SCSC015512 - Judgment Against Sac City Couple in The Amont $942.28 PDF

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT FOR SAC COUNTY

SMALL CLAIMS DIVISION
L. F. NOLL, INC.
705 DOUGLAS STREET, SUITE 344
SIOUX CITY IA 51101
PLAINTIFF
ORIGINAL NOTICE AND PETITION

FOR A MONEY JUDGMENT
VS
DAVID L. HEDBERG
628 OAK ST
SAC CITY IA 50583
NO.
AMYL. HEDBERG
628 OAK ST
SAC CITY IA 50583
DEFENDANT(S)
To Defendant(s):
1. You are notified that the above-named Plaintiff demands of you the amount of $942.28. This claim is
based on the value of goods and/or services supplied by the following persons or businesses in the amounts
indicated below. Said claims are assigned to Plaintiff.
CREDITOR
LORING HOSPITAL
PRINCIPAL
$920.46
PRE-FILING INTEREST
$21.82
2. Judgment may be entered against you unless you file an Appearance and Answer within 20 days of the
service of the Original Notice upon you. Judgment may include the amount requested plus interest and court
costs.
3- You must electronically file the Appearance and Answer using the Iowa Judicial Branch Electronic
Document Management System (EDMS) at https://www-iowacourts.state.ia.us/EFile, unless you obtain from
the court an exemption from electronic filing requirements,
4. If your Appearance and Answer is filed within 20 days and you deny the claim, you will receive
electronic notification through EDMS of the place and time of the hearing on this matter.
5. If you electronically file, EDMS will serve a copy of the Appearance and Answer on Plaintiff(s) or on the
attorney(s) for Plaintiff(s). The Notice of Electronic Filing will indicate if Plaintiff(s) is (are) exempt from
electronic filing, and if you must mail a copy of your Appearance and Answer to Plaintiff(s).
6. You must also notify the clerk's office of any address change.
-^
$SSICA R. NOLL AT0008873

705 Douglas St., Ste 502
Sioux City IA51101
Phone (712) 224-2675
Fax (712) 252-4497
jrn@decklaw.net
ATTORNEY FOR PLAINTIFF
0002927755
OCTOBERS, 2014

L. F. NOLL, INC.
PLAINTIFF
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
VS
NO.
DAVID L. HEDBERG
AMY L. HEDBERG
For Defendant: AMY L. HEDBERG
DEFENDANT(S)
1. I, T. L. Noil, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose claim(s) is (are)
shown in the attached statement(s). I have personal knowledge that the attached statement(s) is (are) a true
copy of the original creditor's records showing the balance due is true and correct. I further state that the sum
of $942.28 is the balance due and owing as of OCTOBER 8, 2014 from Defendant(s) to Plaintiff(s) and any
interest amount owing is accurately stated in the Petition and Original Notice.
2. I further state that Defendant, AMY L. HEDBERG, resides at 628 OAK ST SAC CITY IA 50583. is employed
at
, and Defendant's occupation is
.
3. Check A, B, or C for Defendant:
A. X Defendant is not in the military service of the United States government, I have verified this fact
by (check one):
X Checking the Defense Manpower Data Center (DMDC) (requires name and SSN or name
and date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.do.
Contacting Defendant who informed me, or
Regularly seeing Defendant and believing Defendant is not active in the U.S. military.
OR
B. O I have investigated, and I am unable to determine whether or not Defendant is in the military
service of the United States government.
OR
C- O Defendant is in the military service of the United States government.
4. I also state to the best of my knowledge (check one):
Defendant O is X is not under a disability or confined in any reformatory, jait, or penitentiary.
I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are true and
correct.
L.F. NOLL, INC.
T. L W&tL, VICE PRESIDENT

705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0002927755
NOTICE OF RIGHT TO CURE DEFAUI

NCS, INC DBA

NOLL COLLECTION SERVICE
70S DOUGLAS STREET, SUITS 344
?0 BOX 593
SICUX CITY IA 511Q2-C593
(712)252-G583
RE:
(LISTED BELOW IF MORE THAN ONE}

TOTAL, AMOUNT DUE: S 942. 2 8
AMOUNT IN DEFAULT: $942.28
You are now in default on this credit transaction. You have a right to
correct this default within 20 days. If you do so, you may continue with the
contract as though you did not default.
YOUR DEFAULT CONSISTS OF:
FAILURE TO PAY AS AGREED
Correct this default by:
Paying the ar.our.t in default, $942.28 to

Nell Collection Service, agent for the above
creditor.
I;! you do net correct this default within 2C days, we may exercise our
rights against you under the law.
If you default again in the next year, we may exercise our rights without
sending you another notice like this one. If you have any questions, write or
Telephone p r orr.p 11 y -
THIS IS AN ATTEMPT TO COLLECT A DEBT,

ArCY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
Client Ref No
Q RING
HO3P- TA
_,
HO 3 PITA ^
O RING HCSPI TA Li
-0 RING HOS?I TA L
.0RING HOSPITA L
0RING-
541558
544419
546779
546013
547699
Principal
30 .29
27 .26
27 .26
33 .66
27 .06
Interest
.47
.49
.41
. 61
.40
Other
.00
.00
.00
.CO
. CC
30 . 76
2 7. 75
27 . 67
34 .21
2 7.46
Client Ref No
. _ .LSn
> - _ - rv
;RING HOSPITAL 564152

;RING HOSPITAL 565230
-OPING HOSFITA
Principal
27.26
29.96
24.04
488.40
31.92
83.77
29.96
29. 96
29.66
:her
.41
.96
.65
12.31
.74
2.63
.60
.57
.51
_otai
GO
00
00
00
LORING HOSPITAL
ATTN JAN WISEMAN
211 HIGHLAND AVE
S~C CT""Y ~A 5C583
_
The above debtor refuses to cooperate. We recommend further action, in
order to enforce collection. Before our attorney can proceed, we will require:
ompletion of the assignment at the bottom cf this page.
opy cf the itemized statement showing balance cue 'if net
revicusly provided)
ASSIGNMENT FOR PURPOSES OF SUIT

consideration, receipt hereby acknowledged, the undersigned hereoy
assign, transfer, ana set over unto L.F. Noll, Inc. that certain claim against
r> -.'iT ;" r* -j
u
i-j^-i
n T7
SL r^
uDDIT:iur\r*
thereon; and does hereby authorize said assignee to do and perform a".i acts
necessary for collection; commencement of suit in the name of the assignee,
settlement, adj ustn.er.t, compromise or satisfaction of said claim. Assignor
hereby certifies that said claim, is justly due and owing and warrants
compliance with requirements of the Iowa Consumer Credit Code as well as
disclosure ana other provisions of truth in lending, and that same is free of
set~offs and other ciefenscs.
2Ci!_
E-FILED 2014 OCT 14Lorin#

8:20 AMHospital
SAC - CLERK OF DISTRICT
COURTNO.
TELEPHONE
DOCTOR
BISSELL,
BENJAMIN
PAGE
21 1 Highland Ave Sac City, IA 50583
POLICY NUMBER
INSURANCE COMPANY
07 BLUE CROSS
05
140
SELF -PAY
24964
POLICY HOLDER
PEV810415271
HEDBERG
111111111
HEDBERG
PATIENT
TYPE
OAK STREET
SAC CITY IA
M^H*
MED. REC. NO. / ADMISSION NO.

24964
ADMISSION DATE DISCHARGE DATE
22
50583
03/10/14
BIRTHDATE
03/10/14
DESCRIPTION
MMM
^
^B
RADIOLOGY, TI:CH
AGE
^^MfWftra^^^l
AMOUNT
40 . 603
PROFESS
569372
SEX
CPT
CHARGE
^^HB^P^^^^^^^^^^^^
RADIOLOGY,
03 -10
QUANTITY
/^/Ol M 12
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS' DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
CHARGE
DATE
CODE
03 -10 IMBMi
569372
DAVID
MM* HSDBERG
DAVID L HEDBERG
PLAN
.PATIENT NAME
GUARANTOR
628
" / \ \ \T
03/18/14
NO.
712-210-3017
f~^~*?
BILLING DATE
EXTENSION
40.60
DEPT TOTAL
40.60
DEPT TOTAL
148 .50
148 . 5 0 0
148 . 5 0
SUMMARY OF CHARGES
RADIOLOGY,
PROFESSIONAL
RADIOLOGY,
TI ;CH
TOTAL CHARGE*
40.60
148.50
189.10
BALANCE
189.10
4^.W^
î Cx
A/ 1 /)Cs
**"Q
\o
/**
OJ *-~
10
-^
f^
^sr
rtTV
"X
^s
^^
.
DOCTOR
E-FILED 2014 OCT 14 8:20

AM SAC
- CLERK OF DISTRICT COURT
Lorm#
Hospital
TELEPHONE NO.
BILLING DATE
03/04/14
MED. REC. NO. / ADMISSION NO:

PAGE
INSURANCE COMPANY
JO.
BLUE CROSS 140

SELF-PAY
POLICY NUMBER
PEV810415271
111111111
24964 /
POLICY HOLDER
HEDBERG, DAVID
HEDBERG,
MED. REC. NO. / ADMISSION NO

24964 /
568823
HEDBERG
PATIENT
TYPE
628 OAK STREET

SAC CITY IA 50583
22
02/24/14
BIRTHDATE
02/24/14
02-24
02-24
DESCRIPTION
QUANTITY
CHARGE
ELB LT COMPJL MIN 3 V

RADIOLOGY, JPROFESS
40.603
ELB LT COMPJL MIN 3 V

RADIOLOGY, TECH
148 .500
CRT
DEPT TOTAL
DEPT TOTAL
SUMMARY OF CHARGES
RADIOLOGY, IPROFESSIONAL
RADIOLOGY, TECH
40.60
148.50
TOTAL CHARGES
189.10
SEX
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
CHARGE
CODE
568823
PLAN
PATIENT NAME
GUARANTOR
DAVID L HEDBERG
DATE
EXTENSION
712-210-3017
BISSELL, BENJAMIN
AGE
12
PAY LAST
BALANCE
AMOUNT
40.60
40 . 60
148.50
148 .50
189.10
BALANCE
I3.MO
Cfl
TELEPHONE
E-FILED 2014 OCT 14Lorm#
8:20 AMHospital
COURTNO.
MARCZEWSKI, L. J.
712-210-3017
DOCTOR
BILLING DATE
02/28/14
PAGE
24964 /
211 Highland Ave Sac City, IA 50583
INSURANCE COMPANY
O.
EXTENSION
POLICY NUMBER
BLUE CROSS 140

SELF-PAY
IPEV810415271
111111111
POLICY HOLDER
PLAN
HEDBERG, DAVID
HEDBERG,
MED, REC. NO, / ADMISSION NO,

24964 /
563707
PATIENT NAME
UARANTOR
HEDBERG
DAVID L HEDBERG
PTYPENT
628 OAK STREET

SAC CITY IA 50583
22
568707
02/20/14
02/20/14
iUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
CHARGE
CODE
DESCRIPTION
02-20
QUANTITY
CHARGE
CRT
RADIOLOGY, PROFESS
40. 60
40.60
DEPT TOTAL
148 .50
148 . 5 0 0
02-20
RADIOLOGY, T
SUMMARY OF:CHARGES
RADIOLOGY, PROFESSIONAL
RADIOLOGY, TECH
40.60
148.50
TOTAL CHARGED
189. 10
BALANCE
AMOUNT
DEPT TOTAL
40 .603
148.50
189.10
AM SAC
- CLERK OF DISTRICT COURT
DOCTOR E-FILED 2014 OCT 14 8:20
LoringHospital
TELEPHONE
LEIGH,
HUGH
<>-v
BILLING DATE
12/05/13
NO.
PAGE
f\ \
07
BLUE CROSS
05
SELF -PAY
'. PEV810415271
^^(^78 87
GUARANTOR
OAK
30580
POLICY HOLDER
HEDBERG,
DAVID
HEDBERG,
UMft
SAC CITY IA 5 0 5 8 3
PATIENT
TYPE
30580
11 11/29/13
BIRTHDATE
11/29/13
DATE
11-29
iÂ
DESCRIPTION
QUANTITY
1
CHARGE
EMERGENCY RM PROFE
11-29
MM*
11-29
11-29
11-29
^t
IM^MM^
IBB ^^^îBBk
V ^Mfr '
CPT
SEX
AGE
t
AMOUNT
145. 00
DEPT
TOTAL
DEPT
TOTAL
145. 00
405.000
EMERGENCY ROOM
565132
^^H-jffKlSlSf^^^l
145 . 0 0 0
^^
^/^/07 F
CHARGE
CODE
565132
I.VV HEDBERG
STREET
PLAN
PATIENT NAME
DAVID L HEDBERG
628
>*
POLICY NUMBER
140
EXTENSION
712-660-3825
INSURANCE COMPANY
NO.
4 0 5 . 00
4 0 5 . 00
18 . 0 0 0
17.720
17.72
44 . 0 0 0
44 . 00
LABORATORY
18.00
79. 72
DEPT TOTAL
SUMMARY O^ CHARGES
EMERGENCY RM PROFESSIONAL
145.00
EMERGENCY RpOM
405.00
LABORATORY
79 .72
TOTAL CHARGES
629.72
BALANCE
629.72
Bern
i5D.fr?
^
^
f

NCS, INC DBA
'A Professional Debt Collection Service Since 1965'
SIOUX CITY, IA 511C1
(712) 252-0583
DATE: AUGUST 4, 2C14
014345
ATTENTION:
RE: DAVID LEE KEDBERG
541558
S747.ll
10/25/12
order to enforce collection. Before our attorney can proceed, we will require
* Completion of the assignment at the bottom of this page.
* Copy of the itemized statement showing balance due (if not
previously provided)
* If the original account is a contract or note, we must have the
original.
Please return promptly. Court costs will be advanced on your behalf.
Do not accept payments or make arrangements, without calling us first.
THANK YOU FOR YOUR COOPERATION

For valuable consideration, receipt hereby acknowledged, the undersigned hereby
assign, transfer, and set over unto L.F. Noll, Inc. that certain claim against
DAVID LEE HEDBERG
AMY HEDBERG
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of
3747.11
lawful interest
thereon; and does nereby authorize said assignee to do and perform all acts
settlement, adjustment, compromise or satisfaction of said claim. Assignor
hereby certifies that said claim is justly due and owing and warrants
compliance with requirements of the Iowa Consumer Credit Code as well as
disclosure and other provisions of truth in lending, and that same is free of
set-offs and other defenses.
, 20/*/- .
Dated this
Name and Official Title)

THIS IS AN ATTEMPT TO COLLECT A DBT,
ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
OOC2918381
DOCTOR
E-FILED 2014 OCT Loring~

14 8:20 AM
SAC - CLERK OF DISTRICT COURT
Hospital
ELEPHONE NO.
712-660-3825
GYANO , B . K .
BILLING DATE
06/15/12
PAGE
POLICY NUMBER
INSURANCE COMPANY
NO
EXTENSION
07 BLUE CROSS 140

05 SELF-PAY
PEV810415271
:7372
14408 /
POLICY HOLDER
PLAN
HEDBERG, DAVID
HEDBERG, DAVID
PATIENT NAME
GUARANTOR
DAVID L HEDBERG

14408 / 541558
DAVID L HEDBERG
PATIENT
TYPE
628 OAK STREET

SAC CITY IA
50583
22
541558
06/06/12
AGE
06/06/12
CHARGE
CODE
DATE
DESCRIPTION
06-06
QUANTITY
CHARGE
CRT
67.270
RADIOLOGY,
PROFESS
RADIOLOGY,
TECH
06-06
67. 27
DEPT TOTAL
67.27
DEPT TOTAL
231.00
231.00
231. 000
SUMMARY OF CHARGES
RADIOLOGY, TECH
231.00
TOTAL CHARGES
298.27
BALANCE
AMOUNT
67 .27
298 .27
Loririij Hospital
DOCTOR
TELEPHONE NO.
E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT
COURT
ft?
LANKFORD, TONYA
BILLING DATE
08/21/12
INSURANCE COMPANY
NO
712-660-3825
PAGE
POLICY NUMBER
BLUE CROSS 140

SELF-PAY
PEV810415271
7372
14408 /
POLICY HOLDER
DAVID L HEDBERG
HEDBERG, DAVID
HEDBERG, DAVID
DAVID L HEDBERG
628 OAK STREET

SAC CITY IA
50583
TYPE
22
544419
PLAN
PATIENT NAME
UARANTOR
EXTENSION
14408 /
08/13/12
BIRTHDATE
08/13/12
54441S'
SEX
AGE
31
DATE
CHARGE
CODE
DESCRIPTION
08-13
QUANTITY
CHARGE
CRT
38.670
RADIOLOGY, PROFESS
08-13
DEPT TOTAL
38.67
38.67
DEPT TOTAL
135.00
135.00
135.000
RADIOLOGY, TECH
SUMMARY OF CHARGES
RADIOLOGY , PROFESS IONAL
RADIOLOGY, TECH
38.67
135.00
TOTAL CHARGES
173.67
AMOUNT
BALANCE
173 . 6 V
33.
f plo
DOCTOR
MEYER,
E-FILED 2014 OCT 14 Lorin^

8:20 AM Hospital
COURT
TELEPHONE

PAGE
^V^
211 Hig hland Ave Sac City, IA 50583
INSURANCE COMPANY
NO.
07 BLUE CROSS
SELF-PAY
140
24964
POLICY HOLDER
POLICY NUMBER
05
PEV810415271
HEDBERG ,
111111111
HEDBERG
PATIENT
TYPE
OAK STREET
SAC CITY IA
50583
22
' H^m
ADMISSION DATE
10/03/12
24964
DISCHARGE DATE
BIRTHDATE
10/03/12
DATE
10-03
QUANTITY
DESCRIPTION
C A gf E
O^^^V
135 . 0 0 0
TECH
546779
[ SEX
AGE
*
PAY LAST
BALANCE
AMOUNT
38 .67
DEPT TOTAL
^M* Mi^^^^MM
RADIOLOGY,
CPT
38 . 670
^
^B
RADIOLOGY , PROFESS
V/fe/01 M
GUARANTOR IS RESPONSIBLE CQR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
10-03
546779
DAVID
MMM1 HEDBERG
DAVID L HEDBERG
PLAN
PATIENT NAME
GUARANTOR
628
EXTENSION
712-210-3017
STEVEN
BILLING DATE
10/09/12
NO.
38 . 67
135. 0 0
DEPT
TOTAL
135 . 00
SUMMARY OF CHARGES
RADIOLOGY,
PROFESSIONAL
RADIOLOGY,
TECH
TOTAL
38 . 67
135. 00
CHARGES
173 . 67
BALANCE
173 .67
\s^- a>^.^
/
Ijlte ,
6Cp j
rrV
3S.U?
13 ou
'
ioteO\
--,
.^LcTl
)3S.^
C-T ' I
C '{
/C"1
^
cb
3c;C
~>> TO
-^4-3-L^
\
\
\E
^75
16
.
E-FILED 2014 OCT 14

8:20 AM
COURTNO.
Lorin^
Hospital
TELEPHONE
DOCTOR
MARCZEWSKI,
L.
J.
f^~*?
BILLING DATE
NO.
PAGE
INSURANCE COMPANY
07
BLUE CROSS
05
SELF-PAY
140
MED ' REC - N0- /
24964
POLICY NUMBER
PLAN
POLICY HOLDER
PEV810415271
HEDBERG,
DAVID
111111111
HEDBERG,
I'M*
PATIENT NAME
MJV^BlP
DAVID L HEDBERG
OAK
SAC CITY
ADMISSION NO.
211 Highland Ave Sac City, !A 50583
GUARANTOR
628
712-210-3017
/\
09/24/12
PAT3EWT
STREET
TYPE
IA 5 0 5 8 3
11
09-16
09-16
CHARGE
CODE
09-16
09-16
DESCRIPTION
QUANTITY
mi^^to
^v
09/16/12
BIRTHDATE
RADIOLOGY,
^^^V$Wflf3^^^H
AMOUNT
405 . 000
154 . 3 0 0
4 0 5 . 00
154 . 3 0
DEPT TOTAL
1
559.30
3 5 . 150
PROFESS
^M* ^^V
RADIOLOGY, TECH
SEX AGE
^/Jf/01 M ^
CHARGE
EMERGENCY ROOM
I^^HMBW
546013

24964 /
546013
HEDBERG

09/16/12
DATE
EXTENSION
35 . 15
DEPT
TOTAL
35 . 15
DEPT
TOTAL
135.00
135.000
135.00
SUMMARY OF CHARGES
EMERGENCY
ROOM
559.30
RADIOLOGY ,
PROFESS IONAL
RADIOLOGY,
TECH
35 . 15
135, 00
TOTAL CHARGES
729.45
BALANCE
,,-7-r-- r^-i
729.45
! \'C^'
rO oLJ
SI
3 D sv
^\T
rcT
E-FILED 2014 OCT 14 8:20 AM

Hospital
DOCTOR
MEYER,
Loring
STEVEN
orAJ
BILLING D A T E
10/30/12
PAGE
07
BLUE CROSS
05
SELF-PAY
MED
211 Highland Ave Sac City,IA50583
POLICY NUMBER
INSURANCE COMPANY
NO.
TELEPHONE NO.
140
HEDBERG ,
111111111
HEDBERG ,
628
PATIENT
TYPE
SAC CITY
IA
50583
22
MM
MED. REC. NO / ADMISSION NO
24964
DISCHARGE DATE
ADMISSION DATE
8IRTHDATE
10/24/12
10/24/12
DESCRIPTION
CODE
QUANTITY
CHARGE
CPT
35.150
10-24
10-24
l^^^f
M
B
^HM*
MM1^H
RADIOLOGY,
PROFESS
RADIOLOGY,
547699
SEX
AGE
PAY LAST
BALANCE
AMOUNT
35 . 15
DEPT TOTAL
135 . 000
TECH
e/*/01 M *
DATE
547699
DAVID
M^^B^ HEDBERG
OAK STREET
PLAN
PATIENT NAME
DAVID L HEDBERG
REC. NO. ,' ADMISSION NO.
24964
POLICY HOLDER
PEV810415271
GUARANTOR
EXTENSION
712-210-3017
S^>~$
35 . 15
135.00
DEPT
TOTAL
135.00
SUMMARY OF CHARGES
^j
r-
RADIOLOGY,
PROFESSIONAL
RADIOLOGY,
TECH
35 . 15
135.00
TOTAL CHARGES
170 , 15
* (siAo
Jx s^^\E
^ -'~/y >
BALANCE
~*.
170 . 15
^S',V7
jSo^-"^-^
'AC ' '\/
- 1 ^\?
^-
,
~2>\
.,/V,U3.
''">[
".-x-^1
(' ^''
I -*, ' --; I ,

r) f. ./ yf-?~>
X,^^.
^^
^
& r*

LORING HOSPITAL
211 HIGHLAND AVENUE
SAC CITY,
IA SOS83
ADMISSION STATUS INQUIRY/REPORT
03/24/13
PAGE
PATIENT S
24964
ADMISSION #
NAME
HEDBERG, MVHMI
ADM. DATE
: 05/OS/13
DISC. DATE
: OS/06/13
ADDRESS
628
CITY,
STATE
OAK STREET
SAC CITY,
IA
5S6014
LAST PAY AMOUNT :

LAST PAY DATE
12 . 00
: 06/07/13
50583
STATEMENTS
PHONE fc
712-210-3017
LAST STMT DATE
: 09/04/13
SOC.SEC. S
BIRTHDAY
fffiMMM
*.''i
INS.
GUAP. S
14408
PRIMARY FC
GUAR NAME
HEDBERG,
PAT.
22
2IP
CODE
TYPE
DOCTOR NAME
AGENCY S
DATE
DAVID L
XRAY
FILED DATE
05 5
HELD : NO
: OS/13/13
PAPERLESS
: 07 BCBS
PRIMARY PAYER
F/C
: 140
BLUE CROSS
140
SELF-PAY
LANKFORD, TONYA
:
RESPONSIBLE PAYOR NAME
CHECK\REF
DESCRIPTION
AMOUNT
05/06/13
ORIGINAL BAL
173 .67
09/24/13
NON POSTED CHARGES
.00
09/24/13
NON POSTED PAYMENTS
.00
09/24/13
WON POSTED ADJUSTMENTS
.00
06/05/13 BLUE CROSS 140
BCBS PUT
-97.04
06/05/13 BLUE CROSS 140
BCBS ADJ
-13 .70
0 6 / 0 7 / 1 3 BLUE CROSS 140
BCBS PMT
-12.00
0 6 / 0 7 / 1 3 BLUE CROSS 140
BCBS ADJ
-23 .67
CURRENT BAL:
DOCTOR
LANKFCRD,
Lorin# Hospital
TELEPHONE
E-FILED 2014 OCT 14 8:20 AM SAC -)CLERK OF DISTRICT COURT
\^\ft.
vxroc^7r
T\Ay
TONYA
BILLING DATE
10/C9/13
NO
PAGE
INSURANCE COMPANY
, C" BI.L'E CROSS

05
POLICY NUMBER
140
PEV810415271
22265
DAVID L HEDBERG
HEDBERG ,
DAVID
HEDBERG ,
AMY L
PATIENT
TYPE
IA 5 0 5 8 3
22
22265

10/02/13
BIPTHDATE
DATE
DESCRIPTION
QUANTITY
i . - 'J , MHV i^BBMBBMMMMR
10-
02
RADIOLOGY,
PROFESS
RADIOLOGY,
*
TECH
562515
SEX
AGE
31
PAY LAST
BALANCE
AMOUNT
40 . 60:
DEPT
CPT
MW/81 F
10/02/13
GUARANTOR is RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
CHARGE
CCDE
562515
AMY L HEDBERG
623 OAK STREET
PLAN
PATIENT NAME
GUARANTOR
SAC CITY
i
POLICY HOLDER
SF: ----PAY
EXTENSION
712-660-3825
2 1 1 Highland A ve Sac City. IA 50583
NO.
40 . 60
40 . 60
TOTAL
148 . 5 0 C
148 . 50
DEPT TOTAL
148 . 50
SUMMARY OF CHARGES
RADIOLOGY,
PROFESSIONAL.
RADIOLOGY,
TECH
TOTAL
CHARGES
BALANCE
40.60
I
148 . 50
185. 10
189.10
-j-j
/ 0*7- V fa
^\E
"\?
\ s
^'^
E-FILED
8:20 AM SAC - CLERK OF DISTRICT COURT
1 2014
. OCT 14
Loriruj
DCCTOR
MO-plt^l
cLEPHONE NO.
o ?r -1
BILLiNG DATE
11/14/13
j
PAGE
|\
0 7 BLUE CROSS
0 5 SELF - P A Y
^ /\. REC. NO. / ADMISSION NO.
'
POLICY NUMBER
HEDBERG,
DAVID
HSDBERG,
AMY L
PATIENT
TYPE
SAC CITY
IA
20
50583
22265
ADMISSiON DATE DISCHARGE DATE

H/
564010
AMY L HEDBERG
OAK STR3ET
PLAN
PATIENT NAME
DAVID L HEDBERG
22265
POLICY HOLDER
PEV8104 ^ 5 2 7 1
140
GUARANTOR
628
712-6GC-3825
211 Highland Ave SacCity, IA 50583
INSURANCE COMPANY
NO.
04/13
11/04/13
BIRTHDATE
DATE
11-04 *
j l l - 0 4 VMBMM*
11 - 3 4 pl^HBM
DESCRIPTION
I^VMB^MMH^V
^^
^t
i 1 - 04
MM* flHBMBMl
QUANTITY
CHARGE
^V
VMMHMHM
REFERRAL
564010
SEX
AGE
31
PAY LAST
BALANCE
AMOUN-
CRT
18 . 000
17 . 720
17 . 72
44 . 0 0 0
44.00
35.350
LABORATORY
11-04
0/^/81 F
G J A R A X T O R IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
C.-iARGE
CODE
EXTENSION
18 . 00
35 . 3 6
DEPT TOTAL
115 . 0 8
16.250
LABORATOR
16.25
DEPT
TOTAL
16 . 2 5
SUMMARY OF CHARGES
LABORATORY
REFERRAL
TOTAL
LABORATORY
CHARGES
115 . 0 8
16 .25
131.33
BALANCE
131 . 33
?"L
'
=.
5
-^* L>
' . '-_>
-^J --+-
05/29/2014
2:47:04 pm
MR#/Adm#:
Guarantor #:
Doctor #:
Ins Codes:
22265/564152
HEDBERG,AMY L
14408
HEDBERG, DAVID L
241
GYANO, B. K.
05
Bed#: 523-1
Patient Type: 14
Charge Date Date Ent
Date Pst
11/07/13
11/07/13
11/07/13
11/12/13
11/12/13
11/12/13
11/07/13
11/07/13
11/07/13
OPERATING ROOM
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/21/13
11/11/13
11/07/13
11/21/13
11/07/13
11/21/13
11/07/13
11/21/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
12
70.00
12
48
710
11/12/13
11/26/13
1
-1
3.50
18.00
18.00
AR_DemandJ3i!l_History.rpt
11/12/13
11/12/13
18.00
-18.00
0.00
310
302
302
302
302
302
302
88304
86803
86803
86703
86703
86705
86705
112.00
69.73
69.73
122.60
122.60
94.25
94.25
Dept Total
112.00
69.73
-69.73
122.60
-122.60
94.25
-94.25
112.00
250
250
250
250
250
250
250
250
250
88.31
88.31
173.01
164.78
171.77
207.59
104.85
109.83
115.00
90.58
173.01
164.78
171.77
207.59
104.85
109.83
115.00
90.58
Dept Total
11/07/13
11/07/13
168.00
168.00
Dept Total
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
840.00
840.00
48
300 36415
300 36415
11/14/13
11/12/13
11/26/13
11/12/13
11/26/13
11/12/13
11/26/13
246.90
151.19
398.09
Dept Total
PHARMACY
11/07/13
11/07/13
246.90
151.19
964
11/12/13
990.00
495.00
247.50
1,732.50
Dept Total
REFERRAL LABORATORY
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
990.00
495.00
247.50
370
370
11/12/13
LABORATORY
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
Qty Unit Price Charge Amt
Dept Total
RECOVERY ROOM
11/07/13
11/07/13
Rev Cpt
360 25111
360
360
11/12/13
11/12/13
ANESTHESIA CRNA
11/07/13
Charge # Description
Admission Date: 11/07/2013

Discharge Date: 11/07/2013
Patient Age:
31
DRG#:
LOS: 0
Dept Total
ANESTHESIA
11/07/13
Page: 1
Demand Bill From History

LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
1,225.72
272
271
17.94
9.14
17.94
9.14
2:47:04 pm
Page: 2

LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
MR# / Adm #:
Guarantor #:
Doctor #:
Ins Codes:
22265/564152
14408
241
05

11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
HEDBERG,AMYL
HEDBERG, DAVID L
GYANO, B. K.
Bed#: 523-1
Patient Type:
Date Pst
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
MEDICAL SUPPLIES
11/07/13
11/07/13
11/07/13
11/07/13
IV SOLUTIONS
14

Patient Age:
31
DRG#:
LOS: 0
Rev Cpt
271
272
272
272
272
271
272
272
272
272
272
271
Dept Total
258
258
11/12/13
11/12/13
8.82
19.56
17.39
357.62
40.38
30.28
13.68
25.32
11.64
40.32
42.24
59.68
Dept Total
Balance Due
8.82
78.24
17.39
357.62
40.38
30.28
13.68
25.32
23.28
40.32
42.24
59.68
764.33
16.34
16.34
Dept Total
Patient Total
Payments Received
AR_Demand_Bi!l_History.rpt
1
4
1
1
1
1
1
1
2
1
1
1
18
16.34
16.34
32.68
410 99211
RESPIRATORY THERAPY
125.00
125.00
125.00
5,398.32
4,909.92
488.40
E-FILED 2014 OCT Lorina

14 8:20 AM
COURT
Hobpita
-LEPUONE NO
DOCTOR
C-YANO ,
B .
K.
Qs^>
BILLING DATE
NO
PAGE
POLICY NUMBER
140
PEV810415271
4|fc^73 37
SELF- PAY
30580
POLICY HOLDER
HEDBERG ,
HEDBERG
'
DAVID L HEDBERG
PATIENT
TYPE
SAC CITY
IA
20
50583
Lmm

30580

12/02/13
12/02/13
DATE
C coE E
DESCRIPTION
WM^fc WHMMBMfc
VMM* MVBM^^MBMM*
QUANTITY
CHARGE
565230
BIRTHDATE
SEX
AGE
4P/W/07
12-02
555230
DAVID
L^fe HEDBERG
OAK STREET
PLAN
PATIENT NAME
GUARANTOP
628
MED. REC NO ' ADMISSION NO.
INSURANCE COMPANY
C 7 BLUE CROSS
C5
712-660-3825|
|\ y\^ /p
^ .12/09/13
EXTENSION
CPT
PAY LAST
BALANCE
AMOUNT
18 . 000
17 . 720
1^.72
1 2 - 0 2 MBMft ^0
28 . 550
28 . 55
MM1 MV
44 . COO
12-02
12 - ., ;
-2- 02
LABORATORY
2
REFERRAL
TOTAL
DEPT
TOTAL
108 . 27
I C C . 66
ICO . 66
OF CHARGES
LABORATORY
108 .27
REFERRAL
100 . 66
LABORATORY
TOTAL CHARGES
BALANCE
44 . CC
DEPT
50 - 330
LABORATOR
SUMMARY
18.C C
2 0 8 . 93
2 0 8 . 93

L. F. NOLL, INC.
PLAINTIFF
VERIFICATION OF ACCOUNT
IDENTIFICATION OF JUDGMENT
DEBTOR AND CERTIFICATE RE
MILITARY SERVICE
VS
NO.
DAVID L. HEDBERG
AMYL. HEDBERG
DEFENDANT(S)
For Defendant: DAVID L. HEDBERG
1. I, T. L. Noll, Vice President of L. F. Noll, Inc., am a party or employee of Plaintiff whose claim(s) is (are)
shown in the attached statement(s). I have personal knowledge that the attached statement(s) is (are) a true
copy of the original creditor's records showing the balance due is true and correct. I further state that the sum
of $942.28 is the balance due and owing as of OCTOBER 8, 2014 from Defendant(s) to Plaintiff(s) and any
interest amount owing is accurately stated in the Petition and Original Notice.
2. I further state that Defendant, DAVID L. HEDBERG, resides at 628 OAK ST SAC CITY IA 50583. is
employed at EVAPCO 925 QUALITY PR LAKE VIEW IA 51450. and Defendant's occupation is
3. Check A, B, or C for Defendant:

A. X Defendant is not in the military service of the United States government, I have verified this fact
by {check one):
X Checking the Defense Manpower Data Center (DMDC) (requires name and SSN or name
and date of birth) https://www.dmdc.osd.mil/appi/scra/scraHome.do.
Contacting Defendant who informed me, or
: ; Regularly seeing Defendant and believing Defendant is not active in the U.S. military.
OR
B O I have investigated, and I am unable to determine whether or not Defendant is in the military
service of the United States government.
OR
C. O Defendant is in the military service of the United States government.
4. I also state to the best of my knowledge (check one):
Defendant O is X is not under a disability or confined in any reformatory, jail, or penitentiary.
I certify under penalty of perjury and pursuant to the laws of the State of Iowa that these facts are true and
correct.
L.F. NOLL, INC.
T. L. N<3LL, VICE PRESIDENT

705 Douglas St., Suite 344
Sioux City, IA51101
712-252-0583
0002927755
NOTICE OF RIGHT TO CURE DEFAULT

NCS, INC DBA

?0 BOX 593
SIOUX CITY IA 51102-0593
("12)252-0583
SEPTEMBER 18, 2C14
RE:
(LISTED 3ELCW I? MORE THAN ONE)

TOTAL AMOUNT DUE: S942.28
AMOUNT IN DEFAULT: $942.23
You are now in default on this credit transaction. You have a right: to
correct this default within 20 days. If you do so, you may continue with the
contract as though you did not default.
YOUR DEFAULT CONSISTS OF:
FAILURE TO PAY AS AGREED
Correct this default by:
Paying the amount in default, $942.28 to

Noll Collection Service, agent for the above
creditor.
If you do not correct this default within 2C days, we may exercise cur
rights against you under the law.
If you default again in the next year, we may exercise our rights without
sending you another notice like this one. If you have any questions, write cr
telephone pror.pt 1 y.
Sincerely,

ANY AND ALL INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
Client Ref No
- o
^-j
r\~\-r.\
HOSPITAL 541558
HOSPITAL 544419
LOP.ING HOSPITAL 546779
CORING n ^ > -L. /rt-L_j 546013
IORING HOSPITAL 547699
~ o ~^ ~~ ^^ r~_Or<._;>J^:
1 ' 1 ^ r-1
Zl "i"
Principal
Interes-
30 .29
27 .26
.47
.49
.00
.00
27 .26
33 .66
27 .06
,41
. CO
.61
.40
.00
27 . 57
34 .2"?
.00
2" .46
30 . / 6
' !D
'I "T
tL. i
Client Ref No
- ORING HOSPITAL 556014

LJ
CRT N'~ PC'S ^TTE. T 5 625 " 5

ORING HOSPITAL 564010
HOSPITAL
iCRING HOSPITAL
1CRI NG HOSPITAL
CRIKG HOSPITAL
~> ORI NG r.^Sr_ _^,^
OR:NG HOSPITAL
L. OR ING
-J
564152
5.65230
565132
568707
568323
569372
Principal
27. 26
29. 96
24. 04
488. 40
31. 92
83. 77
29. 96
29. 96
29. 66
nteres'
.47
. 96
.65
12.31
.74
2.63
.60
.57
.51
:her
_otai
r\ 0
,0 0
.n ^
0
. 3n
,0 nU
.0 <-.j
.0 ->
n
. U0
27 . 73
7 ^.CO
.5 ^
x^
5CC . 71
32 .66
3 5 ii Q
30 . 56
3 0.53
30 - -

XDS, INC DBA
'A Professional Debt Collection Service Since 1965"
~C5 DOUGLAS STREET, S'JITE 344
(712) 252-0583
he above debtor refuses to cooperate . We

order ~c enforce collection. Before our attorney can proceed, we will requi:
' Completion of the assignment at the bottom of this page.
* Copy of tne itemized statement snowing balance due (if not
oriainal .

r or valuable consideration, receipt hereby acknowledged, ~he undersigned hereby
assign, transfer, ana set over unto L.F. Noli, Inc. that certain claim against
DAVID L HEDBERG
AMY L KED3ERG
for gccas, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of 113.55gj/73 _ 55
lawful interest
thereon; and does hereby authorize said assignee to do and perform all acts
settlement, adjustment, compromise or satisfaction of said claim. Assianor
hereby certi c i es that said claim is j ustly due and owing and warrants
Dated this 0j^g(ciay of CXqltft/m-&-tA^

LQRING HOSPITAL
20 |4
TELEPHONE
E-FILED 2014 OCT 14Lorin#
8:20 AMHospital
COURT NO.
BISSELL, BENJAMIN
712-210-3017
DOCTOR
BILLING DATE
03/18/14

PAGE
INSURANCE COMPANY
O.
IPEV810415271
.'111111111
24964 /
POLICY HOLDER
POLICY NUMBER
BLUE CROSS 140

SELF-PAY
HEDBERG, DAVID
HEDBERG,
DAVID L HEDBERG
HEDBERG
PATIFNT
628 OAK STREET

SAC CITY IA 50583
TYPE
22
24964 /
03/10/14
BIRTHDATE
DESCRIPTION
QUANTITY
03-10
CHARGE
CPT
40.603
RADIOLOGY, PROFESS
RADIOLOGY, TECH
SUMMARY OF)CHARGES
RADIOLOGY, TECH
40 -60
148.50
TOTAL CHARGE
189.10
BALANCE
SEX
.AGE
12
PAY LAST
BALANCE
AMOUNT
DEPT TOTAL
40.60
40 .60
DEPT TOTAL
148 .50
148.50
148 .500
03-10
569372
/l/Ol M
03/10/14
UARANTOR IS RESPONSIBLE FOR ANY AMOUNTS-DUE-AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
CHARGE
CODE
569372
PLAN
.PATIENT NAME
UARANTOR
DATE
EXTENSION
189.10
DOCTOR
BISSELL,
Loring Hospital
TELEPHONE NO.
BENJAMIN
712-210-3017
BILLING DATE
03/04/14
NO.
PAGE
POLICY NUMBER
INSURANCE COMPANY
07
BLUE CROSS
05
SELF -PAY
140
24964
POLICY HOLDER
HEDBERG,
DAVID
111111111
HEDBERG,
MMHB
PATIENT NAME
DAVID L HEDBERG
P^pENT
SAC CITY
IA
50583
22
24964

02/24/14
02/24/14
B1RTHDATE
DATE
02-24
DESCRIPTION
i
ELB LT
RADIOLOGY,
02-24
ELB
QUANTITY
COME L MIN 3 V
LT
SEX
AGE
12
^^H-iVWnffliif^^^l
40 .60
148.500
TECH
563823
AMOUNT
40 . 6 0 3
DEPT TOTAL
COME L MIN 3 V
RADIOLOGY,
CHARGE
PROFESS
/^fc'Ol M
CHARGE
CODE
568823
MMMM HEDBERG
OAK STREET
PLAN
PEV810415271
GUARANTOR
628
EXTENSION
40 . 60
148 . 5 0
DEPT TOTAL
148.50
SUMMARY C F CHARGES
RADIOLOGY,
PROFESSIONAL
RADIOLOGY,
TSCH
TOTAL
40.60
148.50
189.10
CHARC rES
BALANCE
189.10
15^*-^
wx
T^CjPci
35.ID
Cfl
X
C/\l$ 'T\^r~y
\T
DOCTOR
MARCZEWSKI,
E-FILED 2014 OCT 14Loiinq

8:20 AMHospital
COURTNO.
TELEPHONE
L.
J.
<V-vx
BILLING DATE
02/28/14
NO.
PAGE
POLICY NUMBER
140
PEV810415271
'111111111
GUARANTOR
24964
POLICY HOLDER
OAK
SAC CITY
PTYPENT
IA 5 0 5 8 3
22

24964 /

02/20/14
BIRTHDATE
02/20/14
CHARGE
CODE
DESqRIPTION
02-20
QUANTITY
1
RADIOLOGY,
' CHARGE
CPT
148 .500
148.50
TOTAL CHARGES
189.10
AMOUNT
40 .60
148 .50
DEPT
SUMMARY OF CHARGES
RADIOLOGY, TIICH
AGE
12
40 . 6 0
DEPT TOTAL
1
02-20
SEX
PAY LAST
BALANCE
40.603
PROFESS
568707
0/^/01 M
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS] DUE AFTER THE INSURANCE COMPANIES MAKE THEIR PAYMENTS
DATE
568707
HEDBERG, DAVID
HEDBERG, MttMft
MflM^ff HEDBERG
STREET
PLAN
PATIENT NAME
DAVID L HEDBERG
628
MED. REC. NO. / ADMISSION NO. -
INSURANCE COMPANY
07 BLUE CROSS
05 SELF-PAY
712-210-3017
?br
^\
EXTENSION
TOTAL
148. 50
40 .60
BALANCE
189. 10
^LSCb, <~\Q - ^^
7%\lo^>
M y.iv
)<4JC2'^^
Cfl
X/
1
1
DOCTOR
Lorin# Hospital
LEIGH, HUGH
S^"
-SKXi
BILLING DATE
12/05/13
NO.
' f\
PAGE
INSURANCE COMPANY
POLICY NUMBER
'. PEV810415271
^^^7887
GUARANTOR
30580 /
POLICY HOLDER
HEDBERG,
HEDBERG,
PATIFNT
TYPE
11
DAVID
IflHft

30580

11/29/13
11/29/13
BIRTHDATE
DATE
DESCRIPTION
1
1
11-29
AGE
^
DEPT TOTAL
145. 00
145. 00
DEPT TOTAL
405.00
405.00
DEPT TOTAL
18.00
17.72
44 . 00
79. 72
4 0 5 . 000
EMERGENCY ROOM
11-29
SEX
AMOUNT
145.000
EMERGENCY RM, PROFE

11-29
565132
^^HsVWlffla!^^^!
QUANTITY
11-29
^/W/07 F
CHARGE
CODE
565132
PLAN
1 W HEDBERG
STREET
EXTENSION
PATIENT NAME
DAVID L HEDBERG
OAK
>*
07 BLUE CROSS 140

05 SELF -PAY
628
TELEPHONE NO.
712-660-3825
18 . 0 0 0
17 . 7 2 0
44 . 0 0 0
LABORATORY
SUMMARY O^1 CHARGES

EMERGENCY RM PROFESSIONAL
EMERGENCY ROOM
LABORATORY
145.00
4 0 5 . 00
79.72
TOTAL CHARGES
629.72
BALANCE
629.72
i\i*-J ^^
. jAi * "" *+-^
\L+ ^^ ' ^~"^
l|0.
4SI
Bern
i &~~~ f-(c~ Gf>
rtjQ
\E
\T
^-;

NCS, INC DBA
"A Professional Debt Collection Service Since 1965
(712) 252-0583
DATE: AUGUST 4, 2014

014345
SAC CITY IA 505S3

ATTENTION:
RE: DAVID LEE HEDBERG
541558
$747.11
10/25/12
order to enforce collection. Before our attorney can proceed, we will require
* Completion of the assignment at the bottom of this page.
* Copy of the itemized statement showing balance due (if not
original.
-eturn promptly. Court costs will be advanced on your behalf.
; payments or make arrangements, without calling us first.
THANK YOU FOR YOUR COOPERATION
For valuable consideration, receipt hereby acknowledged, the undersigned hereby
assign, transfer, and set over unto L,F. Noll, Inc. that certain claim against
DAVID LEE HEDBERG
AMY HEDBERG
for goods, wares and merchandise sold and delivered or services rendered and
performed in the principal amount of
$747.11
lawful interest
thereon; and does hereby authorize said assignee to do and perform all acts
settlement, adjustment, compromise or satisfaction of said claim. Assignor
hereby certifies that said claim is justly due and owing and warrants
disclosure and other provisions of truth in lending, and that same is free of
set-offs and other defenses.
Dated this ^
day of
(L.UAjJ^L
, 20/4-
LOR1NG HOSPITAL
Name and Official. Title)

ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE
E-FILED 2014 OCT 14

8:20 AM
COURT
Lorin^
Hospital
ELEPHONE
NO.
DOCTOR
GYANO,
B. K.
BILLING DATE
06/15/12
NO
14408 /
211 Highland Ave> Sac City, IA 50583
PAGE
POLICY HOLDER
POLICY NUMBER
INSURANCE COMPANY
PEV810415271
i7372
07 BLUE CROSS 140

05 SELF-PAY
HEDBERG, DAVID
HEDBERG, DAVID
DAVID L HEDBERG
DAVID L HEDBERG
628 OAK STREET
50583
SAC CITY IA
PTYPENT
22
541558
PLAN
PATIENT NAME
GUARANTOR
EXTENSION
712-660-3825
14408 /
06/06/12
BIRTHDATE
06/06/12
541558
SEX
/flV/81 M
AGE
31
CHARGE
CODE
DATE
DESCRIPTION
QUANTITY
CHARGE
CPT
67 . 2 7 0
06-06
RADIOLOGY , PROFESS
06-06
DEPT TOTAL
67 .27
67.27
DEPT TOTAL
231.00
231.00
231.000
RADIOLOGY, TECH
SUMMARY OF CHARGES
RADIOLOGY, TECH
67 .27
231.00
TOTAL CHARGES
298 . 2 7
BALANCE
AMOUNT
298 . 2 7
TELEPHONE
E-FILED 2014 OCT 14Loring
8:20 AMHospital
COURTNO.
DOCTOR
LANKFORD , TONYA
712-660-3825
BILLING DATE
08/21/12
PAGE
211 Highland Ave -Sac C/fy, IA 50583
INSURANCE COMPANY
NO.
EXTENSION
POLICY NUMBER
BLUE CROSS 140

SELF -PAY
PEV810415271
7372
14408 /
PLAN
POLICY HOLDER
HEDBERG, DAVID
HEDBERG, DAVID
PATIENT NAME
GUARANTOR
DAVID L HEDBERG

14408 / 544419
DAVID L HEDBERG
PATIFNT
628 OAK STREET

SAC CITY IA
50583
TYPE
22
544419
08/13/12
BIRTHDATE
08/13/12
SEX
AGE
31
DATE
CHARGE
CODE
DESCRIPTION
08-13
QUANTITY
1
CHARGE
CPT
38 .670
RADIOLOGY, PROFESS
DEPT TOTAL
38.67
38. 67
DEPT TOTAL
135.00
135.00
135.000
08-13
RADIOLOGY, TECH
SUMMARY OF CHARGES
RADIOLOGY, TECH
38.67
135.00
TOTAL CHARGES
173.67
AMOUNT
BALANCE
173.6"'
f i^
10
E-FILED 2014 OCT 14 Loving-Hospital

8:20 AM SAC - CLERK OF DISTRICT
COURT NO.
TELEPHONE
DOCTOR
MEYER, STEVEN
BILLING DATE
10/09/12
NO
712-210-3017
MED. REC. NO. /ADMISSION NO.
277 Highland Ave - Sac City, !A 50583
PAGE
POLICY NUMBER
INSURANCE COMPANY
PEV810415271
111111111
07 BLUE CROSS 140

05 SELF-PAY
24964 /
HEDBERG, DAVID
HEDBERG,

24964 / 546779
HEDBERG
PflTIPWT
TYPE
628 OAK STREET

SAC CITY IA 50583
22
10/03/12
BIRTHDATE
10/03/12
DESCRIPTION
UAIt
QUANTITY
CHARGE
CRT
38 . 670
RADIOLOGY,
PROFESS
RADIOLOGY,
TECH
10-03
38 .67
135.00
TOTAL CHARGES
173 .67
AGE
PAY LAST
BALANCE
AMOUNT
38.67
DEPT TOTAL
38 . 67
DEPT TOTAL
135 . 00
135.00
135 . 000
SUMMARY OF CHARGES
RADIOLOGY, TECH
SEX
/Bl/01 M
10-03
546779
PLAN
POLICY HOLDER
PATIENT NAME
GUARANTOR
DAVID L HEDBERG
EXTENSION
BALANCE
173 . 67
38- U?
DOCTOR
Lorin#
Hospital
E-FILED 2014 OCT 14
8:20 AM
COURTMO.
TELEPHONE
712-210-3017
MARCZEWSKI, L. J.
BILLING DATE
09/24/12
NO
EXTENSION

PAGE
INSURANCE COMPANY
POLICY NUMBER
PEV810415271
111111111
07 BLUE CROSS 140

05 SELF-PAY
GUARANTOR
DAVID L HEDBERG
24964 /
POLICY HOLDER
PLAN
HEDBERG, DAVID
HEDBERG,
PATIENT NAME
PATIFMT
TYPE
628 OAK STREET

SAC CITY IA 50583
11

24964 /
546013

09/16/12
GUARANTOR IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES
CHARGE
DESCRIPTION
QUANTITY
DATE
CODE
09-16
09-16
EMERGENCY ROOM
BIRTHDATE
MAKE THEIR PAYMENTS

