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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. 4 ,-'-� •y' a ,�...4"+• ,4 2 t 4 e..,!' tt � ,.+ r .i* i Date#of Service „Description #patent Named Charges) DatePayment(s)� ., ._,... � ._.. .....:,.. ..µ__. .�a r.,..�.�kr.,_,,.. __��....>..�.:..t3.�_ti�..�,.a..,c.a..�..z .�:...��-.�_-��e�.._�„ -�ti+-._. --. -.,_.r�xx s....�c..f��..,.--,..,z.gib-_�.z_�• 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) c0-C b832-g7?l�lo 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 Ph[Xt4Y l�r r I illlll illll VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII 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 .................... �.._.:.._ ..__...__._......._._.... _....._...... l.`. ........ ......._.._..............................._...............................................................-....................................................................................................................................................................._......................_.._........,....._..—.........__....._. _. REMARKS G9:3- Gcyod nowwil��f.?(.1rare.nmv sbmrt,pai h CL'LmS(i(X:ifUnt:9 Pt f0:'?^i,i p^.YY1er,mereffore.ltmro iti no nFk%1 for you to.o4nd"tiC:your F,-;imb'S from mc-icare.ii1,,j,k you for cjY,,xnij of MESSAGE A":C;ror'wid.?Fie:1.i.tEl r s• t 932 S J'Yrinion f;d.•CcN:.mbtjF,GA:+'7cY-?d•'t.a:a. d!..A,- i I.ui Ci A9}1_;:35?i'j. v' i•C i':.,t.:i: 2:} l