HomeMy WebLinkAboutInv# 2202161446BSFRE - SUNSHINE STATE HEALTH PLAN - 05/01/2023MANUAL REFUND REQUEsT FORM
TO: FINANCE DEPARTMENTOF BROWARD SHERIFFS FIRE RESCUE
BELOW REPRESENTS A REQUEST FOR YOUR ORGANIZATION IO ISSUE A RETUND FOR THE
FOTTOWING ACCOUNT, THT REFUND CHECK MUST 8E ISSUED TO THT PAYOR/PATIENT SHOWN
BELOW. PLEASE CONTACT CIIENT RETATIONS SHOUtD YOU NEED FURTHER INTORMATION.
REFUND DETAITS;
PATIENT ACCOUNTfl
REFUND PAYABLE TO:
NAME:
63695141
DATE OF SERVICE: 2/t6/2022
PATIENT NAME DARREN B. SMITH
REFUND AMOUNT: $110.00
REFUND REASON COB: MEDICARE HMO lS PRIMARY
INSURANCE CLAIM $: V210FtE67689
ADDRES5:
SUNSHINE STATE HEALTH PLAN
ATTN: PROVIDER REFUND
PO BOX 864986
CITY, STATE ZIP ORLANDO, FL 32886
t
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Account #
63695141
Itemized Statement
Smith, Darren
730 sw 3rd PL
DANIA FL 33004
Patient
Date of Service
lncident #:
Pickup
Destination
Trip
02-'t6-2022
220216- 1446-BSFRE
730 sw 3rd PL
MEMORIAL REGIONAL HOSPITAL
Description Unit Cost Units Amou nt
ALS1 Emerqency Base Rate Dania 1225.66 1 12?5.66
ALS Emerqencv Mileaqe Dania 21 .62 3.5 75.67
I
Transaction Scan #Post Date Amount
Pavment to EMS - Primarv lnsurance ps1765506 03-01-?o22 42',t.U
AdiuslmenUAssionment - Pnmary lnsurance ps1765506 03-o1-2022 799.49
Payment to EMS - Primarv lnsurance i1661878362953 09-02-2022 190.31
Payment to EMS - Primarv lnsurance 1481288042 09-19-2022 -11031
Pavment to EMS - Pnmarv lnsurance 1482491152 09-?8-2022 1 10.31
AdiustmenVAssignment - lnterest Payment r1661878362953 09-28-2022 -0.31
Payment to EMS - Primary lnsurance 't4824922U 09-28-202?-1 10.00
Account Summary
Total Charges
$1301 .33
Total Payments
$502.'15
Assign/Adjust
$799.18
Balance Due
$0.00
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Transaction 39 Summary
Transactron Total: 2,064.31 USD
DepositAccountr 4132991530
Deposit Date oat29n022
Ch6ck 1 2,064.31 USD
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