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HomeMy WebLinkAboutCC 5 CLAIM #92-50 12-07-92CONSENT CALENDAR NO. 5 si ! 12-7-92 Z Inter -Com S A." TATE: NOVEMBER 11, 1992 TO: HONORABLE MAYOR AND CITY COUNCIL FROM: CITY ATTORNEY SUBJECT: CLAIMANT: EMIL MARMOL; CLAIM NO: 92-50; D/L: 06-11-92; DATE FILED W/CITY: 10-30-92; CARL WARREN FILE NO: S 72864 CLB After investigation and review it is recommended that the above -referenced claim be rejected and the City Clerk directed to give proper notice of the rejection to the claimant and to the claimant's attorney. JAMES: G. 10_URKE City Attorney __.. JGRJab:111192(C1. 9250 jab) Enclosure: Copy of Claim cc: Carl Warren & Co. Finance Director City Manager AIM AGAINST THE CITY OF TT "IN (For ages to Persons or Persoi Property) The law pz'ovidesof generally that a claim must be file oi`event occurredrk Be the City of Tustin within 6 months after the incident sure your claim is against the City of Tustin, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph number. Completed claims must be mailed or delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin, California 92680 WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INR TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California: The undersigned respectfully submits the following claim and information relative to damage to person and/or property: 1. a. NAME OF CLAIMANT: EMIL MARMOL, a minor b. ADDRESS OF CLAIMANT: d. TELEPHONE NO: f. SOCIAL SECURITY NO: g. DRIVERS LICENSE NO: 2. Name, telephone and post office address to which claimant desires notices to be sent (if other than above): JERRY N. GANS, Attorney 714 838-3938 jl. orba t., te. Tustin CA 92680 3. Tnis claim is submitted against: a.The City of Tustin only. b. The following employee(s) of the City of Tustin only. rr following e: Yloyee (s f of t. c, X The City of Tustin ?*�d the f of Tustin only: Tustin Unified School District, �Irs. Sims (teacher) and possiblv. other employees of the `Dustin [;nif ied School istrict not yet identified. 4. Occurrence or event from which the claim arises: a. DATE: June 11. 1992 b. TIME: Appr.ox. .:00 P.m C. PLACE (Exact and specific location): Tustin Huh School 1171 1 Camino'Real Tustin CA Mrs sClass. d. HOW and under what circumstances did damage or injury u laimSpecify the particular occurrence, event,- act or caused the injury or damage (Use additional paper if necessary): TU T N UNIFIED SCHOOL DISTRICT, Y OF TITSTIN.MRS SI`S were- soiely, Jointly and /or concilrrenr i y responsible and ne, 1i went for the tact, of supparyision of studen" dLrino school hours including- - but not limited to, failure to s v maintain students while in MRS. SIMS' classroom and during school hours; failure to control and supervise students while on campus at a tine when school principle, personel and school district knew or should alleged damage__ injury? Please see achment. 5. Give a description of the injury, property' damage or loss so far known at the time of this claim. If there were no injuries, state "no injuries". Broken facial bones. 6. Give the name(s) of the City employee(s) causing the damage or injury: 7. Name and address of any other person injured: 8. Name and address of the owner or any damaged property: 9. Damages claimed: a. Amount claimed as of the date: b. Estimated amount of future costs: C. Total amount claimed: d. Attach basis for computation of all bills, invoices, estimates, In excess of $17,000.00 and continui Unknown. In excess of $17,000.00 and continuer amounts claimed (include copies of etc. 10. Names and addresses of all witnesses, hospitals, doctors, etc. Tustin Hospital, 14662 Newport Ave., Tustin. CA 92680 Leonard Prutsok, M.D., 1310 W Stewart Dr.. #214. Orange. CA 92668 _ MRS SIMS the students in Mrs Sims' English rl cc on dime 11 1Q4) WARNING: IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!! (Penal Code Section 72; Insurance Code Section 556.0) I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated to be upon information or belief and as to such matters I believe the same to be true. I certify under penalty or perjury that the foregoing is TRUE ANTD CORRECT. yxecuted .this `r` day of DATE FILED: October CLAIM 'S SIGNATU JERRY GANS, Att rn-ey for Claimant Emil Marmor, a'minor _,l: CLFORM Revised 4/29/91 o� 19 - at Tustin, California. 4.d. have known racial tension at Tustin High School would likely result in altercations, fights, riots and/or other potentially violent and injurious acts; failure to take adequate measure to protect students from the results of potentially injurious acts. 4.e. TUSTIN UNIFIED SCHOOL DISTRICT, CITY OF TUSTIN, MRS. SIMS, were solely, jointly and/or concurrently responsible and negligent for the lack of supervision of students during school hours, including but not limited to, failure to supervise and maintain students while in MRS. SIMS' classroom and during school hours; failure to control and supervise students while on campus at a time when school principle, personnel and school district knew or should have known racial tension at Tustin High School would likely result in altercations, fights, riots and/or other potentially violent and injurious acts; failure to take adequate measure to protect students from the results of potentially injurious acts. VERIFICATION STATE OF CALIFORNIA, M' OF I have read the foregoing and know its contents. M' CHECK APPLICABLE PARAGRAPH ❑ I am a party to this action. The matters stated in the foregoing document are true of my own knowledge except as to those matters which are stated on information and belief, and as to those matters I believe them to be true. ❑ I am ❑ an Officer O a partner O a of a party to this action, and am authorized to make chis verification for and on its behalf, and I make this verification for that reason. ❑ 1 am informed and believe and on that :round allege that the matters stated in the foregoing document are true. O The matters stated in the foregoing document are true of my own knowledge except as to those matters which are stated on information and belief, and as to those matters i believe them to be true. ❑ I am one of the attorneys for a party to this action. Such party is absent from the county of aforesaid where such attorneys have their offices, and I make this verification for and on behalf of that party for that reason. I am informed and believe and on that ground allege that the matters stated in the foregoing document are true. Executed on . 19 , at California. I declare under penalty of periury under the laws of the State of California that the foregoing is true and correct. Typc or Print Name PROOF OF SERVICE 1013.A u► CCP Revised t/i/M Signature STATE OF CALIFORNIA. COUNTY OF ORANGE I am employed in the county tit'. ORANGE State of California. I am over the age of 18 and not a party to the within action; my business address is: 14131 Yorba St., Ste 204, Tustin, CA 92680 On O c t. �`L1992. I served the foregoing document described as C L A i_ M A G A I N S T 11-4 F CITY OF TUSTIN (For Damages to Persons or Personal ProDertr) on the interested parties in this action by placing the true copies therenl' enc!osed in sealed envelopes addressed as stated on the attached mailing list: by placing C the originai G :► true copy thereof enclosed in scaled envelopes addressed as follows: © BY NMAIL ® *1 deposited such err.eiope in the mail at TI, g ?- i r California. The civ,-c!ope %%as mailed wid, po.�tagc thereon fully prepaid. U A- follows : ! and with the iirni's pracuc: collection and processing, correspondenct for mailing. Under that practice ii 1,: edc osii,id with U.S. postal ser•iec on that same clay with postage thereon fully prepaid at California in the ordinary course of business. I am aware that on motion of the party served. service is presumed invalid if postal cancellation date or posta_­, meter date is more than one day after date of deposit for mailing in affidavit. Executed Tustin Executed on 0 C t o b e r ;!7 19-2-2. atCalifornia. ❑ **(BY PERSONAL SERVICE) I delivered such envciope by hand to the offices of the addressee. Executed on 19 , at California. (State) i declare under penalty of perjury under the laws of the State of California that the above is true and correct. (Federal) I declare that I am employed in the office of a member of the bar of this court at whose direction the service was made. SHARON SEELERT Typc or Print Namc STuAaTS EzeaCOK T.raESAVER .�r�•SL^• S/�:aa. NEW O!SCOVEQv LAV. 2030 ANO 2.31 CC (May ae usea n Ca-lan-a State w seocra; Ccwn;+ ILI ) -' :fir Signature Er vA- SG%A' = %'u57 BE Cr 0:2SCv :.ENCS' %G Eti+_:OPE a IVA,_ S,0" 3Cn CZ _AG, .%FO= aEQSCNA: SEQ':'CE S G%ATUA: VL:S'7 BE Tr4A7 Or '6'ESSE%GEQ1 MAILING LIST CITY OF TUSTIN Attn.: Valerie Whiteman Chief Deputy City Clerk 15222 Del Amo Ave. Tustin, CA 92680 TUSTIN UNIFIED SCHOOL DISTRICT Attn.: Leticia Barrozo 300 S. "C" Street Tustin, CA 92680 MRS. SIMS C/O TUSTIN UNIFIED SCHOOL DISTRICT 300 S. "C" Street Tustin, CA 92680 � �� • �- • a --. ... Qr�'���•1T� /� ,� � t � .... ��- _ 'T t^iv -. �1 '`. _....� _ _ s. �yt�: • 4 � � 7i �1�.~- ` l .KTP !1t_►� 7�+� ~ `�x•i_:�g;�y.. w.�`�C �v� r�?i �_: �'J-i...-Y �•►'^ NO _ i : J tas t•wov. $o _ - ::. t;tRRAt TAx tw. : • _ . s .,� z �..� S .. '.:.J' :{_- •'i •.f1 .••: s•_ 7 ..%+.� -71 .i t_ .�:.a.t.•✓.'_. ��. ^: •..�+•�: w.:'J �ICY=t'�c a� tom:•-•� t;, •� �'..-.�- - _ k.w. •�.. ;♦ r ... �♦ ..*� :..�� _: _•...;._:�,.. �? �t a'�p-4.�, ern ;_ _ 10PATMMTa LA{T $AYE-ti..rrt v+•.1w .tTFIRST MAW 11 PA-1 A00P1iN ,. _� ^� � .� - -► �-� •_. .�-w'. ZIP _'•��. . • �•�� •.. rte+ ,....ti�.,•l�i ,•,;i••�._�.^�J.�i •+•1A••�_'a••:: ''.::1 :�►^� .. • ,��1"�ir�. !.' ' . ..` .,•,•. -%_�. .'�:-�._ :..�� ' Q *^Tot CARsu $ r~ i• • •• q AJI. 70 OX It, tiTAT ' DA I+C-O. s CA& ! baa w - y� �ti .��•. •�T� i j.. sy: IE OAii �. MPR 1TT'I( _ 11tDU s.; TMOtJO$ .�.. s .•.�. �� J� -• rt• .s'i ' _� K ':=� i :.:c» o -fes► ° i h. ::.�A•.1.r, .._ •_ 1copAli . %..: CD DATE CD .- FPKW �,: _-►: :*�.• TMouam ...•. •rtr' . CD.r-. • . r '• •;.•.�• �.�.. 'i�4' _ .. ... .� n_ .r �.: • to s► Al ... ... - .. .. _ • yt .. • - i 11IIt1 At KA Q MOT M. O OED IROG. 36 f47 31 MARMOL; DARSARA -VALUE - 4 01 1.510.00... .:`. OESCRMTIOM I- 51R COOS STS UM115 y TOTAL CHARGES S. 36 3660 ' PHARMACY.-,- `:� - _ ___... _ =- - �Q 5;� mar-cL 'sU�-f'LTE- - - - -7� 64- Lx1T�GIRAT£3RY�. 300 - -3 CT :SAN = :� O 1. 7C3c5 - ANL T! •IF I A 370 -1. t. �i ,b?C:4 .:.. . _ swr:✓......_. • .�illtv.::na�_ .J __l .�.w .w .c. ate.:-c.` � _. v.. -... :... , - I .. _ .a ..s�:.11__ r...rL•wiiJ�.a �•A<-'.'A._: ..._... �LJ�. .�'��L .__.V...J Vim.•. _.,� �..J:.0 .._._ - _ ... . �_�.r.rr�►- .u�._. __ • ... ,. �. _...• -..mow. _. �_. ..• .. _•. ... ...: EMETZ ROOM 450 1 35000 _.1_i.•. iL'. wr r�.:w..r •...-r .21.'i�r•.�..i.�s.\:�.aJ rr.��� • ._..r �.l•r:..-r•-r. .._. _ _. _ .. •. a .:l-. _.. ... � _ _ . - _ _ _ .w _ '- : . 57 PAYER tf0 DEDUCTIBLE I t►t CO wSURM•CE Ct EST RES►OhSt8tL1TY I O PRIOR PAyMEMT$ I M EST. AMOVtiT DUE A~•i { !t { i L� I•j.• V'' ��� < f;- a' _�...f n ♦1(_ r `,•. _ _1.. • .T .v.:�r-c;.� �%!'� _ •-. .� .. e .�-"'%: . --. . --.- .• � 'a+rr� -,.. ..Z_y0:r:..;J-�--...a��::+�•..�__A/:^..1� �•r •_1.. �.w_ rJ.L.._ r .. .. ____ .+_. - ... _ .. .. _ Elm on E6 tMSURED'S kA&AE USES I G PJIE_. be CERT -'.%k MK -C MO i GROW NAME 70 thSVRAhCE GROUP t•G Ar. \ l.r.t /.`-•� _ Vr'tY%�(+•-i^"\/=L� _- (;`_-1_T E�+AT'.Jv�:Ti !`{J`�.• �: ;�r� >,, y�ir{f-tt-.L'�t �!tl-1 -- - • .^ - \� �� �l t ��.Jr....: '.f.� ; •n_t C 71E10 7 ES: 73 EMPLOYER MADE 74 EMPLOYEE tD 75 EMPLOYER LOCATtO•t +) J'JS Vii. t•.••cT•t'K-Z -. .A`•_s-i '.'_ ` • ..._ �.�-- �,� i : a • • �' r•... r•r • 1 _ .-� " - 'r�. J.t '�a.�� '-''� __'�:� i; •`'"J•i�%•.L moi. e` I:i`'iJ.�•+�K-w:�• •t�.;a ,.:w. ...t' •.\ �;�"+•' _...' ' = COOE • 74 PRr•CMK Aho OTHER DtAONOSES OESCJ mnsOHd _ 17 PRIt. COOE FX • ',I if'�/MAXT11. AfiY—L'1_t�E . - _ • - - . _ _ ....... /� .4 ��. cSC96----00 Q `J'� .a R Okm O f5 MKvK AMD OTHER PROCEMARES DE3CF-WT00.4 _ OATE W OATS cm DATE 9 �:� F�E?�UC7' t'u`,�AFti/ZYt 3 FX 77/b�y•.?72�y �1 h— .- OAT" - •t 7REJ�7MEltT AUT M. y Q ATTEM�A 10 IJtJ .t,s 47Jc:J Q OTHER MTS+CtJJi O - B7 CO -M APP. FROM F AM. T W OUGM _. PRLI snK. � .F Na n REMARKS - FROM VERIFED M•C. iTAF�TEt.S •i� - PR rsc o •• . �,,,, L_Ur ,r PRUPEW BUYER � APPr*y By • DATE AI7t� ''1. 4..i.10�Ca - • _ - RE..MI,RSED A./,,, co �mii, �'% .9 0: 1--0000 _ _ . _ •A J - _ • x, I CEATIF7 THAT i>IE GEllTtffCJ\TgttS Oh THE REVERSE APPLY TO tw3 all ^NO AAE NADC A IMi atREO/ VATc HCFA -.1450 INSTITUTION COPY �yRE3EMTATTVE _ :. --=— "'Tustn'Ha spu ASV, k FINAL BILL te V. 7 75 -Z. vl.'%� Ar. -oftL -A ut LrTY,4 A HEALTHCARE INTERN.ATIONAL FAC4 ---P.O. BOX 1046 -'*TU- STIN CA 92681.1046 -,n -"'GUARANTOR ILLING DATE E�7; 7� *.,.,.,.NUMBER / 16 16/?2 a4ccA44VI KVU13L I BARBi�FtA RNANCIAL THIRD PARTY PAYOR CLAW 1 2 3 115 301&S* AGE PHYSICIAN 17Y DATE OF SERVICE is PROCEDURE CODE -PROCEDURE DESCRIPTION ..... .. OUA14TTTY UNIT PRICE 6 %31. 12 0002 6 ffaVIOLRG M"Ll-F-RI V. ROOM, Jju I 1 510.00 i /11.l 47W, 0270 9 n. LNIA Ly rz3 10 3%j.00 V! 1 "72 A'3 0 0 10-16 4 rT NrT CK V M7 E, ZE. AL 65 -co 6/11 -,172 4 1,6111 011. 2 9 1 V 0, i Mr G a Z Y S 0 120 Z 3 41:60 0023 9 CT SIM "D '-,A X I A L W,5.$0 4 L (,'0 C� 6 5 6 FACIAL BUES X-RAY 1 135.00 4600 0, �) i fjAIZAL ?()JEC M f )RA 5; hINrv) -6/11/1712 Al A -t -0,2, 11:..3 r'Al I :a:: Ar L IZ - , f 4 1 1): �_:' MA r 1 -H. 4102 1162 :%5 is; ON C ALL VROJAR5E I ST F. R .0100 5� r.2 4102 12-170 6 " MkM TRAY A. 100 '(110 '.6A IM 4140 002 3 ANS Tr ES TA 0Z 15 ril N 40 7 2 9 ^0 -6/11/94 4140 0002,. 6 AqM- GAIS-FIFST R 1270.10* -6/111R2 4 143 0014 1 PULSE OxIllrETER S2.00 5/11/92 4140 0(>Q 9 C-02 KNIMR q6.00 6/11/92 4140 Ck 4 0 7 CAFM PC "J IT OR 45.00 114L IL R12 4153 2YF5 8 -33711 A r%V Kr4ok\j MEATH INGS - P-0 - .0 16.00 34.00,, ios/1' R2 41`0 7 ITUBTN ULATOR /l 1 /-y_jM 4.L2) 01,14 2 REDWS, Y .1.46.00 6/ii/9-1 34120 0599 4 iRECCryUY fq"*-l--I1p•t,Sn-:"* 1:?` 2 i 73.00 4710 0138 8 r -r-. 1/4 HaR 2 14,00 :%_/92 IS.& TI 0 OXYGE14 MASK DISFIL 16.002" 14150 2 2 4 F .4, (N. , WAT I N -M r% SM P � 1 i 72M., _.x11.32 4150' 4601 018-00 S:,' FS 5:11/72 14 102, 1-477 30 CNJ9 .7r\Y PLL 1 65.00 4102 1269 0 FINEWT11c LIGHT ga-JFCE 1 40.00 6 1/92 4150 3M7 7 KIT, NEIROR-ASTY I 345,00 6/11/52- 4150 3`64 6 MVISrER SLCTION LI ERS 15= 2 20-00 -6/1 1/y2 4102.12 5 F M: PETM NULUSM 1 70.00 -6/11/92 4102 4 HMMCA IMMTS LOOn FEE 1 751.40. -6/11/92 .9999 4150 0160.1 COITMIIG 2 31400 r 6/111/92 4220 2647 8 KEFZO,' lui I GH I -6/11/9" 420 '1558. 8 DWROGE 5A -INJ 50 K� 54#50 bLLt/72 4200.4978 5 VICODIN JAB 6 :. :..21400 7 TERMS OF PAYMENT:* WEEKLY & IN FULL AT DISCHARGE INSURANCECOPY2 PRUTISOK t LEWARD AMOUNT it'. 110 %f 35.00 711��i. 0 0 7'v5 4 405 0' 1 'D5.00 1:A 00 10 Cl A_ t J. ,8 7: 15 0 0 111) .1 AlAt 00 lvv 202J. 00 1. *2 (). 0 0 8''•- _ CIO 86-1.00 65.00 16.0-0 34.00 1-16.00 146,00 28, 00 16.00 Moo 18.00 65. 00 40.00 305.00 40.00 70,00 751.40 62.00 .46,25 54,50 168.00 7M, 7015 7G:& 015- 70l& . 1. .-. ­'.­ - - I - PLEASE MAIL PEMrrTAIYCE TO: TUSTIN HOSPITAL MEDICAL CENTER P.O. BOX 1046 PLEASE PAY THIS AMOUNT TUSTIN, CA 92681-10" t&NFAI 1 �Tustifi N_ospital -': r+yam • • •�=i1,L�>,i�;!p�ti�' �.'. "a `� ��.�1 Rj►'e"�.�' -r .YL -1 �,�it�- Ji'�fiy• ` 1 � .-G-•Medical Ce:j�l•.- -- .-.ri-..: ..:`�'ii�..:T��� •���a��:+:•�i�.... - .. - • --- _�`.'+.'rt:.,a� ~'�- _.-.+�~�'� I- }.+,Y,-.,_ N •?.••� ""'�r. �' r LF�� nter :�},; �,:- _ ^ . -..:,x:..1,;:1_ .- ••-_~ _ ` j _ . -�..; .:' "�'" ' •' FINAL' Fitly "'� tE ae ••__ '- :..-=` �: :`.;- 'A FEALTHCARE INTERNATI P.O. BOX 1046=�TUSTIN CA 92681 _1046 '�:a''"�^.= -�"'' •-' • ' '� ' • e • - , •- ..-• ONAL FAClL1TY �.: «.•1.• ti• '.�-•. �!�l�t: '1(�•�A��� :i •/..'.t�t.!•=i: t. rrit•�7••'t7\ �:r..�1 :�Nr H•.;. �1 :..ri. 1:A 'Its•,• • �M�►i �_ �, �f, -i 'MEN m. GUARANTOR - .. �,• ; +. :::s'. ' ' :.. - _ `' NUMBER 131LUNG DATE . - " • • - - : • - :: : _ _ .. -• .. - .. - - . � .7/'16192 326643401 AGE FINANC K. i THIRD PARTY PAYOR CLASS 1 2 3 115 I 3%,,;,16a 17 Y ATE OF PROCEDURE - . -- ••- .�. 1....111... _ ......... _ _ _ ..,,__. ERVICE CODE _ 7. _ :� PROCEDURE DESCRIPTION_.` OUANTITY UNIT PRICE _�.- .� '11/'92 4'7W -'9; S l.'I•`_�IILtq TAB il12 . 4200 ••t, 88 :. f� �{ lri NJ JV h01 1::�1DI Ei S '.1!1072 4200 5.00= 6 VI`'TriL 5� INJ 1 Y,L 54.50 1 '•� 15.00 ".1.09') 4L.Ir C -j 1 v I'L.rt., .. T !-: /1'&, ?2 411 .41-1615- 6 A y ."_:!92 41s'1 r -!6 6 TL•LE: E114D)Tf� 7.0 i/?2 4150 2724 2 r ill, s ��'�� I: A LT i A 10.50 i `' H i I:ISr ! :+. '92 41.0 4Y 8 . •....cl'. �1.1.� EfU 1 : 25,00 ' 4150 2441 2 , 't ASM- SPLINTP.EZlT 1�V .11E :n 2,•92 14150 15u4 1 T% �:��i, �a.►CiIt3'� "215+2 13M 0402 6 ' ticI4 �SLFG SEMI-HUY- FMA D13, !12/92 ' 4150 02.67 4 ; E0-IVX M- O-rC :21'92 # 4150 0267 4 EQ-IVPC 2 ,O-iC ,11" t 4150 2633 5 SLFFIRS ?152 42ci� 1558 8 I��XTir1C�E 5:: I��.t ;ice':! 4200 1884 8 : it : ' 0. 91440-L < -IinJ�1bC0. 2/92 42Ov 02 52 7 CEFP.ZMIh SCDILt -1 G�, :2.y� " "'"' ' ' ^00 035•? 7 •,� .0 .1 ► CC AZCZIA: '�r;h 1.50;10 r�1L 12x2 I 14200 1558 8 �.�� D XTSCBE 5A,50 t ':2/'92 42�X� 155$ ° ti i'•En`?fiLSE 5,50 ? �f:: � •nom .ccn r• : 4c L,,,i0 O � r- •T� .+ r,E`^ RZE .cJn,5✓r h 7�0.1 1558- G . L-/:1 R''L_r+� rJn,,h/ I+L '420C 2L47 6 ! CEFAI.CLI,d M;ItJ 1 GM, 10 ei :�"92 i 4_'7,C0 2647 S i C r sMIN S -OMAN 1 Cri,10 VL 1?.'92 4200 a47 8 ' CErr►Z�IN SiDIlif 1 G?;,10 2%r2 I4200 26478 C' ZCLIN SWILM, 1 GV410 ML 12)72 4200 4045 3 DIMiiERIA-TETM 0,5 N-0.5 M riZ�SZ 42'00 4x78 5 ACETA�IHf Hr i-N� MC,1 TABLET 2,?2 4200 4978 5 F, cTAMItJ,°�{�'- 2 TAfETS, 2 TA /12)92 4154 0429 0 FAN HOT/CC_-D ' x.2 192 4190 1100 6 CAIN, A 010 20GA 1-1/4 r12R2 4150 22797 IV STMT KIT N� ,*2 _ 4150 2670 7 TUBIW-3t* A^CX�T-It�FtlSION 10.50 29.50 �4.j�� c 21.ti0 151CIO 12.00 45.00 t 1 , �•,;.0. i ./ '7 C ...� 1 46.2 . a • `1 1L.VV 54.50 1 '•� 15.00 ,-; 510.00 1 46.25 - 36.00 1 .16.00 1 8.00 1 J4.50 t 1 , 76.5;G 1 ./ '7 C ...� 1 46.2 1 54.50 54.50 1 54.Jv A V . 54.50 50 1 46.25 1 4, .25 1 46.2 1 46.25 1 32.10 1 10.50 1 21.00 1 1740... 1 : 25,00 i 67.00 F-iYSICIAN FRTI 6210, LECKAF•S1 AMOUNT 4 C5 1V..;t cC, c 4,.1.00 w IVf J :n r. A- , v o 1;28.130 13, 00 510.00 36.00 IV, •O0 8100 54.50 c 46, 25 54. %0 54, : ^ s•i. 5^ S ►. �� 46.25 46.25 4o.25 46.25 32,10 10.50 21,00 17.00 20.00 19.00 J . 67.00 ::ems _-� .-i �.:?�=, :^ki:'T •,Y�:•••�c,fr ^;:COMMENTS TERM - i . - PLEASE MAIL AEMRTANCE TO: . . S OF PAYMENT: _. _ _ _ TUSTIN HOSPITAL ' 1EEKLY d IN FULL AT DISCHARGE MEDICAL CENTER INSURANCE COPY 2 TUUS IN CAA92681.1.046 ` ._... : PLEASE PAY THIS AMOUNfi = AS FA* •-..- ��.r �'::J �} A t• �3/ j )�.' L��'-';y �•�i�'�s1.7 ''�`+4� '. Y�• -�.a�' •�*A+�:>'.a►.•1.1!'!7t�'�� SY.•*:j 4+r - R :Tustin Hospital �.r 1 _ _ 3, �• w :�:� • '� •+' •..! 1--•••`^1't .:�.5,. `•;. r+w..- •y.:.y��. .7.�• :f ;•!:�-_J•?1C �v`-�'Fky�! •,ice �,t,-'�iy ti�` h.w. Mre.r.; •! 3 7 - xt'' � :_1� s: t',,,,i' + - �� M1�.ry �-• •,- - • .� -.A••� wl � is=. �;.'tt .,e... moi, ��• � •• , .. P:-'!i►.� '.� .t Medical Cen• ter r, /'. �,,.�'•.••"a.....M -_ .�: •w.:- _":.I•! t`:.--� � .._•7� 1��..�i--•�.�`"��`=-"•='+. __. �f.•.• _• �it�t.. MILL _ .-� a�l.f .vim. .r �-•.�• - • •1`" _ � _ '•' .� ��'r •_-��•t-•.P=•...� a _.�i�- �.1::��7:�Y.w.....•_1w �.w..••....r �•Z.I:`�+A.IwiN �. _ a«.U�!._..r._• _.s....1�� _ ._ ��. ".`•.:.,��. AJ•�. ��: .•. .. �1c• - ' :� v . •••J �..«-•vr. .l.��1 t •� ♦.�•- •�: �,: •�J ��:�•'- •..--•. •�. .v•s.-�y:�.•1�3ri -.-. �A HEALTHCARE INTERNATIONAL FA P..' BOX 1046-TUSTIN CA 92681=1046 = .� _ _, _ = l � - _ ' �.r% :`t'•,�:•x;..:� - CI ► f ss:-.••.•.. lRY O coo%2=0.221111c 114 ji BE3 %�, GUARANTOR = '� - c...: ;t.:; NUMBER BILLINGOATS- :. . . • ., ., • . -: • _ : ' . : _ . .: '�li 6/92 . 326642-;91 _ FINANCIAL ' THIRD PARTY PAYOR CLASS 1 2 3 115 1 30168 AGE 17Y DATE OF ... PROCEDURE �-• RE DESCRIPTION f - J T PROCEDU DESCRI ^ --_-•CRI. _ OUANTITY �� •: UNIT PRICE-� .Y _: SERVICE CODE TERMS OF PAYMENT: WEEKLY d IN FULL AT DISCHARGE • =. INSURANCE COPY 2 14.00 13.00 54.50 64.50 . 5 510.00 36.0 V n 6f 0 12.00 12.x+ 5,00 76.50 76.50 76.50 76,50 27.00 54.50 Cc10 � d'A t�\1 1 Sti.Sn 46.E 46,2 46.25 510.00 12.00 12.00 36.00 .19.00 15.00 12.00 12 #00� . • .- 12.00 _:12*00 14.03 `I .,.00 - •67.00 ••••�+.•• - PLEASE MAIL REMITTANCE TO: TUSTIN HOSPITAL MEDICAL CENTER _ -_- ' P.O. BOX 1046 PHYSICIAN F'RiTSa l LE& ARD AMOUNTCOMMENTS 41-; ••7-40 S : T���r._, IV C�r ..". w11 Gr. fi:.00 )6Al2192 -1t-0 7'32) 4 TU K, EXTDlEGN Y ;,4.G i .ili/ 1.=J -2 9 6 i iv5 I EXTn. L�rr JA It" J licit,3L 7 1. r.n .JJ1�J•� nJ ..., ?t 400 lv: J II .Jr•aA`✓J INJt.fO L 12.00 i 1 21 010 t'!L.IY'EMP3 9001h t,hii • 1 :61113R2 4I" 0`2257 4 230 -DC 76.50 76.50 76.59TV !1 .6/1319 2 • r. �y -' 1 /+ •7 .; x _ , V.s.,G L C'' t �j +T' 1.0 i rr • ,JrCi�L'�, G+,., r ./. 4 • vt% 1 6/ X13/'92 41` _66? i FL11r �L Ili i ;669 `� L.a� �'•FwiUl i 1 92 X72 3 ; V:a3SJMI (F5 ITE 2X3 1 ./92 415r 2672 3 .1IOSSIN5, CFr7 c 2X3' 1 i :5113/92 4:-,r 1£,q4 8 D 5X a S14,CL INJ 1U?3 FL s 1 : .4 6 00 18q P tGo SlY- It�J 1000 MIL6/_3/ ► 1 �� 42V1.1 1654 8 i n 5X 0.?;A, � L DIU 1000 K_ ' s ��I h/13N2 42- ,1 15-94 8 D `% 0.9&"CL INJ 1000 HL •-: s::- f 1 � �•": :-6A13/ • 42'.,) 1044 c Fs�ARZ'�! Ftttgi 100 U 1 _;._• 4 1558 2 ,50 FL Z / "13/? � •TSG 1.^i:J� E T i l'E/1 i R& 5-n 150 rL - 1 GA1:ti 7G : 14.._ 1 1.;._'{] ME" T RME JR5,.•. `,K ` i 5/:3/'92 �2-xi 264 7 8 CEt=;ZCLiN' IrLh 1• -m 10 NL 1 :U/13/S2 42�i0 2647 8 ' CEFAZd.IF! S00IL �1`'IGi,10 ML' i 5!13/92 42,D) 261 r E CE*rt MP", SMILM 1 Gi,10 F, 1 5/:4!92 : 3•i:2 C002 6 i K-JStF:G 5�1•21-�Iti.Ci`i M -i J; Ci j 4 R CfiT;, Sl�i� 14ri: l!'C 1 6/14/'92 : 41f 014? w ClMUIT-EkE ;lri11N < 4 i ;6/1;/92 ; 415r) CQ67 4 EQ ",/ 230-110 1 -6/14 /92 41 -) C•452 2 P'C.R-1vw1p1'C_sb1 i1z'9_1Y 1 6/14/92 j 4 "L 5) =8 6 SMIu, FrAYEX 1 ,6/14/S2 ; 5.::� 0 0 2 :: "Ah\"Imw"ousun pos WI• �'.ti�'�,Y�_"'�•-L �i ��j. ;T t'., r.-(Z}��'!��•��t. •!�••^`f. �.i':c: ��:i':i,r�.•M_' �.f�`�.«� �•�r�'yi •a.y ��. v";.SJy w...�Mv� Twr`�Q�,;ar�{�;rT.�I Medical Center `••�-�.:: -:: .= =-� _ ��-• - _ ... .:,�.ti,;•r-.�...,;=.�.,;- _-,.• �,;a� �-- ;} �-��� . �� � _.r -J r«.fY �.r--\r St ��.. �-J.1-.-.+. • n. ..1 ••�. --' - _`__'�•. .�..,�.. +•' ". �, -uH.i. �.+; .�_�. a.;�• i... - •- - ,• - .\ \, •.I-I•.[,.A..� -_ �.� . - :. •.1.•_1r• •L\„•�i- _t��T•T :��i• ./`r � .✓ I'..y.���,y V . • -_..- P.O. BOX 1046-TUSTIN, CA 92681-1046 - _`" '. �. _ " '� rte= '- = A` HEALTHCARE INTERNATIONAL FACILITY �» ACCOU�T B'R _ ISS+OP117ATE�q A�E`ROi�IBER� +► ---mom . • GUARANTOR .... • _... _ : = - _NUMBER:BIWNG DATE • - :. . ' - 7/16/92 1 •32,6643401 - . MARtCI, PARWA - FINANCIAL THIRD PARTY PAYOR CLASS 1 2 3 115 30168 •_ i AGE PHYSICIAN 17 Y PRUiSCK, LEGIAAD 4 T E OF _RVICE i PROCEDURE CODE 1 ':-- ---.---...�__. _._��..__ __ - ^fir-�- :" :• PROCEDURE DESCRIPTION ::- OUANTI7Y - , �w UNfTPRICE i .4,?,? !4150 2672 3 I nE '6I�'�ii, +'� J.TE 2X.3 1 S.Ou V2 : 41`0 2-722 6 ; PFII, TAC;: NII,? T ECG 425A 2723 4 ; CATH) FEED F%'K',,rG,'N �8 _,.92 4150 2724 Phi:, �.0,JJ:! IT ADILLT 1 ?,�: +0 4. 72 t2 , M . 730 7 iE-711 E tri t\� " J 4 _-/ 72 'l1 �t-,� 4 ` Ti. r tX I:��:.�t...� 't 1 13.�:; A'1 A.rte &."110147'i �••,- .,...• ,r n-14 A �-5 3 •/"'••� • 4,iS/r 18f2 1 D.i'.! ..,.v 42C* -7392 i s D c 4~d!ACL 1 76 +St? ''_-t. Y2 0200 3912 5 LACTATUI RIKKEIR8 Itq i* 1C. SEL ! 1 j _-.`'••.`" 7S.Sr 142160 4163 �r� r, a 34"4/92 .tr`420 4412: i� STERILE ht f\`:-.4-5 .1 5 /.,d '? 1141200 1030 8 ; KEENRN F? MI lOC U,1 ML fit;. r:'`•• 1 27.00 4/92 4200 1030 6 '• HEEK.G: N FLU3i 100 U t l I:Ly -. lr 27.00 14/92 S IMO 1030 8 1 FE PAR 1N F V• N 100 U, I htz-. ""` ..�:`f-3 3 2 i .CEJ --^,.'9.' 1! 42700 15.08 8 ti,: 1 SX,50 �1 �•., _G . • { 1 ' :4.50 �.:V�r ��.i� GV TII-_X3';�.��= j L��l:l hl�.� v� tJl'J'A''== j in �2 ' 4200 1558 8 DEXT wr 54't�50* t✓`_ 1`• = 1 i i 5t , �f: ':4/92 4200 2547 8 CIE FAZ(IIN Sf11iL 'I Giwit1C i aL ':,-'92 4200 2647 F#, ' CUAZ2IN S[DILA 1 G i,10 IAL I ; 4,6.25 s c -riz��t� S3JIL'i 1 16, 1 46,2`5 4200 364 7 7 ! AC. i A-&ffN'G0HEN' E::3? tiG;? TAP 1.50 14200 3647 7 ACETAK_1N-0PFa c50. 1A,G,2 TA!, � 4 � 1.50 ': ti:'72 4200 31647 7 A,CETAt'S? CPHEI� E0 NG 2- T*' 4 1 1.`0 t 'I4.92 4200 45382 KEFERIDIWE WA. 50 MG,l tAL 1 29.50 'i= !/�►9�j2 4200 44�-77\�//78 5 A`Ct=s AMT�Or'HB!-}iII�L�,2 TAEr• U 1 21.00 '01/72 42CO W00V 6 VISMFU 1K 50 M,1 t'L 1 2*1.50 ':. ri'2 3112 000-1 6 ffJVSiJ\-G GDE-FR I V, MJMi DG. 1 510 . 0_0 %.!/72 41 W. 0267 4 EG -•I VAC 230-i1C 1 36.00 5/92 4150 05602 SF-DrGE, WE 4X4 10Fn ! 12.00 '.15/7 2 4150 2670 7 TUDING, rMSET Ii USIGN i 67,00 n 5/42 4150 2716 8 SUFER SMIGE 1 14.00 2 4153 2744.0 T1P_f , APD/PEh/31 NJ :. 1 8100 AMOUNT 5.00 45+c . 00 "„ 010 33.00 1 00 1_3.00 1V. C•J ?0* 0. v0 -r ! G. +s V 76. f50 79. 'J0 54.50 L' , .��r, _:� 27.00 61.00 X81, 00 `54.50 =. 50 514.50 46,2 46, 2-5 46.25 1. �✓� 6.00 6.00 25'.50 21.00 24.50 510.00 36,00 12,00 67.00 14,00 8, 00 PLEASE MAIL REMITTANCE TO: - TERMS OF PAYMENT: TUSTiN HOSPITAL ' =EKiY a IN FULL A7 DISCHARGE - - L: ' MEDICAL CENTER INSURANCE COPY 2 0. BOX 10646 PLEASE PAY THIS AMOUNT USTIN, CA 92681-1046 COMMENTS�� A�`VA�-•v ,L•, l f s ivy si' „�4 •- =• .r' ♦ �L. ' ' �• \' ' 4v, justin Aospbl ----=� -,;� :_ � :K ...� �,. ;,•x�.., �- .�; - , ; � w JF.r. ��•., *... . � � .� Medical Center • -' -_-• ;;;tet_ . _,:.�=-,.- -w .:.. .,.,;...h FI��.;�;•�,,z. ,u,..�.. :�.� ,.;.. .�_•��:-_,_ ri..,.;.; tiAL'PIL'• •' -`-l• ;J_ i �_,• �t•\�y�,•. �•� �•l-••.L �b .��Y'.ti- •1. ...f1vf \7..►-�./Y-%.�..�r-.-J f'1I-'�.:Y. '.' `Y:'!�f-�l�►-I•� -� . r , w� � -. -� .�. . •.�• �. •J-• ... • - w J. i'.• t �... . `'.'. _ .�.-A•�. � '�%,j � .•.�...1-�1 � -�.r. • \-:.r:.�:\. � . ���...�-Y�yf��•�ai/� iw '+..._ v � P•0. BOX 1046--TUSTIN, CA 9258.1.1046 •> •, .., A�IHEALTHCARE INTERNATONALG F UTy':, v...-��,.a....�-!•L•. '�. ..! .- �..-i'yj'i.43�i'si•�.Ifi.�i�!•.�:! �• �� .1 •! /.i - aH •; 7-. •.. .• O A 111"SSOW"Do GUARANTOR... NUMBER _ - • .... BIWNG DATE 7/16/x'2 . 326643401 MARK , EA PRA - :ATE OF i PROCEDURE 'ERVICE / CODE 1 1 4200 1892 1 '15/92 422Z 1e 0, 2 1 f15 J2 1 • 4200 lv7i L i 15/T2 42V M J0. 4 A , 115/92 42'0O 0752 7 rrSJ/9242M0 06%61 i 1 4�0-) 14':.0 8 /15/92 ` 42()3 1030 8 /15!92 � 42tX.1 15'� e po 1.`.'I7."'. 4�'N 1,-58 2 14200 1556 6 2 4200 155 J-6 8 110192 4200 1553 8 !15,'92 j 4200 2647 8 /31 5/42 14200 2647 S 5/5-2 4200 a-4-1 8 ,'•.5/'92 4200 2647 8 54.50 424) ?647 8 „ `•/'9� ! 