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CI"1'Y EL
JA,%iFs BRAINARD, MAYOR
February 23, 2017
Christine Pawlovich
12072 Bay Hill Drive
Carmel, IN 46033
RE: RUN # 20167252:1 DOS 12/24/2016 Mary Ann Riemer
Dear Christine Pawlovich:
Enclosed you will find a refund check for$523.00.
February 9, 2017 we received your$523.00 payment Check#496.
Anthem sent an electronic payment on 02/10/2017 $523.00.
Duplicate payment received created overpayment.
Refund to be issued to Christine Pawlovich.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
//�.�ze�'� -J� r"�-
Michelle T. Harrington
EMS Billing Administrator
CAILNIEI. FIRE DEPARTMENT
,STE\--F,N A. COUTs HFADQUatTERS
Two CIS Ic SQI-BARE, CARAIEL, IN 46032 OFFICE 317.571.2600, F.ax 317571.2615
Ct CARMEL FIRE DEPARTMENT
F@D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Cl�A4'TiV (317) 571 2604 Federal ID#356000972
Patient Name: RIEMER, MARY ANN
MARY ANN RIEMER CARMEL FIRE DEPARTMENT
ATTN : CHRISTINE A PAWLOVICH 2 CIVIC SQUARE
12072 BAY HILL DR CARMEL, IN 46032-2584
CARMEL, IN 46033
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 02/23/17 990116306
Ticket# : 20167252:1
Date of Service: 12/24/2016
DETACH HERE
ENCLOSED IS REFUND $523.00 ON 02/09/2017 WE RECEIVED YOUR CHECK#496.ANTHEM
SENT A PAYMENT$523.00 ON 2/10/2017. OVERPAYMENT REFUND PATIENT
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.001
Pay online at www.govpaynet.com with PLC#7487 Run Number 20167252:1
Online Payment will charge a service fee.
Patient Name ' ;Char e s .Date Pa mint s `
Date of`Serv�ce Descr�pt�on g ( �
'.' ,�, Cs�*Ky+•f'�!t�k"'-s
Charges
12/24/2016 "BASIC LIFE SUP RIEMER, MARY ANN $475.00
12/24/2016 *MILEAGE RIEMER, MARY ANN $48.00
---------------------------------
Charge Total: $523.00
Payments
Paid By: Invoice 12/24/16 $523.00
Paid By: RIEMER, MARY ANN Payment 02/09/17 ($523.00)
Paid By: ANTHEM BLUE CROSS & BLUE BLUE SHIELD PAYMENT 02/10/17 ($523.00)
Paid By: RIEMER, MARY ANN REFUND 02/23/17 $523.00
BALANCE $0.00