Exhibit F to Decl. in support of Cost Bill, Page 1 of 4

DATE 10/07/15 PATlENT NAME Dean S Wessels 

P ATIF.NT NUM.RER 127363 

NAME OF 

COMl,ANY OGLETREE, DEAKINS, NASH, SMOAK & 

STEWART, PC ATTORNEYS AT LAW 

ADDRESS 

CITY 

PHONE: 

TO WHOM IT MAY CONCERN: 

WE HAVE RECEIVED YOUR REQUEST FOR INFORMATION REGARDING THE PATIENT 

ABOVE. IT IS OUR POLICY TO SECURE PAYMENT FOR THlS SERVICE. PLEASE SUBMIT 

$24.75 FOR THE ENCLOSED MEDICAL RECORDS. THE CHECK 4600 1707 fOR $40.00 HAS 

ALREADY BEEN DEDUCTED FROM THE TOTAL AMOUNT DUE. 

0 MEDICAL RECORDS: l69 PAGES. 

PAYMENT SHOULD BE REMITTED TO: 

NORTHWEST PRIMARY CARE 

P.O. BOX 22075 

MILWAUKIE, OR 97269 

IF YOU WOULD LlKE TO MAKE A CREDIT CARD PAYMENT OVER THE PHONE, PLEASE 

CALL (503) 353-1256 

OUR TAX ID #: 93 0599056 
Exhibit F to Decl. in support of Cost Bill, Page 2 of 4

PROVIDENCE HEALTH & SERVICES 

dba Providence Central Release of Information 

4400 NE Halsey Street 

REQUESTER: 

Deakins Ogletree 

Attn to: 

The Koin Center 

222 Sw Columbia Street 

Suite 1500 

Portland, Oregon 97201 

DATE: 9/22/15 

POP 1, STE 286 

Portland, OR 97213 

(503) 215-7423 

HIM DEPT #481-87090 RELEASE OF INFORMATION INVOICE 

For producing copies of medical records for: 

Patient Name: Wessels, Dean Smith 

EPN: 

MRN: 20001697087 

Request Date: 9/8/2015 Invoice Date: 912212015 Invoice Number: 90456 

Taxes: 

Balance Due: 

$0.00 

$38.32 

------------------------PLEASE RETURN LOWER PORTION WITH PAYMENT----------------------

HIM DEPT#481-87090 PROVIDENCE HEALTH & SERVICES IRS# 51-0216586 

PO BOX 4950, PORTLAND, OR 97208 

dba Providence Central Release of Information 

Requester: Deakins Ogletree 

Attn to: 

Patient Name: Wessels,Dean Smith 

MRN: 20001697087 

Release 10: 23888558 

Thank you, 

Santiago Barajas 

Health Information Management 

Invoice Number: 90456 

Invoice Date: 9/22/2015 

Page Count: 23 

Balance Due: $38.32 

PLEASE WRITE THE MRN ON CHECK 
Date Initials Name / Invoice Number Code Quantity Rate Amount Description Cost Index

