HomeMy WebLinkAbout961535.tiff Sherry L. Rawlings
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1rR,rf�irt �$ ( u1 Lour --.
Essex Square
1122 9th Street, Suite #203
Greeley, Colorado 80631
Phone: (970) 352-4776 Fax (9,7Q ' 52-6160
August 9 , 1996
Russ Anson, Esquire
City Attorney for the City of Evans
3700 Golden Street
Evans, CO 80620
City of Evans
Sewer Department
Public Works
3700 Golden Street
Evans, CO 80620
Bruce Barker, -Esquire
County Attorney for the County of Weld
915 Tenth Street
Greeley, CO 80631
Weld County Board of Commissioners
915 Tenth Street
Greeley, CO 80631
Re: Mary Waters
D.O.A. : 05/16/96
To Whom it May Concern:
On May 16 . 1996 , when exiting Schwartz 's Krautburger Kitchen
located at 820 39th Street in Evans, Colorado, Ms. Mary waters
tripped, fell and was seriously injured. A Notice of Claim
Pursuant to C.R. S. 24-10-109 Against the City of Evans was
delivered by U. S. mail on July 25, 1996 .
Ms. Waters has incurred, and will continue for some time to incur,
medical bills. Please submit the enclosed bills to your insurance,
or notify us of the proper carrier.
Greeley Anesthesia $ 315 . 00
Greeley Orthopedic $1, 417 . 00
Greeley X-Ray $ 41. 80
North Colorado Medical Center $6, 011. 73 .
C i ui � mcxc„
961535
Letter to Russ Anson, City of Evans Sewer Department, Bruce Barker
and Weld County Board of Commissioners
August 9 , 1996
Page 2
In addition, Ms. Waters is currently continuing treatment with Dr.
Heare at Greeley Orthopedic, as well as receiving physical therapy.
Please let us know to whom to submit future bills.
Thank you for your assistance.
Sincerely,
)1x2
Linda. Jaye
Paralegal
Enclosures
pc: Greeley Anesthesia
Greeley Orthopedic
Greeley X-Ray
North Colorado Medical Center
STAPLE
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� PREb NAN('Y E1n P� GIVE FIRST DATE !All DD VV is DATES P NAeL'--TO JGRR al Cu !T
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' TRAVIS HEARE M. D. MM OD YY
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29 AMOUNT PAID 30 BALANCE OBE
l -SIGNATURE OFPHYSIC AN OR SUPPLIER - ' YES XXIO s
INCLUDING DEGREESPH OR R )2 NAME AND ADDRESS OF FACILITY WHERE 315 . 00 A ' 0 . 00 S 3 1 5 O 0
a CREDENTIALS RENDERED nI o, e Ian Rome .HE SERVICES WERE JJ PHYSICIANS SUPPLIER$BICUNG NAME 4DPRE$B.ZIP CODE
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GREELEY ANESTHESIA SERV. , P . C . ,
NORTH COLORADO MEDICAL CE P .O . BOX 5280
CHRISTOPHER 5 MICHAEL MD
'sIGNEn OSA, 8/96 GREELEY CO F10631
Pills 1 ORP:
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___________ ___
—=- 10 CHARGE
i r_ I_I_Lr ik Il1UILOii. it ,i:i_ (611E id Ii-i i 1.14ilIN'
1800 1 111 Si 5U1 TL 60O PRINTED 09 : 3s : 1 r i9 Jun Irr[A .
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GRLELL r, CO bob 3I c-5-r ib 1N`i4��
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MORY WATERS 144187i 970- 56-0631
2626 15 f AVE NO E59
GREELEY LU 8061.
bRTE REF-=="===WHO-- --=TRANSACTION==== -DING --AMOUN_i. BOLONC L---FL
-- -------- t - - -
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06/ 11 /96 54751 303 73100 X-RAY WRIST, S VL-J 53. 00 - -1364. 00o1.
Ora/ .1 1 /96 54751 303 99024 POSTOPERATIVE FO 813. 41 0. 00 1311 . 00o1
06/O4/96 54499 101 -, 3100 X-RAY WRIST, 3 vW 53. 00 1311 . O0o1
Oh/O4/96 54499 101 99024 POSTOPERATIVE 1U 613. 41 O. 00 1258. 0001
105-.;1 -96 i 73
05/26/96 54169 101. 7.. 1O0 X-RAY WR151 , 2 VW 53. 00 1256. Oooi
05/J8/96 54189 101 99024 POSTOPERATIVE PO 813. 41 0. 00 12O5. 00oi
O5/ 16/96 53116 101 6'5611 TREATMENT OF CLOSED, CON 1O29. 00 1305. 0001
05/ 16/96 53116 101 MARY 99222-57 COMP H&P MOD. 813. 41 176. 00 176. 0001
( <4418711
DR. NAME SSN ID#
303 THOMAS J. PAZIK, M. D. 64-0610942
101 TRAVIS C HEARE, M. D. 84-0610942
** PATIENT DETAIL **
PATIENT# 44167 MARY WATERS DOE:O3/22/1947 SEX :F 520-52-6986
***Please note that this report runs chronologically from bottom
to top. The balance due as of this date is found at the top. **a*
ORE ELFY XRAY GROUP, PC
1624 1 7TH AVE
GRC-ELI-Y CO 80631
383S
STATEMENT DATE ' PAY THIS AMOUN- ACCTa
BOOKKEEPING PHONE- (9/0)353 5400 06/26/96 41 .80 F 307565
PATIENT NAME: WA ERS, MARY A BILL: 7 CODE: PPP PAGE. 1 SHOW AMOUNT
PATIENT PHONE: (970)356-0831 DIAGNOSIS: 814.00 PAID HERE
ADDRESSEE: - REMIT TO:
MARY A WATERS GREELEY XRAY GROUP, PC
2626 1 ST #289 1624 17111 AVE
GREELEY, CO 80631 GREELEY CO 80631
RBLOZ4YZ000C
Please check box above address is mcorrer I Ix insurance
mlormaeon has changed and ed:cale change(.)ar:ovc sc side - STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYr
DATE CL CODE DESCRIPTION OF SERVICE CHARGES PAYMENTS ADJUST. BALANC
05/16/96 H 73090 FOREARM 20.90 20 . 9
05/16/96 H 73110 WRIST 20.90 41 .9
ACCOUNT IS PAST DUE. PLEASE SEND
BALANCE TODAY. THANK YOU.
ACCOUNT NO. CURRENT 30+ DAYS 60+ DAYS 90+ DAYS PLEASE PAY
THIS AMOUNT. ... 41.80
02 302566 0.00 41 .80 0.00 0. 00
FOR SERVICES RENDERED AT: NORTH COLO MEDICAL CENTE INSURANCE
TAX ID: 84-0628383
REFERRING PHYSICIAN: MILLER, JOHN F MD
PATIENT NAME — - - ACCOUNT NUMBER
Li " i i . Y ( 7; . )3 3 J 7 e North Colorado
DATE OF BIRTH - - - — Medical Center
ADMISSION DATE DISCHARGE DATE
— 1801 16th Street •Greeley, Colorado 80631-5-
J 2 2/,4 7 ' / l 07 t u 3/1 J/ )0 970-352-4121 Extension 6320 - Patient Accounts
RESPONSIBLE PARTY _ --- --
-- - - - FED. ID. H 8 4-12 076 3 8
2.J 1 .. ' AJ -' ' BILL DATE TYPE OF BILL AGI
GaL . Y� UJ jLo ;1 _ _ J/ )/ 'L/ Yu EPLACcr
40 INSURANCE COMPANY POLICY HOLDER POLICY NUMBER GROUP NUMBERI J T PLAt
YES ❑ NO WE HAVE BILLED THE INSURANCE COMPANY INDICATED ABOVE.
POSTING
DATE DESCRIPTION- UNITS CHARGE CREDI OR REVENUECODE CHARGE
CODE
. . _,i [.i7: J.1 Jr': CNA.2 .,_„
TJiAL CriiiduE : atJ11 . 7J I
J AL P. AAM CY 33. 13 453
/13 1Y :i Jc:iil.l4 diTARTRATE/APAP 2 5. 34 233 1325667
3/13 VERSED IWJ 1rlG/s1L 2:IL VIAL 1 2o. 24 L5J 3333957
5/10 710: Pdi Ic I ,4j 13146/11L 1 23. E4 25J 3E31211
TOTAL NE6 & SURGICAL SUPPLIc3 3392. 56 27J
5/1a CS-OPER ert SUPPLIES 1 311 . 06 27J 23044
5/1a CS-OPER i2i1 SUTURES/CLIPS 1 9. 90 27U 23d79
5/16 CS-OPER RH IMPLANTS 1 31U6. 03 27J 32979
5/11 D 'EQUIPMENT ITEMS LEVEL IV (CA) 7 r_
1 143. 3r Z7 3 5Ji�73
5/16 PREP LEVEL IIZ I 157. 71 27J 3350U75
3/16 E4u1PAE+JT ITEMS LEVEL I (LA) 2 20. 10 27J 3050216
5/16 EQUIPMENT ITEMS LEVEL I (EA) 1 1U. 0d 273 5650210
3/17 3JLUTION. SALINE 10JOML POUR 1 3. 3 270 352C21d
5/16 FIRST TLtIP PROBE COVER 1 11 . 70 27J 3030392
S/16 SX OEX. ICI LR 1060 1 22. 71 27J 3510263
5/16 ;JLJTION. LACTATED RINGER 1000 1 21 . 05 27J 3511066
5/1J SURGICAL IV SET 1 37. 03 27J 353011U
5/10 AAE3TdE3IA "T" TUaI'IG 1 31 . 19 279 43506776
TOTAL LAdU U TORY
36. 03 3.,J
5/10 VEtIPJACTJ:iE 36415 1 3. 55 iij d 7J53
S/10 COMPLETE: JLUOD COUNT 35'325 1 33. 73 300 i5JJ99
TOTAL DIAGNOSTIC RADIOLOGY 327. 00 32J
5/1a FOREARM 73090 1 60. 00 32J loldd
5/10 FLJJ J < 1 IGUR 769)9 1 174. 30 S2J 42192
5/16 PORT C-ARM 76030 1 93. 33 32J 67676
TJTAL OPERATING ROO,Y SERVICE 632. 64 30J
POSTING DATE DOES NOT NECESSARILY COINCIDE WITH THE DATE OF SERVICE
IATRR$. M1.ARY A 77043)65 NORTH COLORADO MEDICAL CEi1TE 5 /22/9. .
,,,, ,•,- —r-
PATIENT NAME anCnl INT AllIIAPPP ,,,,„,_„
PATIENT NAME ACCOUNT NUMBER North Colorado
4;. _ ; ; 3 71 Medical Center
DATE OF BIRTH ADMISSION DATE DISCHARGE DATE 1801 16th Street• Greeley, Colorado 80631-51
j/ 2 >/6 3 71 3/ - 3 9/1 .j/ i tE 970.352-4121 Extension 6320 - Patient Accounts
RESPONSIBLE PARTY _ — FED. ID. tl84-1287638
xlik _::: je -I: ,. Y ,r _..
,J u I — , ) BILL DATE TYPE OF BILL PAGE
u-'LLLCY, CJ i'2Di J7 5/2L/ -U h :PL.ACSMciNT
NO. INSURANCE COMPANY POLICY HOLDER POLICY NUMBER GROUP NUMBER PLAN
❑ YES ❑ NO WE HAVE BILLED THE INSURANCE COMPANY INDICATED ABOVE.
POSTING DESCRIPTION - UNITS CHARGE OR REVENUE CHARGE
DATE CREDIT CODE CODE
i ft it..f TI J4 OF Cr1A.i u_ 5
7/' U '.J. di. E'.' iCi)OkC L :/LL I (ri .l) 4.3 03G. ail, 3oi 5.i3J109
TUTAL i1Jti:TH :a 1A LJ /. ;rJ 31
Sri AA L _iii[i. 111 't JUT iNI_ uLA:tkAL I 269. 3J 37 , .J30132
TOTAL t1 . ; CN..Y J:PAR7MLN7 3S5. 93 43 )
5/1u PHI' FIL- ML .iC SJC 1 131 . UJ 43 : 200o
5/16 CD LEVEL 3 TRAUMA 99233 1 2u4. 93 43J 505123
TOTAL AiCJVCRY ROOM 217. o5 71J
5/1b POST ANESTHESIA CARE ROUTINE 1 217. 35 71J 43443
TOTAL TREATMENT 4 036ERVATiJN 16i2. 33 70J
5/10 OUTPT OUSER ADD' L Na 99211 2 52. 00 7oJ 19711
5/11u JJTPT UUSERVATION 1ST HR 99211 1 130. 00 700 19885
•
POSTING DATE DOES NOT NECESSARILY COINCIDE WITH THE DATE OF SERVICE
ATittSe MAk " A 77J48935 HORTH CJLJHADO MEDICAL CEATE 5/22/9
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