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STATE OF ARIZONA REMITTANCE ADVICE WARRANT NO. 217244823 AGY: HCA AGENCY CONTACT: AHCCCSWarrantInquires@azahcccs.gov INVOICE NO. INVOICE DT. INVOICE DESCRIPTION DOCUMENT/LINE NO. INVOICE AMT. DISCOUNT AMT. NET AMT. TPL JUNE 2014 08/03/2015 TPL June 2014 Casualty Acute P GAX, HCA, $17,273.83 $0.00 $17,273.83 ADM160000198 / 1 , Pa .r1 105 90 1\U 3 s A' , AL G 2 7 2015 IF REMITTANCE ADVICE ABOVE IS BLANK, SEE HTTP://WWW.VENPAY.GAO.AZDOA.GOV/ FOR FURTHER DETAILS. EVER WONDER WHERE YOUR PAYMENT FROM THE STATE IS? OR, WHICH S TATE AGENCY PAID YOU THROUGH DIRECT DEPOSIT/ACH? VISIT OUR VENDOR PAYMENT WEBSITE, HTTP://WWW.VENPAY.GAO.AZDOA.GOV/. 11 ll 110 I II 101 10 IHI VENDOR NAME: MARICOPA COUNTY ISSUE DATE: WARRANT AMOUNT: VENDOR ID: PZ000010983 08/18/2015 $17,273.83 PAY THIS AMOUNT $17,273.83 .SEVENTEEN THOUSAND TWO HUNDRED $EVE -NTY.::THRL:E AND 83/100 DOLLARS RACOPN,COUNETY,' FINANCE: )1 WJEFIERSONST '"FiVE-Nix.,. --„,At 800414.3 PAYABLE 41-* s*h SEOICING BANK OF STATE TREASURER OF ARIZONA 2444323• 1:1, 2 210 L 331: 0000000000 2 Lo toc/Ei Disbursement Plan $17,273.83 $17,273.83 7z- pz Incident of 8/27/2001 Date ID AHCCCS A42604731 2014 Name First ADRIAN june 5 Page Detail Name Plan Last HALL Budge and Health Name Management Mandat Plan of Care Health Office W Budget-Health C Type and PA55 (00 —717-Ac),st) 65o Service Acute p Management TPL of • Project Casualty Office Douglas A. Ducey, Governor ° Arizona Health Care Cost Containment System Thomas J. Betlach, Director •••••••••••••••••••••••••• ....... ••••••••••••••ie• • ***** • • * 0 • • 0 • • ••••••••••••••••• ..... •••••••• ***** ••••• ********* August 18, 2015 Maricopa County Dept of Finance 301 W Jefferson St Phoenix, AZ 85003-2143 Enclosed is out warrant #21-7244823 in the amount of $17,273.83 for recoveries from a third party liability source for the AHCCCS members listed on the attached worksheets. If you have any questions, or need additional information, please contact Jeffery Marshall at HMS 602.954.8380 x 110. Thank you for your assistance in this matter. Sincerely, Mark Heck TPL Administrator Division of Business & Finance 602-417-4386 • •••••• •••• ***** ••••••••••••••••••••••• ••• ••••• • ••••••••••• •••••••••••••••••••••••••••••••••••••••••••••••• ****** ••••••••• 801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov