Arcadia-Detail Gl_10 31 2009

8/14/2019 Arcadia-Detail Gl_10 31 2009

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1121

ACCT#3012846486

155

00

15

-

rAINS

InvDate

CNAInsurance

InvNbrComment

SPECIALTYSURGICALCENTEROFARCADIA,LP

.

c

Dae

Dis

122

NetAro

InvAmount

*

50


3/43

CNA DIRECT BILL ACCOUNT STATEMEBil!ing Date110-13-0~ I

Account Number PageI 3012846486 I 11 of

333 S WABASH AVEC/O BILLING & COLLECTIONS 29SCHICAGO IL 60604-4107For Account Information or Overnight Payment options call: 1-800262-19

The above address is not a Remittance AddressYour Agent/Broker: 240006516ISU INS SVCS - MERIDIAN BROKERAG22801 VENTURA BLVD. SUITE 203WOODLAD HILLS CA ~1364-1252

m001253SPECIALTY SURGICAL CENTER OF ARCADI8670 WILSHIRE BLVD.# 301BEVERLY HILLS CA ~0211-2~30

PHONE: 818-225-7025Piease call your agent regarding policy and address changes.

Due Date Minimum Due Account Balance11-04-09 $1,540.50 $12,275.00IMPORTANT NOTICEIf we do not receive the minimum due or amount due to retain current policy coverage by the due date on this invoi. You may be charged a late fee.. The due date of your next installment wil be accelerated to be due immediately.

BALACE FORWARDPAYMENTS - THAK YOU $1,540.50INSTALU~ENT PREMIL1 DUEINSTALLMENT CHARGE (Included in Minimum Due Amount)NEW BALANCE

1,540.501,540.50CR1,533.507.001,540.50

13,808.501,540.50C7.0012,275.00

1,.,?L().~ .y'?gg. ~LrS:p ,'S

SEE PAGE 2 FOR BILLING INFORMATION..............................................................................................................................................................................................................................,.'......'m,...,.........,.........__ ..............._...._...__,...__m'......,........, _. n_' ... "_......,___ 'm_m..."_."..'......__....,. ,__ . . _


4/43

CNA Due Date11H4-091

DIRECT BILL ACCOUNT STATEMEBilling Date

110-13-091Account Number Pa.ge

I 3012846486 1 I 2 of For Account Information or Overnight Payment options call: 1-80026-19

POLICY BIl:i:ING,INFORMA TION ,... ". ..".,-',...;....'-"',;,,'-,Workers CompensationPOLICY # 4 012133226ACeD - Amer ican Casualty Co of Reading i PAPolicy Term: 08/01/2009-08/01/2010INSTALLMENTINSTALLMENT CIIRGE

AMOUNTS BILLEDTOTAL AMOUNTS BILLEDTOTAL ACCOUNT BALANCE

~o~ooooooooo;;ooSN~;:oNrooN~oooo

. $PSTDUE'~:"" .$ CURRENT DUE .'$ BALANCE0.00

0.000.00 +

1,533.50 12,268.0

7.00 7.01,540.501,540.50

12,275.0


5/43

.

ISUN

ISUInsuranceServices

A

Date:10/21/2009

InvDate

InvNbr

Cmme

InvAmount

Ds

NetAmount

912

1

PolicyRenewal268042947

400

00

400

.


**********$4,017.00

0


6/43

(

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ISU Insurance Services - Meridian Brokerage22801 Ventura Blvd, Suite 203Woodland Hills CA 91364Phone: 8182257025Fax: 8182257026

Bill To: Specialty Surgical Center Of Arcadia, LP8670 Wilshire Blvd" Ste, 301Beverly Hills CA 90211

InvoiceInvoice Number: 11704

Ocr 2 1 2lgContact Code: SPECIAL T005

Agency Contact: Serge 8inanian

Involce,Dat.e "l\gent5/12/2010/11/2009

Due Date Effe;tive Date Expiration Date9/11/2009 9/15/2009

Type LOB:-Co~pny',"P.oHy',NWribtlr AmountferenceREN EPL CNA 268042947 $4,017,00olicy Renewal - Specialty Surgical Center Of ArcPlease Make Check Payable To:ISU INSURANCE SERVICES. MERIDIAN BROKERAGEThank You For Your Business!!

Coded:Q~"

'Invoice Total:.$4,017.00

V\ t a-.!,

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7/43

( E RaC;~Wi for privateNOTICE:

Declarations

THIS IS A CLAIMS.MADE POLICY AND, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TOANY CLAIM FIRST MADE DURING THE POLICY PERIOD. NO COVERAGE EXISTS FORCLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THEEXTENT THAT, THE EXTENDED REPORTING PERIOD APPLIES.DEFENSE COSTS REDUCE THE LIMIT OF LIABILITY AND ARE SUBJECT TO THERETENTION. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS THE COVERAGEWITH YOUR INSURANCE AGENT OR BROKER.-e.:" ' ,'I-;r4:N\E(D:COMpANY AND ADDRESS ,PRODuCER ,',,' ....,'.dItem 1. Specialty Surgical Center of Arcadia LP MBISI. Inc, dba SU InsuranceServices.1Vleridian Brokerage51 North 5th Avenue Kirk SinanianArcadia, CA 91006 22801 Ventura BlvdSuite 203Attn: WOODLAND i-ILLS, CA 91364I~ , " 'GUSliMER NUMBER ", 'I.l\S\!RER...'. .".406735 Continental Casualty Company1,.."",,'. MlUCYNUMBER 333 S. \\iabash Ave.268042947 Chicapo, IL 60604Ilem 2, Policy Period: 9/15/2009 to 5/12/2010

12:01 a,m, local time at the address stated in Item 1.Item 3. Policy Premium: $4.017Item 4. Notices to insurer:

CNA ProC/O: Claim Inlake Manager40 Wall Street8th FloorNew York, NY 10005Fax: 212-440-3710Phone: 212-440-3439

Item 5. Limits of Liability and Retentions iinclusive of Defense Costs), Regardless of the Optionselected, as indicated by a checked box, please refer to Columns 1 and 4 below forapplicable Coverage Parts and Prior or Pending Date.

This Policy is issued with the limits o liability and Retention Option selected below;OSingle Limit of Liilbilily and Single Retention:

Single Limit of Liability: $Single Reientlon': $0Single Limit of Liability and Scheduled Retentions:CNA Dee Page 1 or 3

G-119160-A (G/OO)


8/43

,r-.... EQa;c~'. forprivate\ '~'''-Single Limit of Liability: $1,000,000Scheduled Retentions': Refer to Column 3 below.

DScheduled Limits of Liabiliiy and Scheduled Retentions:Scheduled Limits or Liability: Refer to Column 2 below,Scheduled Releiitions*: Refer to Column 3 below.

--_.

CNA

Declarations

Dee Page 2 of 3G. 129160-A (6/00)


9/43

E ~fC,.~"~"..~1~t,,l4"""",,,,,t\4 for private DeclarationsCOVERAGE SCHEDULEThis Policy includes only those coverages designated with a "Yes" as "Included" in t.he Coverage Schedule

set forth below. If neither "Yes" nor lINoO is designated for a Coverage Part or Insuring Agreement, suchCoverage Part or Insuring Agreement is not included.1', 'Scheduled :Limits'of:LiiJility,.$

CD'.'Included, (Ys,or"No) ,

Yes

OJ, Scheduled, 'Retentions',

$25,000mployment Practices LiabilityG-129169-ADirectors' and Offcers' LiabilityG-129170.AEntity LiabilitylGeneral Coverage)G-132829-A

Yes $ $10.000(Applicable to D&O

Yes Liability and Entity $10.0DDLiability combinedwhere purchased.)No $ $No $ $

Fiduciary LiabilityG-129171-AMiscellaneous Professional LiabilityG-139035-AOther - please specify

,(1),'gr.iormpenqipg/:,'Rtroai:ive.ite ,.,'Prior or Pending Dale:

9/15/2004Prior or Pending Date:9115/2004Prior or Pending Date:9115/2004

Prior or Pending Dale:Prior or Pending Date:

RelroacLive Date:N/A

"'Pursuant to Section Vi of the General Terms & Conditions, no Retention shall apply to Loss paid onbehalf of the Insured Persons if Named Company, any Subsidiary anellor any Plan are not permitted toadvance Defense Costs or to indemnify them for loss.ltern 6. Endorsements forming a part of this Policy at issuance:

PRO-3007-A Medical Malpractice Exclusion EndorsementG-J45J25-A OFAC Renewal Policyholder NoticePRO~3 J 31 Named Company Jl1sureds EndorsementPRO.3075-A(c) Addtiol1allnsured EndorsementG- i 45 i 84-A OF AC EndorsementPRO-3059-A Entity Liability Coverage Part ExclusionsGSL-3908-XX Notice. Offer Of Terrorism Coverage Notice - Disclosure Of PremiumGSL-3842-XX Coverage And Cap On Losses From Certified Acts Of Terrorism

These Declarations, along wit.h the completed and signed Application, the Policy, and any writtenendorsements attached shall constitute the contract between the Named Company Insureds and theLnsurer.

A& 13 ,~Authorized Representative: T'.

Date: 09/11/2009

, ,---j CNA Dee Page 3 of 3C-l.29160-A (6/00)


10/43

eNAE ~;.ac;~\\~., for private companies' General Terms & Conditions

THIS IS A CLAIMS-MADE POLICY AND APPLIES ONLY TO CLAIMS FIRST MADE AGAINST THEINSURED DURING THE POLICY PERiOD. .NO COVERAGE EXISTS FOR CLAIMS FIRST MADEAGAINST THE INSURED AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THE EXTENTTHAT, THE EXTENDED REPORTING PERIOD APPLiS. DEFENSE COSTS REDUCE THE LIMIT OFLIABILITY AND ARE SUBJECT TO THE RETENTION. PLEASE REVIEW THE POLICY CAREFULLY ANDDISCUSS THE COVERAGE WITH YOUR INSURANCE AGENT OR BROKER.The Insurer and the Named Company Insureds agree as follov\.'s, in consideration of the payment of thepremiurn and in reliance upon all stat.ements made in the Application furnished to the Insurerdesignated in the Declarationsi a stock insurance corporat.ion, hereafter called the "lnSl:lrer;"i. ;rERMS AND CONDITIONSThe temis and conditions of each Coverage Part apply only to that Coverage Part and shall not apply toany other Coverage Part. If any provision in the General Terms & Conditions is inconsistent or in conflictv-,Iith the terms and conditions of any Coverage Part, the terms and conditions of such Coverage Partshall control for purposes of that Coverage Part.

Ii. EFINrrlQNSFor purposes of this Policy, words in bold have the meaning set forth below. However, any balded wordreferenced in these General Terms & Conditions but defined in a Coverage Part shall, for purposes ofcoverage under that Coverage Part, have the meaning set forth in that Coverage Part.

1, Application means all signed applications for this Policy and for any policy in anuninterrupted series of policies issued by the Insurer or any affiliate of the Insurer of whichthis Polcy is a renewal or replacement. Application includes any materials submitted orrequired to be submitted therewith. An "affiiate of the Insurer" means an insurercontrolling, controlled by or under common control with the Insurer.Coverage Part means only those coverage parts designated as included in theDeclaration.s.Defense Costs n-ieans all fees charged by attorneys designated by the Insurer, or by theNamed Company, with the Insurer's written consent and all other reasonable andnecessary fees, costs and expenses resulting hom the investigation, adjustment, defenseand appeal of a Claim if incurred by the Insurer, or by the Named Company Insuredswith the written consent of the Insurer, including the costs of appeal, attchment orsimilai' bonds. The Insurei. has no obligation to provide such bonds. Defense Cosls shallnot include salaries wages, fees, overhead or benefit expenses associated with thedirectors, officers, and employees of Named Company or any Subsidiary,ERISA or any Similar Act means the Employee Retirement Income Security i\ct or 1974,as amended/or any similar common or statutory law of the United States, Camida or theirstates, territories or provinces or any other jurisdiction anywhere in the world.Executive Officer means:

2,,J,

4.

S.d. with respect to Named Company or any Subsidiary, its chairperson, chierexecutive ofncer, president, chie financial offcer and in.house general counsel,and, under the Employment Practices Lia.bility Coverage Part (if included) only, thedirector of human resources or equivalent position; andb. with respect to a Plan, its natllal person fiduciaries as defined in ERISA or any

Similar Act,

GTe Page 1 or 11G-132823-A (6)00)


11/43

l420

Entity#165593H001

.

418

00

418

RSDae

AnthemBlueCross

InvNbr

Caroment

:ALYSURICLCNTOFAR

DIA,L

.

Ac

Date:11/5/2009

InvAmount

Dis

NetAmount

*

8

0


12/43

ANTHEM BLUE CROSSP.O, BOX 629WODDLAND HL S , CA

Anthem 0+1 of 2615987

'91365UIIlC.,,,IndBpBndliiiUcllllBBB altha BluB CroBoABBccialion.~

Invoice Number 000269279B Billing Enti ~y No. 165593H001Prior Bill AmountAmount PaidPrior Balance :Due $

65,178.6065,178.60-o .00$

E1igibili ~y Adjus~men~ Sub~0~a1Manual Adjus~ment SubtotalMembership De~ai1 Subto~al

1,604.020,0070,240.52Total Amount Due (; 71,844.54

OCT 2 6 2009Anthem Blue Cross .is colleciing premium doller.s on benel f 'of Anthem B1uB Cross Land H.

Please Return this Page With Your Check- - -- -- - - --- - -- -- - ---- -- -- - ------ - - - -- -- - ---- - -- - - - --,- - -- - -- -- - ----- -- -- - --- - - - - - - --- - - - - --Please Fold Here for Mailing

ANTHEM BLUE CROSSP.O, BOX 629WOODLAND HLS , CA 91365

t:) 10_:1ti:iJi

11,1..11",,,1.1,,,11,,,11,,1,11,1,,..11,11,..1,,,1,11,,11..,1 WH 'Bill En~ No. : 165593HOOIcococo'"U1'"SPECIAL TY SURGICAL CENTERC/O YVETTE DAVIS-DUCKETT8670 WILSHIRE BLVD STE 301BEVERLY HILLS CA 90211-2930

Invoice Number:Billing period:Date Billed:Total Due:

000269279B11-01-09 To 12-01-0910-14-09$71 ,844,54

Enter Amoun~ Paid J_.__'___ 2SYS DESK2 4463

BILL,ENTITY165593H001

MBSNUMBER66300000

ANTHEM BLUE CROSSDepartment 5812Los Angeles, CA 90074-5812

Make Check Payable To: . ~

Due Date11-01-09 5812


13/43

BILLING DETAIL Anthemo-i 19 of 2616005ui..c,,~IndepandentLiclUee 01he BluB Cro1lsAssQcalion.

Billing Entity Name:Billing Entity No.Group Contact

SPECIAL TV SURGICALI65593H001VVETTE D. DUCKETTCENTER Invoice No,:Page No.: 000269279B18

Premium Specialist: HERMOSURA) C. Desk No.: 4463 Telephone: (818) 234-2322Billing Period:Date Ililled:Payment Due Date:

FRDMll-01-09 TO 12-01-0910-14-0911- 01-09

~EMIlERSHI P DET AI L .-----.Dept Emp. COBRA Group No Grp Prod Cont No. Premo

to No. No, No, Subscriber Name End Dab / Suff ix Type Type Type Cvd Volulre Amt..-- --50A1122.7 005 PHUONG ~ CHA.LANG 165593H001 A CALC S+DEP 2 669.57005 1655930003 A LCNS LSUB 15,000 2.40

DOS 1655930004 A ADD LSUB 15,000 0.30005 ,165593000.5 A vis S+DEP 2 IE .03fi321\66858 005 RAPHAEL) LACEY A 165593H001 A CALC 2P 2 818 . 36005 1655930003 A LCNS LSUB 15,000 2.40

005 1655930004 A ADD LSUB 18,000 0.30f99A63796 005 SPELLMAN, JASON D 165593Ho01 A cALC 2P 2 a18 .36005 16,65930003 A LCNS LSUB .15,000 2.40005 1655930004 A ADD LSUB 15,000 0.30;$OA72732 005 VELAZQUEZ, EDUARDO 1655930003 A LCNS LSUB 15.,000 2.40005 1655930004 A ADD LSUB 1S.,000 0.30,6A20455 005 VITTDRI, HEATHER T 165593H001 A CALC S 1 371 . 98005 165S930003 A LCNS LSUB 15,000 2.40

005 16SS930004 A ADD LSUB 15,000 0.30005 1655930005 A vis S 1 8.35L22A61774 005 HEISER, JOY A 165593H001 A CALC S 1 371.98005 1655930003 A LCNS LSUB 15,000 2,40005 16S5930004 A ADD LSUB 15,000 0.30005 1655930005 A vis S 1 8.35~64A62B7B 005 WHITE, TERI A 165593H001 A CALC S 1 371,98005 165.5930003 A LeNS LSUB 1.5,000 2,40

005 1655930004 A ADD lSUB 1.5,000 0.30005 16559'3000.5 A vis S 1 8.35Subtotal for tne DBPartinBni: li 005 17 9,761.44L03A51577 006 AULT, SHERYL A 165593H001 A PBPe S 1 596.92006 16551)30003 A LeNS lSUB 1.5,000 2.40

006 165.51)30004 A ADD LSUB 15.,000 0.30006 1655930005 A vis S 1 8.35

L03A69946 006 BUEND) REGINA H 16.5.593H001 A CALC S 1 371. 98006 165.593t1D03 A LCNS LSUB 1.5,000 2.40006 1655930004 A ADD LSUB 15,000 0.30

Group Number identifies the Product and Carrier


14/43

BILLING DETAIL Anthem.~""~",, 20 of 2616006Independent Liclloeoftli BJueCrassAisoeatian.Billing Entity Name:Billing Entity No.Group Contact

SPECIAL TV SURGICAL CENTER165595HOOIVVETTE D. DUCKETTInvoice No.:Page No,: 000269279B19

Premium Specialist: HERMOSURA, C, Desk No,: 4465 Telephone: (818) 234-2522Billing Period:Date Billed:Payment Due Date:

FROM 11-01-09 TO 12-01-0910-14-0911-01-09MEMBERSHI P DET AI L

in No.Depi;No.

698A69767 006006006006

064A72897 006006169A50791 006006006006607A70012 006006006219A73487 006006006217A69758 006006006S31A68941 006006006006OOSA71S41 006086258A70589 006006006

Einp.No. COBRAEnd Daieubscriber Nams Group No Grp Prod Cont/ Suffix Type Type TypeCANDILORAJ SUSAN L 165593HOOl A

1655930003 A165.5930004 A1655930005 ACELIS) .JENNY S 16559$0003 A1655930004 ACENIZAL, JOSEPHINE B 165593HOl A1655930003 A1655930004 A1655930005 ACROWLEY J KATHLEEN 165.593H001 A1655930003 A1655930004 AHALL) TONI R 1655930003 A1655930004 A1655930005 A

JENSEN, SEDLEY W 165593HOOl A1655930003 A1655930004 AKWAK, KARYN 165593H001 A1655930003 A1655930004 A1655930005 AMUNOZ) JOSE L 1655930003 A1655930004 AQUEZADA) HARISOl 165!l93MODl A1655930003 A1655930004 ASti~totai..,c;for.,~thB,.,Depar:Llleni: tll\':'".:'.,",\,'.; ;"',,...;-.,_.......~,-.-:"~~ : .,-;,."".,.-,

No,CvdPBPC SLCNS LSUBADO LSUBvis SLCNS LSUBAOD LSUBPBPC SLCNS LSUBADD LSUBvis SCALC SLCNS LSUBADD LSUBLCNS LSUBADD LSUBvis 2PPBPC SLCNS LSU8ADD LSUBCALC SLCNS LSUBADD LSUBViS SLCNS LSUBADD LSUBPBPC SLCNS LSUBADD LSUB006 '

VolultB1

15,00015)0001 lS.100015)0001 15.100015,.00011 15)00015,00015.100015,,0002,1 15)00015,0001 15,00015,0001 15,00015,0001 15,,00015)00011

Pren.Ant.596.92

2.40.0.308,352.400.30596.922.400.308..3.6371.982,400.302,400.3014.20596,922,400.30371. 982.400.308.352.400.30596. 922.'100.30

'fr-"~j7.8~,

Group Number identifies the Producl and Carrier


15/43

Summary of Blue Cross Invoices for Novetter 2009

310 311 312 315 318 ,,;~G.?O. 321SARC BW Wilshire Encino Irvine f:~Arcadia.:" Thousand Oaks TotalEligibility Adjs 383.03 837.96 383,03 1,87295 3,476.97COBRA 383.03 599,62 835.26 743.96 2,561,87Membership Dept 001 13,158,74 13,158.74Membership Dept 002 5,485,51 5,485,51Membership Dept 003 12,678,20 12,678.20Membership Dept 004 12,988.69 12,988.69Membership Dept 005 9,761.44 9,761.44Membership Dept 006 4,177.84 4,17784Membership Dept 007 7,555,28 7,555,2813,924.80 6,085.13 12,678,20 14,661,91 10,888.43 1',11.;1;77,841: 9,428.23 71,844.54


16/43.

.

InvDate

51Group,LLC

InvNbrComment

Ac

5GRU

1221

ReNo0

200

00

200

InvAmount

Date:10/22/2009

DiscountNetAmount


*

00

0

~


17/43

Specialty Surgical Center of Arcadia

Check Request FormDate: 10/21/2009

Amount: $ 29,021,00

Payable To: 51 Group(51GRDU)

Address:

Reason 'for Check:Rent Nov-09

G/L Account#: 1550-0000-00-00

Approved: Contract Date:

RH


18/43

Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 10f1Time: 10:39AM Detail General Ledaer M Standard Report: 0162D.rpUser: KMEHR Period: 10-09 As of: 11/5/2009 Company: 32Ledaer ID: ACTIJAIAccount Subaccount Description Beginning Credit EndingPer Jrnl Trn Ref Tran Debit NetPost Type Type Nbi Date Description Balance Amount Amount Change Balance

1730 0000.00-00 LEASEHOLDS IMPROVEMENTSTotals 10-09 1,129,690.00 0.00 0.00 0.00 1,129,690.0

1740 0000.00-00 FURNITURE, FIXTURES & EQUIPTotals 10-09 73,493.31 0.00 0.00 0.00 73,493.3

1750 0000.00-00 COMPUTER & SOFlW ARETotals 10-09 107,765.86 0.00 0.00 0.00 107,765.8

1760 0000-00-00 MEDICAL EQUIPMENTTotals 10-09 2,037,133.76 0.00 0.00 0.00 2,037,133.7

1765 0000.00.00 MED EQUIP - CAP LEASETotals 10.09 51,765.41 0.00 0.00 0.00 51,765.4

* Indicates that the period entered is different from the period post.** Indicates an account that is out of balance.


19/43

Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 10fTime: 1 0:39AM Detail General Ledaer - Standard Report: 01620.rpUser: KMEHR Period: 10-09 As of: 11/5/2009 Company: 32Ledaer 10: ACTUAlAccount Subaccount Description Beginning Credit EndingPer Jrnl Trn Ref Tran Debit NetPost Type Type Nbi Date Description Balance Amount Amount Change Balance

7010 OOOO~OO-OO CONTRACT LABOR .0-09 AP VO 011714 10/6/2009 EDDRAM Eddie Ramirez 1.720,00./ 0.0010-09 AP VO 011735 10/13/2009 EDDRAM Eddie Ramirez 1,750.00 .. 0.0010-09 AP VO 011795 10/21/2009 EDDRAM Eddie Ramirez 1,799.80 0.0010-09 AP VO 011829 10/29/2009 EDDRAM Eddie Ramirez 1,615.00 if 0.0010..9 AP VO 011876 11/5/2009 EDDRAM Eddie Ramirez 1,600.00/ 0.00

Totals 10.09 70,348.00 8,484.80 0.00 8,484.80 DR 78,832.87011 0000-.0-00 NURSING SERVICES /0-09 AP VO 011744 10/14/2009 INNMED Innervisions Medical LL 180.00 0.00

10-09 AP VO 011745 10/14/2009 INNMED lariarvisions Medical LL 90.00 V 0,0010.09 AP VO 011796 10/21/2009 INNMED Innervisions Medical LL 90.00 v' 0,0010-09 AP VO 011797 1 0/21/2009 INNMED Innervisions Medical LL 180.00 V 0,0010.09 AP VO 011798 10/21/2009 INNMED lnnervisions Medical LL 180.00 j 0,0010-09 AP VO 011819 10/28/2009 INNMED lnnervislons Medical LL 180.00 0.0010-09 AP VO 011872 11/4/2009 SURSTA Surgical Staff, Inc 969,00/ 0.00Totals 10-09 37,633.39 1,869.00 0.00 1,869.00 DR 39,502.3

'" Indicates that the period entered is different from the period post.*'" Indicates an accunt that is out of balance.


20/43

Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 2 of Time: 1 0:39AM Detail General Ledaer - Standard Report: 01620.rpUser: KMEHR Period: 10-09 As of: 11/5/2009 Company: 32Ledaer 10: BlJDGFTAccount Subaccount Description Beginning Credit EndingPer Jrnl Trn Ref Tran Debit NetPost Type Type Nbr Date Description Balance Amount Amount Change Balance

7011 0000.00-00 NURSING SERVICES10.09 1,650.00 0.00

Totals 10.09 14,850.00 1,650.00 0.00 1,650.00 DR 16,500.0

* Indicates that the period entered is different from the period post.** Indicates an account that is out of balance.


21/43

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160

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Camment

LTYSURGICALCENTEROFARCADIA,LP

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De152

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Ds

NetAmount

*

*

60

0


22/43

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Employeename:EddieRamirez

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24/43

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OCT292009

WeeklyTimeSheet

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INERVISIONS MEDICAL, LLC Invoice12155 Riverside Dr.Valley Vilage, CA 91607 Date Invoice #10/13/2009 091008

Bill ToSpecialty Surgical Center of Arcadia51 N. Fifth Ave.Suite 101Arcadia, CA 91006

((j'j:1)', '\ i \\ .,'...,..~".:..."P.O, No, Terms Project

Net7Quantity Description Rate Amount

4 Certified Radiological Technologist for staffing purposes. Operator of: C-arm/X.ray 45,00 180,00equipment. Charges include a minimum of(4) hours for each day services areprovided.Date of Service: 10-1"2.09Hours of Service: 9:30am-1:30pmTech: Rebecca Regala

Please make checks payable to:iNNERVISIONS MEDtCAL, LLC12155 Riverside DriveValley Village, CA 91607

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33/43

INNERVISIONS MEDICAL, LLC12155 Riverside Dr.Valley Vilage, CA 91607

InvoiceDate Invoice #

10/1312009 091011

Bill ToSpecialty Surgical Center of Arcadia51 N. Fiftb Ave.Suite 101Arcadia, CA 91006 I~';",r )~'"" ,.~~\~) /'-=../

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P.O, No, Terms ProjectNet?

Quantity . Description Rate Amount1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45,00Date of Service: 10-08-09

Tech: Gentry Dawson

1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45.00Date of Service: 10. i 2.09Tech: Randy Vejar

Please make checks payable to:INNERVISIONS MEDICAL, LLC12155 Riverside DriveValley Village, CA 91607

: ,-\'.;:c( ~ ~ If

!l -lqO ,74 a~.~- -~~~~,_._,.---_..,~.---- ....-._--_.-Thank you for your business. Total $90,00


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35/43

INERVISIONS MEDICAL, LLC Invoice12155 Riverside Dr.Valley Vilage, CA 91607 Date Invoice #10/1/2009 090945

Bill ToSpecialty Surgical Center of Arcadia51 N, Fifth Ave,Suite 101Arcadia, CA 91006 /'i:;;:"

/ 1,\:3:1 '\\, (/;)~:" J. .",_41 /'-~

P.O. No. Terms ProjectNet?

Quantity Description , Rate Amounti Weekly Fluoroscopy Testing and Monitoring. 45,00 45,0Date of Service: 09.21-09Tech: Randy Vejar1 Weekiy Fluoroscopy Testing and Monitoring. 45,00 45,0

Date of Service: 09-28-09Tech: Randy VejarPlease make checks payable to:1NRVISIONS MEDICAL, LLC12155 Riverside DriveValley Vilage, CA 91607

7Q)L ",.'.~ --. .~ fa lb..J2;f..9-,..,.-, ..''.-- ._,,--,...,~"""'.' .."~-~~..~". ._".

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36/43

INERVISIONS MEDICAL, LLC12155 Riverside Dr.Valley Vilage, CA 91607


10/1/2009 090948

Bill ToSpecialty Surgical Center of Arcadia51 N, Fifth Ave.Suite 101Arcadia, CA 91006 (~fi\

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P,O, No, Terms ProjectNet 7

Quantity Description Rate Amount4 Certified Radiological Technologist for staffing purposes. Operator of: C-annlX-ray 45.00 180.0equipment. Charges include a minimum of (4) hours for each day services areprovided.

Date of Service: 09-28-09Hours of Service: lO:OOam-2:00pmTech: Randy Vejar

Please make checks payable to:INRVISIONS MEDICAL, LLC12155 Riverside DriveValley Vilage, CA 91607

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INERVISIONS MEDICAL, LLC12155 Riverside Dr.Valley Vilage, CA 91607


9/J 7/2009 090921

Bill ToSpecialty Surgical Center of Arcadia51 N, Fifth Ave,Suite 101Arcadia, CA 91006 ('A\,Q

P,o. No. Terms ProjectNet7

Quantity Description Rate Amount4 Ceitifjed Radiological Technologist for staffng purposes. Operator of: C.ann/X-ray 45.00 180,00equipment. Charges include a minimum of(4) hours for each day services areprovided.

Date of Service: 09-14-09Hours of Service: IO:OOain.2:00pmTech: Randy Vejar

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39/43

1NNERV1S10NS MEDICAL, LLC12155 Riverside Dr.Valley Vilage, CA 91607


9/17/2009 090922

Bill ToSpecialty Surgical Center of Arcadia51 N. Fifth Ave.Suite 101Arcadia, CA 91006

-:

----_.._.._~---./A'\g

p,o, No, Terms ProjectNet?

Quantity Description Rate AmountI Weekly Fluoroscopy Testing and Monitoring. 45,00 45,0Date of Service: 09-08-09Tech: Gentry Dawson

1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45,0Date of Service: 09-14.09Tech: Randy Vejar

Please make checks payable to:tNRVIS10NS MEDICAL, LLC12155 Riverside DriveValley Village, CA 91607

..' ."..,'.', '4t:1(01\ ,....',. O"-CO.._,9;,2..,..,..".._-_.....

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40/43

INNERVISIONS MEDICAL, LLC Invoice12155 Riverside Dr.Valley Village, CA 91607 Date Invoice #9/22/2009 090935

Bill ToSpecialty Surgical Center of Arcadia51 N, Fifth Ave.Suite 101Arcadia, CA 9J006 ('11~..I

P,O. No. Terms ProjectNet?

Quantity Description Rate Amount4 Certified Radiological Technologist for staffing purposes. Operator of: C-ar11/X-ray 45.00 180.0equipment. Charges include a minimum of (4) hours for each day services areprovided.Date of Service: 09-21-09Hours of Service: 11 :30am-3:30pmTech: Randy Vejar

Please make checks payable to:lNERVISI0NS MEDlCAL, LLC12155 Riverside DriveValley Vilage, CA 91607

loa .tJ ""~"---'-'~""~-tiO)Thank you for your business. Total $180.


41/43

CORPORATE OFFICEPO BOX 192SAN MATEO, CA 94401-0192accounting rg surgicalstaff .com800-780-4029800-339-9599Fax 650-558-3949SURGICAL STAFF, me.

79-4SPECI.TY SURGICAL CE-ARCAIA51 N. FIF AVE #101ARCADIA, CA 91006ATT, BRI GRAYL

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Northern CaliforniaSan Francisco Bay Area(800) 339-9599Travel DivisionNationwide 1 West(888) 339-9559Central CaliforniaSacramento 1 Valley(800) 540.5285Southern CaliforniaLos Angeles I San Diego(800) 331-7720Pacific NorthwestSeattle 1 Portland(888) 339-9559East CoastPAlNY/Mid.AtlanIc(800) 722-6794SoutheastGA/TN/FL(800) 699.7001Travel-MidwestNationwidelEast(BOO) 996-0577INVOICE198884 10-28-20#

DATE WORK WEEK ENDING: .10-24-2009PLEASE INCLUDE INVOICE NUMBER WITH PAYMENT

LN Date Emloyee/Description Day 'lii/Desc.1 10-21 YUO BAH,ORN2 10-22 YUO . BAH,ORN WEI.1'!ll

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THIS INVOICE REPRESENTS WAGES AND IS PAYABLE UPON RECEIPT,1 1/2% interest per month charged on past due accounts.Tfj~ .~gGI.GA~_STAfEJ J.N_C,


42/43

Oct 26, 200S 10: 50 SURG I CAL STAFF 31057000S0 p. is~ OCT -22-2009 THU t 2; 07 PM~ IJURG1CA.L STAF" INC.

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Oct 26 20DS 10: 50 SURG I CAL STAFF 3105700090 p.20'DC-22-20DB TliU 12;07 Ptl~ FAXNIJ. P. 02SIGN-IN SHEET (J MvfLOY IJ 61678'1'101 Parkway, Sulle 440 ' ,Cui..r City, CA 802"0.&812(810) 57P-0D92FAX" 310-570..090PERIQD i:i:VSReD: tDh ~

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Arcadia-Detail Gl_10 31 2009

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