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HomeMy WebLinkAboutClaim No. 522 - P. J. CliffordXD CITY OF PALM DESERT COMMUNITY SERVICES DIVISION CITY CLERK OPERATIONS STAFF REPORT REQUEST: CLAIM AGAINST THE CITY (#522) BY PATRICK J. CLIFFORD IN THE AMOUNT OF $50,000 DATE: March 25, 2004 CONTENTS: I. Staff Report II. Claim No. 522 Recommendation: By Minute Motion, reject the Claim and direct the City Clerk to so notify the Claimant. Background: Based on a review of the subject Claim and the recommendation of the Claims Adjuster, Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected. Discussion of this item should be held in Closed Session pursuant to Government Code Section 54956.9(b), potential litigation. Submitted by: 0I-- ik CHELLE D. KLASSEN, CMC CITY CLERK Approved: CARLOS L. ORT A CITY MANAGER rd k Attachment (as noted) SHEILA R. GILLI AN, ' t C ASST. CITY MANAGR " OR COMMUNITY SERV 'S H:IWPdata\WPDOCS\CLAlMS1522 reject staff rpt wpd 5V-10-03 12:200From-PALM DESERTCITY-CLERK 750 400574 • . • :.• , • via: • - ' • ' , „, U.S. Interoffice. Over -the -Counter CITY. ) i eR vn -r"---30e4 CLERK, CITY OE PM-M TO THE HONORABLE MAYOR AND CITY COUNC[L, city of Paim Desert, Caliiormaz; The undersigned respectfully submit(s) the following claim and information relative to dama e s t petsOn(s)andjoi'PertOnalPiiiPeitYi , N ' I • CLAIMANT INFORMATION: NAME al,' 6/ ADORESS PRONE NO. IR SOCIAL SECURI Y NO. bgivgFes Ogg,. 2.- Name ; teiepnone nurnber and post office address to which claimant desires notices to be sent, if othe+ than above': CLAIM A4AR4ST rkip. „ (For Damage(s) to Person(s) or Personal Property) Received by-:' /003 SEP 23 A q: Ob A CLAM UST BE W T MONTHS AGAINST INSUPF EUSE ADDITIONA PARAGRAPHC E1E DES 73-510 • 3_ Occurrence or event from which the claim arises: a. DATE: //tea 24 749 b. TIME: 4/my, c. PLACE (exact and specific location) 6 el, Ade "A 0.444 azwl 60v.-re Pete,1- Pda. d. How and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act or ommission you claim caused the injury or damage. (Use addition paper if necessar .) .57 rreve. e. What particular action by the City, or its employees, caused the alleged damage or injury? Page 1 of 2 k1 iv Sap-16-03 12:29pns Give a so 8 injur SERT CITY C . RK S. Give the narne(s) of the C 6. Name a}n0d address of any other persons, 1803400514 Name and address of the owner of any damaged proper Damages claimed: a Amount claimed as of'this elate: b Estimated amount of" future costs: Tatail`amouint cialrned d. Basis`' for computatio of a estimates, etc.' Names and address of all itr esses, hospitals, dotors, etc.,: 10. Any addition, this claim: 'ur'red no 4az. P7 information, including police reports, which might be helpful in ooisiddring WARNING:IT LS A CRIMINAL OFFENSETOTO FILE A FALSE CLAIM! INSURANCE CODE 556_1). PENAL CODE 72; I have read the matters and statements made in the above claim, and 1 know the same to be true of my own knowledge, except as to --those matters stated upon information or belief as to such matters I believe the same to be true. I .certify under penalty of perjury that the foregoing is TRUE AND CORRECT. Signed this ZZ day of SIGNATURE OF CLAINIAINT SIGNATURE 0 CL NT Office of the City Clerk, Palm Desert, California DOC. NO. DATE FILED Page 2 of 2 LEA E108 REf310ENAL MED PQ: tQ LI1N NV itti Ogati TCLIFFORD PATRICK J JFFORD to TICK 5I"AIklVH NI QI: AI..`t:tJlFNt:: cLIrroRD P• 11.1.rdillIsssr#'TIuuI1s,JrlrisslrrdllrbpllfL,jJ,1,1fl l�['�tsrl nil [irrl�ttrl'lltil�Wf�I lstrlk11f�I111�tr�1�11�.II TO VIEW/PAY YOUR" ACCOUNT VIA THE *FRNET SEE: THE WEB ADDR#Er 1 EE,OW NNOTE SHOULD YOU WISH TO PAY BY CREDIT GARD,'SEEE AUTHORIZA11ON NO1'1E ON THE TO RECEIVE PAYMENT . trtl%P PROPER CREDIT, PLEASE RETURN THIS EsORTIOIV ViI1TH QUR PA BA;k. ` . QU1rPT SURGERY 04/18/03 To.04/18/03 ATEOMENt DAT `PAG''E., LOS ROBLE.S REGIONAL MED PO BOX 29506 LAB VE0AS NV 89126-9500 (800)307 8012 01/31/0 SUMMARY OF ACCOUNT TO 08/27/0 STATEMENT DATE DtiF1=`O!' D PAT {C'[: 1144 INSuAANC1 CLAIMS (1UTSTANDINO REPRESENTS. OUR E^ ST E OF NSIJRANGE LIAB1LITY BASED OkOUR BEST -000RMATIOW1 04/18/03 OUTPT'SURGERY VISIT 07/30/63 S T stAltmekr ESTIMATED 'PAIENT ESTIORAtiCE 11,711 11711.26 400.00 11,311.26 TO VIEW/PAY YOUR ACCT VIA WEB: WWW.LOSROBLESHOSPITAL.COM/BILL.ASP IF YOU HAVE QUESTIONS .REGARDING YOUR ACCOUNT, PLEASE CALL. 800 30T 8012 THANK YOU FOR USING OUR FACILITY FOR YOUR HEALTHCARE NEEDS. THANK YOU FOR CHOOSING LOS ROBLES REGIONAL MEDICAL CENTER CHARGES MAY INCLUDE TESTS SENT TO REFERRAL LABORATORY THIS BILL IS FOR HOSPITAL SERVICES ONLY__,. ►Y STATEMENT OFACCOUNT Page 1 of 1 STATEMENT DATE PAY THIS AMOUNT LL ACCOUNT NO. EMERG PHYS MED `GRP, INC PO BOX 792 :.. rm CITY OF INDUSTRY CA 91716-9262 (1-800) 322-1991 ADDRESS SERVICE REQUESTED BILL TO: 5481 1 MB 0.309 --�- PATRICK CLIFFORD' IIII',lIt1I16rttlf6114111 IGlri,I1IIIIIIIIIJr,11111111111 11 ___ CARE GIVER 0 AGNOSIS 03/23/03 23 CHARLS GENT2SCH NP 8449 STA1EMENT DATE 06/19/03 PATRICK CLIFF 0-30 DAYS We are cc (as If you cannot pay If you have $0.00 31-60 DAYS PATIENTS NAME PATRICK CLIFFORD $0.00 (19/03 MAKE CHECKS PAYABLE TO: EMERG PHYS MED GRP, INC PO BOX 79262 CITY OF INDUSTRY CA 91716-92 E] Please check box if ad ress or Insurance fraq is incorrect Indicate Gnange(s) on ►eVeTse sic detach and return this top Po.tion. with Y'twr,a DESCRIPTION OF SERVICE 99283 AL ED vzsi LEWEL 3 PLEASE CONTACT OUR OFFICE TODAY. SHQN AMOUNT PAID HERE AMOUNT $158.0( RD was seen at EISENHOWER MEM HOSP as noted above, and the balance for treatment is now due You have previously been sent two statements regarding this visit. ncemed about your past due balance. To protect your good standing with the group well as your credit rating), please pay the amount due within 15 calendar days. the entire amount immediately, please contact us, and we can discuss setting up a payment pl mailed your payment within the last five days, we thank you; please disregard this notice. * PLACE OF SERVICE: 21. INPATIENT 22. OUTPATIENT 23. EMERGENCY ROOM PRIMARY INSURANCE SECONDARY INSURANCE 61-90 DAYS OVER 90 DAYS $158.00 $0.00 LOCATION OF SERVICE EISENHOWER MEM HOSP Office Phone Number: (1-800) 322-1991 Office Hours From: 9:00 - 4:00 Mon - Fri Pacific ACCOUNT NUMBER EMERG PHYS MED GRP, INC PO BOX 79262 CITY OF INDUSTRY CA 91716-9262 emd 5011370 PERSONAL BALANCE: INSURANCE BALANCE: WORKERS COMP. BALANCE: $158.00 $158.0( $0.0( $0.0( © »? 5yoO . 43.5.0 y DENetIBLE 60.00 $41,AN, 373.50 PAYABLE 100 PCT BENEFIT 373.50. PATIENT NOT LIABLE FOR ULT AN PHYSICIAN DISCOUNT. A COPY OF THIS NOTICE HASBEEN SENT TO THE PROVIDER D fE ■01mE$. 0 TOT ONE HEALTH PLAN - SAN FRAN. P.O. BOX lil!! FT. SCOTT, KS. 66701 PH (800) 663-8081 M008 545".` TEMP -RETURN SERV"I" E REQUESTED Billing Questions: (800) 478-2778 ACCOUNT# rs Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse` side. PROVIDER 06/02/03 ,FACIANA`' 07/25/03 07/25/03 06/04/03 FACIANA 07/25/03 07/25/03,. 06/06/03 FACIANA 07/25/03 07/25/03 06/05/03 FACIANA 07/25/03 07/25/03 06/11/03 FACIANA 07 / 25;03 06/13/01 FACIANA 07/25/03 07/25/03 06/16/03 FACIANA 07/25/03 07/25/03 06/18/03 FACIANA 07/25/03 07/25/03 06/19/03 FACIANA 07/25/03 07/25/03 06/23/03 FACIANA The amount shown in the still pending from your STATEMENT DATE 08/18/2003 PAY THIS AMOUNT' 1,92.00 SHOW AMOUNT PAID HERE M00RPA1 ii PHY 'CAL THf!ri pY 545 W LOs "ANCELE8 Avalbt mOORPAPIK CA 53021 PLEASEDETACI AND RETURN TOP PORTION WITH YOUR PAYMN' TRANSACTION / DESCRIPTION PT EVALUATION ,xr TNSU —CE ADJttSTMtNT 108 OE'PAYS`C NTAAC THEM PHWIC EXC RtISE KE PAY N2+IT CONTRAC At�F i is _ sCERCI5E SF3 Af C ADJt4STh N T NStJRANCE PAS' CONTRAC `EXC*R*ICE' Ate E STi w INS NCE PA NT CONTRAC THEI�APEtiTIC EXCECISE INSi*M CE PAY N ' CONTRAC' PH 1 APE iTT:C EXCEF2CISE INstmANC> AtxJUSTMEN'r INStRANCE PAYMENT CONTRAC THgAikPEUTTC 'EXCERCTSE INSURANCE ADJUSTMENT INSURANCE PA esi CONTRAC THEE A?EUTIC I EXORCISE INSURANCE ADJUStVIENT INSURANCE PAYMENT CONTRAC THERAPEUTIC EXC8ACISE INSURANCE AbJUSTMENT iNSURANc$ PAY zENT CONTRAC TI#ERA?EUTIC EXCERCISE CHARGES PAYIy(E At Jt1S'1$ 80.00 80.00 80.00 80.00 80.00 claims in process box is the amount of charges insurance tTS/ .' PATIENT ENTS BALANCED'. -$15.75 $69.25 $ .2.00 -$48:00 -$12.00 -$48.00 -$12.00 -$48.00 -$48.00 -$12.00 -$48.00 -$12.00 -$48.00. -$12-00 -$48.00 -$12.00 -$48.00 20.00 20.00 32.00 20.00 20..00 20.00 20.00 TOTAL BALANCE Billing Questions: PLEASE REMIT TO: CLAIM IN PROCESS PAY THIS AMOUNT PAGE#s1 WLZ75317C-O5-03 WLFM-39161 PAINTED IN U.S.A. • • MA(E',_;HE,..„N PA YACIL.,_ 10°14''H t/itIWY 5' OS E010tiE 45 cot "11011 TEMP-RETURatirtylq-litOOEST., Etk • . • . • ' BillingQueStions: (800) 478-2778 RICK j.tL4iiokb AccoOtit# n Please ched(binc if above addr is incorrect or insurance informatiOn has Chniiged, andindiente change(s) on retier0e Side..• . . DATE'. - - • ,' „.•,..,•P•Ro-VOtiErtitT- • SINifil4-1-"OATS.• .08/18/2003' ••-••••, •.: PAGE # OF PAY THIS AMOUNT ACCT IMO 19244 SHOW AMOUNT d. Pia:. HERE $ MOORFARk PRYSICAL tHERAPY 545 0 to NOELES AVENUE MOORPARX CA 93021 PoFtilONWri'Fft sirblit'PAYMEr •„, . , ..„ . „ 07/15/03 07/25/03 06/13/03 'FACIANA 07/25/03 07/15/03 07/25/03 07/25/03 06/25/03 PACIANA 06/25/03 VAttAistA• 07/25/03 01/25201 07/02/03 FACIANA 07/02/03 FACIANA 07/03/03 FACIANA 07/03/03 FACIANA TRAk$ACIT01•41OSSCsUrrION t , InangHANL eq:4:rrtme DYUTMft I 01‘"1"-4s. ftlgt1"7 INStWJC oAiEi 0Airgs NT, R87;_E , XC c At PRA A IsE aR4F y PRPRAp ti-18 ei.HE 80.00 100.00 80,00 100.00 80.00 100.00 The amount shown in the claims in process box is the amount of charges Still pending from your insurance COARdES PAY!!!!!5r8/ PATIENT AD,JUS*ENrS. SALANCtt -$12.00 -$58.00 10.00 100,00 -815-00 -$32.60 -$48-00 -$85.00 -80-00 -$15.00 -$75.00 10.00 PATIENT NAME: PATRICK CLIFFORD Billing Questions: PLEASE REMIT TO: (800) 478-2778 MOORPARK PHYSICAL THERAPY TOTAL BALANCE 572.00 CLAIM IN PROCESS 380.00 PAY THIS AMOUN 192.00 W12753170-05-03 WLFM-39164 PAINTED IN U.S.