HomeMy WebLinkAbout313802 07/18/2017 (9, )
CITY OF CARMEL, INDIANA VENDOR: 371809
ONE CIVIC SQUARE STEVEN HARDY CHECK AMOUNT: S*******404.12*
CARMEL, INDIANA 46032 3040 MAQUA COURT CHECK NUMBER: 313802
CARMEL IN 46033 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 404.12 OTHER EXPENSES
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CITY . EL
JAibIES BRAINARD, MAYOR
July 10, 2017
Steven Hardy
3040 MAQUA COURT
CARMEL, IN 46033
RE: Account#20160323 D.O.S. 01/19/2016
Dear Steven Hardy:
Enclosed you will find a refund check in the amount of$ 404.12.
On April 5, 2016 we received your payment for$ 404.14 Check#1911.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is $0.00.
Issue refund of$404.14 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
CARMEL FIRE DEMRTMEXT
STENF,N A. Coors HEADQUARIERs
T%xo Clelc SQUARE, C WOEL, Iii' 46032 OFFICE 317.571.2600. F.�x 317.571.261li
Cz CARMEL FIRE DEPARTMENT
F# D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q"TF/i�'� (317) 571 2604 Federal ID#356000972
Patient Name: HARDY, STEVEN R
STEVEN HARDY CARMEL FIRE DEPARTMENT
3040 MAQUA CT 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 990108447
Ticket# : 20160323:1
Date of Service: 1/19/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. NO COPAY DUE. PATIENT PAID
$404.14 REFUND OVERPAYMENT TO PATIENT$404.14 THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20160323:1
Online #Payment will charge a service fee.
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Pat�en �lame Charg
pes) <°Dafe Y a s
Charges
1/19/2016 *ADVANCED LIFE HARDY, STEVEN R $575.00
1/19/2016 *MILEAGE HARDY, STEVEN R $86.40
---------------------------------
Charge Total: $661.40
Payments
Paid By: Invoice 01/19/16 $661.40
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICADE 03/02/16 ($207.59)
Paid By: HARDY, STEVEN R MEDICARE PAYMENT 03/02/16 ($49.67)
Paid By: HARDY, STEVEN R Payment��eC l 04/05/16 ($404.14)
Paid By. ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 ($215.67)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 $49.67
BALANCE $0.00
�x CARMEL FIRE DEPARTMENT
F,A.D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Qom" (317) 571 2604 Federal ID#356000972
Patient Name: HARDY, STEVEN R
STEVEN HARDY CARMEL FIRE DEPARTMENT
3040 MAQUA CT 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 990108447
Ticket#: 20160323:1
Date of Service: 1/19/2016
DETACH HERE
}
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. NO COPAY DUE. PATIENT PAID
$404.14 REFUND OVERPAYMENT TO PATIENT$404.14 THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 $207.59
Paid By. HARDY, STEVEN R REFUND 06/30/17 $404.14
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 ($445.73)
BALANCE $0.00