CHARGE
CPT
405.000
154 .300
TOTAL
DEPT TOTAL
35. 15
35 .15
DEPT TOTAL
135.00
135 . 00
135.000
RADIOLOGY,
TECH
SUMMARY OF CHARGES
EMERGENCY ROOM
RADIOLOGY, TECH
559.30
35.15
135.00
TOTAL CHARGES
729.45
BALANCE
AMOUNT
405.00
154.30
559.30
DEPT
RADIOLOGY , PROFESS
09-16
AGE
09/16/12
35.150
09-16
546013
729.45
E-FILED 2014
8:20 AMHospital
COURTNO.
. OCT 14Lorin^
TELEPHONE
DOCTOR
MEYER ,
STEVEN
f^~^
BILLING DATE
PAGE
07 BLUE CROSS
05
211 Highland Ave- Sac City, IA 50583
140
SELF-PAY
24964
POLICY HOLDER
POLICY NUMBER
INSURANCE COMPANY
NO.
/\ Xx/V /'
10/30/12
PEV810415271
HEDBERG , DAVID
HEDBERG
MflHBI HEUBhJRG
PATIENT
TYPE
22
24^64

10/24/12
10/24/12
BIRTHDATE
10-24
10-24
CHARGE
CODE
^HIV
QUANTITY
DESCRIPTION
DEPT TOTAL
^HHV ^H1^B*
135.000
DEPT
RADIOLOGY, TECH
SEX
AGE
AMOUNT
35.150
^^^PROFESS
0
RADIOLOGY,
b4V699
PAY LAST
BALANCE
CRT
CHARGE
9/V/01 M %
DATE
547699
' "*"*
PATIENT NAME
628 OAK STREET

PLAN
111111111
GUARANTOR
DAVID L HEDBERG
EXTENSION
712-210-3017
TOTAL
35 . 15
35 . 15
135 . 00
135.00
SUMMARY OF CHARGES
RADIOLOGY,
PROFESSIONAL
35 . 15
RADIOLOGY, TECH
135 . 00
TOTAL CHARGES
V"s(&
' ^
170.15
170 . 15
BALANCE
^^
~n
O-- \7
'"^
/ 6 fr
.,/
/- . ,- 1 !

LORING HOSPITAL
211 HIGHLAND AVENUE
SAC CITY, IA 50583
ADMISSION STATUS INQUIRY/REPORT
C3/24/13
PAGE
PATIENT S
2-1964
ADMISSION ft
NAME
HEDBERG, M^HMi
ADM.
ADDRESS
5S6014
DATE
05/06/13
DISC. DATE
05/06/13
628 OAK STREET
LAST PAY AMOUNT
CITY, STATE
SAC CITY, IA
LAST PAY DATE
ZIP CODE
50583
ft STATEMENTS
PHONE tt
712-210-3017
LAST STMT DATE
12 .00
06/07/13
4
HELD : NO
09/04/13
SOC.SEC.H
tVVMM
BIRTHDAY
04fl/4Pl
INS. FILED DATE
OS/13/13
GUAR S
14408
PRIMARY FC
07 BCBS
GUAR NAME
HEDBERG, DAVID L
PRIMARY PAYER
PAT. TYPE
22 XRAV
F/C
DOCTOR NAME
AGENCY
tt
DATE
05 5
140
PAPERLESS
BLUE CROSS 140
SELF-PAY
LANKFORD, TONYA
:
RESPONSIBLE PAYOR NAME
CHECK\REF
DESCRI PTION
AMOUNT
05/06/13
ORIGINAL SAL
173 .67
09/24/13
NON POSTED CHARGES
.00
09/24/13
NON POSTED PAYMENTS
.00
09/24/13
NON POSTED ADJUSTMENTS
.00
06/05/13 BLUE CROSS 140
BCBS PMT
-97.04
06/05/13 BLUE CROSS 140
BCBS ADJ
-13 - 70
06/07/13 BLUE CROSS 140
BCBS PMT
-12 .00
06/07/13 BLUE CROSS 140
BCBS ADJ
-23 .67
CURRENT BAL:
AM SAC
- CLERK OF DISTRICT TELEPHONE
COURT
Hospital
DOCTOR E-FILED 2014 OCT 14 8:20
Lorin#
LANKFORD ,
^j\?br
PAGE
07
BLUE
C5
SE; ,-PAY
CROSS
POLICY NUMBER
140
22265
POLICY HOLDER
HEDBERG ,
DAVID
HEDBERG ,
AMY L
31
PATIENT NAME
DAVID L HEDBERG
PATIENT
TYPE
SAC CITY IA
22265
22
50583
562515
AMY L HEDBERG
OAK STREET
PLAN
PEV810415271
GUARANTOR
628
MED. REC. NO. / ADMISSION NO,
211 Hishland A ve Sac City, IA 50583
INSURANCE COMPANY
NO,
EXTENSION
712-660-3825
TONYA
BILLING DATE
10/09/13
NO.
BIRTHDATE
/
SEX
562515
AGE
10/02/13
MB/31 F 31
PAY LAST
BALANCE
DATE
CHARGE
DESCRIPTION
QUANTITY
CPT
AMOUNT
UAIt
CODE
1 0 - 0 2 <*
10-02
10/02/13
40 . 603
^
^R
RADIOLOGY, PROFESS
j^BHB
148 . 500
*
RADIOLOGY, TECH
SUMMARY OF
40 . 60
DEPT TOTAL
148 . 50
DEPT
TOTAL
148 . 50
CHARGES
RADIOLOGY,
PROFESSIONAL
RADIOLOGY,
TECH
40 . 60
148 . 50
TOTAL CHARGES
189.10
BALANCE
Cfl
40 . 60
189 . 10
\ci4L
v^s
8
Psr- tr
O\ i
f L.
\v
\
\E
E-FILED 2014 OCT 14

8:20 AM
COURT
_OnJlT
HO^plTÎ
cLEPHONE
NO.
DOCTOR
'JHENEY,
o }r
RONALD
BILLiNG DATE
11/14/13
NO.
PAGE
POLICY NUMBER
140
PEV810415271
^
22265
POLICY HOLDER
HEDBERG,
DAVID
HEDBERG,
AMY L
PATIENT
TYPE
OAK STREET
SAC CITY
IA
50583
20
ADMISSION DATE
11/04/13
22265
DISCHARGE DATE
BIRTHDATE
11/04/13
tf/9/81
DATE
11-04
CHARGE
CODE
BH^V
11-04 JVHMH*
11-04
fl^^BM
il-04
MMH9
DESCRIPTION
QUANTITY
CHARGE
^^9
CPT
564010
SEX
AGE
31
PAY LAST
BALANCE
AMOUNT
MH^^HL
18 . 0 0 0
^^MI^BIW
17 . 720
17 . 72
44 , 000
44.00
35 . 360
^^B
MHMH^Â
REFERRAL
18 - 00
35 . 36
115 . 0 8
DEPT TOTAL
LABORATORY
11-04
564010
AMY L HEDBERG
DAVID L HEDBERG
PLAN
PATIENT NAME
GUARANTOR
628
MED, REC. NO. / ADMISSION NO,
21? Highland Ave SacCity, I A 50583
INSURANCE COMPANY
0 7 BLUE CROSS
05 SELF-PAY
712-660-3825
^ /\
^
' /\
EXTENSION
16 . 25
16.250
DEPT
LABORATOR
16 .25
TOTAL
SUMMARY OF CHARGES
LABORATORY
REFERRAL
LABORATORY
TOTAL CHARGES
115 . 08
16.25
131.33
131. 3 3
BALANCE
19-3-13
05/29/2014
2:47:04 pm
MR# / Adm #:
Guarantor #:
Doctor #:
Ins Codes:
22265/564152
14408
241
05
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
HEDBERG, AMY L
HEDBERG, DAVID L
GYANO, B. K.
Bed#: 523-1
Patient Type:
Date Pst
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/21/13
11/11/13
11/07/13
11/21/13
11/07/13
11/21/13
11/07/13
11/21/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
12
70.00
12
710
11/12/13
11/26/13
48
1
-1
3.50
18.00
18.00
AR_Demand_Bill_History.rpt
11/12/13
11/12/13
18.00
-18.00
0.00
310
302
302
302
302
302
302
88304
86803
86803
86703
86703
86705
86705
1
1
-1
112.00
69.73
69.73
-69.73
1
-1
1
-1
122.60
122.60
94.25
94.25
122.60
-122.60
94.25
-94.25
Dept Total
112.00
69.73
112.00
250
250
250
250
250
250
250
250
250
88.31
173.01
164.78
171.77
207.59
104.85
109.83
115.00
90.58
Dept Total
11/07/13
11/07/13
168.00
168.00
Dept Total
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
840.00
840.00
48
300 36415
300 36415
11/14/13
11/12/13
11/26/13
11/12/13
11/26/13
11/12/13
11/26/13
246.90
151.19
398.09
Dept Total
PHARMACY
11/07/13
11/07/13
246.90
151.19
964
11/12/13
990.00
495.00
247.50
1,732.50
Dept Total
REFERRAL LABORATORY
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
990.00
495.00
247.50
370
370
11/12/13
LABORATORY
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
Dept Total
RECOVERY ROOM
11/07/13
11/07/13
Rev Cpt
360 25111
360
360
11/12/13
11/12/13
ANESTHESIA CRNA
11/07/13
14

Patient Age:
31
DRG#:
LOS: 0
Dept Total
ANESTHESIA
11/07/13
11/12/13
11/12/13
11/12/13
OPERATING ROOM
11/07/13
11/07/13
Page: 1

LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
88.31
173.01
164.78
171.77
207.59
10485
109.83
115.00
90.58
1,225.72
272
271
17.94
9.14
17.94
9.14
pm
Page. 2

LORING HOSPITAL
211 HIGHLAND AVE
SAC CITY, IA 50583
712-662-7105
MR# / Adm #:
Guarantor #:
Doctor #:
Ins Codes:
22265/564152
HEDBERG.AMYL
14408
HEDBERG, DAVID L
241
GYANO, B. K.
05
Bed#: 523-1
Patient Type: 14

11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
Date Pst
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
11/12/13
MEDICAL SUPPLIES
11/07/13
11/07/13
11/07/13
11/07/13
11/07/13
271
272
272
272
272
271
272
272
272
272
272
271
11/12/13
11/12/13
1
4
1
1
1
1
1
1
2
1
1
1
8.82
19.56
17.39
357.62
40.38
30.28
13.68
25.32
11.64
40.32
42.24
59.68
18
258
258
11/12/13
16.34
16.34
Patient Total
Payments Received
Balance Due
16.34
16.34
32.68
410 99211
Dept Total
8.82
78.24
17.39
357.62
40.38
30.28
13.68
25.32
23.28
40.32
42.24
59.68
764.33
Dept Total
RESPIRATORY THERAPY
AR_Demand_Bill_History.rpt
Rev Cpt
Dept Total
IV SOLUTIONS
11/07/13

Patient Age:
31
DRG#:
LOS: 0
125.00
125.00
125.00
5,398.32
4,909.92
488.40
E-FILED 2014 OCT Loriruj

14 8:20 AM
Hospital
DOC~TOR
1
GYAXO ,
1
-BILLING DATE
3 .
L 12/05/13
t
jNO
[07
05
K.
O^^-^Q
fasT
PAGE
|\
/[
POLICY NUMBER
140
PEV810415271
-4^^778 37
SELF- PAY
HEDBERG ,
SAC CITY
IA
DAVID
L^
MED.
L^fe HEDBERG
TYPE
20
50583
ADMISSION DATE
12/02/13
REC, NO. ' ADMISSION NO.

30580
DISCHARGE DATE
12/02/13
BIRTHDATE
40/V/C7
G J A P A N T C R IS RESPONSIBLE FOR ANY AMOUNTS DUE AFTER THE INSURANCE COMPANIES MAKE THEIfl PAYMENTS
DATE
Ct-iARGE
CODE
12-02
DESCRIPTION
QUANTITY
VMM^M
12-02
12-02
12- ".
MMft Mî^
jflMI
CHARGE
PAY LAST
BALANCE
AMOUNT
17 . 72
28. 550
28 . 55
44 . 000
44 . 00
50 . 330
1
|
]
108 - 27
100.66
DEPT TOTAL
100.66
CHARGES
LABORATORY
108 . 2 7
REFERRAL LABORATORY
100 . 66
TOTAL CHARGES
2 0 8 . 93
BALANCE
AGE
T O
1
o . OL îy
DEPT TOTAL
OF
SEX
17 . 720
REFERRAL LABORATOR
SUMMARY
565230
CRT
18 . 000
LABORATORY
12- 02
565230
HEDBERG
HEDBERG
OAK STREET
PLAN
PATIENT NAME
DAVID L
628
30580
POLICY HOLDER
'
GUARANTOR
EXTENSION
712-S6C-3325
JN-ft
211 Highland Ave- Sac City, IA 50583
INSURANCE COMPANY
BLUE CROSS
-: L EP--ONE NO
;6(:
rV
t O "6 -(3
Cf
2C8 . 93
ib.y : -
34 3,
-* '
E-FILED 2014 OCT 27 4:27 PM SAC - CLERK OF DISTRICT COURT
E-FILED 2014 NOV 06 4:30 PM SAC - CLERK OF DISTRICT COURT
IN THE IOWA DISTRICT COURT IN AND FOR SAC COUNTY
Plaintiff(s),
L F NOLL INC
PO BOX 593
SIOUX CITY IA 51102

Case: 02811 SCSC015512
vs.
JUDGMENT ENTRY
Defendant(s),
DAVE LEE HEDBERG
628 OAK ST
SAC CITY IA 50583
AMY L HEDBERG
628 OAK ST
SAC CITY IA 50583
Amy L. Hedgerg is in default. David Lee Hedberg admits the claim but requests a $65 per month
payment plan and the court believes that the request was made on behalf of both defendants.
It is therefore Ordered that judgment is entered in favor of the plaintiff and against the defendants,
jointly and severally, in the amount of $ 942.28 with interest at the rate of 2.11 % from the 14th day
of October, 2014 and court costs.
The forgoing judgment shall be paid at the rate of $65.00 per month with the first payment due on
December 1, 2014 and on the 1st day of each month thereafter.
YOU ARE HEREBY NOTIFIED that you have a right to appeal the decision to the District Court by
giving written notice to the Small Claims Office within 20 days of the filing of this order. Filing Fee for
appeal is $185.00. Appeal Bond is set in the amount of: $950.00
1 of 2
State of Iowa Courts

Case Number
SCSC015512
Type:
Case Title
L.F. NOLL, INC. V HEDBERG, DAVID AND AMY
ORDER FOR JUDGMENT
So Ordered
Electronically signed on 2014-11-07 15:34:42
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SCSC015512 - Judgment Against Sac City Couple in The Amont $942.28 PDF

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E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT FOR SAC COUNTY

ORIGINAL NOTICE AND PETITION

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

$SSICA R. NOLL AT0008873

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

IN THE IOWA DISTRICT COURT FOR SAC COUNTY

For Defendant: AMY L. HEDBERG

T. L W&tL, VICE PRESIDENT

NOTICE OF RIGHT TO CURE DEFAUI

NCS, INC DBA

(LISTED BELOW IF MORE THAN ONE}

FAILURE TO PAY AS AGREED

Correct this default by:

Paying the ar.our.t in default, $942.28 to

THIS IS AN ATTEMPT TO COLLECT A DEBT,

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

;RING HOSPITAL 564152

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

ASSIGNMENT FOR PURPOSES OF SUIT

E-FILED 2014 OCT 14Lorin#

21 1 Highland Ave Sac City, IA 50583

MED. REC. NO. / ADMISSION NO.

ADMISSION DATE DISCHARGE DATE

MED. REC. NO. / ADMISSION NO.

E-FILED 2014 OCT 14 8:20

MED. REC. NO. / ADMISSION NO:

BLUE CROSS 140

MED. REC. NO. / ADMISSION NO

628 OAK STREET

ADMISSION DATE DISCHARGE DATE

ELB LT COMPJL MIN 3 V

ELB LT COMPJL MIN 3 V

MED. REC. NO. / ADMISSION NO.

211 Highland Ave Sac City, IA 50583

BLUE CROSS 140

MED, REC. NO, / ADMISSION NO,

628 OAK STREET

ADMISSION DATE DISCHARGE DATE

ADMISSION DATE DISCHARGE DATE

MED. REC. NO. / ADMISSION NO.

MED. REC. NO. / ADMISSION NO.

21 1 Highland Ave Sac City, IA 50583

E-FILED 2014 OCT 14 8:20 AM SAC - CLERK OF DISTRICT COURT

ASSIGNMENT FOR PURPOSES OF SUIT

Name and Official Title)

E-FILED 2014 OCT Loring~

MED. REC. NO. / ADMISSION NO.

211 Highland Ave Sac City, IA 50583

07 BLUE CROSS 140

MED. REC. NO. / ADMISSION NO.

628 OAK STREET

ADMISSION DATE DISCHARGE DATE

211 Highland Ave Sac City, IA 50583

BLUE CROSS 140

MED. REC. NO. / ADMISSION NO

628 OAK STREET

ADMISSION DATE DISCHARGE DATE

E-FILED 2014 OCT 14 Lorin^

MED. REC. NO. / ADMISSION NO.

211 Hig hland Ave Sac City, IA 50583

E-FILED 2014 OCT 14