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7/27/2019 Judgment against Sac City couple in the amount $1,137.60
1/22
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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 ';'; . ' ' ' .
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
JUSTIN A B U S C H M A N N 227S6 /A D M I S S I O N D A TE D I S C H A R G E D A T E B I R T H D A T E S E X03/27/13 03/27/13 m84M
554219A GE28
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
03 27MMBHP03 2703-2703-2703 27
03-2703 2703 27
WBWnmMMV
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
04-22
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C H A R G E C O D E
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D E S C R I P T I O NBHVMM
RADIOLOGY TECH
S U M M A R Y O F CHARGESRADIOLOGY TECH
TOTAL CHARGES
BALANCEL^
Q U A N T I T Y
C H A R G E135.000
135.00
135 . 00
;Ui
C R T
DEPT TOTAL
qA )1
Q t
ifit1
o
A M O U N T135.00135.00
N
135.00
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
C H A R G EC O D EMBHfe
j HHb
k-3t/-/3
D E S C R I P T I O N0UMMMRRADIOLOGY, PROFESSBMB MHHH^ ^ iM BiMBWP
ULTRASOUND
SUMMARY OF CHARGES
f
RADIOLOGY; PROFESSIONALULTRASOUND
TOTAL CHARGES
BALANCE
- O_
v.
Q U A N T I T Y
1
132.110294.000
132.11294. 00426.11
^\T
DEPT TOTAL
DEPT TOTAL
_ H p
A M O U N T132.11132. 11294.00294 . 00
426.11\S .\
u
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
E-FILED 2014 MAY 30 4:12 PM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
20/22
E-FILED 2014 JUN 27 10:50 AM SAC - CLERK OF DISTRICT COURT
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
7/27/2019 Judgment against Sac City couple in the amount $1,137.60
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
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