314276 07/31/2017 (9)
CITY OF CARMEL, INDIANA VENDOR: 371834
ONE CIVIC SQUARE SALLY DENNIS CHECKAMOUNT: $*******154.14*
CARMEL, INDIANA 46032 12394 HYACINTH WAY CHECK NUMBER: 314276
CARMEL IN 46032 CHECK DATE: 07/31/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 20161873 :1 154.14 OTHER EXPENSES
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JANLES BRAINARD, MAYOR
July 17, 2017
SALLY DENNIS
12394 HYACINTH WAY
CARMEL, IN 46032
RE: Account#20161873:1 D.O.S. 04/11/2016 Helen Wells passed away 04/16/2016
Sending check to POA.
Dear SALLY DENNIS:
Enclosed you will find a refund check in the amount of$154.14.
On October 3, 2016 we received your payment for $404.14 Check#122.
On July 03, 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,
14 dd,
Michelle T. Harrington
EMS Billing Administrator
CAR.\IR.L FiRt: DEPARTNIE-vT
STe\e-x A. Cor Ts HEADQ1 ARTERS
Two QVIC SQUARE, C ILMEL, IN 46032 OFFICE 317.571.2600, FA-�"- 317.571.2617
CAx CARMEL FIRE DEPARTMENT
F�D 2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 571 2604 Federal ID#356000972
Patient Name: WELLS, HELEN G
HELEN WELLS CARMEL FIRE DEPARTMENT
ATTN SALLY DENNIS 2 CIVIC SQUARE
12394 HYACINTH WAY CARMEL, IN 46032-2584
CARMEL, IN 46032
TO ASSURE PROPER CREDIT, RETURN Statement Date I Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/20/17 201204057
Ticket# : 20161873:1
Date of Service: 4/11/2016
DETACH HERE
ANTHEM REPROCESSED YOUR CLAIM. YOU PAID $404.14 AND AMOUNT DUE $250.00
CREATED OVERPAYMENT. REFUND $154.14
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0.00'
Pay online at www.govpaynet.com with PLC#7487 Run Number 20161873:1
Online Payment will charge a service fee.
IN
� D'ae f Servide} `��Description � Patient Name ' �" t:Charge4�)��' ¢�ba#e� ` � P�J��$ht�,$)
Charges
4/11/2016 "ADVANCED LIFE WELLS, HELEN G $575.00
4/11/2016 "MILEAGE WELLS, HELEN G $56.40
---------------------------------
Charge Total: $631.40
Payments
Paid By. Invoice 04/11/16 $631.40
Paid By: ANTHEM SENIOR ADVANTAGE/ ASSIGNMENT MEDICARE 04/26/16 ($191.78)
Paid By: ANTHEM SENIOR ADVANTAGE/ MEDICARE PAYMENT 04/26/16 ($35.48)
Paid By: WELLS, HELEN G Payment 10/12/16 ($404.14)
Paid By: WELLS, HELEN G WRITE OFF 07/03/17 ($194.86)
Paid By: WELLS, HELEN G BLUE SHIELD PAYMENT 07/03/17 ($186.54)
BALANCE $0.00
CARMEL FIRE DEPARTMENT
F ._jj 2 CIVIC SQUARE
CARMEL, IN 46032-2584
• (317) 571 2604 Federal ID#356000972
Patient Name: WELLS, HELEN G
HELEN WELLS CARMEL FIRE DEPARTMENT
ATTN SALLY DENNIS 2 CIVIC SQUARE
12394 HYACINTH WAY CARMEL, IN 46032-2584
CARMEL, IN 46032
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 07/20/17 201204057
Ticket# : 20161873:1
Date of Service: 4/11/2016
DETACH HERE
ANTHEM REPROCESSED YOUR CLAIM. YOU PAID $404.14 AND AMOUNT DUE $250.00
CREATED OVERPAYMENT. REFUND$154.14
Paid By: WELLS, HELEN G BLUE SHIELD PAYMENT 07/03/17 $35.48
Paid By. WELLS, HELEN G WRITE OFF 07/03/17 $191.78
Paid By: WELLS, HELEN G REFUND 07/20/17 $154.14
BALANCE $0.00
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