judgment against sac city couple in the amount $1,137.60

7/27/2019 Judgment against Sac City couple in the amount $1,137.60

1/22


2/22

IN THE IOWA DISTRICT COURTFOR SAC CO UN TYSMALL CLAIMS DIVISIONL. F . N O L L INC .705DOUGLASSTREET SUITE344SIOUXCITY IA 51101PLAINTIFF

VSJUSTIN A.BUSCHMANN710 S 9TH STSAC CITY IA 50583 -2236TAYLOR J.BUSCHMANN710S9THSTSACCITY IA50583-2236DEFENDANT(S)

ORIGINAL NO TICE AND P ETIT IONFO R A M O N EY JUDG M EN TNO.

To Defendant(s):1. You are notif iedthatthe above -nam ed Plaintiff dem ands of you the amo unt of 1161.90. This claim isbasedon thevalueofgoodsand/orservicessuppliedby thefollowingpersons orbusinessesin the amountsindicated below. Said claimsareassignedto Plaintiff.

CREDITORLORING HOSPITAL PRINCIPAL 1137.60 PRE-FILING INTEREST 24.302. Judg men t may be entered against you unlessyou file an Appe arance and Answer w ithin 20 daysof theserviceof the Original Notice upon you. Judgment m ay include the amount requested plus interest andcourtcosts.3. Youmust electronically fi letheAppearance andAnswer using the Iowa Judicial Branch ElectronicDocument Management System (EDMS) at https://www .Jowacourts.state.ia.us/EFile, unless you obtain fromthe court an exemption fromelectronicfiling requirem ents.4. Ifyour A ppearance andAnswer isfiledwithin 20daysand youdenythe claim,you will receiveelectronic notification through EDMSof the placeandtime of the hearing onthis matter.5. Ifyou electronicallyfile, EDMS will serve acopyof theAppearance andAnswer on Plaintiff(s) or on theattorney(s) for Plaintiff(s). The Notice of Electronic Filing will indicate ifPlaintiff s) is (are) exempt fromelectronicfiling, and if you must mail acopyofyour Appearance andAnswer to Plaintiff(s).6. You mustalsonotify the clerk's office of any address change.

E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT


3/22

fiCAR.NOLLAT00088^3DouglasSt.,Ste502' j?.( .. Sioux City IA5 110 1 >'- Phorie;(712)224-2675 - VFax (712) 252-4497

irnfojdecklaw.net 5*1-ATTPRNEYFORPLAINTIFF^;0002810456 ' : .,MAY 27,2014 ';'; . ' ' ' .



4/22

IN THE IOWA D ISTRICTCOURT FOR SAC COUNT YSMALL CLAIMS DIV IS IONL. F.NO LL INC .PLAINTIFF

JUSTIN A . B U S C H M A N NT A YLO R J. B U S C H M A N NDEFENDANT(S)

VERIF ICATION O F A C C O U N TIDE N T IF ICAT IO N O F J U D G M E N TDEBT O R A ND CERT IF ICA T E REMILITARY S E R V I C EN O.

For D efendant: JUSTIN A. BUS CHM AN N

1. I, T. L. Noll, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose claim(s) is (are)shownin the attachedstatement(s). have personalknowledgethat theattached statement(s)is (are) atruecopyof the original creditor s records sho wing the balance due istrue and correct. Ifurther state tha t the sumof $1161.90 is the balance due and owing as of MAY27, 2014 from Defendant(s) to Plaintiff(s)and anyinterest amount owing is accurately stated in the Petition andOriginal Notice.2. I further state that Defendant, JUSTIN A. BUSCHMANN, resides at 7105 9T H ST SAC CITY IA 50583-2236. is employed at LORING HOSPITAL 211 HIGHLAND AVE SAC CITY A50583.and Defendant soccupation is .3. CheckA, B, or C for Defendant:A. X Defendant is not in the military service of the United States government, I have verified this facby (checkone):

X Checking the Defense Manpower Data Center (DMD C) (requires nam e and SSN or nameand date of birth) https://www.dmdc.o5d.mi /appi/scra/scraHome.do.n Contacting Defendant who informed me, orn Regularly seeing Defendant and believing Defendant is not active in the U.S. military,have investigated,and I am unable todetermine whetheror not Defendant is in themilitaryR B. Oservice of the United States government.OR C. O Defendant is in the military service of the United States government.4. Ialso state to the best of my knowledge (check one):DefendantO is X is ot underadisability orconfined in any reformatory, jail,orpenitentiary.I certify under penalty ofperjury and pursuant to the laws of the State of Iowa that these facts are true andcorrect.

L.F.NOLL, INC.

T. LrTNOLL, VICE PR ESID EN T70 5 Douglas St., Suite 344SiouxCity,IA51101712-252-0583 28 456



5/22

NOTICE OF RIGHT TO CURE DEFAULTNC5, INC DBAMOLLCOLLECTIONSERVICE705 DOUGLAS STREET, SUITE 344POBOX 593SIOUX CITYIA51102-0593(712)252-0583APRIL24 2014JUSTIN ABUSCHMANNTAYLORJBUSCHMANN710 S 9 STSACCITYIA50583-2236

RE: (LISTEDBELOWIF MORETHAN ONE)TOTALAMOUNTDUE: 1161.90 . . . .AMOUNT INDEFAULT: 1161.90 ..You are now indefault-onthis credit transaction. Youhave rightto

correctthis default within20days. If you doso,you.maycontinue with thecontract a sthoughy o u d i d n o tdefault. . YOURDEFAULT CONSISTS OF:Correct this default by:

FAILURETO PAY ASAGREEDPayingthe amount in default, 1161.90 toNoll Collection Service/agentfor theabovecreditor.

If you do not correct this default within 20 days, wemayexercise ourrightsagainstyouunderthelaw. . . . .If you default again in the next year,we.may exercise-ourrightswithoutsending you another notice likethisone. :If you have any questions* write' ortelephone promptly.

Sincerely,

L. F.Noll /THISIS ANATTEMPTTOCOLLECTADEBT,

ANY AND ALLINFORMATION OBTAINED WILL BE:USED FORTHAT-PURPOSE.0002810456Client Name Client Ref No Principal Interesi Other Total

LORIHGLORINGLORINGLORINGLORING

HOSPITALHOSPITALHOSPITALHOSPITALHOSPITAL

538605554219555406556988560165

30331173426175

18 8.94.67.11.00

8374

.49 .09

.26

. 7 6 . . ,

.70 .

.00 .00

.00

.00

.00

31.340.176.433.179.

3703938770

1,161.90



6/22

NCS,INC DBANOLL COLLECTION SERVICE

AProfessional Debt Collection Service Since196511705 DOUGLAS STREET, SUITE 344

SIOUXCITYrIA 51101(712)252-0583

DATE:APRIL23, 2014LORING HOSPITAL 014345ATTNJAN WISEMAN211HIGHLANDAVESACCITYIA 50583ATTENTION:RE: JUSTIN A BUSCHMANN

538605 1-3.7.60 08/27/12The abovedebtorrefuses tocooperate.We recommendfurtheraction, in

order toenforce collection. Beforeour attorneyca?i~ qceed,we willrequire* Completion of the assignment at the bottom of thispage. Copy of the itemized statement showing balance due (if notpreviously provided)*If the original account is a contract or note, we musthave theoriginal.

Please return promptly. Court costs will be advanced on your behalf.Donot accept payments or make arrangements, without calling us first.

THANK YOU FOR YOUR COOPERATION

ASSIGNMENTFORPURPOSESOFSUITForvaluable consideration, receipt hereby acknowledged, the undersigned herebyassign, transfer, and set over unto L.F. Noll, Inc.thatcertain claim against

JUSTINABUSCHMANNTAYLORJBUSCHMANN

for goods, wares and merchandise sold and delivered or services rendered andperformed in the principal amount of 1137.60 lawful interestthereon;anddoes hereby authorize saidassigneeto do andperformallactsnecessary for collection; commencement of suit in the name of the assignee,settlement, adjustment, compromise or satisfaction of said claim. Assignorherebycertifies thatsaidclaim is justly due and owing and warrantscompliance with requirements of the Iowa Consumer Credit Code as well asdisclosure and other provisions of truth in lending, and that same is free ofset-offs and other defenses.Datedthis(3 d a y o f A}. 20LORING HOSPITAL

(NameandOfficialTitle)THIS IS AN ATTEMPT TO COLLECT A DEBT,

ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.0002914261



7/22

D O C T O R Loring Hospital T E L E P H O N E N OP E K , 2. L. PrsXf

B I L L I N G D A T E J\\P 712 661 9590' O-E X T E N S I O N

/\ ' M E D . R E C .NO./A D M I S S IO NNO.04/02/13 P A G E 1 j 211H igh landAve SacCi t y A 50583 22756 / 554219

N O .0405

I N S U R A N C E C O M P A N Y P O L I C Y N U M B E R P O L I C Y H O L D E R ' P L A NN A T I O N W I D E S P E C H EALTH CLF00812823SELF-PA Y 481131762

31WG U A R A N T O RJUSTIN A B U S C H M A N N71 0 S O U T H 9T H S T R E E TS A C CITY IA 50583

B U S C H M A N N , JUSTB U S C H M A N N , JUST

P A T I E N T N A M E MED. REC. NO. /ADMISSION NO.

P A T I E N TT Y P E20

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G U A R A N T O R I SR E S P O N S I B LE F O R A N YA M O U N T S D U E .A F T E R T H EI N S U R A N C E C O M P A N I E S M A K ET H E I R P A Y M E N T S ^H?f f ^^D A T E C H A R G EUAlt C O D E

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8/22

D O C T O RMARCZEWSKI L. J.

I L L I N DATE04/05/12 PAGE

Loring Hospital T E L E P H O N E

211 Highland Ave Sac C ity IA 50583

712 661 9590. . E X T E N S I O N

7 6 53860SO . IN S U R A N C E C O M P A N Y POLICY NUM ER - p Q U c V O L D E R PLANNATIONWIDESPECHEALTHSELF-PAY

QLF00812823481131762

BUSCHMANN JUSTBUSCHMANN JUST

U A R A N T O R PATIENT NAME ^MED. -REC,N O . / A D M I S S I ON N OJUSTIN ABUSCHMANN

710SOUTH9TH STREETSACCITYIA 50583

JUSTIN A BUSCHMANN 22756 / 538605PATIENTT Y P E ADMISSION DATE

03/30/12DISCHAHGE DATE03/30/12

BiRTHDATE SEXM

AGE27

G U A R A N T O R I S R E S P O N S I B L E FO R ANY^AMOUNTS DUE;A;FTERTHEJNsURANC^COf^PAfs||tS;MAkE :THEIR;PAYMENTS :-DATE CHARGECODE DESCRIPTION :;cpr

P Y L STB L NCE.AMOUNT

LABORATORY

SUMMARY OF CHARGESLABORATORY

TOTAL CHARGES

BALANCE

12.00038.44045 68093.88044.00047.500

DEPT TOTAL

12.0038.4445 .6893.8844.0047.50281.50

281.50

281.50

281.50



9/22

z 1 1 niyiit dnvweoacu iry ,N O .0405

I N S U R A N C E C O M P A N YNATIONWIDE SPEC HEALTH CSELF-PAY

P O L I C Y N U M B E RL.FQ0812823481131752

G U A R A N T O RJUSTIN A B U S C H M A N N710 SOUTH 9TH STREETSAC CITY IA 50583

P O L I C Y H O L D E R ^BUSC H M A N N JUS TB U S C H M A N N , JUST

P A T I E N T N A M EJUSTIN A B U S C HM A N N -

P A T I E N TTYPE22

A D M I S S I O N D A T E04/22/13

D I S C H A R G E D A T E04/22/13

PLAN

M E D . R E C . N O . / A D M I S SI O N N O .22756 / 555406

B I R T H D A T E S E X A G E'm-i M 29

G U A R A N T O R S R E S P O N S I B L E F O R A N Y A M O U N T S D U E A F T E R T H E I N S U R A N C E C O M P A N I E S M A K E T H E I R P A Y M E N T S ^KTfTfTC ID A T E

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10/22

D O C T O R Lorin HospitalGYAJSIO, B. K.. x-N _ o

B I L L I N G D A T E | \ ~ \ N O . E X T E N S I O N712-297-0460

MED. REC. N O . / A D M I S S I O N N O .06/05/13 PAGE 1 211 HighlandAve Sac City, A5 583 ( 22756 / 556988

