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HomeMy WebLinkAboutInv# 18091100004940 - EDWARD MARGOLIN - 09/30/2021Don'o MANUAL REFUND REQUEST FORM TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE BELOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUNO FOR THE FOLTOWING ACCOUNT. THE REFUND CHECK MUST BE I55UED TO THE PAYOR/PATIENT SHOWN 8ELOW. PTEASE CONTACT CTIENT REI.ATIONS SHOUTD YOU NEED FURTHER INFORMATION, REFUND DETAILS: PATIENT ACCOUNT#: REFUND PAYABLE TO: NAME: ADDRESS: CITY, STATE ZIP: ADDITIONAL INFORMATION: EDWARD MARGOLIN 49464520 DATE OF SERVICE: 9lLl/2O18 MARI N. MEARMAN REFU ND REASON:OVERPAYMENT: PATIENT OVERPAID RESPONSIBILITY INSURANCE CLAIM #: 930 BUCHANAN ST ttlA , FL 33019 PATIENT NAME: REFUND AMOUNT: S45O.OO Patient Mearman, Mari 930 Buchanan St HOLLYWOOD FL 33019 Trip Date of Service: 09-11-2018 lncident #:: FON18091 1 00004940 Pickup: 408 Se 6th St Deslination: MEMORIAL REGIONAL HOSPITAL Item ized Charqes Description Unit Cost U nits Amount ALSl Emergency Base Rate Oania 1008.36 1 1008.36 76.34ALS Eme nc [,4ilea Dania 18.62 4.',| Account Transaction Scan #Post Date Amount Payment to EI/S - Primary lnsurance p310020461390 10-31-2018 553.04 ey OrderPavment to EMS - Check / Mon p4'1002147217O 07 -'t7 -2019 50.00 Payment to E[,4S - Check / Money Order 0910021716180 08-23-2019 s0.00 Payment to EMS - Check / l,/oney Orde!o710021599243 09-23-2019 50.00 Payment to EMS - Check / Money Order D110021837770 11-01-2019 50.00 Payment to E[/S - Check i Money Order o210022002990 '1 1 -'1 9-20'1 9 50.00 Payment to EMS - Check / Monev Order p510022004916 12-10-20',t9 50.00 Paym ent to EMS - Check / Money Order p810022005306 't2-29-2019 50.00 Payme nt to EMS - Check / Money Order p810021886286 01-12-2020 50.00 Payment to E1,,4S - Check / Monev Order p010022000336 o2-04-2020 50.00 Payment to El,ils - Check /Money Order p610022159795 03-09-2020 50.00 Payment to EMS - Check / l\4oney Order p510022235993 03-31-2020 50.00 Payment to EN,lS - Check / Monev Order i1588078352257 05-08-2020 50.00 AdiustmenVAssiq nment - Primary lnsurance p310020461390 09-20-2021 381.66 Payment to EMS - Check / Monev Order 1413095517 09-20-2021 450.00 Account Summary Total Charges $1084.70 Total Payments $703.04 Assign/Adjust $381.66 Balance Due $0.00 Printed on 09-20-2021 Broward Sheriffs Fire Rescue PO Box 865346 Orlando, FL 32886-5346 Account # 49464520 Itemized Statement ililtilil1il]ilill[lll 310020461390 201 8-'t 1 -05 09:42:03 B3'l 002046 1 390 Batch: 70{ Lockbox: MCO E65348 < Provious Trarcadion Eqbh Swunary TEnt cdon 41 SuImlIy Transaction Total: 1991.10 Deposit Account i1132991 530 Ncxt TraBlattion > Deposit oate: 10129r20t8 cffi1 Front lmagB check Amountr $901.10 Check Number 153138 Check Account Numbec \\\-liWE$ AVHED HEA]-IH P!'INS P , o. 8ox 1'19 CAIIJESVILLE, FL 32 502 $IEI,I,S FARCO NAto{ NoBrH t!l^lN stREEa GAINESVILLE, FL 32601 64-913/6L2 cHEC(l 153138 Nltib ifuNrrRttD NrNE'ly o!{-q q('l-['ris fEr{ ctNrs rol22l1s tI.tOUNl -Jffi;r-ti:f 0 co-U!{TY OF BROWARD S EIIJI TT O.FFICE ffi PO BOX I553a 5 oRlar{DO, EL 328a6-5346 2te e fol5lllS'r. r:ogl2Oq?5gr: eo?qqooEloo?5i. tte.n 1 Ftoi( lrEoo Pag€ 111of164 4t*./ / r'r%!- {"6a,2!o3.cut.. 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'r'{D,'E.Ell d..rr.E'rr'!|..a .r .o l..r !a.a llllr ilililiflliltU]tl[ 41002t472170 201 9-07-1 8 16.45.27 8410021 47 2',17 0 < Pr€vlous Transaclion fllrf,ti/,rylHr BEldl Summary TrerEecdon {,1 Summary Transaction Total: $50.00 Doposit Ac@unt: 4132991 530 oeposit Date: 07 l15nO1S Check 1 Front lmage Check Amount $50.00 Check Number: 5001 CheckAccountNumberi 1000158598283 r.OO 5OO I'p ':OE IOOo lOr.r: lO00 l5g 5qE e8:lr' ) 1..-l&buht:. lg{Gls2d $ FIFIY.D 00r',100 s50-00 BROWARD SHERIFIS fIRE RESCUE F6 goxstssac ffigoRLANoo, FL 328a6 5346 lhl'h,trl,lt't'l,ltlrIrlt,,Ill.tlrlltI'lh,lrrll'rl[!ll'll ' Void Aff.r 180 DAYS: ^ '' sisindlure In'Fi\e '. .ffs checl ha6 b66n adhorizqd-- " ' by io{r d€poaltor TO THE OROEROF iu:tsr tost rnr ravlrlt ror pgr rq'tuA! cua.rof,Et - - ' Plarso Oirect.Any Oue.tions 'To - 8flA'&ffiroxs oepnrturt r' 4eM6NI6co(@'rc(G Page 155 ot 166 Batch:49 Lockboxi MCO 885346 Next Transac,tion > .'101610 .. . oooooosdol..,-.; .r '. JUlv 16: 2019. ilililil1ilI il ilt[I]r 910021716180 2019-08-23 1 6:1 2:26 B91 0021 71 61 80 < Pae\riorc Tranaaclion Batc,| Summary Trans.(don 2 Summary Transaction Total: $50.00 DepositAccount 4i32991530 ,{extrra'sscdoo> llflfllllllfllfl,fl 9100 2171 6180 Deposit Oate: 08iDDO19Batch:85 Lockbox: MCO 865346 Check 1 Front lmage Accourt:?!asE'49464520. : '. CheckAccount Number: 10001585962E3 ro3r rrn ,^l.r.r,P ,oi:.ruiru^r:9t srolE. 35O,OO ' :.,.'::i . EDIXASD lrAiGOUl{ :, ';i 6OEL'CfiAI{AN,ST i,,.",,BOulEA FL3totEtl05 PlGfic Di.€.t A,ry Oucstiofir To - : 8U?Sffinors oLpArruiin' 10610 i; sriniduir: . j rosidsir oa*rs oi6ts @,@a Ea6o3 ooofin5004 $ OROER TO THE OF r'OO 5OO LrP r:oE tooo tol.r: looo l5a 5qg aB llF Page 4 of 111 BROWARD SHERIFFS FIRE RESOJE Po Box 8553,16 oRL Nm, FL 328a6 5346 \Il.rllrh,trlntlknrllllhllhltx.lllll.nur,-l,rl,hl Vdd Afic. r80. DAYS- ::, Signatute OnElla,: ''' I rhir .nc.k hes bacn'.dh{Si.d :by your dcpoitor..:. :; : :r Ch6ckAmount 350.00 Check Numbec 5004 rlil ililtlil[[lilt]t 710021599243 2019-10-02 1 0:05:39 B7'l 0021 599243 Batch: 106 Lockbox: MCO 865346 < Pr€virus Transacdon gatch Surlmary Tr.ngac{on 5 Summary Transaction Total: 350.00 Deposit Accoun(: 4132Ssl 530 Next Transac'tion > Deposit Date: 09/r6/2019 Check 1 Front lmago CheckAmount: S50.00 Check Number: 5OO€ CheckAccountNumber: 1000158598283 (.oo 500gu' r:oE looo Iol.t: t000 1585q8?8 lrF 50.00 hhrrr,rhrllIllh",rh Jl\nllltllnntlhlhltfl 'rillliltll I 001100 ''...-I EROi\,/ARD SHERIFFS NRE RESCUE PO BOX E6&3{5 oRLAtlDO, FL 3280&5J46 TO IHE OROGRof vold At r 160 DIYS. Sisod,l1:eo,t de:-' ' :t '. This dleck ha! !€.n auqlodz4 . ', by your d€pGftor . ,:' ; diano irias'iror' ' 'ra qE drc8attll{ 5T ;' i "-.. HO(I.Y1^O@. ll iarlll lF l.t, i..,.,i - l- .l q Eih N.NS Page 6 of '129 To D€PARTM€NT 10,610 :-quxxto6ul6 si{nfmber 16,201e lrIIIIIIIlIrililr Irrl[ 110021837770 < Pr€vixJs Transaction Batdr Summary Transadion '15 Summary Transaction Total: $50.00 Deposit Account: 4132991530 Nsxt Trensaction > Deposit Date: 10/152019Batch: 131 Lockbox: lilCO 865318 Check 1 Froht lmage Check Amounti 950.00 Check Number: 5008 Check Account Number:'100015@8283 Account: 49464520 HOrLYl,ltOOO. FL lf,Ol9l105 SUNTRUST cBrmcsrrs o!!t90 o]i550 CaOt!06 rolr '3' October 1q 2019 DOLLARS 0000005008 atlDoon00 "50.00 TO THE IllilrlIth'l.r!nl'l,tlIpr,l,r,nillhh,,r,lhIhr",lll' 'l oo 5OO8ll. r:OE IOOO lOrrr: looo I5A 5q8 ?8 1!' ltillllllllNlllilllllil'|1lm 21A3 7770 ORO€R OF Paqe 28 of 232 2019-1 1-05 16:08:58 B'l 1002'1837770 Pb.se Dlrocl AnY Quo!|ixl3 To ffi Bltffirlort o."*'u*' EROWARD SHERIFFS FIRE RESCUE PO BOX 865345 oRLANDo, FL 328t&53,16 t0/610 't votd ,,lter 180 DAYS. signature Oii F e ' : This checl has been aulttolrzed bv Yot, dePosilor Milil1ililil1ru!illI 210022002990 2019-1 1-19 15.37:25 B2't 0022002990 Batdl Summary Transadion 33 Summary Transaction Totali 350.00 Deposit Account: 41329S1530 Deposit Date: 11112f2O19 Check 1 Front lmage Check Amountr S50.00 Check Numbe[ 5010 CheckAccountNumber:'1000158598283 ' Abcburit: '49454520 rLErsE POST rli3 FAYXlxf roi OUA (Un Ar cu5rora4 s50.00' SI]NIRUSI (3!15 59€l$t Or c6r oru! Mr.rco. r0r@t r 10,510 0000005010 Novei'nber 20'lg " DOLLARS Pleas€ Dlr€d Any Oueniong To l80O) 27&4n02 \ .' OT'R OPERATIONS DEPARTMEI.IT E ig FtFrY AXO 00/r00 3IO THE AROWARD SHERIFFS FIRE RESCUE PO aOX 8653.{6 oRLANOO. Ft 3288&5346 VordAier 180 oAYS.. : ISignalirc on File'' . ', ' ' This check has bden aulhdrized i ' by yo0i dapositor r: - .', OROER ll,,,rtr,rt,l,.lt,llul.,l,lll'l'lltlhrl'lmlt",l,rrlr ,,,r u.0050 Io!. r:oE LOOO lOLr: t00B I58598 aBlll. \\\$\$Ilti\$ Paqe 113 of 158 Balch:'157 Lockbox: MCO 865346 < Previous Transaction Next Transaction > OF EDWAFo M icooll ,' I]O BUCHANAN SI ,: ' :. lor-tYtlDoo..Fl:Salllal 105 ililililililllllllllll[ s10022004916 20 19-1 2-12 12:37 :46 851 002200491 6 Batch:183 Lockboxr MCO 865346 < Previous Transaclion Batch Summary Transaction 24 Summary Iransaction Totali $50.00 Deposit Account: 4132991530 Next Transaction > DepositDatei 120912019 Check 1 Front lmag€ Check Amount: $50.00 Check Number; 5011 Check Account Number: 1000158598283 r\ru,rNul}lu!l][l\l **.rri.iso.00 rLE SE ?O3tr'lis P YrExrfOAOUArI,UAL Pls.36 Dlroct Any Queslloi! To' . 1S.t 1C5 casr. icv2e21 0!712 @r? o@5e6 ko3/m DOLLARSFTFTYAXO 001100 -- {600)OUR EDWAAO,MiRGOLIN +loLlYlrDoD, Fr- !3c . Accoirnt:,19464520 SUNINUST . r,ll,tltrtrL,tlrhtlllhlLtttltrllt,,hhl,rtrtllllrllUr 50.00 10/€r0 . -: 0000005011 DeGembbi 11, 2019 TOrflE ORDER OF 27A-63,2 OPEBATIONS DEPABT}IENT EROWAfiO SHERIFFS FIRE RESCUE PO BOX 855345 oRLANOO. FL 328E&5346 ED ura. r.r (ir!rn! a4) rceN 3o@E, .00 50 I I[. ':oE I000tolr: loootSBSqS?g]r' Paqe 47 of 98 I VddAngl t60OAYS. Signaluo On Flte'. TNs che.l ha! bsbi ,ulhodzed ' ty your depositoi. ; , ';j : ; ililililililmilrI[!r 810022005306 20'19-1 2-31 1 4:36:46 881 0022005306 Batch: 195 Lockbox: MCO 865346 < Previous Transaction Batch Summary Transactlon 15 Summary Transaction Total: $50,00 Deposit Accounl: 4132991530 Next Transaction > Deposit Date: 1Z24nO1g Front lmage ,14 Ir I l/,emo Item I Front lmage Check Amount: $50.00 Check Number: 480 Check Account Number: 1000158598283 EDWARD J MARGOLIN ma'sEoru sr-, '1."r-: : ' DAfriA BEACH, FL:.?qdo4 irlulill\lulllu\lltr .:- 63:2't5l8il '48b..;i:iL'ii. .:ii::|| tri the I I " ., -l:'- :.t'rl' ,. '$i{A;d ' . ., :l', .., -,' ". i,,,r'..'. : -;r{ns AEl ,tilu SrNThUsr ..' iirr ,r,l:,.:ii:;,.:, . ' 4+l.Er-osloootoa - -- I lli::' ' :;: .','"r . .. 'r..i;l .riji:.";r'. ., r. ir:q_E 1 lo E I 5'er: tooo t 58 5c8 e8 til! o 60 Bro$Erd Shrrihs Fir! R.scu. PO Bor 865346 Odando FL 328&5346 fu,1 4'{.t /1 It, tt- 4 €"1.A+"1-tilufl lufl tilrHiililll] rniluilfllil ll ill ll Chack if adde3sfinsu"ance chsngss de oo back (D i;ii'd;;;il' dilis'ni,E!.;i.iEi;'&r;, i,', jY. Bitb:ssi -1 i77 :.T; ibd;G haiiiancr inrormartb ir oo lD:'wliyijnlemedirii;mAiloiv .'' .r . : " ' .....,.1...{,,-1,.-'.. l,hr,,rtn.Ir,lur,urIlhl.rl,,hrrr,trrn,-r,.r,,,h 40E SE 6rh Sr Osnia Beach FL 33004-4700 a9454520 Oua Dr!!: ssri,6ii l'$ 5o.oo nr.r,rl,Iltrlrl!l,n,lnrll[.l,.r,rrtllt|lrrllr.l,t,tl,rltl Browed sh.riffs Fi.. R.Bcuc PO Box 865346 Orb.do FL 32486-534.6 w g i! F IMPORTANT NOTICE Pleass make checks payable and remit to: Back lmag€ Paqe 45 of 92 Chock I .,1 ffii I1ililil[ll[illillllllll 810021886286 202Q-O1 -15 1 1 :09:32 B81 0021886286 Batch: 206 Lockboxi MCO 865345 < Previous Transaction Batch Summary Transaction 21 Summary Tran$ction Totai: $50.00 Deposil Account: 4,l32991530 Next Transaction > Deposif Date: 01 10812020 Front lmage Check Amount: t50.00 Check Number: 5013 CheckAccount Number:'10001585982E3 ,,rrrrrrtw AccouhC i494611520 tiotlYLlooo, F1.33!, .'rE^lE PO3i rXrS r YrErat Fofl OUR IUTU^L CUSIDT.ER l.lrllr,tl,llltIll,,rl,rrrl,llllrr,,,rIrlll,r,ll,,,/,lrlrrl ,00 i Plesse Dlrect Anyoi.sdoailTo _lwo\270d302. . ".OUH OPEFATIONS DEPAFTTTENT ,:-..'.,! :.., .SUNTRUST', .'.i. o23rf 7 t7r0{ 61279 6l z,1l @r 5,@r, rcai265 llri05 TO IHE OROER OF votd An€r i8o oAVs.SisnaiweOh.riiiil.' ThiE check hii fts€ hdkidzedbyyod+doii|;r:j!: : ;. .' .): SROWARO SHERIFFS FIRE RESCUE PO BOX 8653,16 oRln!,rOO, FL 3288e5345 'l0,Elo .,. ' .''.i OOo0Oo5ol3 .liniriri;oe.:2ozir DOLLARS Page 48 o1117 Check 1 rioo 50 t 3rI. ':og 1000 lol.r: loo0l5E5ga ?a1'r. I ililililililt[[rrfll[ 010022000336 2020-02-05 1 6:08: 1 3 B01 0022000336 Batch: 230 Lockbox: MCO 865346 < Previous Transact,on Bai.h Summary Transaa{ion I Summery Transaction Total: $50.00 Oeposit Account: 4132991530 Next Transaction > Deposil Datei 02103t2O2O Check 1 Check Amount: S50.00 Check Numberi 5015 Check Account Number: --..N"N Front lmage Accouot '49464520 :}!EI]E'06II S ?TYIEII fOR OI',R TUfuTL CT'STOIEA. Pl€Es€ Direct Any Ou€sllons To (800) 27&Clo2, . OUB OPERAfIONS DEPARTEi{T .00 " 10610 zbr.,riLxrncatrN. ' .- -,. ' : toBUcH MNST " .' :, FOLrYr^IrqO, FL 3!01$r1o5- .I 00000050t5' rbuiu;'irv b5,'zozo : sirNTRUSr TO ANO 00/100 ORDER T}tE OF VoidAner 180 DAYS- Sionatie on Fit; '. . ': This ch;x hai b€e; aurhoiiied , by.your d6p6sitor'l . ' . :il,,,rrl,rr,lht,tlrtlIt,t,rh,r,lhtl,rl,rhrI.ll.,Ihh,r '50.00 t; tBRO/VARO S}IERIFFS FIRE RESCUE PO BOX 865316 oRTANOO, FL 3288e5346 rrOO50 lSrF r:OB lOE0 iOLr: t0OO I585qB 2BlrF Page 21 of 136 ilt ilfl1ilil Inl 610022159795 2020-03-10 1't :28:40 8610022159795 Batch: 255 Lockbox: MCO 8653,15 Batch Summary Transaclion 5 Summary T.ansaction Total: $50.00 Deposit Accounl:,(132991530 I'lext Transaclion > Check 1 Front lmage CheckAmount 150.00 Check Number 5017 CheckAccount Number: 1000158598283 prI^sE ?osriis FAYll ar{I aoR olJi lrJni^L cuslo{ER 00-' , : ,.: , -... .\: Eo!!ARO llARGOLlNi. ' 1alo BrrcHANan sT a: i- :.HairrYt/vooD. ft !3orr r ros, .:_ J_-;, :- :,.t . , SUIJIRUSf '.'.'' roa92?] er cB..gr ris!.3, tb:roo rorarr: PleEse Dirctl AnYQuelto.lqTo' .t800)27&5302 :qVF oPEl norys DEPAFTI{RIT Account: ANO 00/1 1Ct 510 'Mircti 2020 ',,0000005017 50:00I TO rHE ORDER OF BROWAAD SHERIFFS FIRE RESCUE PO gOX 865346 oRTANDO, FL 32886-536 void Afror l8o OAYS. sionati.a oh Eil6' | 'l ; ;.1 : ' ; ms cru& Us ti:io a.ultroi'lzeit '. : I ' : i by ygur deposilol ,:: ..1.: ;.".'.I'I'hl,'rl.\r'rrt,l,rllll,l.lIl,,rrIrl.rl'Ililnrnrlhr [.oo 50 I?rF r:oB looo IoLr: looo l5B5q8 e8]n' qIjEx,fiurGs.Er4J.cd+m Page 7 ol 161 < Previous Transaction Deposit Date: 0310312020 ."',a '..t il!ililil1ililtil1I[ilt 51002223s993 2020-03-3'1 1 5:56:42 851 0022235993 Batch:285 Lockbox: MCO 665346 < rlevrsrjs r lel.!:Cr:Orr oitLu'r nu.,,r'r<ry Transaclion 11Summary Transaction Total t50.00 Oeposit Accounl: 4132991530 tro(t r ransaoaroll > Deposit Date: 03/30f202O Check'1 Front lmage \lulut\ulu\!u\\ Check Amount: S50.00 Check Number: 50'19 Check Account Number: 1000,158598283 n ouF ru&^L cutrorceAccounl: ,1946/t520 $50.00 EOWARDMARGOIIN '. rioL!Y1,1/o00, Fr 3lo )9.I r !5 Ploslo Or€ct Any Ou6slion3To {8OO) 27&6302 OUR OPERAIIONS OEPARTMENT DOLL RS SUNTRUST ul tro IIIE OROER OF EROWARD SIIERTFFS FIRE RESCUE PO aOX 8653.6 oeraNoo, F! 32865.53a5 Vod An.r,!80 DAYS Sighat ,e Cjn File : This checl has been auhori2ed by yotrdeposilorrrlrltrrllhrlrhIh,rlInlllI , rrlllh,lIl.,\h r r.OO 5O Lqr'' r:OE IOOO IOLt: !OOO 158 5qB e8lrp Page 30 of 138 t016t0 0000005019 April 01, 2020 ffilililr[!!rilrrIIl[ 51002223s993 2020-03-31'1 5:56:42 85 1 0022235993 Batch: 285 Lockbox: MCO 865346 < rlsvl!us r rdnJ;crriJ oiucil Jur'rlllery Transaclion 11Summary Transaction Total: $50.00 Oeposit Account: 4132991530 lrex( r lansdsuoir 2 Deposit Dale: 03130f2020 Check 1 Front lmage CheckAmounr $50.00 Check Number: 5019 Check Accounl Number: 1000i5E598283 \\u}[\$IuN r€^sErortfBst^Yr€ir rcnoli ruru^LAccount: 49464520 $50.00 €DWARDiIARGOIIN HOILYWOOD. f! 3301 9 tr0t Pl€6so Oir€ct Any Ou6stions To(6@) 27&6302 OUR OPEBATIONS OEPAFIIUENT , SUNIRUST B,TJ 7.rr52a 0yras 0xr'5 loornd)l r05.rr3 DOLLARS t 0i610 llFIF r'r ANO 001r00 tTO IHE OROER OF EROWARO SHERIFFS FIRE RESCUE PO BOX 8653.6 oRLANOO. Fr- 32865.53.6 rrH"tllhtlrh h,rlIrIlllhI,Irlllln,lut'rrhIrl r.oo 50 Lqn. r:oE looo tor.r: t000 t585q8 e81'r. Page 30 of 138 . 0000005019 April pl, 2o2O Vod An!r,r8O DAYS Sigt ahire Oi F e . . This ched has b€cn rdhorzed by yourdeposito( ' .