HomeMy WebLinkAbout233753 06/18/14 y o!.F�ny
`! CITY OF CARMEL, INDIANA VENDOR: 368317
;, ONE CIVIC SQUARE BECKY GRUBB CHECK AMOUNT: $********57.27*
;• �, CARMEL, INDIANA 46032 820 MOHAWK HILLS APT B CHECK NUMBER: 233753
��'��ion�°' CARMEL IN 46032 CHECK DATE: 06/18/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 57.27 OTHER EXPENSES
�I AI�IVIEL
,JAMES BRAINARD, MAYOR
June 16, 2014
Betty Grubb
820 Mohawk Hills Dr. Apt B
Carmel, IN 46032
RE: Ticket#20133970:1 D.O.S. 09/06/2013
Dear Betty Grubb:
Enclosed you will find a reimbursement check in the amount of$ 57.27.
On October 29, 2013 we received your payment for$ 71.58 claim applied
to your deductible.
Associated Administrators reprocessed your claim paid$ 57.27 on December 9, 2013
patient responsibility amount was $ 14.31.
The overpayment amount is $ 57.27.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
4V
Michelle T. Harrington
Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. CouTs HEADQuARTERs
Two CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
CARMEL FIRE DEPARTMENT
w 2 CIVIC SQUARE
CARMEL, IN 46032-7543
w• (317) 571 2604 Federal ID#356000972
Patient Name: GRUBB, BETTY M
BETTY GRUBB CARMEL FIRE DEPARTMENT
820 MOHAWK HILLS DR APT B 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-7543
TO ASSURE PROPER CREDIT, RETURN Statement Date= Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 06/16/14 990104669
Ticket# : 20133970:1
Date of Service: 9/6/2013
DETACH HERE
ASSOCIATIED ADMINISTRATORS PAID $57.27 AND THE PATIENT PAID$ 71.58 THE PT r!
AMOUNT DUE WAS $14.31 REFUNDING PT$57.27
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT I BALANCE $0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20133970:1
Online Payment will charge a service fee.
-'Mc ofSe _Y. , ,- Patient Namer 'Cha..,r,g. e;.
(s) ,. '-Date= Payment(s).
Charges
9/6/2013 *BASIC LIFE SUP GRUBB, BETTY M $375.00
9/6/2013 *MILEAGE GRUBB, BETTY M $25.67
---------------------------------
Charge Total: $400.67
Payments
Paid By: Invoice 09/06/13 $400.67
Paid By. MEDICARE PART B ASSIGNMENT MEDICARE 09/23/13 ($48.49)
Paid By: MEDICARE PART B MEDICARE PAYMENT 09/23/13 ($280.60)
Paid By. GRUBB, BETTY M Payment 10/29/13 ($71.58)
Paid By. ASSOCIATED ADMINISTR COMMERCIAL INSURANCE 12/09/13 ($57.27)
Paid By: GRUBB, BETTY M REFUND 06/16/14 $57.27
BALANCE $0.00
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER Ci�Fo�,No.2o1`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
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
jUN 16 20#
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund