FILED
`12/22/2023 3:12 PM
`FELICIA PITRE
`DISTRICT CLERK
`DALLAS CO., TEXAS
`Kellie Juricek DEPUTY
`
` IN THE DISTRICT COURT OF
`
`
`
` DALLAS COUNTY, TEXAS
`
`
`162ND JUDICIAL DISTRICT
`
`20231222
`CAUSE NO. DC-23-17662
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`§
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`§
`§
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`CRISTIAN LOPEZ-MORENO;
`
`
`
`Plaintiff,
`
`VS.
`
`CITY OF IRVING;
`
`
`
`Defendant.
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`PLAINTIFF'S NOTICE OF SERVICE AND FILING RECORD AFFIDAVITS AND
`CERTIFIED COPIES
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`Plaintiff Cristian Lopez-Moreno files with the Court the attached record
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`affidavits and certified copies:
`
`STATE RECORDS:
`Certified copy of the police report
`
`MEDICAL RECORDS:
`1. Absolute Chiropractic & Rehab affidavit dated 5/24/2023
`2. Andrew Indresano, M.D. affidavit dated 10/13/2022
`3. ATI Physical Therapy – Euless affidavit dated 5/9/2023
`4. Baylor Scott and White Medical Center - Irving affidavit dated
`8/10/2022
`5. Dallas Pain Consultants affidavit dated 10/20/2022
`6. Daytime Surgery Center affidavit dated 5/5/2023
`7. Lone Star Neurology – Grapevine affidavit dated 5/9/2023
`8. MRI Centers of Texas with affidavit dated 12/13/2023
`9. The Spine & Orthopedic Academic Research Institute affidavit dated
`5/4/2023
`
`BILLING RECORDS:
`1. Absolute Chiropractic & Rehab affidavit dated 5/24/2023
`2. Andrew Indresano, M.D. affidavit dated 10/13/2022
`3. ATI Physical Therapy – Euless affidavit dated 5/9/2023
`4. Baylor Scott and White Medical Center – Irving affidavit dated
`5/22/2023
`5. Dallas Pain Consultants affidavit dated 10/20/2022
`6. Daytime Surgery Center affidavit dated 5/5/2023
`7. Integrity Anesthesia, PLLC affidavit dated 5/5/2023
`8. Lone Star Neurology – Grapevine affidavit dated 5/9/2023
`
`PLAINTIFF'S NOTICE OF SERVICE AND FILING RECORD AFFIDAVITS AND CERTIFIED
`COPIES – Page 1
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`
`

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`9. MRI Centers of Texas affidavit dated 12/13/2023
`10. The Spine & Orthopedic Academic Research Institute affidavit dated
`5/4/2023
`11. Uptown Radiology affidavit dated 5/4/2023
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`
`
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`By copy of this notice, opposing counsel is notified that these affidavits and
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`certified copies are being filed with the Court pursuant to TRE 902. The certified
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`copies and records corresponding to the enclosed affidavits will be kept in Plaintiff's
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`counsel’s office for use at trial. Opposing counsel has been previously provided
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`with a copy of the affidavits and corresponding records and the certified copies
`
`listed above.
`
`Respectfully submitted,
`
`WITHERITE LAW GROUP, PLLC
`
`BY: /s/ Laura Andrade
`LAURA ANDRADE
`State Bar No. 24089966
`Laura.Andrade@witheritelaw.com
`10440 N Central Expy Suite 400
`Dallas, TX 75231
`(214) 378-6665
`(214) 378-6670 (fax)
`
`ATTORNEY FOR PLAINTIFF
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`PLAINTIFF'S NOTICE OF SERVICE AND FILING RECORD AFFIDAVITS AND CERTIFIED
`COPIES – Page 2
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`CERTIFICATE OF SERVICE
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`I hereby certify that a true and correct copy of the foregoing has been
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`forwarded to all counsel of record on this 22nd day of December, 2023, pursuant
`
`to the Texas Rules of Civil Procedure.
`
`
`
`
`Jason McClain
`Saul Pedregon
`City Attorney's Office City of Irving
`825 West Irving Boulevard
`Irving, Texas 75060
`
`/s/ Laura Andrade
`LAURA ANDRADE
`
`PLAINTIFF'S NOTICE OF SERVICE AND FILING RECORD AFFIDAVITS AND CERTIFIED
`COPIES – Page 3
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`
`

`

`hu 9 May 2022
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`MORENO V. CITY OF IRVING 000094LOPEZ-MORENO V. CITY OF IRVING 000094
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`Ft Texas Department of Transportation
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`125 EAST 11TH STREET, AUSTIN, TEXAS 78701-2483 | 512.463.8588 | WWW.TXDOT.GOV
`
`STATE OF TEXAS
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`Jim Hollis
`Director, Crash Data & Analysis Section
`125 East 11" Street
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`MORENO V. CITY OF IRVING 000099LOPEZ-MORENO V. CITY OF IRVING 000099
`
`MEDICAL RECORDS AFFIDAVIT OF ABSOLUTE CHIROPRACTIC & REHAB
`REGARDING PATIENT CRISTIAN |. LOPEZ MORENO
`STATE OF TEXAS
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`COUNTY oF CNU((\INY
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`| am the custodian ofthe records ofAbsolute Chiropractic & Rehab. Attached hereto are records
`from Absolute Chiropractic & Rehab regarding Cristian |. Lopez Moreno. These records are kept by
`Absolute Chiropractic & Rehab in the regular course of business, and it was in the regular course of
`business for an employee or representative with knowledge of the act, event, condition, opinion, or
`diagnosis recorded to make the record or to transmit information thereof to be included in such record;
`and the record was made at or near the time of the event recorded or reasonably soon thereafter. The
`records attached hereto are the original oréxXact dypticates of the originat.
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`MORENO V. CITY OF IRVING 000205LOPEZ-MORENO V. CITY OF IRVING 000205
`
`AFFIDAVIT OF MEDICAL RECORDS
`
`STATE OF TEXAS
`*
`COUNTY OFL222
`*
`BEFORE ME, the undersigned authority, personally appeared Andro Oboe
`who, being by me duly sworn deposed as follows:
`I, the undersigned, am over 21 years of age, of sound mind, capable of making this
`affidavit, and personally acquainted with the facts herein stated; and
`I am the Custodian of Records for Andrew Indresano, M.D..
`Attached hereto are
`medical records pertaining to Cristian I. Lopez Moreno.
`These said records are kept in the
`regular course of business, and it was in the regular course for an employee or representative of
`Andrew Indresano, M.D. with personal knowledge of the act, event, condition, or diagnosis,
`recorded to make the record or to transmit
`information thereof to be included in such
`memorandum or record; and the memorandum or record was made at or near the time of the act,
`event or condition recorded or reasonably soon thereafter.
`The records attached hereto are originals or exact duplicates of originals, and nothing has
`bee
`been removed from the original files before making copies.
`
`5
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`LS
`Affiant
`SWORN TO AND SUBSCRIBED before me on the \)__
`
`Notary’s printed name: Mn. “einen
`
`day of
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`Notary Public, State of Texas G=S
`My commission expires: © “
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`MORENO V. CITY OF IRVING 000210LOPEZ-MORENO V. CITY OF IRVING 000210
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`MY COMMISSION EXPIRES:
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`1/14/2024
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`NOTARY'S PRINTED NAME:
`Stephanie Ruiz
`
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`NOTARY PUBLIC -STATE OF ILLINOIS
`STEPHANIE RUIZ
`OFFICIAL SEAL
`SWORN TO AND SUBSCRIBED before nmeonthe____
`9
`
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`
`CUSTODIAN OF MEDICAL RECORDS
`
`attached hereto are the original or exact duplicates or
`record was made at or near the time of the event recorded or reasonably soon thereafter. The records
`recorded to make the record or to transmit information thereof to be included in such record; and the
`for an employee or representative with knowledge of the act, event, condition, opinion, or diagnosis
`Physical Therapy - Euless inthe regular course of business, and it was in the regular course of business
`from ATI Physical Therapy - Euless regarding Cristian |. Lopez Moreno. These records are kept by ATI
`| am the custodian of the records of ATI Physical Therapy - Euless. Attached hereto are records
`
`this Affidavit, and personally acquainted with the facts herein stated:
`. | am of sound mind, capable of making
`My name is
`__John Petrusek
`, who, being by me duly sworn, deposed as follows:
`the
`undersigned
`personally
`authority,
`
`John Petrusek
`BEFORI
`
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`
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`
`county or Will
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`STATE OF TEMAS IL
`
`§
`§
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`REGARDING PATIENT CRISTIAN I. LOPEZ MORENO
`MEDICAL RECORDS AFFIDAVIT OF ATI PHYSICAL THERAPY - EULESS
`
`MEDICAL RECORDS AFFIDAVIT OF ATI PHYSICAL THERAPY - EULESS
`REGARDING PATIENT CRISTIAN I. LOPEZ MORENO
`§
`§
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`
`STATE OF TEMAS IL
`ni
`county or Will
`
`BEFORI
`John Petrusek
`
`ME,
`
`appeared
`
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`undersigned
`personally
`authority,
`, who, being by me duly sworn, deposed as follows:
`. |am o* ~~"~~ mind, capable of making
`My name is
`__John Petrusek
`this Affidavit, and personally acquainted with the facts herein stated:
`lam the custodian of the reco~*= ~*T! Dbvsin-! Theranss Euless. Attached hereto are records
`from ATI Physical Therapy - Euless regarding Cristan 1.Lopez Moreno. These records are kept by ATI
`iness, and it was in the regular course of business
`Physical Therapy - Euless inthe regular
`for an employee or representative with knowledge of the act, event, condition, opinion, or diagnosis
`recorded to make the record or to transmit information thereof to be included in such record; and the
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`record was made at or near the time
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`MY COMMISSION EXPIRES:
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`MORENO V. CITY OF IRVING 000267LOPEZ-MORENO V. CITY OF IRVING 000267
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`Comm. Expires 08-29-2022
`Notary Public, State of Texas|
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`My Commission Expires: August 29, 2022
`Notary’s printed name: Jean Balensiefen
`.
`.
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`SWORN TO AND SUBSCRIBED before me on the {
`
`day of Quus
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`»2022
`
`AFFIANT
`ON boar Williams
`
`#0
`originals or exact copies ofthe originals.
`course ofbusiness at or near the time of the act, event, condition, opinion, or diagnosis, The records are the
`to make the record or to transmit information to be included in the record. The records were made in the regular
`MEDICAL CENTER — IRVING, with knowledge ofthe act, event, condition, opinion or diagnosis recorded
`employee or representative, or a healthcare provider permitted to practice at BAYLOR SCOTT & WHITE
`the regular course of business ofBAYLOR SCOTT & WHITE MEDICAL CENTER —IRVING foran
`BAYLOR SCOTT & WHITE MEDICAL CENTER — IRVING in the regular course ofbusiness, and it was
`Attached hereto are 223 PAGES concerning CRISTIAN LOPMORENO,The attached records are kept by
`1ama Custodian of Medical Records for BAYLOR SCOTT & WHITE MEDICAL CENTER—IRVING.
`and personally, acquainted with the facts herein stated:
`“My name is, Christine Williams, RHIA, I am ofsound mind and capable ofmaking this affidavit,
`who, being by me duly sworn, deposed as follows:
`Before me, the undersigned authority, personally appeared Christine Williams, RHIA.
`
`MEDICAL RECORDS AFFIDAVIT
`§
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`§§
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`COUNTY OF DALLAS
`STATE OF TEXAS
`
`ah BaylorScott&White
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`IRVING
`MEDICAL CENTER
`
`1
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`Health Information Management
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`MORENO V. CITY OF IRVING 000491LOPEZ-MORENO V. CITY OF IRVING 000491
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`AFFIDAVIT OF MEDICAL RECORDS
`
`*
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`STATE OF TEXAS
`COUNTY OF |
`BEFORE ME, the undersigned authority, personally appeared ___Jason Chapman
`who, being by me duly sworn deposed as follows:
`I, the undersigned, am over 21 years of age, of sound mind, capable of making this
`affidavit, and personally acquainted with the facts herein stated; and
`Tam the Custodian ofRecords for Dallas Pain Consultants. Attached hereto are medical
`records pertaining toCristian 1. Lepez Moreno. These said records are kept in theregular course
`of business, and it was in the regular course for an employee or representative of Dallas Pain
`Consultants with personal knowledge ofthe act, event, condition, or diagnosis, recorded to make
`the record or to transmit information thereof to be included in such memorandum or record; and
`the memorandum or record was made at or near the time ofthe act, event or condition recorded or
`reasonably soon thereafter.
`The records attached hereto are originals or exact duplicates of originals, and nothing has
`been removed from the original files before making copies.
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`;
`
`/\_
`U
`Affiant
`SWORN TO AND SUBSCRIBED before me on the
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`Qu
`
`(Qualified Witness}
`
`20
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`OCTOBER, _ 2022
`day of
`VWirchasé lancer
`Notary Public, State ofTexas
`My
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`Notary’s printed name:
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`Michael Manser
`
`ission expires:
`
`01/08/2023
`
`ea
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`MICHAE,, MANSER
`Wek Notary Pubbe, State of Texas!
`ae Comen Fxpires01-08-2073
`o Notary 1D 193849037
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`MEDICAL RECORDSAFFIDAVIT OF DAYTIME SURGERY CENTER, C/O ANCILLARY RESOURCE
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`GROUP
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`REGARDING PATIENT CRISTIAN |. LOPEZ MORENO
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`STATE OF TEXAS
`COUNTYOF Denton
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`§§
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`the
`undersigned
`authority,
`personally
`BEFORE
`ME,
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`, who, being by me duly sworn, deposed asfollows:
`Ary Yk j ¢ Oncor
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`| am of sound mind, capable of making
`My nameis asx Vt C OnAcy
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`this Affidavit, and personally acquainted with the facts herein stated:
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`appeared
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`| am the custodian of the records of Daytime Surgery Center, C/O Ancillary Resource Group.
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`Attached hereto are records from Daytime Surgery Center, C/O Ancillary Resource Group regarding
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`Cristian |. Lopez Moreno. These records are kept by Daytime Surgery Center, C/O Ancillary Resource
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`Group in the regular course of business, andit wasin the regular course of business for an employee or
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`representative with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the
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`record or to transmit information thereof to be included in such record; and the record was made at or
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`near the time of the event recorded or reasonably soon thereafter. The records attached hereto are the
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`original or exact duplicates of the original.
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`20/2.
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`aUSTOSAN MEDICAL RECORDS
`wo
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`SWORN TO AND SUBSCRIBEDbefore me on the 4)
`day ofY a f
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`SHAG Huon AliHovdy)
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`XAS:
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`NOTARY'S PRINTED NAME:
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`MY COMMISSION EXPIRES:
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`1D No 132356804
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`hadayan Ali-Gordon
`a conenasion Expires
`02/12/2024
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`*
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`MORENO V. CITY OF IRVING 000505LOPEZ-MORENO V. CITY OF IRVING 000505
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`LOPEZ-MORENO V.CITY OF IRVING 000505
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`MEDICAL RECORDS AFFIDAVIT OF LONE STAR NEUROLOGY- GRAPEVINE
`REGARDING PATIENTCRISTIAN I, LOPEZ MORENO
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`§§
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`§
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`STATE OF TEXAS
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`COUNTY OF COLLIN
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`personally
`authority,
`undersigned
`the
`ME
`BEFORE
`, who, being by me duly sworn, deposed asfollows:
`Nilay Sheth
`Nilay Sheth
`_|_am of sound mind, capable of making
`My nameis
`this Affidavit, and personally acquainted with the facts herein stated:
`
`appeared
`
`| am the custodian of the records of Lone Star Neurology - Grapevine. Attached hereto are
`records from Lone Star Neurology - Grapevine regarding Cristian |. Lopez Moreno. These records are
`kept by Lone Star Neurology - Grapevine in the regular course of business, and it was in the regular
`course of business for an employee or representative with knowledge ofthe act, event, condition, opinion,
`or diagnosis recorded to makethe recordor to transmit information thereofto be included in such record;
`and the record was made ator near the time of the event recorded or reasonably soon thereafter. The
`records attached hereto are the original or exact duplicates of the original.
`
`ey
`CUSTODIAN OF MEDICAL RECORDS
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`SWORN TO AND SUBSCRIBEDbefore me on the 9th day of
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`May
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`, 2023
`
`NOTARY PUBLIC IN AND FOR THE STATE OF TEXAS:
`
`ST
`Alexander Bannister
`{2“peee MyCommissionExpires
`ity,
`Alexander Neal Bannister
`'
`a
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`04/08/2024ys «=|,=~SsNOTARY’S PRINTED NAME:
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`E ORAeS
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`MY COMMISSION EXPIRES: 04-08-2024
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`MORENO V. CITY OF IRVING 000560LOPEZ-MORENO V. CITY OF IRVING 000560
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`LOPEZ-MORENO V.CITY OF IRVING 000560
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`Page - 3
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`MEDICAL RECORDS AFFIDAVIT OF MRI CENTERS OF TEXAS REGARDING PATIENT
`CRISTIAN LOPEZ-MORENO
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`STATE OF TEXAS
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`COUNTY OF
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`BEFORE ME, the undersigned authority, personally appeared ________________________,
`who, being by me duly sworn, deposed as follows:
`
`My name is __________________________________. I am of sound mind, capable of
`making this Affidavit, and personally acquainted with the facts herein stated.
`
` I
`
` am a custodian of records for MRI Centers of Texas. Attached hereto are records from MRI
`Centers of Texas regarding Cristian Lopez-Moreno. These records are kept by MRI Centers
`of Texas in the regular course of business, and it was in the regular course of business for an
`employee or representative with knowledge of the act, event, condition, opinion, or diagnosis
`recorded to make the record or to transmit information thereof to be included in such record;
`and the record was made at or near the time of the event recorded or reasonably soon
`thereafter. The records attached hereto are the original or exact duplicates of the original.
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`SWORN TO AND SUBSCRIBED before me on the ___ day of __________, 20___.
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`______________________________________________
`NOTARY PUBLIC IN AND FOR THE STATE OF TEXAS:
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`CUSTODIAN OF MEDICAL RECORDS
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`NOTARY'S PRINTED NAME:
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`MY COMMISSION EXPIRES: ______________________
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`MORENO V. CITY OF IRVING 000601LOPEZ-MORENO V. CITY OF IRVING 000601
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`10440 N. CENTRAL EXPRESSWAY SUITE 400, DALLAS, TX 75231 | MEDWRECKS.COM
`
`DALLAS
`
`Klara Moniclyd Bendebel
`
`Klara Moniclyd Bendebel
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`13th December 23
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`NINA IDRIS
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`6/14/2024
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`VW
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`NINAA IDRIS
`Notary ID #130700473
`My Commission Expires
`June 14, 2024
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`MEDICAL RECORDS AFFIDAVIT OF THE SPINE & ORTHOPAEDIC ACADEMIC RESEARCH
`INSTITUTE
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`RISTIAN I, LOPEZ MOREN
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`REGARDING PATIE
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`STATE OF TEXAS
`COUNTY OF Do \ akd AO
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`ME,
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`My name is_~ WoO “Pi 7EX Ty ke . lam of sound mind, capable of making
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`this Affidavit, and personally acquainted with the facts herein stated:
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`appeared
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`| am the custodian of the records of The Spine & Orthopaedic Academic Research Institute.
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`Attached hereto are records from The Spine & Orthopaedic Academic Research Institute regarding
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`Cristian |. Lopez Moreno. These records are kept by The Spine & Orthopaedic Academic Research
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`Institute in the regular course of business, andit wasin the regular course of business for an employee
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`or representative with knowledgeof the act, event, condition, opinion, or diagnosis recorded to make the
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`record or to transmit information thereof to be included in such record; and the record was madeat or
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`near the time of the event recorded or reasonably soon thereafter. The records attached hereto are the
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`CUSTODIAN OF MEDICAL RECORDS
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`original or exact duplicates of the original.
`SWORNTOANDSUBSCRIBEDbeforemeonthe 4 dayoe
`Hae. NOTARY'S PRINTED NAME:
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`RUBY LAUREN IBARRA
`rhsNotary Public, Stete of Texas
`%ATS Notary 1D 133475504
`!2= Comm. Expiras 12-06-2025
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`MY COMMISSION EXPIRES: 2 w 25—
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`MORENO V. CITY OF IRVING 000622LOPEZ-MORENO V. CITY OF IRVING 000622
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`LOPEZ-MORENO V.CITY OF IRVING 000622
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`MORENO V. CITY OF IRVING 000715LOPEZ-MORENO V. CITY OF IRVING 000715
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`AFFIDAVIT OF RECORDS CUSTODIAN OF ABSOLUTE CHIROPRACTIC & REHAB
`REGARDING PATIENT CRISTIAN |, LOPEZ MORENO
`STATE OFTEXAS
`§
`county oF LONVONY
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`BEFORE ME, the undersigned authority, personally appeared DpCs i(
`who, being by me duly sworn, deposed as follows:
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`My name ey
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`this Affidavit, and personally acquainted with the facts herein stated,
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`| am a custodian of records for Absolute Chiropractic & Rehab. Attached to this Affidavit are
`records that provide an itemized statement of the service and the charge for the service that Absolute
`Chiropractic & Rehab provided to Cristian |. Lopez Moreno on 5/11/2022 to present. The attached records
`are a part ofthis affidavit.
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`The attached records are kept by Absolute Chiropractic & Rehab in the regular course of
`business, and it was the regular course of business of Absolute Chiropractic & Rehab for an employee
`or representative of Absolute Chiropractic & Rehab, with knowledge of the service provided, to make the
`record or to transmit information to be included in the record. The records were made in the regular
`course of business at or near the time or reasonably soon after the time the service was provided. The
`records are the original or a duplicate of the original.
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`The services provided were necessary and the amount charged for the service was reasonable
`at the time and place that the services were provided.
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`The total amount paid for the services was $
`which Absolute Chiropractic & “YD
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`and the amount currently unpaid but
`tobe paid after
`any adjustments or credits is
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`CUSTODIAN OF BILLING RECORDS
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`SWORN TO AND SUBSCRIBED before me on the br
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`NOTARY PUBLIC IN AND FOR THEYSTATE OF TEXAS:
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`NOTARY'S PRINTED NAME:
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`TEIAR. GOMEZ
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`My Notary ID #129921977
`Expires August 13, 2026
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`MY COMMISSION EXPIRES; \ WA]
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`MORENO V. CITY OF IRVING 000726LOPEZ-MORENO V. CITY OF IRVING 000726
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`AFFIDAVIT OF COST OF SERVICES BY CUSTODIAN
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`Qhdee Muso
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`Al
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`STATE OF TEXAS
`COUNTY OF(>9QQ2,—
`the undersigned authority, personally appeared Delica
`Before me,
`who, being by me duly sworn, deposedas follows:
`My name is
`. 1am of sound mind and capable of making this
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`affidavit, and personally acquajf
`the facts herein stated.
`Iama custodian of records for Andrew Indresano, M.D.. Attached to this affidavit are
`records that provide an itemized statement of the service and the charge for the service that
`Andrew Indresano, M.D. provided to Cristian I. Lopez Moreno from ~t-(. oA___ through
`“lV-L, wQ—. The attached records are apart of this affidavit.
`The attached records are kept by Andrew Indresano, M.D. in the regular course of
`business, and it was in the regular course of business of Andrew Indresano, M.D. for an
`employee or representative of Andrew Indresano, M.D., with knowledge of the services
`provided, to make the record or to transmit information to be included in the record. The records
`were made in the regular course business at or near the time or reasonably soon after the time the
`service was provided. The records are the original or duplicate ofthe original.
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`The services provided were necessary and the amount charged for the services was
`reasonable at the time and place that the services were provided.
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`The right, title, and interest in the accounts receivable pertaining to the services
`provided by Andrew Indresano, M.D., to Cristian I. Lopez Moreno was purchased by and
`assigned to AGG Medical Management.
`The total amount paid to Andrew Indresano, M.D. for the services was $0.00 and the
`amount currently unpaid but which Andrew Indresano, M.D. hasa right to be paid after any
`adjustments or credits is $0.00 due to the assignment of the right,
`title, and interest in the
`accounts receivable to AGG Medical Management. The total amount paid to AGG Medical
`Management to reduce the balance owed for the services was $0.00 and the amount currently
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`unpaid but which AGG Medical Management hasaright to be paid after any adjustments or
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`My Notary 1D # 130319537
`Expires August 4, 2023
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`MORENO V. CITY OF IRVING 000728LOPEZ-MORENO V. CITY OF IRVING 000728
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`MORENO V. CITY OF IRVING 000731LOPEZ-MORENO V. CITY OF IRVING 000731
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`BSWH.HIM.017.P
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`LrLr
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`Release of Information
`
`STATE OF TEXAS
`COUNTY OF Dallas
`
`BUSINESS RECORDS AFFIDAVIT
`Affidavit of Records Custodian of
`Baylor Scott & White
`Before me, the undersigned authority, personally appeared
`who, being by me duly sworn, deposed as follows:
`
`Jason Chapman
`
`;
`
`| am of sound mind and capable of making this
`Jason Chapman
`“My name is
`affidavit, and personally acquainted with the facts herein stated.
