTYUNIT PRICE TOTAL CHARGE 06/05/05 17425 ROOM 480 S 121 32 1 4100.00 4,100.00 06/06/05 17425 ROOM 480 S 121 56 1 4100.00 4, 100.00 06/07/05 1742S ROOM 480 S 121 =.119 1 4100.00 4, 100.00 06/08/05 1742S ROOM 48'0 S 121 143 1 4100.00 4,100.00 06/09/05 1742 ROOM 480 S 121 164 1 4100.00 4,100.00 TOTAL MED SUR-GY/2 BED 20,500.00 06/05/05 207 MORPHINE 4MG/ML, 1 ML 250'. 1 1 78.00 78.00 06/05/05 207 MORPHINE, 4MG/ML, 1 ML,. 250 3 1 _ 78 . 00 78.00 06/05/05 243 IBUPROFEN 200MG,TA TAA 25`0 1`0 1 74.50 14 .50 06/05/05 2434 IBUPROFEN 400MG,TABLET 2 0 11 1 14 .50 14 .50 06/05/05 648 02 THERAPY 'INITIAL ' "250 " �4 1 196.75 196.75 06/05/05 648 02 DAILY CHARGE 250 35 1 1129.75 1, 129.75 06/06/05 203 PANTOPRAZOLE 40MG,10 ML 250 8 1 166.00 166.00 06/06/05 648 02 DAILY CHARGE 250 120 '1 1129.75 1,129.75 06/07/05 106 LEUOFLOXACIN 500MG,TABIET 250 28 1 82 .00 82.00 06/07/0- 203 PANTOPRAZOLE 40MG, 10 ML 250 8 1 166.00 166.00 06/07/0 243 PROPOFOL 200MG/10ML,20 ML 250 ` 29 1 121.00 121.00 06/07/05 6484 02 DAILY CHARGE 250 121 1 1129.75 1,129.75 06/08/05 106 LEVOFLOXACIN 500MG,TABLET 250; 28 1 82.00 82.00 06/08/05 203 PANTOPRAZOLE 40MG, 10 ML 250 8 1 166.00 16-6. 00 06/08/05 446 MULTIPLE VITAMIN/MINER,TABLET 250 33 1 14 .50` 14 .50 06/09/05 143 APAP/HYDROCOD 10-325MG,TABLE 250 20 2 15.85 31.70 06/09/05 2031 PANTOPRAZOLE 40MG, 10 ML 250 8 1 166.00 166.00 06/09/05 224 FOLIC ACID 1MG,TABLET 250 38 1 14.50 14 .50 06/09/0' 270 KCL 20MEQ,TABLET 250 39 2 14 .50 29.00 06/09/05 272 KCL 20MEQ/'15M 20MEQ/15ML, 15 M 250 34 1 14.50 14 .50 06/09/05 274 KCL 40MEQ/20ML,'20 ML 250. 35 1 76. 00 76.00 06/09/05 274 KCL 40MEQ/20ML 20 ML 250 36 1 76..00 76 .00 06/09/05 274 KCL 40MEQ/'20ML,20 ML 250 36 1 76. 0076.00 ContinuedPATIENT NUMBER , TOTAL AMOUNT 55555-16360 DUE 'HE HOSPITAL SILLS FOR CERTAIN'HOSPITAL BASED JOHN MUI'R t M7 DIABLO HEALTH SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT 'HYSICIANS.YOUR SURGEON,ASST SURGEON, P.O.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT 4NESTHESIOLOGIS3 RADIOLOGIST,ETC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE 3EPARA7ELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. -EDERAL TAX I.D.NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL(925)947-3336 2251L(12111103) =ASE REMIT YOUR PAYMBNT TO: � � TYPEOFBILL11 DATEOFBILL HN MUIR/MT DIA 3LO HEALTH SYSTEM � �, � 1.Bbx'.39000 D:1-TRI: 0 6/15/ 5,.0 I 2 I PARTMENT 33370 wx N FRANCISCO,CA 94139-3370 5�r 947-5336 PATIENT NAME PATIENTNUMBER SEX AGE ADMISSION DAYS MXIA MACARANAS 55555-16360 F 49Y 06 015 05 rF 06 110 0 INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER 005301 GREAT' WEST LIFE 359606 575390649 025503 USAA DOI06/05/05 16870628 CHARGE TO MY: �- ❑ VISA 0 MASTERCARD ❑ AMEX ❑ DISCOVER MARIIA MACARANAS ` CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE' L J SIGNATURE AMOUNT PAID'$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE ERVtCE *, DESCRIPTION TOTAL_ _. TE ITEM NO 06/09/0,5 3300 FERROUS SULFATE E 325MGTABLE 250 37 1 14.50 14.50 06/09/0''5 446 MULTIPLE VITAMIN/MINER,TABLET 250 33; 1 14.50 14.50 06/10/05 2030 PANTOPRAZOLE 40MG, 1.0 ML 250 8 1 166.00 166-.00 06/10/05 224 FOLIC ACID 1MG,TABLET 250 38 1. 14 .50 14.50 06/10/05 330FERROUS SULFATE E 325MG,TABLE 250 37 1 14 .50 14.50 06/10/05 446 MULTIPLE 'VITAMIN/MINER,TABLET 250 33 1 14.50 14.50 TOTAL PHARMACY 5,290.70 06/05/05 1004 D5 - LACT 'RINGERS,1,000 ML 258 4 1 210.00 210.00 06/05/05 1004 D5 - LACT P.19di ` 3258 9 210.00 210.00 06/06/05 1004 D5 - LACT ''RINGERS,1000 ML 258 12 1 210.00 210.00 06/07/05 1000 D5W 5%,50 ML 258 ' 23 1 120.00 120.00 06/07/05 1000 D5W 5%,50 ML 258 23 1 120,00 120.00 06/07/05 1000 D5W 5%, 50 ML 258 23 1 120.00 120.00 06/07/05 1000 D5W 5%,50 ML 258 23 '1 120.,00 120.00 06/07/05 1004 D5 - LACT RINGERS, 1000 ML 258 24 '1 210.00 210.00 06/07/05 1004 D5 - LACT RINGERS,1000 ML 258 32 ,1 210.00 210.00 06/07/05 1004 LACTATED RINGERS, 1000 ML 258 27 1 210.00 210.00 06/09/05 1000 NS 0.9%, 100 ML 258 35 1 120 .00 120.00 06/09/05 1004 DSW 5%,250 ML 258 36 1 120.00 120.00 06/09/05 1004 D5W 5%, 250 ML 258 36 1 120.00 120.00 06/10/05 1000 D5W 596,50 ML 258 42' 1 120. 00 120.00 TOTAL IV SOLUTIONS 2,220.00 06/06/05 500 PCA MORPHINE 1MGM/ML,30 ML 259 14 1 113 .00 113 .00 06/07/05 252 KANAMYCIN 333 .333MG/ML,3 ML 259 25 1 104.00 104.00 06/07/05 252 KANAMYCIN> 333 .333MG/ML,3 ML 259 26" 1 104-.00 104.00 06/07/05 CEFAZOLIN 1GM/5ML,5 ML 259 23 '1 84. 00 84.00 06/07/05 CEFAZOLIN 1GM/5ML,5 ML 259 23 1 84.00 ' 84.00 06/07/05 CEFAZOLIN' 1GM/'5ML,5 ML 259 23 1 84.00 84.00 Continued PATIENT NUMBERi 55555-16360` rHE HOWTAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT'DIABLO''HEALTH SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT 'HYSICIANS.YOUR SURGEON,ASST.SURGEON, P.O.BOX 39000 FOR YOUR RECORDS.ALL SUSSEOUENT kNESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILLYOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE 3EPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. 2251E It2iiyiosy -EDEHAL TAX I,D,NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL(925)94'7.3338 ............ ........ EASE REMIT YOUR PAYMlENT TO:, HN MU48/MT DIABLO HEALTH SYSTEM ).BOX39000 PARTM ENT 33370 N FRANCISCO,CA 94139-3370 5)-347-3336 DISCHARGE DAYS ADMISSION PATIENT NAME MARIA MACARAS 55555 --A-s�y-1 Oi05 05 06 10 0 INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER 005301 GREAT WEST LIFE r-359606 575390649 026503 USAA D0106/05/05 16870628 CHARGE TO MY- 0 VISA 0 MASTERCARD 0 AMEX 0 DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE SIGNATURE AMOUNT PAID'$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE DESCRIPTION TOTAL CHARGE 06/07/05 E CEFAZOLIN 1GM/SML,5 ML 259 23 1 84 .00 84.00 06/07/05 84E MIDAZOLAM 2MG/2ML,2 ML 259 31 1 77.00 77.00 06/09/05 85-d LIDOCAINE 1 1% MDV 50ML,2 .5 M 259 36 1 74 .00 74 .00 06/09/05 85'j LIDOCAINE 1 1% MDV 50ML, 2.5 M 259 36 1 74 .00 74 .00 06/10/05 E CEFAZOLIN 1GM/5ML,5 ML 259 40 2 47.00 94 .00 06/10/05 E CEFAZOLIN 1GM/SML, 5 ML 259 41 1 84 .00 84. 00 TOTAL DRUGS/OTHER 1, 060.00 06/06/05 112- DRESSING',COBAN 4 IN 270 81 1 0.00 0.00 0.00 0.00 !$G' ,,216 82. .7 06/06/05 114, DRESS 06/06/05 117A DRESSING GAUZE SPG 4X4TI 12PL ,ST ;2 70 8.3 1 0.00 0.00 I 06/06/05 119A DRESSING,SvkbIP)!0 °4XT.z S'S 270':`l 84 2 0.00 0.00 06/06/05 1289! DRAPE, SPLIT (6X40) U-SHEET 270 96 '2 78 .00 156.00 06/06/05 157 STOCKING,TED THIGH MEDIUM REG 270 87 1 65.00 65.00 06/06/05 1844( SUT,VICRYL 3-0 J-838D CT-1 181- 270 98 1 143 .00 143 .00 06/06/05 185C PCA SET LONG MINI BORE. 270 '173 1 102.25 102.25 06/06/05 218E DURAPREP 26CC 270 90 1 0. 00 0.00 06/06/05 291E CLEANER,KLENZYME 1 OZ 270 91 1 0.00 0.00 06/06/05 303E SLEEVE,THIGH LENGTH SEQUENTIAL 270 92 1 473 .00 473.00 06/06/05 305C DRAPE, IOBAN 36 X 18 270 93 1 67.00 67.00 06/06/05 306E DRAPE,C-ARM 60 X 106 270 94 -1 0.00 0.00 06/06/05 3236! HANDLE LITE RIGID 270 100 1 0.00 0.00 06/06/05 32881 SUTURE,VICRYL 2-0 CT -1 CR 1811 270 101 1 140. 00 140.00 06/06/05 8037( PUMP IV INFUSION RENTAL 270 175 1 217.00 217.00 06/06/05 8315E TED, UNITS (SCD) 270 118 1 277 .00 .277 .00 06/06/05 8315E MOTOR TED COMPRESSION DEVICE REN 270 174 1 293 .50 293 .50 06/06/05 8366( PUMP PCA RENTAL 270 50 1 306-50 306.50 06/06/05 863( PACK,LARGE TABLE 270 95 1 216 .00 216 .00 06/07/05 8037( PUMP IV INFUSION RENTAL 270 67 1 217.00 217.00 06/07/05 8315E MOTOR TED COMPRESSION DEVICE REN 270 66 1 293 .50 293 .50 Continued PATIENT NUP41SER 55555-16360 'HE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MMR/MT.DIABLO HEALTH SYSTEM PLEASE RETAIN THiS DETAIL STATEMENT 1HYSICIANS.YOUR SURGEON,ASST.SURGEON, P.O.SOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT kNESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE 'EPARATELY FOR THEIR SERVICES i SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. -EDERAL TAX I.D.NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL(925)947-3336 2251L(121111031 =ASE F3EMIYOUR PAYMENTtO: , rTYPE OF BILL DATE ; F BILL qN MUIR/MT.DIASLO HEALTH SYSTEM YfiL`ir '� BOX 39000 �'✓ Dl-TRI 06/15/05 PARTMENT 33370 N FRANCISCO,CA 94139-3370 5)'447-3336 PAflENT NAME PATIENT NUMBER SEeDISCHARGE DAYS MAMA MACARANAS 55555-16360 F 49Y 06/05/05' 06/10/0 INSURANCE • ,, GROUP NUMBER POLICY 005301 GREAT WEST LIFE 359606 575390649 026503 'USAA I D0206/05/05 16870628 CHARGE TO MY: 0 VISA ❑ MASTERCARD Q AMEX ❑ DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE L J SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE �ERVICE DATE ITEM NO DESCRIPTfONTOTAL CODL 06/07/05 8366C PUMP PCA RENTAL 270 68 1 306.50 306.50 06/08/05 8037C PUMP IV INFUSION RENTAL 270 122 1 217.00217.00 06/08/05 8366C PUMP PCA RENTAL 270 123 1 306.50` 306.50 06/09/05 8037C PUMP 'IV INFUSION RENTAL 270 148 1 217.00 217.00 06/09/05 8315E MOTOR TED COMPRESSION DEVICE REN 270 147 1 293 .501 293 .50 06/09/05 8366C PUMP PCA RENTAL 270 149 1 306.50' 306.50 TOTAL MED/SUR SUPPLIES 4,613.75 06/06/05 3 INSTRUMENT PROCESSING, MAJOR 272 80 2 0.00 0.00 06/06/05 123 GLOVES>'TRIPL k `.St�R.G01NE` 8e 5%. 27 x., 85 0.00 0.00 06/06/05 149E STOCKINETTE,TUBULAR STRILE 6" 272 86 1 0.00 0.00 06/06/05 179 SODIUM CHLORIDEINJ 1000CC'' ` "27.2"' 8 1 0. 00 0.00 06/06/05 179 WATER,STERILE 1500ML SRR AQUA 272 89 2 0.00 0,00 06/06/05 1821 STAPLER SKIN ROYAL 35W 272 97 'x. 105.00 105.00 06/06/05 211 IV PUMP SET W/O FILTER 272 ;176 1 257.75 257.75 05/06/05 30941 NEEDLE STIMUPLEX. INSULATED 22G 272 99 1 99.00 99.00 06/06/05 3306 BLANKET LOWER BODY 272 102 1 90.00 90.00 06/06/05 3606 SET MAJOR BASIN 272 '`103 ;1 134.00 134.00 06/06/05 3689 NERVE BLOCK PAIN PAK CUSTOM' 272 104 1 115.00: 115.00 06/06/05 3824 PAD GROUNDING SUREF'IT W/101 CA 272 105-1 0. 00' 0.00 06/06/05 3824 PENCIL ROCKER W/HOLSTER' DISP 4 272 '106 1 0.00 0.00 06/06/05 4862 PACK `,START 272 107 1 110.00 110.00 TOTAL STERILE SUPPLY 910.75 06/06/05 9'Bfl0 SCREW 3 .5MM CORTEX 'SELF-TAPPIN 278 "108 1 203 .00' 203.00 06/06/05 9800 SCREW 3 .5MM CORTEX 'SELF'-TAPPIN 278 109 1 203 .00 203 .00 06/06/05 9800 SCREW LOCKING 3 .5 SELF-TAP 40M 278 -'.110 3 566.001 1,698.00 06/06/05 9800 SCREW LOCKING 3 .5 SELF-TAP 36M 278 ,111 "2 554. 00' 1, 108.00 06/06/05 9800 SCREW LOCKING 3 .5 SELF-TAP 34M 278 '112 1 566.00 566.00 06/06/05 98000 SCREW LOCKING 3 .5 SELF-TAP 32M 278 113 1 566. 00' 566.00 Continued TOTAL AMOUNT 55555-16360DUE' THE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT.DIABLO HEALTH SYSTEM PLEASIY RETAIN`PHIS DETAIL STATEMENT PHYSICIANS.YOUR SURGEON,ASST.SURGEON, RO'.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILLYOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. FEDERAL TAX I.D.N0:94-1461843 FOR BILLING INQUIRIES PLEASE CALL(926)947-3336 2251L(12/11/03) =ASE REMITYOUR PAYMENTTO: , 7!TR� -IN MUIR/MT,DIABLO HEALTH SYTEM BOX 39000PARTMIENT 33370N FRANCISCO,CA 94139-3370 5)-347-3336` PATIENT NAME OF 616 0 MA MIAME • -• a 005301 'GREAT WEST LIFE 359606 575390649 026503 USAA DOI06105105 16870628 CHARGE TO MY: (" 0 VISA 0 MASTERCARD ❑ AMEX 0 DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE L SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE DESCRIPTION QTY UNIT PRICE TOTAL CHARGE LGODE 06/06/05 9800C SCREW LOCKING 3 .5 SELF-TAP 24M 278 114 2 566 .00 1,132,00 06/06/05 9800 K-WIRE SYNTHES 2.00K150MM PK/l 278 '115 1 74.00 74 .00 06/06/05 9801C PLATE LCP' PROX HUM 3 .5 6H 35 278 '116 1 437 .:00 4,371.00 TOTAL SUPPLY/IMPLANTS; 9, 921.00 06/05/05 632 ER-URINE DIP W/O MICRO 81002 300 124 1 13.75 13 .75 06/05/05 639 ER-VENIPUNCTURE 300 :127 1 10.00 10.00 TOTAL LABORATORY 23 .75 06/05/05 1057 CPK TOTAII 3, 22- 1 i'17.95 77.95 06/05/05 1089C ALCOHOL (ETHYL}: ,LEVEL., 301, 16 1 285.,62 285.62 06/05/05 1167C AMYLASE 304 16 '1 185.35 185.35 06/05/05 11.95 MYOGLOBIN 301 22 '1 327.45 327.45 06/05/05 1227 BASIC METABOLIC PANEL 301 16 1 376.18' 376.18 06/05/05 1240 CK-MB - CHRG ONLY 301' 21 1 300.36 300.36 06/05/05 12401 TROPONIN-I - CHRG ONLY 301 22 1 772 ..29 772.29 06/06/05 1057 CPK TOTAL 301 37 1 77.95 77.95 06/06/05 1057 CPK TOTAL' 301. 48 1 77.95 77.95 06/06/05 1057 CPK TOTAZ, 301 58 .1 77.95 77.95 06/06/05 1195 MYOGLOBIN 301 37" 1 327.45 327.45 06/06/05 1195 MYOGLOBIN 301'' 48 1 327.45 327.45 06/06/05 1195 MYOGLOBIN 301 58 "1 327.45 327.45 06/06/05 1218 COMP. METABOLIC PANEL 301 42 1 669.43 669.43 06/06/05 1240 CK-MB - CHRG ONLY 301 36' 1 300.36 300.36 06/06/05 1240 CK-MB - CHRG ONLY 301 47 1 300.361 300.36 06/06/05 1240 CK-MB - CHRG ONLY 301 57 1 300.36 300.36 06/06/05 1240E TROPONIN-I - CHRG ONLY 301 37 1 772 .29 772.29 06/06/05 1240E TROPONIN-1 - CHRG ONLY 301 48 1 772 .29 772.29 06/06/05 1240E TROPONIN-I - CHRG ONLY 301 58 1 772 .29 772.29 06/07/05 12277 BASIC METABOLIC PANEL 301 70 1 376.18 376.18 Continued PATIENT NUMBER TAL AMOUNT 55555-16360`` DUE THE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT,DIABLO HEALTH'SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT PHYSICIANS.YOUR SURGEON,ASST.SURGEON, P.O.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILL YOU DEPARTMENT'33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. FEDERAL TAX I.D.NO.94-146143 FOR BILLING INQUIRIES PLEASE CALL(925)947-3336 2251L(12/11103) =ASE REMIY YOUR PAYMENT TO: `� + • -IN.MUIR/MT,DIABLO HEALTH SYSTEM t ARRTMENT33370 C.' Dl-TR> 06/15/05 I U N FRANCISCO,CA 94139-3370 5)947-3336 , AGE ADMISSION DAYS MARIA MALARIAS 5 55551649Y360'; F 061 05 05! 06 10 0 INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER 005301 'GREAT WEST LIFE 359606 575390649 026503 'USAA DOI06/05 05 16870628 CHARGE TO MY: CI VISA O MASTERCARD 0 AMEX D DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE J SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE tDESCRIPTION GLAlt CODi QTY UNIT PRICE TOTAL CHARGE 06/09/05 11911 HEMOGLOBIN AIC 301 =.163 '1 228.60 228 .60 06/09/05 1227 BASIC METABOLIC PANEL 301 '154 l 376.18 376.18 06/10/05 10561 MAGNESIUM 301 '169 1 189.72, 189.72 06/10/05 1091C IRON,' SERUM 301 167 1 185.35 185.35 06/10/05 1136C FERRITIN 301 ,172 1 341.64 341.64 06/10/05 1227 BASIC METABOLIC PANEL 301 168 - 1 376.18 376.18 06/10/05 1240E TIBC `- CHRG ONLY 301 167 1 191.96 191.96 TOTAL LAB/CHEMISTRY 9,694.59 06/05/05 10 c ANT IBODY'_S /T'Nbt RkT, 6QOM `5... x3.0'2 , lei. 1, , 164.23 184.23 06/05/05 1300 HCG-SERUM, QUALITATIVIE 302 17 1 205.85 205.85 TOTAL LAB/IMMUNOLOGY 390.08 06/05/05 1364 HEMOGRAM 4 (WBC,H\T\H,PLT) 305 15 1 77.34 77.34 06/06/05 1381 CBC W/ AUTO DIFF 305 41 1 190.12 190.12 06/07/05 1377 HEMOGRAM 3 (H\T\H W/ PLT) 305 65 1 77.43 77.43 06/08/05 1377C HEMOGRAM 3 (H\T\H W/ PLT) 305 133 1 77.43 77.43 06/09/05 1381 CBC W/ AUTO DIFF 305 146 '1 190°.12 190.12 06/10/05 1381 CBC W/ AUTO DIFF 305 166 1 190 .12 190.12 TOTAL LAB/HEMATOLOGY 802.56 06/07/05 1567 CULTURE, URINE- 306 157 1 308 .64 308.64 TOTAL LAB/SACT-MICRO 368.64 06/05/05 1515 UA MICROSCOPIC' EXAM 307 20 1 162.05 162.05` 06/05/05 1517 ER URINAL'Y'SIS SCREEN 307 19 1 81.80 81.80 06/06/05 1515 UA MICROSCOPIC EXAM 307 43 1 162 .05 162.05 06/07/05 1511 URINALYSIS SCREEN 307 63 '1 147.13 147.13 06/07/05 15150 UA MICROSCOPIC' EXAM 307 64 1 162.05 162.05 TOTAL LAB/UROLOGY 715.08 Continued TOTAL AMOUNT 55555-16360 DUE THE.HOSPITAL.BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT.'DIABLO'HEALTH SYSTEM PLEASE RETAIN TRI§5ETAIL STATEMENT PHYSICIANS.YOUR SURGEON ASST:SURGEON, P.O.BOX 39000 FOR YOUR RECORDS,ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLZIGIST,FTC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY FEDERAL TAX I.D.NO.94-1461843 FOR BILLING INOUIRIES PLEASE CALL(926)947-3336 2251L(12/11/03) =ASE OQMrr YOUR PAYMENT TO:, • s • r HN MUIR/MT.DIABLO HEALTH SYSTEM 1.BOX 390130 PAR'T'MENT33370 �/'` _TR 06/77075 06/15/05 177 N FRANCISCO,CA 94139-3370 5)-947.3336 DISCHARGE MARIA + oF9Y 5 0655 0 INSURANCE COMPANY NUMBER 005301 `GREAT WEST LIFE 359606 575390649 026503 'USAA DOI06/05/05 56870628 CHARGE TO MY: ❑ VISA ❑ MASTERCARD 0 AMEX ❑ DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP DATE L SIGNATURE AMOUNT PAID"$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE • s aTOTAL CHARGE 06/05/05 105 PELVIS IP (1-2` VWS) (72170) 320 3 1 466.25 466.25 06/05/05 1064 HUMERUS IP (73060) 320 5 1 468.75 468.75 06/05/05 106 HUMERUS IP (73060) 320 4 1 468 .75 468 .75 06/06/05 106 SHOULDER COMP IP (2+ VWS) (73030) 320 49 1 454.50 454.50 06/06/05 118 C-ARM > 1HR 320 38 1 1.344.00 1,344 .00 06/07/05 106 SHOULDER COMP IP (2+ VWS) (73030) 320 73 1 454 .50 454 .50 06/07/05 106 814OULDER COMP :IP (2+ VWS) (73030) 320 75. 1 454.50! 454.50 TOTAL DX X-RAY 4,111.25` 06/05/05 102 CHEST 1..VIE'W_. IP ; 71010) 3 4. ;; '1 400.54 400.50 06/05/05 1.02 CHEST"i VIEW II? ('71010) 324 11 1 400.50 400.50 06/06/05 172 CHEST 1 VIEW--; BLi'IP °(''lolo)' 324 " 2`19 1 400.50 400.50 06/08/05 172 CHEST 1 VIEW-PORTABLE IP (71010) 324 139 1 400.50 400.50 TOTAL DX X-RAY/CHEST 1, 602.00 06/06/05 91 (ORIF) UPPER EXTREMITY 360 77 125 110.00 13, 750.00 TOTAL OR SERVICES 13,750.00 06/06/05 23 GENERAL W/BLOCK ANESTHESIA 370 '117 125 35.26 4,407.50 TOTAL ANESTHESIA 4,407 ..50 06/05/05 10401 ABO BLOOD GROUP 390 , 18 1 175.32 175.32 06/05/05 1040 RH BLOOD TYPE CHRG ONLY 390 18 1 130.87 130.87 TOTAL BLOOD/STOR-PROC 306.19 06/07/05 10 PT EVALUATION AND TREATMENT 420 71 1 0. 00 0.00 06/07/05 1.23 PT-THERAPEUTIC' ACT-15 MIN 420 155 1 78 .00 78.00 06/08/05 122 PT-THEREAPEUTIC PROC-15 MIN 420 '150- 1 78 .00 78.00 06/08/05 122 PT-THEREAPEUTIC PROC-15 MIN 420 152 1. 78.00 78.00 06/08/05 122 PT-GAIT TRAINING-15 MIN 420 151 2 78 .00 156.00 Continued PATIENT NUMBER s 55555-16360.' THE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT,DIABLO HEALTH'SYSTEM PLEASE RETAIN THISDETAiL STATEMENT PHYSICIANS.YOUR SURGEON,ASST SURGEON, P.O'.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY 91LL'YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT'BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-.3370 FORWARD ONLY. FEDERAL TAX I.D.NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL($25)947-3336 2251/(1211 1103) =ASE REMIT YOUR PAYMENT TO:° �� TYPE OF BILL DATE OF BILL -IN AAUfR/MT DIABLO HEALTH SYSTEM BOX 39000 I I71-TRI 06/15/05 PARTMENT 33370 N FRANCISCO,CA 94139-3370 5j 947-3336 ..TIENT NUMBER SEX _AGE_ ADMISSIONDISCHARGE MARIA 1�IACARANAS 55555-163Yt 06/05/05 06/';10/0; INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER 06536-1—GR WEST LIFE j 359606 � 5'75390649 026503 USAA I DOI06/05/05 16870628 CHARGE TO MY: �- -� ❑ VISA'' 0 MASTERCARD ❑ AMEX © DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE L SIGNATURE AMOUNT PAID'$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE - - ITEM NO DESCRIPTION CLAINI CITY UNIT PRICE TOTAL CODE I NO- j 06/08/05 122 PT-GAIT TRAINING-15 MIN420 153 1 78.00 ' 78.00 06/09/05 123 PT-THERAPEUTIC ACT-15 MIN 420 178 2 78 .00 156.00 TOTAL PHYSICAL THERP 624.00 06/07/05 139 PT EVALUATION 30" 424 156 1 207. 00 207.00 TOTAL PHYS THERP/EVAL 207.00 06/09/05 215 OT-SELFCARE/HOME MNGT 1-5 MIN 430 .170 2 83.25 166.50 'T'OTAL OCCUPATION THER 166.50 06/09/05 210E OT EVALUATION 7 ,15 MIN 43.4 171 1 103.50 . 103 .50 TOTAL OCCUP/EVAL` 103 .50 06/05/05 641 IV INJECTION MODIFIER 59 450 125 3 195.25 585.75 06/05/05 646 ER-CRITICAL CARE LEVEL s6 W/ PROC' 450 '130 1 2540.75 2,540.75 TOTAL EMERGENCY ROOM/SERVICES 3,126.50 06/05/05 639 ER-PULSE OX CONTINUOUS 460 '126 ,1 ' 48.75 48.75 TOTAL PULMONARY FUNC 48.75 06/08/05 302 ECHO COMBINATION 480 138 1 1711..00 1,711. 00 06/08/05 303 COLOR FLOW MAPPING' 480'140 "1 577. 00 577.00 TOTAL CARDIOLOGY 2,288 00 06/08/05 302 DOPPLER ECHOCARDIOGRAPHY 483 241 1, 804.75' 804 .75 TOTAL ECHOCARDIOGRAPHY 804 .75 06/05/05 75S ONDANSETRON 4MG/2ML,2 ML 636` 2 1 156.00 156.00 06/06/05 505 MEPERIDINE 50MG/ML, 1 ML 636' 13 1 78.00 78 .00 06/07/05 4437 SUCCINYLCHOLINE 20G/ML, 10 ML 636' 30 '1 83 .00 83 .00 ContinuedAMOUNT' PATIENT NU MBER TOTAL 55555-16360 THE HOSPITAL Ra FOR CgWAIN HOSPITAL BA E13 JOHN MUIR/MT.DIABLO HEALTH SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT PHYSICIANS.YOUR SURGEON ASST.SURGEON, P.O.BOX 39000 FOR YOUR RECORDS,ALL SUBSEQUENT ANESTHESIOLOGIST RADIOL6GIS7 ETC.MAY RILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPAAA7ELY FOR THEIR'SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. FEDERAL TAX I.D.NO:94.1461843 FOR BILLING INOUIRIES PLEASE CALL"(926)9473835 2251L(12/11/03) =ASE REMIT YOUR PAYMENT TO:, �� -IN MUS/MT DIASLO HEALTH SYSTEM - B6x 39000' RARTMENT 33370 4 FRANCISCO,CA 94139-3370 5)947-3336 PATIENT NAME PATIENT NUMBER MARIA MACARt1NAS 55555�1636a' 4 9YI 06/C35I05' 06/10/0 INSURANCE COMPANY NAME GROUP 005301 'GREAT WEST LIFE 359606 5753901649 02'6503 'USAA DO106/05/05 16870628 CHARGE TO MY: ❑ VISA 0 MASTERCARD ❑'AMEX 0 DISCOVER MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP.DATE - SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE • DESCRIPTION CODE NO. TOTAL Drugs/Detail `:Code 317.00 06/05/05 300 ER-TRAUMA SERVICES 99291 682 129 1 7625.75 7, 625.75 TOTAL TRAUMA LEVEL 2 7, 625.75 06/06/05 30 PACU NURSING CARE - ACUTE 710 78 50 18.50 925.00 06/06/05 50 PACU NURSING CARE-INTENSIVE 710 79 15 27.50 412.50 TOTAL RECOVERY ROOM 1,337.50 06/05/05 1001 EKG COMPLE'T'E . =' 730. Y: 26 1 °:475 .50 475.50 06/05/05 633 ER-ECG RHYTHM MNTR INTERP 91041 730 ;128 1 43 .25; 43,25 06/06/05 100 EKG STAT 730 ' 4'0 1 475.50 475.50 06/07/05 100 EKG COMPLETE 730 55 ' 1 475.50! 475.50 06/08/05 100 EKG COMPLETE 730 '134 1 475.501 475.50 TOTAL EKG/ECG 1, 945.25 06/06/05 4084 INPATIENT OBSERV 1 HOUR 762 46 1 0.00 0.00 TOTALOBSERVATION SERVICE 0.00 06/06/0 402 NP ENVIRN INTERVENT 15 MIN 914 76 2 101.00 202. 00 TOTAL PSTAY/INDIV RX 202.00 06/05/05 200 EKG PROFESSIONAL FEE 985 26 1 68.00 68.00 06/06/05 200 EKG PROFESSIONAL FEE 985 40 1 68.00 68.00 06/07/05 200 EKG PROFESSIONAL FEE 985': 55 1. 68.00 68 .00 06/08/0,5 200 EKG PROFESSIONAL FEE 985 ''134' 1 68 . 00 68.00 TOTAL PRO FEE/EKG 272.00 Continued PATIENT NUMBER -AL AMOUNT 55555-16360 DUE THE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT.DIABLO HEALTH SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT PHYSICIANS.YOUR SURGEON,ASST SURGEON, P.O.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY FEDERAL TAX I.D.NO.94-1461843 FOR BILLING INQUIRIES PLEASE CALL(925)947-3338 2251L(12/11/03) Pj-r:A2E REMITYOUR PAYMENTTO:, JOHN MUIR/MT,DIABLO HEALTH SYSTEM 0.BOX 39000 D1'-TRJ 06/15/05 J0 i. PARTI'�IENT 33370 SAN FRANCISCO,CA 94139-33711 (925)947- 336 PATIENT NAME MARIA MACARANAS 55555163609Y 0S 05 05 06 10INSURANCE COMPANY NAME 0 GROUP 005301 GREAT 'WEST LIFE' 359606 575390649 026503 USAA D0106/05/05 16870628 CHARGE TO MY. TO: 0 VISA '0 MASTERCARD 0 .AMEX 0 DIS= MARIA MACARANAS CARD# 2825 PENDLETON DR SAN JOSE CA 95148 EXP,DATE L SIGNATURE AMOUNT PAID$ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE IIENI NO DESCRIPTION "roTAL CHARGE WAll TOTAL CHARGES 99, 696.34 08/23/05 10075 040 HMO DISCOUNT PAYMENT -30,499.99 08/23/05 10075 040 HMO DISCOUNT PAYMENT 57,232.79 08/23/05 A0004 040 HMO PPO CONTRACT ALLOWANCE -11, 963 .56 TOTAL p'AYMtk'is'A JL ft* 1' S �. _ z (PATIENT NUMBER � f -99, 696.34 s 0.00 55555-1.5360 � THE.HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED' JOHN MUIR!MT.DIABLO HEALTH SYSTEM' PLEASE RETAIN THIS DETAIL STATEMENT PHYSICIANS,YOUR R SURGEON,ASST SURGEON, P.O.BOX 39000 FOR YOUR RECORDS.ALL SUBSEQUENT ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILL YOU DEPARTMENT 33370 STATEMENTS WILL REFLECT BALANCE SEPARATELY FOR THEIR SERVICES SAN FRANCISCO,CA 94139-3370 FORWARD ONLY. FEDERAL TAX I.D,NO,94-1461843 FOR BILLING INQUIRIES PLEASE'CALL(925)947-9336 22811 (12/11103) -- STATEMENT ! STATEMENT )t .... OF Po.SOX.14m YaA1 t T CREEK,CA 34595 AALANGE'DUE AUODUNT MC.'LOS'ED ;V 1 I'C r a.-n FEDERF L 1 u P�t1#�1t3E_ _.a +J f 30G0 Cr 53_L TYF'rE j lr PLEASE L E 1ACH AWN3 PERFORAMN AND F TUM UPPER PORTION WITH YOUR PAYMENT � FOR SIDING INQUIRIES.PLEASE GALS(I?Zb)847-Md,OUF NVG#WRt AL I tU61KE55,hOURS PAt' NT I<tAME `.3r"4iA _CC?C►E o PRClMOURE I Or-SC..RIA'`CiON LIOC JlA RI{ r.5 s NIC ,�T -1-5 ' 4, CT 1`a"I" Wr'`r.C3la) s ,-cs1; L 3:s`n '+ '' 14 a 1 .} Itf 0 O?-.! 3P464-C', '.r4,dif r.—fi T P GRE ;i' WPES I'/01'1#ii_ 1-1 � i As 0 courtesy, We have sulb rniftd these Charges to your insutc nca a carriel Please note fha physician c.4cxrge.s are sOPOrafe from the hors itu charges, P c sa of/*--'30 days for processing. i - --" _.. r'r_7.,�; 00 GAY8 f Eb -90 CAYS 9 4zo SAY c7id�"W s �rrr gat„'JLi! _. ___ ___.__ .__. L.,O jOh4N414Jt€ii`if�t:.lMA^1-t'l,�tC�dN$ yY PC o"(902, WALN"f:RGPK.0 -Anna 1"or 1"l.Jdf a7.[�w'!"'t1�..t.L7i"'t {�Ii+ y1C''��ZL5;1 ,1-- Ra.t .r . -inc 'e:xLj.. � ! + yrha�s,t 7' Call ('�4t"^''.5`. ) '3477"'528 If YOU. .11ct�r+�? '1+tYiA' Cil STATEMENT ACCOUNT NUMBEA J04N MU IR TRAUMA PRYS!CANS wP.0,Box 9021 -- 1 ! ,NALNUT GREEK.'CA�Wgf' t_.L i 1 « tM' C)SRJYL i L} N JUFSi Fm; E,8 30 w , y RLLASE Onikt:H ALONG PEFtFORkrtON A114LI RE'YJHN Ctrh'.4F1 PORTION WITH YUJR 4XIMEEN" j PON 014UNG IiV<i hAIES,PLEASE CAt..L(5.28KM2..BR:DUPING N0,14ML,PRKSMES,S Xl-wMS PATIENT14A� �#�TE i ��5C3E Mt? d� 34. M)CEt URC-;OPSCRit+rI'iONmt s.}j iAG�3�ISIS � m�)Qv" i P° V:L i ::!"t1 L! t. i 315 D, s .; lylad c 7.;i. ,.!J '«C?':t ..t(sV... rf,+ :L ;� '.1(P.1 tIIC`'w'-1 a..• 1 n .G.. ,'t ..L I'I JL4± i.'-,f�-i � -0.00 "Dr1C'0 2(L F° HLGtdC.'b"hkt% 3*, 7Lc .L v _I #!A'.lY ss: V.?'` C'5 119 Chest I L}itLyLJ iy k' 05 ICI r tis:• l`1�6;,4's tv�LGn"ia j 1 3. t 1' i ...tr4,'z A.`Jwqi SENT". ! t � 1 As o ,courtesy, � have s�+b x a� those charges to your Insu,'ande carrier. Piedse note thei physiclnn char es ore separate from the hos,'' � ctac+rg es. i Please Otow 30 days for processing. i ! I I It5 E...Y'i i JG«� w jitli-# >V p,t, .'.. v e't a .,.! 'R -li 1-".,'+I. F,Wb•:::I"`'(:. f t ( {r t� I. ..+.. :+l'a i�.L�•i.: �".'{� # �:a tlti, s.;st�f�i J,.�' - �' is cx t at,t;s t i a..- a:S �• s q n a'DAYS , � A'rsob a 27tnxSLt�TRAJnA.t' Y�::Airy_ . M-IF .-j ` - s,� � 1 >adC t:l i.�4 1 1 : �...�1 sk f'`�( � ('1•rtU ft sr�1�'g f�' v i •.'t C1 (' �rLct #;l j"t 7, �31ts � #tv[t wtt". f• i�n'..1.a.4. s x.�. 1 4rsTt'�f c—r,� �%S }1 L� . � �- 1C7t.i, I'f,*lYl.*'t h1n,Y I":#LL{,i »•1[.?.. A£L;UU}dl IYUFs Ut?* _ Uig rA n -IN PkiF17:RAlJtM11 A PHYSICIANS C, J4'7'--- E3J3;9ti21 ;NUT PREEK:CA 94555 "+ 15 +ir. TO; EDE€RAL I t I",3�+E? __ t •__. 'v F~&.EASS DE'.ACH ALONG PERFORATION AND RETURN UPPER PORT{G\WITH YOUR PAY64EENT =011 Ff:,J",G IN0111RIES;PLEASS CALL(9225) +4741,268:DURING NORMAL EUSiNESS f',OL11 PATIENT C NAMEyw� DAC I CODE �.4 D 69 NU T PFIOCEDUF E i DESCHWTION_~ 0 DJ AGhtOSI`�' 'Y +�tu1C3Ltty f' {+`:r"A 1..1,ea I.J t.N 4J.J •t`,1.:. 9925/r-5-7 I'l.2T. •671.1, kr;L.Sa I"h,",. 7. .....,..� yy •9 —�--r'"77"--�—ry�- I ..�f`vw� � ..w . i,�. , 1251 (,ILFlt+e C`ll... 'l w.. Cl Or C.-D n. �.i.. ila- is lf"FS ..,r�t�.._U,r_- )4 7-51. �:p: r)C ]''0tl".(:1''x.1Z '` ;.,�_..I L,....05 �`)•'•�n" �'�'El'3 l v. CE C=I s � L i i t t � I As courtesy, have sub T d these charges to your msv an 'e carrier, Floc se Arte the physician >µ dr es are separate from the hos �ts��I charges. t�tel tb 30 days for procr�ss#ng4 I � t � I ( I I I � , I f ' f f�>itfl ";t t t1tl � t-' i ,s y" M>1»,t,' iS�:iT(: X11'y ` Ca_� 1 dl-4 moi:_.a r•1..�,Ir.d.),t,r >l"1l°i ii i�..5"�,tlJ._..a tri ^. �i:�:�`..e.Lrl .�.. ' I i , °. 'l 3;' 7 F'l __ '777777t.} f 'J r. .'0 .. >. . f: :'}., ,.'(;" "� � � l 30 GAY, Vii_ i,— $D''�,AYS, S1 -' DAY�a , �'i . ted i3AM S 3 t�trwra 2t: Ciav� IN MUM,TRAUMA FHYSI CIAN iaox902 CAE��iu9G 1.7. e'ifyi:i:S.4 �..t2+ �•i W�1a1`{` �)t:3a3 Havr:' ,Vtw1ti;:.i..t 14S-l~HT" c-, '.�. �o'T'i��t i�!''i {.a i..e i i ''t CJ t 4 =t'l."3 t:t t't.. ["il'? !'�L t.'"L C?7"i F;> l"4 f'<{;�i; � "'"t i '��Fl .3 t»".'6" F;c:t • L; .i. r'-r 53; 134'7-SS F."ae, T Y Q L k t",.l'Y0-, r-I 1{ LLe 1 C 11'�. �H 3pt}46`�tFtB; `TATEMENT Y PC.wx 90211 - WALNUT 9EmK: CA U695 ` ff C?isf A�1tJ 'rvTCS*k`.LOS__ _ELS--I !.D.Pdlll•AE3cl~i _j _:3;:5 mat•;}ac.l':I.L tr�t *t ..?.l f itba I Cp PL%ASf Z;!YA H ALONIQ PLA110RATIONAND fi€T IRN UPPV51 PC$i'"I{11t'Wr-, H YOjR PAYSaiEW rG1R,5iLLt)43 NOUTAIES;PLEAM CALL(2251 947-SM,DURING ISIOA M' SU5SREw`S MOUSS . _ et1 . .... Qtt ?IAa\O$CuWiGRC"ATIEN! IA sw1, '�3"Y (` 'y 'b rr. 1 ) 71 sa f ✓ y D I 111ar�1r,}3 k��..J �' 4�.i `016 0...i_�... r�� Ilj abL. 7 ��� ��.l�t I.t11��...i.CYt �� I. � �r� 4. 0 16 f i As courtesy, ivs have snub ltt�d fhese choices to your insu a carrier, � 'lease note thai physician G arr vs are s+�paraafe from the hus an stat charges. I ' please110 w 30 days for processing: � f I ; E i s �..I" '�!; !-'t`•��r !SL.I:'1tii,.:stv1�!'' �i«7 k:,�.,.I"'>:,.' ;�1"i:. '�C";'';:s r'I.iC??�,�el,.,.. } - j t".1 AN J TL 1 Ct .',' 71.D a (.dXWl Lil"I F:' _T, IYi,.t t''e i-11'?r.i„�y �'`I..i f'�!.ct. •. n i ( ... ._ W...,,_.1.._..+.+-----»--..�....._: 1?cs CtA'P 01 BQ DAYE Ri 90 QAYS I 1 120 DAYS �C-i?r�ca .VC,, Z.AYS j Ei,A:.,,.OUE P"19prXr30',W.c.«,S:Da6i& Thi'LS t� Chrs'-(,gcyfie... ('"Ia41.1?. E4iZ411.1 16tS 1,1"1-1 Tr'-) •(nl.1," fcif f 1 z"f I t b' a1`1 s1 tjt4)'f` I;ipII C 1.o ri I La R e q I Yo t. r, i°cA'' ., .H „� t i fC by t' � 1"_t��yy,,yy Y..j! 1J t - ,r4f 1' .4.M.r,[a F. .,�r'.t.l..�. J rS �'��I..r s.i�L:.TC! 1 I f;JLi I.a v t.'. 1�i f. r_v LQ T A TE M E N .T -'---- ACCOUNT NUMHEIR PATE Fr+6K H.N'WUIFI TRAUMA PHYSICIANS i L .Box 5O$r 9459f, r S �iAaWA -O'F:DtJi YA r1CJt itiT EIy:LC35 TO — r I `E-:ceF+A6 E f+ P i'1t1SE Y PLEASEDETACHALOWN :'EJAFOPATION ANO PC,URNUPPER PAYMENT w FOR SiLUNG INCUIR)E5,PLEASE GRLL(9251947.5286,DURING NORMAL 8L1S;NESS NU4'GCS PATIENT NAME I � s";.#t�E �� C�+�E Q+ID�I��N�. P>�tb�EDU*aE 1 C}E.zs�t�'.f'�1ON i LL"7L`� t71t��?dt��'�� A14�C:,�t.NT ..... �"_..�..T�� f I.�' y15 11 i I � ; { + As a courtesy, �e have submiffed these charges to your insr,fcna e carriel•. PTegse note the( physician 31o* es are separate from the hospital'charges. Please 30 days for processing. I, I � l i + i —L7,7 i AYE_ DA'f�$_ 91 -120 GAY'S t,JFK 120 LaA''Y,. SAt_DUE JOWii MUIR TRAI MA PIdYSCC)ANS T ;,E -i.(..,.:L C .4,cri' LU > '+a_ � i,; .,.�,.f.:R� Ifni: f A W4SWI s i'i , s� I 1 i C.C_z"s ��:. { G7. + "7 .t?t �Ss11�i.;Is s Ft tL"((t��,, iYIC} C'IC. E.':;•,�1� :a ` +� :�tl"1 �",�� `is's r 't + „'',„ CIL H.Al:Z.." II.Z,f' ',%OF +(..a .0.,`?. STATEMENT .':�3 -s ATE M` NT . .� ,VAINUl CREEK,CA D453 _ 5AS:_ANCCB DUE AWU41 41 i..OSEL' .i 1 2 V.I.00 r 10. -- + t ._cF t,t 1. x tai .t I,.. [;,5....'t ;.::ki./ .t �`r{..`i. 3•�5.�,. ;t "..-.Y S:I 'w.f.L rvLt4gac DRTA�Fi A�CING PYEWCMAMN AND REMAN UPPER PORTION WiTHYCLA 6tA'MSINI'T � MR IiaW40INQUIRiF-S.KSASM(ALL(%2s)347-52M,MIAINIS NORMAL 81 SINCCSS HC',FS PATIENT N.fW)E cr�Ie MOP �P-X0 _P15flCP�UFi�i DESvFiiPT[Gd�dNti 'Lt��tiAGT £els �Pi�C)! �? y 'i.,.:�.- �'•i ___I C '~-�' .� Q,IQ—t2 t-. ze? k_li st. i E i 1 i , I As aC courtesy, *a have subi l'ttpd these charges to your insv once carrier. P104*e nate Me,phys diaan khat es are separate from the hosp' itaf charges. , '. Moase allow 30 days for processing. t i f i ")t"t!a �f f:1? � ) �°t 1 ��."�`��� ��� '::,��1^"1-!�'a�l��� tf?:+ �-+ ..-• t �.z .cif..... ' I J rlk' W CO DAYS ) aS_ tF CRLYS 2U C , 0vFR 1,20 DAY` _l 4 t DUE �i-1 -.3.+.''1:_1.3"6�1 C—1,i0-Ur:S H,4: JYi? 'X"st_t.,t!f�..� �� y. }.�f�'y +.. rf.,)t',':� C? 'Y"'0. l{:'It"'1a iiCJ. 11t.'•"C::14 t�,..w �.O.i WOICE:71J . ars ts�7 �.�. WWttV.aIT3Y-Ir1C,GC}Ci"i American Medl[cai Response _ AMERT CAN MEDICAL RESPONSE WEST P.O. Box 3429 Modesto,CA 95353 T :. 401-55137839-00 ACCT.# 00 1057899 ' I�tTll* 1 I€AME= - MARI A` M. MACARANAS 06/105/2005 ACCOUNT NUMBER: 001057899 A C,'j-lNI"#3UI 1 , 986.58 I�uE E��T�: .! 08/21/2005 .:. , MARIA M. MACARANAS REMIT PAYMENT TO: 2825 PENDLETON DR SAN JOSE 'CA 95148-3016, AMERICAN METRICAL, RESPONSE FILE 73329 PO BOX 60000 SAN FRANCISCO, CA 94160-3329 CHARGE MY 0 V4SAC MA$TERCAR0 NT �`� t. 3 a L ❑ t�J ExPIRATtOU DATE'' J .J URE PLEASE ENTER AMOUNT PAID: PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT PATIENT DAME ACCOUNT NO. TRIP NO. INVOICE DATE .RIA M. MACARANAS 001057899-0001 401-5513783-.9-00 08/01/2005 OF SERVICE SERVICE FROM SERVICE TO ,/05/2005 VASCO: RD-BYRN/CAMINO DIABLO JOHN MUIR MEDICAL CENTER. IMPORTANT(MESSAGES claim was 'filed on your behalf but we have not received payment from your AUTO surance carrier. In order to avoid further collection activity, pease send .yment :in full. AMR accepts' VISA, MASTERCARD, AMERICAN EXPRESS and SCOVER CARD. Thank you. CODE DESCRIPTION : UNITS UNIT CHARGE TOTAL CHARGE t )368 ALS1 EMERGENCY 1 904 .02 904.02 )425 ALS MILEAGE 35 20.34 711.90 398 DISPEL PLS OX SENSOR' 1' 48. 52 48.52 398 CERVICAL COLLAR " 1 54.77 54 .77 394 J .V. START PAK 1 15.63 15.63 "030 NORMAL SALINE 100OCC 1 60.98 60.98 422 OXYGEN 1 62.58 62. 58 398 02 MASK/CANNULA 1 7.85 7 .85 394 ALS DISP IV SUPPLY 1 .00 .00 005 EKG MONITOR, 1 93.88 93.88 1398 EKG ELECTRODES 1 15. 63 15.63 1393 HEADBED IMMOBILIZER 1 10.82 10.82 398 ALS' DISP SUPPLIES 1 . 00 .00 ,LL RC'VD, 14:59 TOTAL CHARGES DUE 1,986.58 AGNOSIS, 71949 E8121 SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to. American Medical Response, P.C . Box 3429, Modesto, CA 95353 ire Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 t.iP A r7# ........... ................. OMNI IF PAYING BY MASTERCARD,DISCOVER,VISA WAM ICAN EXPRESS,FILL CHECX CARD USING FOR PAYMENT MUIR(g). --POBOX 31396 MASTERCARD 001SCOVER = FVIA I= [A]MERICAN EXPRESS 11.1 ORTHOPAEDIC WALNUT CREEK,CA 94698-8396 CARD NUMBER SIGNATURE CODE M SPECIALISTS On _n A Mtmv-G.-,.INc. 31902 SIGNATURE EXP.DATE Url ADDRESS SERVICE REQUESTED STATEMENT DATE PAY THIS AMOUNT ACCT.# o C3 PAYMENT DUE BY: 0712812005 07113/2006 $25.00 69237 ru 0 SHOW AMOUNT FOR BILLING INQUIRIES, PLEASE CALL: 925-210-8593 $ PAID HERE PAGE: 1 of 1 ADDRESSEE: immii REMIT TO. 11 11 It I toll IfIll 1 1111111111#1 11 111 111111 11 111 11 1 1.1.1;1..Ih11 11#111111,111€-If 11 If 111 t 111111€ 1I'l I I I I I if 111#1111111 If 11 I I d I MARIA MACARANAS MUIR ORTHOPAEDIC SPECIALISTS 2825 PENDLETON OR PO BOX 31396 SAN JOSE, CA 95148-3016 WALNUT CREEK, CA 94598-8396 31902*1 KDOUUW78000002 -1 Plesiacheck box if address is incorrect or insurance STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT I infortnation has changed, and indicate changelsl on reverse side. DATE CPT DESCRIPTION FEE UNITS FEE TOTAL INSURANCE PATIENT 1MAria Xacaranas 454759 Donald X Lewis MD Muir Orthopaedic Specialists 106/21/2005 73030 Radiotogic examination, shoulder; compLete, 59,00 1.00 59.00 59.00 0-00 minimum of two views 106/21/2005 73030 RadiaLogic examination, shoulder; compLete, 59.00 1.00 59.00 59.00 0.00 minimum of two views 06/21/2005 99024 Post op office visit 25.00 1.00 25.00 0.00 25.00 106/23/2005 Filed,charges of 143.00 to Great West 0.00 .00 0.00 0.00 0.00 HeatthCare 118-00 25-00 CURRENT 31-60 DAYS 61-90 DAYS 91-120 DAYS OVER 120 DAYS ACCOUNT BALANCE INSURANCE BALANCE $25.00 $.00 $.00 00 $.00 $143.00 $118.00 Reflects transactions posted through 07/13/2005 II DUE FROM PATIENT ll 1. $25.00 11 FOR BILLING INQUIRIES, PLEASE CALL 925-210-8593 Let us know how we are doing. Take our customer satisfaction survey at www.muirortho.com. Thank you