scsc015550 - judgment against odebolt couple in the amount $824.00.pdf

8/9/2019 SCSC015550 - Judgment against Odebolt couple in the amount $824.00.pdf

http://slidepdf.com/reader/full/scsc015550-judgment-against-odebolt-couple-in-the-amount-82400pdf 1/20



IN THE IOWA DISTRICT COURT FOR SAC COUNTY

SMALL CLAIMS DIVISION

L.

F. NOLL INC

70 5 DOUGLAS STREET SUITE 34 4

SIOUX CITY

IA

51101

PLAINTIFF

VS

MICHELLE A. BIRD

50 1

S

MAIN

ST

PO BOX 407

ODEBOLT IA 51458-0407

ROBERT BIRD SR

501 S MAIN ST

PO BOX 407

ODEBOLT IA 51458-0407

DEFENDANT(S)

ORIGINAL NOTICE

AND

PETITION

FOR A MONEY JUDGMENT

NO

To Defendant(s):

1.

You are notified that the above-na me d P laintiff dem and s of you the amoun t of 846.40. This claim is

based on the value of goods an d/or services

supplied

by the following persons or businesses in the amounts

indicated below. Said claim s a re assigned to Plaintiff.

CREDITOR

PRINCIPAL

SIOUXLAND

UROLOGY

ASSOCIATES

388.80

SIOUXLAND OBSTETRICS

&

GYNECOLOGY,

PC

435.60

TOTAL

824.40

PRE-FILING

INTEREST

7.14

14 86

22.00

2

Judgm ent may be entered against you unless

you

file

an

Appearance

and

Answer within 20 days

of th

service of the Original Notice upon

you.

Judgment may include the amount requested plus interest and

cour

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

yo u

obtain from

the

court

an

exemption from electronic filing requirements.

4. If your Appearan ce and Answer is filed within 20 days and you deny the claim, you will receive

electronic notification through EDMS

of the

place

an d

time

of the

hearing

on

this m atter.

5. If you electron ically file, EDMS will serve a copy of the Appearance and Answe r on Plaintiff(s) or on the

attorney (s) 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 Plaintiff(s).

6.

You mu st also notify the

clerk's

office of any address change.

E-FILED 2014 DEC 02 1:23 PM SAC - CLERK OF DISTRICT COURT



iSlCA

R. NOLL AT0008873

Douglas St. Ste 502

Sioux

City IA 51101

Phone 712) 224-2675

Fax 712) 252-4497

[email protected]

ATTORNEY

FOR

PLAINTIFF

0002973482

NOVEMBER 24, 2014




IN THE IOW DISTRICT COURT FOR S C COUNTY

SM LL CL IMS DIVISION

L. F. NOLL INC.

PLAINTIFF

VS

NO.

MICHELLE A. BIRD

ROBERT BIRD SR.

DEFENDANT(S)

VERIFICATION OF

ACCOUNT

IDENTIFICATION O F JUDGMENT

DEBTOR AND CE RTIFICATE RE

MILITARY

SERVICE

For

Defendant: MICHELLE A. BIRD

1 . I, T. L.

Noll, Vice President

of L. F.

Noll,

Inc. am a

party

or

employee

of

Plaintif f whose claim(s)

is

(are)

shown

in the a ttached statement(s). I have personal know ledge that the attached statem ent(s) is (are) a true

copy

of the original creditor's records showing the ba lance due is true and correct. I further sta te that the sum

of 846.40 is the balance due and owing as of NOVEMBER 24, 2014 from Defendant(s) to Plaintiff(s) and an

interest amount owing

is

accu rately stated

in the

Petition

and

Original Notice.

2.

I

further state

that Defendant

MICHELLE

A.

BIRD resides

at 501 S MAIN ST PO BOX 407

ODEBOLT lA

51458-0407, is employed at SHADY OAKS CARE CENTER 1409 W MAIN 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 m ilitary service of the United S tates governme nt, I have verified this fa

by

(check one):

X

Che cking the Defense Manpower D ata Center (DMDC) (requires name and SSN or nam e

and date of birth)

https: //www.dm dc.osd.mi l /appj/scra/scraHome-do.

Contacting Defendant

who

informed

m e, or

Regularly seeing Defendant

and

believing Defendant

is not

active

in the

U.S. mil itary.

OR B. O I

have investigated,

and I am

unable

to

determine whether

or not

Defendant

is in the

m ilitary

service

of the

United States governm ent.

OR C. O

Defendant

is in the

military service

o f the

United States government.

4. I

also state

to the

best

of my

knowledge (check one):

Defenda nt O is X is not under a disa bility or confined in any reform atory, jail, or penitentiary.

I

certify

under

penalty

of

perjury

a nd

pursuant

to the

laws

of the

State

of

Iowa that these facts

are true and

correct.

L.F. NOLL INC.

T.

L.

NOLL,

VICE

PRESENT

705 Douglas St., Suite 3 44

Sioux

City, IA 5 1 1 0 1

712-252-0583

0002973482




NOTICF,

OF

RIGHT

TO CURE

DEFAULT

NCS, INC DBA

NOLL

COLLECTION

SERVICE

705 DOUGLAS STREET,

S'JITE

344

PO BOX 593

SIOUX

CITY

TA

51102-0593

712)252-0583

NOVEMBER

4, 2014

MICHELLE A BIRD

ROBERT BIRD

SR

501 S MAIN ST

PO BOX 407

ODE3CLT IA 514580407

RE :

(LISTED BELOW IF MOR E THAN

ONE)

TOTAL AMOUNT

DUE:

846.40

AMOUNT

IN

DEFAULT: 846.40

You are now in default on this credit

transaction..

You have a right to

correct this default within 20 days. If you do so, you may continue wi th the

contract

as

though

you did not

default.

YOUR

DEFAULT CONSISTS OF: FAILURE TO PAY AS AGREE D

Correct t his default by: Paying the amount ir default, S846.4C to

Noll Collection Se rvice, agent for the above

creditor.

If you do not correct this defa ult within 20 days, we may exercise ou r

rights against you under the

law.

If

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

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

teIephone promptly.

THIS

IS

AN ATT EMPT

TO

COLLECT

A

DEBT,

AN Y

AND ALL

INFORMATION OBTAINED WILL

BE

USED

FOR

THAT PURPOSE.

Client Ref No

Princip al Interest

SIOUXLAND

UROLO

00423848 388.80

7.14

S10UXLAN D OBSTE 44734 435.60

14.86




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:

OCTOBER 24,

2 14

SIOUXLAND

UROLOGY ASSOCIATES 025500

P O BOX

2020

NORTH SIOUX CITY 3D 570492020

ATTENTION:

RE: MICHELLE A BIRD

00423848 $388.80 04/18/14

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

MICHELLE

A

BIRD

ROBERT

BIRD

SR

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

performed in the principal amount of $388.80 plus 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

thia?f

day of

SIOUXLAND UROLOGY ASSOCIATE

By:

THIS IS TT

ATTEMPT

TO

COLLECT

A

DEBT,

INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE

0002960040




Account Ledger

Urology Associates

Box 2020

Dunes, SD 57049

(605)217-7010

Bird

1 S Main

Box 407

51458

(712) 490-684.

Ph one:

2 5 7 - 0 0 -

1 0 9 - 0 0 -

2 2 • 8 0 -

5 8 3 8

:count:

00423848

ssponsible

Party:

Self

urance 1 (HSV807621451) BCBS Iowa

Wellmark

Patient Balance

Insurance Pending

Total

S22.80

$117.00

Current

0.00

$0.00

— rrimary

Provider:

(18) And rew Bourne

Referring

P hysician: (924) Shelly E lse

Account Balance

1to3 31 to

6 0

61 to

90 91 to 120 121 to 150

0.00 0.00 0.00 0.00 22.80

$117.00 $0.00 $0.00 $0.00 $0.00

Ove

Provider

Bourne

I (18) Bourne

A (18) Bourne

A (18) Bourne

(18 ) Bourne

I

(18 ) Bourne

A (18) Bourne

A (18) Bourne

M

Memo

M Memo

Entry Da te: 10/02/2013

(16)Kassin

PA-C

I

(16)

Kassin

PA-C

A

(16) Kass in PA-C

A (16) Kassin PA-C

M Memo

M Memo

Entry Date: 12/17/2013

(18) Bourne

I (18) Bourne

A

(18)

Bourne

M Memo

M Memo

Entry Date:

05/22/2014

(18) Bourne

M Mem o

Entry Date: 10/17/201 4

ill

Status Service Date Code Description Charqe P ayment

Bill

09/26 /201309/26 /2013

$285.00

Bill 10/21/2013 10/21/2013 3 0 BCBS

Iowa

Wellmark

0034236410

Bill 10/21/2013 10/21/2013 CO 45

0

Charges exceed contracted

fee

schedule

Bil l 04/17/201 4 04/17/2014 C 0 Collection Write O ff

Bi ll 09/26/2013 09/26/201 3 $158.00

Bi ll 10/21/2013 10/21 /2013 3 0 BCBS Iowa

Wellmark

0034236410

Bid

10/21/2013 10/21/2013 CO 45 0 Charges exceed contracted fee

schedule

Bil l 04/17/20 14 04/17/2014 C 0 Collection Write O ff

10/02/2013 Ins

Code sequence

on

visit [3];

by

user:

DBertrand

1

0/21/201

3

$366.00 appl ied to deductible.

Visit Balance: $0.00 $443.00 $0.00

Bill

12/05/201312/05/2013

$117.00

Bi l l 01 /14/201401 /14/2014

3 0

BCBS Iowa Wellmark ($91.20)

0034253558

Bill 01/14/2014 01/14/2014 CO45

0


fee

schedule

Bil l 04/1 7/201 4 04/17/2014

C 0

Collection Write

O ff

12/17/2013 Ins Code sequence on visit [3]; by user:

DBertrand

01/14/2014 $22.80 appl ied to co-payment.

Visit Balance: 0.00 $117.00 ($91.20)

Bi ll 05/08/20140 5/08/2014 $117.00

Bill 0 6 / 16 / 2 0 14 0 6 / 16 / 2 0 14

3 0

BCBS Iowa Wellmark ($91 .20)

0034283500

Bill

06/16/2014 06/16/2014

CO45 0


fee

schedule

05/22/2014 Ins Code sequence on visit [3]; by user:

DBertrand

06/16/2014 $22.80 appl ied to co-payme nt.

Visit Balan ce: $22.80 117.00 ($91.20)

No

ll 10/09/2014 10/09/2014 $11 7,00

10/17/2014 Ins Code sequence on visit

[3];

by user:

DBertrand

Visit Balance: 117.00

117.00

$0.00

Ad

($

($2

(S

($1

($4

(

($

($

(

(

Bill:

22.80

No-Bill: 117.00

Total :

139.80

794.00

( 182.40)

Charge ;

I =

Insurance Payment;

P =

Private P ayment;

A = Adjustment; F =

Insurance Filing;

M = Memo

All Vis i ts

a

preliminary (open) transaction that

is

subject

to

review.

( 4

Created

by : RTorres

ID:

17 Ver

1 .15 .2 .9

Page




F r o m S i o u x l a n d O b g y n

7122772645

10/21/2014

09:20 #556 P.002/00

NCS, INC DBA


A

Professional

Debt Collection Service Since 1965

705 DOUGLAS STREET, SUITE 344

SIOUX CITY,

IA

51101

(712) 252-0583

DATE:

OCTOBER

24 2014

SIOUXLAND OBSTETRICS &

026122

GYNECOLOGY PC

2730 PIERCE ST SUITE 201


ATTENTION:

RE: MICHELLE A 3IRD

44734

$435.60 10/17/14

The above debtor refuses to

cooperate.

We recommend

further

action, in

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.

r o z accept payments

or

make arrangements, without calling

us

first.

THANK

YOU FOR

YOUR COOPERATION


r valuable consideration, receipt hereby acknowledged, the undersigned hereby

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

MICHELLE A

BIRD

ROBERT

BIRD

SR

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

in the principal amount of $435.60 plus lawful interest

does hereby authorize said assignee to do and

perform

all acts

for collection; commencement of suit in the

name

of the

assignee,

compromise or satisfaction of said claim. Assignor

that said claim is justly due and owing and warrants

with requirements of the Iowa Consumer Credit Code as well as

and ether provisions of truth in lending, and that same is free of

other defenses.

this

OBSTETRICS &

(Name and

O f f i a l

THIS

IS AN

ATTEMPT

TO

COLLECT

A

DEBT,

AMY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE




Pr in ted : 09/16/2014

12:16

P M

User: M T Y L O R

Financial

Group: 2-SIOUXLAND OBGYN PC SIOUX CITY

Guar :

44734

Guar: MICHELLE A. BIRD

FinOass: PRIVATE

P A Y

Guarantor

A d d r e s s :

t G

501 S

MAIN

ST

PO BOX 407

ODEBOLT, IA 51458

Home: (712)210-3539

Work:

Guarantor Employer: None

Bird

Sp ru i t

SIOUXLAND

OBGYN PC

ACCOUNT

DETAIL REPORT

Guar

Account Balance:

$

435 60

0

- 30 days :

0.00

31

to

60 d a y s :

0.00

61 to 90

days

:

0.00

91 to 120 days: 0.00

121 to 150 days 0.00

Over 150 days: 435.60

Last Statement Date: 04/30/2014

Patient

:

Patient:

45733

Patient Balance: 4 3 5 . 6 0 Insurance Balance: $ 0.00 Collection Balance:

MICHELLE

A. BIRD

Patient Address:

501 S

MAIN

ST

P O BOX 407

ODEBOLT,

IA

51458

Home: (712)210-3539

Work: (712) -

Patient Employer: None

Enc.

Date: 10/08/2013

E n c .

;

Blling Provider: 2-EASTMAN

MD, PAUL

J

Primary Diagnosis

for

this

Encounter:

61917 Enc. Post

Date:

02/12/2014 Loc:

Examining Provider:

2-EASTMAN

MD PAUL J Referring Provider:

BCBS

PAY MENT

BCBS ADJUSTMENT

RESPONSIBILITY CHANGE


'CHECK

BCBS

P AY MENT

BCBS ADJUSTMENT


RESPONSIBILITY

CHANGE

*CHECK

10/08/2013

10/30/2013

10/30/2013

10/31/2013

10/31/2013

02/10/2014

10/08/2013

10/30/2013

10/30/2013

10/31/2013

10/31/2013

02/10/2014

BCPMT

BCADJ

RESP

RESP

CHECK

BCPMT

BCADJ

RESP

RESP

CHECK

SIOUXLAND OBSTE TRIC

130.0

84.8

24.0

21.2

21.2

-21.20

294.0

220.0

19.0

55.0

55.0

-3.8

C P T only

©2000

American

Medical Association. All Rights

reserved.

AcctDtt. rpt

V e r

8.2.0 landscape




rinted: 09/16/2014 12:16 PM

ser: MT A Y L O R

Primary

Insurance

Policy

for th is

Encounter:

Plan Code

BCBS1

Policy*: HSV80762H51

Holder: MICHELLE

A BIRD

Relationship to

Holder:

SELF

Effective Date:

Policy

Holder

Employer : None

SIOUXLAND OBGYN

PC

ACCOUNT

DETAIL

REPORT

Plan Name

:

Group :

Group Name

:

Expiration Date:

BCBS OF IOWA

Enc.

Date: 02/10/2014

Enc.

:

Billing Provider: 2-EASTMAN,

MD, PAUL

J

70350

Enc.

Post

Date:

03/05/2014 Loc

Examining

Provider:

2-EASTMAN, MD,

PAUL

J

Referring Provider:


Primary Diagnosis

for this Encounter

02/10/2014

03/05/2014

03/05/2014

03/05/2014

03/05/2014

BCPMT

BCAOJ

RESP

RESP

BCBS

PAYMENT

BCBS

ADJUSTMENT

RESPONSIBILITY

CHANGE

RESPONSIBILITY

CHANGE

274.00

0.00

14.00

260.00

260.00

Primary

Insurance

Policy

for

this

Encounter:

Plan Code

BCBS1

Policy*: HSV807621451

Holder: MICHELLE A. BIRD

Relationship to

Holder:

SELF

Effective Date:

Policy Holder Employer: None

Plan

Name

:

Group

:

Group

Name

:

Expiration

Date:

BCBS

O F IOWA

Enc. Date: 11/13/2013

Enc.

:

Billing Provider:

2-EASTMAN,

MD,

PAUL

J

6 5

Enc.

Post

Date:

12/10/2013

Loc:

Examining

Provider: 2-EASTMAN,

MD, PAUL J Referring

Provider:

SIOUXLAND

OBSTETRIC

Primary D iagnosis

for

this

En counter

11/13/2013

12/04/2013

12/04/2013

12/10/2013

12/10/2013

BCPMT

BCADJ

RESP

RESP

BCBS

PAYMENT

BCBS

ADJUSTMENT



721.00

497.60

99.00

124.40

124.40

Primary

Insurance

Policy

for

th is

Encounter:

Plan

Code

BCB51

Policy

: HSV80762H51

Holder: MICHELLE

A.

BIRD

Relationship to

Holder: SELF

Effective

Date;

Plan Name

:

Group

:

Group

Name

:

Expiration D ate:

BCBS

O F IOWA

CPT

only

©2000

A mer ican

Medical

A ssociation Ail

Rights reserved

AcctDtl.rpt Ve r 8.2.0

Landscape




IN THE

IOWA DISTRICT COURT

FOR SAC

COUNTY

SMALL CLAIMS DIVISION

L F

NOLL

INC

PLAINTIFF

VS

NO

MICHELLE A BIRD

ROBERT

BIRD

SR.

DEFENDANT(S)

VERIFICATION OF ACCOUNT

IDENTIFICATION

OF

JUDGMENT

DEBTOR AND CERTIFICATE RE

MILITARY SERVICE

For Defendant: ROBERT BIRD SR.

1. I T. L.

Noll,

Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose claim(s) is (are)

shown in the attached statement(s). I have personal knowledge that the attached statement(s) is (are) a true

copy of the original creditor s records showing the balance due is true and correct. I further state that the sum

of

846.40 is the balance due and owing as of NOVEMBER 24, 2014 from Defendant(s) to Plaintiff s) and an

interest amount owing

is

accurately stated

in the

Petition

and

Original Notice.

2.

I further state that Defendant,

ROBERT BIRD SR.,

resides at 501 S

MAIN

ST PO BOX 407 ODEBOLT IA

51458-0407.

is employed 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/appj/scra/scraHome.do.

Contacting Defendant wh o 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

service

of the


OR

C. O

Defendant is

in the

military service

of the


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

70 5

Douglas St., Suite

34 4

Sioux City, IA51101

712-252-0583

0002973482




NCS,

IKC

DBA

NOLL

COLLECTION

SERVICE

705

DOUGLAS STHEET, SUITE

344

PO

BOX 59 3

STOUX CITY

TA

5 , 102-0593

712)252-0583

NOVEMBER 4,

2014

YICHELLE A BIRD

ROBERT

BIRD SR

301 S M A I N ST

PO BOX 407

ODE3CLT 1A 514580407

You are now in defau lt on t is credit transaction.

You

have a right, to

correct t h i s default w i t h i n

20

days.

If you do sc, you nay cor.r.ir.ue witr.

rhc

contract as though you did not

default.

YOUR DEFAULT CONSISTS OF : FATLURE TO PAY AS AGRE.-ID

If you

do not

correct. t h l s

default w i t h i n 20

days,

we may

exercise our

r i g h t s against you under the law.

It

you

default again

in the

next year,

we may

exercise

our ri ghts

wiihou'

sendin g

yo u another notice like this one. If you have any ques tions, wri~e c.

telephone promptly.

C

n

ient Ref No Pri ncipal Interest Other

SiOUXLAND (JROLO

00423848 388.80 7.14

SFOUXLAND

OBSTE 44734 435.60 14.86




NCS,

INC DBA


A Professional Debt Collection Service Since 1965

70S

DOUGLAS STREET, SUITE 344


(712)

252-0583

DATE:

OCTOBER 24,

2014

SIOUXLAND UROLOGY

ASSOCIATES 025500

P O BOX

2020

NORTH SIOUX CITY

SD

570492020

ATTENTION:

RE:

MICHELLE A BIRD

00423848 $388.80 04/18/14


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


*

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

MICHELLE

A

BIRD

ROBERT BIRD

SR

for


performed

in the principal

amount

of $388.80

plus

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 f

/ day of

CS fr A.

, 2 _

SIOUXLAND

UROLOGY

ASSOCIATI

By:

THIS IS AN ATTEMPT TO COLLECT A DEBT,

INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.

0002960040




Account Ledger

Box 2020

Dunes, SD 57049

(6 0 5 )2 1 7 -7 0 1 0

IA 51458

Phone (712) 490-684

Phone

Patient Balance

Insurance Pending

0 3

3 684^

Total Current

$22.80

$0.00

$117.00 $0.00

2 5 7 - J O - r

1 0 9

0 0

-

:count:

00423848

22 80^

ssponsible

Party:

Self

urance

1

(HSV807621451) BCBS Iowa Wellmark

5 3 8 • 8 0 *

primary

Provider:

(18)

Andrew

Bourne

Referring

Physician: (924)

Shelly Else

Account Balance

11030 31 to 60 61 to 90 91 to 120 121 to 150

$0.00 $0.00 $0.00 $0.00 $22.80

$117.00 $0.00 $0.00 $0.00 $0.00

Ove

Provider

Bill

Status Service Date Code

Description Charge

Payment

Ad

Bourne

I (18) Bourne

A

(18) Bourne

A

(18) Bourne

Bourne

(18)

Bourne

A (18) Bourne

A (18) Bourne

M Memo

M

Memo

Entry Date: 10/02/20 13

(16)

Kassin

PA-C

I

(16) Kass in PA-C

A

(16) Kassin PA-C

A (16) Kassin PA-C

M Memo

M Memo

Entry

Date:

12/17/2013

(18) Bourne

I (18) Bourne

A

(18) Bourne

M Memo

M Memo

Entry Date: 05/22/2014

(18)

Bourne

M Memo

Entry Date: 10/17/201 4

Bill

09/26 /201309/26 /2013 $285.00

Bill

10/21/2013 10/21/2013

3 0

BCBS Iowa Weiimark

0034236410

Bill 10/21/2013 10/21/2013 C045

0


fee

schedule

Bill 04/17/2014 04/17/201 4

C 0 Collection Write O ff

Bill 09/26/201309/26/2013 $158.00

Bill 10/21/2013 10/21/2013 3 0 BCBS Iowa Wellmark

0034236410

Bill 10/21/2013 10/21/2013 CO45 0 Charges exceed contracted fee

schedule

Bill 04/17/2014 04/17 /201 4 C 0 Collection Write Off

10/02/2013 Ins

Code

sequence on visit [3]; by

user:

DBertrand

10/21/2013

$366 .00 applied

to deductible.

Visit Balance: $0.00 $443.00 $0.00

Bill 12/05 /20131 2/05/201 3 $117.00

Bill

01/14/201401/14/2014 3 0 BCBS

Iowa

Weiimark

($91.20)

0034253558

Bill 01/14/2014 01/14 /2014 CO45

0


fee

schedule

Bill

04/17/2014 04/17/2014

C 0

Collection

Write Off

12/17/2013 Ins

Code

sequence on visit [3]; by user:

DBertrand

01/14/2014 $22.80 appl ied

to co-payment.

Visit Balance: $0.00 $1 1 7.00 ($91 20 )

Bil l 05/08/201 405/08/20 14 $117.00

Bill 06/1 6/20 14 06/16/2014

3 0

BCBS Iowa Wellmark ($91.20)

0034283500

Bill 06/16/2014 06/16/20 14 CO45

0


fe e

schedule

05/22/2014

Ins

Code sequence

on

visit

[3]; by

user:

DBertrand

06/1 6/201

4

$22.80 appl ied

t o

co-payment.

Visit Balance: $22 .80 $117.00 ($91.20)

No

Bill

10/09/2014 10/09/2014 $117.00

10/17/2014 Ins Code sequence on visi t [3]; by user:

DBertrand

Visit Balance: $117.00 $117.00 $0.00

($

($2

($

( $ 1

($4

(

($

($

(

(

Bill:

22.80

No-Bill: 117.00

Total : 139.80

794.00 ( 182.40)

= Charge; I = Insurance Payment; P = Private Payment; A = Adjustment; F = Insurance Filing; M = Memo

All Visits

a

preliminary (open) transaction

that is

subject

to

review.

4

AM

Created

by: RTorres

ID:

17 Ver

1.15.2.9

Page




F r o m : S i o u x l a n d O b g y n

-

7 1 2 2 7 7 2 6 4 5

1 0 / 2 1 /2 0 1 4 0 9 : 2 0

5 5 6

P . 0 0 2 / 0 0

NCS,

INC DBA


A

Professional Debt Collection Service Since 1965

705 DOUGLAS STREET, SUITE 344


(712) 252-0583

DATE:

OCTOBER 24, 2014


026122

GYNECOLOGY

PC

2730 PIERCE ST SUITS 201

SIOUX

CITY,

IA 51104

ATTENTION:

RE: MICHELLE A

3IRD

44734 S435.6G 10/17/14


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


* Tf the

original account

is a

contract

or

note,

we

must have

the

original.

Please

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

not: accept payments

or

make arr angements, without calling

us

first.

THANK

YOU

FOR YOUR

COOPERATION


consideration, receipt hereby acknowledged, the undersigned hereby

transfer, and set over unto L.F. Noll, Inc.

that

certain claim against

MICHELLE A BIRD

ROBERT BIRD

SR


principal amount

of

S435.60 plus lawful interest

es hereby authorize said assignee to do and perform all acts

for

collection; commencement

of

suit

in the

name

of the

assignee,

, compromise or satisfaction of said claim. Assignor

certifies that said claim is justly due and owing and warrants

and

ether provisions

of

truth

in

lending,

and

that same

is

free

of

and other defenses.

this

f y of

OBSTETRICS &

:

(Xame

and Official

title)

THIS

IS AN

ATTEMPT

TO

COLLECT

A

DEBT,

INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.




Printed:

09/16/2014 12:16 PM

User :

M T Y l

O R

Financial Group: 2-SIOUXLAND OBGYN PC SIOUX CITY

Guar : 44734

Guar: MICHELLE

A.

BIRD

Findass: PRIVATE

PAY

Guarantor A d d r e s s :

c U

501 S

MAIN

ST

PO

BOX 407

ODEBOLT,

IA

51458

Home: (712)210-3539

Work:

Guarantor

Employer:

None

i r

O K to

SIOUXLAND

OBGYN PC

ACCOUNT

DETAIL

REPORT

Guar

Account Balance: $ 435 60

0 - 30

days

:

0.00

31 to

60

days: 0.00

61 to 90 days : 0.00

91 to 120 days: 0.00

121 to

150 days 0.00

Over

150

days: 435.60

Last Statement Date:

04/30/2014

Patient*:

45733 Patient Balance:

Patient: MICHELLE

A.

BIRD

Patient Address:

501 S

MAIN

ST

PO

BOX 407

ODEBOLT, IA

51458

435 60 Insurance Balance: 0.00 Collection Balance: $

Home:

(712)

210-3539

Work:

(712)

-

Patient

Employer:

None

Enc.

Date:

10/08/2013

Enc.

:

61917 Enc.

Post

Date: 02/12/2014

Loc:

SIOUXLAND

OBSTETRIC

Billing Provider:

2-EASTMAN MD PAUL J

Primary

Diagnosis

for this Encounter:

Examining

Provider: 2-EASTMAN MD PAUL J Referring Provider:

BCBS PAYMENT

BCBS ADJUSTMENT



CHECK

BCBS PAYM ENT

BCBS

ADJUSTMENT

RESPONSIBILITY

CHANGE


•CHECK

10/08/2013

10/30/2013

10/30/2013

10/31/2013

10/31/2013

02/10/2014

10/08/2013

10/30/2013

10/30/2013

10/31/2013

10/31/2013

02/10/2014

BCPMT

BCADJ

RESP

RESP

CHECK

BCPMT

BCADJ

RESP

RESP

CHECK

130 00

84 80

24 0

21 2

21 20

21 2

294

•220 00

19 00

55 00

55 00

3 80

C P T only©2COO A merican Medical Association. All Rights reserved.

AcctDtl.rpt

V e r

8.2.0 andscape




Printed; 09/16/2014 12:16 PM

User: M T Y L O R

Primary

Insurance Policy

for this

Encounter:

Plan Code

BCBS1

Poh cyi : HSV807621451

Holder:

MICHELLE A. BIRD

Relationship to Holder: SELF

Effective Date:

Policy

Holder

Employer : None

SIOUXLAND OBGYN PC

ACCOUNT DETAIL

REPORT

Plan

Name :

Group :

Group Name :

Expiration

Date:

BCBS OF IOWA

Enc. Date: 02/10/2014 Enc.

:

70350 Enc. Post Date:

03/05/2014 Loc:

SIOUXLAND OBSTETRI

Billing

Provider: 2-EASTMAN MD, PAULJ Examining Provider: 2-EASTMAN MD, PAUL J Referring Provider:

Primary Dagnosis

for this

Encounter:

02/10/2014

03/05/2014

03/05/2014

03/05/2014

03/05/2014

BCPMT

BCADJ

RESP

RESP

BCBS

PAYMENT

BCBS ADJUSTMENT

RESPONSIBILITY

CHANGE

RESPONSIBILITY C HANGE

274.0

0.0

14 00

260 00

260 0

Primary

Insurance Policy

for

th is

Encounter:

Plan Code BCBS1

Policy

:

HSV807621451

Holder: MICHELLE A. BIRD

Relationship

to Holder: SELF

Effective Date:

Policy Holder

Employer :

None

Plan Name

:

Group

:

Group Name

Expiration

Date:

BCBS O F IOWA

Enc. Date: 11/13/2013 Enc.

:

Billing Provider:

2-EASTMAN

MD

PAUL J

64451

Enc. Post Date: 12/10/2013

Examining Provider: 2-EASTMAN MD, PAUL 3 Referring Provider:

Loc:

SIOUXLAND OBSTETRIC

Primary

Diagnosis

for this

Encounter:

11/13/2013

12/04/2013

12/04/2013

12/10/2013

12/10/2013

BCPMT

BCADJ

RESP

RESP

BCBS

PAYMENT

BCBS

ADJUSTMENT

RESPONSIBILITY

CHANGE


721 0

497 60

99 00

124 40

124 4

Primary

Insurance Policy

for

this

Encounter:

Plan Code BCBS1

Policy*: HSV807621451

Holder: MICHELLE

A .

BIRD

Relationship to

Holder: SELF

Effective

Date:

Plan Name

:

Group :

Group

Name

:

Expiration Date:

BCBS OF IOWA

CPT

ony

©2000

Ame rican Medical As sociation. All

Rights

reserved.

AcctDtl.rpt Ver

8.2.0

Landscape




E-FILED 2014 DEC 19 10:56 AM SAC - CLERK OF DISTRICT COURT



IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY

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

Case: 02811 SCSC015550

vs.

JUDGMENT ENTRYDefendant(s),

MICHELLE BIRD501 S MAIN STREETODEBOLT IA 51458

ROBERT BIRD SR501 S MAIN STREETODEBOLT IA 51458

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 $ 824.40 with interest at the rate of 2.13 % from the 2nd day of December, 2014 and court costs. The Court further enters judgment for prejudgment interest in the amount of $22.00.

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: $850.00

1 of 2




State of Iowa Courts

Case Number Case TitleSCSC015550 L.F. NOLL, INC. V BIRD, MICHELLE AND ROBERT SR.Type: ORDER FOR JUDGMENT

So Ordered

Electronically signed on 2014-12-30 21:10:55


scsc015550 - judgment against odebolt couple in the amount $824.00.pdf

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