Claim Birch, Stacy
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CLAIM AGAINST THE CITY OF DUBUQUE:IOWA ~~
This written report constitutes your claim against the City of Dubuque, Iowa. You should
complete this form in full and attach lmy addillonallnformation that supports your claim.
The Claim must be filed with the City Clerk at City Hall, 50 W. 13th SL, Dubuque, IA 52001.
It will then be referred by the City Council to the appropriate department for investigation.
Once that Investigation Is completed, a report and recommendation will be submitted to the
City Council. You will be provided with a copy of that report and recommendation.
THE I'INAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE
OF THE CITY OF DUB.UQUE HAS THE AUTHORITY TO MAKE ANY REPREseNTATION TO
YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID.
1. Name of Claimant: ~-\o-L "I \b~ r ( ~
2. Addrelis: C;2:,C\;'j 'r\ \IC\'N..~~ \' ~ rr \~ ~ ';:l
3. Telephone Number: S~ '?:J - ~ 'r,'d - ~--:-tC::PJ
4. Date of Incident: ~ - do\.\ - ()"f")
5. TIme of Incident: d. '- d. \ ~) '\Y\ ,
6. Locationoflncident(Bespeclflc): Q,~~~"")~O""..Q. ~)(\ \.\!"1\-';G~' b~
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7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give
full details upon which you base your claim.. If 8 City employee was involved, give the
e(T1ployee's name.)
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8. Wh,~t_were weaifier conditions Iike?~ \t-.,\H"~l.r \lo."\(\", "'~,,)\.'''''''00~ \/'..\',:t~ '"
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9. Give name and address ofany witnesses: ~ lA"", 'Stc.(:-':'<' ~'X\r~~ ~(Jr\'\r~
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1 O. Old police investigate? (If so, give names of officers.)
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11. Was anyone Injured'? (If so, give names, addresses, and extent of injuries).
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12. Was any damage done to property? (If so, describe property and the extent of damages.
Attach estimates of damages or describe basis for ascertaining extent of damage.)
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13. What other damages do you claim,lf any? ~orA \f-'~/,1<("", ~\\ ~,(,(\~~\CJ...'\\C~
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14. Have you been eompensated for any part or all of your claim by any insurance
company? (If so, give name and address of Insurance company and amount paid.)
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15. What amount do you claim from the City of Dubuque? VO'c'-\"""'!{'\,-\ ~ry
,
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16. Why do you claim the City of Dubuque is responsible?
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17. Have you made any claim against anyone else for damages as a result of this Incident?
(If yes, give name and address.) '" "
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18. If the answer to Question 17 is yes, have you received any payment from that source,
and if so, in what amount? ~ \ \\
Dated at Dubuque, Iowa this
day of
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(SI9nat?:!
CO~kL 'f~
PrInt Name)
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(Rev. 1/00 &7/91)
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DUBUQUE FIRE EMS
(800)786-4911 Ext. 230
Call Number: 30-05-2848 PP A006
Date Of Call: 08/24/2005
Call Time: 02:21 PM
From location: MVA DODGE ST & DEVON DR
To location: MERCY HEALTH CENTER - IOWA
Patient Name: STACY BIRCH
Reason(s) 829.0
For
Transport
#BWNKMRY
STACY BIRCH
3395 KENNEDY CIRCLE APT 2
DUBUQUE, IA 52001
Insurance: MEDICARE PART B
480705401C2
Amount of Bill:
$412.00
In order for us to process your bill with Medicare, Medical Assistance and/or your insurance carrier you
must return this form, completed and signed, to us as soon as possible. No request for reimbursement
may be made to Medicare, Medical Assistance or other insurance carriers without signatures. If
the responsible party is someone other than yourself, have your authorized representative sign this form.
NO PAYMENT is due at this time unless you do not complete, sign, and return this form to us. If
we do not receive a completed form, you will then be responsible for the entire bill.
INSURANCE INFORMATION RELEASE
I hereby specifically authorize DUBUQUE FIRE EMS to release or obtain any information needed to determine these
benefits or the benefits payable for related services to or from any party necessary for payment of this obligation. I authorize
payment of any benefit due to DUBUQUE FIRE EMS. This authorization shall remain in effect, at a minumum, throughout
the duration of my "inpatient" status in a hospital or skilled nursing facility, and shall remain effective thereafter until so
revoked or rescinded by myself or my authorized represenative.
Signed:
Relationship:
Address:
Patient unable to sign because:
Date:
Time:
ampm
City:
State:
Zip:
_.___ Refold Here _._-~- Refold Here ------- So that the return address below fits in the return envelope window ..._.M Refold Here m____ Refold Here -.-----
FINANCIAL RESPONSIBILITY FORM
I understand that I am financially responsible to the DUBUQUE FIRE EMS for charges not covered by my insurance plan,
including but not limited to collection costs and attorney fees, as required in the collection of my ambulance account.
Signed:
Relationship:
Address:
Patient unable to sign because:
Date:
Time:
am pm
City:
State:
Zip:
DUBUQUE FIRE EMS
c/o L1FEQUEST BilLING OFFICE
N2930 STATE ROAD 22
WAUTOMA, WI 54982-5267
<<<<< Please ensure that this address shows through
<<<<< the window on the return envelope.
.
DUBUQUE FIRE EMS
(800)786-4911 Ext. 230
Call Number: 30-05-2848 PP RVW
Date Of Call: 08/24/2005
Call Time: 02:21 PM
From Location: MVA DODGE ST & DEVON DR
To Location: MERCY HEALTH CENTER - IOWA
Patient Name: STACY BIRCH
Reason(s) 829.0
For
Transport
#BWNKMRY
STACY BIRCH
3395 KENNEDY CIRCLE APT 2
DUBUQUE, IA 52001
Insurance: MEDICARE PART B
480705401C2
DESCRIPTION OF CHARGES
ALS EMERGENCY RES NO SPEC SRVS
MILEAGE RESIDENT
!:ICPC
A0429
A0425
QUANTITY
1.0
2.0
UNIT PRICE
400.00
6.00
AMOUNT
400.00
12.00
Total Charges
412.00
This collection agency is licensed by the:
Office of the Administrator of the Division of Banking
P.O. Box 7876, Madison, Wisconsin 53707
Total Credits
TOTAL AMOUNT DUE =>
0.00
$412.00
,--------------------------------------------------------------------------------------------------------------------------------------.----------,
^DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT^
*
Your account is SERIOUSLY PAST DUE. If unable to pay your bill in full
we will accept regular payments. Call 920-787-2291 ASAP!
Patient Name: BIRCH, STACY L
Call Number: 30-05-2848
Billing Date: 10/31/2005
DUBUQUE FIRE EMS
cia L1FEQUEST BILLING OFFICE
N2930 STATE ROAD 22
WAUTOMA, WI 54982-5267
Total Amount Due: $412.00
Amount Enclosed: $
Federal Tax 10: 42-6004596
.. ..., "
DUBUQUE FIRE EMS
CIO LIFE QUEST BilLING OFFICE
N2930 STATE ROAD 22
WAUTOMA, WI 54982
(800)786-4911 Ex!. 230
IMPORTANT NOTICE! INSURANCE REQUEST!
Important Notice! Your account has been flagged as PRIVATE PAY. This means that either you have NO
insurance to cover your ambulance transport, or we have insufficient INSURANCE INFORMATION to process a
claim with your insurance carrier. If you have NO insurance coverage, please contact our office at 800-786-4911
immediately to discuss payment arrangements. Interest may be charged on all past due accounts.
If you would like our office to process your claim with your insurance company, you must supply us with complete
insurance information. Please completely fill out the following information or send us a copy of both sides of your
insurance card(s).
Please also verify the following information for accuracy and add any information, making the necessary changes
directly on this form. Please return your information/this form as soon as possible in the enclosed return envelope.
Patient Information Account Number:
Account Balance: 412.00
Social Security Number: ~ ..-
Patient Name: BIRCH, STACY L
Address: 3395 KENNEDY CIRCLE APT 2
DUBUQUE, IA 52001
Phone Number: (563) 583-3793
Date of Birth: -
Insurance Information
PLEASE PROVIDE US WITH
YOUR AUTO INSURANCE i
INFORMATION -
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Medicare Number: 480705401 C2
insurance Company Narne #1: ~
Insurance Company Address:
Policy Holder Name:
Policy OR 10 #:
-
Policy Holder OOB: - \ - \
Group #:
Insurance Company Name #2:.
Insurance Company Address:
--
, olicy Holder Name Secondary:
("Ilicy OR 10 #:
-
Policy Holder OOB: - \ -\
Group #:
-
Other info OR Auto Insurance: