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Home My WebLink About306185 W 5�q CITY OF CARMEL, INDIANA VENDOR: 371378 q ONE CIVIC SQUARE JEANNE SHOCKLEY CHECK AMOUNT: $`***`**`77.78* CARMEL, INDIANA 46032 4627 RIVER RIDGE DR CHECK NUMBER: 306185 INDIANAPOLIS IN 46240 CHECK DATE: 12/12/16 �TpN DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 77.78 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 I hereby certify that the attached invoice(s), or DEPT.# 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 EL JAMES BRAINARD, NLA�-OR December 5, 2016 Jeanne Shockley 4627 River Ridge Drive Indianapolis, IN 46240-6406 RE: Ticket#20154628:1 D.O.S. 10/20/2015 Duplicate Payments Received Dear Jeanne Shockley, Enclosed you will find a refund check in the amount of$42.16. We received your payment on October 27, 2015 for$42.16. On October 24, 2016 Blue Cross Blue Shield of Illinois sent a check also for$42.16. Overpayment invoice—refund issued to patient for $42.16. If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator C_1R\IEL Fn.E DER_MCIAIEN r STEVEN A. COU rs HEADQUARTER,, 'T.._._ r`.... c -.... /`.... TA? 4Gn2I /l..`..,.,. 2 1� C-71 1/nn L'..- 21-7 C'71 7/.1, CA CARMEL FIRE DEPARTMENT F6 .D 2 CIVIC SQUARE CARMEL, IN 46032-2584 CIr. (317) 571 2604 Federal ID#356000972 Patient Name: SHOCKLEY, JEANNE L JEANNE SHOCKLEY CARMEL FIRE DEPARTMENT 9580 LOGWELL DR. 2 CIVIC SQUARE INDIANAPOLIS, IN 46240 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID THIS PORTION WITH YOUR PAYMENT 12/05/16 200701318 Ticket# : 20154628:1 Date of Service: 9/12/2015 DETACH HERE BLUE CROSS BLUE SHIELD OF ILLINOIS REPROCESSED YOUR CLAIM. DUPLICATE PAYMENTS RECEIVED. REFUND ISSUED TO PATIENT$42.16 THANK YOU MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0 00 Pay online at www.govpaynet.com with PLC#7487 Run Number 20154628:1 Online Payment will charge a service fee. D}ate of ServiceDescription Patient Namers Charges) Date kPayment� nz ry ' .rr . „_ Charges 9/12/2015 *ADVANCED LIFE SHOCKLEY, JEANNE L $475.00 9/12/2015 *MILEAGE SHOCKLEY, JEANNE L $16.61 --------------------------------- Charge Total: $491.61 Payments Paid By: Invoice 09/12/15 $491.61 Paid By: MEDICARE PART B MEDICARE PAYMENT 09/30/15 ($330.66) Paid By: MEDICARE PART B ASSIGNMENT MEDICARE 09/30/15 ($76.60) Paid By: ANTHEM BLUE CROSS & BLUE BLUE SHIELD PAYMENT 10/13/15 ($42.19) Paid By: SHOCKLEY, JEANNE L Payment 10/27/15 ($42.16) Paid By: ANTHEM BLUE CROSS & BLUE BLUE SHIELD PAYMENT 10/31/16 ($42.16) BALANCE $0.00 CAP CARMEL FIRE DEPARTMENT �4�.fl 2 CIVIC SQUARE CARMEL, IN 46032-2584 rr (317) 571 2604 Federal ID#356000972 Patient Name: SHOCKLEY,JEANNE L JEANNE SHOCKLEY CARMEL FIRE DEPARTMENT 9580 LOGWELL DR. 2 CIVIC SQUARE INDIANAPOLIS, IN 46240 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID THIS PORTION WITH YOUR PAYMENT 12/05/16 200701318 Ticket# : 20154628:1 Date of Service: 9/12/2015 DETACH HERE BLUE CROSS BLUE SHIELD OF ILLINOIS REPROCESSED YOUR CLAIM. DUPLICATE PAYMENTS RECEIVED. REFUND ISSUED TO PATIENT$42.16 THANK YOU Paid By. SHOCKLEY, JEANNE L - REFUND 12/05/16 $42.16 BALANCE $0.00 VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF $ V ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or INVOICE NO. ACCT#!TITLE AMOUNT I hereby certify that the attached invoice(s), or DEPT.# 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 CITY - EL JAMES BRAI ,ARD, MAYOR December 5, 2016 Jeanne Shockley 4627 River Ridge Drive Indianapolis, IN 46240-6406 RE: Ticket #20155365:1 D.O.S. 10/20/2015 Duplicate Payments Received Dear Jeanne Shockley, Enclosed you will find a refund check in the amount of$35.62. We received your payment on December 30, 2015 for$35.62. On October 24, 2016 Blue Cross Blue Shield of Illinois sent a check also for$35.62. Overpayment invoice—refund issued to patient for$35.62. If you have any questions, please feel free to contact me at (317) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator C RAIEL FIRE DEP_ARTNIENT S'EEV-FN A. COUTs HEADQUARTERS Two Civic SOUARE, CARMEL„ IN 46032 OFFICE ,317.771.2600. FAx 317571.2617 CAnCARMEL FIRE DEPARTMENT .TAMP. 2 CIVIC SQUARE CARMEL, IN 46032-2584 T"• (317) 571 2604 Federal ID#356000972 Patient Name: SHOCKLEY, JEANNE L JEANNE SHOCKLEY CARMEL FIRE DEPARTMENT 9580 LOGWELL DR. 2 CIVIC SQUARE INDIANAPOLIS, IN 46240 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID THIS PORTION WITH YOUR PAYMENT 12/05/16 200701318 Ticket# : 20155365:1 Date of Service: 10/20/2015 DETACH HERE i BLUE CROSS BLUE SHIELD OF ILLINOIS REPROCESS THIS CLAIM. DUPLICATE PAYMENT. REFUND PATIENT$35.62 THANK YOU MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0 00' Pay online at www.govpaynet.com with PLC#7487 Run Number 20155365:1 Online Payment will charge a service fee. Da a°of Seance s,q escription-&x k Patient Name Cha�ge(s� Date Paymen s�, Charges 10/20/2015 `BASIC LIFE SUP SHOCKLEY, JEANNE L $375.00 10/20/2015 "MILEAGE SHOCKLEY, JEANNE L $15.10 --------------------------------- Charge Total: $390.10 Payments Paid By: Invoice 10/20/15 $390.10 Paid By: MEDICARE PART B MEDICARE PAYMENT 11/06/15 ($279.29) Paid By: MEDICARE PART B ASSIGNMENT MEDICARE 11/06/15 ($39.56) Paid By: ANTHEM BLUE CROSS & BLUE COMMERCIAL INSURANCE 12/08/15 ($35.63) Paid By: SHOCKLEY, JEANNE L Payment C�ec,K*- �b� 12/30/15 ($35.62) Paid By: ANTHEM BLUE CROSS & BLUE COMMERCIAL INSURANCE 10/31/16 ($35.62) BALANCE $0.00 CA CARMEL FIRE DEPARTMENT A 2 CIVIC SQUARE CARMEL, IN 46032-2584 (317) 571 2604 Federal ID#356000972 Patient Name: SHOCKLEY, JEANNE L JEANNE SHOCKLEY CARMEL FIRE DEPARTMENT 9580 LOGWELL DR. 2 CIVIC SQUARE INDIANAPOLIS, IN 46240 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID THIS PORTION WITH YOUR PAYMENT 12/05/16 200701318 Ticket# : 20155365:1 Date of Service: 10/20/2015 DETACH HERE BLUE CROSS BLUE SHIELD OF ILLINOIS REPROCESS THIS CLAIM. DUPLICATE PAYMENT. REFUND PATIENT$35.62 THANK YOU Paid By: SHOCKLEY, JEANNE L REFUND 12/05/16 $35.62 BALANCE $0.00