242117 2 /10/2015 CITY OF CARMEL, INDIANA VENDOR: 367102
CHECK AMOUNT: $*******382.70*
ONE CIVIC SQUARE W P S MEDICARE PART B
d. CARMEL, INDIANA 46032 PAYMENT RECOVERY CHECK NUMBER: 242117
9Mi*oN`�' MARION8N8162959-0910CHECK DATE: 02/10/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 2014428:1 382.70 REFUND-2014428:1
- 1
C I `ARMEE
JAMES BRAINARD, MAYOR
February 5, 2015
WPSMEDICARE PART B
Payment Recovery
P.O. Box 8811
Marion,IL 62959-0910
RE: Account#2014428:1 D.O.S. 08/28/2014
Dear Payment Recovery:
Enclosed you will find a reimbursement check in the amount of$ 382.70.
On January 6, 2015 we received your payment for$ 382.70 EFT 885071697.
On January 30, 2015 we received a check from Community Pro Health for$567.87.
Mr. Robbins Primary Insurance on this day of service was Community Pro Health
and secondary was Medicare. Overpayment enclosed for Medicare.
If you have any questions,please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS,Billing Administrator
- CARNIET FTRF DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
Two Civic SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
i
i
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# #
EP or
EPT. INVOICE NO. ACCT#/TITLE AMOUNT
DI 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
I
FEB 9 2015
I
5-
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund