Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 10f1

Time: 10:38AM Detail General Ledaer - Standard Report: 01620.rpt

User: KMEHR Period: 10-09 As of: 11/5/2009 Company: 320
Ledaer 10: ACTUAL
Account Subaccount Description
Ending
Beginning Debit Credit Net
Per Jrnl Trn Ref Tran
Description Balance Amount Amount Change Balance
Post Type Type Nbr Date
1510 0000.00-00 PREPAID INSURANCE
10-09 GJ GL STD 05 10/3112009 EXP MONTHLY PORTION OF INS 0.00 10,738.70

10-09 AP VO 011791 10/21/2009 CNAINS CNA Insurance ,.540.50~ 0.00

10.09 AP VO 011806 10/21/2009 ISUINS ISU Insurance Services 4,017.00 ;/ 0.00
10-09 AP VO 011810 10/27/2009 BLCROS Anthem Blue Cross 4,177.84 ' 0.00
10-09 AP VO 011812 10/27/2009 HUMDEN HumanaDental Ins. Co. 614.25 0.00

Totals 10-09 19,787.24 10,349.59 10,738.70 389.11 CR 19,398.13

1520 0000-00-00 PREPAID CONTRACTS

10-09 GJ GL STD 05 10/31/2009 EXP MONTHLY CONTRACTS 0.00 2.482.05

Totals 10-09 4,590.66 0.00 2,482.05 2,482.05 CR 2,108.61

1550 0000-00-00 PREPAID RENT

10-09 GJ GL STD 05 10/31/2009 EXP 51 GROUP LLC-OCT RENT 0.00/29,021.00
10.09 AP VO 011807 10/20/2009 51 GROU 51 Group, LLC 29,021.00 0.00
Totals 10-09 29,021.00 29,021.00 29,021.00 0.00 29,021.00

1560 0000.00-00 PREPAID TAXES

10-09 GJ GL STD 05 10/31/2009 EXP OCT PPD TAXES 0.00 1,547.5

Totals 10-09 13,927.06 0.00 1,547.45 1,547.45 CR 12,379.61

1590 0000.00.00 PREPAID OTHER

Totals 10-09 15,000.00 0.00 0.00 0.00 15,000.00

* Indicates that the period entered is different from the period post.
** Indicates an account that is out of balance.
r
.
CNAINS CNA Insurance Ácct:
.
Date: 10/22/2009
Inv Date Inv Nbr Comment Inv Amount Discount Net Aro
10/13/2009 101309 ACCT # 3012846486 1,540.50 0.00 1,540.
-
SPECIALTY SURGICAL CENTER OF ARCADIA, LP **********$1,540
0320005
 BILL ACCOUNT STATEMENT
CNA DIRECT

Bil!ing Date Account Number Page

110-13-0~ I I 3012846486 I 11 of 21
For Account Information or Overnight Payment options call: 1-800262-196
333 S WABASH AVE
C/O BILLING & COLLECTIONS 29S
CHICAGO IL 60604-4107

The above address is not a Remittance Address 001253

Your Agent/Broker: 240006516 SPECIALTY SURGICAL CENTER OF ARCADIA
ISU INS SVCS - MERIDIAN BROKERAGÉ ¡m 8670 WILSHIRE BLVD.# 301
22801 VENTURA BLVD. SUITE 203 BEVERLY HILLS CA ~0211-2~30
WOODLAD HILLS CA ~1364-1252

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

Due Date Minimum Due Account Balance

11-04-09 $1,540.50 $12,275.00

IMPORTANT NOTICE
If we do not receive the minimum due or amount due to retain current policy coverage by the due date on this invoice,
. You may be charged a late fee.
. The due date of your next installment wil be accelerated to be due immediately.

..- BALACE FORWARD 1,540.50 13,808.50

PAYMENTS - THAK YOU $1,540.50 1,540.50CR 1,540.50CR
INSTALU~ENT PREMIúL1 DUE 1,533.50
INSTALLMENT CHARGE (Included in Minimum Due Amount) 7.00 7.00
NEW BALANCE 1,540.50 12,275.00

1,.
.,?L().~ .y'?gg. ~LrS:Çpù ,'S

SEE PAGE 2 FOR BILLING INFORMATION

..............................................................................................................................................................................................................................,.'......'m,...,.........,..........
n.__ ..............._...._...__,...__m'......,........, _. n_' ... "_......,___ 'm_m..."_."..'......__....,. ,__ . . _
 DIRECT BILL ACCOUNT STATEMENT
CNA Due Date Billing Date Account Number Pa.ge
11H4-091 110-13-091 I 3012846486 1 I 2 of 21
For Account Information or Overnight Payment options call: 1-80026-196

..".,-',...;....
POLICY BIl:i:ING,INFORMA TION ,... ". '-"',;,,'-,
. $PÄSTDUE'~:"" .$ CURRENT DUE .'$ BALANCE'
Workers Compensation 0.00 1,533.50
POLICY # 4 012133226 12,268.00
ACeD - Amer ican Casualty Co of Reading i PA
Policy Term: 08/01/2009-08/01/2010
INSTALLMENT

INSTALLMENT CIIRGE 0.00 7.00 7.00

AMOUNTS BILLED 0.00 + 1,540.50

TOTAL AMOUNTS BILLED 1,540.50
TOTAL ACCOUNT BALANCE 12,275.00

-
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 ISU Insurance Services Acct:
. Date: 10/21/2009
ISUINS
Inv Date Inv Nbr Comment Inv Amount Discount Net Amount
9/11/2009 11704 Policy Renewal 268042947 4,017.00 0.00 4,017.00
.

SPECIALTY SURGICAL CENTER OF ARCADIA, LP **********$4,017. 00

0320005501
 Invoice
ISU Insurance Services - Meridian Brokerage
22801 Ventura Blvd, Suite 203
Invoice Number: 11704
Woodland Hills CA 91364
( Phone: 8182257025
Fax: 8182257026

Ocr 2 1 2lg
Bill To: Specialty Surgical Center Of Arcadia, LP
8670 Wilshire Blvd" Ste, 301
Beverly Hills CA 90211 Contact Code: SPECIAL T005
Agency Contact: Serge 8inanian

Involce,Dat.e "l\gent Due Date Effeç;tive Date Expiration Date

9/11/2009 9/11/2009 9/15/2009 5/12/2010

Type LOB:-Co~pàny',"P.oHçy',NWribtlr Réference Amount

REN EPL CNA 268042947 Policy Renewal - Specialty Surgical Center Of Arc $4,017,00

Please Make Check Payable To: 'Invoice Total:.$4,017.00

ISU INSURANCE SERVICES. MERIDIAN BROKERAGE
Thank You For Your Business!!

Coded:
ßQ~" V\ t a-.!
,

"~=-..,._D_""''''_'''''''''''~~'''';L__""

~-""==--==~==.,

'~-' J
 Declarations
E RaC;~Wiç for private
(
,
NOTICE:

THIS IS A CLAIMS.MADE POLICY AND, SUBJECT TO ITS PROVISIONS, APPLIES ONLY TO

ANY CLAIM FIRST MADE DURING THE POLICY PERIOD. NO COVERAGE EXISTS FOR
CLAIMS FIRST MADE AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THE
EXTENT THAT, THE EXTENDED REPORTING PERIOD APPLIES.

DEFENSE COSTS REDUCE THE LIMIT OF LIABILITY AND ARE SUBJECT TO THE
RETENTION. PLEASE REVIEW THE POLICY CAREFULLY AND DISCUSS THE COVERAGE
WITH YOUR INSURANCE AGENT OR BROKER.

-e.:" ' ,'I-;r4:N\E(D:COMpANY AND ADDRESS ,PRODuCER ,',,' ....,'.d

MBISI. Inc, dba ¡SU Insurance -_._~.._..~
Item 1. Specialty Surgical Center of Arcadia LP
Services.1Vleridian Brokerage
51 North 5th Avenue
Kirk Sinanian
Arcadia, CA 91006
22801 Ventura Blvd
Suite 203

I~
Attn:
, " 'GUSliüMER NUMBER
406735
WOODLAND i-ILLS, CA 91364
",
'I.l\S\!RER...'.
Continental Casualty Company
.".
1,.."",,'. MlUCYNUMBER 333 S. \\iabash Ave.
268042947 Chicapo, IL 60604

Ilem 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: $4.017

Item 4. Notices to insurer:

CNA Pro
C/O: Claim Inlake Manager
40 Wall Street
8th Floor
New York, NY 10005
Fax: 212-440-3710
Phone: 212-440-3439

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

This Policy is issued with the limits oí 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)
 Declarations
,r-.... EQa;cí~'. forprivate
l\ '~'''-
Single Limit of Liability: $1,000,000
Scheduled 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 Dee Page 2 of 3

G. 129160-A (6/00)
 Declarations
il4"""",,,,,t\4
E ~fC,.~"~"..~1~t,, for private
COVERAGE SCHEDULE
This 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, such
Coverage Part or Insuring Agreement is not included.
CD

'.'Included
1', '
Scheduled :
OJ
, Scheduled
,(1),
'gr.ior¡mpenqipg/:,'
, (Yès,or"No) , Limits'of:LiàiJility,. , 'Retentions', Rètroai:Íive.¡¡ite ,.,'
Employment Practices Liability Yes $ $25,000 Prior or Pending Dale:
G-129169-A 9/15/2004
Directors' and Offcers' Liability Yes $ $10.000 Prior or Pending Date:
G-129170.A (Applicable to D&O 9115/2004
Entity LiabilitylGeneral Coverage) Yes Liability and Entity $10.0DD Prior or Pending Date:
G-132829-A Liability combined
9115/2004
where purchased.)
Fiduciary Liability No $ $ Prior or Pending Dale:
G-129171-A
Miscellaneous Professional Liability No $ $ Prior or Pending Date:
G-139035-A RelroacLive Date:
N/A
Other - please specify

"'Pursuant to Section Vi of the General Terms & Conditions, no Retention shall apply to Loss paid on
behalf of the Insured Persons if Named Company, any Subsidiary anellor any Plan are not permitted to
advance 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 Endorsement
G-J45J25-A OFAC Renewal Policyholder Notice
PRO~3 J 31 Named Company Jl1sureds Endorsement
PRO.3075-A(c) Addítiol1allnsured Endorsement
G- i 45 i 84-A OF AC Endorsement
PRO-3059-A Entity Liability Coverage Part Exclusions
GSL-3908-XX Notice. Offer Of Terrorism Coverage Notice - Disclosure Of Premium
GSL-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 written
endorsements attached shall constitute the contract between the Named Company Insureds and the
Lnsurer.

A& 13 ,~
Authorized Representative: T'.

