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HomeMy WebLinkAboutInv# ACID4181 - SHERRI CHASTAIN - 05/05/2023frC, BROWARD SHER IS EIRE R6CUE 260I W, EROWARD ELVD FORT LAUDERDALI, TL ] ]] I2 For Ouestons Conlacl the refund depanmenl R6fu nds@0rgrlechComputer com Erplanation ol' Relirnrl Palrent Chasiarn DennE Servlce Oat€ 061 122022 Clarm Rsttr Rafund Amounl -5.08 R60o.rsrde odlv oad n ,}!rrdra !.d Resp..rede p.rty p.d !fi|o nvo€. lrr.€ lNErc6 pad $De clm lsce 6il6d lrro.r€d ffioraraa aunoa.y olt€r (sp6ol, pAnENr BlttEo sEo{.rEslnaloN rN ERRoR A rD rs DUE A REFUNo Pohcy lD# ACtD ACtD.4181 lssue Check Payable lo: PAYEE SHERRICHASTAIN AddTgss 237 SE 1ST STREET APT 3 City. State Zip OANIA. FL 33004 Requssled by Cynthra Oors€y Dal€ 05/05/2023 0.- Payer: HUMANA INC ChectiEf T Trace ?tunber: 006523 I I 5 ch€ct/EFT oale: 06,26,2022 TdtatPri(tsl92tT0l Palienl Name: CHASIAIN. DENNIS Claim tlttrnber: 820221 720723939 Clairn Dalei 0612.?0?2 061122022 Claim Stalus Code I Patient lO: H51741627 PatanlCrI mb: DCBS6556 B6rde.iE Pryd EBOWARD SHERIFFS FrBE RESCUE OriIi.El nel Nmb.: G.d+ / poliiy: 0Y065901 Facllly Typq 41 Co.nrrct Hd: MEDCABE ADVANTAGE HMO Cbim F oq.Dr€y: 1FLORIDA C|ain Received D!te: Ben lertlg Prv lD: 062t 2022 Chim Charge: Cl3im Prymenl: Patied ne3F $1.3 r 8 53 s503.18 t0 00 Lhe ClrlNmb,Oatss ol ID Sub Proc Unals A4rrd Proc llod6.r , Unils Payer Code Supp lnlo(AIIT)Charg€Adustmads (OtY) 06t12AO22 061122022 HC:A0,127 / RH I S473 77 (86l $1.225 66 co 253 co 45 $4 74 $751.89 s469 03 PayeT: HUMANA INC Lhe Details checkiEfT Trace mber: 006623r I5 ctEck,tFr oate: 06 26'2022 TotalPrltt $19 217 0l Drta3 ol Fend Pro!, ID 9$ PToc I Lodlld / Ur{lr A4d Pr@ ; llo.lli.r / lJritr namark / Ptysr Cod. Supp lnlo (AIT)Charqe (otv) 061122022 06/124022 $34 49 (86t s92 97 co 253 co45 $0 34 $5E:rE s34 15 PaqE 5 lalch. ockbo)( 507 ATL 865346 Transaction I Summary Trans€cton folalr 5-04 USD Deposrl Accounl: il !32991!30 Deposrt Dal€01109t2023 lheck I Check Amounli Chock Account Numb€r: Check Number: 5.08 USD 91213533 045 'ront lmag€ SHERRI E CHASTAIN DENNIS L CHASTAIN 237 SE. lst Succl Apt 3 D;rnia, Fl- 330G1 M5 s fa: Cri,oDorlors r too oo.,'^o. 0 E- i.REGIONS -+**rffeSo,J*31 €.U,a;e; r:oB l !otEESr: ooqIailSllNooELS l- ?-)o>t *n i I latch 507 ATL 865346 Trsnsac on E Contnu€d Transactron Total: 5.0E USD DeposrlAccounl: 4132901530 Deposrt Date 01t@no23 Ean 1 .onr lmego BiOWARO S}IERIFFS FIFE R'SCUE cBso-.202 378676594 ll,!ltrtln,rnIrlltlllqll,llrt,,rlt,r ltu[,l,,r,.,rrlll,, SHOWAMOLJNTPAIO HEREi S t P.ym.ntAddress vflflII l OENNIS CIIASTAIN 237 SE 1ST SlAPt 3 l.t.nnr.lIileldoi,oh'lilg.- BFC,WAFO sHERIFFS FIRE RESCUE PO SOX 0a$46 oRIANC'O. FL 328&5346 PLEASE FEIURNTHIS IORTIOi/ Wln{ YOUR PAYMENI raci lmag€ IIfVOICE t: OCBaOaalt You tr.y sbo c.lloor omcc lol lr.. sr 033-532-2231 or vltilEEEE4Ellf&eAIAUgll,llllEBellU lo provrd. us with ,ou r in3unnca nlormalion. ABOUTYOT: AEOUTYOUR INSURANCE: IOPROVIDE II{SURAI{CE INFORMATION PLEASE V SII HITPS://BSOFR.PAYAMBULANcE.coM n Refund Request PAYEE NAME: SHERRI CHASTAIN ADDRESS 237 SE 1ST STREET APT 3 DANIA FL 33004 Crty Stale Zp 418'l 51512023 -5.08 0.00 0.00 0.00 0.00 000 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -5.08 I R.t *AC ID INVOICE DATE NET ATI,IOUNT j --.t =