9/8/2015 3347 Molly Hester 5070 165 0.10           16.50$ Copies 7768028

10/20/2015 Invoice=1443373 165 0.10           16.50$

9/9/2015 3347 Molly Hester 5070 24 0.10              2.40$ Copies 7768982

10/20/2015 Invoice=1443373 24 0.10              2.40$

9/23/2015 2807 Aimee Davis 5070 380 0.10           38.00$ Copies 7781459

10/20/2015 Invoice=1443373 380 0.10           38.00$

9/23/2015 3347 Molly Hester 5070 220 0.10           22.00$ Copies 7781460

10/20/2015 Invoice=1443373 220 0.10           22.00$

9/23/2015 2807 Aimee Davis 5070 695 0.10           69.50$ Copies 7781461

10/20/2015 Invoice=1443373 695 0.10           69.50$

9/24/2015 3347 Molly Hester 5070 22 0.10              2.20$ Copies 7782721

10/20/2015 Invoice=1443373 22 0.10              2.20$

9/25/2015 2807 Aimee Davis 5070 15 0.10              1.50$ Copies 7783782

10/20/2015 Invoice=1443373 15        0.10 $      1.50

9/25/2015 3347 Molly Hester 5070 108 0.10           10.80$ Copies 7783783

10/20/2015 Invoice=1443373 108 0.10           10.80$

9/25/2015 3347 Molly Hester 5070 91 0.10              9.10$ Copies 7783784

10/20/2015 Invoice=1443373 91 0.10              9.10$

9/29/2015 3347 Molly Hester 5070 180 0.10           18.00$ Copies 7788987

10/20/2015 Invoice=1443373 180 0.10           18.00$

10/12/2015 3347 Molly Hester 5070 36 0.10              3.60$ Copies 7828831

11/19/2015 Invoice=1455369 36 0.10              3.60$

11/13/2015 2807 Aimee Davis 5070 1 0.10              0.10$ Copies 7888783

12/16/2015 Invoice=1469524 1 0.10              0.10$

11/20/2015 3672 Amanda Wickham 5070 5 0.10              0.50$ Copies 7895418

12/16/2015 Invoice=1469524 5 0.10              0.50$

11/20/2015 3672 Amanda Wickham 5070 11 0.10              1.10$ Copies 7895419

12/16/2015 Invoice=1469524 11 0.10              1.10$

11/20/2015 3672 Amanda Wickham 5070 1        0.10 $      0.10 Copies 7895420

12/16/2015 Invoice=1469524 1 0.10              0.10$

12/4/2015 1932 Heidi King 5070 14 0.10              1.40$ Copies 7927741

1/25/2016 Invoice=1481737 14 0.10              1.40$

12/21/2015 2807 Aimee Davis 5070 25 0.10              2.50$ Copies 7943702

1/25/2016 Invoice=1481737 25 0.10              2.50$

12/21/2015 2807 Aimee Davis 5070 25 0.10              2.50$ Copies 7943703

1/25/2016 Invoice=1481737 25 0.10              2.50$

Exhibit F to Decl. in support of Cost Bill, Page 3 of 4
12/29/2015 3347 Molly Hester 5070 36 0.10              3.60$ Copies 7947983

1/25/2016 Invoice=1481737 36 0.10              3.60$

12/29/2015 3347 Molly Hester 5070 116 0.10           11.60$ Copies 7947984

1/25/2016 Invoice=1481737 116 0.10           11.60$

1/7/2016 658 Elizabeth A. Falcone 5070 4 0.10              0.40$ Copies 7976268

2/5/2016 Invoice=1485153 4 0.10              0.40$

1/22/2016 1932 Heidi King 5070 12 0.10              1.20$ Copies 7987978

2/5/2016 Invoice=1485153 12 0.10              1.20$

2/23/2016 1932 Heidi King 5070 7 0.10              0.70$ Copies 8063964

3/15/2016 Invoice=1503967 7 0.10              0.70$

2/24/2016 1932 Heidi King 5070 52 0.10              5.20$ Copies 8065372

3/15/2016 Invoice=1503967 52 0.10              5.20$

2/25/2016 1932 Heidi King 5070 2 0.10              0.20$ Copies 8067067

3/15/2016 Invoice=1503967 2 0.10              0.20$

3/2/2016 2807 Aimee Davis 5070 93 0.10              9.30$ Copies 8080876

3/11/2016 2807 Aimee Davis 5070 12        0.10 $      1.20 Copies 8092462

UNBILLED TOTALS:   WORK:    10.50$ 2 records

UNBILLED TOTALS:   BILL:    10.50$

BILLED TOTALS:     WORK: 224.70$ 25 records

BILLED TOTALS:     BILL: 224.70$

GRAND TOTAL:       WORK: 235.20$ 27 records

GRAND TOTAL:      BILL: 235.20$

Date Initials Name / Invoice Number Code Quantity Rate Amount Description Cost Index

9/24/2015 3347 Molly Hester 5072 18.00            0.75$ 13.5 Color Copies Rate .75/pg 7782722

10/20/2015 Invoice=1443373      18.00       0.75$ 13.5

BILLED TOTALS:     WORK: 13.5 1 records

BILLED TOTALS:     BILL: 13.5

GRAND TOTAL:       WORK: 13.5 1 records

GRAND TOTAL:      BILL: 13.5

Exhibit F to Decl. in support of Cost Bill, Page 4 of 4