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HomeMy WebLinkAbout233728 06/18/14 9,y u!_FAgy `/ f� CITY OF CARMEL, INDIANA VENDOR: 368316 ONE CIVIC SQUARE JACKSON EDWARDS CHECK AMOUNT: $*******186.89* FISHERS CARMEL, INDIANA 46032 11142 BILLINGSGATE PLACE CHECK NUMBER: 233728 'M��oN�o. FISHERS IN 46038 CHECK DATE: 06/18/14 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 186.89 OTHER EXPENSES 1 C1 EL JAMES BRm HARD, MAYOR June 16, 2014 Jackson Edwards 11142 Billingsgate Place Fishers, IN 46038 RE: Ticket#20140269:1 D.O.S. 01/10/2014 Dear Jackson Edwards: Enclosed you will find a reimbursement check in the amount of$ 186.89. On March 7, 2014 we received your payment for$ 336.89 claim applied to your deductible. Anthem reprocessed your claim paid$ 186.89 on June 4, 2014 the patient responsibility amount was $ 150.00. The overpayment amount is $ 186.89. If you have any questions, please feel free to contact me at (3 17) 571-2604. Sincerely, 440 Michelle T. Harrington Billing Administrator CARMEL FIRE DEPARTMENT STEVEN A. Com HEADQuARTERs Two CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615 CARMEL FIRE DEPARTMENT Y 2 CIVIC SQUARE CARMEL, IN 46032-7543 " '• (317) 571 2604 Federal ID#356000972 Patient Name: EDWARDS,JACKSON JACKSON EDWARDS CARMEL FIRE DEPARTMENT 11142 BILLINGSGATE PLACE 2 CIVIC SQUARE FISHERS, IN 46038 CARMEL, IN 46032-7543 TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID THIS PORTION WITH YOUR PAYMENT 06/16/14 990105868 Ticket# : 20140269:1 Date of Service: 1/10/2014 DETACH HERE REFUND $ 186.89 ANTHEM REPROCESSED YOUR CLAIM MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE .$0.00 Pay online at www.govpaynet.com with PLC#7487 Run Number 20140269:1 Online Payment will charge a service fee. Datb:of Setvice * Description :_Patient.Name., : - = Charges) ,Date ,:,-'- Payrnent(s) Charges 1/10/2014 *BASIC LIFE SUP EDWARDS, JACKSON $375.00 1/10/2014 *MILEAGE EDWARDS, JACKSON $7.55 --------------------------------- Charge Total: $382.55 Payments Paid By: Invoice 01/10/14 $382.55 Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 02/27/14 ($38.50) Paid By. ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 02/27/14 ($7.16) Paid By: EDWARDS, JACKSON Payment CK4 313 03/07/14 ($336.89) Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/04/14 $0.98 Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/04/14 ($0.98) BALANCE $0.00 i r, CARMEL FIRE DEPARTMENT 2 CIVIC SQUARE CARMEL, IN 46032-7543 (317) 571 2604 Federal ID#356000972 Patient Name: EDWARDS,JACKSON JACKSON EDWARDS CARMEL FIRE DEPARTMENT 11142 BILLINGSGATE PLACE 2 CIVIC SQUARE FISHERS, IN 46038 CARMEL, IN 46032-7543 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID THIS PORTION WITH YOUR PAYMENT 06/16/14 990105868 Ticket# : 20140269:1 Date of Service: 1/10/2014 DETACH HERE --7 REFUND $ 186.89 ANTHEM REPROCESSED YOUR CLAIM I Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/04/14 ($186.89) Paid By: EDWARDS, JACKSON REFUND 06/16/14 $186.89 BALANCE $0.00 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5-11-10-1.6. , 20- Clerk-Treasurer 20Clerk-Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF $ ON ACCOUNT OF APPROPRIATION FOR Board Members Po#or INVOICE NO. ACCT#!TITLE AMOUNT DEPT.# I hereby certify that the attached invoice(s), or © bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except AN 2014 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund