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HomeMy WebLinkAboutInv# Adriazola Ramiro - SIMPLY HEALTHCARE PLANS - 04/18/2024BROWARO SHERIFFS TIRE RBCUE 260t w. BnorvARo BrvD foRT |-AUD[ROAI. Ft 33] | 2 For Ouostons Cont8cl tho refund dspanmont Rofu nds@Drgilechcompu16r com Explanation ol Refirrrrl Servrc€ Oal€ Claim Ref* Patrenl Nargrso Dan,eL 03to5t2023 Polrcy lD* XJ1H35685489 o 1 0000 1 062239598 ACID ACID 31350 Refund Amount -201 13 Reason lor refund RasoJnebb paiy ood fid .s!,a,r. D.d Resro.isds ,.ny p.d sarlc 'nro|c. &1c6 ltu,an e p.'d sarE cbm $.cs Blbd lm,/yrel nq,,rrf,, airn9eny lssue Check Payable lo: Peye€ BcBs oF FL (CARE HMo) Address PO 8OX 1798 Crly. State Zrp Jac*sonvdl€. FL 32231.0014 Darc OA)3112023 ( Reouesred D' l ^l' F.' BROWARD SHERIFFS FIRE RESCUE OIGITECH COMPUTER LLC PO BOX 1280 oAKS PA 19456-1280 \8331532-2231 TAX rO 596000534 OANIEL NARGISO 5303 SW 40TH AV DANIA BEACH FL 33004 Paticnt Name NARGISO OANIEL Origin Addrcss PATIENT RESIDENCE 5303 SW 4OTH AV OANIA BEACH, FL 3300.4 vP.ymcnt Addr6ss V BROWARD SHERIFFS FIRE RESCUE PO BOX 947346 ATLANTA GA 30394.7346 Statement DAtEr @31i2023 Tho bdlance due is an oslimate basad on th6 anformation provid6d rnd rs subjgct to chrngc Date O, S.rvicc 03,c5t2023 .PCR # FDN23030500001479 lnvoica # DCBSO5o160 ACID' 31350 Oaatination Addrcas MEMORIAL REGIONAL HOSPITAL 35O1 JOHNSON ST HOLLYWOOD. FL 3302I - E | ^"rio6 o.r. I rn.*cto ; r,*. I :lectronic Remittance Report: BCBS ACH#:850583789 ounty of Broward Office of the Sheriff hi6 cr.rms ld o.porr d.ll 0312r,2023'.frrt 0L:03/20/2023 FLOiIOA BL!,E .!@ OEERWOOD CATPUS PARXWAY JAC(3OIfVILLE FI !22/l.rod ChGt Ahost iraSa ,, Chrc Ap!. t.duct lovr P.id 20113 Sub tdl t3l2la a50 al .1? R.r 322r00 22540 .12 ,2404 Toralltumb.r ot C,.rms 13121t 0oo 225 00 2i5,ll AmbulanceCommander * "h I Co-r6FdAlE6r -C.5 CnrlEu.rdal.. t(EdrollEffiJot dad.dit*t(rt9air.dk r.!!rFr Lr!a. lr..6ffirur!.ridlqarE:xd rcd c|.odEq.llqri rtd (d 'r.a d.or..! po.d€.qu$61,Br! rp.yGft lxt crt&nll ert tdlrru n*.drd tun D.q p.y.n3r.4!.t qr (ur ol! isr c'nD :od6 FR d c3 a!.nd! te.r lEllr,l\3tt ao3.i u cd{erd .94n6r rd r.rrrt6!;tnn9p.yrEn sdm.ton 'dr.d to !* dslF r €n by LFOX on rnuG6.! Aoqosr 11 2021 10 1/ 06 AM :lectronic Remittance Report: BCBS ACH#:850633934 ounty of Broward Office ot the Sheriff l.rm cl.im3 ror D.Dotll d.i.0612l/2023 'LORIOA ALUE rlOO OEER!/YOOO CAI'PU3 PAR(WAY JACKSOIiVILLE FL !22116 Toa.r chcl arcrr 7al r9 Pr Chr! A!f. O.dct Xov. o-a! aa.t2 503 lor.r Nunh.r ot o.im. Tobl ch.o .r2613 000 :o .5 chrg. .e..rB le sltd'rgl11.r,1M ,bridd. , c$a-l.d4.cRr*d t ,rFirr u..c. Ih6 !4drBr eM. ovsl .ad ,t brr ft d .Lm cn c.,rlu e 4u.r.d drr<r.9,6dd {6rnsi Mr3lg.rrEr. -n.duiEtd r.daro.) 6i h.(,aLoftFrro 9.r.(.).qrdro lut drrv dt G.o? :dr.. Fe d an @.6,19 uDon rlBnly)\3t! cdei .onr&rud a9rffitid,e$(nsnlrrxlp.tffi 'ntu Bllo.r rc{.r.(rro de.tEF Ambulancecofinandei+ EROWARD SHERIfTS FIRE RESCUE 260t w. EROWARO SLVD FORT LAUDERDALT, FI- '] ] I2 For Ou6sllons Contact lh6 rofund dep€nmanl Refu nds@0rgitechoomputer com Erplanation of Relrrrrrl Servrce Date Clarm Ref* Palrcnl Fallona Tonr Polrcy lD# VMYH36r 37865 ACID ACID 9451 o100000992.r72896 Retund Amounl .335 3l R6A6n3abF p.rt.nd ln!!r..E o.d R..por6ai6 P..r, pcd s.nb invoi.a lrtc hsu,trco pld sm cLm ts.! B.ll€d r.cfirad 'ncorsn . comD..ry o't" (sp€o{v, wb.rgc (rrp ms,'n . pd 116 hp rn lr.att lEil.fic',i a. r..nid lssue Check Payable to: Payo6 BCBS oF FLoRIOA Address PO BOX 1798 Cty Stale Zip Jacksonvrllo. FL 32231-0014 R.ouesled hv I v^n For Dale 08/31/2023 sN\N BROWARD SHERIFFS FIRE RESCUE DIGITECH COMPUTER LLC PO BOX 1 280 oAKS. PA 19456-1280 (833)532-2231 TAX rD 59,6000534 TONI FALLETTA {697 SW 35TH AV DANIA BEACH. FL 33004 FALLETTA TONI Origin Addrcas PATIENT RESIOENCE 1697 SW 35TH AV DANIA EEACH FL 33004 VPaym6nt Addr.3s Y BROWARD SHERIFFS FIRE RESCUE PO AOX 947346 ATLANTA GA 303S4.7346 Statement oAlE: 0&312023 cas oF Th6 balanc6 du6 is an cstim.E b.scd on the informrtion providcd 6nd is subiecr io chang.. Datc Ot Scrvic. o$46i2022 oPCR # FDN22080600005086 DCaSO11315 ACID* 9451 l).stin.lion Addr.is MEMORIAL REGIONAL HOSPITAL 3501 JOHNSON ST HOLLYWOOD, FL 33021 ; :: l fal'nltarElirtllr5@I A.rd o.t" I rr.ne.,,6 | :lectronic Remittance Report: BCBS ACH#:704300785 r.rm cr.rmr td o.po.il d.t oa/i9zo22 HEALTtt OPTtOt{S. ll{C rOO,0 DEERwOOO CAIyP|S PARKWAY JACklOl{vlll'E FL 522a4 ToLr ch-r anountr a2r3.3o DOS Chrq Appr O.du.l Xovr Prrd Arr6ra1crv \arvH3t37s50 6&,?022 8{156 Torrl Numb.r of Cl.i63 2 r 355 3a 000 111n 335 31 :o .5 ci!!. .'c..d. h. *tEd4.lEm Jo*ror. d csr.-EorraBi.d t nr!6'Er r-,r.c. rt. .qfrrar tu .,rer .q(d r. ror, rc d .r.ft :,f!. :0d.. PF d CO d.r.r6rE uD; lEliiyl \33r asln d .dr*irr, .r6in lq r6ftrBbl{ll9ipry4nr 6ldtu ,.€.d io r* (rrF AmbulanceCommandei * nnted by LFOX on thurld6y Augcr 31 2021 r0 17 43 AM letch:494 ATL 8A$4a Transedbn I Summary Transachon Total: 325.42 USO OepostAccount:,1132991530 oeposrl Dale:12127 t2022 lh€ck 1 Ch€ck Amount: Check Account Numbor Ch€ck Numbe.: 325.42 USD 6018r7533 5763903 ront lntag€ PO 8ox 740042 athnta, GA 30374.0042 Thrpp H,'h.lrF.l Tw.6rv-Flv. an,t 4)/rOn< rrrlhr<a{r*'r PAY]O BROWARD SI]ERIFTS FIRE RESC1JE THE OPTR of BROWARO SHERIEFS flNE RE5CUE PO EOfi 865L5oitaNoo-- , Ft 128a6- froTilut frr^qtuta{ t uru.u, lar. i.o 5 ?6lqo lr r:oetloql?qr: Eol87?5ltn. lalch 494 An 865346 Transactim 8 Conlinu€d Transactron Total: 325.42 USD Depos,lAccounl: 41329S1530 Doposrt Date 1221t2U22 oml 'ront lmag€ Ernll im (raillRdd ]t4t029-l TECHNOT .r]Y NSURA]ICE (Cl.id fudim) | 015 tE35t4ll FP t-TEtL{t4?ta TWCaOgl rgTlAridio . P.a aStl lr. AROWARD SHERIffS FIRE &ESCUEAY2O22 F?|.TEFL{!,1?i4 a55l Holly*ood Bld. Houy|ood fL llo2l " 335o9 ADTn6t Nqil Arriq t8!.219.rr09 yrrrtt.d'r.t!.r d€raolntor. E Hdor r(r.l-,D.rar.{d i,dt *dl!!.!rrd IE-!E BROWARD SHERI;fS NM RtsctJE 260I W, BROWARD ELVD rORT I-AUDTRDAI TL ]3]I2 For Oue3tioo6 Contact th6 refund dopartment Rofu nds@D€il€chcompu16r com Explanation ot' Relirnrl S6Mc€ Det6 Cl6im Retfl PatBnl Ferngren,Trmolhy 11141t2o22 PolrcylDP R2K897A73625 H100001017417238 Reflnd Amount -1084.31 R.s9drsrd.F !.6rd nslltEE p.d Fl66po..aL F..r, !.'d siri. nvolc' !w hrr'l.. pd:.lrE (ttn rre &lrsd rrEo.rad dElr rcs .rrno*w c'lhar (sptcltY' !&rt* dtrp cdrE 9d o16 tp.rxt rre.tn rEdrg ,r drr...turd AC|D AC|D. t7352 lssue Chsck Payaolo lo: PAYEE BCBS OF FLORIDA Address PO BOX 1798 C{y Stale Zip Jacksonvrlle. FL 32231,0014 Reou.slod bv I vnn F.lr Date o8131t2023 G BROWARD SHERIFFS FIRE RESCUE DIGITECH COMPUTER LLC PO BOX 1280 oAKS. PA 19456-1280 (833)532-2231 TAX rD 59-6000534 Statement DATE: 08/31,2023 TIMOTHY FERNGREN 9713 NW 25TH CT CORAL SPRINGS FL 