judgment against sac city couple in the amount $5,000.00

8/12/2019 Judgment against Sac City couple in the amount $5,000.00

http://slidepdf.com/reader/full/judgment-against-sac-city-couple-in-the-amount-500000 1/24



IN THE IOWA DISTRICT

COURT

FOR SAC

COUNTY

SMALL CLAIMS

D IV IS ION

L.

F. N OLL IN C

705

DOUGLAS STREET

SUITE

344

S I O U X

C IT Y

IA

51101

PLAINTIFF

VS

J E R R Y

L. RAHN

5 5

PLATTST

SAC

CITY

IA

50583

AMY L.

RAHN

FKA AMY

GERRY

5 5

PLATTST

S AC

CITY

IA

50583

DEFENDANT(S)

ORIG IN AL

NOTICE AN D PETITION

FOR

A

MONEY JUDGMENT

N O.

To

Defendant(s):

1. You are

notified that

the

above-named Plaintiff demands

of you the

amount

of 5191.74.

This claim

is

based on the value of goods and/or services supplied by the following persons or businesses in the amounts

indicated

below.

Said claims

are

assigned

to

Plaintiff.

CREDITOR

LORING HOSPITAL

PRINCIPAL

5000.00

INTEREST

191.74

2. Judgment

may be

entered

against you

unless

you

file

an

Appearance

and

Answer

within 20 days of the

service

of the

Original Notice upon you. Judgment

may

include

the

amount requested plus interest

and

court

costs.

3. You

must

electronically

file

the

Appearance

and

Answer using

the

Iowa Judicial Branch Electronic

Document Management System (EDMS) at

https://www.iowacourts.state.ia.us/EFile.

unless you obtain from

the court an exemption from electronic filing requirements.

4. If

your Appearance

and

Answer

is

filed within

20

days

and you

deny

the

claim,

you

will receive

electronic notification through EDMS

of the

place

and

time

of the

hearing

on

this matter.

5. if you electronically

file,

EDMS will serve a copy of the Appearance and Answer on Plaintiff s) or on the

attorney^) for Plaintiff(s). The Notice of Electronic

Filing

will indicate if Plaintiff(s) is (are) exempt from

electronic filing, and if you must

mail

a copy of your Appearance and Answer to Plaintlff(s).

6. You must also notify the clerk's office of any address change.

E-FILED 2014 JUN 13 2:56 PM SAC - CLERK OF DISTRICT COURT



NOLL AT0008873

70 5

Douglas

St., Ste 502

Sioux

City IA 51101

Phone

712)

224-2675

Fax 712) 252-4497

i [email protected]

ATTORNEY FO R PLAINTIFF

0001875723

JUNE 9, 2014




IN

THE

IOWA DISTRICT

COURT FOR SAC C O U N T Y

S MA L L

CLAIMS DIV IS ION

L. F. N O L L IN C

PLAINTIFF

J E R R Y L . RAHN

A MY L .

RAHN

F KA A MY

GERRY

DEFENDANT(S)

V E R I F I C A T IO N O F ACCOUNT

I D E N T I F I C A T I O N O F JUDGMENT

D E B T O R A N D

C E R T I F I C A T E

R E

MILITARY SERVICE

N O.

For Defendant A MY L . RAHN F KA A MY GERR

1.

I,

T. L. Noll,

Vice President

of L. F.

Noll,

Inc.,

am a

party

or

employee

of

Plaintiff whose

ciaim(s) is

(are)

shown

in the

attached statement(s).

I

have personal knowledge that

the

attached

statement(s)

is

(are)

a

tru

copy

of the

original creditor's records showing

the

balance

due is

true

and

correct.

I

further state that

the sum

of

5191.74

is the

balance

due and

owing

as of

JUNE

9,

2014 from

Defendant(s)

to Plaintiff(s) and any

inter

amount owing

is

accurately stated

in the

Petition

and

Original Notice.

2.

further state

that

Defendant, AMY L. RAHN FKA AMY GE RRY, resides at 515

PLATT

ST SAC

CITY lA

50583,

is employed at STEWART MEMORIAL COMMUNITY HOS

1301

WMAIN ST LAKE

CiTY

IA 51449.

and Defendant s

occupation

is .

3. Check A, B, or C for Defendant:

A. X

Defendant

is not in the military

service

of the

United States

government, I

have verified this fa

by

(check one):

X

Checking

the

Defense Manpower Data Center (DMDC) (requires name

and SSN or

name

an d

date

of

birth)

httPs://www.dmdc.osd.mil/appi/scra/scraHome.do.

Contacting Defendant

who

informed me,

or

Regularly seeing Defendant

and

believing Defendant

is not

active

in the

U.S. military.

OR B. O I

have investigated,

and I am

unable

to

determine whether

or not

Defendant

is in the

military

OR

service of the United States government.

C.

O

Defendant

is in the

military service

of the

United States government.

4. I

also

state to the

best

of my knowledge (check

one):

Defendant

O is X is not

under

a

disability

or

confined

in any

reformatory,

jail, or

penitentiary.

I

certify under penalty

of

perjury

and

pursuant

to the laws of the

State

of

Iowa

that

these facts

are

true

and

correct.

L.F.

NOLL,

INC.

T. L. NOLL,

VICE

PRESIDENT

705

Douglas St., Suite

344

Sioux City,

1A51101

712-252-0583

875723




NOTICE OF

RIGHT

TO

CURE

DEFAULT

COLLECTION SERVICE

05

DOUGLAS

STREET,

SUITE

344

BOX 593

IA 51102-0593

25, 2014

L RAHN

Y

RAHN

C

CITY IA 50583

:

(LISTED BELOW IF MORE THAN ONE)

TOTAL AMOUNT DUE:

5876.36

AMOUNT IN DEFAULT: 5876.36

You are now in default on this credit transaction. You have a right to

ult within 20 days. If you do so, you may

continue

with the

a s though y o u d i d n o t

default.

.

DEFAULT CONSISTS OF:

by:

FAILURE TO PAY AS AGREED

Paying the amount in default, 5876.36 to

Noll Collection Service, agent for the above

creditor.

If you do not

correct this default within

20

days,

we may

exercise

our

If

you default again in the next year, we may exercise our rights without

ng you another notice like this one. If you have any questions, write or

promptly.

THIS

IS AN

ATTEMPT

TO

COLLECT

A

DEBT,

ANY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE

Client Name Client Ref No

Principal Interest Other

Total

HOSPITAL

HOSPITAL

HOSPITAL

HOSPITAL

HOSPITAL

50855

50855

50855

493712

493713

1,

2,

239.

94.

94.

671.

933.

21

00

00

78

36

3.

1.

.

64.

11.3.

37

09

82

81

72

.00

.00

.00

.00

.00

1,

•3 ,

242.

95.

94.

736.

047.

58

09

82

59

08




Client Name Client

Ref No

Principal Interest

-Other

-Total

HOSPITAL 558955 646.99 13.21 .00 660.20

5 876.36




NCS, INC DBA

NOLL COLLECTION

SERVICE

A Professional Debt Collection Service Since 1965

705 DOUGLAS STREET, SUITE 344

SIOUX CITY, IA 51101

(712)

252-0583

DATE: FEBRUARY 24,

2014

LORING

HOSPITAL 014345

ATTN JAN WISEMAN

211

HIGHLAND AVE

SAC CITY

IA 50583

ATTENTION:

RE: JERRY L RAHN

GERRY, -M» L 558955 $5679.34

01/14/14

The above debtor refuses to cooperate. We recommend further action, in

order to enforce collection. Before our attorney can proceed, we will require

* Completion of the assignment at the bottom of this page.

* Copy of the itemized statement showing balance due (if not

previously provided)

*

If the

original account

is a

contract

or

note,

we

must have

the

original.

Please return promptly. Court costs will

be

advanced

on

your behalf.

Do

not accept payments or make arrangements, without calling us first.

THANK YOU FOR YOUR

COOPERATION

ASSIGNMENT FOR PURPOSES OF

SUIT

For

valuable consideration, receipt hereby acknowledged, the undersigned hereby

assign, transfer, and set over unto L.F. Noll, Inc. that certain claim against

JERRY L RAHN

AMY

RAHN

for goods, wares and merchandise sold and delivered or services rendered and

performed in the principal amount of $5679.34

lawful

interest

thereon; and does hereby authorize said assignee to do and perform all acts

necessary

for

collection; commencement

of

suit

in the

name

of the

assignee,

settlement,

adjustment, compromise

or

satisfaction

of

said claim. Assignor

hereby certifies that said claim is justly due and owing and warrants

compliance with requirements of the Iowa Consumer Credit Code as well as

disclosure

and

other provisions

of

truth

in

lending,

and

that same

is

free

of

set-offs and

other defenses.

Dated

this

< t f > day of

LORING HOSPITAL

By: Qftxi \j^^k£L C^Q-r+^*&uJ$^^

J ame and Official Title)

^

THIS IS AN ATTEMPT TO COLLECT A DEBT,

ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE

0002949661




D O C T O R

Lo r i n ^ r Ho sp i ta l

BLESSINGTON KAY

BILLING

DA TE

08/21/09

PAGE

1

o .

> p

211

Highland Ave • Sac City , A 50583

TELEPHONE NO

712 662 0131

\N

MED REC

NO. / ADMISSION NO.

9501 /

493712

NO

INSURANCE

COMPANY

POLICY NUMBER

POLICY HO LD ER PLAN

05

SELF-PAY

481803956

RAHN JERRY L

GUA RA N TO R

PATIENT NAME

MED REC NO. / ADMISSION NO

JERRY L RAHN

202 S

13TH STREET

SAC

CITY

IA 50583

JERRY

t RAHN

9601

/ 493712

PATIENT

TYPE

ADMISSION D A T E

08/10/09

D ISC HA R G E D A T E

08/10/09

B IR T HD A T E SEX

M

AGE

39

G U A R A NT O R IS

RESPONSIBLE

FOR ANY AMOUN TS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS

DATE

C HA R G E

C O D E

DESCRIPT ION QUANTITY

C H A R G E

CRT

P Y

L ST

B L NCE

AMOUNT

08-10

08-10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08-10

08-10

08-10

08-10

08-10

08-10

08-10

08 10

08-10

EMERGENCY ROOM

LABORATORY

PHARMACY

RADIOLOGY PROFESS

RADIOLOGY TECH

MEDICAL SUPPLIES

IV

SOLUTIONS

711.000

102.000

12. 000

36.240

36.400

64.520

45.680

44.000

55.000

47

.500

38

480

69.000

2.

650

5.

020

87.830

47.630

135.000

7 .620

4.380

8

.000

DEPT

TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT

TOTAL

DEPT TOTAL

DEPT

TOT L

711.00

102.00

813.00

12.00

36.24

36.40

64.52

45.68

44.00

55.00

47 .50

38.48

373.82

69.00

69 .00

2.65

5 .02

175.66

183 .33

47

.63

47 . 63

135.00

135.00

7 .62

4.38

12.00

32. 00

32.00




D O C T O R

Loring- Hospital

BLESS

INGTON KAY

Q

^

BILLING DATE

|\

f?

08/21/09

PAGE 2

7 7

Highland Ave • Sac C ity IA 50583

TELEPHONE NO. EXTENSION

712-662-0131

MED

REC

NO. /

ADMISSION

NO.

9601

/

493712

N O I N S U R A N C E C O M P A N Y

POL I C Y

N U M B E R P O L I C Y H O L D E R P L A N

05 SELF-PAY 481803956 RAHN JERRY

L

G U A R A N T O R 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

JERRY L RAHN JERRY L RAHN 9601 / 493712

202 S

13TH STREET

TYPE^

A D M I S S I O N D A T E D I S C H A R G E D A T E B I R T H D A T E SEX AGE

SAC CITY

IA

50583

11

08/10/09 08/10/09

0T H 1Q M 39

G U A R A N T O R I S R E S PO N S IB L E F O R A N Y A M O U N T S D U E A FT E R T H E IN S U R A N C E C O M P A N I E S M A K E THEIR P AYMEN TS

D A T E

C H A R G E

C O D E

DESCRIPTION

SUMMARY OF CHARGES

EMERGENCY ROOM

LABORATORY

EKG

PHARMACY

RADIOLOGY PROFESSIONAL

RADIOLOGY TECH

MEDICAL SUPPLIES

IV SOLUTIONS

TOTAL

CHARGES

BALANCE

QU A N T IT Y

C H A R G E

813.00

379.82

69.00

183.33

4 7 . 6 3

135.00

12 .00

32.00

1571.78

CP T

PAY LAST 1

BALANCE 1

A M O U N T

1671.78




D OC TOR

Lorin^

H ospita]

MILLER RODNEY

B I L L I N G DATE

09 11 09

PAGE

O-—. -x.O

211 Highland

Ave-Sac

City, A 50583

TELEPHONE NO

712 662 0131

EXTENSION

MED REG NO / ADMISSION NO

9601 / 493713

N O

POLICY NUMBER

P O L I Y

H O L D E R

PLAN

SELF-PAY

481803956 RAHN

JERRY L

GUARANTOR PATIENT NAME

MED REC

NO /

ADMISSION

NO

JERRY L

R HN

515 PLATT

STREET

SAC CITY IA 50583

JERRY L

R HN

9601 / 493713

P TIENT

TYPE

DMISSION D TE

08/10/09

DISCH RGE

D TE

08/12/09

BiRTHD TE

GU R NTOR IS RESPONSIBLE FOR NY MOUNTS DU E FTER TH E INSUR NCE COMP NIES M KE THEIR P YME NTS

D TE

CH RGE

CODE

DESCRIPTION

QU NTITY CH RGE

CP T

SE X

M

G E

39

P Y L ST

B L NCE

OUNT

08-12

08-11

08-11

08-12

08-11

08-11

08-12

08-11

08-11

08-12

08-11

08-11

08-12

08-11

08-11

08-12

08-12

08-11

08-11

08-11

OBSERVATION

ROOM

LABORATORY

REFERRAL

LABORATOR

EKG

495 840

12.000

12.000

12

.000

3S.400

36.400

36.400

64.520

64.520

64.520

45.680

17.720

81.120

55 .000

55 .000

55 .000

14.200

16.250

69.000

69.000

4.780

126 900

3

.130

3.130

2.650

2.650

14.250

279.240

279.240

87.830

57.500

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

PHARMACY

DEPT TOTAL

991.68

991.68

12. 00

12.00

12 .00

36.40

36.40

36.40

64.52

S4.52

64 .52

45.68

17.72

81.12

55. 00

55.00

55.00

14.20

662.48

16.25

16.25

69. 00

69.00

138 .00

9.56

126 .90

6.26

6.26

2 65

5.30

14.25

279.24

279.24

87.83

230 .00

1047.49




DOCTOR

spital

• L A N K F O R D ,

TONYA

BILLING DATE

07/23/13

PAGE

211 Highland Ave • Sac City, A 50583

r

-

TELEPHONE

NO.

712 651 8342

EXTENSION

MED. REC. NO 7 ADMISSION NO.

20253 / 558955

N O . • I N S U R A N C E COMPANY •

•

• POLICY N U M B E R

•

. , . - . ;

POLlC Y HO LDER -PLAN

. ,

04

BAAI

ABC 20Q41LA4605A RAHN,

JERRY

L

05

SELF-PAY

484252683 GERRY,

L«ft

L _ <

GU A R A N T O R , •

• • . -

. .

•

PATIENT NAME

. O

- / • M E D . R E C.

N O . /

A D M I S S I O N

N O .

JERRY

L

RAHN LJK

L

GERRY 20253

/ 558955

P A T I F N T

515

PLATT STREET

TY P E A D M I S S I O N D A T E D t S C H A R G E . D A T E . B I R T H D A T E SEX AGE

SAC CITY IA 50583 11 07/15/13 07/15/13 /l /96F 16

G U A R A N T O R

IS

R E S P O N S I B L E

FOR.

ANY

A M O U N T S

D U E.A F T ER T H E

I N S U RA NC E C O M P A N I E S M A KE T H E J R

P A Y M E N T S . - - , , ^HfTFWy H

D A TE

07-15

07-15

07-15

07-15

07-15

C H A R G E

- C O D E

•^^^^^^^•fli

l ^HHBV*

anmB*-

,

m m

i n

|| I H I B I

jiuiujm

.

D E S C R I P T I O N

• •

WflBVnHHVnKMVfe

E M E R G E N C Y ROOM

a m

m m n i H i i i i i

M I I I

P H A R M A C Y

•BfiBSBMMHHBOfe

RADIOLOGY,

PROFESS

WMHHHHHm

RADIOLOGY, TECH

S U MMA R Y

OF CHARGES

EMERGENCY

ROOM

P H A R M A C Y

RADIOLOGY,

PROFESSIONAL

RADIOLOGY,

TECH

TOTAL CHARGES

BALANCE

iS.Sti

Q U A N T I T Y

^

. C H A R G E . -.

405.000

183.620

82.990

4 0 . 60 3

148

.500

588

.62

82.99

40 .60

148 .50

•

860.71

r\

C P T

DEPT

TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

^pdl

( L A

A M O U N T

405.00

183.62

588

.62

82. 99

82.99

4 0 . 6 0

40 . 60

148

.50

148 . 50

860.71

O

\n




IN T HE IOWA DISTRICT COURT FOR SAC CO UNTY

SMALL CLAIMS DIVISION

F. NOLL INC

PLAINTIFF

JERRY L RAHN

AMY L RAHN FKA AMY GERRY

DEFENDANT(S)

V ERIF ICATIO N O F

ACCOUNT

IDENTIFICATION O F JUDGMENT

DEBTOR AND CERTIFICATE R E

MILITARY SERVICE

NO

For Defendant: JERRY

L

RAHN

1. I, T. L. Noll, Vice

President

of L. F. Noll,

Inc.,

am a

party

or

employee

of

Plaintiff whose clairn(s)

is

(are)

shown in the attached statement(s). I have personal knowledge that the attached

statement(s)

is (are) a true

copy

o f the original creditor's records showing the balance due is true an d correct. I further state that the sum

of

5191.74 is the balance due and owing as of JUNE 9,

2014

from Defendant(s) to Plaintiff(s) and any intere

amount

owing is accurately stated in the Petition and Original Notice.

2. I further state that Defendant, JERRY L. RAHN, resides at 515

PLATT

ST SAC CITY A 50583. is employe

at

,

and Defendant's occupation is .

3. Check A, B,

or

C for Defendant:

A. X

Defendant is not

in the

military service

of the

United States government,

I

have verified this fa

by (check one):

X Checking the Defense Manpower Data Center (DMDC) (requires name and SSN or name

and date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.do.

n Contacting Defendant who informed me, or

a Regularly seeing Defendant and believing Defendant is not active in the U.S. military.

OR

B. O I have investigated, and I am unable to determine whether or not Defendant is in the military


OR C. O Defendant

is

in the

military


4. I

also

state to the

best

of my knowledge (check

one):

Defendant O is X is

not

under a disability or confined in any reformatory, jail, or penitentiary.

I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are true and

correct.

L.F. NOLL, INC.

T. L MOLL, VICE PRESIDENT

70 5 Douglas St., Suite 344

Sioux City,

IA51101

712-252-0583

875723




NOTICE OF RIGHT TO CURE DEFAULT

ECTION SERVICE

STREET, SUITE

344

BOX 593

25,

2014

L RAHN

(LISTED BELOW IF MORE THAN ONE)

TOTAL AMOUNT DUE:

5876.36

AMOUNT

IN

DEFAULT: 5876.36

You are now in default on this credit transaction. You have a right to

rect this default within 20

days.

If you do so, you may

continue with

the

a s though y o u d i d n o t default. . . . .

DEFAULT CONSISTS OF:

by:

FAILURE TO PAY AS AGREED

Paying

the

amount

in

default, 5876.36

to

Noll Collection Service, agent

for

the above

creditor.

If

you do not

correct this default within

20

days,

we may

exercise

our

ts against you under the law.

If you default again in the next year, we may exercise our rights

without

otice like this one. If you have any questions, write or

promptly.

THIS

IS AN

ATTEMPT

TO

COLLECT

A

DEBT,

ANY

AND ALL

INFORMATION OBTAINED WILL

BE

USED

FOR

THAT PURPOSE

Client Name Client Ref No

Principal Interest

Other

Total

HOSPITAL

HOSPITAL

HOSPITAL

HOSPITAL

HOSPITAL

50855

50855

50855

493712

493713

239

94

94

1,671

2,933

.21

.00

.00

.78

36

3.

1.

.

64.

113.

37

09

82

81

72

.00

.00

.00

.00

.00

242.

95.

94.

1,736.

3 047-

58

09

8 2

59

08




Client

Name Client

Ref No

Principal Interest Other

Total

HOSPITAL 558955 646.99 13.21 . .00 660.20

5 876.36




NCS, ING DBA

NOLL COLLECTION SERVICE

A Professional Debt Collection Service Since

1965

705

DOUGLAS STREET, SUITE 344

SIOUX CITY, IA 51101

(712) 252-0583

DATE: FEBRUARY 24, 2014

LORING HOSPITAL 01434S

ATTN JAN WISEMAN

211 HIGHLAND AVE

SAC

CITY

IA

50S83

ATTENTION:

RE:

JERRY

L

RAHN

GERRY, *m L 558955 $5679.34 01/14/14

The

above debtor refuses

to

cooperate.

We

recommend further action,

in

order to

enforce collection. Before

our

attorney

can

proceed,

we

will require

* Completion of the assignment at the bottom of this page.

*

Copy

of the

itemized statement showing balance

due (if not

previously provided)

*

If the

original

account is a contract or note, we must have the

original.

Please

return promptly. Court costs will be advanced on your behalf.

Do not accept payments or make arrangements, without calling us first.

THANK YOU FOR YOUR COOPERATION

ASSIGNMENT FOR PURPOSES OF SUIT

For

valuable consideration, receipt hereby acknowledged,

the

undersigned hereby

assign,

transfer, and set over unto L.F. Noll, Inc. that certain claim against

JERRY L RAHN

AMY

RAHN

for goods,

wares and merchandise sold and delivered or services rendered and

performed

in the principal amount of $5679.34 lawful interest

thereon;

and

does hereby authorize said assignee

to do and

perform

all

acts

necessary for collection; commencement of suit in the name of the assignee,

settlement, adjustment, compromise or satisfaction of said claim. Assignor

hereby certifies that said claim is justly due and owing and warrants

compliance with requirements of the Iowa Consumer Credit Code as well as

disclosure

and

other provisions

of

truth

in

lending,

and

that same

is

free

of

set-offs

and

other defenses.

Dated this

c C o

day of

^J?yuxcuK^j^

s o l 1 - ^ - .

HOSPITAL

}~

Qft i.

\j^\l£tf a-rr - £yijJbJLSFSL^

[Name and Official

Title)^U °

THIS

IS AN

ATTEMPT

TO

COLLECT

A

DEBT,

ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

0002949661




D O C T O R

Lor i ng Hospital

BLESS INGTON , KAY

BILLING DATE

08/21/09

PAGE 1

o—

, p

2 1 1 Highland Ave • Sac

Ci ty IA 50583

T E L E P H O N E NO .

712 562 0131

E XT E NSI O N

MED. REC.

N O . /

A D M I S S I O N

N O .

9601 / 493712

N O

I N S U R A N C E C O M P A N Y

POLICY NUMBER

P O L I C Y H O L D E R

PLAN

O S

SELF PAY

481803956

RAHN,

JERRY

L

G U A R A N T O R

PATIENT

N A M E

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

JERRY L RAHN

202 S

13TH STREET

SAC

CITY

IA

50583

JERRY

L

RAHN

9601

/

493712

P T I E N T

T Y P E

A D M I S S I O N

D A T E

08/10/09

D I SC H A R G E D A T E

08/10/09

B I R T H D A T E

i W 7

S E X

M

G

39

G U A R A N T O R

IS

R E S P O N S IB 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 IR P A Y M E N T S

D A T E

C H A R G E

C O D E

D E S R I P T I O N

QUANTITY

C H A R G E

C P T

P Y

L S T

B L NCE

AMOUNT

08-10

08-10

08 10

08-10

08 10

08 10

08 10

03 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

08 10

EMERGENCY ROOM

LABORATORY

PHARMACY

RADIOLOGY, PROFESS

RADIOLOGY,

TECH

MEDICAL SUPPLIES

IV SOLUTIONS

711.000

102.000

12.000

36.240

36.400

64.520

45.680

44.000

55.000

47

.500

38.480

69.000

2.650

5.020

87.830

47.630

135.000

7.620

4.380

8.000

DEPT TOTAL

DEPT TOTAL

DEPT

TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

711.00

102 .00

813.00

12 .00

36.24

36.40

64.52

45.68

44 .00

55 .00

47.50

38.48

379.82

69.00

69.00

2 65

5.02

175.66

183.33

47.

3

47 . 63

135.00

135 . 00

7

.62

4 38

12

.00

32.00

32 .00




O T O R

Lorin Hospital

BLESSINGTON KAY o °-v

BILLING DATE

|

~>°

8/21/03 PAGE 2 J 21 1

Highland

A ve • Sac Ci ty, A 50583

TELEPHONE

NO. EXTENSION

712-662-0131

M E D REC. NO. / ADMISSION NO.

9601

/

493712

N O 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 BE R P O L I C Y H O L D E R P L A N

05 SELF-PAY 481803956 RAHN JERRY

L

GU A R A N T O R PATIENT N A M E MED. R E C N O / A D M I S S I O N N O

JERRY L RAHN JERRY L

RAHN

9601 / 493712

PAT1FNT

202

S

13

TH

STREET

TYPE A DM I S S I O N D A TE D IS C H A R G E DA T E

B1RTHDATE

SEX AGE

SAC CITY

IA 50583 11 08/10/09 08/10/09 -/ /7QM 39

G U A R A N T O R IS RESPONSIBLE F O R A N Y A M O U N T S D UE AFTER TH E INSURA NCE COMPANIES MAKE THEIR PAYMENTS

D A T E

C H A R G E

C O D E

D E S CRI P T I O N

SUMMARY

OF

CHARGES

EMERGENCY

R O O M

LABORATORY

EKG

PHARMACY

RADIOLOGY PROFESSIONAL

RADIOLOGY

TECH

MEDICAL

SUPPLIES

IV

SOLUTIONS

TOTAL CHARGES

BALANCE

Q U A N T I T Y

C H A R G E

813 .00

379 . 82

69. 00

183.33

47 .63

135.

00

12.00

32 .00

1671.78

OP T

PAY

LAST

BALANCE

A M O U N T

1671.78




DOCTOR

p t l

MILLER;

RODNEY

BILLING DATE

09/11/09

PAGE 1

O K J3

21 1

Highland

A ve

-Sac

City, A

50583

TELEPHONE NO .

712 662 0131

EXTENSION

MED.

REG.

NO . /

ADMISSION

NO .

9601

/ 493713

N O

INSURANCE COMPA NY

POLICY NUMBER

POLICY

HOLDER

PLAN

SELF-PAY

481803956

RAHN

JERRY L

G U A R A N T O R

PATIENT NAME

MED . REC . NO. / AD MISSION NO,

JERRY L RAHN

515

PLATT

STREET

SAC CITY

IA 50583

JERRY L RAHN

9601

/ 493713

P T I E N T

T Y P E

ADMISSION DATE

08/10/09

DISCHARGE DATE

08/12/09

BIRTHDATE

G U R N T O R IS

RESPONSIBLE

F O R N Y

AMOUNTS

D U E

AFTER

T H E

INSURANCE COMPANIES MAK E THEIR PAYMENTS

DATE

C H R G E

CODE

DESCRIPTION QUANTITY

CHARGE

C P T

SEX

A G E

39

P Y L ST

B L NCE

AMOUNT

08 12

08 11

08 11

08 12

08 11

08 11

08 12

08 11

08 11

08 12

08 11

08 11

08 12

08 11

08 11

08 12

08 12

08 11

08 11

08 11

OBSERVATION

ROOM

LABORATORY

REFERRAL

LABORATOR

EKG

495.840

12

.000

12.000

12.000

36.400

36.400

36.400

64.520

64.520

64.520

45.680

17.720

81.120

55.000

55

.000

55.000

14.200

16.250

69.000

69.000

4.780

126.900

3 .130

3 .130

2

.650

2 . 650

14 25

279.240

279.240

87.830

57.500

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

DEPT TOTAL

PHARMACY

DEPT TOTAL

991.68

991.68

12.00

12.00

12

.00

36.40

36.40

36.40

64.52

64.52

64 .52

45 .68

17.72

81.12

55.00

55.00

55.00

14.20

662.48

16.25

16.25

6S.OO

69.00

138.00

9.56

126.90

6.26

6.26

2.65

5 .30

14.25

279.24

279.24

87.83

230.00

1047

.49




DOCTOR

Lorin Hospital

MILLER

RODNEY

BILLING DATE

09/11/09 PAGE

21

Highland Ave • Sac Ci ty IA

50583

TELEPHONE

NO

712 662 0131

EXTENSION

ME REC.

NO. /

ADMISSION

NO.

9601 / 493713

_ . . . , , .

.

N O . I N S U R A N C E

C O M P A N Y P OLIC Y N U M B E R

POL ICY

H O L D E R P LA N

05

SELF-PAY

481803956

RAHN JERRY

L

G U A R A N T O R P A T I E N T N A M E M E D .

REC.

N O . / A D M I S S I O N N O .

JERRY L R A H N JERRY L

RAHN 9601

/ 493713

53 PLATT STREET

T P^

A D M I S S I O N D A T E D I S C H A R G E D A T E B I R T H D A T E

SEX AGE

SAC CITY IA 50583 13 08/10/09 08/12/09 / /70M 39

G U A R A N T O R I S R E S P O N S I B LE 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 IR PA Y M E N T S

D A T E

08 10

08 11

08 10

08 10

08 10

C H A R G E

C O D E

tfEgSOl

4flHGH0

jpMBBpljffP

_jtIE


YBBHHHMHHHKSEM

-gma^BHMMEV

^ BHBWMHSSV

mnmnHME^RK

MEDICAL

SUPPLIES

jmnmmwwm Ku

IV SOLUTIONS

S U M M A R Y O F

CHARGES

OBSERVATION

R O O M

LABORATORY

REFERRAL LABORATORY

EKG

P H A R M A C Y

MEDICAL

SUPPLIES

IV

SOLUTIONS

TOTAL CHARGES

BALANCE

Q U A N T I T Y

1

1

3

C H A R G E

5 . 200

1.800

16.460

30.000

8 .000

991.68

662

. 48

16.25

138.00

1047 .49

53 .46

24 .00

2933 .36

C PT

DEPT

TOTAL

DEPT TOTAL

PAY

LAST 1

BALANCE 1

O U N T

5.20

1.80

16.46

30 .00

53 .46

24

.00

24. 00

2933.36




D O C T O R

.

1 ~ ~ ' Lorin Hospital

-

- L ANKFORD, TONYA

S ~

oT

i

B I L L I N G D A T E -

' • . |\

*f 0

07/23/13 PAGE 1

2

Highland

Ave -Sac

C / f y , IA 5 583

'

T E L E P H O N E

N O .

E X T E N S I O N

712-661-8342

M E D .

R E C . NO. 7 ADM ISSION'NO.

20253 / 558955

N O . '

' - 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 N '

. .

,

04 BAA ABC 20041LA4605A

R A H N ,

JERRY L

05 SELF-PAY 484252683 G E R R Y ,

L«R L

<f

G U A R A N T O R

' - • • . • • • • . ; • PATIENT

N A M E

. • • ;

* J . - V

. • . •

M E D . R E C .

N O . /

A D M I S S I O N

N O .

JERRY L RAHN LJK L GERRY 20253 /

558955

515 PLATT

PAT1FNT

STREET ' T Y P E A D M I S S IO N D A T E D I S C H A R G E . D A T E . B I R T H D A TE S E X A G E

SAC

CITY IA 50583 11

07/15/13 07/15/13

«B/Bfc/96 F 16

G U A R A N T O R I 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 l R

P A Y M E N T S

- .

DATE

07-15

07-15

07-15

07-15

07-15

C H A R G E

.CODE

_^^ M

i ^HBBd

PBH^^^^*

^•^AfflR^^F

^^P^Bi^^^^

jBaiaa^n

^

.

.


• • , • '

VflBBBBBHBHBSMHfc

EMERGENCY

R O O M

•iiiiii^wininp •mil

PHARMACY

VOMaSSHHHMBnfe

R A D I O L O G Y ,

PROFESS

MHHMHMM

RADIOLOGY,

TECH

SUMMARY OF CHARGES

EMERGENCY R O O M

PHARMACY

RADIOLOGY, PROFESSIONAL

RADIOLOGY,

TECH

TOTAL CHARGES

BALANCE

X

UANT1TY

1

1

1

1

1

L

C H A R G E . .

405. 000

183 .620

82.990

4 0 .6 0 3

148.500

588.62

82 .99

40. 60

14 8 . 5 0

860.71

L

.

C PT

D E P T

TOTAL

DEPT TOTAL

D E P T TOTAL

DEPT TOTAL

?£

PA Y LAST •

BALANCE

I

A M O U N T

4 0 5 . 0 0

133 .62

588.62

82

.99

82.99

4 0 . 6 0

4 0 .6 0

14 8 . 5 0

148.50

860.71

O

•




E-FILED 2014 JUL 24 11:00 AM SAC - CLERK OF DISTRICT COURT



IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

Plaintiff(s), SMALL CLAIMS DIVISION LF NOLL, INC705 DOUGLAS ST, STE 344SIOUX CITY IA 51101

Case: 02811 SCSC015455

vs.

JUDGMENT ENTRYDefendant(s),

JERRY LYNN RAHN515 PLATT STREETSAC CITY IA 50583-2202

AMY LYNN RAHN515 PLATTSAC 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 defendantin the amount of $ 5,000.00 with interest at the rate of 2.10 % from the 13th day of June, 2014 andcourt costs.

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: $5,200.00

1 of 2

E-FILED 2014 JUL 24 1:13 PM SAC - CLERK OF DISTRICT COURT



State of Iowa Courts

Case Number Case TitleSCSC015455 L F NOLL INC VS JERRY & AMY RAHNType: ORDER FOR JUDGMENT

So Ordered

Electronically signed on 2014-07-24 13:13:21

E-FILED 2014 JUL 24 1:13 PM SAC - CLERK OF DISTRICT COURT

judgment against sac city couple in the amount $5,000.00

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