313918 7/18/2017 4a W Cggy'
CITY OF CARMEL, INDIANA VENDOR: 368538
ONE CIVIC SQUARE JOYCE BYLLESBY CHECK AMOUNT: $"* ""'90.33'
?4; CARMEL, INDIANA 46032 1335 S GUILFORD ROAD#A3405 CHECK NUMBER: 313918
CARMEL IN 46032 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 90.33 OTHER EXPENSES
<
7] k ?
�o D
ƒ / q m
. � _ m
� a 2 ? Cb
2
\ / <
/
m O
\ D W
\( _ 0
f
k
\ f n p D
27 / _ m
\ \ M. Q w
. / \ O 2
_ 2 z O
0 0 [
O
\
�
CD /
CD
0 � CD _ O
CD n 5 2
CD � \ !�) q ?
\ � $
G / CD \ 6q
3 � M_. CL 7
' CD _
R :=
§ 3
CD C
�
o
7 R a E
N) k 2 0_ < q
o p § g 0-
CL J 7 cn 3 o
C
i CD
/
E'
CI EL
JAINIES BRAINARD, NLAYOR
July 10, 2017
JOYCE BYLLESBY
1335 S GUILFORD RD APT A3504
CARMEL, IN 46033
RE: Account#20165921:1 D.O.S. 10/18/2016
Dear Joyce Byllesby:
Enclosed you will find a refund check in the amount of$90.33.
On March 17, 2017 we received your payment for$340.33 Check#587.
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,
dvl L" J• �/
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVE.y A. Coors HEADQLARTERs
TVV(� CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.�7I.2600, F.Ax 317.j�'L.2615
CIL CARMEL FIRE DEPARTMENT
F.%V D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID# 356000972
Patient Name: BYLLESBY, JOYCE E
JOYCE BYLLESBY CARMEL FIRE DEPARTMENT
1335 S GUILFORD RD APT A3504 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 200102536
Ticket# : 20165921:1
Date of Service: 10/18/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. UPDATED COPAY$250.00. PATIENT
PAID$340.33 -$250.00=$90.33 OVERPAYMENT REFUND SEND TO PATIENT.THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20165921:1
Online Payment will charge a service fee.
a e o Rid 'Y Description k Patient Name4
Char s 'Date � it(s)
Charges
10/18/2016 "BASIC LIFE SUP BYLLESBY, JOYCE E $475.00
10/18/2016 "MILEAGE BYLLESBY, JOYCE E $16.80
---------------------------------
Charge Total: $491.80
Payments
Paid By: Invoice 10/18/16 $491.80
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 11/22/16 ($144.37)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 11/22/16 ($7.10)
Paid By: BYLLESBY, JOYCE E Payment 03/17/17 ($340.33)
Paid By: BYLLESBY, JOYCE E ASSIGNMENT MEDICARE 06/30/17 ($146.18)
Paid By: BYLLESBY, JOYCE E MEDICARE PAYMENT 06/30/17 ($95.62)
BALANCE $0.00
L*A z CARMEL FIRE DEPARTMENT
1-%P D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
L'lrA4>rT[ (317) 571 2604 Federal ID#356000972
Patient Name: BYLLESBY, JOYCE E
JOYCE BYLLESBY CARMEL FIRE DEPARTMENT
1335 S GUILFORD RD APT A3504 2 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/10/17 200102536
Ticket# : 20165921:1
Date of Service: 10/18/2016
DETACH HERE
ANTHEM SENIOR ADVANTAGE REPROCESSED CLAIM. UPDATED COPAY$250.00. PATIENT
PAID $340.33 -$250.00=$90.33 OVERPAYMENT REFUND SEND TO PATIENT.THANK YOU
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 ($90.33)
Paid By. BYLLESBY, JOYCE E MEDICARE PAYMENT 06/30/17 $7.10
Paid By: BYLLESBY, JOYCE E ASSIGNMENT MEDICARE 06/30/17 $144.37
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 06/30/17 $90.33
Paid By: BYLLESBY, JOYCE E REFUND 06/30/17 $90.33
BALANCE $0.00