313876 07/18/2017 CAA .
� CITY OF CARMEL, INDIANA VENDOR: 371813
ONE CIVIC SQUARE NANNETTE SCHMITT CHECK AMOUNT: S********90.33`
CARMEL, INDIANA 46032 5859 LOST OAKS DRIVE CHECK NUMBER: 313876
' 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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JA:NIES BRAINARD, MAYOR
July 10, 2017
NANNETTE SCHMITT
5859 LOST OAKS DRIVE
CARMEL, IN 46033
RE: Account#20166087:1 D.O.S. 10/28/2016
Dear Nannette Schmitt:
Enclosed you will find a refund check in the amount of$90.33.
On July 29, 2016 we received your payment for $340.33 Check#4536.
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,
kiche T. Harrington
EMS Billing Administrator
CAKMEL FIRE DEPARTMENT
STEVEN A. Cores HEADQL ARTER>
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CA�?L CARMEL FIRE DEPARTMENT
F .D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
1 (317) 571 2604 Federal ID# 356000972
Patient Name: SCHMITT, NANNETTE M
NANNETTE SCHMITT CARMEL FIRE DEPARTMENT
5859 LOST OAKS 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 990113349
Ticket# : 20161336:1
Date of Service: 3/13/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. COPAY$250.00 PATIENT PAID
$340.33 -$250.00=$90.33 OVERPAYMENT REFUND TO BE SENT TO PATIENT.THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161336:1
Online Payment will charge a service fee.
�paf Ser ince escriptianP.atiename s` '; rr -. ,
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Charges
3/13/2016 'BASIC LIFE SUP SCHMITT, NANNETTE M $475.00
3/13/2016 "MILEAGE SCHMITT, NANNETTE M $116.40
---------------------------------
Charge Total: $591.40
Payments
Paid By. Invoice 03/13/16 $591.40
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 05/04/16 ($182.24)
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 05/04/16 ($68.85)
Paid By: ANTHEM SENIOR ADVANTAGE WRITE OFF 05/04/16 $0.02
Paid By: SCHMITT, NANNETTE M Payment 07/29/16 ($340.33)
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 ($184.05)
BALANCE $0.00
,MZ CARMEL FIRE DEPARTMENT
F,44 D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID#356000972
Patient Name: SCHMITT, NANNETTE M
NANNETTE SCHMITT CARMEL FIRE DEPARTMENT
5859 LOST OAKS 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 990113349
Ticket# : 20161336:1
Date of Service: 3/13/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED YOUR CLAIM. COPAY$250.00 PATIENT PAID
$340.33 -$250.00=$90.33 OVERPAYMENT REFUND TO BE SENT TO PATIENT.THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 06/30/17 ($157.35)
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 06/30/17 $68.83
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 $182.24
Paid By. SCHMITT, NANNETTE M REFUND 06/30/17 $90.33
BALANCE $0.00