Exhibit List PartyCal. Super. - 6th Dist.March 30, 2021Electronically Filed by Superior Court of CA, County of Santa Clara, on 5/10/2021 2:13 PM Reviewed By: Tunisia Turner Case #21CV381524 Envelope: 6411358 21CV381524 Santa Clara - Civil Tunisia Turner OWNJQLh-bWN-d OOVQM-bwwfloom‘dmm-hme-o Gary T. Blate #85951 Attorney at Law 49099 Road 426 P.O. Box 2253 Oakhurst, CA 93644 (559) 642-0181 Attorneys for Plaintiff SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE COUNTY OF SANTA CLARA GRANT MERCANTILE AGENCY Case No. (Q: Ct v W 6.1L} Plaintiff, -vs- JESSICA BOMBACI , et al., Defendants. GRANTMERCANHLEAGENCYJNO 49099 ROAD 426 l PO BOX 658 OAKHURST, CA 93844 Tebphone(800)821-7530 05-03~2020 VJESTMED AMBULANCE SERVICE 14275 Nicks Blvd San Leandro, CA 945')? Name: JESSICA BOMBACI GMA Acct. E: 1017128 Client Acct. #1 lB-lSSéO Balance: 2881.00 Last Service: 07-09-2618 Request for Authority to Sue and/or Lien The undersigned does hereby assign and transfer for collection unto Grant Mercantile Agency, Inc. and their selected agent all right, title and interest in and :o the claim owing from the above referenced debtor. The undersigned does certify that the said amount is justly due and owing and that there are n0 set-offs or counter claims and permits the agency and their selected agent the right to sue for, lien, collect, receive and endorse the remittances on behalf of the undersigned client of Grant Mercantile Agency, Inc. I declare under penalty of perjury that the foregoing is true and correct. Date: 08/09/2020 By: A/ ‘ 5m Official Title: ‘flceFWesMent P()Bcn;658 Oakhumt,Cfix93644 Phone(800)821-7 530 mm; w Vs ’03; ” GRANT MERCANTILE AGENCY, INC. 49099 ROAD 426 / PO BOX 658 OAKHURST. CA 93644 Telephone (800) 82137530 06-03-2020 HES'I'MED AMBULANCE SERVICE 14275 Wicks Blvd San Leandro, CA 9457') Name: JESSICA BOMBACI GMA Acct. fl: 1017130 Client Acct. 6: - 18-16476 Balance: 4213.00 Last: Service: 08-06-2018 Request for Authority to Sue and/or. Lien The undersigned does hereby assign and transfer for collection unto Grant Mercantile Agency, Inc. and their selected agent all right. title and interest in and to the claim owing from the above referenced debtor. The undersigned does certify that the said amount is justly due and owing and that there are no set-offs or counter claims and permits the agency and their selected agent the right to sue for, lien, collect, receive and endorse the remittances on behalf of the undersigned client of Grant Mercantile Agency, lnc. I declare under penalty of perjury that the foregoing is true and correct. Date: J51c1912020--..___ MLByuNngyfiaaflLm/I/ déL_ Official Title Vice Presidentfi_______..___-.____..___...._---_-______ PO Box 658 Oakhurst, CA 93644 Phone (800) 82 l -7530 «a or; E ‘mmn I'm (-3662 Osr H’ KMA Emergency Services Inc. dbn Westmwl Ambulance |4275 Wicks Blvd San Lcauulro. CA 9457'} (888) 3314420 I’nticnt mime: BOMBACI. CHLOE From: CHLOE BOMBACI Tn.- 4023 HASTINGS AVE SAN JOSE. CA 95] I8 Primary payer: Sccondnr)‘ payer: 1845540 799.270 l 8 ISTJS LYNN Run Number: ”Mo nftnll: Time nf mil: (fuller: [{MQ FAMILlES FIRST - CAMPBELL Hcmom Ilospilzll Blue Shield ()I'Cnlil'ornia AQTGOIOBOU‘) Bill Pulicnl P;I_\n|cur Dnrrlplinn Payer ('im'kfl f)lulnlil,\‘ I IIiI I'ncc ”M" Anunnnl "LS vaI-‘nuzrg nuv: Urban 1 SLI/r-LLUII i: 9mm" Milx‘ngr lhlmn 220 “5 {Ill W5” “‘I For your convcnicncc you may llm' vour hill securely unlino al wwnuvostnmlmnbula[100.com -.-----__ $183 l .(JU PLEASE I'AY THIS AMOUNT DELK’H '\l.fl,\‘(: LIME AM)!“ IL'R}. SI|'|H\ I'I || HOLE P.\\'!ollf.\'T 1H1“; Nil. 13455.1(! .wmmRun Nunlhn': ENCLOSED: Pallicnlnmnr: BOMBACI CI‘LILOI wsa I‘VE? 3 V m \Vc Accept. [ IVISA [ ] MasterCard l | Discover Curd Number: { Mmerlcml Express Dm ml: IZ'II-‘Cfllu _ w Exp|)alu:__u Billinglll’ C0dc:_ Currcnl (hue: I.?.‘IEO I‘JCard l-loldcr Namu: _ ___ __ Sccurh) CodeSignmulu: u ___ _ _______" Rl :'\l|f IO: KMA Enmgwlcy Services Inc dba \N'estmed Alulnflancc I4275 Wicks Blvd Sun Leandro. CA 9‘13??? [aMm pa) '2)ch 659W JUplift fl ‘ 3: FamilyServices :E::::::°::t ’---~ll ‘ . [g €23 [Azm‘gpg \dCC'CSU PROGRAM ONLY- ‘ Tlmwumwu‘mmu CUSTOMER ENROLLME'NT/CLOSE FORM UMCAHEFAcesHEa- 61:3 (mm CUHOMERLEGALMAth-r :waemamm ssu: m ' :03 Dos: A véLDSBIRmpLACECOUmcouwsmmmuomsa smhficoumcfv-m LEGALGEN ER: [1M BF iu' ‘ wne‘mma'mémcobz:“30er mnem mL ' - __Aponéss c5155;ZiPCODE: _ b ) _ - woué'm‘o'e;PHONE:( .URRENT GRADE LEVEl:v mcemrupmmm '1) u/Anlt “\00 21 ‘ msmmc. mes gm Duumown cusmmmuwcums: 9mm.Wpammo g-lg[Q&v IOU Is customs“ mssweaovzasm‘ arms nME: u vss Ho u yes, usr auuoen 13mm ow:__mAnqovm_ mum: emsW0 wumowu umtsmuscooe 0 elmmomawuws ’ _ mg sMpLomszuunMEm:nmtm) u noun meonmncwm nmnorqsmp mcmsm IN pom cm: D Yes no Ir r5, Is Pucemm wrm A nmnve- [J YES u No \oonzss- SML qr ‘1 4W cm: mmzJPcoos. Aonnesscooz- puoneq‘WflM-MWOMCODE mount -' ' ' p'uonecooz. ucALGUMDLAH-mkflmu $ .1” V . 7 ‘_ nmnoNsnw. & Zia; I ____'LMHijcU510ME ‘anvuueum [DD moms. cnv: srm:__zwcocsz 7 mnnzsscoos:___- PHONE-(LplL-v (2&2 PaioNEcooE: ' Pnonmwlflw Eiymasmmg 'mermqui .sfi-r‘ wua Howtfl NAME: -___,__7___m4 rflwmnm: \Joumumem: nan Io; 53643.3 Adm‘u Dale: 713/1 a ' m Humsk - ' BornbatLChbe Admin‘rme: 1905 i g thUMBER'fifimQLmeD-Lr 008:3/15/05 mISema/F I P° ' ‘ scccnmsubimmn Counwmnsmo : “Mgmomn manor: . I _ -.....-. 1.. mamnummmm '1 ficoMMERClAUPNVA I ORANGEHCommudaIm 'm'ed) UMEmOL-Mfmwu I umeormsuwcc: ‘ . 'Nsvonsonio: '4 A. H HuquaJJ 514; T3034 oi- H gnaw u: wmwnla - Health a ”i - ' nu Human 83mm; Agency {S‘SLeO Canfomm Depanmenl ol Health Care Services APPLICATION FOR ASSE$MENT DETAINMENT ADVISE HENTEVALUATION. AND cams mrenvérmon Navm- - 3 W 4 . v0R PLACEMENT FOR EVALUAnou AND ' mni'gefc. omQ/«rfi‘mm neawacagzmmao ma;WWW m 93hHWHL" I (name of agency) You m nOI unde/ cnllvinaé anosr, - - . b 1 kw ' V -_Confldenfla! Client/Paflen! ln/ormalion mg!m prolvesasrgfilsnagn {smfzfafiggflm by meow hem e CmfomlaWU Coda Secliun 5328 and r7 ,. Ogoryx)~JPM Privacy Rum <5 am. 5mm H L” ‘33“ ‘0‘ You wm be 1cm you: rights by me manual mun m n, Wcflaro and Innillu1lons Coda {WM Code}. Socuon 5mm and (g), require ma: Illakenhlocusladyafmsorhsneydenne. m9each pejson.wnen rust detained (or psychiauic evaluation, be men canaln spearpc person shuldsobcloldmo Iolenngarman'on' v inronnahon claw and a rooovd be kapl o! lhe advisemom by tho evaluating laciliry, You may hrlng a lew poisonal vlerns with you. whSdI lfiAdvlsement Complete D Advisement Incomplete W‘” haw 1° WWW Plea“ WW“ me If Yw need assistance lumw'ng 0H ally awlianco or water, YouGoodCause Ior Incomplela Advisement may Wk" n PM"? £8“ 3nd leave 0 "016 l0 la“ WM ‘ friends orlaufly where you hnve been taken. Amisamcnt Completed By l Posilion Language utNodal fy Used Dale ofAdvisemenl swam; B858 I Pw-A-te wbfibmerz vzmmu~%b-\ 7! SUE To (nameorsmodosignmeu tawny) 5, Pu (-1 LC»! o.cEmeKU-W Mr;Wma ' Application Is hereby made forms assessment and evalumionolflglg (SDHM3 3 hg 59 S _ Residing at LJ'DZ'E H 9'31“!) L53 M6 _ Calliomia, for up lo72- hour assessment. ovalualion and crisis intervention or placement for avaiuau'on and treatment al a designated facilitypursuam to Section 5150. eI seq. (adult) or Seciion.5585 el seq‘ (mlnor). oi the W&I Code. If a min‘nr. authorization for voluntary tmalmanl is not available and 10 lhe bast of my knoMedge, tho legally responsible pany appears lo be Iis: (Circle one) Pamnt; Legal Guardian; Juvenile Com under W84 Code 300; Juvenile Court under \N&I Code 601F602; Conservalor. 1f known. provide names. address and telephone number: The above person's condition was called to my aflenxion under the following circumstances:m gpgu. 35m msaehm-onab% M?0MINL». menm WU“ u»- begmg;w 13 gym ¢rr FakeeANc-a. x_z I have probahia cause \o believe lhal lhe parson is. as a result of a menial honllh disorder. a danger to others. or lo himself! harseu, or gravely disabled because: (slaie specific facts) m H 33") ~ «a *QAfl-M 'E-M) W5 Q \J \U" H‘w M_\ WM "17160 wW‘V‘Hk-W "b Mm *rk‘J'er-qsru Fri\HA mwkr-L 01mm nr-J W $TWBN-x 1 D ea'V‘eau .wfl‘) ~Ma- Whabemmm a QMbm m w»)mag Based upon the above Iniormau'on, there is probable cause to believe that said person Is, as a result or mama! heaILh disordur. danger to hlrnsalffhemolf. C] A danger to others. D Gravely disabled adult. U Gravely disabled minor. 8' t ta, Ede and badge numoot ofpeace olfiw. prolsssional person In charge own facility unjunmled by the Dal ho?CERUIM uvaluauon and lwmmenl. msmbsr 0| U10 afland‘m Han. designated wombat: cl a moblu cnsls learn, j ‘7: i I 3m gfi ‘7 '7- or udasshna: person deslgnaied by lhe wumy. hm i q K0,; l LDM‘sK‘I C v ...__ lfi'fl/j] __ Namu of Law Enlcvcernenl Agunq or Evafiualbn Fau‘ilyleson Adams 0| Law Enrotwmonuaoncy or Evalualian Fmiltnywson ‘51? D ”last vo- Hc.53,\:h_, g-T NOTIFICATIONS T0 BE PROVIDEO T0 LAW ENFORCEMENT AGENCY Nofily (olficerlunil é |elephune :5) H F 0N 0F PERSON'B RELEASE IS REQUESTED BY IHE REFERRING PEACE OFFICER BEQAUSE: r I"Doghgcselon ha: bean relenod Io lhe facility under circumflanw: Mich. basfid upon an allegahon of tad: rugmdlng actions wlmcssm o,- mo «ificelor anolhal perwn. would suppad 1h: Ming ol a uiminal complainl. Manon wan confiscated pulsuan! Io SacIion 3102 WU Code. Upon ruieaw. faciliiyis rwuilod lo provfida notice Io the person mgawnq tho powdum to obtain relurn cl any confismiad firearm pulsuanl to Bewon8w2 wu Code. SEE REVERSE SIDE REFERENCES AND DEFINITIONS nuro wm mvmu u ,7mama; £21» 'pqy-zs ox; H mgtmgd Transport Order Form _M=£i_ Complete ‘hls form {er 3H non-emergency D Medi'ca]Ambwan‘? semi“ Ambulance or gurncy transgort [j Other Ph.‘ 1-853 331-1420 Fax: [510) 514-1429 Lisl olhel lypaPa'enl Name. Ct n'm) [02. Tvansfgmq By: Tn'Je: BU TeIJFager l3:BOY"b\C[ 403-154-4033 Pi& up Localion. (Narnia andAdd/ess) J DOS' Fax fl (Alwelenam Uplift Flmiiy Strvfru- Cthil Subiliulinn Unil 251 Lkuellyn AV: BHF Cmpkllfi 95008 O7/y’ /{& 4017,22-3IIS Deslinalion: (Nam?MAAdm“w Seonding MD Name (Pant)PW] Jami Swag D, IM‘ u I’ gAP DLCuhflnz Muon MD Med. Llcanse i3 (Ho Lzmsa a "qmam. Au meataxpmm; A43852 U PCS ls vahd Yo: round ln'ps on this dale and Iorau repetitive trips in me away range. ll H l: H uansfer. describe services needed al 20d facility no! available at (he 1s! facility: ln-palienlmcnm hum: kulmcm/mbihmiun Mediralfllc. lint: Descn'be ihe MEDICAL CONDITION {Physical and/orMenlal) ollhis pallenl AT THE UME OF AMBULANCE TRANSPORT lhal requires the PT Io beUansported in an ambulance and why lranspcri by ulhel means Es conlvainmcalco by the PT‘: cond‘ytion Palienl on SISO herd vequin'ngsnuk lmhullnc: luntpcn Is this palienl'bed confined' as defined below? DYeslI No lo be 'bed cmMed' Ma patienlmuusan’sy all Wee ollbe following cwdvhons: (I) unamo [a galup Irom ago wimpy] assume: AND (2) unahu’e ru ambulafe AND {3)MW: lo .11! fr: a chairwwheelmair Can this palien! wary be transpnned by caromheelmatrvan [I a seated during Itanspcd \m'mcul a mcmcal allendanl or monilonng?) Dyegm'qo J 1. Any vofunlary psychlam admission or pabenl on a 5150- hold «oqu‘lfng Lmnspon 2. Pnlieutrequifing rashalnls duling bansport because ofnighl risk considerallons J 3. Any palienl designated as a danger lo (hemsclvas or others, whe1her m n01 5‘50 A 4A Nlmd mental slalusyecvere msan‘emationwzhe’mev'slagerrelaxed demenlia J 5. any psych patient requiring Iranspan balween campuses lnr testing'lrealmem h ”-‘I 6. Isolation p(ecauliom (MRSANRE. Cvo'fl, 78. elc) 7. Nol a danger 1o se‘l Cl olhevs but Ieaulrex some assistance In Vanspan B. Dewhilus utcers (wound precaulmns) g fl B. Comalvegelaliva _ V N“ lD.Acuvaly seizure prone u g ILUnsule alanding, plvolkzg, or ambulaling 12. Palmnl must lie down. be scmlqeclming or mqure special posilionlng dunng transpon - l3. Patiunl Palaiysis or ssml-consdou u l4. Patienl requlws continuous oxygen during hanspon lhal ls not the PT's own 15‘ Palienl has PGA or olhe! patient mnuouad dmg aetivery duvice 16. Clamped NG~lube. G~lube, saline lock, camelers. damped indweuing vaswrar lines h "”- 11. smalcd wiln NonM sedation including narcoticswimin last 30mm. 1B. Tram palienl- non'venl deparflenl (may have sell-regulated vent) --_ 19. Aspiyauon plecaulion or polenlisl sucb'oning 20. Clamped cenl'al line 2|. Pain IV (DB. LR. NS. DSNS, DfimNS) . 22. ALS or CCY-RN. Pulse aximelerlmrdiac monllocina (possibte dafibmialiun needed) 23, ALS or CCT-RN: Clamped chest tube [no suclnon requ'ued) 24. ALS orCCT-RN: Airway mng (lradleal u! nasal tracheal sucuaning) 25‘ CCT-RN Only: IV wiIh medication or 'nluslon Dump (i1 pump Is locked mum he ALS) 20. CCT-RN Only: Tempotary pacemakerNuh‘JCcr-llal venuslarlelial Inelchesl tube (a sucliun 2?. CCT-RN Only: Intrmcranial pressule Iinefinlra-aodic bauoon pump m prace 28. CCT-RN Only; Open ccnlral Una. Cn'rcal Care nutilng OI Iospl'ralory llwrapisl veqwrid 29. Other: ,_._. fl ....__. __.__. c y .E I H . The undersigned ccmfles {ham} he/sne rs familiar vn'Ih ma Patienl's condm'on. (2) agrees mm medicchondJEan mlozmalron noled on mi: {arm and (J) has dalsrmlnsd ambulance service is medicafly necessary as spawned in Seclians A and B Ambulance servica is hewby ordered. ,MD ‘ Name (P‘inl). of_wl S'wgnamle; H nuezu-c‘w Dam: 047/271ch MD RN, 0P h1chca/a Patients may be signed by MD, RN, DP. NP, PA or Ch’m‘cal Nurse Spacnah‘sl m r, . -NP PA. CNS Medl-Calf’alianls Mn signature ONLY ‘1'; “‘37 «WK :3: Tn ‘1: 3% 3UQ l \ E‘mifii‘i Egbi‘ ‘ ?65 KMA Emergency Services Inc. (lba Wostmcd Ambulance |x|275 Wicks Blvd Sun Lcnmlro. CA 94577 (888) 33l-l430 BOMHACL CIILOfiPnticnl name: From: JESSICA BOMBACI 'l'u: 4023 HASTINGS AVENUE SAN 1035, CA95 I 18 I‘rim a ry puyur: Secondary payer: Ruuh‘umlm‘: 18-16476 Dale ut‘cnll: 8.’6"20|S Time urea”: '3 l :30 ('nfirr: (.‘HARHENIE HMO FAMILIES FIRST - CAMPBELL SJ MARY'S PSYClll.-\'I'RICT WARD “III: Shield ()I'Callil'nmi.‘1 AQTOUIO'DUUE) Bil] Patient Pu) mrnl Unk- Dcscriptiun l’upcr (htck h' Qlwltii) l'IIli Pl'il‘c Amoum “LS Nun-Iinmg Ruse L'rhun 51.90001 31.9mm) 51 0 <45 r10 3.1313,th Mileage (eran For your convenience you may pew your bill securely oulinc at wwwaveslmedmnhulauccwum PLEASE PAY'I'HIS AMOUNT “‘ 51.213.0H |1l'F\C|| U1.).\fi E l\l'.\.\|JR|‘Ti H\ bl||'|\\'llli\fH ki‘v\\'.\ll'\l’ IiH\K‘.0l. RuIINmnhcr: IS-IGJ'IGPmient nnmt: BOMBACI. CHLOE .v' 7%" (25 5234:. L‘ 5 LI We Auccpl: [ IVISA i ] Mastercard [ 1 Discover [ JAmcri nnExprcss (?nrd Numbcr:_ 7 Card Holder Name:- . m__ _____ _ Exp Daic:__ Sigmull'¢=__..,m_V..._. . __. ..__. umur‘l‘n: KMA Emergency Services Inc. dba \Vestlncd Ambulance [427$ Wicks BIVLI Sun Leantlro. CA 945 77 m Billing ZiPCude:_ fl rim ya mull; m- .\\[(H \l \ IINK LUSH): V Due nn: ll’lZ-‘ZU | 9 ('urrcnl llnlc: |2-’2:20l ‘) _ security Coda ______ .. ,. Trip Details A nu.“‘wuuunaw-um-uw u-‘wua 1|»w4WLM-vaflunnuuuw‘m..uuuw..nnuun~ “unashum «4......"rpr m. a 1.1.. w 1-4:. ».. p.- ..x. .4” v w -u.m.:,~.-n-,.mamas“... v. .~ . Mu, -_ -r;- r.‘ -- ~- h Date of Service: 8/6/1201 B CustomerName: BOMBACI’ CHLOE Customer SSN: 000-00-0000 Taken By: Kirk. Dean Dispatched By: Kitk, Dean Responded From: No Assigned Post CaliType: BLS 5150 Nature of Call: 5150 Pn’mary Complaint: ALTERED MENTAL STATUS UNSPECIF Complalnt #2: Other sympwms and signs involving emot Primary Payer: Blue Shield of California At Scene Odometer: 79m L_oa dgg Milog At Des! Odometer: 51.4 R T Pi __..... Fm... Dispatch Comments: DXI/51 60/IDTSIIWT. 140L881] EMQ FAMILIES FIRST - CAMPBELL - enier @ intersection of Lam Initial Priority: CAMBELL, CA 95008 Phone: Drag Off lnfgtmation ST MARY'S PSYCHIATRIC WARD Trampon Priority: SAN FRANCISCO. CA 94117-1013 Phone: un Number: 16,476 rip Number: 0024-A Vehicle: 731 ck IJp Time: 21:30:00 ETA: 22:30:00 Callsmrted: 19:11:02 CailTaken: 19:13'50 Dispatched: 20:50:14 Enroute: 20250 'l7 AtSccno: 21:30 24 Transporting: 21:44:09 At Uesiination: 22:51:23 Partlally Available: 23 26: 50 Available: 23: 28: 50 Crew1: DAWSON, MICHAEL Crow 2: MUSSELMAN, BRITTAI‘ Crew 3: NO CREW LISTED CODE1 (408) 379.3790 Ext. CODE 1 {415) 750-5649 Exl. 08/06/ 1 8 ‘ v :1\ '. 08/06/1 8 ikescueNel‘” .mmwammsamnmkwmmmwnRPm” Eib‘iflfliéfia Mw-E:I;)E§Cfigl\ Printed 0n 5121/2020 al H.3649 8/6/20 1 8 8.61201 8 8/8i2018 9/24/2018 9/26/2018 9/28/2018 12/2/2019 5/1 1/2020 5/2 1/2020 5/2 1/2020 1m 7:12:28PM 7:1323 l PM 3:57z3 [PM 4:04:261‘M |2t7200l’M |106256PM 10:36:07AM | l:23:302\§\'1 IDIOHIZAM | 1:34:40AM g! DKJRK DKIRK ZBAHR DliSlRL‘II‘iM MVl’4 'I'ERESAC AI’ONDIER JCLA ll K APONDL'R AHARRIS De§crigglon DKMASONL’INSBLUE CROSS A0 ‘60]0739fJ9-0l ETA 2 |30-2300 PT IS MINOR I’LS VRF INS I’luztsc verify puliunt insurance l’aticnl BC 3A0 £601 07390901 inclig bile per Zimlod. No l-‘S :mc! no guarantm lisml 0n PCR. PER ZIRMED I"|' INEHGIBLE I'Ul 1K BILLING I’l' I’OR COR UI'IM'I'L. léeccivcd message :uld crniul from (3.\ A that .suhsuilm- slated never um hillul In insurance. Mcmlwr held another Irip IS IS Per Bfue Shield porlul shous munhcr 'Iil S-Ill lhzll \m-s billed and puiLl lu llw .sul.\\vrilwr. lcligiblc fur hencfils. updnlcd inx’urunw and nllucllcd eligibilil). Sending claim b} upcr, :llnng uh!) cover lt‘lltl um] (II! dm‘llmcnls. Also reversed cullccll'ons amd nuril'lcd UMA llml claim will h: sum I'm procur‘iiug. Ptr [5qu Shivld u'cbsilc. ulniln um pa <| nn IZ?- I‘J“.’0l‘):lnd hulmuc (Inc {mm Ihu subscriber Copy ol' lEOU (m lnh X GMA was I'L'quosling information ml L|;Ii1 HOB :nlnchcd nol sluming enough in! n'n claim number |EJ5553760'IOU \ms rcmiw sum lhc ctnim wus filed ai’lcr Illc limcl A fi n. ('asllcll Iiluc Shield ul B(JUXfllUOL .Ih |In- mlion. Spnkc n'ilh King :Iml pcr rcpwscmmiw d |3.l LZUI Duml procusscd l3, |-|.2(I l0. H.- ling IimiLoI' I yum: l':.\p|zxinc:| tn him KMA rvcuivcd wrong insurance inlku'mmim .1! Ihc lime nl‘sun ice, HL- sialcd czm uppcal :md included in supporting docmncnlnlinn He is f'uxing LOB 11ml slates I'F denial, \n'H receive within 2~I«113huurs. Cal] rcf'erc Ice number 20l-120008l52. Placing call in PT info schedule nnd \riH follow up will) laulugmnenl :Iml (EMA un :ummnl. rccd cull l'r a ponder re timcl)‘ filing. n couling w lhc |:i~|..u"\' we chcckcd ligilxifil} umi lmd wrong policy number. billed pmie :l \mhin limci} filing hut pzalicm dul :m: rcwmn! 10 invoiccsv'collcction lullcr lmlil :li'lcr near uhcn account when (u {i\l.-\, pm is I'cxgmnsihlc i __... _..l RescueNel‘” A'r‘n'nlcad HRESCU ENETByStpHPR! NTTRP.RF'T ‘rl P!inled on 5121:2020 m 14-3649 ~ ."v , ' . (mk, A. ‘._ * .«Adm. umu Ln Tfnnsachonrlo Bsafmzuw Sisuésfififi? 0534924593TransacLon [‘{ale Aug 27. 20 lb 3? AS; AM EDTCustL-g: 1n 5-1 7825 Subscnhc! Nan‘c BOMBACI CHLOE Claim Numer 18235CW26'33CMCR NLIII‘i‘B" N A Subscuber ID AOTGMOIJSDQ BM Type N‘A Check Dale N A I’alicnl Name EOMBACJV CHLOE Voucher ID N'A Check Acdlcss: N A Paiicn! Accounl 9: 18l5540 Bflled Amount s 255i ,00 Paid Amount S 2&9! Go Prowdu Name- KMA EMERGENCY SERVtCLSCEaIm P{occssc-d Date O&OWOIS PM T01 Subsu. . NPI‘ 150393994] C-alm Received Dale‘s 07:24-20! 8 Paid Yo Name: Payrnc. nade lo $.li)5:tl|.‘-"' DRGI N’A Pald To TaxlD: Pawnent made lusuiuu ha: Aulflouzal‘cn Number; 95608 Claim Level Status Slalusi Finahledfldjudicalion Comp‘elg No paymcnl lofihcovw’ng‘ Th} Clmm‘tncou iter has been ad,le (516-1 M-o nJ fI-I1 =0! Cilifi-zml i5 {Kil'li‘r-UW"; Baiancc um llcm lhe sunscfiuel Slall‘s Dale 08012035 Serwce Line Status Shormzde a:atus Messages 5*: a 1 u/109r2018 07:00I2018 A9428 N'A DH I - 5 Iguana s I38“)? 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