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HomeMy WebLinkAboutInv# 22021900001196 - MICHAEL A. ZWYER - 05/01/2023MANUAI. REFUNO R€QUEST FORM TO:FINANCE OTPARTMTNTOF BROWARD SHERIFFS FIRE RESCUE ATLOW REPRTSE NIs A IIQUTST FOR IOT,,R ORGANIZATION TO I55UI A REFUND FOR tHt FOLLOWTXG ACCOUNT IHt RTFUNOCBTC( MUST 8t r5sutolOlHE PAYOS/PAITtNI SHOWN afl ow Pl fasf coNTAcr (r rrnll Ra r AIroNS sHour D you Nf I D alRTHa R riiFonMAI rot{ REfUND OETAIIS: PATIENT ACCOUNTf, DATE Of SERVICT: PATITNT NAME: RETUND AMOUNTi REfUND RTASOiI: INSURANCE CLAIM I 63717001 2/t9/2022 MARILYN ZWYER 5140 00 OvERPAYMENT: PATIENT OVtRpAID R€SPONSIBILIIY MICHAEL A ZWYER RTFUND PAYABTE fO: NAME ADDRESSI CITY. STATE ZIP: AOI)IIO AI INTONMATION 321 St IRD Sr ApI 401 DANIA, FL 33004 .l r-\ Brorvard Sheriffs Fire Rescue PO Box 865346 Oriando FL 32886-5346 Account # 63717001 Patient Zwyer. Marilyn 321 SE 3RD ST 401 DANIA FL 33004 ALS E ro EMs - uslmenu ro EMs - Total Charges 1316 46 [4r Danra ro EMS - Pflma Total Payments Assagn/Adjust Balance Due s0.00513.43 Itemized Statement Tnp Dat€ ot Servic€ 02-19-2022 lnddent r: FDN22021900001 196 Pickup 321 SE 3RO ST, 401 D€stnaton MEMORIAL REGIONALHOSPITAL Itemrze( Unit Cost Units AmountDescription 1ALSl Emero€ncy Base Rale Dan€ 12 90 8021 62 Scan #Post Date AmountTransaction 03-02-2022ps1769730 282 45 ps 1769730 03-o2-2022 809 01 )avment lo EMS - Check / Mon€y Order ,16J9255917878 225 An ps2310062 -282 45 02-27 -2023 Asslonment - Pimarv lnsuranc€lt ,5 98 02-27 -2023 409 01 ps1769730 03-13-2023 -809 01 )avment to EMS - Check / Money Order 150{1A2307 04-03-2023 ?, ;li ;l & ln-: j ,-[ . 61il l. i5i:. !'li I !x:,'I lf f !, r't ;, I ! t'l !r a--, i "! . l,rr l i. Batch r Lockbox 18,1 ATL Ed5346 Transaction 12 Sumrnary Transectron Toral 225.00 USD DeposdAccounl 4't3299'1530 Depos( Dat€utuno22 Ch€ck 1 Chac* Arnount: Ch€ck Account Number Ch€cl Numbsr: 225.00 USD 8981 2051 8532 1ilil FIorIt lmag€ MICHAEL A ZIIYYER M FILYN ZWYER 3?I SE 3RD SI API4Ol oANL f L 3300sO34 143 ))5i,oo @ r+r. BANX OF AMETICA r:OE :lOOOOl.?.: Bl8 I ?05 l85l lr'O Il. l ->/ li * I! r!:irIi I" : t"1 i,, gr;i 'c t,tl ,1" . 1,: .,Ei !i u EI 'i Bi ii; El;t -E- lj 1rY:[rrrrt l:t"s:""1t 5( <:!rrr! lr *":rr' I",:!l :.t"t ,'"tr IE :.:! ., ..:: ,.r g 9 !,,r -tl .1- .1.3 ;t I