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HomeMy WebLinkAbout313788 07/18/2017 +u,C�yyf e CITY OF CARMEL, INDIANA VENDOR: 371811 ONE CIVIC SQUARE BETTY FOWLES CHECK AMOUNT: $`"'"'*154.14" ,? r`' CARMEL, INDIANA 46032 14465 JEFFREY COURT CHECK NUMBER: 313788 +M. CARMEL IN 46032 CHECK DATE: 07/18/17 trove ca' DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 154.14 OTHER EXPENSES o-0 O O )/ z R m n / ? n ] # O k \ < k E & G ¥ 3c m0 R & a = o Q> D / CD \ > ' \ \ \ ƒ Cl) \ k 0 / �_ m ¥ \ O \ - \ 2 O O z CD§ \ 7 cr 7 CD =f CD 0 CD o 07CL UT 2 CD _ � ? q CD 0 �_ 2 ® CD3 � -n U) J CD W k -(A (D Ar 3 \ CCDI- T. CCD » / 3 CD 3 §k § ' § / o C 0 0 A 2 § 03 o_ N) k ) 0 0 9 0 CL k CD ƒ m / / 3cr o 0 C (n AM— QVI WEL JANIES BRAINARD, MAYOR July 10, 2017 Betty Fowles 14465 Jeffery Court Carmel, IN 46032 RE: Account#20161145:1 D.O.S. 03/03/2016 Dear Betty Fowles: Enclosed you will find a refund check in the amount of$ 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 s.�z 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. ori 'ter - �a ien ; �me �° � '. ����� h fi s Dat t . . 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