313832 07/18/2017 9�W C�Mw
*• CITY OF CARMEL, INDIANA VENDOR: 371808
ONE CIVIC SQUARE LUCINDA MCCARTHY CHECK AMOUNT: S"""`154.14`
? Q CARMEL, INDIANA 46032 5738 OPUS DRIVE CHECK NUMBER: 313832
v CARMEL IN 46033 CHECK DATE: 07/18/17
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 154.14 OTHER EXPENSES
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JA!NIES BRAINARD, IVLwOR
July 10, 2017
Lucinda McCarthy
5738 OPUS DRIVE
CARMEL, IN 46033
RE: Account#20165518:1 D.O.S. 09/27/2016
Dear Lucinda McCarthy:
Enclosed you will find a refund check in the amount of$ 154.14.
On December 28, 2016 we received your payment for $ 404.14 Check#291.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is $250.00.
Issue refund of$154.14 the overpayment to the patient.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
141dC(�j a �
Michelle T. Harrington
EMS Billing Administrator
CAILMEt. F[RE DERARTNTNT
STEVEN A. COUTS HEADQ1 ARrE.RS
(,.,. , TN 217 911 -)(,00 r- 21- C-1 7(.I,
cjutjwz]L CARMEL FIRE DEPARTMENT
F�D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
CL"T"• (317) 571 2604 Federal ID#356000972
Patient Name: MCCARTHY, LUCINDA
LUCINDA MCCARTHY CARMEL FIRE DEPARTMENT
5738 OPUS DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990115314
Ticket# : 20165518:1
Date of Service: 9/27/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. COPAY DUE IS $250.00. PATIENT PAID
$404.14-$250.00=$154.14 OVERPAYMENT REFUND SENT TO PATIENT. THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00
Pay online at www.govpaynet.com with PLC#7487 Run Number 20165518:1
Online Payment will charge a service fee.
,a {.#e°. ;::,f ''`wir. r_. ✓D .a ,x v, `"i, p 9fi i' x ...:�k->-r ?.a. s ksa..' f`5ervfceDescnpt�on F k � PatienNam� Charge(satlt�s
Charges
9/27/2016 "ADVANCED LIFE MCCARTHY, LUCINDA $575.00
9/27/2016 *MILEAGE MCCARTHY, LUCINDA $66.00
---------------------------------
Charge Total: $641.00
Payments
Paid By: Invoice 09/27/16 $641.00
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 10/28/16 ($172.36)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 10/28/16 ($64.50)
Paid By: MCCARTHY, LUCINDA Payment 12/28/16 ($404.14)
Paid By: MCCARTHY, LUCINDA ASSIGNMENT MEDICARE 06/30/17 ($197.37)
Paid By: MCCARTHY, LUCINDA MEDICARE PAYMENT 06/30/17 ($193.63)
BALANCE $0.00
ciunmy, CARMEL FIRE DEPARTMENT
D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q.AY7P� (317) 5712604 Federal ID#356000972
Patient Name: MCCARTHY, LUCINDA
LUCINDA MCCARTHY CARMEL FIRE DEPARTMENT
5738 OPUS DR 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 990115314
Ticket# : 20165518:1
Date of Service: 9/27/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. COPAY DUE IS $250.00. PATIENT PAID
$404.14-$250.00=$154.14 OVERPAYMENT REFUND SENT TO PATIENT.THANK YOU
Paid By: MCCARTHY, LUCINDA MEDICARE PAYMENT 06/30/17 $64.50
Paid By: MCCARTHY, LUCINDA ASSIGNMENT MEDICARE 06/30/17 $172.36
Paid By. MCCARTHY, LUCINDA REFUND 06/30/17 $154.14
BALANCE $0.00