313875 07/18/2017 od G.1q*
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ONE CIVIC SQUARE PATRICIA SCHENKEL CHECK AMOUNT: S"""""""154.14`
r CARMEL, INDIANA 46032 13631 SMOKEV RIDGE PLACE CHECK NUMBER: 313875
" CARMEL IN 46033
„aN� CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 154.14 OTHER EXPENSES
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CI EL
JAMES BRAIN_ARD, MAYOR
July 10, 2017
PATRICIA SCHENKEL
13631 SMOKEY RIDGE PLACE
CARMEL, IN 46033
RE: Account#20166087:1 D.O.S. 10/28/2016
Dear Patricia Schenkel:
Enclosed you will find a refund check in the amount of$ 154.14.
On January 19, 2017 we received your payment for$ 404.14 Check#9574.
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
CARMEL FIRE DEPARTMENT
STEVEN A. COGTs HEADQGAR"FERS
Two Civic SQC?ARE, CARMEL, IN 46032 OFFICE 317.771.2600, FAN- 317.571.2615
CARWX CARMEL FIRE DEPARTMENT
F,%P D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
• (317) 5712604 Federal ID#356000972
Patient Name: SCHENKEL, PATRICIA
PATRICIA SCHENKEL CARMEL FIRE DEPARTMENT
13631 SMOKEY RIDGE 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 200300212
Ticket# : 20166087:1
Date of Service: 10/28/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. COPAY$250.00 PATIENT PAID
$404.14-$250.00=$154.14 REFUND PATIENT
MAKE CHECKS PAYABLE TO: CARMEL FIDE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20166087:1
Online Payment will charge a service fee.
k Da � fdSeiv7ce "Description Paten Name " � G arge(s) "Diti 'Pay's nth
f'?n,�
Charges
10/28/2016 *ADVANCED LIFE SCHENKEL, PATRICIA $575.00
10/28/2016 *MILEAGE SCHENKEL, PATRICIA $26.40
---------------------------------
Charge Total: $601.40
Payments
Paid By: Invoice 10/28/16 $601.40
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 12/02/16 ($14.19)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 12/02/16 ($183.07)
Paid By: SCHENKEL, PATRICIA Payment 01/19/17 ($404.14)
Paid By: SCHENKEL, PATRICIA ASSIGNMENT MEDICARE 06/30/17 ($186.15)
Paid By: SCHENKEL, PATRICIA MEDICARE PAYMENT 06/30/17 ($165.25)
BALANCE $0.00
CA M- 14 CARMEL FIRE DEPARTMENT
F�,D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
in (317) 571 2604 Federal ID#356000972
Patient Name: SCHENKEL, PATRICIA
PATRICIA SCHENKEL CARMEL FIRE DEPARTMENT
13631 SMOKEY RIDGE PLACE 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 200300212
Ticket# : 20166087:1
Date of Service: 10/28/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. COPAY$250.00 PATIENT PAID
$404.14-$250.00=$154.14 REFUND PATIENT
Paid By: SCHENKEL, PATRICIA MEDICARE PAYMENT 06/30/17 $14.19
Paid By. SCHENKEL, PATRICIA ASSIGNMENT MEDICARE 06/30/17 $183.07
Paid By. ANTHEM SENIOR ADVANTAGE/ REFUND 06/30/17 $154.14
BALANCE $0.00