Ibarra ;�
NOTICE OF CLAIM FORM t�o the City of Saint Paul, Minnesota
�
Minnesota State Statute 466.05 states that "...every person...who claim.c damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of cnmpensation 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 ezplain your 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 J� (��r p � Middle Initial �-- Last Name�� �(`�
Company or Business Name �F C'_�I\/��
Are You an Insurance Company? Yes� If Yes,Claim Number? ►I AV n C 'A�1k
Street Address p � ��Y�� '� �
City �+ �V� State ��'1 � Zip Code �'
Daytime Phone (�s� )�-g�Y Cell Phone(j�51 );�'�L� -_�,�Evening Telephone(� p�-1-�Q�1
Date of Accident/Injury or Date Discovered ;�c�J�� Time / � am/pm
Please state,in detail,wha.t occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved andlor responsible for your damages.
..� �JQ� Wca►��►��ta �r�, �.� r�Xn��� ��.��� r��������t��, ,`�; ���� E � -��i ( �li�rrl �t���,� �'�� ;r�� �� �
�, � - � � �' � -
��;t%G ���4�;+� i- 4� �F� l«�l���r �i�_�-c�11 �c��' ��1 �t,�( T �� a, 1' t�' ��'�� t�� ,�, ,�:c ��Cri� �
,�-�, ; ���fs `<<� xa - �;: : �i,���{;� oU�=S r� c� 4 �
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 �I 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 WII�L 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
and/or receipts for the repairs; detailed list of damage�items
O Injury 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 ha�rdling of your claim.
All Claims—nlease comulete this section
Were there witnesses to the incident? es No Unlrnown (circle)
Provide their names, addresses and telephone numbers: i :J" �1` �:�" `1 �� j
('. �G'P'�S 't n x-r- -3-,� _.c ���r iF.�
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Were the police or law enforcement called? Yes � Unlrnown (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 landmark, etc. Please be as detailed as possible. If necessary,attach a diagram. 30���.5�ly G�/Q�"��;
� Gl!})(�_TS /�'I l�U� �lj'k C�3�Ot7Jvun �}V�'
Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim
to your satisfaction. �n {np�(� r��
Vehicle Claims—please complete this section 1S(check box if this section does not applv
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
Injurv Claims—please complete this section ❑ check box if this section does not applv
How were you injured? ? �;�r G.-� e ' - ° ^
1"f., �\��'ii;G 'C...;1 i :a,�,1 ��, � �Cf ':� ,:e , i�_�—�'OC� 5�11��Y`L=? ���' ��r}".•'
1!,� . � �
What part(s)of your body were injured?� /2iG h t- ,'f'.�i-
Have�you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? � '�'�- . U (provide date(s))
Name of Medical Provider(s): j "
Address Telephone
Did you miss work as a result of your injury? Yes `N ,
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
�I Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stati�zg that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed J:�^= `-�
� Print the Name of the Person who Completed this Form� ��GL�'f�f�'l�l � Q
Signature of Person Making the Claim: e
�� Revised February 2011
I
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•� -s e � -x s � 8 �
:ii;: Regions Hospital� ❑ CHEC❑K CARD USING FOR PAY�NT ❑
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Regions Pharmacy d�R �`.� ��! �s� A�a�a.
250 14th Ave E ��N�R a�ou�r
Sartell, MN 56377 ��n,�------------ �.a,.�
STATEMENT DATE BRFANCE DUE CHART NUNBER
'` 04/14/14 $31.5$- - 31728831
�
SHOW AMOUNT PAID HERE
• ss� s - �
^ BETUEL IBARRA Regions Pharmacy
$ 283 MORTON ST E Mail Stop 11502G
" � SAINT PAUL MN 55107-3014 640 Jackson St
� St. Paul, MN 55101
❑ Please chedc box if above address is incorrect or insurance informa6on
has changed,and indicate d�ange(s)on reverse side. Please detach and retum top portion with your payment
DATES PATIENT CHART CASE CHARGE EXPLANATION AMOUNT DUE
NUMBER
,3131/2014 BETUEL _ . 31728831 4 SM NATURALrLAXATNElST0.,8.6-50 „._. ,_ w. _.. :,�..-._� .- $���_
, _ � _..aF� . ... � . w ,
3/31/2014,BETUEL _ 31728831, _ ENOXAPARIN SODIUM 40MG/0.4ML S „ $7.00
r�.� �.�� � , x a _ �. , �
q . _ � ., - ;
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3131/2014,.BETUEL,_ s 31728831. _,. . , OXYCODONE HCL 5MG TABS_ . r.,._r ..�.F .� ..._ - �7.�_
y r ��. � �_ _. _
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,
3/31/2014�BETUEL _ , r. . 31728831_ HYDROX1fZINE HCL 25MG TABS _ _.__ � _ ._..; _. _ .__ ___ _... _._ � . _ _ $7.��
� _. . _. . �,_
�,- � � t�= „ ,, . �. ;., .� - � . �
_3/31/2014 BETUEL 31728831 MAPAP 325MG TABS .. : l_. $2.59
_ . ___ s , . .,. ,., .. -.
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, -� . :. . .. . . � �._ � ,
Past Due Past Due Past Due
Patient Current 3fl Da 60 Da 90 Da ��a��
BETUEL $31.58 $0.00 $0.00 $0.00 $31.58
; MESSAGES � = ' " � �3'I .SH
� Now you can make your payment ontine at j
� https://www.prosource-epay.comlregions-hospital �
Or contact us via telephone at 866-511-4297 � �.Regions Pharmacy
' • Maii Stop 11502C
, � 640 Jackson St.
-� -��" Regions Hospital° ��Pa"i'MN 55101
� :��1+: Phone:866-511-4297
ST PAUL FIRE AND SAFETY
PO BOX 18157
ST. PAUL, MN 55118
RETURN SERVICE REQUESTED
STATEMENT DATE PAY THIS AMOUNT ACCT.#
04/18/2014 $495.00 SP409300
PHONE: (651) 450-7133 OR 1-888-424-6944
Federal Tax ID: 41-6005521 SHOW AMOUNT �
PAID HERE
� ��- •
BETUEL IBARRA ST PAUL FIRE AND SAFETY
283 MORTON ST E PO BOX 18157
SAINT PAUL, MN 55107-3014 ST. PAUL, MN 55118
�������I���I��I����������������n�nl�l���l�������1�'����I������� O 0 2 1 2 ����II����I���III�n����I�������I��II�I����������l�l����������1��
O Please check box if above address is incorrect or insurance
information has changed,and indicate change(s)on reverse side. � PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
Patient Number: 79632309 Caller: 911 CALL UPiN lf SLF000
Call Number: SP409300 From Location: 328 CESAR CHAVEZ ST
Patient Name: BETUEL IBARRA To Location: REGiONS HOSPITAL
Insurance: BLUE CROSS UPA848358345
Date Of Call: 03/30/2014 Reason(s) s59.a
Call Time: 09:28 AM For 719.49
Transport 7s0.96
DESCRIPTIC}N OF CHARGE HCPL ' QUAN7ITY UNIT PRICE AMt3UNT
EMERGENCY AMBULANCE SERVICE A0427 1.0 1595.00 1595.00
MILEAGE A0425 2.7 16.00 43.20
Total Charqes 1638.20
***This bill is for your ambulance service. Please call our office or visit our wesite
below for payment arrangements and questions a"o�� your bi1� . P��ass slsc srr-re.'e*'� --- --
side of this statement. Thank You.***
DESCR1PTlON OF PAYMENT ' RE�EIPT ' PAYMEhIT�ATE 'AMOUNT '.
BC /EFT - BLUE CROSS 04/15/2014 1143.20
`���� �� � � ���Y� r
----------
L` • Z �r Total Credits 1143.20
C1
PLEASE PAY THIS AMOUNT y $495.00
i
PO BOR 18157 SAINT PAUL, l�i 55118
www.emspatientpay.com
f12 01101 R654-341 F01 L0005747 FORM=F-0
iF ANY OFTHE FO�.LOWiNG FiAS CHANGED SINCEYOUR LAST STATEMENT, PLEASE INQICATE . . .
Your Name __ Marital Status
Street _ _— Home Phone __—.__
City __ ___ State ------ --- - ZiP ---
Employer __________--__ __ —_____ ___ Business Phone
Employer Address ______ _______ ---_ --
Insurance C,�mpany _._--.—_____ Contract No. _
Ins. Compa!�y AadrESS _ _ ___ ins. Policy No. —._
Other Informa±ion --------------
Being that the 911 Ambuiance service files your Insi�rance claim, it is necessary for us to obtain your signature on
fileto be used fcr record and auditing purposes. Anyfuture claims may be submitted underyoursignature.
MEDICARE NUMBER:
IN�URAI�CE INFORiVlATION
COiVI�'1�NY:
ADDR�SS�
POLICY#�_�_ � ��
GROIiF' #
PHON� �#
Thank yota for y°c��r cooperatian.
INSURANC�WAIVtR: I request that paymznt of autharized Medicare and/or insurance benefits be made to the
911 Ambulance service for any services furnished to me by that supplier. I authorize any holder of hospital or
medical infr�rmation about rne to be released to the He�lth Care Financing Administration and /or my insurance
carrier, and their agents, any other information needed ta determine these benefits payable for related services. I
permit a copy of thi�authorization to be used in place o`the original. I understand this authorization may be used
by the supplier for all services in the future until such time I revoke this in writing.
SIGNATURE:
RELATiONSHI� 70 PATIENT:
DATE: