Dana RECEIVED
FEB 2 5 2�14 �
CITY CLERK
NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota
Minnesota State Statute 466.05 stares that "...every person...who claims damages from any mernicipaliry...shall cause to 6e presen�ed to the
governing body of the n:unicipaliry withi�t 180 days after the a!leged loss or injury is discovered a no�ice stnting the time,place,and
circ�uns�ances thereof,and the amoun�of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain yonr claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name Middle Initia� Last Name �,,JA��
Company or Business Name
Are You an Insurance Company? Yes/(V✓o If Yes,Claim Number?
Street Address��� t �.1:.(ft�- /'{'J
City��� ����CJI'� State T'I�� Zip Code J �
Daytime Phone(� L��C�11 Phone(�Zy - � vening Telephone(�--
-�' �" 6
Date of AccidenV Injury or Date Discovered 1 f,tJU). � � Time � 3 am pm
7.d l3
Please state,in detail,what occurred(happened),and why you are submitdng a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are ' volved and/or responsible for your damage,�s;
� ri (.11�
Please check the box(es)that most closely represent the reason for completing this form:
❑My vehicle was damaged in an accident ❑My vehicle was damaged during a tow
❑My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑My vehicle was wrongfully towed and/or ticketed �was injured on City property
❑ Other type of property damage-please specify
/ `
❑ Other type of injury-please specify
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00;or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills
an or receipts for the repairs;detailed list of damaged items
�'�ijury claims:medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2-Please complete and return both pages of Claim Form
�
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims—nlease complete this section
Were there wimesses to the incident? Yes No Unknown (circle)
Prov e the names, addresses and telepho numbers:
r� (�.UZvv� ��r-��- (�G.�
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facility,
closest la dmazk,etc Please be as detailed as possible. If neFessary,attach.a d'agram.
�' �� .
Please indicate the amount you are seeking in com ensation or what you would like the City to do to resolve this claim
to your satisfaction. _ _ , __
Z - . � .
Vehicle Claims—please comnlete this section ❑ check box if this section does not annlv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims— lease com lete this section ❑check box if this section does not a 1
How were you injured? — ' �t v�
What part(s)of your body were injured?
Have you sought medical treatment? e No Planning to Seek Treatment(circle)
When did you receive treatment? � � i Z- (provide date(s))
Name of M dical Prov'd r(s):
Address � Telephone
Did you miss work as a res lt of your injury? Yes o
When did you miss work? (provide date(s))
Name of your m lo er•
Address Telephone (
heck here if you are attaching more pages to this claim form. Number of additional pages��.1�
�
By signing this fornz,you are stating that all ifaforn:ation you have provided is true and correct to the best
of your knowledge. Unsigized forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed o�/r�% /�J�
,
Print the Name of the Person who Completed thi Form: �
Signature of Person Making the Claim:
Revised February 2011
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' �1'I�� CHECK CAHD USING FOH PAYMENT �
■�"�■ HealthPartrners� �OSTERCARD ��ER D❑ISCOVER r'J~ � ��R�OERICAN
�VZI{�ZGS CARDNUMBER
P.O.BOX 77026
MINNEAPOLIS MN 55480-7726 SIGNANRE IXP.DATE
. : . � � �. . � �
For Billing Questions: Office Hours-8:00 a.m.-5:00 p.m.
�� (651)265-1999 22735223 49507 02/10/14 $919.80
Toil Free: 1-877-655-2669
�• •� � . �
TTY: 1-800-627-3529
$899.34 $104.00 $20.46
To pay online, log on to www.healthpartners.com
...- � - .
� NANCY R DANA . (, HEALTHPARTNERS
° 748 GOODRICH AVE ' (' �J�(
� � SAINT PAUL MN 55105-3343 ��(� � P.O. BOX 77026
� �� \ MINNEAPOLIS MN 55480-7726
N �00 000049507 7 022735223 4 009198� 3 1 8 � O �
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To pay online,log on to www.healthpartners.com.to pay via phone call 651-265-1999 or,to mail your payment,please detach and return the above portion with your payment.
Account Number Account Name Statement Date Pay This Amount
49507 NANCY R DANA 01/23/14 $104.00
Service Insurance Patient patient
Date Patient Name Location Description Charges Payments/ Payments/ Due
Adjustments Adjustments
Balance Forward from statement dated 899.34
12/23/13
01/03/14 Nancy Dana HS SPECIALTY CTR II Radiology Services;Radiology 41.00
Provider:KODL,CHRISTOPHER T
Insurance Payment 20.54
Deductible 20.46
MESSAGE: '
A payment plan has been set-up on your account.The detaiis of that agreement were included in the Please Pay This Amount �
payment agreement letter we sent you. Mail payment 10 days prior to the due date to ensure that
your payment is properly credited to your account. ��QL�.QQ
PLEASE DO NOT ATfACH CORRESPONDENCE WITH YOUR PAYMENT Page 1 of 1
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�11� CHECK CARD USING FOR PAYMENT
■a"�■ HealthPartners� ❑ D��E� ❑ �'�� y❑jgp F7�RE55�ERIC
, � y ' MASTERCAND DISCOVER
CYZ�ZGS CARD NUMBER
P.O.BOX 77026 '
MINNEAPOLIS MN 55480-7726 SIGNATURE E%P.DATE
� . � . �. . � �
For Biiling Questions: Office Hours-8:00 a.m.-5:00 p.m.
� �, (651}265-1999 22644328 49507 01/10/14 $1,003.34
Toll Free: 1-877-655-2669
,. .� � �
1TY: 1-800-627-3529
$883.22 $104.00 $120.12
To pay online, log on to www.healthpartners.com
...- .�, . - .
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NANCY R DANA �i � / � EALTHPARTNERS
° < 748 GOODRICH AVE �� , r� 1 i I� j�p,p, gOX 77026
M � SAINT PAUL MN 55105-3343 �i t t'� �� ��"� MINNEAPOLIS MN 55480-7726
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00 00�049507 7 022644328 1 0100334 2 1 8
To pay online,log on to www.heaithp�rtners.com,to pay via phone call 651-265-1999 or,to mail your payment,please detach and return the above portion with your payment.
Account Number Account Name Statement Date Pay This Amount
49507 NANCY R DANA 12/23/13 $104.00
Service Insurance Patient patient
Patient Name Location Description Charges Payments/ Payments/
Date Adjustments Adjustments Due
Balance Forward from statement dated 883.22
11/24/13 •
11/25/13 Nancy Dana HS SPECIALTY Radiology Services;Shoulder X-Ray 89.00
CENTER 435
Provider:GREER,STEVEN A
Insurance Payment 28.94
Deductible 60.06
12/09/13 Nancy Dana HS SPECIALTY Radiology Services;Shoulder X-Ray 89.00
CENTER 435
Provider:GREER,STEVEN A
Insurance Payment 28.94
Deductible 60.06
MESSAGE:. ;
A payment plan has been set-up on your account.The details of that agreement were included in the Please Pay This Amount �
payment agreement letter we sent you. Mail payment 10 days prior to the due date to ensure that
your payment is properly credited to your account. �104.��
PLEASE DO NOT ATTACH CORRESPONDENCE WITH YOUR PAYMENT Page 1 of 1
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����„�� CARD NUMBER
P.O.BOX 77026 L
MINNEAPOLIS MN 55480-7726 SIGNAiURE �'�A�
For Billing Questions: Office Hours-8:00 a.m.-5:00 p.m.
� : • . � � �. . � .
��;' "•� (651)265-1999 22558889 49507 UPON RECEIPT $987.22
Toli Free:1-877-655-2669
7TY: 1-800-627-3529 � � � �
$867.10 $0.00 $120.12
7'o Pay onfir�e, �ag on�o wtiv��.health�ar�ners.co�
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o NANCY R DANA HEALTHPARTNERS
� �,< 748 GOODRICH AVE � �. I'.O. BOX 77026
Q SAINT PAUL MN 55105-3343 MINNEAPOLIS MN 55480-7726
N
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00 �00049507 7 D22558889 6 0098722 2 1 8
To pay cnline,log on to�,vvnv.healtnoartners.com:to pay via phone call 651-265-1999 or,to mail your payment,piease detach and retum the above portion with your payment.
Account Number Account Name Statement Date Pay This Amount
49507 NANCY R DANA 11/24/13 $987•22
insurance Patient patient
Sennce patient Name Location Description Charges Payments/ Payments!
Date Adjustments Adjustments Due
Balance Forvvard from statement dated . 867.10
10/22/13
10/30/13 Nancy Dana HS SPECIALTY Radiology Services;Shoulder X-Ray 89.00
CENTER 435
Provider:GREER,STEVEN A
Insurance Payment 28.94
Deductible 60.06
11/11/13 Nancy Dana HS SPECIALTY Radiology Services;Shoulder X-Ray 89.00
CENTER 435'
Provider:GREER,STEVEN A
Insurance Payment 28.94
Deductible 60.06
MESSAGE:
You are receiving this statement because there is an overdue patient baiance.Please pay the Please Pay This Amount
amount noted in the lower right hand comer.
$987.22
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______ .�_________ ___ ______ ._._._.._.__ __ �
��Z���� ciwo Numa�
P.O.BOX 77026
MINNEAPOLIS MN 55480-7726 SIGNANRE E%D.DATE •
For Billing Questions: O�ce Hours-8:00 a.m.-5:00 p.m.
� : , � � �. . � �
;�_, (651)265-1999 22468774 49507 UPON RECEIPT $867.10
Toll Free: 1-877-655-2669
.• •. � .
TTY: 1-800-627-3529
$0.00 $20.54 $867.10
To pay online, log on to www.healthQartners.com
,,�. . •
m NANCY R DANA HEALTHPARTNERS
° • 748 GOODRICH AVE P.O. BOX 77026
� � SAINT PAUL MN 55105-3343 MINNEAPOLIS MN 55480-7726
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DO 000049507 7 022468774 9 �086710 1 1 8
-- -_ - . _ _ __ __
To pay online,log on to tivw�v.healthpartners.com to pay via phone call 651-265-1999 or,to mail your payment,please detach and return the above portion with your payment.
Account Number Account Name Statement Date Pay This Amount
49507 NANCY R DANA 10/22/13 $867.10
Senrice Insurance Patient patient
Date Patient Name Location Description Charges Payments/ Payments/ Due
Adjustments Adjustments
10/15/13 Nancy Dana HS SPECIALTY CENTER JOSLYN SLING 13.00
435
Provider.GREER,STEVEN A
Insurance Payment 0.25
Deductible �2•�5
10/15/13 Nancy Dana HS SPECIALTY Surgical Services;Surgical/Nonsurgica 754.00
CENTER 435
Provider.GREER,STEVEN A
Insurance Payment 173.42
Deductible 580.58
10/15/13 Nancy Dana HS SPECIALTY Evaluation&Management Services; 275.00
CENTER 435 Office Vsit
Provider:GREER,STEVEN A
insurance Payment 61.29
Deductibie 2�3'��
10/15/13 Nancy Dana HS SPECIALTY Radiology Services;Shoulder X-Ray 89.00 _ � _ _ __ __ __
-- - __ -_. _ ____ _ . ._-CENTER- 8 - ---_
-- -
- - ----- ----- - - -- -----—
Provider:GREER,STEVEN A
Insurance Payment 28•�
Deductibte 60.06
MESSAGE:
Please Pay This Amount
$867.10
�
=E���� Regions�Iospital8 'VACCOUNT N0. STATEMENT DATEV
HealthPartners Family of Care 49507 11/0712013
M11AIL STOP 12A03A-6A0 JACKSON ST.•ST.PAUL,AiN 55101 . AMOUNT NOW DUE PAYMENT DUE DATE
$1,087.17 11l25/2013
Customer Service Phone: 651-254-4791
Thank you for using Regions Hospital's facilities for your services. We expect payment in full now unless you call
' to make other arrangements. Please see the important information on the reverse side of this statement.
DATES PATIENT AND SERVICES PREVIOUS pMTS 8 ADJUST YOUR BALANCE
BALANCE
Admit Nancy Dana 100572621
10l08/2013 Emergency Room
Discharge New Charges$2,00220
10/OS/2013 Previous Balance $0.00
Insurance Pmts/Adj $-915.03
Personal Pmts/Adj $0.00
Balance Due $1,087.17
Total Patient Liability $1,087.17
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Please detach and return bottom portion with your payment and write your account number on your check.See reverse side for important information.
� PATIENT ACCOUNT STATEMENT iF PnviNC sv MnsTertcarto,DISCOVER,VISA OR AMERICAN EXPRESS,FILL OUTBELOW.
CHECK CARD USING FOR PAYMENT
��_�,,-,,'r�' �� ❑ ❑ �� ❑ ❑
m� t±n p 1'�t;� I MASTERCARD � DISCOVER I,� VISA h`x"� AMERICAN EXPRESS
A���� �a ��'yT �+ 9 e�1
� x�,q�y�G ���,rg1O�S 1�O�7�Jl�6�a CARD NUMBER SIGNATURE CODE EXP.DATE
FIQL1ItiJPC�YtYlCrS FQY7116y Of CQrE S�GNATURE AMOUNT PA�D
MAI�STOP'12403A•640 JACKSON ST.•ST.PAUL.MN 55101 30696
ACCOUNT NO. " STATEMENT DATE
RETURN SERVICE REQUESTED 49507 11/07/2013
, -AMOUNT NOW DUE' PAYNIENT DUE DATE '
�y PAGE: 1 of 1 $1,087.17 11/25/2013
�� 6535i6D(PC2
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NANCY R DANA REGIONS HOSPITAL
748 GOODRICH AVE PO BOX 77093
SAINT PAUL, MN 55105-3343 - MINNEAPOLIS, MN 55480-7793
:����: Regions Hospital° �
_ , HealthPartners Family of Care t �
Regions Hospital•Patient Accounting Office
6�0 Jackson St.Mail Stop 12403A•St Paul,MN 55101 30696
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�1955 0101
02/08/2014
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NANCY R DANA
748 GOODRICH AVE
SAINT PAUL, MN 55105-3343
Re: Nancy R Dana
Account # 49507
Visit ID 100572621
Account Balance: 1,087.17
Regions Hospital has filed claims to the State of Minnesota Department of Revenue for the unpaid
medical bills listed above. Minnesota Statutes 270A.01 through 270A.09 authorize us to submit
these hospital expenses for payment through the Revenue Recapture Program. These claims will be
in effect for six years until resolved.
At the time of payment for income tax refunds, renter credits, lottery winnings or property tax
refunds, the State of Minnesota will send payment to Regions Hospital, to be applied to the
listed accounts.
You have the right to contest the validity of this claim and to have a hearing if necessary.
While the following are examples of justifiable reasons to contest the claim validity, these
would be subject to review without guarantee the claims will be cancelled:
Income below the minimum guidelines as established by the State of Minnesota
Medical Assistance coverage at the time of service
Current coverage in the Minnesota Family Investment Program
Currently receiving Social Security Disability Income (SSDI)
Incorrect Social Security Number for the Responsible Party
If you wish to contest the claim, you are required to advise us in writing of the reason within 45
days of this letter. Please address correspondence to Regions Hospital Revenue Recapture, Mail
Stop 12403A, 640 Jackson Street, Saint Paul MN 55101.
This is your only Notice of this claim. Please call our office if you have any questions regarding
this action.
Regions Hospital Patient Accounting
Customer Services
651-254-4791
RH/12200
30696'TZUI5ZJZ5000261 1�1111111�161�II�111�111111111611YII�11��11�19pp� 613784(PCA)
� PATIENT ACCOUNT STATEMENT� 30696"TZWOH9QG7000682 I 1
NANCY R DANA PAGE: 1 of 1
:�I1�: Regions Hospital• ACCOUNT NO. STATEMENT DATE
HealthPartners Family of Care 49507 02/10/2014
MAIL STOP 12403A•640 JACKSON ST.•ST.PAUI,MN 55101 AMOUNT NOW DUE PAYMENT DUE DATE
$132.43 02/28/2014
Customer Service Phone: 651-254-4791
Due to the past history on your account with us, we expect payment in full this month to avoid further collection
action. Otherwise, please cail our office immediately to make formal payment arrangements.
DATES PATIENT AND SERVICES PREVIOUS pMTS&ADJUST YOUR BALANCE
BALANCE
Admit Nancy Dana 100651995
01/03/2014 Outpatient
Discharge New Charges$327.00
01/03/2014 Previous Balance $0.00
Insurance Pmts/Adj $-194.57
Personal Pmts/Adj $0.00
Balance Due $132.43
Total Patient Liability $132.43
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Please detach and return bottom portion with your payment and write your account number on your check.See reverse side for important information.
�
� PATIENT ACCOUNT STATEMENT � IF PAYING BY MASTERCARD,DISCOVER,VISA OR AMERICAN EXPRESS,FILL OUT BELOW.
CHECK CARD USING FOR PAYMENT
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_=11r_ ^" ❑ ❑ ❑ AMERIDW ❑
„ •+A 1� �-� MASTERCARD � DISCOVER �� VISA °�" AMERICAN EXPRESS
:/��1: R�g1Ol1S HOSpilCil ., CARD NUMBER SIGNATURE CODE EXP.DATE
HealthPartners Family of Care SIGNATURE AMOUNTPAID
MAIL STOP 12403A•640 JACKSON ST.•ST.PAUL,MN 55101 30696
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RETURN SERVICE REQUESTED 49507 I 02/10/2014
;: ��H_ .n ue_��� '.i�� 'u�i .�..
���� PAGE: 1 of 1 $132.43 02/28/2014
653546D(PC2)
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NANCY R DANA REGIONS HOSPITAL
748 GOODRICH AVE PO BOX 77093
SAINT PAUL, MN 55105-3343 MINNEAPOLIS, MN 55480-7793
0000000495070000000132436
ST PAUL RADIOLOGY PA � �
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Pay Oniine � Update Info
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Patient: NANCY DANA Referred By: ROBERT LEFEVERE
Services Were Provided at: REGIONS HOSPITAL
10-08-13 73030 1 X-RAY EXAM OF SHOULDER 30.00 DENIAL 17.14
10-16-13 FILED PRIMARY TO MEDICA(ME226)
10-25-13 FILED SECONDARY TO HEALTH PARTNERS(HE109)
11-21-13 Commercial Payment 0.34
11-21-13 Commercial Non Allowed 12.52
11-21-13 GUARANTOR RESPONSIBILITY DATE(ChargelD:2849044)
The insurance carrier noted above denied payment of your claim and indicated that the amount due is now your responsibility. If you have questions about your
benefits or your EOB please call your insurance company.Please remit total amount due immediately or contact us to make payment arrangements.
Current 31-60 Days 61-90 Days Over 90 Days PAYMENT DiTE: BALANCE DiTE:
$17.14 $0.00 $0.00 $0.00 Upon Receipt $17.14
---- — ST PAUL RADIOLOGY PA
WE HAVE,FILED�YOUR INSURANCE YOU ARE NOW� ; p0 BOX 812
RESPONSIBLE FORTHE 6ALANCE-OF:THIS ACCOUNT 5�:�� -��s INDIANAPOLIS, IN 46206-0812
877-556-0695
When you provide a check as payment, you authorize
us either to use information from your check to make a
one-time electronic fund transfer from your account or to
process the payment as a check transaction.
Patient Statement For: NANCY R DANA Statement Date
12/05/13
Account Number
468479-QMPS1-13
STATEMENT
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
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