HomeMy WebLinkAbout313885 07/18/2017 � "'• CITYOF CARMEL, INDIANA VENDOR: T1841
CHECK AMOUNT: $*k.....154.14*
ONE CIVIC SQUARE GEORGE STAMPER
:3 a CARMEL, INDIANA 46032 2828 141 ST STREET WEST CHECK NUMBER: 313885
,* WESTFIELD IN 46074 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 154.14 OTHER EXPENSES
o-UO Z O
\/ > /
a0
( m
W.� / 2 k )
T. g \ z O
\ \ m 0 _
7 � VA
(
\� k
n
J / k
k
ch.
7 D
:3 /
± J > z 0 k
_ 0 / • § .
z /
� 0 / CD
� CD p
$ n 2 F cr2
» \ § ?
)q cn _
2 2 O
CD
@ » -n
G . I p K -co
a k / ' m �3 OL �
k §
3 0 _
_
B 3 7 3 §
o a a =r
C 7 W=3
E
§ CL _
0 » 0 CL
CL 0 :7CD
CCD En 3 o
cr
0 (D
(n
CI EL
JAMES BRAINARD, MAYOR
July 10, 2017
GEORGE STAMPER
2828 WEST 141s' STREET
CARMEL, IN 46074
RE: Account#20161599:1 D.O.S. 03/26/2016
Dear George Stamper:
Enclosed you will find a refund check in the amount of$154.14.
On October 28, 2017 we received your payment for $404.14 Check#3749.
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
SrE%EN A. CoL;rs HE_�nQL ARTER
Two CIVIC Sot_ARE, CARMEL, IN 46032 OFFICE 317.5?1.2600, F:Lx 31-7.5,1.2615
CAXWL CARMEL FIRE DEPARTMENT
Ft%.D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
• (317) 571 2604 Federal ID#356000972
Patient Name: STAMPER, GEORGE R
GEORGE STAMPER CARMEL FIRE DEPARTMENT
2828 WEST 141ST ST 2 CIVIC SQUARE
WESTFIELD, IN 46074 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 201203894
Ticket#: 20161599:1
Date of Service: 3/26/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. COPAY$250.00 PATIENT PAID $404.14 -
$250.00=$154.14 OVERPAYMENT REFUND SEND TO THE PATIENT.THANK YOU
1
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT I BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161599:1
Online Payment will charge a service fee.
K Sery c� c Ipt!on Patient Name ffi. � Charges Dated, 1 �
. '�.'ra'�h� ��;d� �u� a a `�rs'r_ +so-' a.�es� ..,Y ,,.,w=•a _:,',-�:��'.a`h .a.� �':--
Charges
3/26/2016 *ADVANCED LIFE STAMPER, GEORGE R $575.00
3/26/2016 *MILEAGE STAMPER, GEORGE R $78.00
---------------------------------
Charge Total: $653.00
Payments
Paid By: Invoice 03/26/16 $653.00
Paid By: ANTHEM SENIOR ADVANTAGE/ BLUE SHIELD PAYMENT 04/21/16 ($46.12)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 04/21/16 ($202.74)
Paid By: STAMPER, GEORGE R Payment 10/28/16 ($404.14)
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 ($205.82)
Paid By. ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 ($197.18)
BALANCE $0.00
CSL CARMEL FIRE DEPARTMENT
.TAP 2 CIVIC SQUARE
CARMEL, IN 46032-2584
CLAXT". (317) 571 2604 Federal ID#356000972
Patient Name: STAMPER, GEORGE R
GEORGE STAMPER CARMEL FIRE DEPARTMENT
2828 WEST 141ST ST 2 CIVIC SQUARE
WESTFIELD, IN 46074 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date= Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 201203894
Ticket# : 20161599:1
Date of Service: 3/26/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. COPAY$250.00 PATIENT PAID $404.14 -
$250.00=$154.14 OVERPAYMENT REFUND SEND TO THE PATIENT.THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 06/30/17 $46.12
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 $202.74
Paid By: STAMPER, GEORGE R REFUND 06/30/17 $154.14
BALANCE $0.00