N O .0405

I N S U R A N C E C O M P A N Y P O L I C Y N U M B E RNATIONWIDE SPEC HEALTH CLF00812823SELF-PAY 481131762

G U A R A N T O RJUSTIN A BUSCHMANN710 SOUTH 9TH STSAC CITY IA 50583

P O L I C Y H O L D E R P L A NBUSCHMANN, JUSTBUSCHMANN, JUST

P A T I E N T N A M E MED. R EC . NO. / A D M I S S I O N NO.JUSTIN A BUSCHMANN 22756 / 556988

P A T I E N TTYPE23

A D M I S S I O N D A T E05/30/13

D I S C H A R G E D A T E B 1 R T H D A T E S E X A G E05/30/13


11/22

t \>1pm

/ Adm : 15869/560165 : 756

Doctor#: 215InsCodes: 05

DemandBidFromHistoryLORINGHOSPITAL211HIGHLANDAVESACCITY,IA50583712-662-7105

BUSCHMANN,TAYLORJBUSCHMANN,JUSTIN ABLESSINGTON, KAYBed : PatientType: 20

Page:

AdmissionDate:DischargeDate:PatientAge:

DRG#:

08/12/201308/12/201325LOS: 0Date DateEnt DatePst Charge# Description Rev Cpt Qty UnitPrice ChargeAm

08 12 13 8 12 13 8 12 13

08/12/1308/12/1308/12/1308/15/1308/15/1308/15/13

18.0044.00113.00DeptTotal

18.0044.00113.0175.00

PatientTotalPaymentsReceived

175.000.0BalanceDue 175 00



12/22

IN THE IOWADISTRICTCOURT FOR SACCOUNTYSMALLCLAIMSDIVISION

L. F.NOLL,INC.PLAINTIFFVS

JUSTINA.BUSCHMANNTAYLORJ. BUSCHMANNDEFENDANT(S)

VERIFICATION O F ACCOUNTIDENTIFICATION OF JUDGMENTDEBTORANDCERTIFICATE RE

MILITARYSERVICENO

ForDefendant: TAYLOR J BUSCHMANN

1. I T. L.Noll, Vice President of L. F.Noll,Inc., am aparty oremployee ofPlaintiff whose claim(s) is(are)shown in theattachedstatement(s). Ihavepersonalknowledge thattheattachedstaternent(s) is(are) atruecopyof theoriginalcreditor'srecordsshowing thebalancedue istrueandcorrect. Ifurtherstatethat the sumof 1161.90 is the balance due and owing as of MAY27 2014 from Defendant(s) toPlaintiff s)and anyinterest amount owing isaccuratelystated in the Petition and Original Notice.2. Ifurther state that Defendant, TAYLOR J. BUSCHMANN. resides at 710 S 9TH ST SAC CITY IA50583-2236,isemployedat BOMGAARS 3141 255TH ST SAC CITY IA 50583. and Defendant's occupation is

3. CheckA, B or C forDefendant:A. X Defendant is notin the military service of the United States government, I have verified this factby(check one):X CheckingtheDefenseManpower DataCenter(DMDC) (requiresnameand SSN ornameand date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.do.n Contacting Defendant who informed me, orn Regularly seeing Defendant and believing Defendant is not active in the U.S. military.OR B. O Ihave investigated,and I amunabletodetermine whetheror notDefendantis in the militaryservice of the United States government.OR C. 0 Defendant isin themilitary serviceof theUnited States government.4. I also state to the best of my knowledge (check one):Defendant O is X is not underadisabilityorconfinedin anyreformatory, jail,orpenitentiary.Icertifyunderpenaltyofperjuryandpursuantto thelawsof the State of Iowathatthese facts aretrueandcorrect.

L.F.NOLL, INC.

T NOLL VIC'E PRESIDENT705 Douglas St., Suite 344Sioux City IA51101712-252-0583 28 456



13/22

NOTICEOF RIGHT TO CURE DEFAULTNCS,INCDS&MOLLCOLLECTIONSERVICE705DOUGLAS STREET, SUITE 344POBOX 593SIOUX CITYIA51102-0593{712)252-0583APRIL24 2014JUSTINABUSCHMANNTAYLORJBUSCHMANN710 S 9 STSAC CITY IA50583-2236

(LISTEDBELOWIFMORE.THAN ONE)TOTAL AMOUNTDUE: 1161.90 - . , , . : . . .AMOUNT IN DEFAULT: 1161.90 . - ...Youare now indefaulton this credit transaction. Youhavearight to

correct this default within 20 days. If you do so, you may continue with1thecontract a s though y o u d i d n o t default... . . . . . . . . , YOURDEFAULTCONSISTS1OF:Correct this default by:

FAILURE TO PAY AS AGREEDPayingtheamountindefault, 1161.90 toNoll Collection Service, agentfor theabove,.creditor.

Ifyou do notcorrect this defaultwithin20days,wemay,xerciseourrightsagainst,y o u under t h elaw. . . . . .If youdefault againin thenextyear,we,may exercise.- ourrightswithout

sending youanother notice like this one. If youhave.anyquestions;writeortelephone promptly.Sincerely,

L. F.Noll . :THISIS AN ATTEMPT TO COLLECT ADEBT,

ANY ANDALL INFORMATION OBTAINED WILL BE: USED FOR THATPURPOSE..0002810456Client Name Client Ref No Principal Intqresl Other Total

LORINGLORINGLORINGLORINGLORING

HOSPITALHOSPITALHOSPITALHOSPITALHOSPITAL

538605554219555406556988560165

30 .331.173..426.175.

8894671100

8374

. 4 9 - - .

.09'

. 2 6 -

. 7 6 . , .

.70. .

.00 . 0 0

.00

.00

.00

31.340.176.433.179.

3703938770

1,161.90



14/22

NCS, INC DBA - -NOLL COLLECTION SERVICE

AProfessional Debt Collection Service Since 1965705DOUGLAS STREET, SUITE 344

SIOUX CITY, IA 51101(712) 252-0583

DATE: APRIL 23, 2014LORINGHOSPITAL 014345ATTNJAN WISEMAN211HIGHLANDAVESAC CITY IA 50583ATTENTION:RE: JUSTINABUSCHMANN

538605 $1 3.7.60 08/27/12Theabove debtor refuses to cooperate. We recommend further action, in

order to enforce collection. Before our attorneyca^^r-oceed,we will require*Completion of theassignmentat thebottomofthis page.*Copyof theitemized statement showing balancedue (if notpreviously provided)

*If the original account is a contract or note, we must have theoriginal.

Pleasereturn promptly. Court costswillbe advanced on your behalf.Donot accept payments or make arrangements, without calling usfirst.

THANKYOU FORYOUR COOPERATION

ASSIGNMENT FOR PURPOSES OF SUITForvaluable consideration, receipt hereby acknowledged, the undersigned herebyassign,transfer, and set over unto L.F. Noll, Inc. that certain claim against

JUSTINA BUSCHMANNTAYLOR J BUSCHMANNforgoods, wares and merchandise sold and delivered or services rendered and

performed in the principal amount of $1137.60 lawfulinterestthereon;anddoes hereby authorize said assigneeto do andperformallactsnecessary for collection; commencement of suit in the name of the assignee,settlement, adjustment, compromiseorsatisfactionofsaidclaim.Assignorherebycertifies that saidclaimis justly due and owing and warrantscompliance with requirements of the Iowa Consumer Credit Code as well asdisclosure and other provisions of truth in lending, and that same is free ofset-offs and other defenses.Datedthisprr day ofLORINGHOSPITALBy:

(Nameand Official Title)THISIS ANATTEMPTTOCOLLECTADEBT,

ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE0002914261



15/22

D O C T O R Lorin^HospitalPEK Z. L. f ~

B I L L I N G D A T E /{T E L E P H O N E N O . E X T E N S I O N712-661-9590M E D , R E C .N O . / A D M I S S I O N N O .

04/02/13 PAGE 1 J 211 HighlandAve-Sac City iA50583 22756 / 554219N O .0405

I N S U R A N C E C O M P A N Y P O L IC Y N U M B E RNATIONWIDE SPEC HEALTH CLF00812823SELF-PAY 481131762

G U A R A N T O RJUSTIN A BUSCHMANN710 SOUTH 9TH STREETSAC CITY IA 50583

P O L I C Y H O L D E R P L A NBUSCHMANN JUSTBUSCHMANN JUST

P A T I E N T N A M E M E D . R E C . N O . / A D M I S S I O N N O ,JUSTIN ABUSCHMANN 227S6 / 554219

P A T I E N TT Y P E20

A D M I S S I O N D A T E03/27/13

D I S C H A R G E DATE B I RT H D A T E S E X A G E03/27/13 lBa/84M 28

G U A R A N T O R IS R E S P O N S I B L EFOR ANYA M O U N T S D U E - A F T E R THEI N S U R A N C E C O M P A N I E SM A K E T H E I R P A Y M E N T S ^HFW^D A T E

03-2703-2703-2703-2703-27

03-2703-2703-2703 -27

C H A R G EC O D EMVM H M B f rMBPP4HHBMVAHWouma3HBHS9mBBOM M B W f^

D E S C R I P T I O N^BBBavwoaMPUHPMMHBNo^I^BbH^^^^^ KoHIBv^^^^^^HM^BDtAS^^^^^^^^^VIWWLABORATORY

VHHmBHnHBpa*WBBHHlMHnZSSBbv ^ MH H ^ l HMMIIIIJ Bj B ^ j ^ ^^ l ^K l ^ ^ iVwCnT VTT*REFERRAL LABORATOR

S U M M A R Y OF CHARGESLABORATORYREFERRAL LABORATORY

TOTAL CHARGES

BALANCE

1

Q U A N T I T Y11111111

C H A R G E1800085. 00093.88044. 00091.000

151.130115.38050.70038.850

331.88406.06737.94

CF T

DEPT TOTAL

DEPT TOTAL

S3

A M O U N T18.0085. 0093 .8844 . 0091. 00331.8815113115.38

SO .7088. 85

406.06

737.94

V gS-*ZEttW L f r



16/22

DOCTORM A R C Z E W S K I L J.

BILLING DATE04/05/12 PAGE

Loring Hospital T E L E P H O N . E N O . . . E X T E N S I O N211 HighlandAve-SacCity IA50583

712 661 9530

;WEDi'-REG;.NQ;-/'-AD'MlSS|ON-NO.2275S / 53 S60S

INSURANCECOMPANY POLICY NUMBER .iPO'LICY HOtDER PLANNATIONWIDE SPEC HEALTHSELF-PAY

QLF008128234S1131762

BUSCHMANN JUSTBUSCHMANN JUST

UARANTOR PATIENTNAME ,MED,-REC-.N0 7ADMISSIONNO.JUSTIN ABUSCHMANN710 SOUTH 9TH STREETSACCITYIA 50583

JUSTIN A BUSCHMAHN 22756/ 538605PATIENT

T Y P E20

A D M I S S I O N DATE03/30/12

DISCKA R GE- DA TE03/30/12

BIRTH D A T E

U A R A N T O R [S R E S P O N S I B L E FO R AN Y - A M O U N T S :DUrAFTER T J 4 E J N S U R ^ ^D A T E - C H A R G E-C OD E- UANTITY

SE XM

A G E27

P YL STB L NCE. A M O U N T

3 33 33 33 303-303 3

1200038.44045.68093.88044.00047.500

LABORATORY DEPT TOTAL

12.0038.4445. 6893.8844.0047 .50281.50

SUMMARYOFCHARGESLABORATORYTOTALCHARGES

BALANC E

231.50

281.50

281 50

3



17/22

^ u*NO.0405

INSURANCE COMPANYNATIONWIDE SPEC HEALTH CSELF-PAY5 )~~}

1 i myni dilu r tvu oao POLICY NUMBER

L.F00312823481131762

GUARANTORJUSTINA BUSCHMANN

710 SOUTH 9TH STREETSAC CITY IA S0583

O/fy. t/\ \ / DDuo iPOL ICY H O L D E R ^PLAN

BUSCHMANN, JUSTBUSCHMANN, JUST

PATIENT NAME MED. R-EC.NO. / ADMISSION NO.JUSTINA BUSCHMANN- 2275S / 555406

PATIENTTYPE22

ADMISSION DATE04/22/13

DISCHARGE DATE B lRTHDATE SE X AG E04/22/13 **lfc?-=M 29

G U A R A N T O R S RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THEINSURANCE COMPANIES MAK E THEIR PAYMENTS ^WFT^DATE

04-22

1~

fcf ~ \

. CODE

-7 t .j ? W^

DESCRIPTIONVBHWHBW^^H^^^BPRADIOLOGY, TECH

SUMMARY OF CHARGESRADIOLOGY, TECH

TOTAL CHARGES

BALANCE

] - ^ w 7

CP T

DEPT TOTAL

/CyP {

x?V-y/

AMOUNT135.00135.00

~j f vC-25 icT\

135.00~l



18/22

O T O R . Loring-HospitalGYANO , B . K. St^A

T E L E P H O N E N O . E X T E N S I O Nv 0 712-297-0460v^viB - I L L I N G D A T E \/\ .M D .REC.N O . / A D M I S S I O N N O .05/05/13 PAGE 1 J 211HighlandAve Sac City A50583 [ 22756

