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Home My WebLink AboutFinal Agenda Packet Noe ter'' CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, January 19, 2006 1:30 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF DECEMBER 15, 2005 3. CORRESPONDENCE Memo and e-mail regarding Bruce Phillips' election 4. MONTHLY STATEMENT TO DECEMBER 31, 2005 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS 8. ADJOURNMENT Ntre Nue MINUTES FIREMEN'S PENSION BOARD CITY OF RENTON December 15, 2005 Kathy Keolker, Mayor Don Persson, Council Finance Committee Chair Bonnie Walton, City Clerk Ray Barilleaux, Fire Department Representative William Henry, Fire Department Representative William Larson, Fire Department Alternate The regular meeting of the Firemen's Pension Board was called to order by Chairman Kathy Keolker at 2:30 p.m. in the Mayor's conference room, 7th floor of Renton City Hall. In attendance were Board members Kathy Keolker, Ray Barilleaux, Bill Henry and Bonnie Walton. (Don Persson was absent.) Also in attendance was non-member Jill Masunaga, Finance Department Representative. MINUTES APPROVAL MOVED BY BARILLEAUX, SECONDED BY HENRY, THE PENSION BOARD APPROVE THE MINUTES OF THE NOVEMBER 17, 2005,MEETING. CARRIED. CORRESPONDENCE A memo from the board secretary to the fire chief regarding Bill Henry's term expiration on 12/31/2005, and the election requirement was acknowledged. Bill Henry stated that he has decided to resign from the Firemen's Pension Board and therefore is not running for re-election. MONTHLY STATEMENT The financial report as of November 30, 2005, was reviewed. Total cash/investment balance was $4,841,101.79. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY HENRY, SECONDED BY BARILLEAUX, THE BOARD APPROVE THE PENSION/MEDICAL PAYMENTS FOR DECEMBER 2005, IN THE TOTAL AMOUNT OF $33,304.07. CARRIED. UNFINISHED BUSINESS A spreadsheet draft entitled Firemen's Pension Fund Financial History covering the period 1990-2004 was reviewed. The board secretary was asked to complete the form and provide copy at the next meeting. NEW BUSINESS Medicare Part D. After a brief discussion, it was determined that any inquiries received from Firemen's Pension retirees concerning whether to sign up for Medicare Part D, Prescription Drug Plan Nov ‘100 benefit, should be referred to Michael Webby, Human Resources &Risk Management Administrator. Mr. Webby would be able to evaluate and advise the Firemen's Pension retirees accordingly. Bill Henry resignation. Bill Henry thanked the Board for the opportunity to serve as a Board member for twenty-five years (1973-1982 and 1990-2005). He encouraged the Board to keep up the good work, and stated that he felt it is time for him to step aside and let someone else serve. Board members Keolker, Barilleaux and Walton thanked Mr. Henry for his service on the Board. ADJOURNMENT MOVED BY BARILLEAUX, SECONDED BY HENRY, THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:55 p.m. 160-7tA4AiJ. 41cteto-74- Bonnie I. Walton, City Clerk Member and Secretary, Firemen's Pension Board 2 Ntre *err CITY OF RENTON C"r(C: O�• FIRE DEPARTMENT DEC 3 0 2005 MEMOR A NDUM CITY CLERKI S OFFICE DATE: December 29, 2005 TO: Bonnie,Wal on, ity Clerk FROM: A. Lee er, Fire Chief SUBJECT: FirkneL's Pension Board Voting Results An election was conducted to fill the vacancy created by the expiration of Bill Henry's term as the Department's representative on the City of Renton Firemen's Pension Board. By unanimous vote, Bruce Phillips has been elected for this two-year term of office, effective from January 1, 2006 to December 31, 2007. Thank you. cc: Lawrence Rude, Deputy Chief is\unionsandpensionbd\pension board\05ffpensionmemotocityclerk.doc *1110, 44110 From: Mary Weirich To: Bonnie Walton; Lee Wheeler Date: 12/30/2005 3:52:07 PM Subject: Re: Firemen's Pension Election Results 19611 SE 150th Renton, WA 98059 (425)226-2974 B29M26P@comcast.net >>> Bonnie Walton 12/30/05 3:45 PM >>> I am in receipt of your memo indicating that Bruce Phillips has been elected to the Firemen's Pension Board. Please provide Mr. Phillips'address, phone number and email address for the Board records. Thank you. Bonnie Walton City Clerk and Board member&secretary x6502 CC: Lawrence Rude CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF DECEMBER 31, 2005 pre Fireman's Pension Fund Comparison of Cash and Investment Activity >r 6 III2005 ❑2004 A , 4 0 0 0 3 2 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2005 2005 LAST YEAR 2004 2004 ACTIVITY: MONTH YTD BUDGET CURR MO YTD ADJ BUDGET BEGINNING CASH/INV BALANCE $4,841,101.79 $4,976,122.73 $4,976,123 $5,006,563.08 $5,133,315.47 $5,133,315.47 RECEIPTS: Property Taxes 0.00 0.00 $0 0.00 0.00 $0 Fire Insurance Premium Tax 0.00 72,403.73 $60,000 0.00 70,249.69 $40,000 Investment Interest 2,058.45 177,622.88 $100,000 1,279.36 154,280.97 $110,000 DISBURSEMENTS: Fire Pension 33,012.44 402,201.54 $410,000 31,161.71 374,624.19 $375,000 Office/Operating Supplies 0.00 400.00 $400 82.82 399.21 $400 Actuarial/Firemen's Pens 0.00 7,075.00 $5,000 0.00 0.00 $0 Reimb General/Clerical&Acct 575.00 6,900.00 $6,900 558.00 6,700.00 $6,700 ENDING CASH/INV BALANCE $4,809,572.80 $4,809,572.80 $4,713,823 $4,976,039.91 $4,976,122.73 $4,901,215 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH $384,771.97 $416,300.96 $24,748.64 $55,188.99 INVESTMENTS CD's&State Investment Pool 454,767.46 454,767.46 754,767.46 379,767.46 Snohomish County Housing Authority 0.00 0.00 0.00 0.00 Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84 Treasury Strips&Zero Coupon Bonds 3,870,477.53 3,870,477.53 4,097,050.79 4,472,050.79 Corporate Bonds 0.00 0.00 0.00 0.00 Convertable Bonds 0.00 0.00 0.00 0.00 Mutual Funds 0.00 0.00 0.00 0.00 TOTAL CASH AND INVESTMENTS $4,809,572.80 $4,841,101.79 $4,976,122.73 $5,006,563.08 The State Investment Pool interest 4.1605% 3.9627% 2.0740% 1.8810% H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2006.xls\Dec05 draft Page 1 1/13/2006 FIREMEN'S PENSION BOARD nrr PENSION/MEDICAL PAYMENTS FOR JANUARY, 2006 Recipient Pension Amt Medicals Total * ANKENY, Charlie (Captain) $245.97 245.97 * ASHURST, James (Assistant Chief) $4,166.00 2,065.29 6,231.29 * BANASKY, George(Captain) $1,200.16 1,200.16 * BARILLEAUX, Ray(Battalion Chief) - - * BEATTEAY, Karlen (Widow) $297.62 297.62 * BERGMAN, Claudette (Widow) $228.57 228.57 * CHRISTENSON, Chuck (Firefighter) $398.54 398.54 * CONNELL, Robert(Captain) $777.65 777.65 * GEISSLER, Dick (Fire Chief) - - * GOODWIN, Charles (Captain) $3,780.00 542.25 4,322.25 * GOODWIN, Donald (Firefighter) $1,002.32 1,002.32 HAWORTH, Constance (Widow) $2,521.49 2,521.49 * HAWORTH, Jack(Firefighter) $2,851.50 - 2,851.50 * HENRY, Teresa A. (Widow) $393.40 393.40 * HENRY, William, Jr. (Captain) $1,312.78 1,312.78 * HURST, Gerald (Firefighter) $660.30 660.30 * JONES, Gerald D. (Firefighter) $317.25 317.25 * LARSON, William (Firefighter) $51.42 51.42 * LAVALLEY, Theodele (Captain) $440.33 440.33 * MATTHEW, James (Deputy Chief) - - * MC LAUGHLIN,JACK(Battalion Chief) $874.70 874.70 * NEWTON, Gary(Lieutenant) $350.88 350.88 * NEWTON, Roger(Firefighter) $58.98 58.98 * NICHOLS, Gerald (Battalion Chief) $470.56 470.56 * PARKS-ANDREASON, Arlene(Widow) $410.74 410.74 * PARKS, John (Firefighter) $2,959.50 257.62 3,217.12 * PHILLIPS, Bruce H. (Deputy Chief) $231.41 231.41 * PRINGLE, Arthur(Captain) $545.98 545.98 PRINGLE, S. Joan (Widow) $2,166.25 2,166.25 * RIGGLE, David E. (Firefighter D Step) $168.84 168.84 * RUPPRECHT, Jim (Firefighter D Step) $198.99 198.99 * SMITH, Leroy(Firefighter) $449.29 449.29 * STROM, Karl (Firefighter) $2,851.50 - 2,851.50 * TODD, Franklin (Firefighter) $500.94 500.94 * TONDA, Lila Jean (Widow) $164.06 164.06 * VACCA, Nick (Lieutenant) $378.53 378.53 * WALLS, Kenneth (Firefighter D Step) $226.65 226.65 * WALLS, Mercedes (Widow) $108.80 108.80 * WALSH, David (Firefighter) $1,042.53 1,042.53 * WALSH, Patrick (Captain) $978.21 978.21 * WEISS, Larry(Battalion Chief) $671.84 671.84 * WILLIAMS, Alta (Widow) - - * WOOTEN, Marilyn E. (Widow $300.58 300.58 Prior Year Pension/Medical Payments: Total Pension Payments for January, 2005 34,570.22 Total Medical Bills Reimbursed in January, 2005 366.01 Total Expenses: Medical/Pension 34,936.23 * Includes a 3.0% cost of living increase effective January 1 per union contract. 4_SUMMARY 2006.XLS 1/13/2006 lw° •w FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN JANUARY, 2006 PAYMENT Page Name Pharmacy/Medical Facility Amount of Bill 2 James Ashurst Safeway 6.75 2 James Ashurst Safeway 7.75 2 James Ashurst Safeway 167.90 2 James Ashurst Safeway 74.94 2 James Ashurst Safeway 167.90 2 James Ashurst Safeway 167.34 2 James Ashurst Safeway 6.75 2 James Ashurst Safeway 79.23 2 James Ashurst Safeway 167.90 2 James Ashurst Safeway 167.90 2 James Ashurst Safeway 7.75 2 James Ashurst Safeway 167.34 2 James Ashurst Safeway 6.75 2 James Ashurst Safeway 79.23 2 James Ashurst Safeway 173.68 2 James Ashurst Safeway 7.75 2 James Ashurst Safeway 173.68 2 James Ashurst Safeway 6.75 2 James Ashurst Safeway 79.23 2 James Ashurst Safeway 167.34 2 James Ashurst Safeway 173.68 2 James Ashurst Safeway 7.75 2,065.29 4 Charles Goodwin Bartell Drugs 62.56 4 Charles Goodwin Bartell Drugs 6.35 4 Charles Goodwin Bartell Drugs 210.57 5 Charles Goodwin Bartell Drugs 128.21 5 Charles Goodwin Bartell Drugs 6.35 5 Charles Goodwin Bartell Drugs 128.21 542.25 Jack Haworth 0.00 7 John Parks Olympic Drug 115.02 7 John Parks Olympic Drug 94.01 7 John Parks Olympic Drug 25.37 7 John Parks Olympic Drug 23.22 257.62 Karl Strom 0.00 TOTAL 2,865.16 3_2006 FP Medical.XLS 1/13/2006 SEND CLAIM TO: City of Renton ''"'" '109Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 e 4 CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE /` `/ / e) C 2) DISABILITY RETIREE'S NAME(print) IW'I 514 L- d 3) ADDRESS °2 6,61-0.Veivr Q,4/ (1/44" B 4) ISABILITY AT TIME OF RETIREMENT i- p 7; o,tr- 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Note: Medical coverage is limited to current treatment of the retiree's disability as determined at the time of retirement. (RCW 41.18) Submit only claims that relate to item #4.) /✓lf:AeZ7 1.-1-t` e,/ /r—Pit ?L'!z �—N 3!O�t� A'71 6) TOTAL AMOUNT OF CLAIM i-- ? O 4) f 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 all claims submitted are related to my disability as determined at the time of myaretirement from the Renton Fire Department. Signature: ‘,/ Note: Supporting documentation must be attached. Tads Page: 1 M E D I C P '. EXPENSES ASHUJA1 Patient: ASHURST, JAMES 'toePharmacy: SAFEWAY #27-1563 RespPty: 200 SOUTH 3RD STREET 223 B GARDEN AVE N. RENTON WA 98055 RPh: GOH, HEATHER RENTON NA 98055 NCPDP#: 4927034 Birth: 12/02/1917 Prescriptions: Date: 01/01/2005 TO 12/09/2005 LastFill Rx # Drug Name Qty Physician Name T/P Price RPh 01/20/05 6659862 M. T• ,,, . 50MG 100Dr.GRAVES WWA406.75 TGS 0 15r.GRAVES .,. 014+la �.., �. .$, s� t - "� `i<�. �TG 7.75 TGS ,.a 0141 -PR. 1. e . _,, 0 Dr VES,,.. 167.90 fttY 01 - 863 COZAAR 50MG 50 Dr.c r + . 74.94 TGS` 01/28/05 6658835 HUMULIN N 10 Dr.GRAVES BWA 28.91 TGS 01/28/05 6660221 HUMULIN R 10 Dr.GRAVES BWA 28. 91 TGS 01/28/05 6660223 --D UF U100 .5CC-30 100 Dr.GRAVES BWA 24.26 TGS 02/10/05 6660471 FREESTYLE STRIPS 100 Dr.GRAVES AWD 69.58 HSG 02/10/05 6660715 FREESTYLE LANCETS 100 Dr.GRAVES AWD 9. 99 HSG 02/17/05 6658837 BRIMONIDINE 0.2% OP 10 Dr.SHIELDS BWA 54.55 MT e ' ', ,16$0%a41-7. 4° •1 • c', a� _..,.uu�., a-=..�,, 167.90 CHi -i' ----i4 05 .6658803" L P}'; -' ' A 50Dr.GRAVHS 'AMC" 167.34 JK 03/14/05 6658835 HUMULIN N 20 Dr.GRAVES BWA 55.81 HSG 03/22/05 6660223 --D UF U100 .5CC-30 100 Dr.GRAVES BWA 24.26 DHH 03/28/ -6:6598.6_METOPROLOL 50MG 100_Dr.GRAVES /Mk__ 6.75 HQT 04x/05/ W 98 3 COZAAR 50MG 50 Dr.Gkal BWA. 79.23 HOT ' 4/11/ . 65,9861 PROTONIX 40MG 50 Dr.G BWA 167.90 HSG 05/23/05 6658835 HUMULIN N 20 Dr.GRAVES BWA 55.81 HSG :9F 66'59861 PROTONIX 40MG 50 Dr.GRAVES BWA 167.90 HSG 6 -,A, 6 986 F� OSEMI 4Q 100 Dr, : ' �y BWA 7.75 HSG _ � iTiw!G7.�0 "i'�V►719�#:6� �.Zd ,.- .... . _ "a+sna,r3e.:...... ._, 06/16 0 , . .S803 LIPITOR 40MG 50 I r: 3. '-S BWA 167.34 RMG 0.6 . 9862 METOPROLOL 50MG 100 Dr.GRAVES BWA 6.75 RMG ' 50 Dr.GRAVES: EWA, 79.23 JJI,► 0'f' : x1 P at l 40MG : 50 Dr`" GAVES BWA 33.3.68 Jim:, 08/ ; - * SD40MG 100 Dr G 7.75 Jilt 09 . ,, ,4, „,,,,.„,,50_, ' S 173.68 l , .,• ' i • e_ SMG -1 0 £r .-kms ,EN"-- �. 6,7 -IG-. . 59 :. -0 50 Dr.G .,Ig .�.�.{ ,�.M.• .2..,X 23..- . 09122/05 6668820 L'IPTTOR 40MG 50 Dr.GRAVES BWA 167.34 HSG 09/29/05 6669109 HUMULIN N 20 Dr.GRAVES BWA 60. 11 HSG 10/15/05 6669767 MURO 128 5% OP 15 Dr.HAYNIE 17.62 HSG 1 • t,;:;-6659861 PROTONIX 40MG 50 Dr.GRAVES BWA 173.68 HSG I1:30 1_,:1,:66559860 FUROSEMIDE 40MG 100 Dr.GRAVES BWA 7.75 HSG Report Date: 12/09/2005 $2,495. 10 1V 'o, 'A '`` aW �oz = o , �,. . 0 ,o tt\ ,,, ,b w < o o (CO fr I0C Q f Pte) N 03 n zz . T Q ¢ o Z -p, d rte, v to 9 0 ¢ o AIql� • Nay SEND CLAIM TO: City of Renton Finance Dept.- Fire Pension 1055 South Grady Way Renton, WA 98055 US�y 0 • a 4. CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request i 1) DATE fl �y� fy ,, 2) DISABILITY RETIREE'S NAME(print) `�---/1 �.....Gt /4--, L-75-0(7.boimi l /II 1/ !i�i',� /h/i:„ Ai '� eg g; 3) ADDRESS (_r = i� �_ ` 4) DISABILITY AT TIME OF RETIREMENT /hr(i; /7 a `' k- ; ` _'�' - , ,a'i,... 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Note: Medical coverage is limited to current treatment of the retiree's disability as determined at the time of retirement. (RCW 41.18) Submit only claims that relate to item#4.) S, ,,e.._ e / . , /bc,a_e_A lii„,zf-2,,,,_, 6) TOTAL AMOUNT OF CLAIM' ��`1" y 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 ether than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that all claims submitted are related to my disability as determined at the time of my retirement from the Renton Fire Department. Signath �re:- � '-"-----� E t -"Th- ._ Note: Supporting documentation must be attached. 1 3 0. BARTELL DRUGS 01111•••=••••••••1 Washington's Own Drngsto,.. RX# 45-278358 E DR. KATO,GARY H DATE: 10/09/05 N (425)255-9310 NAME: CHARLES GOODWIN 201 UNION AVE SE 99 FLOMAX 0.4MG CAPSULE(ABB)- 00597-(g9101 73414057 REFILL NO QUANTITY 30,00 BARTELL DRUGS PRICE= $84.99 BARTELL DRUGS• WITH XPS THE AMOUNT DUE:$62.56 kr, . RO 45-246622 E DR- FLO DATE: 11/04/05 R (425)251-5110 BARTELL DRUGS#45 (425)793-1015 NAME: CHARLES GOODWIN 4700 NE 4TH STREET 201 UNION AVE SE 99 RENTON,WA 98059 NOWASC 10MG TABLET THANK YOU 00 1540 6 77446268 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILL 1 QUANTITY 100.00 REFILLS 24-48 HOURS IN ADVANCE BARTELL DRUGS PRICE= $257.09 WITH XPS THE AMOUNT DUE 4210.57 BARTELL DRUGS BARTELL DRUGS#45 (425)793-1015 RXA2g7149-.2 n' '` " 4700 NE 4TH STREET 45- 42 E DR. LORCH,GERALD RENTON,WA 98059 DATE: 11/04/05 R (425)251-5110 NAME: CHARLES GOODWIN THANK YOU 201 UNION AVE SE 99 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR ALLpRUMNOL 100MG TABLET(MYL REFILLS 24-48 HOURS IN ADVANCE 0037k:0137-0) 77025268 REFILL YES QUANTITY 30.00 BARTELL DRUGS PRICE= $10.99 WITH XPS THE AMOUNT DUE:$6.35 BARTELL DRUGS#45 t - } f -- (425)793-1015 4700 NE 4TH STREET RENTON,WA 98059 i Y THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE 1 � PAS • /J j �. �+ d I ! /fir t 161/1 r ff��. / [1:1 !! %/ lir r t i,jf� koil-ifiv . ii , i9 , 6c,,, ,,,),_ ()Iii. /.:,(177f-r..4-A, ,,-,-(/ . ethil-i ' ' ' C I BARTELL DRUGS --Wwhington's Own Drugstores® Rx# 45-283091 E DR. MOSLEY DATE: 11/11/05 -14P-------(425)899-3123 NAME: CHARLES GOODWIN 201 UNION AVE SE 99 AGGRENOX CAP 200/25 00597-0001-60 7953, -- REFILL 4 QUANTI I't� A BARTELL DRUGS PRICE= $167.99 I BARTELL DRUG S ��......Wwhtngton's Aon, �� RX# 45-283091 E DR. MOSLEY WITH XPS THE AMOUNT DUE:$128.21 DATE: 12/03/05 R (425)899-3123 r , BARTELL DRUGS#45 lrc'�'lit( NAME: CHARLES GOODWIN (425)793-1015 201 UNION AVE SE 99 4700 NE 4TH STREET RENTON,WA 98059 AGGRENOX CAP 200/25 00597-0001-60 83467803 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU REFILL WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR 3 QUANTITY sQ,QQ REFILLS 24-48 HOURS IN ADVANCE I BARTELL DRUGS PRICE= $167.99 WITH XPS THE AMOUNT DUE:$128.21 it') - ., # BARTELL DRUGS#45 (425)793-1015 4700 NE 4TH STREET I BARTELL DRUGS RENTON,WA 98059 sAwbington's Own+rugsiores�.......= RX# 45-254492 E DR. LORCH,GERALD THANK YOU DATE: 12/02/05 R (425)251-5110 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR NAME: CHARLES GOODWIN t_ REFILLS 24-48 HOURS IN ADVANCE 201 UNION AVE SE 99 ALLOP� INOL 100MG TABLET(MYL T# ' 'pi 00378-001 82617278 rI` t\41411 ° -- r)`4 , REFILL YES QUANTITY 30.00 n . 'I L f.41 1 t i_./ (/ f:::/, rr BARTELL DRUGS PRICE= $10.99 `� ,) WITH XPS THE AMOUNT DUE=$6.35 BARTELL DRUGS#45t u'—. ��' j ( /' (425)793-1015 /��/" �` ' _ � F 4700 NE 4TH STREET .- %4) . of J RENTON,WA 98059 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR L REFILLS 24-48 HOURS IN ADVANCE SEND CLAIM TO: City of Renton tire e ''Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98055 CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE ,j0 -0, 3l a9c 6 2) DISABILITY RETIREE'S NAME (print) `J (' h fl L . 17-0-irk„, 3) ADDRESS /335 3 44 v / Y z.d,n itt WyW, yfa3A v 4) DISABILITY AT TIME OF RETIREMENT S7-- Ala 1 (J (./ • Y5 , ii a L 1-i--e-rryr t a -rt X i ety Fro, It-- 71-15� 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Note: Medical coverage is limited to current treatment of the retiree's disability as determined at the time of retirement. (RCW 41.18) Submit only claims that relate to item #4.) f1e.1 / , ; -re -PO --r ,_5 e in 4cI all d 6 nx . eteit b 6) TOTAL AMOUNT OF CLAIM _,,5 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 all claims submitted are related to my disability as determined at the time of my ent from the Renton Fire Department. Signature -k14 • -)..i j Note: Supporting documentation must be attached. Noy `rr00 i'atue at the smiting-Cr ' the srniiine Y��DRUG 4 Winn DRUG 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 1244 15th Ave.,Longview,11,1/4482,2 Ph.(360)423-3360 wuuanc:�am«rmaa�aror�¢o-e«aea,m,gm�ypersmoewnanreae�mrx+nmieacpeK,mm wrwvwcsm�.«r-ea�w.vaamcara� aesm am«na�nea�mm�ntwnn�Pe�een RX#C548153 DR.RICHARDS RX# 525995 DR.RICHARDS ACCEPTED 12/7/05 WM ACCEPTED 12/7/05 WM PARKS, JOHN PARKS, JOHN 111 17 7111111111HIMIll AMBIEN 10MG TABS#### LACTULOSE SOL 10G/15ML QTY#30 NDC#00024-5421-50 WINTH QTY#946 NDC#60432-0037-32 MORT 1 REFILLS UNTIL: 5/6/06 9 REFILLS UNTIL: 8/13/06 PRICE: $115.02 PRICE: $25.37 1IIIIIIIIIIIIIIIIIIIIIIM 111110111111111111110111 RECEIPT RECEIPT vatue at the smiling'C Yatue at the smitinq'0 1244w15th«Aveaa.6=ew,WZ862 emnae,xeanenva(3on6a0423as-3360 124415th«Averd.,mo50-iew,ae'sa+emmypamnaaxa,aetev�(360)ro423os-33so6me0 RX# 548155 DR.RICHARDS RX#C548154 DR.RICHARDS ACCEPTED 12/7/05 WM ACCEPTED 12/7/05 WM PARKS, JOHN PARKS,JOHN MIRTAZAPINE SOLTAB 45MG ALPRAZOLAM 0.5MG TAB QTY#30 NDC#66993-0712-30 QTY#120 NDC#00781-1077-05 GENEV Generic For:REMERON SOLTAB 45MG 1 REFILLS UNTIL: 11/7/06 1 REFILLS UNTIL: 5/6/06 PRICE: $94.01 PRICE: $23.22 1111111111111111011111101111111 111011IIIIIIIInIIIIII MIM RECEIPT RECEIPT Vie46 1