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CLAIM OF LION ~ ~
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STAT$ OF FLORIDA
(;OjJNTY OF BROWARD
Donald J. Redmond, Memorial Hospital, 3501 Johnson St., Hollywood, Fla. 33021
Hollywood, Florida, being first duly sworn, says that he is the .Patient
Accounts Manager of Memorial Hospital, Hollywood, Florida.
That Memorial Hospital, in Pursuance of a contract with Joaquin
Camejo pf ~ r
Florida has furnished care, treatment and maintenance to Joaquin Camejo
•
at Memorial Hospital, 3501 Johnson St., Hollywood, Florida 33021;
That Joaquin Camejo -Was admitted to Memorial Hospital, on
the 22nd day of September ~ ig 79 and was thereafter cared for,
treated and maintained by Memorial Hospital to and including the 1~ day
of December ~ lg 79
That the affiant is informed and to his best knowledge believes that
~:•person-or persons unknown is resFsonsible to Memorial Hospital
for the injury or illness of Joaquin Camejo
That the anwunt due and unpaid is just and reasonable, and Memorial
Hospital does hereby claim a lien upon any and all causes of action, suits,
'I' claims, counter-claims and demands accruing to Joaquin Camejo
f 1
and upon all judgments, settlements and settlement agreements rendered or
p entered into by virtue thereof on account of the illness or injury giving rise
s to such causes of action, suits, claims, counter-claims, demands; judgments,
settlement agreements and which necessitated or shall have necessitated such
~ hospital care, treatments and maintenance as furnished the said
Joaquin Camejo by Memorial Hospital. .
That there is now due and ow3.ng Memorial Hospital, for care, treatment
and maintenance of Joaquin Camejo the sum of $ 52,668.00
Subscribed and sworn to before me Don old J. Re nd, Patient Accts. Mgr.
L..? ~ _
this ~ 7 day of , ~ ~ ~
~ , ~,~„~~j:~~r,,, Notary Pui~lic State of Fla. at Large
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