HomeMy WebLinkAbout313746 7/18/2017 CITY OF CARMEL, INDIANA VENDOR: 371814
CHECK AMOUNT: $****....90.33*
ONE CIVIC SQUARE JAMES BAKER
?Q CARMEL, INDIANA 46032 1644 BRADFORD PLACE CHECK NUMBER: 313746
CARMEL IN 46033 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 90.33 OTHER EXPENSES
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CIS EL
JA:N[ES BRAINARD, NLwOR
July 10, 2017
JAMES BAKER
1644 BRADFORD PLACE
CARMEL, IN 46033
RE: Account#20164671:1 D.O.S. 08/20/2016
Dear James Baker:
Enclosed you will find a refund check in the amount of$90.33.
On January 12, 2017 we received your payment for $340.33 Check#9625.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is $250.00.
Issue refund of$90.33 the overpayment to the patient.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
C_ttmF,i F[RE DEPARTMENT
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C,�z CARMEL FIRE DEPARTMENT
F 'D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID#356000972
Patient Name: BAKER,JAMES A
JAMES BAKER CARMEL FIRE DEPARTMENT
11644 BRADFORD PLACE 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990112016
Ticket# : 20164671:1
Date of Service: 8/20/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. UPDATED COPAY$250.00. PATIENT
PAID $340.33-$250.00=$90.33 OVERPAYMENT REFUND SEND TO PATIENT.THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20164671:1
Online Payment will charge a service fee.
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Charges
8/20/2016 *BASIC LIFE SUP BAKER, JAMES A $475.00
8/20/2016 *MILEAGE BAKER, JAMES A $39.60
---------------------------------
Charge Total: $514.60
Payments
Paid By: Invoice 08/20/16 $514.60
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 09/16/16 ($142.02)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 09/16/16 ($32.25)
Paid By: BAKER, JAMES A Payment 01/12/17 ($340.33)
Paid By: BAKER, JAMES A ASSIGNMENT MEDICARE 06/30/17 ($154.79)
Paid By: BAKER, JAMES A MEDICARE PAYMENT 06/30/17 ($109.81)
BALANCE $0.00
CAR-W14 CARMEL FIRE DEPARTMENT
F Q D 2 CIVIC SQUARE
ow CARMEL, IN 46032-2584
irF (317) 571 2604 Federal ID#356000972
Patient Name: BAKER,JAMES A
JAMES BAKER CARMEL FIRE DEPARTMENT
11644 BRADFORD PLACE 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990112016
Ticket# : 20164671:1
Date of Service: 8/20/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. UPDATED COPAY$250.00. PATIENT
PAID$340.33-$250.00=$90.33 OVERPAYMENT REFUND SEND TO PATIENT.THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 ($90.33)
Paid By: BAKER, JAMES A MEDICARE PAYMENT 06/30/17 $32.25
Paid By: BAKER, JAMES A ASSIGNMENT MEDICARE 06/30/17 $142.02
Paid By.: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 $90.33
Paid By: BAKER, JAMES A REFUND 06/30/17 $90.33
BALANCE $0.00