245161 05/13/15 :� 4qA\�. CITY OF CARMEL, INDIANA VENDOR: 369355
h; � �• ONE CIVIC SQUARE MARK HYNDMAN
CHECK AMOUNT: $*******334.98*
=e _� CARMEL, INDIANA 46032 847 MORELEY COURT CHECK NUMBER: 245161
M; �: WESTFIELD IN 46074 CHECK DATE: 05/13/15
«ON
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 334.98 REFUND
t rt
CI7' OF 1�R1VIEL
JAIti1ES BRANARD, NIAYOR
May 11, 2015
Mark Hyndman
847 Morely Court
Westfield, IN 46074
RE: RUN #2050468:1 DOS 01/24/2015
Dear Mark Hyndman:
Enclosed you will find a refund check for $ 344.98.
We received.your payment of$ 3 83.31 on 02/02/2015.
04/28/2015 United Health Care processed your claim and paid$ 344.98 copay $ 38.33
and we are sending you the overpayment.
If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
-- - �'4�[
Michelle T. Harrington
EMS Billing Administrator
I
CARMEL FIRE DEPARTMENT
STEVEN A. CouTs HEADQUARTERS
Two CIVIC SouARE. CARMEL. IN 46032 OFFICE 317.571.2600. FAx 317.571.2615
C Y� r' CARMEL.FIRE DEPARTMENT
r JD 2 CIVIC SQUARE
CARMEL, IN 46032-2584
CL4XTM. (317) 571 2604 Federal ID#356000972
Patient Name: HYNDMAN, MARK A
MARK HYNDMAN CARMEL FIRE DEPARTMENT
847 MORELY CT 2 CIVIC SQUARE
WESTFIELD, IN 46074 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOURPAYMENT 05/11/15 990109433
_ Ticket#:- 20150468:1
Date of Service: 1/24/2015
DETACH HERE
DUPLICATE PAYMENTS RECEIVED 02/02/2015 CREDIT PAYMENT$ 383.31 MADE BY PATIENT. j
UNITED HEALTH CARE PAID$ 344.98 ON 04/28/2015 COPAY$38.33. REFUND $344.98 j
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE1.
Pay online at www.govpaynet.com with PLC#7487 Run Number 20150468:1
Online Payment will charge a service fee.
Date,of Service Description Patient'Name Char e s Date.,,,Payment(s) r;
Charges
1/24/2015 *BASIC LIFE SUP HYNDMAN, MARK A $375.00
1/24/2015 *MILEAGE HYNDMAN, MARK A $8.31
---------------------------------
Charge Total: $383.31
Payments
Paid By. Invoice 01/24/15 $383.31
Paid By. HYNDMAN, MARK A Credit Card Payment 02/02/15 ($383.31)
Paid By. UHC NEW BUSINESS COMMERCIAL INSURANCE 04/28/15 ($344.98)
Paid By: HYNDMAN, MARK REFUND 05/11/15 $344.98
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 i
DEPT.# INVOICE NO. ACCT#!TITLE AMOUNT 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
MAY ' 1 2n15
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund