HomeMy WebLinkAbout218034 03/13/2013 CITY OF CARMEL, INDIANA VENDOR: 367004 Page 1 of 1
` ONE CIVIC SQUARE DONALD FERGUSON
i CHECK AMOUNT: $93.56
�•�% CARMEL, INDIANA 46032 5574 DUNK DR
INDIANAPOLIS IN 46224 CHECK NUMBER: 218034
CHECK DATE: 3/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 93 . 56 OTHER EXPENSES
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CITY 0 ` EL
JANIFs BRAINARD, MAYOR
March 4, 2013
Mr. Donald Fergusan
5574 Dunk Drive
Indianapolis, IN 46224
RE: INVOICE 920125618:1/ D.O.S. 12/13/2012
Dear Mr. Fergusan:
Enclosed you will find a reimbursement check in the amount of$93.56.
On January 11, 2013 we received a money order from you for your ambulance transport
on December 13, 2012 in the amount of$517.00. On February 20, 2013 we received a
check from Cigna in the amount of$93.56 for the same ambulance transport.
Since you paid this invoice in full, I am issuing you a refund of$93.56.
If you have any questions, please feel free to contact me at (3 17) 571-2604.
Sincerely,
Michelle Harrington
EMS Billing Administrator
CARNIEL FIRE DEPART�vIFNT
STEVEN A. CoUTs HEADQUARTERS
Two CIVIC SQUARE, Gutm L, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
' CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-7543
CL4XTi (317) 571 2604 Federal ID#356000972 S
Patient Name: FERGUSAN, DONALD E
DONALD FERGUSAN = CARMEL FIRE DEPARTMENT
5574 DUNK DR - 2 CIVIC SQUARE
SPEEDWAY, IN 46224 CARMEL, IN 46032-7543
TO ASSURE PROPER CREDIT, RETURN Statem AM
ent Date Patient ID OUNT PAID
THIS PORTION WITH YOUR PAYMENT 02/28/13 201203905
Ticket# : 20125618:1
Date of Service: 12/13/2012
DETACH HERE
REFUND $93.56
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE4ye,�����,,���, _�n,;
Pay online at www.govpaynet.com with PLC#7487 Run Number 20125618:1
Online Payment will charge a service fee.
DatexnD suiot . � n . ` fa m n t s e
Charges
12/13/2012 *ADVANCED LIFE FERGUSAN, DONALD E $475.00
12/13/2012 *MILEAGE FERGUSAN, DONALD E $41.53
---------------------------------
Charge Total: $516.53
Payments
Paid By: Converted Invoice 12/13/12 $516.53
Paid By: WRITE OFF-INSURANCE 01/11/13 $0.47
Paid By: PAYMENT 01/11/13 ($517.00)
Paid By: FERGUSAN, DONALD E REFUND 02/20/13 ($93.56)
Paid By: CIGNA/ 182223 COMMERCIAL INSURANCE 02/20/13 ($93.56)
BALANCE $0.00
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Cigna Health and Life Insurance Company
BOURBONNAIS CLAIM OFFICE
P.O.BOX 182223 °o o -Pon n
CHATTANOOGA TN 37422-7223 C Y
Cigna Health and Life Insurance Company
ASAGENTFOR
ASCENSION HEALTH MINISTRY SERVICE CENTER Provider Number:
®� 356000972 0000
®� Date through which claims were processed:
01/19/2013
® Payloc
CARMEL FIRE DEPT 765
2 CARMEL CIVIC SQ How to Contact Us
CARMEL IN 46032-2584
Mail to the return address in upper
�F left corner of this page
RECCEI`d ED jAN 2 9 2-0113
W, Phone: (800)244-6224
Provider Explanation of CIGNA Choice Fund Health Reimbursement Account(HRA)Payment
Understanding this Statement
This page provides a summary of the Choice Fund HRA payments made this period.
• The accompanying pages give more detail on the claims we processed for this period. Please review both the front and back of each page to see
how the benefit amounts in the Providers Explanation of CIGNA Choice Fund Health Reimbursement Acount Payment Report were deter mined.
Payment Summary
ICheckNumber: 00252198057 Check Amount: 593.56 LCheckDate: 01/19/20:L3
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