N O ,0405

I N S U R A N C E C O M P A N Y ' P O L I C Y N U M B E RNATIONWIDE SPEC HEALTH CLF00812823SELF-PAY 481131762

. G U A R A N T O RJUSTIN A BUSCHMANN710 SOUTH 9TH STSAC CITY IA 50583

P O L I C Y H O L D E R P L A NBUSCHMANN; JUSTBUSC H M A N N, JUS T

P A T IE N T N A M E '

/ 556988

M E D .REC. NO. / A D M I S S IO N NO.JUSTIN A BUSCHMANN 22756 / 556988

PATIENTTYPE23

ADMISSION DATE05/30/13

DISCHARGEDATE BIRTHDATE SEX AGE05/30/13)/84 M 29

G U A R A N T O R IS R E S P O N S I B L E F O R A N Y A M O U N T S D U E A FT E R T H EI N S U R A N C E C O M P A N I E S M A K E T H E I R P A Y M E N T S ^KTTrTTO BD A T E05-30

05-30

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D E S C R I P T I O N0UMMMRRADIOLOGY, PROFESSBMB MHHH^ ^ iM BiMBWP

ULTRASOUND

SUMMARY OF CHARGES

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RADIOLOGY; PROFESSIONALULTRASOUND

TOTAL CHARGES

BALANCE

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Q U A N T I T Y

1

132.110294.000

132.11294. 00426.11

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DEPT TOTAL

DEPT TOTAL

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A M O U N T132.11132. 11294.00294 . 00

426.11\S .\

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19/22

uarantor :Doctor :

In sCodes:

15869/56016522756215 Bed :

DemandBillFromHistoryLORINGHOSPITAL211 HIGHLAND AVESACCITY,IA 50583

712-662-7105BUSCHMANN,TAYLORJBUSCHMANN,JUSTINABLESSINGTON,KAY

Patient Type: 20

Page

Date DateEnt DatePst Charge Description

AdmissionDate: OS/12/2013DischargeDate; 08/12/2013PatientAge: 25DRG : LOS: 0

RevCpt Qty UnitPrice ChargeA

08/12/1308/12/1308/12/13

08/12/1308/12/1308/12/13

08/15/1308/15/1308/15/13

18.0044.00

113.00DeptTotal

18.044.0

113.0175

PatientTotalPaymentsReceived

175,00 0

Balance Due 175.0

R_Demand__BIll_History.rpt



20/22

E-FILED 2014 JUN 27 10:50 AM SAC - CLERK OF DISTRICT COURT


21/22

IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s), SMALL CLAIMS DIVISIONL F NOLL INCPO BOX 593SIOUX CITY IA 51102

Case: 02811 SCSC015449

vs.

JUDGMENT ENTRYDefendant(s),

JUSTIN A BUSCHMANN710 S 9TH STSAC CITY IA 50583

TAYLOR J BUSCHMAN710 S 9TH STREETSAC CITY IA 50583

The court file shows that the defendants have received proper notice and have failed to answer. Therelief is readily ascertainable from the Original Notice. Pursuant to Iowa Code Section 631.5(6), thedefendant is in default and judgment should enter accordingly.

It is therefore Ordered that judgment is entered in favor of the plaintiff and against the defendants,jointly and severally, in the amount of $ 1137.60 with interest at the rate of 2.10 % from the 30th dayof May, 2014 and court costs.The Court further enters judgment for prejudgment interest in the amount of $24.30.

YOU ARE HEREBY NOTIFIED that you have a right to appeal the decision to the District Court bygiving written notice to the Small Claims Office within 20 days of the filing of this order. Filing Fee forappeal is $185.00. Appeal Bond is set in the amount of: $1200.00

1 of 2

E-FILED 2014 JUL 01 1:54 PM SAC - CLERK OF DISTRICT COURT


22/22

State of Iowa Courts

Case Number Case TitleSCSC015449 L F NOLL INC VS BUSHMANN JUSTIN A AND TAYLOR JType: ORDER FOR JUDGMENT

So Ordered

Electronically signed on 2014-07-01 13:54:44

E-FILED 2014 JUL 01 1:54 PM SAC - CLERK OF DISTRICT COURT

judgment against sac city couple in the amount $1,137.60

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