HomeMy WebLinkAboutInv# 1157336266 - CONCENTRA MEDICAL CENTERS - 11/18/2024Concen tra7
Tax Id: 75-2014828
Account: N33-1242003529
Invoice: 1157336266 Balance: $1631.93
INVOICE
Remit To:
Invoice Date:
Date Printed:
Occupational Health Centers
of the Southwest, P.A.
PO Box 82549
Hapeville, GA 30354-0549
(800)686-0468
10/28/2024 - 11/02/2024
11/04/2024
Bill To: City of Dania Beach
Location:
City of Dania Beach
Attn: Linda Gonzalez
Attn:
Linda Gonzalez
100 W Dania Beach Blvd
100 W
Dania Beach Blvd
Dania, FL 33004-3643
Dania,
FL 33004-3643
PLEASE
RETURN THIS
PORTION WITH YOUR REMITTANCE.
Name J
SSN /
Charge
Charge Pmts /
Date PO Number
Birth date
Description
Amount Adjmnts
The Following Services Performed
at CMC - MIA Golden Glades
10/31/2024 Lane-Rozea, Austin J
✓PrePl
XXX-XX-1575
Phys w/Reg UDS Coll & BAT, DFWP
XX/XX/XXXX
Breath Alcohol Test
41.39
DOT Physical
128.22
HER Company Defined -Level 2
122.01
Regulated UDS Collect
29.00
CF20296010
The Following Services Performed
at CMC - MIA Ft
Lauderdale
10/29/2024 ✓Gamboa, Carlos A
XXX-XX-3017
Phys w/DFWP UDS 10 Pnl (FL Only)
PrePl
XX/XX/XXXX
DFWP UDS 27869 - 10 Panel (FL On
39.29
HPE Company Defined -Level 2
122.01
Physical Exam Concentra Standard
45.50
Breath Alcohol Test
41.39
10/29/2024 ✓Stewart, Khiry R
XXX-XX-9345
Phys w/DFWP UDS 10 Pnl (FL Only)
PreP1
XX/xX/XXXX
Breath Alcohol Test
41.39
DFWP UDS 27869 - 10 Panel (FL On
39.29
HPE Company Defined -Level 2
122.01
Physical Exam Concentra Standard
45.50
The Following Services Performed at
CMC - MIA Sawgrass
10/28/2024 /Desiderio, Zaira S
XXX-XX-1033
HPE Company Defined-Lvl 2
PreP1
XX/XX/XXXX
HPE Company Defined -Level 2
122.01
10/31/2024 /Larkin, Jeffery J
XXX-XX-0608
Phys w/Reg UDS Coll & BAT, DFWP
PrePl
XX/XX/XXXX
Breath Alcohol Test
41.39
HPE Company Defined -Level 2
122.01
Physical Exam Concentra Standard
45.50
Regulated UDS Collect
29.00
CF17635994
11/01/2024 Aortes, Alvaro
XXX-XX-7037
Phys w/DFWP UDS 10 Pnl (FL Only)
PrePl
XX/XX/XXXX
DFWP UDS 27869 - 10 Panel (FL On
39.29
HPE Company Defined -Level 1
101.33
Physical Exam Concentra Standard
45.50
Breath Alcohol Test
41.39
11/02/2024 wall, christina A XXX-XX-6930 Phys w/DFWP UDS 10 Pnl (FL Only)
Prep] XX/XX/XXXX Breath Alcohol Test 41.39
Occupational Health Centers
Remit To: of the Southwest, P.A. We appreciate your business. You can now pay online at
Account: N33-1242003529 https://payments.concentra.com/. Online payments must be
Inv Date: 10/28/2024 - 11/02/2024 made via credit card. Please contact our Central Business
Office at 800-686-0468 for additional information.
Page: 1/2
AA/EEO Employer PAYMENT DUE UPON RECEIPT
Concen tra
Taxid: 75-2014828
Account: N33-1242003529
Invoice: 1157336266 Balance: $1631.93
INVOICE
Remit To:
Invoice Date:
Date Printed:
Occupational Health Centers
of the Southwest, P.A.
PO Box 82549
Hapeville, GA 30354-0549
(800)686-0468
10/28/2024 - 11/02/2024
11/04/2024
Bill To: City of Dania Beach
Location:
City of Dania Beach
Attn: Linda Gonzalez
Attn:
Linda Gonzalez
100 W Dania Beach Blvd
100 W
Dania Beach Blvd
Dania, FL 33004-3643
Dania,
FL 33004-3643
PLEASE
RETURN THIS
PORTION WITH YOUR REMITTANCE.
Name /
SSN /
Charge
Charge Pmts /
Date PO Number
Birth date
Description
Amount Adjmnts
DFWP UDS 27869 - 10 Panel (FL On 39.29
APE Company Defined -Level 1 101.33
Physical Exam Concentra Standard 45.50
Balance Due: $1631.93
C�)'u Ck
1
Occupational Health Centers
Remit To: of the Southwest, P.A. We appreciate your business. You can now pay online at
Account: N33-1242003529 https://payments.concentra.com/. Online payments must be
Inv Date: 10/28/2024 - 11/02/2024 made via credit card. Please contact our Central Business
Office at 800-686-0468 for additional information.
Page: 2/2
AA/EEO Employer PAYMENT DUE UPON RECEIPT