420x} K•`.1 9 nL C1.I'1IUFi 1 G•'i;10 42CO 264-7 7 !i 5!92 4200 36-47 7 '15/92 4200 3779 E .• � J A-) •: Ar)/.AL 1. '74.00 J,r7 L .LJ/ 2 497. 14200 `17 1 G J '72 4203 2-e7 8 6/52 4150 056-0 2- f16/72 '16/; 2 415 0 0560 2 '1&/ 2 420U 1892 1 6/42 4203 1.30 6 .L/,/?2 4200 1030 8 '16/5x2 :. 4200 VA 7 '16/72 . " 4200 3547 7 /16/92: ' 4200 3647 7 -/17M,4200 1030 8 '17/92 * •. 4200'4978 5 `2 = 4200 4978 5 FINANCIAL THIRD PARTY PAYOR CLASS 1 2 3 115 3016$* AGE 17 Y _PROCEDURE DESCRIPTION;_ -_; OUANTITY _ .UNIT PRICE ,..z: INJ 1000 eel LC%-n � 1. 1 76.50 - � v ` "`-"`^"' INJ It�'`0 M1. 1 76.50 D s 45,`x= INJ 1 C)3 0 „L 1 76.50 = L RAN r'_ GAS 3 1iIS: ,50 ='� S;U; i G, IC �:L 1 46.25 -,S B 10 tlL,1 I1N.ECTIO 1 76.00 ' fF R Zs' c-;94 104 U,1 h L ICR 27.00 50 v v .a ..f,.,0 1 5ti,,v :'E�: �= S�,SO h L 5-4 50 1 -F -V R 5>; ►SO mL VER -=} 54.50 V E ME also PiL � ISR , -''�f� r 54.50 m:y SCi►I i 1 Gm,1:; NL 2 , i 46.25 nL C1.I'1IUFi 1 G•'i;10 ' �'"�':1` 1 `� J 46.25 LE= 114 SMILM 1 Gmt10 teL :'r 1=�'1'��� �tG,ZJ 46.25 CE==.?riI.'4 5iu1 3 GM,7�i `� I� 1 40.25 Cf:1 itF 4),1�.%::.- . ::.1 v } 74.50 --MG 2.:TA�- 4 � i .`0 Nc"I'h5�' X50 \ _ . It 10 LII:�CfiI4=-t�'iNFF; , IM,10 ML f 5 1 7 410 SLI=M TARM CITRATE 50 MM I M 1 44.00 A2=- A st 10q- 2 TABLETS, 2 TA i 4 21.00 LPY-z _ 2GV Mu, 20 'WI L ', } 61.00 ' S; •��� �, GlIUM tv.4 10^1: 1 12.00 S�-Zt r_, GAM -7 .44 10K 1 12.00 J.1 .` .''i.=CL INJ 1000 rL 1 76.50 F:rF.-RU4 rufm lOG UPI to 3 27.00 N -::Srl FLU%i 100 U,1 HL 3CR 27.40 A' * r.7*GNCr- 9I 110 MG,2 TAE 4 1 • .. 1.50 i Ark--Tk ND:1-B 650 tiG,2 TAB 3 PD-E-1A!•si, •TPRI 650. M P2 TAE 4 RN rLU%i IC4 .U,1 tQ..:::.. 3 I Ar 'TA.'ltoo- , I=,2 TABLET DFOC12 TAE ET 1 �.. -1.00 •. 1.50 27.00 .. -. '21.00 21.04 PHYSICIAN PRLTrSD',, LEWAM AMOUNT =x6.50 "4 I J1•d0 i '5JO �� cG J . 2.1 C 4�� 76, VV 01,00 18.0xF. 5fi.50 - , cy. 54.20 J4. 5CCF 54. •- OCR 46.25 •25 A / .1% '10.x0 4b. 46.2 I. 7A 0 6.00 ♦ 5CCI\ C �. 35. 50 44.00 84.00 61.00 12.00 12.00 76.50 81.00 81, OOCR 6.00 4.5XR .6"m 81.00 21.00 - ri COMMENTS . .-ice•-..'. �i �• .. ' ,. - .C- __ - ._• - •_- ..• - __ - w��_.a7.- � �/•1 ..: l-� Ji•. -l.\: 1•: •�•'TwiY.t; fir\II J' ,rY.aa• si , \tea �!. .;Y 1`.•;: - ` -�.2 iT Iry V•-:F.�/� % �'. •�ti w.:/ .: I �v. ,Y• r 7• * .)1, ...5�.1i-� .-i�'v.: ._ �••::.1' ..t''r �••+.G .:�s"L?-��y�• fir. �''C• 7 ��a•'R • ,r +'-^Y17�r'''' ;f. �: C ':.. .. .�. :..�� ... !i: f�•' i .% �R-• s y l g �7�;{��' 1�T ��'� � i rw,�,,:tiv';Z•.�c� ti.'1 ti �'♦ __ "c..�T' ::�o.i.6:r 1.�'.=<< ` '.��:::�.�3: `''� %J�:i !'.=}.. ' Ifi3t .�� �. t'�11` �,`Sj-'�f�f'•'�i.�'t�j!•�yi/ �w�i�t ��''C�`h�F,•./ r.-•r�rY.•f�7-Yr�^ICfiK'�. j 1, .�� + �� �: TERMS OF PAYMENT: - 'PLEASE MAIL PEM rrTANCE To: _ �. :'.TUSTIN HOSPITALcEKLY IN FULL AT DISCHARGE MEDICAL CENTER "= `• -. INSURANCE COPY 2 = -=- -• o sox 1045 = _ _ PLEASE PAY THIS AMOUNT -. USTIN, CA 92681-1048 __ 99A Z 1 FAVR'Tustin Hospital Medical Center TML zi A L d -A HEALTHCARE INTERNATIONAL FACILITY.-;- P.O. BOX 1046—TUS11N. CA 9268 i -I'0'4'6 16, 4.?. , ..% WILISISI02 A. 901 S.; I GUAAANTOR% NUMBER t: BILLING DATE .:,p6643401 WRmt L-Mpmto%. FINANCIAL THIRD PARTY PAYOR CLASS 1 1 1 115 3016Dt 2 3 I AGE PHYSICIAN 17 y T ATE OF PROC DiRE OUANTITY :ERVICE CODE PROCEDURE DESCRIJ ;UNIT PRICE I SL -FRVffiTE RLTN PAYbON'T, GDERX KIRGI-Ry R U < Y R 121 EWY EINT 14- sipo V E5.10,04CY RUN TWIG CAT SCn J' RES.IrIATMY T140*y FRTiSCKt LECNAFt, AMOUNT 00 IDAA tm. 11r692.UCR 6 tOO1, 40 K 1 00 5Z 6. C0 1 ?990. 00 0 00 1-100 4c- 28.00 . % 7__ AMFAXZ� ONMATIPMM PLEASE MAIL REMrrTANCE TO: TERMS OF PAYMENT: 5 -TUSTIN HOSPITAL -VEEKLY & IN FULL AT ZISCHARGE MEDICAL CENTER INSURANCE COPY 2 P.O. BOX 1046 X046PLEASE PAY THIS AMOUNT TUSTIN, CA 92681