HomeMy WebLinkAboutInv# 22011800000439 - DOLORES A. HOIDA - 05/01/2023MANUAL REFUND REQUEST FORM
TO; FINANCE DIPARTMTNT OF BROWARD SHERIFFS FIRE REsCUE
8IlOW RtPRTStNIS A RTQUEST FOR YOUR OAGANIZATION TO ISSUT A NETUND FOR IHt
.OIIOWING ACCOUNI IHT RTfUNDCHECX MUSI BE IS9U[O IOIHT PAYOi./PATIfNT SHOWN
EILOW PtTA5T CONIACT CTITIII R' TAIIONS sIIOI,LD YOU NTTD FUFTHES INFORMATION
REFUNO DETAIl.s:
PATI€t'IT ACCOUNTS:
DATE OF SERVICE:
PATIENT NAM€:
R€FUND AMOUNT:
R€FU D REASOIi:
INSUiANCE CTAIM I
634a2114
\/$/2022
DITORTS A HOIDA
s40.42
OvIRPAYM'NT 'AT TNT OVERPAID RTSPONSISIL TY
DOTORTS A, HOIDA
THtR€SE R. TTTLINGTR
REFUND PAYASI.T TO:
NAMT:
AD0Rt55l
CITY, STATE ZIP:
ADUTIONAI. INFORMATION:
I41 SI 3RD AVTNUL
APT: 205
DANIA, FT 33004
@
.t
- Check /Order
Broward Sheriffs Fire Rescue
PO Box 865346
orlando. FL 32886-5346
Account #
6348217 4
Balance Oue
30.00
Total Charges Total Payments
$504.971 318.63
n/Adiusr
$813.66
Itemized Statement
Tdp
Date of Servica 01-1&2022
lnodentf, FDN2201 I EO0O00439
Pictup 141 SE 3RD AV # 205
DestnstDn: MEMORIAL REGI@AL HQSeIAL
Patient
Hoida, Dolores
141 Se 3rd Ave #205
DANIA FL 33004
AmountUnit Cost UnitsDescription
1 1225 6
-E51
Ernerqerrcy Base Rate Danra :t3 92 9721 62Dan'aALS E
AmounlScan #Post DateTransaction
r1650391867401 0t-21-2022 328 26
810 37r165039186740104-21-2022AdiustrienvAssronmenl - Pnmary lnsurance
r1652723674138 or17 -2022 r80 00to EMS - Chsck i Order
06-o3-2022 180 00Orderr1654114712139
oa-10-2022 -180 00r476007525Psvr ;t to EMS - Check / Money Order
37 13r167511S79164801-30"2023Pavmenl to EMS - Pnrnary lnsurarrce
01-30-2023 -0 39r1675119791648
-36 74t 501611125 03-07 -2023toOrder
1503658283 03-2a-2023 36 7,{to EMS - Check i
r1675119791644 03-2a-2023 168
03-24-2023 40 4215036583a5
Itemized
Account
Batch Nl
Lockbox ATL E653,16
Transadbn 50 Sumrnary
Transactron Toral ,1.749.78 USD
DepoetAccounl 4132991530
Deposrt Oal€Mt1Ar2022
Chock 1 Check Amount:
Chec* Ac.ounl Numbar
Check Number:
4,749.76 USD
16695{mt2
2,19719436
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Transadbn 18 Sumrnsry
Transacbon Total l8O.00 USO
Depos(Account 4i32991530
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Check I Ch6ck Amountl
Clieck Ac.ount Number
Chack Numb6r
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Barch: 251
Lockbox: ATL 8663a6
Transaciion 35 Sumrnary
Transaclron Tolal 180.m USD
DeposrtAccount 4132901430
Deposrt Dal6 05,/31nO22
Ch€ck I Ch€ck Amount:
Chec* Account Numb€r
Check Numb€r:
't80.00 usD
101(xE3a53277
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THERESE R. ETITINGER
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