33065 Pationt I{ame FERNGREN TIIIIOTHY Origin Addrcss PICK UP FROM SCENE 2755 SW 42ND ST FORT LAUDERDALE FL 33301 VPoyment AddressV BROWARD SHERIFFS FIRE RESCUE PO BOX 947346 ATLANTA GA 30394-7346 rcBs ICBS IfF FLORIOA Tho balanc€ dus is an astimrrs bassd on the information provided and is subied to change. Dato Of Sorvice 11,O1t2O22 EPCR # F8C22110100007855 DCBSO24465 acto# 17352 D6stination Addr6ss BROWARD HEALTH MEDICAL CENTER 1600 S ANDREWS AVE FORT LAUDERDALE, FL 33316 31 225 66 sr_2! 7i s. t55 3a sl J55 t8 | *to o:t. I rranocton -----:-::::-- :inancial Audit Report nty d Brcwad Ofrce dEe Sh€,'ifr .ClO: 17352 P.ticnl Nsrno: FERNGREN TIMOTHY OOS: 11,1,:022 lalr.aa alt5.2 AmbutancoCommanderI Ed by LFOX onThu6dav A!,gusl31 2023 !t l :inancial Audit Report ounty of Bmvvard O,mce d tte Shodfi .ClD: 1735:Pn.|iN.lr: FERNGRENTIMOTHY DOS '1 1 :C:: AnbulanccCommandet+ . nnid by LFCX @ JruBday Ar,96 3l ?O?3i0rt5l AM :lectronic Remittance Report: BCBS ACH#:21 0217 944 ounty of Broward Offrce of the Sheriff Irrm cl.im3 fd o.positd.t 12D22022 !!(x) OEERWOOD CAi/FUS PARXWAY JACXSONVILLE FL 322'6 Torrl chGk Amsr: 1olgo.73 HlCt DOS lnv! Proc Chrg ADD. O.dlct Xoat PaLd Clrrl ERft{*EN rHOrH R2Ka97A7$25 10r 20?2 2!r30 a0.29sH 1??J6 !225 @ 00C ?3A n101 Tor.l lluhrr.r oi clrm. 2 r 355 38 1,355 38 rR Z isu,.'Er Arlun \3a1 Cmln u .stdrd drel6 d rdn.t@!t rrnSel,Mr '.r'rDi.. ,.rr.,i b rh.e .rw9a 0.00 271.01 1 o8a 31 AmbulanceCommandei* .nled by LrOX on Tndsd6v A!qu$ 31 2023 10 l7 52 AM latch.551 ATL 865346 Transaclion 11 Summary Transectron Tolal: 347.17 USO DeposrtAccounr: 4132991530 D€posrl Dale:oz1a2g23 lh€ck 1 Ch6ck Acc_ount Number Check Numb€r: 347.17 USD 2079950059703 13371791 ront lmaq6 PAY: ""^'IHREE HUNDRED FORTY SEVENAND 17ll0OOOLLARS BROWARD SHERIFFS FIR rttll?l?qtrr r:0llloot2l': 20 ?qq Soosc ?o ln. oarE:02/03,2023 1313r1701 -tzt2- s317.17 PAY TO THE ORDER OF Se/gwir*. lalch.551 ATL 8653it6 Transadion I 1 Continusd Transactron Totai 347.t7 USD DeposrlAccounlr 413290153O Daposl Dal€oz13no23 s'n2 'roatt lmE€o (o) ExPL raAIon or a1tt R€v€w sedBwick. Ik.i,6io,!.ee{ert..q rtbrEz . -g,bcad:adt...3r d cct d rc{i.^orn t3 -d,6ll,db'!{fui'c'.dddnh $lfu.trEbtrcd..ledhdjd!r,, dcrtr $Cr rt !| ro cql'lcr ^ @ irtE A HIA!'H CAi! tiOVrOEi XaY rO Oi rHC 6EiVrCE! itr{OEiaD fon CODela^a!€ OIJESIIOIis AAOUI OIHER SEOGwlCK PAYEtrT3? v'Jt!.cg'l.r,ls,'.lblrhn.5 oulliTK,xs l8oi,T tHt6 Exrlanllrloll oa FEvtEty, Lorls, rY 6147 FOR iECOI3|OtiATlOt{3 re'*1nh.{r.64.., .h!'r.r'h{.e.c!..'d ,.. x+nd&bd lalch:551 ATL 865346 O6posrl Dale o2113t2023 -.d-*E lrii..rblEc-' .d i.ri'd-ffi.rfrt{4- N'd_ch'd.dhlll,. hfuIltfrr^adr5rr'bhrll.dn-.dlhffi .r..&ch'4h.&db..-6hii,jltc.l.fu,rddffh,lrdF*ci.,tfuhis6,id@ ebq5heErdillfrcfrlrtdr 4r,(r,.r '.4frrdr.Fdd.!a !!(r, ,r d i d.' i.h...rs !q,t'lli r,tri. (.atdrd nrd-rno(,({) tuE d-l6ctu'4sddFd!-6bd{c* o ltn.a hEdi.!ea-I.,td..{- d.-.,.-En!e'd'1') (.,,...t-e [r dii ft Frlr 6 d s., r.a&b dr *i !.f& -tu Fr... r. rjd '|1fr'bddoi-i!lo'.&*.,.{dl,ibtfihtdrh{dEd*..rhtu -6ry/rr^r.r.!rr r!-h h F-nd !d. b tu b.r- t r'ddtu k r ..r.Y 6 q*l d.-. d ^,5...C-.naq*!IrLl.ar..-'a.'trtu'rFr-CF rrr.ar!(to-r.L r.Err,*.cfr cbt*.r-rr-..qcr-itu6--&r.t r.o llrx.rcdi@'!x.rt..drtrc-F ' 0- b- t -{6 t2dr@ . ..F.r rrd, .!. ord . rtrr o-: clwe I ! ria-r .-r i...- q! rhi. rr* Transadion 1 1 Contnu€d Transactron Tota 347.'17 USO DeposrlAccounl: 413299J53O }act lm8q€ EXPtAtAItOll G alf iaVtctt BROI,VARD SHERITfS FIRE RESC1IE 250r w. BROWARD ELVO rORT TAUDERDALE, fL 3'3I2 For Ougslions Conlact lhc refund departmcnl Rofu nds@Digatechcompuler.com ErPIirrratiorr ot' Retirrr<l SeMca Dsl6 Cl6im Rof* Patont Mnazola Ramrro O6t2Ot2023 Pohcy lD+ 729148355 248972408500751 ACrD ACro 43051 Refund Amount -lg2 73 R.spo.E6{. pdly a.d ..n ,E!,.,r.a O.Jd n6spdrebL prty !.d sorlg mvs.a t*lco lnermc. pad sft clrm llwl ttlL.! l,H *l nsuraE mp.ny lssue Check Payable to Payee srMply HEALTHCARE (cArD HMo) Addross P.O 8OX 61010 Crly. State. Zrp Vrrgnra 8each. VA 2346S1010 Requested by Lynn Fox Oate oat31t2023 BROWARD SHERIFFS FIRE RESCUE OIGITECH COMPUTER LLC PO BOX 1 2AO oaKS. PA 1S456-1280 (833)532-2231 TAX lD 5S6000534 RAMIRO ADRIAZOLA 5O2O SW 28TH TERR DANIA BEACH. FL 33004 P.tiont Nlmo ADRIAZOLA, RAMIRO Origin Addrcas PATIENT RESIDENCE 5020 sw 28TH TER DANIA EEACH FL 33004 VPrymGnt Addr.ssV BROWARD SHERIFFS FIRE RESCUE PO BOX 947346 ATLANTA. GA 3039.1.7346 Statement OATE; 0&312m3 .I[IPLY HEALTHC]ATIE Th6 balance due is an 6stimate bdssd on the information provided and is subiect to chang€. Orta Ot S.rvic. 06i20t2023 .PCR ; FDN230620000041 19 ocBSo54729 AC ID* .13051 Dcstin.tion Addr.ss MEMORIAL REGIONAL HOSPITAL 3501 JOHNSON ST HOLLWVOOD FL 33021 25RH DILEAGE L5 O Lh'15r @@ :lectronic Rem ittance Report: BCBS AcH#i321 51 u262 ounty of Broward OfIice of the Sheriff r.rd cl.ms tq o.oorlr d.r.07072021'.frn o.t.i 0?10&2023 SIiIPLY HEALTHCARE PLANS PO BOX Taat ' G OllE.{X'la COLUiTBU3 6A 3tEO! tottr cher Anounrr trlo 'L_Hrcr Dos_ - r"tr ffi Pnd cit, --l t,RrA2,:t A RA[trR r29ii3]55 (5ifr,?02r 5lCO5 ACTJ5FH !2c7 nm 000 0rr oco 243972103500' 5! oRIAZO(ARA,lrlR 7Ar.a$5 o97 a9 97 tub Tor, 1!116! t'.2.f3 5r Toi.l Nunb.r ol Cl.lm! 2 r 318 63 192 7l 000 ,92 73ooo -o 9l TrE Edrtr r( nE gE 6 idr/Ga n trr p.rErrr&*rr! ror rdE *fl@!.@dr! r'I'l na.rltr,y t a 4r:t d ltiaa Rdd L [E 335 ]i.-r.. ,oa.v rddn *6 s.o.qi thq 2ti0 sdyE Ptr-t [tmen nEF) i rGsrul5 s.er.n d.6418!3,r.* neh.urdlr6rtyrcrcEilrlrrdEEGolr! ..tEGt . s.t-r. rffEi 6.d *{d :O.5 Cn lEelaE t *l!..trarlElmrdrcd'E*l.(n Cd*dbrr.{.rEr Ur+ Ir.dl-rrrrE r rvd.qd trt., g@ o clF dsqEtm.i ri_lB d dilpk& ,lwd6 {dGr 'Bds rDn sll3 rd.qffEl GixEE)iii r* GeLd tft rru pi.nt) rqJocrqr llr.. dir ior Gap :dr.q PR d aO rhEilnl! !t .t h.hdrr) lA 9a Prc.r..d n EtGr o{ dEs6\3tr cdBrl .dlxnrr ecctuir k r6n.iortltnq! nstl '.lo.trr.br ..rrd, lo te EcB AmbutanceCofifiander+ nrled by LFOX on Thu<ay Algosl,1 2021102205A11 :lectronic Remittance Report: BCBS ACH#:3216268656 ounty of Broward Office of the Sherifl l.rm cl.rmr lor Lllpoln dlla 07/20/2023 .mit O.t. 07/10/2023 SIIIPLY HEALTHCARE PLANS PO BOX '3aa ' GAOSiE.lX't4 COLriirBlJS GA 3lto6 Tot r ch.r Ano6t gl7a.35 oRta.z.-tA R .lJrR 729rra355 Pre ChrC ADf. thduct Xovr lolal Numb.r otClrrfi. 750 o0 192 73 000 ooo 192 73 AmbulanceCofimender + :oa5 circ..r..d. h. rh.drrturlu &.bL d crd-|.dt!lt..d L rrE.rEr Ut{. rrr..qur,Er -tM. a@r <nd nrdr g@ a.Ln ctrg.xtun &d n6i not araca. pl@{,.i .qrdrGi turs (D.yrin! .r! catirdl rdEtqE, tllr h* t.r.rftd tm FU parns) a.|!6.4o {ue dly iih cdt-.des FRd CO rbFdrrnuoo.t ry) !3gr c63., @ @t*tu l.pr6d{ kf ..rtEtdl,bair9palnfi h&.nErE r i.li.d 10 tE.r*9.5 nnled oy LFOX on rhuEdav AuO6r 11 20211022 06 A^r