HomeMy WebLinkAboutInv# 22040200002178 - SIMPLY HEALTHCARE - 05/01/2023MANUAL REFUND REqUEST FORM
ro: FINANCE DEPARTMENT oF BROWARD SHERIFFS FIRE RESCUE
BELOW RTPRISENTs A REQUEST FOR YOUR ORGANIZATION TO ISSUT A REFUND FOR THE
IOT[OWING ACCOUNT, ]HT REFUND CHECK MUST 8E ISSUED TO THE PAYOR/PATIENT SHOWN
8EIOW. PTTASE CONIACT CTITNI RETATIONS SHOUTD YOU NEED FURTHfR INFORMATION.
REFUND DTTAITS:
PATIENT ACCOUNTS:64002900
DATE OF SERVICE:4/0212022
PATIENT NAME RICHARD J E NTIS
REFUND AMOUNT: 5175.68
REFUND REASON:BILTE D IN ERROR t EVE OF SERVICE/MILEAGE CORREL CTI o N
TNSURANCE CLAIM s: 2219L579t4O0255 / 228706805600
REFUND PAYABTE TO:
NAME:
ADDRE55:
SIMPLY HEALTHCARE
9250 W FLAGLER 5T
STE 600
CITY, STATE ZIP:MtAMt, FL 33174
s'N'*
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Account #
64002900
Itemized Statement
Trip
Oate of Service: 0442-2022
lncident #: : F ON22O4O2OOOO2 1 7 I
Pickup: 150 STIRLING RD # 402
Destination: MEMORIAL REGIONAL HOSPITAL
Patient
Jentis, Richard
150 STIRLING RD
402
DANIA FL 33004
Itemized Charges
Units AmountDescriptionUnit Cost
1225.66't225.66BLS Emerqency Base Rate Dania
84.322',t .62 3.9BLS Emerqency Mileaqe Dania
Account Oetail
Post Date AmountScan #
400.00os185267704-23-2022Pavment to EMS - Primary lnsurance
ps1852677 04-23-2022 808.97AdiustmenvAssignment - Primary lnsurance
os1871377 05-o5-2022 101.0'1Pavment to EMS - Secondary lnsurance
-400 00ps194075606-23-2022Payment to EMS - Pnmary lnsurance
ps1940756 06-23-2022 340.75Payment to EMS - Primarv lnsurance
ps'1940756 06-23-2022 883.18AdiustmenuAssiqnment - Primary lnsurance
07 -o1-20?2 59.25Pavment to EMS - Pnmarv lnsurance ps1940756
-883.18147066232107 -05-202?AdiustmenUAssignment - Primary lnsurance
ps2007387 08-'t6-2022 -59.71Payment to EMS - Primary lnsurahce
883.18147868037108-30-2022AdjustmenuAssignment - Primary lnsurance
-808.97ps185267708-30-2022AdjustmenuAssignment - Primary lnsurance
ps2007387 09-0't -2022 0.46AdiustmenuAssignment - Primary lnsurance
1478988629 09-o1-2022 -14.95Payment to EMS - Secondary lnsurance
09-01-2022 -14.96Pavment to EMS - Secondary lnsurance 1478988712
14.95147898885709-01-2022Payment to EMS - Secondary lnsurance
p810023342655 09-'t9-2022 160.72Payment to EMS - Secondary lnsurance
1482493810 09-28-2022 14.96Pavment to EMS - Secondarv lnsurance
09-28-2022 - 175 68Pavment lo EMS - Secondarv lnsurance '1482495552
Account Summary
Balance Due
$0.00
Assign/Adjust
$883.64
Total Payments
$426.34
Total Charges
$1309.98
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COUI'TY OF 8ROIARO OFFICE OF SHERIFF
F0 BOX 865345
oRLAi{DO FL 32at6-5346
DEPOSITED TO:
ABA
ACC
EFT
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