HomeMy WebLinkAboutInv# 22041600002483 - SUNSHINE STATE HEALTH PLAN - 05/01/2023MANUAT REFUND REqUEST FORM
TO: FINANCE DEPARTMENT OF BROWARD SHERIFFS FIRE RESCUE
EETOW RIPRTSTNTS A RTQUEST FOR YOUR OR6ANIZATION TO ISSUE A REFUND FOR ]HE
FOLTOWING ACCOUNT, TIIT RTTUND CHECK MUSI BI ISSUTD TO THE PAYOR/PA]IENT SHOWN
BTIOW, PTEASE CONTACI CTIENT RETATIONS SHOUTD YOU NETD FURTHER INFORMATION.
REFUND DETAIt5:
PATIENT ACCOUNT$
REFUND PAYABTE TO:
NAME:
64095430
DATE OF 5E RVICE 4/t612022
PATIENT NAME FRANK ADAN
REFUNOAMOUNT: 589.96
REFUNO REASON COB: MEDICARE IS PRIMARY
INSURANCE CLAIM f: V185F1E55023
ADDRESS
SUNSHINE STATE H EALTH PLAN
ATTN: PROVIDER REFUND
PO BOX 864986
CITY, STATE ZIP ORLANDO, FL 32886
Cr
Broward Sheriffs Fire Rescue
PO Box 865346
Orlando, FL 32886-5346
Account #
64095430
Itemized Statement
Adan. Frank
3OO4 SW sOTH ST
DANIA FL 33004
Patient Trip
Date of Service: U-'16-2022
lncident #: : FDN22041 600002483
Pickup: 3004 SW 50TH ST
Oestination: MEMORIAL REGIONAL HOSPITAL
Itemized Charqes
Unit Cost Unats Amo u ntDescription
1225.66 1 1225.66ALS'I Emerqencv Base Rate Dania
J5 71 .35ALS Emeroencv Mileaqe Dania 21 .62
Account Detail
Post Date AmountTransactionScan #
396.20Pavment to EMS - Pnmarv lnsurance ps1870082 0r05-2022
ps1870082 05-05-2022 800.77AdiustmenuAssrgnment - Pramary lnsurance
r1658945506573 07 -29-2022 190.00Payment to EMS - Secondary lnsurance
09-02-2022 -89.96Pavment to EMS - Secondarv lnsurance '1475166231
Account Summary
Balance Due
$0.00
Total Charges
$1297.O1
Total Payments
$496.24
Assign/Adjust
$800.77
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Transaction 20 Summary
Transaction Totali 4,,484.56 USD
DeposrlAccount: 4132991530
Deposit Date 07126t2022
Ch6ck 1 4,484.56 USD
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