HomeMy WebLinkAboutInv# 21072200004496 - SUNSHINE STATE HEALTH PLAN - 05/01/2023MANUAL REFUND REQUEST FORM
TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE
ETTOW RTPRTSENTS A REQUEST FOR YOUR ORGANIZATION TO ISSUE A REFUND FOR THT
FOTTOWING ACCOUNI. THT REFUND CHICK MUST BT ISSUTD TO THT PAYOR/PATIENT SHOWN
8ETOW, PIEASE CONTACT CTIENT RITATIONS SHOUTD YOU NETD FURTHER INFORMATION.
REFUND DETAII.S:
PATIENT ACCOUNTS:
REFUND PAYABTE TO:
NAME:
ADDRESS:
519158 31
DATE OF SERVICE:7122/2027
PATIENT NAME KENNETH WEHMEYER
REFUND AMOUNT: 594.50
REFUND REASON:COB: MEDICARE IS PRIMARY
INSURANCE CLAIM H: U224t1E27766
SUNSH INE STATE HEALTH PLAN
ATTN: PROVIDER REFUND
PO BOX 864985
CITY, STATE ZIP:ORLANDO, FL 32886
\.
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Account #
61915831
Itemized Statement
Patient
Wehmeyer, Kenneth
440 PHIPPEN-WAITERS RD
20 BED B
DANIA FL 33004
Trip
Oate of Service: 07 -22-2021
lncident f:: FDN21072200004496
Pickup: 440 PHIPPEN-WAITERS RD # 20 BED B
Destination: MEMORIAL REGIONAL HOSPITAL
Itemized Charqes
Unit Cost U nits AmountDescription
1167.30 1 1 167.30ALS1 Emerqency Base Rate Dania
3.5 t5.4321 .55ALS Emergency Mileage Dania
Account Detail
Scan #Post Date AmountTransaction
08-11-2021 381.99ps1441438Payment to EMS - Primary lnsurance
765.24ps144143808-1',t -202',1AdiustmenuAssiqnment - Primary lnsurance
t1657 M2592602 07 -13-2022 190.44Pavment to EMS - Secondary lnsurance
1479165461 o9-o2-2022 -94.94Pavment to EMS - Secondary lnsurance
09-28-2022 94.9414A2490724Payment to EMS - Secondary lnsurance
-0.44t1657 642592602 09-?8-2022AdtustmenuAssiqnment - lnterest Payment
1482490955 09-28-2022 -94.50Payment to EMS - Secondary lnsurance
Account Summary
Assign/Adjust
$764.80
Balance Due
$0.00
Total Charges
$1242.73
Total Payments
$477.93
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Batch:
Lockbox
298
ATL 865345
Transac{ion 33 Summary
Transaction Total: 190.44 USD
DepositAccount: 4132991530
Deposit Date 07t11n022
Check 1 Check Amount:
Check Account Number
Check Number:
190.44 USD
9647481440
10387505
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