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e CITY OF CARMEL, INDIANA VENDOR: 371811
ONE CIVIC SQUARE BETTY FOWLES CHECK AMOUNT: $`"'"'*154.14"
,? r`' CARMEL, INDIANA 46032 14465 JEFFREY COURT CHECK NUMBER: 313788
+M. CARMEL IN 46032 CHECK DATE: 07/18/17
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 154.14 OTHER EXPENSES
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JANIES BRAINARD, MAYOR
July 10, 2017
Betty Fowles
14465 Jeffery Court
Carmel, IN 46032
RE: Account#20161145:1 D.O.S. 03/03/2016
Dear Betty Fowles:
Enclosed you will find a refund check in the amount of$ 154.14.
On April 12, 2016 we received your payment for$ 404.14 Check#1099.
On June 30, 2017 Anthem Senior Advantage reprocessed your claim
Copay due is only$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,
R- "
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. ColiTs HEADQUARTERS
Two CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.j71.2600, FAx 317.571.2615
CAR-wL CARMEL FIRE DEPARTMENT
F .D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q (317) 571 2604 Federal ID#356000972
Patient Name: FOWLES, BETTY
BETTY FOWLES CARMEL FIRE DEPARTMENT
14465 JEFFREY CT 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURNStatement Date I Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990113252
Ticket#: 20161145:1
Date of Service: 3/3/2016
DETACH HERE
ANTHEM MEDICARE REPROCESSED YOUR CLAIM. CORRECT AMOUNT DUE $250.00 REFUND
ISSUED FOR$154.14. THANK YOU
PT PAID$404.14-$250.00=$154.14
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MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0 00:
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161145:1
Online Payment will charge a service fee.
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Charges
3/3/2016 "ADVANCED LIFE FOWLES, BETTY $575.00
3/3/2016 `MILEAGE FOWLES, BETTY $24.00
---------------------------------
Charge Total: $599.00
Payments
Paid By: Invoice 03/03/16 $599.00
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 03/29/16 ($14.19)
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 03/29/16 ($180.67)
Paid By. FOWLES, BETTY Payment CVC� jogj 04/12/16 ($404.14)
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 ($183.75)
Paid By: ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 06/30/17 ($165.25)
BALANCE $0.00
M CARMEL FIRE DEPARTMENT
F.4A•D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
Q (317) 5712604 Federal ID#356000972
Patient Name: FOWLES, BETTY
BETTY FOWLES CARMEL FIRE DEPARTMENT
14465 JEFFREY CT 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 990113252
Ticket#: 20161145:1
Date of Service: 3/3/2016
DETACH HERE
ANTHEM MEDICARE REPROCESSED YOUR CLAIM. CORRECT AMOUNT DUE $250.00 REFUND
ISSUED FOR$154.14. THANK YOU
PT PAID $404.14-$250.00=$154.14
{
Paid By. ANTHEM SENIOR ADVANTAGE MEDICARE PAYMENT 06/30/17 $14.19
Paid By: ANTHEM SENIOR ADVANTAGE ASSIGNMENT MEDICARE 06/30/17 $180.67
Paid By: FOWLES, BETTY REFUND 06/30/17 $154.14
BALANCE $0.00