174143 06/25/2009 CITY OF CARMEL, INDIANA VENDOR: 363015 Page 1 of 1
ONE CIVIC SQUARE HEALTHCARE RECOVERIES
CARMEL, INDIANA 46032 ATTN: KIM MARTIN CHECK AMOUNT: $286.20
250 SUNNYSLOPE ROAD #150
BROOKFIELD WI 53005 CHECK NUMBER: 174143
CHECK DATE: 6/25/2009
DEPARTME ACCOUNT PO NUMBE INVO NUMBER AMOUNT DESCRIPTION
X102 5023990 10929087 286.20 EVENT 10929087
Suburban Health Organization
P.O. Box 502530
Indianapolis, IN 46250
Date: 6/22/2009
City Of Carmel
1 Civic Square
Carmel, IN 46032
Check# 173554
Dear Provider:
We have received the enclosed refund check from your office. Unfortunately, we must return this
check to you. The reason we must return this refund to you is:
The reason for this refund was not indicated. Please supply additional information.
We are unable to determine the date of service this refund is to be applied to.
We cannot identify the patient in our system.
Please reissue your refund check, made payable to Suburban Health Organization.
XXX Other: Please make check payable to Healthcare Recoveries. Please
Mail to Healthcare Recoveries ATTN: Kim Martin, 250 N Sunnyslope Rd.
Ste. #150, Brookfield, WI 53005. Please include the event 10929087
If we are requesting additional information, please return this letter, the refund check, and a copy of
all other enclosed documentation to:
Suburban Health Organization
Attn: Refund Department
P.O. Box 502530
Indianapolis, IN 46250
If you should have any questions or concerns, please feel free to contact me at 317 575 -7593.
Thank you for your cooperation in this matter.
Sincerely,
Mindi Garrity
Revenue Recovery Dept.
CITY OF CARMEL, INDIANA VENDOR: 356277 Page 1 of 1
ONE CIVIC SQUARE SUBURBAN HEALTH ORGANIZATION CHECK AMOUNT: $286.20
CARMEL, INDIANA 46032 PO BOX 502530 CHECK NUMBER: 173554
INDIANAPOLIS IN 46250
CHECK DATE: 6/10/2009
AMOUNT DESCRIPTION
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER
286.20 OTHER EXPENSES
102 5023990
REMITTANCE ADVICE DETACH AND RETAIN FOR YOUR RECORDS
OR THE CITY OF CARMEL 2002 c I MK �N 0,
APPROVED BY THE STATE BOARD OF ACCOUNTS F
;b 11.1i li
`85 T
735
PA YABLE AT
FIFTH THIRD BANK
INDIANA' ;INDIANAPOLIS ��INDIAN
DATE.".... 6110.12009
GENERAL ACCOUNT
CARMEL INDIANA 46032'
AMOUNT
288.20,
PA
0 E CTS CTS
THIS WARRANT IS VOID TWO (2) YEARS AFTER
DECEMBER 31 OF THE YEAR OF ISSUE,.
N�—
OR GANIZATION GANIZATION CL
ERR�T
The SUBURBAN HE
PO BOX.5
02530
I'NOIANAPdLiSl 46250
PI
O f
II�L 73 55411s 1:0749013I594 9 9 9-9 3 2 7 11 RECEIVED JUN 172009
CI` YY OF RMEL
JANIEs BRAINARD, MAYOR
June 4, 2009
Suburban Health
P.O. Box 502530
Indianapolis, IN 46250
RE Lacy Bursick/ ID #HP8016815601 /DOS 03/17/2009
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $286.20. On May 19,
2009 we received a check for $286.20 from you, paying this towards Ms. Bursick's
ambulance bill for service provided on March 17, 2009. On May 27, 2009 we received a
check from State Farm Insurance for $357.75. Since State Farm is the auto insurance
which is primary, we are issuing you a refund of $286.20. If you have any questions,
please feel free to contact me at (3 17) 571 -2605.
Sincerely,
Beclky S. Lannan
Billing Administrator
RECEIVED JUN 171009
CARMEI, FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
TWO CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615