HomeMy WebLinkAbout309090 03/07/17 (9)
CITY OF CARMEL, INDIANA VENDOR: 371549
ONE CIVIC SQUARE JAMES SKELTON CHECKAMOUNT: S"""""""593.00"
CARMEL, INDIANA 46032 12406 OLD MERIDIAN ST APT 206 CHECK NUMBER: 309090
CARMEL IN 46032 CHECK DATE: 03/07/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 593.00 OTHER EXPENSES
cn L
� O I
L
N0 N
U c CU
O O - O O
L C +, O 0 N
ca
ON
m 0 N �
U -0 O
N O
U ECD
"O N C
+� C (n "O CD
+� m N ca
LL -rm- a E
O +r
N n
—
O O "
w U cz (n
Z T) cU 0 ami
�L
O D v
P
I Z
J. O 0
L o
Z Za
Q w o �
a d d a � 3
a
¢ O U 22
a Q
¢ o
// 0 e w Z ° o
V Q
� I v
Z z A
Z zIL
n
75
V4,
o W
ao
CI`T'Y EL
JA.NiRS BRAINAM), MPYOR
March 1, 2017
James Skelton
12406 Old Meridian St. Apt#206
Carmel, IN 46032
RE: RUN# 20165755:1 DOS 10/09/2016 James Skelton
Dear James Skelton:
Enclosed you will find a refund check for $593.00.
You made three credit card payments and paid this invoice in full 02/22/2017.
United HealthCare sent an electronic payment on 02/23/2017 $593.00.
Duplicate payments received created overpayment.
Refund to be issued to patient James Skelton.
If you have any questions, please feel free to contact me at(317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL TIRE DEPARTMENT
STYVEN A. COUTs HEAPQL"ARTF.RJ
Two CIAIC SOI!ARF. CARMEL. IN 46032 OFFICE 317.571.26Oo. FAX 'ITS71.2615
CARWZ CARMEL FIRE DEPARTMENT
Flt%D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID#356000972
Patient Name: SKELTON,JAMES
JAMES SKELTON CARMEL FIRE DEPARTMENT
12406 OLD MERIDIAN ST APT#206 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 03/01/17 990115440
Ticket# : 20165755:1
Date of Service: 10/9/2016
DETACH HERE
PATIENT PAID INVOICE IN FULL 02/22/2017. UNITED HEALTHCARE REPROCESSED YOUR
CLAIM AND PAID $593.00 ON 02/23/2017. DUPLICATE PAYMENTS REFUND MUST BE SENT TO
JAMES SKELTON. THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE ;$0.00.<
Pay online at www.govpaynet.com with PLC#7487 Run Number 20165755:1
Online Payment will charge a service fee.
Date'of Service" eDescription` `1'Y Patient Game AChar e s R L pate t h P,a merit
s
f�,�0Y
Charges
10/9/2016 *ADVANCED LIFE SKELTON, JAMES $575.00
10/9/2016 *MILEAGE SKELTON, JAMES $18.00
---------------------------------
Charge Total: $593.00
Payments
Paid By: Invoice 10/09/16 $593.00
Paid By: SKELTON, JAMES Payment 01/25/17 ($100.00)
Paid By. SKELTON. JAMES Payment 02/17/17 ($100.00)
Paid By: SKELTON, JAMES Credit Card Payment 02/22/17 ($393.00)
Paid By: UHC NEW BUSINESS COMMERCIAL INSURANCE 02/23/17 ($593.00)
Paid By: SKELTON, JAMES REFUND 02/23/17 $593.00
BALANCE $0.00