Date: 09/11/2009

,,
'---j CNA Dee Page 3 of 3
C-l.29160-A (6/00)
eNA
General Terms & Conditions
E ~;.¡ac;~\\~.,
"' for private companies

THIS IS A CLAIMS-MADE POLICY AND APPLIES ONLY TO CLAIMS FIRST MADE AGAINST THE
INSURED DURING THE POLICY PERiOD. .NO COVERAGE EXISTS FOR CLAIMS FIRST MADE
AGAINST THE INSURED AFTER THE END OF THE POLICY PERIOD UNLESS, AND TO THE EXTENT
THAT, THE EXTENDED REPORTING PERIOD APPLiS. DEFENSE COSTS REDUCE THE LIMIT OF
LIABILITY AND ARE SUBJECT TO THE RETENTION. PLEASE REVIEW THE POLICY CAREFULLY AND
DISCUSS 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 the
premiurn and in reliance upon all stat.ements made in the Application furnished to the Insurer
designated in the Declarationsi a stock insurance corporat.ion, hereafter called the "lnSl:lrer;"

i. ;rERMS AND CONDITIONS

The temis and conditions of each Coverage Part apply only to that Coverage Part and shall not apply to
any other Coverage Part. If any provision in the General Terms & Conditions is inconsistent or in conflict
v-,Iith the terms and conditions of any Coverage Part, the terms and conditions of such Coverage Part
shall control for purposes of that Coverage Part.

Ii. ÐEFINrrlQNS
For purposes of this Policy, words in bold have the meaning set forth below. However, any balded word
referenced in these General Terms & Conditions but defined in a Coverage Part shall, for purposes of
coverage 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 an
uninterrupted series of policies issued by the Insurer or any affiliate of the Insurer of which
this Polícy is a renewal or replacement. Application includes any materials submitted or
required to be submitted therewith. An "affiiate of the Insurer" means an insurer
controlling, controlled by or under common control with the Insurer.
2, Coverage Part means only those coverage parts designated as included in the
Declaration.s.
,
J, Defense Costs n-ieans all fees charged by attorneys designated by the Insurer, or by the
Named Company, with the Insurer's written consent and all other reasonable and
necessary fees, costs and expenses resulting hom the investigation, adjustment, defense
and appeal of a Claim if incurred by the Insurer, or by the Named Company Insureds
with the written consent of the Insurer, including the costs of appeal, attchment or
similai' bonds. The Insurei. has no obligation to provide such bonds. Defense Cosls shall
not include salaries¡ wages, fees, overhead or benefit expenses associated with the
directors, officers, and employees of Named Company or any Subsidiary,
4. 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 their
states, territories or provinces or any other jurisdiction anywhere in the world.
S. Executive Officer means:
d. with respect to Named Company or any Subsidiary, its chairperson, chier
executive ofncer, president, chieî financial offcer and in.house general counsel,
and, under the Employment Practices Lia.bility Coverage Part (if included) only, the
director of human resources or equivalent position; and
b. with respect to a Plan, its natllal person fiduciaries as defined in ERISA or any
Similar Act,

GTe Page 1 or 11
G-132823-A (6)00)
ROS Anthem Blue Cross Acct:
.
Date: 11/5/2009
Date Inv Nbr Caromen t Inv Amount Discount Net Amount
l4/2009 0002692798 Entity #165593H001 . 4,177.84 0.00 4,177.84

:IALTY SURGICAL CENTER OF ARCADIA, LP **********$41177.84

0320005543
 1 of 26
15987
0+ -

~
ANTHEM BLUE CROSS Anthem
UIIlC.,,,
P.O, BOX 629 IndBpBndliiiUcllllBBB altha BluB CroBoABBccialion.
WODDLAND HL S , CA '91365

Invoice Number 000269279B Billing Enti ~y No. 165593H001

Prior Bill Amount $ 65,178.60

Amount Paid 65,178.60-
Prior Balance :Due $ o .00

E1igibili ~y Adjus~men~ Sub~0~a1 1,604.02

Manual Adjus~ment Subtotal 0,00
Membership De~ai1 Subto~al 70,240.52

Total Amount Due (; 71,844.54

OCT 2 6 2009

Anthem 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

h
ANTHEM BLUE CROSS
P.O, BOX 629
t:) 10
_:1ti:iJi-- ~
WOODLAND HLS , CA 91365

11,1..11",,,1.1,,,11,,,11,,1,11,1,,..11,11,..1,,,1,11,,11..,1 WH 'Bill En~ No. : 165593HOOI

RI
co
co
co SPECIAL TY SURGICAL CENTER
'" Invoice Number: 000269279B
U1
'" C/O YVETTE DAVIS-DUCKETT
8670 WILSHIRE BLVD STE 301 Billing period: 11-01-09 To 12-01-09
Date Billed: 10-14-09
BEVERLY HILLS CA 90211-2930 Total Due: $71 ,844,54

¡;
Enter Amoun~ Paid J_.__'___ 2 i.
F
Make Check Payable To: . ~ ANTHEM BLUE CROSS
Department 5812
BILL MBS Los Angeles, CA 90074-5812
SYS DESK ,ENTITY NUMBER Due Date
2 4463 165593H001 66300000 11-01-09 5812
 19 of 26
16005
BILLING DETAIL
Anthemo-i ui..c,,~
~
IndepandentLicßlUee 01the BluB Cro1lsAssQcÎalion.

Billing Entity Name: SPECIAL TV SURGICAL CENTER Invoice No,: 000269279B

Billing Entity No. I65593H001 Page No.: 18
Group Contact VVETTE D. DUCKETT

Premium Specialist: HERMOSURA) C. Desk No.: 4463 Telephone: (818) 234-2322

Billing Period: FRDMll-01-09 TO 12-01-09

Date Ililled: 10-14-09
Payment Due Date: 11- 01-09

~EMIlERSHI P DET AI L
.-----.
to No.

~50A1122.7 005
Dept
No,

005
Emp.
No, Subscriber Name

PHUONG ~ CHA.LANG
COBRA
End Dab
Group No
/ Suff ix

165593H001
1655930003
-- --
A
Grp Prod
Type Type

A
CALC
LCNS
Cont
Type

S+DEP
LSUB
No.
Cvd

2
Volulre

15,000
Premo
Amt..

669.57
2.40
DOS 1655930004 A ADD LSUB 15,000 0.30
005 ,165593000.5 A vis S+DEP 2 IE .03
fi321\66858 005 RAPHAEL) LACEY A 165593H001 A CALC 2P 2 818 . 36
005 1655930003 A LCNS LSUB 15,000 2.40
005 1655930004 A ADD LSUB 18,000 0.30
f99A63796 005 SPELLMAN, JASON D 165593Ho01 A cALC 2P 2 a18 .36
005 16,65930003 A LCNS LSUB .15,000 2.40
005 1655930004 A ADD LSUB 15,000 0.30
;$OA72732 005 VELAZQUEZ, EDUARDO 1655930003 A LCNS LSUB 15.,000 2.40
005 1655930004 A ADD LSUB 1S.,000 0.30
,ö6A20455 005 VITTDRI, HEATHER T 165593H001 A CALC S 1 371 . 98
005 165S930003 A LCNS LSUB 15,000 2.40
005 16SS930004 A ADD LSUB 15,000 0.30
005 1655930005 A vis S 1 8.35
L22A61774 005 HEISER, JOY A 165593H001 A CALC S 1 371.98
005 1655930003 A LCNS LSUB 15,000 2,40
005 16S5930004 A ADD LSUB 15,000 0.30
005 1655930005 A vis S 1 8.35
~64A62B7B 005 WHITE, TERI A 165593H001 A CALC S 1 371,98
005 165.5930003 A LeNS LSUB 1.5,000 2,40
005 1655930004 A ADD lSUB 1.5,000 0.30
005 16559'3000.5 A vis S 1 8.35
Subtotal for tne DBPartinBni: li 005 17 9,761.44
L03A51577 006 AULT, SHERYL A 165593H001 A PBPe S 1 596.92
006 16551)30003 A LeNS lSUB 1.5,000 2.40
006 165.51)30004 A ADD LSUB 15.,000 0.30
006 1655930005 A vis S 1 8.35
L03A69946 006 BUEND) REGINA H 16.5.593H001 A CALC S 1 371. 98
006 165.593t1D03 A LCNS LSUB 1.5,000 2.40 ~
006 1655930004 A ADD LSUB 15,000 0.30 ¡.
p

Group Number identifies the Product and Carrier

 20 of 26
16006
BILLING DETAIL
Anthem.~ a""~",,
~
Independent LicÐlloeoftli BJueCrassAisoeÎatian.

Billing Entity Name: SPECIAL TV SURGICAL CENTER Invoice No.: 000269279B

Billing Entity No. 165595HOOI Page No,: 19
Group Contact VVETTE D. DUCKETT

Premium Specialist: HERMOSURA, C, Desk No,: 4465 Telephone: (818) 234-2522

Billing Period: FROM 11-01-09 TO 12-01-09

Date Billed: 10-14-09
Payment Due Date: 11-01-09

MEMBERSHI P DET AI L

Depi; Einp. COBRA Group No Grp Prod Cont No, Pren.

in No. No. No. Subscriber Nams End Daie / Suffix Type Type Type Cvd VolultB Ant.

698A69767 006 CANDILORAJ SUSAN L 165593HOOl A PBPC S 1 596.92

006 1655930003 A LCNS LSUB 15,000 2.40
006 165.5930004 A ADO LSUB 15)000 .0.30
006 1655930005 A vis S 1 8,35
064A72897 006 CELIS) .JENNY S 16559$0003 A LCNS LSUB lS.1000 2.40
006 1655930004 A AOD LSUB 15)000 0.30
169A50791 006 CENIZAL, JOSEPHINE B 165593HÐOl A PBPC S 1 596.92
006 1655930003 A LCNS LSUB 15.1000 2.40
006 1655930004 A ADD LSUB 15,.000 0.30
006 1655930005 A vis S 1 8..3.6
607A70012 006 CROWLEY J KATHLEEN 165.593H001 A CALC S 1 371.98
006 1655930003 A LCNS LSUB 15)000 2,40
006 1655930004 A ADD LSUB 15,000 0.30
219A73487 006 HALL) TONI R 1655930003 A LCNS LSUB 15.1000 2,40
006 1655930004 A ADD LSUB 15,,000 0.30
006 1655930005 A vis 2P 2 14.20
217A69758 006 JENSEN, SEDLEY W 165593HOOl A PBPC S ,1 596,92
006 1655930003 A LCNS LSU8 15)000 2,40
006 1655930004 A ADD LSUB 15,000 0.30
S31A68941 006 KWAK, KARYN 165593H001 A CALC S 1 371. 98
006 1655930003 A LCNS LSUB 15,000 2.40
006 1655930004 A ADD LSUB 15,000 0.30
006 1655930005 A ViS S 1 8.35
OOSA71S41 006 MUNOZ) JOSE L 1655930003 A LCNS LSUB 15,000 2.40
086 1655930004 A ADD LSUB 15,000 0.30
258A70589 006 QUEZADA) HARISOl 165!l93MODl A PBPC S 1 596. 92
006 1655930003 A LCNS LSUB 15,,000 2.'10
006 1655930004 A ADD LSUB 15)000 0.30
Sti~totai..,c;for.,~thB,.,Depar:Llleni: tll\':'
".:'.,",\,'.; ;"',,.¿..;-.,
006 ' 11 'fr-"~j7.8~,
_.......~,-.-:"~~ : .,-;,."".,.-,

Group Number identifies the Producl and Carrier

Summary of Blue Cross Invoices for Novetter 2009

310 311 312 315 318 ,,;~G.?O. 321

SARC BW Wilshire Encino Irvine f:~Arcadia.:" Thousand Oaks Total
Eligibility Adjs 383.03 837.96 383,03 1,87295 3,476.97
COBRA 383.03 599,62 835.26 743.96 2,561,87
Membership Dept 001 13,158,74 13,158.74
Membership Dept 002 5,485,51 5,485,51
Membership Dept 003 12,678,20 12,678.20
Membership Dept 004 12,988.69 12,988.69
Membership Dept 005 9,761.44 9,761.44
Membership Dept 006 4,177.84 4,17784
Membership Dept 007 7,555,28 7,555,28
13,924.80 6,085.13 12,678,20 14,661,91 10,888.43 1',11.;1;77,841: 9,428.23 71,844.54
. .
5IGROU 51 Group, LLC
Acct: Date: 10/22/2009
Inv Date Inv Nbr Comment Inv Amount Discount Net Amount
10/20/2009 110109 Rent Nov '09 29,021.00 0.00 29,021.00

SPECIALTY SURGICAL CENTER OF ARCADIA, LP

*********$29,021.00
0320005502
~
 Specialty Surgical Center of Arcadia

Check Request Form

Date: 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
Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 10f1
Time: 10:39AM Detail General Ledaer M Standard
Report: 0162D.rpt
User: KMEHR Period: 10-09 As of: 11/5/2009 Company: 320
Ledaer ID: ACTIJAI
Account Subaccount Description
Tran Beginning Debit Credit Net Ending
Per Jrnl Trn Ref
Post Type Type Nbi Date Description Balance Amount Amount Change Balance

1730 0000.00-00 LEASEHOLDS IMPROVEMENTS

Totals 10-09 1,129,690.00 0.00 0.00 0.00 1,129,690.00

1740 0000.00-00 FURNITURE, FIXTURES & EQUIP

Totals 10-09 73,493.31 0.00 0.00 0.00 73,493.31

1750 0000.00-00 COMPUTER & SOFlW ARE

Totals 10-09 107,765.86 0.00 0.00 0.00 107,765.86

1760 0000-00-00 MEDICAL EQUIPMENT

Totals 10-09 2,037,133.76 0.00 0.00 0.00 2,037,133.76

1765 0000.00.00 MED EQUIP - CAP LEASE

Totals 10.09 51,765.41 0.00 0.00 0.00 51,765.41

* Indicates that the period entered is different from the period post.
** Indicates an account that is out of balance.
Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 10f2
Time: 1 0:39AM Detail General Ledaer - Standard Report: 01620.rpt
User: KMEHR Period: 10-09 As of: 11/5/2009 Company: 320
Ledaer 10: ACTUAl
Account Subaccount Description
Beginning Debit Credit Net Ending
Per Jrnl Trn Ref Tran
Balance
Post Type Type Nbi Date Description Balance Amount Amount Change
7010
10-09 AP
OOOO~OO-OO
VO 011714 10/6/2009
CONTRACT LABOR
EDDRAM Eddie Ramirez 1.720,00./ .¡ 0.00
10-09 AP VO 011735 10/13/2009 EDDRAM Eddie Ramirez 1,750.00 .. 0.00
10-09 AP VO 011795 10/21/2009 EDDRAM Eddie Ramirez 1,799.80 0.00
10-09 AP VO 011829 10/29/2009 EDDRAM Eddie Ramirez 1,615.00 if 0.00
10..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 78,832.80

0000-.0-00 NURSING SERVICES

7011
10-09 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 0,00
10.09 AP VO 011796 10/21/2009 INNMED Innervisions Medical LL 90.00 v' 0,00
10-09
10.09
10-09
10-09
AP
AP

AP

AP
VO

VO

VO

VO
011797
011798
011819
011872
1 0/21/2009

10/21/2009
10/28/2009
11/4/2009
INNMED Innervisions Medical LL

INNMED lnnervisions Medical LL

INNMED lnnervislons Medical LL

SURSTA Surgical Staff, Inc

180.00
180.00
180.00
969,00/
j
V 0,00
0,00
0.00
0.00

Totals 10-09 37,633.39 1,869.00 0.00 1,869.00 DR 39,502.39

'" Indicates that the period entered is different from the period post.
*'" Indicates an accunt that is out of balance.
Date: Thursday, November 05, 2009 sse of Arcadia, LP Page: 2 of 2
Time: 1 0:39AM Detail General Ledaer - Standard Report: 01620.rpt
User: KMEHR Period: 10-09 As of: 11/5/2009 Company: 320
Ledaer 10: BlJDGFT
Account Subaccount Description
Beginning
Per Jrnl Trn Ref Tran Debit Credit Net Ending
Post Type Type Nbr Date Description Balance Amount Amount Change Balance

7011 0000.00-00 NURSING SERVICES

10.09 1,650.00 0.00

Totals 10.09 14,850.00 1,650.00 0.00 1,650.00 DR 16,500.00

* Indicates that the period entered is different from the period post.
** Indicates an account that is out of balance.
.M Everardo Ramirez Jr. Acct:
.
Date: i 1/5/2009
~~
te Inv Nbr Cammen t Inv Amount Discount Net Amount
12009 103009 W/E 10/25-10/31/09 1,600.00 0.00 1,600.00
-

LTY SURGICAL CENTER OF ARCADIA, LP

******"-***$1,600.00
0320005545
 1(4\
/"'7"'~""
I\~~tft,
NOV 0 3 2009
Weekly Time Sheet
Employee name: Eddie Ramirez Week starling: 10/2512009
Week ending: 10/31/2009
7:30AM Total 7:30AM
4.50 10:30 AM
Totol I 12:30PM I Tofol Il2:15PMI Total I
"'3OPMI Total I
",30 PM
I
Total I 12,00
PM
I
Totol I I
Total
Total Hours
Scheduled
0.00

0.00
I /~
i "'IOPM
//~

3.50 4:00PM
7..75
. ""--.-

3.75 .
-'-"

3:45 PM
8.25

3.25
.. .'.~", ...

4:00PM
8.00

3.50 5:00 PM i
. _.,......
8.00

5.00
0.00'

0,00
.."r_.... I
40.00 ~0::
./
ô; . tß(cl(c/
Z
Dafe M~n~~ Dote
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DmQ __ 11 4kr,.Q;
flQ/fL
 .
i-
.
EDDRAM Everardo Rarnire z Jr.
Acct:
Inv Date Inv Nbr Date: 10/29/2009
Comment
10/29/2009 102409 Inv Amount Discount Net Amount
W/E 1.0/24/09 1,615.00 0.00
, 1,615.00
-
SPECIALTY SURGICAL CENTER OF ARCADIA, LP J
**********$1/615. DC
0320005541
 OCT 2 9 2009
Weekly Time Sheet
Employee name: Eddie Ramirez Weey starting: 10/18/2009
Week ending: 10/2412009
'~,. '
l~t~\9áli200~.Td" "i:;i¡nz¥lr~i~i¡ I, ....,.rôí~Î,~%í~ i~tli§!~4Ï2il?~~~~, ¡~it!~. :'A~t
Total 7:00AM i Tofal I 7:0AM I Total I 7:30AM I Total I I Tolal ",,:;;~;"')~'.::.,t~!ll!
....'.,
4.00 3:00 PM 8,00 3:00 PM 8.qO 3:30 PM 8.00 0.00
Total 12:30 PM I Total 12:15 PM I Total Total Tofùl Total Total
Total Hours
Scheduled
..
0.00 4:00 PM I 3.50 4:30 PM I 4.25 . (,.00 Q,oo . 0.00 0.00. Jf? tP
0.00 8.00 8.25 8.00 8.00 8.00 0.00 4a.25 11: Ù~(j
YJ ./
/ /D - ;2- 61 (~e-i(C! i
Dote Do e
1ViO \0l'L -c
(, .....u,_''''''',.~"
'i¡
 Everardo Ramirez Jr. Acct:
.
Date: 10/22/2009
lv Nbr Comment Inv Amount Discount Net Amount
1709 WEEK 10/11 10/17/09 1,799.80 0.00 1,799.80

GICAL CENTER OF ARCADIA, LP

**********$1,799.80
0320005519
 ocr 2 0 2009
Weekly Time Sheet
_._,
!
/'Q-. '\
(, ,,'''''.,-
(1' ~ )
\ \\.,.~ J
"",,,.:::.,,Y"" Week starting: 10/11/2009
Employee name: Eddie Ramirez
Weekending: 10/17/2009
1,~i1~é#t~;~1iOl.lt:~~?~::~/~~':~:
Total 6:3AM Total 8:30 AN Total &:3 AM TQtol 8:30 AM Total 7:40AM Total
0.00 12;00 PM 5.50 1:3PM 5,00 4:00PM 7,50 12:00 PM 3.50.' I 2;30 PM 6,83 0.00
Total 12:30 PM Tafel 2:00PM Tolal Total I
12"OPM I Total I I
Tolol I I
Total
Total Hou~ II 0
0.00 6;00 PM 550 7:30 PM 5'.50 0.00 I .,30PM I 4.00 I I 0.00 I I 0.00Scheduled ;J \A
I '-0 C?O
";
/j
0.00
"'.'
1,1.00 .
¡
I 10.50 7,50, I
,,¥",".~-..- .... "
7.50
I
6.83
n ..'~' . . ~ ..I
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fa
re-~~) I () - -
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.
EDDRAM
Inv Date
Everardo Ramirez Jr.
Acct:
.
Inv Nbr Comment Date: i 0/8/2009
10/3/2009 100309 Inv Amount Discount Net Amount
W/E 10/03/09
1,720.00 0.00 1,720.00
,
",,~
SPECIALTY SURGICAL CENTER OF ARCADIA, LP
**********$1r 720.00
0320005488
 ocr ~ 6 2l/
Weekly Time Sheet
Employee name: Eddie Ramirez Weekstarfing: 9/27/2009
Week ending: 10/31'009
Total 6:30AM Total 7:30AM Total 7:00 AM Total 7:30AM Toiol 8:00 AM Totçil Total
0,00 12;00 PM 5.5 12:00 PM 4.50 12:00 PM 5.00 12:00 PM 4.50 12:00 PM 4.00 0.00
-'.":: ~ \i:~%'~;f~~:.%i~;i:~~~;.~..~t:11f;?~~~lti~J£l~jßHf.'; -:.::3?~1~;1:,2)-:": -;":~::~'?Y/~';~'~~:i:l~W~rf~j~:~-~:J\~:' ;~'::'",;~ :~/~? ?rt,~1~.t(~~fIJ;~
Tofol 12: PM Toiol 12:30 PM Total 12:30 PM Total 12:30 PM Totol' 12:30 PM Tofal- Total
--O
Total Hours
Scheduled tJD d. (f
0.09 4:00PM 3.50 5:00PM 4.50 4:00PM 3.50' 4:30 PM 4.00 3:30 PM 3,00 0,00
t/P
0.00 9.00 '9.00 8,50 B.S!? 7.00 0.00 42.00
..7 /7'
lù . r/Oo¡ ¡0(e(0 -1.
Date Date
L/ '7(0 L72.m
,",.'.'ll!';;'-.,"="- .=..'==~"-=.._=~"."_.._.. ~. -_~~
,--..-.~"""'''''.~''..''~='..'---.''
-~=~.~~~.....~.~-~...'=~-"..- RH
l.__
ï
. .
EDDRAM Everardo Ramirez Jr.
Inv Date Acct:
Inv Nbr Conuen t Date: i 0/16/2009
10/10/2009 101009 W/E 10/10/09
Inv Amount Discount Net Are
1,750.00 0.00 1,750
.
SPECIAL~Y SURGICAL CENTER OF ARCADIA, LP
**********$1,750
0320005:
 OCT 1 3 2009
Weekly Time Sheet
Employee nome: Eddie Ramirez Week startng: 10/4/2009
Weekending: 10/10/2009
8:30AM 8:00 AM Total
)2jJOPM 4.0Q.
-l
I--
""'':'
.".. i~"-:~~'::';Y:-.~~:k~~
Total J2:30PM Tofal Totol Total Il2~OPM I Total ¡,2:30PM I Total
Total Hours
Scheduled '- ;) v¡i)
0.00 6:0PM .5.50 0,00 O.DO I 4:30PM I 4.00 I 4:30PM I 4no I O.DO ?-~ ~ iJ (pD
I
.0.00 11.00 8.00 8.00 i 7.50 i 8.00 0.00 42._50
. .....-..-..."..
)0 -ii'
Date
Coded: fÛ RH
?D~O
""~''''''' k,.,-,,,,,,,,=~~_...""=.-.
t?SD.
l,.",_~
'--'
 . Dale: 11/5/2009
Innervisions Medical LLC Acct:
NMED Discount Net Amoun t
Inv Amount
.v Date Inv Nbr Comment
180.00 0.00 180.00
,/13/2009 91008 D.O.S. 10/12/09
. 90.00 0.00 90,00
1/13/2009 91011 D.O.S. 10/8,10/12/09

************$270.00
PECIALTY SURGICAL CENTER OF ARCADIA, LP 0320005547
 INERVISIONS MEDICAL, LLC Invoice
12155 Riverside Dr.
Date Invoice #
Valley Vilage, CA 91607
10/13/2009 091008

Bill To
Specialty Surgical Center of Arcadia
51 N. Fifth Ave.
Suite 101
Arcadia, CA 91006

((j'j:1)', '
\ .,
\ i \
"'...,..~".:..."

P.O, No, Terms Project

Net7

Quantity Description Rate Amount

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

Please make checks payable to:

iNNERVISIONS MEDtCAL, LLC
12155 Riverside Drive
Valley Village, CA 91607

"',o'c,,,::,
',x'.,::'¡'"",. 1t go
ílò\(
"';"","'."~,,,,--, . 0000 _, ( .0)
. ....__..~" -_."_...,,~.~,. ",'"

"----- e",_'__,_.",,'

Thmik you for yOllr business.

Total $180.00
 INNERVISIONS MEDICAL, LLC Invoice
12155 Riverside Dr.
Date Invoice #
Valley Vilage, CA 91607
10/1312009 091011

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

P.O, No, Terms Project

Net?

Quantity . Description Rate Amount

1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45,00
Date of Service: 10-08-09
Tech: Gentry Dawson

1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45.00

Date of Service: 10. i 2.09
Tech: Randy Vejar

Please make checks payable to:

INNERVISIONS MEDICAL, LLC
12155 Riverside Drive
Valley Village, CA 91607

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

-lqO ,74 òa
-~~~~,_._,.---_.
....-._--_.-
.,~.----

Thank you for your business.

Total $90,00
 ;~~-_..
INNMED Innervisions Medical LLC
Acct:
.
Date: 10/22/2009
Inv Date Inv Nbr Comment Inv Amount Discount Net Amount
10/1/2009 90945 D.O.S. 9/21 & 9/28/09 90.00 0.00 90.00
10/1/2009 90948 D.O.S. 9/28/09 180.00 0.00 180.00

SPECIALTY SURGICAL CENTER OF ARCADIA, LP

** ****** * ***$270.00
0320005523
 INERVISIONS MEDICAL, LLC Invoice
12155 Riverside Dr. Date Invoice #
Valley Vilage, CA 91607
10/1/2009 090945

Bill To
Specialty Surgical Center of Arcadia
51 N, Fifth Ave,
Suite 101
Arcadia, CA 91006 /'íi:;;:"
/ 1,\:3:1 '\

~'-~
\, (/¡;)~:¡" J
. .",_41 /

P.O. No. Terms Project

Net?
,
Quantity Description Rate Amount

i Weekly Fluoroscopy Testing and Monitoring. 45,00 45,00

Date of Service: 09.21-09
Tech: Randy Vejar

1 Weekiy Fluoroscopy Testing and Monitoring. 45,00 45,00

Date of Service: 09-28-09
Tech: Randy Vejar

Please make checks payable to:

1NRVISIONS MEDICAL, LLC
12155 Riverside Drive
Valley Vilage, CA 91607

, 7Q)L ",.'.~ --. .~ fa lb

..J2;f..9-,..,.-, ..''.-- ._,,--,...,

~"""'.' .."~-~~..~". ._".

Thank you for your business.

Total $90,00
 INERVISIONS MEDICAL, LLC Invoice
12155 Riverside Dr.
Date Invoice #
Valley Vilage, CA 91607
10/1/2009 090948

Bill To
Specialty Surgical Center of Arcadia
51 N, Fifth Ave.
Suite 101
Arcadia, CA 91006
(~fi\
\"''.\(~1'
f (~/' /
""-"'

P,O, No, Terms Project

Net 7

Quantity Description Rate Amount

4 Certified Radiological Technologist for staffing purposes. Operator of: C-annlX-ray 45.00 180.00
equipment. Charges include a minimum of (4) hours for each day services are
provided.
Date of Service: 09-28-09
Hours ofService: lO:OOam-2:00pm
Tech: Randy Vejar

Please make checks payable to:

INRVISIONS MEDICAL, LLC
12155 Riverside Drive
Valley Vilage, CA 91607

,~"" '..:_~ '-,.\,,'

7?,iJ, __Ø2JjlSL.,_,.__!Jd:r¿JD
. .. -,. '-~.. ".'... -.'-.

Thank you for your business.

Total $180,00
lED Innervisions Medical LLC
Acel':
.
Jate Inv Nbr Date: 10/8/2009
Comment Inv Amount
/2009 90921 Discount Net Amount
D.O. S. 9/14/09 .
180.00 0.00 180.00
/2009 90922 D.a.S. 9/8 & 9/14/09 90 00 0.00 90.00
/2009 90935 D.O.S. 9/21/09 180 00 0.00 180.00

ALTY SURGICAL CENTER OF ARCADIA, LP

************$450.00
0320005490
 ~

INERVISIONS MEDICAL, LLC Invoice

12155 Riverside Dr. Date Invoice #
Valley Vilage, CA 91607
9/J 7/2009 090921

Bill To
Specialty Surgical Center of Arcadia
51 N, Fifth Ave,
Suite 101
Arcadia, CA 91006

('A
\,Q
P,o. No. Terms Project

Net7

Quantity Description Rate Amount

4 Ceitifjed Radiological Technologist for staffng purposes. Operator of: C.ann/X-ray 45.00 180,00
equipment. Charges include a minimum of(4) hours for each day services are
provided.
Date ofService: 09-14-09
Hours ofService: IO:OOain.2:00pm
Tech: Randy Vejar

Please make checks payable to:

INERVISIONS MEDICAL, LLC
12155 Riverside Drive
Valley Village, CA 91607

'0.';' -,:c '_,__ ~'"'

r¿QiL .. 0?9-Q ,~ -" _~lfs !-fl,

--.... - , - ,.__C'~~'_" _, ..u.,..

Thank you for your business.

Total $180,00
 1NNERV1S10NS MEDICAL, LLC Invoice
12155 Riverside Dr. Date Invoice #
Valley Vilage, CA 91607
9/17/2009 090922

Bill To
Specialty Surgical Center of Arcadia
-:
51 N. Fifth Ave.
Suite 101
Arcadia, CA 91006

/A'
----_.._.._~---. \g
p,o, No, Terms Project

Net?

Quantity Description Rate Amount

I Weekly Fluoroscopy Testing and Monitoring. 45,00 45,00

Date of Service: 09-08-09
Tech: Gentry Dawson

1 Weekly Fluoroscopy Testing and Monitoring. 45,00 45,00

Date ofService: 09-14.09
Tech: Randy Vejar

Please make checks payable to:

tNRVIS10NS MEDICAL, LLC
12155 Riverside Drive
Valley Village, CA 91607

..' ."..,'.', '4t:O"-CO

,....',.
1(01\ .._,9;,2..,..,..".._-_.....
~._.,_.~_~."C_~.v.., _,. .

Thank you for your business.

Total $90,00
 INNERVISIONS MEDICAL, LLC Invoice
12155 Riverside Dr. Date Invoice #
Valley Village, CA 91607
9/22/2009 090935

Bill To
Specialty Surgical Center of Arcadia
51 N, Fifth Ave.

Suite 101
Arcadia, CA 9J006
('1
i~..I
1

P,O. No. Terms Project

Net?

Quantity Description Rate Amount

4 Certified Radiological Technologist for staffing purposes. Operator of: C-ar11/X-ray 45.00 180.00
equipment. Charges include a minimum of (4) hours for each day services are
provided.
Date of Service: 09-21-09
Hours of Service: 11 :30am-3:30pm
Tech: Randy Vejar

Please make checks payable to:

lNERVISI0NS MEDlCAL, LLC
12155 Riverside Drive
Valley Vilage, CA 91607

loa .
tJ ""~"---'-'~""~-

tiO¡ó)

Thank you for your business.

Total $180.00
 Northern California
San Francisco Bay Area
(800) 339-9599
CORPORATE OFFICE Travel Division
Nationwide 1 West
PO BOX 192 (888) 339-9559
SAN MATEO, CA 94401-0192 Central California
Sacramento 1 Valley
accounting rg surgicalstaff .com (800) 540.5285
Southern California
800-780-4029 Los Angeles I San Diego

SURGICAL STAFF, me.

800-339-9599 (800) 331-7720
Pacific Northwest
Fax 650-558-3949 Seattle 1 Portland
(888) 339-9559
East Coast
PAlNY/Mid.AtlanIÎc

i
(800) 722-6794
Southeast
GA/TN/FL

í SPECI.TY SURGICAL CE-ARCAIA

79-4
(800) 699.7001
Travel-Midwest
NationwidelEast
(BOO) 996-0577
51 N. FIF AVE #101
ARCADIA, CA 91006
ATT, BRI GRAY INVOICE
198884 10-28-20
L .J #
PLEASE INCLUDE INVOICE NUMBER WITH PAYMENT

DATE WORK WEEK ENDING: .10-24-2009

LN Date Emloyee/Description Day 'lii/Desc. Hours Rate Aaoimt

1 10-21 YUO BAH,ORN WEI.1 8.00 68.00 544.00
2 10-22 YUO . BAH,ORN '!ll 6.25 68.00 425.00
'lAL AMUN DtÆ: $969.00

t\O~ ~ ~ 100g

., .~~" ,,~., ',~ ,--, .

1fUL -"Q(;9----~---r ?(J~6)

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,
 Oct 26, 200S 10: 50 SURG I CAL STAFF 31057000S0 p. is

~ OCT -22-2009 THU t 2; 07 PM FAX NO, p" oi

SIGN-IN SHEET
~ IJ
SURG1CA.L STAF" INC.
l!J
Ri67 Briilbi PlIrkway, Suite 440
0\1- City, eii 9030.afi12
(310) 570.0092
FAX# 310-57D..090

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