HomeMy WebLinkAboutFinal Agenda PacketCITY OF RENTON
FIREMEN'S PENSION BOARD
Regular Meeting
7th Floor -Mayor's Conference Room
Thursday, April 15, 2010
2:00 P.M.
1. CALL TO ORDER
2. APPROVAL OF MINUTES OF MARCH 18, 2010
3. CORRESPONDENCE
4. MONTHLY STATEMENT TO MARCH 31, 2010
5. MONTHLY BILLS AND PENSION PAYMENTS
6. UNFINISHED BUSINESS
7. NEW BUSINESS
8. ADJOURNMENT
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MINUTES
FIREMEN'S PENSION BOARD
CITY OF RENTON
March 18, 2010
Denis Law, Mayor
King Parker, Council Finance Committee Chair
Bonnie Walton, City Clerk
Ray Barilleaux, Fire Department Representative
Bruce Phillips, Fire Department Representative
Chuck Christensen, Fire Department Alternate
The regular meeting of the Firemen's Pension Board was called to order by Mayor Denis Law at 2:04
p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were Board members
Denis Law, King Parker, Ray Barilleaux, Bruce Phillips and Bonnie Walton, as well as Finance Department
representative, Jill Masunaga.
MINUTES APPROVAL
MOVED BY BARILLEAUX, SECONDED BY PHILLIPS, THE PENSION BOARD APPROVE THE MINUTES OF THE
FEBRUARY 18, 2010 MEETING. CARRIED.
MONTHLY STATEMENT
The financial report as of February 28, 2010, was reviewed. Total cash/investment balance was
$4,261,910.57.
MONTHLY BILLS AND PENSION PAYMENTS
MOVED BY PARKER, SECONDED BY BARILLEAUX, TO APPROVE THE PENSION/MEDICAL PAYMENTS FOR
MARCH 2O10, IN THE TOTAL AMOUNT OF $30,319.24, TO BE PAID FROM THE FIREMEN'S PENSION
FUND. CARRIED.
ADJOURNMENT
MOVED BY PARKER, SECONDED BY PHILLIPS, THE MEETING OF THE FIREMEN'S PENSION BOARD BE
ADJOURNED. CARRIED. Time: 2:10 p.m.
Y(J,d'rvn.c�2. � WQ-�'�''
Bonnie I. Walton
Firemen's Pension Board Member & Secretary
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CITY OF RENTON - FIREMEN'S PENSION FUND
CASH 8� INVESTMENT ACTIVITY REPORT
AS OF MARCH 31, 2010
Fireman's Pension Fund Comparison of Cash and Investment Activitv
s
O 2010 ■2009
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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
GURREIVT ' 2p10 2010 LAST YEAR 2009 2�9
ACTtWiTY: MOIVTM YTD BUDGET t�iRR MU ACTUAL ADJ BUDC�ET'
BEGINNING CASH/INV BALANCE $4,263,437.82 $4,332,817.48 $3,895,540 $4,379,605.17 $4,265,991.35 $3,895,540
RECEIPTS:
Fire Insurance Premium Tax 0.00 0.00 100,000 0.00 106,622.90 90,000
Investment Interest 0.00 3,091.68 200,000 7,351.53 437,266.28 200,000
DISBURSEMENTS:
Fire Pension 30,251.21 100,894.63 525,000 41,526.62 443,617.54 500,000
Fire Pension Medical 68.03 1,895.95 25,000 279.36 12,835.48 20,000
Office/Operating Supplies 0.00 0.00 475 0.00 459.88 475
Actuarial/Firemen's Pens 0.00 0.00 0 0.00 11,200.00 10,000
Reimb General/Clerical&Acct 0.00 0.00 0 983.00 11,801.00 11,801
ENDING CASH/!NV BALANGE $4,233,118.5$ $4.233,118.58 $3,645.tN5 $d,344,i67.Z2 $4,329,966.63 $3.643,2fi4
CUftRENT RREVIQUS, LAST YEAR lAS"F YEAR
ACTIVlTY; MONTH M1AC3NTH Cl1RR M0 PREV MO
CASH/StatelnvestmentPool $1,359,041.51 $1,389,360.75 $805,747.46 $841,184.91
INVESTMENTS:
CD's&State Investment Pool 0.00 0.00 454,767.46 454,767.46
Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84
Treasury Strips&Zero Coupon Bonds 2,767,916.83 2,767,916.83 2,984,096.96 2,984,096.96
Interest Receivable 6,604.40 6,604.40 0.00 0.00
TQTAL CASH ANCi lRIYESTMENTS $4,233,118.58 $4,263,437.$2 '$4,344,167.F2 $4,379,6Q5.1T
The State Investment Pool interest 0.2245% 0.2723% 1.0301% 1.0689%
'Finance has not closed month end for March,04/09/10.
H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2010.x1s\Mar Page 1 04/09/2010
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FIREMEN'S PENSION BOARD
PENSION/MEDICAL PAYMENTS FOR APRIL, 2010
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* ANKENY,Charlie(Captain) $117.69 117.69
ASHURST,James(Assistant Chief) - 272.01 272.01
* BARILLEAUX, Ray(Battalion Chief) - -
* BEATTEAY, Karlen(Widow) $218.62 218.62
* BERGMAN,Claudette(Widow) $140.99 140.99
* CHRISTENSON,Chuck(Firefighter) $244.14 244.14
* GEISSLER, Dick(Fire Chief) - -
GOODWIN,Charles(Captain) $4,231.00 - 4,231.00
* GOODWIN, Donald(Firefighter) $1,005.27 1,005.27
HAWORTH,Constance(Widow) $2,910.13 2,910.13
HAWORTH,Jack(Firefighter) $3,191.50 349.57 3,541.07
* HENRY,William,lr. (Captain} $1,322.82 1,322.82
* HURST,Gerald(Firefighter) $531.13 531.13
* JONES, Evelyn M.(Widow) $237.15 237.15
* LARSON,William (Fire�ghter) - -
* LAVALLEY,Theodele(Captain) $343.91 343.91
* MATTHEW,James(Deputy Chief) - -
* MC LAUGHLIN,JACK(Battalion Chief) $982.45 982.45
* NEWTON,Gary(Lieutenant) $258.03 258.03
* NICHOLS,Gerald(Battalion Chief) $516.96 516.96
* PARKS-ANDREASON,Arlene(Widow) $319.23 319.23
PARKS,John(Firefighter) $3,312.50 57.56 3,370.06
* PHILLIPS, Bruce H.(Deputy Chief) $232.48 232.48
* PRINGLE,Arthur(Captain) $464.52 464.52
PRINGLE,S.Joan(Widow) $2,500.14 2,500.14
* RIGGLE, David E.(Firefighter D Step) $69.10 69.10
* RUPPRECHT,Jim(Firefighter D Step) $104.20 104.20
* SMITH, Leroy(Firefighter) $397.89 397.89
STROM, Doris(Widow) $3,191.50 3,191.50
* TODD,Franklin(Firefighter) $458.00 458.00
* TONDA, Lila Jean (Widow) - -
* VACCA, Nick(Lieutenant) $297.25 297.25
* WALLS,Camille(Widow) $131.71 131.71
* WALLS, Mercedes(Widow) $92.23 92.23
* WALSH, David(Firefighter) $1,052.07 1,052.07
* WEISS,Cheryl(Widow) $747.56 747.56
* WILLIAMS,Alta (Widow) - -
* WOOTEN, Marilyn E.(Widow) $226.72 226.72
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* Adjusted to reflect a 0.44%LEOFF cost of living increase effective April 1.
Prior Year Pension/Medical Payments:
Total Pension Payments for April, 2009 36,376.89
Total Medical Bills Reimbursed in April, 2009 987.58
Total Expenses: Medical/Pension 37,364.47
4_SUMMARY 2010.XLS 04/09/2010
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FIREMEN'S PENSION BOARD
MEDICAL BILLS TO BE REIMBURSED IN APRIL,2010 PAYMENT
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2 James Ashurst Safeway 01/19/10 12.70
3 James Ashurst Safeway 01/21/10 100.90
4 James Ashurst Safeway 01/21/10 151.47
5 James Ashurst Safeway 01/21/10 6.94
272.01
7 Jack Haworth Harbor Drug Co. 10/28/09 5.00
7 Jack Haworth Harbor Drug Co. 10/28/09 5.00
7 Jack Haworth Harbor Drug Co. 10/29/09 5.00
7 Jack Haworth Harbor Drug Co. 11/10/09 5.00
7 Jack Haworth Harbor Drug Co. 11/10/09 10.00
7 Jack Haworth Harbor Drug Co. 11/10/09 5.00
7 Jack Haworth Harbor Drug Co. 11/28/09 5.00
7 Jack Haworth Harbor Drug Co. 11/28/09 5.00
8 Jack Haworth Harbor Drug Co. 12/03/09 5.00
8 Jack Haworth Harbor Drug Co. 12/12/09 5.00
8 Jack Haworth Harbor Drug Co. 12/12/09 7.78
8 Jack Haworth Harbor Drug Co. 12/12/09 5.00
8 Jack Haworth Harbor Drug Co. 12/28/09 5.00
8 Jack Haworth Harbor Drug Co. 12/28/09 5.00
8 Jack Haworth Harbor Drug Co. 12/28/09 5.00
9 Jack Haworth Harbor Drug Co. 01/11/10 14.10
9 Jack Haworth Harbor Drug Co. 01/11/10 15.44
9 Jack Haworth Harbor Drug Co. 01/11/10 8.52
9 Jack Haworth Harbor Drug Co. 01/23/10 14.10
9 Jack Haworth Harbor Drug Co. 01/26/10 51.57
9 Jack Haworth Harbor Drug Co. 02/01/10 16.85
9 Jack Haworth Harbor Drug Co. 02/01/10 13.37
9 Jack Haworth Harbor Drug Co. 02/04/10 10.98
10 Jack Haworth Harbor Drug Co. 02/06/10 14.10
10 Jack Haworth Harbor Drug Co. 02/08/10 7.78
10 Jack Haworth Harbor Drug Co. 02/10/10 5.00
10 Jack Haworth Harbor Drug Co. 02/10/10 5.00
10 Jack Haworth Harbor Drug Co. 02/23/10 5.00
10 Jack Haworth Harbor Drug Co. 03/02/10 5.00
10 Jack Haworth Harbor Drug Co. 03/02/10 5.00
11 Jack Haworth Harbor Drug Co. 03/11/10 14.98
11 Jack Haworth Harbor Drug Co. 03/11/10 5.00
11 Jack Haworth Harbor Drug Co. 03/11/10 5.00
11 Jack Haworth Harbor Drug Co. 03/11/10 5.00
11 Jack Haworth Harbor Drug Co. 03/25/10 35.00
11 Jack Haworth Harbor Drug Co. 03/25/10 5.00
11 Jack Haworth Harbor Drug Co. 03/31/10 5.00
349.57
13 John Parks Olympic Drug 03/01/10 7.00
13 John Parks Olympic Drug 03/01/10 6.28
13 John Parks Olympic Drug 03/01/10 5.00
13 John Parks Olympic Drug 03/01/10 7.00
13 John Parks Olympic Drug 03/11/10 7.00
13 John Parks Olympic Drug 04/01/10 7.00
13 John Parks Olympic Drug 04/01/10 6.28
13 John Parks Olympic Drug 04/01/10 5.00
13 John Parks Olympic Drug 04/01/10 7.00
57.56
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3_2010 FP Medical.XLS Page 1 of 1 04/09/2010
�.r SENDCLAIMTO: �' City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton,WA 98057
U��Y ��
+ �a " +
"�,�N'���
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE �Q/Q
r--
2) DISABILIT'Y RETIREE'S NAME(print) ,�� 5
3) ADDRESS ao�.� �j,�� -n �IG� '� /� �� UI 4/►, �.G�/�
4) DISABILIT'Y AT TIME OF RETIREMENT �rT�/�S-io�
5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.)
(Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement,
whether or not related to the retirement disability,provided that the expense is not covered by another
plan,source or insurance coverage. Supporting documentation for all must be attached.)
6) TOTAL AMOUNT OF CLAIM: $ � '"'�f� �`
Amount of total claim (above) that is related to the Retirement Disability: $
7) I certify that I have not been and will not be compensated by any other organization,
insurance carrier or Medicare for the above-mentioned claim for reimbursement other than
the City of Renton. I further certify that the above statements are complete and accurate to
the best of my knowledge, and that any charges other than prescription drug charges, are
related to my disability as determined at the time of my retirement from the Renton Fire
Department. --
Signature: �
Note: Supporting documentation must be attached.
P� �
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RENTON,WA 96055 � GENERIC NAME: HYDRALAZINE (hye-DRAL-a-zeen) ,
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HOW TO USE THIS MEDICINE: Follow the directions for using this medicine provided by your doctor. STORE THIS
ASHURST,JAMES (425)255-6154 MEDICINE at room temperature in a tightly-closed container, away from heat and light. IF YOU MISS A DOSE OF THIS
223 B GARDEN AVE N. 12/17 � MEDICINE, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your �
RENTON,WA 98055 regu�ar dosing schedule. Do not take 2 doses at once. �
DR. GRAVES,DANIEL L. �NW� CAUTIONS: DO NOT SUDDENLY STOP USING THIS MEDICINE without first contacting you�doctor. IF DIZZINESS �
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Rx:6738148 Jan 19, 2010 Safety Cap: No With your d"octor the benefits and risks of usirig this medicine during pregnancy.'FOR WOMEN:THIS MEDICINE IS''
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Re(:30000058237427 NDC:50111•0398-Ot
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REGENCE BS WASHINGTON Cash PriCe: 13.69 POSSIBLE SIDE EFFECTS: SIDE EFFECTS, that rnay:go away;during treatment', include headache, loss of appetite, nausea, �
Amount Due: $12.70 diarrhea, fast or pounding heartbeat, or dizziness. )f they contin�e or are bothersome, check with your doctor. CHECK
, WITH YOUR DO�TOR AS SOON AS ROSSIBL,E if y,ou'experience chest pain; shortne�s c�f breath; vomiting; generalized, �:
muscle or joint pain; fever; rash; severe fatigue; or Swellmg in legs or feet. If you �ottce other effects not listed above, � � ,
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(GERD), erosive esophagitis, or Zollinger;Ellison syndrome. This medicine works by blocking acid production in the stomach.
)fficial Receipt- Please retain for tax or insurance It may also be used to treat other conditions as determined by your doctor.
1SHURST,JAMES (425}255-6154 , HOW TO USE THIS MEDICINE: Follow the directions for using this medicine provided by your doctor. SWALLOW WHOLE. �
223 B GARDEN AVE N. 12��� Do not break, crush, or chew before swailowing. This medicine may be taken with antacids if your doctor has instructed
RENTON,WA 98055 you to take antacids. Do not miss any doses. STORE THIS MEDICINE at room temperature, away from heat and light. FOR ,
BEST RESULTS, continue taking this medicine for the full course of treatment even if you feel better in a few days. IF YOU
)R. GRAVES,DANIEL �R�� MISS A DOSE OF THIS MEDICINE, take it as soon as possible. If it is almost time for you�next dose, skip the missed dose {
17900 TALBOT RD S and go back to your regular dosing schedule. Do NOT take 2 doses at once. �
RENTON,WA 98055 ` �
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'ANTOPRAZOLE 40MG TAB (PRAS)Qt 30 TAB l in this product. If your sympioms do not improve or if they be�ome worse, check with your�octor. KEEP ALL DOCTOR ' �
3eneric for:PROTONIX 4oMG TAB Y� AND LABORATORY APPOINTMENTS while you are using this medicine. This medicine'may affect the resu�ts of certain lab ,
HSGI � tests (e.g., false positive urine screen for THC). Make sure laboratory personnel and yo�r doctors know you use this
Ref:30000058367959 NDC:00008-0607-01 medicine. CONTACT YOUR DOCTOR IF YOU HAVE SYMPTOMS OF A BLEEDING ULCER, such as black, tarry stools or ,
REGENCE BS WASHINGTON Cash Price: 134.99 vomit that looks like coffee grounds; or if you.experience throat pain, Ghest pain, severe stomach pain, or trouble
Amount Due: $100.90 swallowing. This medicine may cause drowsiness ar clizziness. DO NQT DRIVE, OPERA,TE MACHFNERY, OR DO ANYTHING � �
, �,ELSE THAT COULD BE DANGERO,US until you know how you react,tQ this medicine. Usir�g Yhis medicjne alone, with other , (
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Rx RfFQL YOURPHESCR/PTIONS � SHOULD BE USED WITH CAUTION IN ASIAN.PATIENTS; the risk of side effects may be incr�ased in these patients. � �
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May Refr/!unti/Dec 21, 2010 � stomach pain, or vomiting. If they continue or are bothersome; check with your doctor: CHECK WITH YOUR DOCTOR AS �
1-Do not chew or crush. �, SOON AS POSSIBLE if you experience unusual tiredness CON.TAGT.,YOUR DOCTOR(IMMEDIATELY if you experience � ..
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unusual bruising or bleeding; vision changes; or yellowing of the eyes or skih. An allergic reaction to this medicine is �'
2-Follow dosing directions unlikely, but seek immediate medical attention if it oecurs. Symptoms of an allergicireaction include rash, itching, swelling,
very carefully. � severe dizziness, or trouble breathin�. If you no#ice other effects not listed above,contact your doctor, nurse, or �
3-Promptly report unusual pharmacist. This is not a complete list of all side effacfs that may occur. If you have questions about side effects, contact ;
symptoms/effects to Dr your healthcare provider. Call your doctor for medicat�idvice atauut side effects. You may report side effects to FDA at � ;
4-If condition persists or � 1-800-FDA-1088. � �
worsens notify Dr � The information in this monograph is not intended Yo cover all possible uses; directions, precautions, drug interactions, or `
adverse effects. This informaUon is generalized and is not:intended as specifie medical advice. If you have questions about
� the medicines you are taking or would like more info�rnation, check with your doctor, pharmacist, or nurse. Copyright 2010 �'
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�ffiCial Receipt- Please retein for tax or insuranCe arteries. It may also be used to treat other conditions as determined by your doctor. �
aSHURST,JAMES (425)255-6154 HOW TO USE THIS MEDICINE: Follow the directions for using this medicine provided by your doctor. This medicine may
223 B GARDEN AVE N. �2��� be taken on an empty stomach or with food. STORE THIS MEDICINE at room temperature at 77 degrees F (25 degrees C), � �
away from heat and light. Brief storage between 59 and 86 degrees F (15 and 30 degrees C) is permrtted. IF YOU MISS A �
RENTON,WA 98055 DOSE OF THIS MEDICINE, take it as soon as possible. If it is almost time for your ne�tt dose, skip the missed dose and go �'
)R. GRAVES,OANIEL �(�F� back to your regular dosing schedule. Do NOT take 2 doses at once. �
17900 TALBOT RD S r'
RENTON,WA 98055 CAUTIONS: DO NOT TAKE THIS MEDICINE if you have had an allergic reaction to it;or are allergic to any ingredient in this �
3x:6719636 Jan 21, 2070 Safety Cap: No product. DO NOT EXCEED.THE RECOMMENDED DOSE or take this medicine for longer than pr�scribed without checking �. '
with your doctor. DO NOT STOP USING THIS MEDICINE without fi'rst checking with your do�tor. Lal�oratory and/or medical :
'LAVIX 75MG TAB (B-M ) Qty: 30 TAB tests, including blood counts, may be performed to monitor your progress or to check for side effects. Keep all doctor and ; ,
HSGI laboratory appointments while you are using this medicine. BEFORE YOU HAVE ANY:M:EDICAL OR DENTAL TREATMENTS, �
Ref:30000058366037 NDC:63653•1171•O6 EMERGENCY CARE, OR SURGERY, tell the doctor or dentist you are taking this medicine. You may need to stop this �
REGENCE BS WASHINGTON Cash Price: 207.99 medicine before you have certain types of surgery. This medicine may cau�e dizziness. DO NOT DRIVE, OPERATE
Amount Due: $151.47 MACHINERY, OR DO ANYTHINGELSE THAT COULD BE DANGEROUS until you know how.you react to this medicine. � 1
' Using this medicine alone, with other medicines, or with alcohol may les,sen your ability tq drive or to perfprm other
potentially dangerous tasks. THIS MEDICINE MAY REDUCE THE NUMBER OF BLOOD CELLS ITHAT ARE NEEDED FOR � �
REFILL YOUHPRESCR/PT/ONS CLOTTING. To prevent bleeding, avoid situations where bruising or injury may occur.AVOID ANY SPORTS that expose } '
�4I)��I�I`I`�I���I I)��`IIIII�` R� you to risk of serious injury. IF YOU ARE CURRENTLY TAKING ASPIRIN, oonsult your docxor promptly and ask if you r
� � � � � � [u)SAfEWAY.COM should continue or stop taking aspiri� with this medication for your specific conditio�. ff you are.not currently taking � ,
00000068710 aspirin, consult your doctor before starting aspirin for any medical condition. BEFORE YOU BEGTN TAK�NG ANY NEW �
TAKE ONE TABLET BY MOUTH ONE TIME DAILY MEDICINE, either prescription or over-the-counter, cheok with'your doctor or pharmacist :�'heck the labels on all your
medicines because they may contain pair� relie.vars/fever reducers (NSAIDs such as ibuprofen, naproxen, or aspirin). Ask �'
your pharmacist about the safe use of those products wHile ta�Cing this medicine. IF YO..0 BECOME ILL, including a fever, �
May Refi//until Jan 28,20f0 contact your doctor. FOR WOMEN: IF YOU PLAN ON BECOMfNG PREGNANT; discuss::`with your doctor the benefits and �
1-Do not suddenly stop drug risks of using this medicine during pre�nancy. IT IS UNKNOWN iF THIS MEDICINE IS EXCRETED in breast milk. DO NOT
without Dr's instruction BREAST-FEED while taking this medicme. . ; ""' , � �
2-Report any unusual bleed- � POSSIBLE SIDE EFFECTS: SIDE EFFECTS that may occur while takmg this medicine include easy bruising or rninor
ing to your doctor. bleeding. If they continue or are bothersome, check with your,doctor. CONTACT YOUR DOCTOR IMMEDIATELY if you ��
3-Do not take aspirin � experience bleeding in the eye,changes in your vision; change in ths.amount'of u�ine, chest pain, dark or bloody unne, �
without consent of Dr black or tarry stools, unusua� bruisin�, unusual'or severe bleedmg (such as excessive bleedin� from cuts, increased �
4-Check with Dr. betore � menstrual bleeding, unexplained vagmal bleeding, or unusual bleeding from gums when brushmg), loss of appetite, pale
skin, severe or persistent headache, sore throat, fever;speech problems, weakness, unexplained weight loss, or yellowing �' ;
taking any other medicine � � of skin or eyes. AN ALLERGIC REACTION TO THIS MEpICINE is unlikely, but seek immediate medical attention if it occurs. �
5-Promptly report unusual r� � Symptoms of an a�lergic reaction include rash, itching;swelling,severs.:dizziness, or trouble breathing. If an allergic reaction �
symptoms/effects to Dr � to this medicine occurs, seek immediate medical attentian. If.you notice other effects not listed above, contact your
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6-Report persistent cold or � doctor, nurse, or pharmacist. This is not a complete list of aU side etfe�ts that may occur. If you have questions about side
flu symptoms to Dr � effects, contact your healthcare provider. Call your doctor for medical ad�ice about<side effects. You may report side � �
effects to FDA at 1-800-FDA-1088. '
7-Inform Dr/Dentist prior x
to any type of surgery. °C The information in this monograph is not intended to cover al�possible uses, dlrections, precautions, drug interactions, or
, adverse effects. This information is generalized and is not intended as specific medical advice, If you have questions about � 6 �
the medicines you are takin g or woultl;'like more information, check with your,doctor;, pharmacist, or nurse. Co p yr i gh t 2 01 0 �:
Wolters Kluwer Health, Inc. All rights reserved. Database Edition 10.1 Information �xpires Febn.tary 24, 2010 �
Safety Caps: No �
Last Ref:Dec 21,2009
a
Pat Aller ies: NO KNOWN DRU6 ALLERGY, � '
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� °� � RENTON,WA 98055 8°00-332-10�88
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y y y your doctor.
�cia ece�p - ease re ain or ax or insurance
HOW TO USE THIS MEDICINE- Follow the directions for using this medicine provided by your doctor. This medicine may
ASHURST,JAMES (4251255-6154 be taken on an empty stomach or with food. WHEN YOU FIRST START TAKING THIS MEDICINE, it may cause an increase
223 B GARDEN AVE N. 12/17 �n urine or in frequency of unnation. If you are taking 1 dose dail�r, take it in the morning to prevent this medicine from
REN?ON, WA 98055 „ affecting your sleep. If you are taking more than 1 dose, take the last dose no later than 6 pm. STORE THIS MEDICINE at
'room temperature in a tightly-closed container, away from heat and°'light. IF YOU.MISS A DOSE OF���HIS MEDICINE, take
DR. GRAVES,DANIEL �RF� it as soon as possible. If it is almost time for your next dose, skip the missed dose and gd back to your regular dosing
17900 TALBOT RD S schedule. Do not take 2 doses at once.
RENTON,WA 98055 :.
Fi�c:6737093 Jan 21, 2010 Safety Cap: No CAUTIONS: DO NOT TAKE THIS MEDICINE if you have had an allergic reaction to it or ara alletgic to any ingredient in this
FUROSEMIDE 40MG TAB (RANB)Qt 30 TAB product. Laboratory and/or medical tests, including blood electrolytes, kidney function, and blood glucose may be
Y� performed to monitor your progress or to check for side effects. KEEP ALL DOCTOR AND;LABORATORY APPOINTMENTS
Generic for.LASIX 4oMG TAB while you are taking this medicine. YOUR DOCTOR MAY HAVE j4LS0 PRESCRIBED a pdtessium supplement for you. If so,
HSGIPSH
Ref:3000�58372814 NDC:63304•0625•70 follow the dosing carefully. Do not start taking additional potassium on your own or change your diet to include more
REGENCE BS WASHINGTON Cash Price: 9.99 potassium without first checking with your doctor. DO NOT QRIVE, OP�RATE MACHINERY, OR DO ANYTHING ELSE
Arnount Due: $6.64 THAT COULD BE DANGEROUS until you know how you react td�this medicine.Usin�this medicine alone, with other
medicines, or with alcohol may lessen your ability to drive o�io perform other potent�ally da�r�gerous tasks. THIS MEDICINE
MAY CAUSE DIZZINESS, li�htheadedness; or fainting. Alcohol, hot weather, exercise, and fever can increase these
(� REf/LL YOURPRfSCR/PT/ONS ; effects. To prevent them, sit up or stand slowly, especially in the morning.Also, sit or lie dowri at the first sign of
(1�������II��IIIII�(�l f�I��III � dizziness, lightheadedness, or weakness. THIS MEDICINE:MAY CAUSE increased sensitivity to�the sun. Avoid exposure�
� ��� @SAfEWAY.COM the sun, sunlamps, or tanning boqths untif'you know how you rQact tn this medicine, Use a sunscreen or protective
29002100664 clothing if you must be outside for.a prolonged period. BEFORE�OU$EGIN TAKING ANY NEW MEDICINE, ekher
7:,Kc GNE�AE�.ET BY i�nc�;�H o�vE iliviE Di.ILY prescription or over-the-counter, che�k with your doctor or phar aei.st.:FOR WOMEN: IF,.YOU PLAN ON BECOMING
AS NEEDED FOR SHORT OF BREATH PREGNANT, discuss with your doctor ihe�benefits and risks of using this medicine during pregnancy. THIS MEDICINE IS
EXCRETED IN BREAST MILK. IF YOU ARE OR W1tL BE BREASI'�-FEEI]ING while you are usmg this medicine, check with
MayRefi//unti/Dec 28,20f0 your doctor or pharmacist to discuss the risks to your,ba6y. IF Y,OU HAVE DIABETES, this medicine may affect your blood
1-Check w/Dr about eating a sugar. Check blood sugar levels closely and ask your doctor before adjusting the dose'of your diabetes medicine.
banana or drinking juice. POSSIBLE SIDE EFFECTS: SIDE EFFECTS,that may go away during treatment, include dizziness or lightheadedness when
2-Use caution when driving sitting up or standing, or nausea. It they continue:or.are bothersi�me, check`with your doctor. CHECK WITH YOUR
or operating machinery DOCTOR AS SOON AS POSSIBLE if you expe�ience diarrhea, muscle pain or cramp.s, vomiting, loss of appetite,
3-Avoid prolonged exposure restlessness, dry mouth, unusual thirst, unusual tiredness or we8kness, or rapid or;irre�ular heartbeat. If you notice other
to sun.Use sunscreen effects not listed above, contact your doctor, nurse, or pharmacist. ffiis is not a comp ete list of all side effects that may -
4-Limit alcohol intake - occur. If you have questions about side effects, coniact your he'slthca�e provider. Call your doctor for medical advice about
side effects. You may report side effects to FDA at 1-800-FDA-�088.'
rnay cause side effects. '-
5-If dizziness occurs upon m The information in this monograph is not intended"to cover all possible uses, directions, precautions, drug interactions, or
standing, arise slowly. � adverse effects. This information is �eneralized and•is nof'intended as specific medical advice. If you have questions about
6-Check with Dr. before M the medicines you are taking or wou d like more information, check with your doCtor, pharmacist, or nurse. Copyright 2010
taking any other medicine � Wolters Kluwer Health, Inc. All rights reserved. qatabase Edition'10.1 Information Expires February 24, 2010
7-Promptly report unusual �
symptoms/effects to Dr
8-Consult Dr in event of
weakness/fatigue/cramping �
�afety Caps: �io
� Last Ref:Dec 29,2009
Pat Allergies: NO KNOWN DRUG ALLERGY,
_
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63304-0625-10ASHURST, JAMES Copyright 2010 Wolters Kluwer Health, Inc.A�I rights reserved.Database Edition 10.1
�a.r SEND CLAIM TO: �rr' C i t y o f R e n t o n
Finance Dept.-Fire Pension
1055 South Grady Way
Renton,WA 98057
O��Y ��
�
* ,� +
"��y'N���
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement R e�nuest �
.
1) DATE �/ �
-,
2) DISABILITY RETIREE'S NAME (print) QC l�'J�,/� �(�C1
3) ADDRESS Y;�. � dEj7� l ��_',(�,� �� �'f�cS,��'
4) DISABILIT'Y AT TIME OF RETIREMENT 1�S' �� cs/�'�1 � j�
�� t ey�. _
5) DESCRIPTION OF CLAIM: (SuppoYting documentation must be attached.)
(Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement,
whether or not related to the retirement disabiliry,nrovided that the exnense is not covered by another
plan,source or insurance coverage. Supporting documeutation for all must be attached.)
6) TOTAL AMOUNT OF CLAIM: $ � ��'�•S1
Amount of total claim (above)that is related to the Retirement Disability: $ �� �'d
7) I certify that I have not been and will not be compensated by any other organization,
insurance carrier or Medicare for the above-mentioned claim for reimbursement other than
the City of Renton. I further certify that the above statements are complete and accurate to
the best of my knowledge, and that any charges other than prescription drug charges, are
related to my disability as determined at the time of my retirement from the Renton Fire
Department.
Signature: �
� ,�
Note: Supporting documentation must be attached.
���
Harbor Drug C� �rescriptions Narbor Q�Co.Prescriptions
316 Blh St. � Phone 360-532-3067 � 316 8th 5t. Phone 360-532-3067
Ho uiam,WA 98550 24 Hr.i0c RefEIF(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refil[(360)538-4978
R 68�270 R MORRIS, R., MD RX# 677524 R MORRIS, R., MD
HAWORTH,JACK* 10/28/09 DS HAWORTH,JACK* 11/10/09 DS
BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551
OMEPRAZOLE ER 20 MG CAPS AMIODARONE HCI 200MG
QTY# 3Q NDC#60505-0065-01 APOTEX QTY#30 NDC#13107-0056-05 AUROBIND�
REF#UWVINHN3M Generic For:AMIODARONE 200 MG
1 REFILLS REF# DE79ALC
COMC NO REFILLS
COPAY: $5.00 COMC
Illlllllllllil�llllllllllilllllllllllliilllllllllllllllllNlllnll�llll�lllilllll�iulillqll�Ulllihh COPAY: $10.00
Iliillll IIIIIIIII{II�II�III(IIIIIIIII�IIIIIIINIilllillllllllllllllll II�IIIIIIIIIIIIIIIIIlIIIIIIII IIIIIIII
(all�our docror ior medical advice about side effects.You may report side effe�s to fDA at I-800-fDA-1088.; [all your doctor for medical advire about side eHects.You may report side e((ects to fDA at I-600-fDA-1�88.
� Harbor Drug Co.Prescriptions Narbor Drug Co.Prescriptions
376 8th St. Phone 360-532-3061 �316 8th St. Phone 360-53Y-3061
Hoquiam,WA 96550 24 Hr.Rx Qefilf(360}538-99�8 Hoquiam,WA 98550 24 Hr.Rrz Refill(360}538-99T8
RX# 69810$ N MORRIS, R., MD RX# 689201 R KONN, D., MD
HAWORTH,JACK* 10l28/09 D5 HAWORTH,JACK* 11l10/09 DS
BOX 864,OCEAN SHORES,WA 98551
AMLODIPINE 5MG TAB BOX 864,OCEAN SHORES,WA 98551
QTY#45 NDC#68382-0122-05 ZYDUS LOVASTATIN 20 MG
QTY#30 NDC#49884-0755-10 PAR
REF#UIMNUHQFP � � I
MAY REFILL REF#WXDFXIR
COMC 6 REFILLS
COPAY: $5.00 COMC '�=
IIIIIIIIINIIIIhIIiNllllllllllill�lllilllllilllllll�llllllllilllllllll�lllllllillllllilllllllllllllllll8 �oPAY: $5.00
Ilill fllllllilll�ll�llllli INIINIII�IHIIIIIIIIIIIIIIIIIIIIIIIIIN IIIIIIII III IIIIIII�II
Lall your docror for medical advire aEout side elfects.�ou may report side effects to fDA at I-800-fDA-1088. fall�our doctor for medial advire a6out side e(fecu.Vou may report side ef(ects to FDA at I-B00-fDA�1088.
� Harbor Drug Co.Prescrlptions
316 Bth St. Phone 360-532-7061 � Narbor Drug Co.Prescriptions
Hoquiam,WA 96550 24 Hr.Rx Reflt[(360}538-49Y8 Phone 360 532-3061
RX#C691568 R KONN, �., MD Hoquiam,tWA98550 24Hr.RxRefili(360}538-4978
HAWORTH,JACK* 10/29/09 DS RX#C691568 R KONN, D., MD
BOx 864,OCEAN SHGRES,WA 98551 HAWORTH,JAGK* 11/28l09 LL
ZOLPIDEM 10MG soX esa,OCEAN SHORES,WA 98551
QTY# 30 NDC#13668-0008-05 TORRENT ZOLPIDEM 10MG
Generic For:ZOLPIDEM 10 MG QTY# 30 NDC#13668-0008-05 TORRENT
REF#U1M�'IMD9F Generic For:ZOLPIDEM 10 MG
1 REFILLS REF# DFNMMFT
COMC ' NO REFILLS
COPAY: $5.00 COMC COPAY: $5.00
IIIIINIII@Iilllllillll�l�lllllllllUllllllllllllllllllllllllllllllllihl111111111111111illillllllllllll� ' IIIIItIIIIIIIIIhIIIIIIINIIIhIiIIIIIII�IIiIIiIIIIIIIIIIIIIIIIIIIII�III�IiIINl�llllllillllllllllllilll�
[all your doctor for medial advice about side effEcu.Pou ma�report side ei(ects to fDA at I•800-fDA-1088.
• _ � - [allyourdoctorformedicaladvireahoutsideeffeds.Youmavreoortsideeffe�tstofDAatl-800-fDA-1088.
� Harbor Drug Co.Prescriptions ' Narbor Drug Co.Prescriptions
316 Bth St. Phone 360-532-3067 �376 8th St, Phone 360-532-3061
Hoquiam,WA 98550 44 Hr.R�c Retllt(360)538-9478
RX� s87�8.q R KONN, �., MD Hoquiam,WA 98550 24 Hr.Rx Reffl!(360}538-9978
HAWORTH,JACK* 11I10/09 D5 RX# 688270 R MORRIS, R., MD .
BOX 864,OCEAN SHORES,WA 9855t HAWORTH,JACK* 11128l09 LL
ISOSOR MON ER TB 30MG KRE 100 gOX 864,OCEAN SHORES,WA 98551
QTY# 15 NDC#62175-0128-37 KREMERS OMEPRAZOLE ER 20 MG CAPS
Generic For:ISOSORBI MON ER 30MG.-ETHEX QTY#30 NDC#60505-0065-01 APOTEX
REF# DE79AAX
4 REFILLS REF#WXXIWAR
COMC NO REFILLS
COPAY: $5.00 COMC
lIII(IIIIIIIIIINIIBIIIUIII�IIINIII�III�IIIIIIIIIIIIIIIIIIIIIIIIIlIIIIIIIIIIIIIII�IIIIIIIIIIlIIIIIII _ COPaY: $�.�0
II IIII I I II I III III�illl IIIII II II Ilil Ilill II II I I II I II IIIII III�IIi�I III IIII lill I II I III III Ilf
tali rour dostor for medical adrice a6out side effecu.You mar report side e�If�fDA at I•800•FDA•IOBB. (all�our do�or for medicai advice about side effects.iou may report side e�e�s ro fDs at{•BOO�fDA-1068.
�1('�%' �
Narbor Drug C� prescriptions
� HoqBiam,iWA98550 24�Refll!(360)38-9478 Harbor�9 Co.Prescriptions
3t6 9th St. Phone 360-532-3061
RX# 699923 N HOVANCSEK, R., MD Hoquiam,WA98550 24 Hr.Wc Refill(360)538-9478
HAWORTH,JACK* 12/03/09 JR �X# 688270 R MORRIS, R., MD
BOX 864,OCEAN SHORES,WA 98551 �{p�ORTH,JACK'" 12I28�09 DS
GENTAMICIN CREAM BOX 86d,QCEAN SHORES,WA 98551
QTY# 15 NDC#00168-0071-15 FOUGERA OMEPRAZOLE ER 2Q MG CAPS
REF#WX9QHF7 QTY# 30 NDC#60505-0065-01 APOTEX
1 REFILLS REF#UAAWLIH
COMC NO REFILLS
II�IIIIIIIIIIIII�II�IiIIiIIIII�IIIIIIIIII�IIIIIHIIIIIIIIIIIIIIIIIIIIIiIII� COMC COPAY: $�.00
ill�lll lll�li�illilllNII81118111�1111111I�IIIIIIIIIIIIIIINIIilillllllil01111111111Illllllllll�tlllil
[all venr dnrtnr fer mediral advire ahmit�idn eHactc_Ym�.mar ro�rr_��dp off�a+n fDd at.l•800-FDA-IOBB.
� Harbor Drug Co.Prescriptions
316 8th St. Phone 360-532-3061
� Harbor Drug Co.Prescriptions Hoquiam,WA 98550 24 Hr.fGc Refill(360)538-9978
3168thSt. Phone360-532-3061 RX# 701042 N KONN, �., MD
Hoquiam,WA 98550 24 Hr.Rx Refiil(360)538-9578 .
RX# 698108 R MORRIS, R., MD ` HAWORTH,JACK* 12/28/09 DS
HAWORTH,JACK' 12/12/09 DS BOX 864,OCEAN SHORES,WA 98551
BOX 864,OCEAN SHORES,WA 98551 AMIODARONE HCL 200MG
AMLODIPINE 5MG TAB QTY# 30 NDC#00093-9133-52 TEVA USA
QTY#45 NDC#68382-0122-05 ZYDUS Generic For:AMIODARONE 200 MG
REF# DHKN3XC
REF#WiF1WKF 12 REFILLS
MAY REFILL COMC
c�Mc IIIIIIIIIIIIIIdIII�iII�IIiIIINiIIINIiIIIII�IIIIIIIIIIiIIINIIiIIIIN�llllllllllllllilllllll�lllllll��
COPAY: $5.00
IIII�I IIIIIIINIIIIlIIIIIIII�IIillillillllllllllllllllllllllllllllilllllll(IIIIIIIIIIilll�ill Illilllllllll
Lall�our doctar for medical advice about side e((ects.9ou may repart side effecu to fDA at I-800-fDA�1088. �
� Narbor Drug Co.Prescriptions
316 8th St. Phone 360-532-3067
� � Narbor Drug Co.Prescriptions Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-447g
316BthSt. Pl�one360-532-3061 RX#C701041 N KONN, �., MD
Hoquiam,WA 98550 24 Hr.Rz Refll!(360)538.99]8 HAWORTH,JACK"
RX# 681231 R MORRIS, R., MD BOX 864,OCEAN SHORES,WA 98551 �2�28��9 DS
HAWORTH,JACK* 12l12/09 DS ZOLPIDEM 10MG
BOX 864,OCEAN SHORES,WA 98551 QTY#30
FUROSEMIDE 20 fVIG NDC#13668-0008-05 TORRENT
Generic For:ZOLPIDEM 10 MG
QTY#60 NDC#00054-4297-31 ROXANE � ,1 REF#UAAXg9W
REF# 3H3HNR7 � 5 REFILLS
2 REFILLS r COMC
COMC ' IIIIIIIIII��IIIIIIIIIIIIIIII COPi Y: $5.00
CC�PAY: $7.78 �II�IIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIfIIIIIIIIiI�IIIIIIIIIIIIIIIIIIIIIIIII
IIII�IIIIIIIIIIIIIIIIIIIIIIINIIil�lillllllllll�ll�llllllllllllllllllllllll�illlilllllliillf lillltlllil�
fall�our dnctor for medical advire about side effects.You mar report side effects to fDA at I-600-fDA-IOBB.,�
� Narbor Drug Co.Prescriptions
316 8Ih SL Phone 360-532-3061
Hoquiam,WA 98550 24 Hr.Ibc Refllf(360)5�8-9478
RX# 689201 R KONN, D., MD
HAWORTH,JACK* 12/12J09 DS
BOX 864,OCEAN SHORES,WA 98551
LOVASTATIN 20 MG
QTY# 3Q NDC#53489-0608-10 MUTUAL
REF#3H3HNRK
5 REFILLS
COMC
COPAY: $5.00
111111111I1il��llll��llllllllll�ll�ll{I�I�IIIIIIII�IIII III Illllllll IIIIIIIlIIIIIIIIILIIII II
[all your doctorior medical advice about side eflects.Yau mar repoft side e((e�s to fDA at I-800-fDA-1088.
�� �
� Narbor Drug Co.�'rescriptions Narbor�g Co.Prescriptions
316 Sth St. Phone 360-532-3061 316 8th SL Phone 360-532-3061
Noquiam,WA 98550 24 Hr.Ru Reftlt(360j 536-9478 Ho uiam,WA 98550 24 Hr.Rz Refilf(360j 538-9978
RX# 698108 R MORRIS, R., MD RX 69�017 R RUYLE, S., MD
HAWORTH,JACK* 01/11/10 DS HAWORTH,JACK* 01126l10 JR
BOX B64,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551
AMLODIPINE 5MG TAB DORZOLAMIDE 2°lo OPH SOL
QTY#45 NDC#68382-0122-05 ZYDUS QTY# 10 NDC#60505-0567-01 APOTEX
REF#UANX99E REF# DKHWP3D
MAti'REFILL 4 REFILLS
COMC COMC
COPAY.c $14.10 COPAY: $51.57
IIII iflllll�IIIIIIIIIIINlillillllllllilli BIINII►11111 IIIIPI Ililillillllllllll�illilllllllll�flll IIIIIIIIIIIIII�III�IIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIINIIIIIIIIIBIIillllllllllll(IIIIIII
�" ' " " ' ' '� ' " " " " " "' '""'"-' -"' (all your dactar for mcdical advire about side eff�ts.You ma�report side eHects to fDA at I•800-fDA-IU88,
� Narbor Drug Co.Prescriptions
3768th St. Phone 360-532-3061 � Harbor Dru Co.Prescriptions
Hoquiam,WA 98550 24 Hr.Ru RefliF(360J 538-9978 3t 6 Bth St. �
Rx# 5892�� R KONN, �., MD Hoquiam,WA g8550 24 Hr.R�c Refili(360)538-9968
HAWORTH,JACK" 01l11110 DS RX# 688270 R MORRIS, R., MD
BOX 864,OCEAN SHORES,wA sassi HAWORTH,JACK" 02l01/10 RR
LOVASTATIN 20 MG BOX B64,OCEAN SHORES,WA 98551
QTY# 30 NDC#53489-0608-10 MUTUAL OMEPRAZOLE ER 20 MG CAPS
REF#3KVUEX3D QTY#30 NDC#60505-0065-01 APOTEX
4 REF{LLS REF# DKNPNQQ
COMC 1 REFILLS
COPAY: $15.44 COMC
IIIII �lilllll�ll lllll�llilllilllllllilllll llll llllllillllllll llli illlliflll ll l ll lll COPAY: $16.85
� ����:�:.����.r':as�ri���ss IIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIhIIIIIiIIiIIIIIIIIIIIIINIIIfIII�IIIIiIIIIIIIIIIItIIIIIiIINIIN�II
31fi 8th St. Phone 360-532-3061
Hoquiam,WA 98550 24 Hr.Ric Refill(360)538.9978
RX# 687189 R KONN, D., MD _ _ -__
HAWORTH,JACK* 01/11/10 DS � Harbor Drug Co.Prescriptions
BOX 864,OCEAN SHORES,WA 98551 316 8th St. phone 360-532-3061
ISOSORBIDE MONO 30MG Hoquiam,WA98550 24 Hr.We Refill(360)538-9978
QTY# 15 NDC#00143-2230-01 WEST-WAF RX# 701042 R KONN, D., MD
Generic For: ISOSORBI MON ER 30MG.-ETHEX FiAWORTH,JACK" 02/01/10 RR
REF#3KWEXT9 BOX 864,OCEAN SHORES,WA 98551
3 REFILLS AMIODARONE HCL 200MG
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316 8th St Phone 360-532-3061
Hoquiam,WA 98550 24 Hr.Rx Retttf(360)538-997Q � 31 B 8th SS. Phone 360-532-3067
RX# 703320 N MORRIS, R., MQ Hoquiam,WA98550 24 Ha{bc Reit�t(1b0)538-9978
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FUROSEMIDE 20 MG BOX 864,OCEAN SHORES,WA 98551
QTY#60 NDC#00054-4297-31 ROXANE aMEPRAZOLE ER 2�MG CAFS
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316 8N St. Phone 360-532-3061 gj�,gth SE. Phone 360-532-3061
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QTY#30 NDC#53489-0608-10 MUTUAL AMIODAf20NE HCL 200MG
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�r SENDCLAIMTO: � City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
v��Y °�,
A
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��'NT��
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE � D:f) �.. T� � �+ l�
2) DISABILITY RETIREE'S NAME (print) ��,yj _�. �'��f`�'[��" _
� 3) ADDRESS 1 �3.� ,... '7� �/�� . e� t ��a��
s
4) DISABILITY AT TIME OF RETIREMENT �'��-� ��'����� �/ �L� � ,�AQ I
�����',S" . �I,� c'��� � �'�r�i 7
� ' S) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.)
(Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug ezpenses for reimbursement,
whether or not related to the retirement disability,provided that the egpense is not covered by another
plan,source or insurance coverage. Supporting documentation for all must be attached.)
� 4 � � a `� �
6) TOTAL AMOLTNT OF CLAIM: $_,�j'�'�, ,S
Amount of total claim (above) that is related to the Retirement Disability: $��'�jt � �
7) I certify that I have not been and will not be compensated by any other organization,
insurance carrier or Medicare for the above-mentioned claim for reimbursement other than
the City of Renton. I further certify that the above statements are complete and accurate to
the best of my knowledge, and that any charges other than prescription drug charges, axe
related to my disability as determined at the time of my retirement from the Rento:�Fire
Department.
Signature:
Note: Supporting documentation must be attached.
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MIRTAZAPINE SOLTAB 45MG 24415th Ave.,Longview,WA98632 Ph.(360)423-336 SAVE FOR INSURANCE
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