HomeMy WebLinkAbout300801 07/21/16 a`! \ CITY OF CARMEL, INDIANA VENDOR: 370869
® ONE CIVIC SQUARE AFLAC CHECK AMOUNT: $********70.97*
_� CARMEL, INDIANA 46032 1932 WYNNTON RD CHECK NUMBER: 300801
9;ETON� COLUMBUS GA 31999 CHECK DATE: 07/21/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 070616 70.97 OTHER EXPENSES
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
t)10 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
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Afflam 10B
CIS OF EL
JAMES BRAINARD, NIAYOR
July 6, 2016
AFLAC
ATTN CLAIMS
1932 WYNNTON ROAD
COLUMBUS, GA 31999-0001
RE :OVERPAYMENT AFLA Account#20160566 PATRICIA WALTON
Date of Service 02/03/2016
Dear Aflac:
United Health Care Insurance is this patient's secondary insurance paid$70.97.
We also received a check from AFLAC CK# C083249206 for$70.97 in error.
The policy ended 07/21/2015. Refund will be issued to AFLAC for$70.97.
If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTIIIENT
STEVENA. CouTS HEADQUARTERS
Twin C.TVTC gnTTAPP CARURT TN AA,Il2? CIWWW1 217 S71 ?inn 'PA- 217 S71 7tl'1S
CARMEL FIRE DEPARTMENT
.D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
" . (317) 571 2604 Federal ID#356000972
Patient Name: WALTON, PATRICIA H
PATRICIA WALTON CARMEL FIRE DEPARTMENT
1335 S GUILFORD RD 2 CIVIC SQUARE
CARMEL , IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/06/16 990103014
Ticket# : 20160566:1
Date of Service: 2/3/2016
DETACH HERE
)
REFUND TO BE ISSUED TO AFLAC FOR$70.97. POLICY ENDED 07/21/2015
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE a$0 OOr
Pay online at www.govpaynet.com with PLC#7487 Run Number 20160566:1
Online Payment will charge a service fee.
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Date#of Service „Description #patent Named Charges) DatePayment(s)�
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Charges
2/3/2016 "BASIC LIFE SUP WALTON, PATRICIA H $475.00
2/3/2016 "MILEAGE WALTON, PATRICIA H $24.00
---------------------------------
Charge Total: $499.00
Payments
Paid By: Invoice 02/03/16 $499.00
Paid By: MEDICARE PART B MEDICARE PAYMENT 02/23/16 ($278.16)
Paid By: MEDICARE PART B ASSIGNMENT MEDICARE 02/23/16 ($149.87)
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Paid By: WALTON, PATRICIA H C amc
ERCIAL INSURANCE 03/11/16 ($70.97)
Paid By: AARP/UNITED HEALTHCARE COMMERCIAL INSURANCE 03/23/16 ($70.97)
Paid By: WALTON, PATRICIA H REFUND 07/06/16 $70.97
BALANCE $0.00
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EXPLANATION OF
A N, BENEFITS
Lw' rs "�(sL�sa�`' ''R,i !'
`�"4°`
Provider's Name: CITY OF CARMELPaid Data: 02124,'2036................
4
212,'2036
Tax ID: 3S(YJh')072-000 Payment Address: 2 CHIC
NPI Number Payment Amount: 370.97
................_..........._................._........._.... ......_............................................ ._. ... ._.... ... ..._...................-.................................._........ ._.._......__....._..._............._.......___..........I.........-
Paymen:ID: 1,%DP.,32492('6 Backup Vdithha!d: $0.Cii
PasrcaWalton A207(>)?3; � r�t ` i 'Ia1604c'k30K90 i 02:203(2076 4G9.00 364.81 1 , mqr t 0.0101 000 70.971 02i2412016 , 096
UJ 1(; Subtotal '€ 499M' 354.8; ' 70.9r 0.00; O o; 70.97
_ _ _
-............
.......-......._.._...
-_ -_..-.-_._. . .....- Total:-..-.--70.97----.OD .00_... 0.97
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REMARKS
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MESSAGE
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