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`| am a custodian of records for
`BSW
`records that provide an itemized statement of the service and the charge for the service
`The
`BSW
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`that
`ON
`CRISTIAN MORENO
`__os/11/22-05/1222.
`attached records are a part of this affidavit.
`The attached records are kept by___ BSW
`in the regular course of business, and it was in
`BSW
`for an employee or
`the regular course of business of
`representative
`, with knowledge of the service provided to make the record or to transmit
`BSW
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`information to be included in the record. The records were made in the regular course of
`business at or near the time or reasonably soon after the time the service was provided. The
`records are the original or a duplicate of the original.
`The services provided were necessary and the amount charged for the services was reasonable
`at the time and place that the services were provided. Charity adjustments and/or uninsured
`self-pay discounts are not applicable when there is third party liability and are due and payable.
`Any charity adjustments and/or uninsured self-pay discounts may be revoked if a patient
`receives a third-party settlement.
`
`The total amount paid for the services was $
`and the amount currently unpaid but
`0.00
`which__BSW
`has a right to be paid after any adjustments or credits is $__23,598.88__.
`
`Qu
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`APFIANT
`SWORN TO AND SUBSCRIBED before
`rite, TYLER ANTHONY BITTMAN
`f ke=Notary Public, State of Texas
`Byes a
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`on the 22nd_day of
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`Notary Public, State of Texas
`Notary’s printed name:___Tyler Dittman
`My Commission Expires:
`__03/18/24
`
`May
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`, 2023.
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`Page 13 of 19
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`MORENO V. CITY OF IRVING 000734LOPEZ-MORENO V. CITY OF IRVING 000734
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`AFFIDAVIT OF COST OF SERVICES BY CUSTODIAN
`
`__» who,
`
`**
`STATE OF TEXAS
`COUNTYOF | paALLas
`_
`*
`Before me, the undersigned authority, personally appeared ___ Jason Chapman
`being by me duly swom, deposed as follows:
`- 1 am of sound mind and capable of making this
`My name is
`Jason Chaprnan
`affidavit, and personally acquainted with the facts herein stated,
`Tama custodian ofrecords for Dallas Pain Consultants. Attached to this affidavit are
`records that provide an itemized statement of the service and the charge forthe service that
`Dallas Pain Consultants provided to Cristian I, Lopez Moreno from__ 5/11/2022
`through
`. The attached records are a part ofthis affidavit.
`9130/2022
`The attached records are kept by Dallas Pain Consultants in the regular course of
`business, and it was in the regular course ofbusiness ofDallas Pain Consultants for an employee
`or representative of Dallas Pain Consultants, with knowledge of the services provided, to make
`the record or to transmit information to be included in the record. The records were made in the
`regular course business at or near the time or reasonably soon after the time the service was
`provided. The records are the original or duplicate of the original.
`The services provided were necessary and the amount charged for the services was
`reasonable at the time and place that the services were provided.
`The total amount paid forthe services was $__0.00
`andthe amount currently
`unpaid but which Dallas Pain Consultants has a right to be paid after any adjustments or credits
`is $600
`a
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`/\
`
`Ly
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`(Qualified Witness}
`
`Affiant
`day of_ OCTOBER
`SWORN TO AND SUBSCRIBED before me on the_ 20
`Wheckhast TYanata.
`Notary Public, State ofTexas
`My commission expires:
`
`Notary’s printed name:
`
`ew
`
`»__ 2022
`
`Michael Manser
`
`01/08/2023
`
`MICHAEL MANSER
`Notary Pubic, State of Taxes)
`F Comm Expires 01-08-2029
`Notary $0 1318469037
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