HomeMy WebLinkAboutMINUTES - 12162008 - C.30 (7) .s
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: DECEMBER,16, 2008
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
California.Government Codes. ) you is your notice of the action taken
on your claim by the Board of
Supervisors. (Paragraph IV below),
given Pursuant to Government Code
AMOUNT: $64.87 D ,�i) Section 913 and 915.4. Please note all
2 51006 - "Warnings".
CLAIMANT: WALLACE 0. 0 00uNgEL
ATTORNEY: UNMOWN MO sv FaMMyCPDATE RECEIVED: NOVEMBER 25, 2008
ADDRESS: 1479 VIA DON JOSE BY DELIVERY TO CLERK OM NOVEMBER 25, 2008
ALAMO, CA 94507
BY MAIL POSTMARKED: NOVEMBER 24, 2008
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
NOVEMBER 25, 2008 DAVID TWA, Cler
Dated: By: Deputy
Il. FROM: County Counsel TO: Clerk of the Board of Sup rvisors
VThis 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).
O 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:M(JQ:Q A_� ' Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
O Claim was returned as untimely with notice to claimant (Section 911.3).
This
RD ORDER: By unanimous vote of the Supervisors present:
Claim is rejected in full.
O Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for
this date.
Dated: . /`aD AVID TWA, CLERK, By puty 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 deposited in the mail to She 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 18; and that today I deposited in the United
States Postal Service in Martinez, California, postage fully prepaid a certified copy of this
Board/Order and Notice to Claimant, addressed to the claimant as shown above.
DatedY/�G. / _ ,��d.o�AVID TWA;CLERK, By ty Clerk
This warning does not apply to claims which
are not subject to#hekalifornia Tort Claims
Act such as actionsst. vefo4e condemnation,
actions for sific rersuc '±as mandamus or
pec
injunction, or Federal,Civil,Rights claims. The
above list is not exhaustive and
-legal
consultation is essential todunderstand all the
separate limitations periods that-, ay- pply.
The limitations period.within::Which suit must
be filed may be shorter or longer depending on
the nature of the claim. Consult the specific
statutes and cases applicable to your particular
claim.
The County of Contra Costa does not waive any
of its rights under California Tort Claims Act
norldQes it waive rights under the statutes of
limitation`s applicable to actions not subject to
the California Tort Claims Act
•
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. I
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
j I2STSTRUCTIONS TO CLAIMANT
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growing crops 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 945 53.
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.
■■oa ■*masa aaaaaaa■RE a &I
RE: Claim By: Reserved for Clerk's filing stamp
lil�9L�/9C.c dg A&LDIE, ) "
(41e. 1cle q� off!!/a/ago, cA 94Sa7)) RECEIVE®
Against the County of Contra Costa or ) NOV 2 5 2008
CLERK 80A qD
_ District) CONTRA COS ACOV ISORS
(Fill in the nsme) )
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$A;4, 87 and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
s�uygy- <1uc,Us.3�, 2o06 (9 -v 9AM
2. Where did the damage or injury occur? (Include city and county)
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ALAM0 PLHZ4 -SHo/nai/UC/'�.�ivT.�,e /tel/ 4L4.x-s0 CeAlr, w cc4s-rd CovAa/Ty,
3. How did the damage or injury occur? (Give full details; use extra paper if required)
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4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?Q ,y4.
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5 What are the names of county or district officers, servants, or employees causing the
damage or injury? -
ht/ote.'�"v�'vBy <ovar��a 8y•�/i�oy�v' l.9.®o z�e (P/,�.3/,�-7003��`����
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6. Wit damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attack two estimates for auto damage.)
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.) 7y/s 9A44a v,7-/s' 72/,e_5 /6 �1 0'--- ac rr_ or-_ RbcIeE7
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8. Names and addresses of witnesses, doctors, and hospitals: `OR- ►#te tt)e-K`rsa L e'a�� S e,I,
7tvo is/71�e3scS 77Y-9T oFi F2 i oST T(N-, �iS2A�/EL, tK1SuRCAntCC
/ 7/7�ESe S�� � D. 7>/C9G,o7T�CffNJB.VT.S o PROSPECl'tv7
9. List the expenditures you made on account of this accident or injury: D4a�(gC��S 4QE/UoT.4Ni/C1�gr�1�
DATE TIME AMOUNT
x0-21) - 08 52 20 Sar. Ratrror� 'Req�o�lsr l �le��c�t I Cen�ei-
11 - 19 - 06 - i 2 . 6 7 Dr, Wood)a it" AA-I>
641.87
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.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 )
(Claimant's Signature)
11-2W-oB
(Address)
ZV2 1114 Da/,/Jose . 441.i(Or
Telephone No. ) Telephone No. 92 5-f 2e - //2 O
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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 at seq.) Furthermore, any
attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to
public disclosure.
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 ($1,000.00), 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.
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.�'�� es:��_.�� Qc% �os� � �n,�o_�- -sc:-a �c��.r j-��i°-vi7�1'
C//'l'Uh���.�i�i�►�s �or�si�✓el��_�/oGv/may �`,�' ��c���r����c'�
�--- -
/Cry � s� ,��o� ,�,o�,�./��o%.�'���a .,�_
'�ou have questions, please call
SAN RAMON EMERGENCYPHYSICL.- 800 701-0227
PO BOX 5506
CULVER CITY,CA 90231-5506
31987-UL22 Payment Due By 12/14/08
RETURN SERVICE REQUESTED STATEMENT DATE PAY THIS AMOUNT ACCT.#
0101 . 11/12/08 12.67 146018
PAGE: 7 of 1 SHOW AMOUNT Q 1 a• 4 7
PAID HERE �P
Iif16loll 111111111,111111 11111111,1nIII III I111u1IJJ,III IIIII III 11irll11111111till al
WALLACE 0 WADE SAN RAMON EMERGENCY PHYSICIANS
1479 VIA DON JOSE PO BOX 5506
ALAMO, CA 94507-1151 CULVER CITY, CA 90231-5506
31987-UL22'TID14JNK1000227
I-1 Please check box if address is incorrect or insurance STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
U information has changed, and indicate changels)on reverse side. 100001
Date Patient Code Description Amount
08/31/08 WALLACE 23 99283 881.01 LEVEL 3 EXPANDED HISTORY 233 .00
09/29/08 WALLACE 920 MEDICARE PAYMENT 50.66-
09/29/08 WALLACE 820 MEDICARE ADJUSTMENT 169.67-
09/29/08 WALLACE Medicare payment for services
08/31/08
Patient: WALLACE 0 WADE
Seen by: WOODBURY, JOHN D.O.
Services rendered at: SAN
RAMON REGIONAL MED CENTE
PRIMARY INSURANCE
MEDICARE/CALIFORNIA NORTHERN
09/
�C.l •� I<C�'�'►`�'w•' � Claim 1 Total: 12.67
e, -o8U— 6x.4, 7
Account# Total Charges 0-30 Days 31-60 Days 61-90 Days 91-120 Days Statement Date Amount Due
146018 0.00 T
12.67 0.00 0.00 0.00 11/12/08 12 .67
Message: Your insurance paid their share of Employer: RETIRED
your visit. Kindly remit the balance that is Primary Insurance: MEDICARE/CALIFORNIA NOR
due at this time. Secondary Insurance: CIGNA
Location of Service: SAN RAMON REGIONAL MED
Referring Physician: WOODBURY, JOHN, D.O.
31987-UL22'TID 14JNK1000227 1118011 fl11I� ��IIm1ImII IIIY Y11���IIm BW���tlW tl10 WII1N
eT n eT San Ramc,tegional Medical Center STAB RENT Page: 1 of 4
BOX 830913(Use mail address below)
Birmingham,AL 35283-0913 October 09, 2008
WALLACE O. WADE
Account Number: 00833627926
0202 Patient Reference Number: 000933856
Hospital Code: 554
Payment Due Date: Due Upon Receipt
Date(s)of Service: 08/31/2008 - 08/31/2008
Message ID: PFSSTM3
CHANGE SERVICE REQUESTED
#BWNHDLV Primary Insurance: Policy#:
#00833627926G0014# MEDICARE 227329595A
11 I'll 11J111111J1111111 Secondary Insurance: Policy#:
WALLACE O. WADE CIGNA/HMO&OPEN ACCESS PESS P U3270210301
1479 VIA DON JOSE
ALAMO, CA 94507-1151
Thank you for choosing San Ramon Regional Medical Center
Account SummaryP 2 p, o S �1 -Payment Stub
In � -.Account Summary� -Phone Number
Total Charges . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1,716.50
�.�
Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$1,508.76
Page 2
Important , .
Paid by insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . .$155.54 -Payment0ptions
Reach Us
Already Paid by Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$0.00
-Changes to Personal Inform.ation
j Amount you now . . .". . . . . . 1$52:20Understanding Your Statement
Statement D-
6528058
�� 33 (,`�ISIS I�I�IIq�1911��i�OtVII�IIII�II�II��ImIiII��U��
Detach and return bottom portion with payment.Please make checks or money orders 1f7-Zb-
payable in U.S.funds to San Ramon Regional Medical Center and include your petient reference number.
STATEMENT: Page: 3 Of 4 W.L.SCE O.WADE P.mit Reference Number: 000933856
Insurance(s) Policy
MEDICARE 227329595A TeneT
CIGNAMMO & OPEN ACCESS PESS P U3270210301
J
0102 Understanding Your Statement...
A The services You received during your stay at the Hospital
B Total dollar amount charged by the Hospital for services delivered
C Total statement charges on your account
D The dollar amount reduced due to an insurance contractual adjustment or other discount
E The amount paid by one or more insurance companies to the Hospital on behalf of the patient
F The amount already paid to the Hospital by the patient or their guarantor
G The amount due from the patient as indicated on the provider bill or statement
652806A
FA FB 1
— — —Dates-of-Activity-- -- - -item Description=/Activity--- Charges
i 3
108/31/2008-08/31/2008 '4 • PHARMACY { $73.50
08/31/2008-08/31/2008 i EMERGENCY ROOM $970.00
08/31/2008-08/31/2008 SUPPLIES $673.00
y
State and federal law require debtcollectors to treat you fairly and prohibit debt collectors from making false statements or
threats of violence, using obscene or profane languade, and making improper communications with third parties, including your
employer. Except under unusual circumstances, debt'collectors"may not contact you before 8:00 a.m.or after 9:00 P.M. in
general, a debt collector may not give information about your debt to another person,other than your attorney or spouse. A
debt collector may contact another person to confirm your location or to enforce a judgment. For more information about debt
collection activities, you may contact the Federal Trade Commission by telephone at 1-877-FTC-HELP (3,82-4357) or online at
www.ftc.gov. $
Nonprofit credit counseling services may be availablen the area I
r
}
s
t �
C Total Charges _ $1,716 50
DAccount Adjustments $1.508.76
E Paid by Insurance $155.54
P ; Paid by Patient $0.00
f I
l .
G'-; -Remaining Balance $52.20
Thank you for choosing Amount you owe now . . . . . . . . .$52.20
San Ramon Regional Medical Centerl
33350•THF0J1TD0000068
Page Ol of 03
-� Medicare . Summar lotce
UflRr>6«XE6MV, Va = y
November
07, 2008
CUSTOMER SERVICE INFORMATION
HU-P081 108195453024 Your Medicare Number: XXX-XX-9595A
WALLACE 0. WADE If you have questions, call 1-800-MEDICARE
1479 VIA DON JOSE (1-800-633-4227)(#52280)
ALAMO CA 94507
Ask for Hospital Services
TTY for hearing impaired: 1-877-486-2048
Appeals Address: Please see the General
BE INFORMED: Always review your Medicare Information Section.
Summary Notice for correct_information about
the items or services you received.
This is a summary of claims processed ori 09/10/2008.
PART B MEDICAL INSURANCE - OUTPATIENT FACILITY CLAIMS
Dates Non- Deductible You See
of Amount Covered and May Be Notes
Service Services Provided Charged Charges Coinsurance Billed Section
Control number 20825300094204 04
San Ramon Regional Medical Cent a
6001 Norris Canyon Rd
San Ramon, CA 94583-5400
Referred by: John B. Woodbury
08/31/08 Sterile Supply $240.00 $0.00 $0.00 $0.00 b
Emergency dept visit (99283) 942.00 0.00 45.56 45.56
Td vaccine > 7, im (90718). 73.50 0.00 0.00 0.00 b
Immunization admin 90471 28.00 0.00 6.64 6.64 �✓ P d
( ) o
Claim Total 51,283.50 50.00 552.20 552.20
_. sa•aa
Notes Section:
a The amount Medicare paid the provider for this claim is $155.54.
(continued)
THIS IS NOT A BILL - Keep this notice for your records.
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+ CONNECTICUT GENERAL LIFE INSURANCE COMPANY
PHOENIX CLAIM OFFICE 1
P.O.BOX 182223 I
CHATTANOOGA,TN 37422-7223
CONNECTICUT GENERAL LIFE INSURANCE COMPANY CIGNA Healthcare
ASAGENTFOR:
o NATIONAL SECURITY TECHNOLOGIES,LLC Subscriber ID:
0
U32702103
e m Operation Location/Group No. Payloc
47342-9-3329907 919
e�
Date through which claims for these benefits
WALLACE WADE were processed:OCTOBER 3, 2008
e� 1479 VIA DON JOSE
ALAMO CA 94507 How to Contact Us
Mail to the return address in upper
left corner of this page
http://www.cigna.com
THIS IS NOT A BILL.Please retain this Benefits Statement for your records. '� Phone: (800)244-6224
Please provide the subscriber ID for all inquiries and claim submissions.
Explanation,of Medical Benefits
of Medical Ben
You have received this Explanation efits becatise a claim for Medical Benefits was received
by this office
Please review:kind'retain this Explanation of Medical Benefits for your records
This statement identifies benefits for: WALLACE' WADE
Total'of the charges received: 1,516 50
Plan liability: 0':00
Rights of Review and Appeal-For Employee
•Call Member Services at the toll free number on this Explanation of Benefits(FOB)or your ID card if you have questions regarding
this EOB.
•If you're not satisfied with this coverage decision,you can start the Appeal process by submitting a written request to the address
listed in your plan materials within 180 days of receipt of this EOB(unless a longer time is permitted by your plan).
•Send a copy of this EOB along with any relevant additional information(e.g.benefit documents,clinical records)which helps to
demonstrate that your claim is covered under the plan.Contact Member Services if you need further instructions on how and
where to send your request for review.
•Be sure to include your 1)Name,2)Operation Location/Group Number,3)Employee/Patient ID number,4)Name of the patient
and relationship,and 5)"Attention:Appeals Unit"on all supporting documents. _
- -- You-are entitled-to receive free upon request access to,and copies of,all documents,records and other information relevant to
your claim for benefits.
•You will be notified of the final decision in a timely manner,as described in your plan materials.If your plan is governed by
ERISA,you also have the right to bring legal action under section 502(a)of ERISA following our review.
Definitions o f terms used on the detail section o f this statement
Service Date(s): The date the patient received the services recorded on this statement.
Type of service: Description of the type of service rendered.
Charge(s)Submitted: Amount billed for the services.
Not Covered/Discount: Part of the"Charge(s)Submitted"not covered under the benefit plan(eg.,discount amount).
Amount Covered: Part of the"Charge(s)Submitted"eligible for coverage under the benefit plan.
Patient Deduct/Copay: Portion of the bill applied toward the patient's deductible or copay(if any).
Covered Balance: "Amount Covered"minus"Patient Deduct/Copay"(if any).
Percent: The percentage of the"Covered Balance"which will be paid according to the benefit plan.
Pian Liability: What the Plan would pay before coordination of benefits with another insurance carrier.
See Note: Explanation of CIGNA's payment calculation.Please see the final page of the Explanation of Medical
Benefits for the written description of the Note.
other Coverage: The amount of another insurance carrier's payment.
Balance(if any): Patient responsibility amount for this claim.
G2420G 05-26-2004 PROCLAIM Subscriber EOB
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