313874 07/18/2017 4+us Coq*F`
CITY OF CARMEL, INDIANA VENDOR: 371806 CHECK AMOUNT: 5**.....154.14*ONE CIVIC SQUARE JUERGEN SCHALLWIG
=q 13866 RIVER BIRCH WAY CHECK NUMBER: 313874
CARMEL, INDIANA 46032
' 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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JAMES BRAINARD, MAYOR
July 10, 2017
JUERGEN SCHALLWIG
13866 RIVER BIRCH WAY
CARMEL, IN 46033
RE: Account#20167293:1 D.O.S. 12/27/2016
Dear JUERGEN SCHALLWIG:
Enclosed you will find a refund check in the amount of$ 154.14.
On March 28, 2017 we received your payment for $ 404.14 Check#2076.
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,
Michelle T. Harrington
EMS Billing Administrator
CAItNlEI. FiitF DEPARTMENT
STEN-F,\ A. COUTs HEADQUARTERS
Two Qvic SQumA F., CARMEL, IN 46032 OFFICE. 317571.2600, F.tt 317571.2615
CARM CARMEL FIRE DEPARTMENT
FAV D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q�1�'TWP. (317) 571 2604 Federal ID#356000972
Patient Name: SCHALLWIG,JUERGEN
JUERGEN SCHALLWIG CARMEL FIRE DEPARTMENT
13866 RIVER BIRCH WAY 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 990116343
Ticket#: 20167293:1
Date of Service: 12/27/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESS YOUR CLAIM. COPAY IS $250.00 YOU HAD PAID
$404.14 REFUND WILL BE ISSUED TO YOU FOR$154.14 THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20167293:1
Online Payment will charge a service fee.
I No
ce� DescriptioriPatie`rjt:NameP'" Char/�e(/s w # P ►mert sj
iftC .xr
Charges
12/27/2016 *ADVANCED LIFE SCHALLWIG, JUERGEN $575.00
12/27/2016 *MILEAGE SCHALLWIG, JUERGEN $110.40
---------------------------------
Charge Total: $685.40
Payments
Paid By: Invoice 12/27/16 $685.40
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 03/01/17 ($63.86)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 03/01/17 ($217.40)
Paid By. SCHALLWIG, JUERGEN Payment C�eCk 2076 03/28/17 ($404.14)
Paid By: SCHALLWIG, JUERGEN ASSIGNMENT MEDICARE 06/30/17 ($220.48)
Paid By: SCHALLWIG, JUERGEN MEDICARE PAYMENT 06/30/17 ($214.92)
BALANCE $0.00
C, z CARMEL FIRE DEPARTMENT
-wD 2 CIVIC SQUARE
CARMEL, IN 46032-2584
'• (317) 571 2604 Federal ID#356000972
Patient Name: SCHALLWIG, JUERGEN
JUERGEN SCHALLWIG CARMEL FIRE DEPARTMENT
13866 RIVER BIRCH WAY 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 990116343
Ticket# : 20167293:1
Date of Service: 12/27/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESS YOUR CLAIM. COPAY IS $250.00 YOU HAD PAID
$404.14 REFUND WILL BE ISSUED TO YOU FOR$154.14 THANK YOU
Paid By: SCHALLWIG, JUERGEN MEDICARE PAYMENT 06/30/17 $63.86
Paid By. SCHALLWIG, JUERGEN ASSIGNMENT MEDICARE 06/30/17 $217.40
Paid By: SCHALLWIG, JUERGEN REFUND 06/30/17 $154.14
BALANCE $0.00