MRTN-RFAXP1 6/22/2021 12:26:52 PM PAGE 1/003 Fax Server MERITAIN" HEALTH - CONFIDENTIAL - Fax To: hector From: Web Request Fax: (954) 967-0109 Pages: 2 Phone Date: 06/22/21 ie ce [Urgent _ For Review _ Please Comment _ Please Reply _ Please RecycleMRTN-RFAXP1 FRATERNAL ORDER OF POLICE MIAMI LODGE 20 P.O. BOX 011127 MIAMI FL 33101 Pationt Aoct No PAY TO THE ORDER OF: *BWNCOWH #Prs/IETTUTEUSC5* Mv528 CORP 4100 SW 57TH AVE MIAMI FL 33155 6/22/2021 12:26:52 PM PAGE 2/003 ~Fax Server ‘check No: Group Nos Print Date 61720890 1¥59¢4,R01 05.0321 91131601 9r099140.52 ** One Hundred Forty Dollars & Fifty Two Cents ** NOT NEGOTIABLE ProceuRE commen] ent] panewr TASGEROE™ | pares or service] ToraL [rover |weuiamte |yores] arrueo | areueo | ocx. [oainets] uibtey | Rass coor enances | oiscount | AUNT roves. | rocoray| | evr | “evan | Stu EC 19.00] — #8.46 n 100 10.8] 0.00 TOTALS [169.00] —#0.48 10.82 0.00 iim Ho: 058cv08 Processed Under Medical parcients_OCTAVIO EDRA Plan For Services Provided By Check # Amount 6840343052 MARCOS G VALERIO MD 61730690 $140.52 Sierenen. 4100 SW 57TH AVE ‘Mana FL 33174 MIAMI FL 33155. TERESA PIEDRA Te cessae arena ONDER OF POLICE tose ot eth | Coca notes patent et hot $4 154601 a Revie send o stow Vedcor’sepproved aman F RoI acme eye Nome Chee POS Potent not eponaite fo ths amount + IF YOU HAVE ANY QUESTIONS ABOUT THIS EXPLANATION OF BENEFITS CALL * CLAIMS CUSTOMER SERVICE: 952-646-0062 200.925.2272 o 24 HOUR AUTOMATED CLAIM INFORMATION: 952.599.6560 800-5MRTN-RFAXP1 6/22/2021 12:26:52 PM PAGE 3/003 Fax Server FRATERNAL ORDER OF POLICE MIAMI LODGE 20 heck No:_61730001 seven lana atonor Group Wo: 900401 ems capes MIAMI FL 33101 Print Dato: Pationt Aoct No 05.0321 91133267 PAY TO THE ORDER OF: gree9924.89 ++ Twenty Four Dollars & Eighty Nine Cents ** peancoun vote aren 80 oars #Prs/IETTUTEUSC5* Mv528 CORP 4100 SW 87TH AVE NOT NEGOTIABLE MIAMI FL 33155 PROCEDURE Omen | _pyuT PROGERUE® | partes or senvice | TOTAL | provinen | evicwe |yores| arrueo | armueo | wen. |cduners | abe by cope chances | oiscounr | amount rover. |rocoray| % | Pv. | PLAN Tens [easel 197.00] 96.25 3 100 7 “ZOMISTHENT Fo Coowo ATION oF ever TTS too.s0| _-73.6| Forais [_17.00| 96.25 2i.e0] 0.00 Processed Under Medical ecrAvIG Fee Plan For Services Provided By Check # Amount 84022002 MARCOS G VALERIO MD 61730691 324.89 21 Sw 93R0 PL ami FL 33176 TERESA PIEDRA FRATERNAL ORDER OF POLICE M 15944,R01 0627.21 By: sv3 Pationt Acct, No: 9-1-133347 4100 SW 57TH AVE MIAMI FL 33155 TIN; 833638514 NOTES 8. Provider acount through Aetne Choice POS Il Patient not responsible for ths amount The U'S. Department cf Labor's Employee Benetits Security Admnistration (EBSA) has issued deadline reli and other guidance under Title |of the Employee Retroment Income Security Act of 197 (ERISA fr the folowing: The deadline for member to submit healthcare clams. The eacline to submit an appes Deadlines Ialing on of after Moreh 1. 2020 are extended tothe lest of 1) the one yeor anniversary of the ‘orginal deadline, of 2) unt 60 days alter the yet to be announced end of the COVID-T9 National Emergency. ance we do not Krav when the COVID-13 National Emergency wil end. if you need help n deterring your appeal or cls fing desdine . please contact us rect. Charge ‘exceeds foe schedulelmaxmum slowabie or contractedlegilated lee sfengement. Coordination af Benelis has hen appied v= oulined sn the provnons of yout benoft plan, Inthe case where a Boneft Bark hes released “cedta” m excess ofthe amount oxted to the Provider after ‘coordination of benefits, the Member shouldbe retuned. + IF YOU HAVE ANY QUESTIONS ABOUT THIS EXPLANATION OF BENEFITS CALL * CLAIMS CUSTOMER SERVICE: 952-646-0062 200.925.2272 o 24 HOUR AUTOMATED CLAIM INFORMATION: 952.599.6560 800-5