HomeMy WebLinkAboutFinal Agenda Packet Nee Ner
CITY OF RENTON
FIREMEN'S PENSION BOARD
Regular Meeting
7th Floor-Mayor's Conference Room
Thursday, August 21, 2008
2:00 P.M.
1. CALL TO ORDER
2. APPROVAL OF MINUTES OF JULY 17, 2008
3. CORRESPONDENCE
4. MONTHLY STATEMENT TO JULY 31, 2008
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
July 17, 2008
Denis Law, Mayor
Don Persson, 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 Chairman Denis Law at
2:03 p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were Board
members Denis Law, Don Persson, Ray Barilleaux, and Bruce Phillips. Also in attendance was Jill
Masunago, Finance Department representative and Jason Seth, Acting Board secretary.
MINUTES APPROVAL
MOVED BY BARALLEAUX, SECONDED BY PHILLIPS, THE PENSION BOARD APPROVE
THE MINUTES OF THE JUNE 19, 2008, MEETING. CARRIED.
MONTHLY STATEMENT
The financial report as of June 30, 2008, was reviewed. Total cash/investment balance was
$4,520,458.38.
MONTHLY BILLS AND PENSION PAYMENTS
Jill Masunago pointed out that the 3.9 % Consumer Price Index increase for widows (2), as
previously approved by the Board, has been included in the Pension Payments listing, effective July
1 per RCW 41.16.145.
Ms. Masunago also explained that one of the pensioner's Claim Reimbursement Requests received
this period did not include the patient's name on the receipt, so is being held for proper
documentation.
MOVED BY PHILLIPS, SECONDED BY BARILLEAUX, THE BOARD APPROVE THE
PENSION/MEDICAL PAYMENTS FOR JULY 2008, IN THE TOTAL AMOUNT OF $41,768.24
TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED.
ADJOURNMENT
MOVED BY PHILLIPS, SECONDED BY BARILLEAUX, THE MEETING OF THE FIREMEN'S
PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:07 p.m.
ason Seth
Acting Secretary, Firemen's Pension Board
r
CITY OF RENTON - FIREMEN'S PENSION FUND
CASH & INVESTMENT ACTIVITY REPORT
AS OF JULY 31, 2008
Fireman's Pension Fund Comparison of Cash and Investment Activity
6
■2008 02007 1
5 —
m
0 4 _ _
0
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0 3
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1
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
CURRENT 2008 2008 LAST YEAR 2007 2007
ACTIVITY: MONTH YTD ADJ BUDGET CURR MO ACTUAL ADJ BUDGET
BEGINNING CASH/INV BALANCE $4,609,782.19 $4,694,232.48 $4,203,347 $4,538,254.93 $4,672,241.19 $4,459,523
RECEIPTS:
Fire Insurance Premium Tax 0.00 85,949.42 75,000 0.00 85,061.56 73,000
Investment Interest 1,217.08 103,057.07 200,000 3,015.90 389,226.86 175,000
DISBURSEMENTS:
Fire Pension 41,684.05 304,170.31 552,400 34,695.56 427,011.96 463,500
Fire Pension Medical 84.19 4,863.63 20,000 1,949.18 9,059.17 20,000
Office/Operating Supplies 0.00 0.00 459 0.00 450.00 450
Actuarial/Firemen's Pens 0.00 0.00 0 0.00 7,550.00 12,000
Reimb General/Clerical&Acct 829.00 5,803.00 9,948 686.00 8,226.00 8,226
ENDING CASH/INV BALANCE $4,568,402.03 $4,568,402.03 $3,895,540 $4,503,940.09 $4,694,232.48 $4,203,347
CURRENT PREVIOUS LAST YEAR LAST YEAR I
ACTIVITY: MONTH MONTH CURR MO PREV MO
CASH $717,958.65 $759,338.81 $298,227.82 $332,542.66
INVESTMENTS:
CD's&State Investment Pool 454,767.46 454,767.46 454,767.46 454,767.46
Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84
Treasury Strips&Zero Coupon Bonds 3,206,796.27 3,206,796.27 3,651,388.97 3,651,388.97
INTEREST ACCRUED 89,323.81
TOTAL CASH AND INVESTMENTS $4,568,402.03 $4,520,458.38 $4,503,940.09 $4,538,254.93
The State Investment Pool interest 2.2758% 2.2933% 5.2053% 5.2068%
H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2008.xls\Ju108 Page 1 8/14/2008
Noe .1111
FIREMEN'S PENSION BOARD
PENSION/MEDICAL PAYMENTS FOR AUGUST, 2008
01 f` Recipient . ;.. . . . . . ;Peii i i ArrI't. -M dicats°"iz ..x. o al ,#.
ANKENY, Charlie(Captain) $90.81 90.81
ASHURST, James(Assistant Chief) $4,569.00 - 4,569.00
BANASKY, George(Captain) $1,502.59 1,502.59
BARILLEAUX, Ray(Battalion Chief) - -
BEATTEAY, Karlen (Widow) $192.17 192.17
BERGMAN, Claudette (Widow) $118.24 118.24
CHRISTENSON, Chuck(Firefighter) $523.58 523.58
CONNELL, Robert(Captain) $678.13 678.13
GEISSLER, Dick(Fire Chief) $641.73 641.73
GOODWIN, Charles(Captain) $4,010.50 958.79 4,969.29
GOODWIN, Donald (Firefighter) $1,277.48 1,277.48
HAWORTH, Constance (Widow) $2,792.83 2,792.83
HAWORTH, Jack (Firefighter) $3,025.00 - 3,025.00
HENRY, William, Jr. (Captain) $1,805.36 1,805.36
HURST, Gerald (Firefighter) $488.91 488.91
JONES, Evelyn M. (Widow) $208.91 208.91
LARSON, William (Firefighter) $222.80 222.80
LAVALLEY, Theodele (Captain) $306.38 306.38
MATTHEW, James (Deputy Chief) $193.70 193.70
MC LAUGHLIN, JACK(Battalion Chief) $1,601.18 1,601.18
NEWTON, Gary(Lieutenant) $226.76 226.76
NEWTON, Roger(Firefighter) $231.19 231.19
NICHOLS, Gerald (Battalion Chief) $467.89 467.89
PARKS-ANDREASON, Arlene(Widow) $284.16 284.16
PARKS, John (Firefighter) $3,139.50 94.38 3,233.88
PHILLIPS, Bruce H. (Deputy Chief) $909.45 909.45
PRINGLE, Arthur(Captain) $421.16 421.16
PRINGLE, S. Joan (Widow) $2,399.37 2,399.37
RIGGLE, David E. (Firefighter D Step) $49.58 49.58
RUPPRECHT, Jim (Firefighter D Step) $83.02 83.02
SMITH, Leroy(Firefighter) $363.04 363.04
STROM, Karl (Firefighter) $3,025.00 210.73 3,235.73
TODD, Franklin (Firefighter) $420.32 420.32
TONDA, Lila Jean (Widow) $531.29 531.29
VACCA, Nick(Lieutenant) $265.10 265.10
WALLS, Kenneth (Firefighter D Step) $108.43 108.43
WALLS, Mercedes (Widow) $729.93 729.93
WALSH, David (Firefighter) $1,322.07 1,322.07
WALSH, Patrick(Captain) $902.97 902.97
WEISS, Larry(Battalion Chief) $1,354.42 1,354.42
WILLIAMS, Alta(Widow) - -
WOOTEN, Marilyn E. (Widow)
' . $200.10 . 200.10
%7Z; otaExpew. 'eso /A0ial. _.. .. 71.$4164 5 _ 112.163.9tri 42 479
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Prior Year Pension/Medical Payments:
Total Pension Payments for August, 2007 34,695.56
Total Medical Bills Reimbursed in August, 2007 596.87
Total Expenses: Medical/Pension 35,292.43
4_SUMMARY 2008.XLS 8/14/2008
Aso FIREMEN'S PENSION BOARD __
MEDICAL BILLS TO BE REIMBURSED IN AUGUST, 2008 PAYMENT
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James Ashurst 0.00
2 Charles Goodwin Bartell Drugs 6.35
2 Charles Goodwin Bartell Drugs 6.35
2 Charles Goodwin Bartell Drugs 149.16
2 Charles Goodwin Bartell Drugs 5.40
3 Charles Goodwin Bartell Drugs 14.01
3 Charles Goodwin Bartell Drugs 149.16
3 Charles Goodwin Bartell Drugs 6.88
3 Charles Goodwin Bartell Drugs 72.51
4 Charles Goodwin Bartell Drugs 6.88
4 Charles Goodwin Bartell Drugs 6.35
4 Charles Goodwin Bartell Drugs 149.16
4 Charles Goodwin Bartell Drugs 24.82
5 Charles Goodwin Bartell Drugs 361.76
958.79
Jack Haworth 0.00
7 John Parks Olympic Drug 6.28
7 John Parks Olympic Drug 2.41
7 John Parks Olympic Drug 14.11
7 John Parks Olympic Drug 1.25
7 John Parks Olympic Drug 36.77
7 John Parks Olympic Drug 7.84
7 John Parks Olympic Drug 25.72
94.38
9 Karl Strom Sam's Club 4.41
9 Karl Strom Sam's Club 6.32
9 Karl Strom Sam's Club 3.00
10 Karl Strom Sam's Club 11.00
10 Karl Strom Sam's Club 8.72
12 Karl Strom Sam's Club 6.32
12 Karl Strom Sam's Club 8.72
12 Karl Strom Sam's Club 4.41
13 Karl Strom Sam's Club 8.72
13 Karl Strom Sam's Club 6.32
14 Karl Strom Sam's Club 3.00
14 Karl Strom Sam's Club 4.41
15 Karl Strom Sam's Club 3.00
15 Karl Strom Sam's Club 5.46
16 Karl Strom Sam's Club 7.00
16 Karl Strom Sam's Club 8.72
17 Karl Strom Sam's Club 15.20
18 Karl Strom Department of Veterans Affairs 48.00
19 Karl Strom Department of Veterans Affairs 48.00
210.73
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3_2008 FP Medical.XLS Page 1 of 1 8/14/2008
Nor SENDCLAIMTO: City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
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CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE Oh 4
2) DISABILITY RETIREE'S NAME (print) OW LgS 1fi. O O D ul
3) ADDRESS /4'/' MO4 4406 C� . 4 ‘---Re-,0-604 C - '?2OS4
4) DISABILITY AT TIME OF RETIREMENT 4/6/4/61414; 9t 4
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: $ 7o, -r 7
Amount of total claim (above)that is related to the Retirement Disability: gl 153.3/
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.
Signaturee/70'Y'6
Note: Supporting documentation must be attached.
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RX# 45-381218 E DR. LORCH,GERALD DATE: 05/23/08 N (425)899-3123
DATE: 05/23/08 R (425)251-5110 NAME: CHARLES GOODWIN
NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306
1414 MONROE AVE NE#306
1 AGGRE OX CAP200/25
ALLOPURINOL 100MG TABLET(*PA ' 00597-00 -60 As 84385826
`49884-0602-10) Ss 84850672
REFILL 4 QUANTITY 60.00
REFILL 2 QUANTITY 30.00 BARTELL DRUGS PRICE= $195.99
BARTELL DRUGS PRICE= $10.99 WITH XPS THE AMOUNT DUE 4149.16 ! /
WITH XPS THE AMOUNT DUE 4§....31 O BARTELL DRUGS#45 ('
BARTELL DRUGS#45 /---- (425)793-1015
(425)793-1015 4700 NE 4TH STREET
4700 NE 4TH STREET RENTON,WA 98059
RENTON,WA 98059
THANK YOU
THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
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WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU REFILLS 24-48 HOURS IN ADVANCE
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DATE: 06/18/08 N (425)271-151-15
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DATE: 06/13/08 R (425)251-5110
NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN
1414 MONROE AVE NE#306
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HYDROCOALLOPURINOL 100MG TABLET(*PA 05 1-0349-05 NE/APAP 8 6351232 MG
49884-0602-10 85445966
REFILL 1 QUANTITY REFILL NO QUANTITY 16.00
30.00 BARTELL DRUGS PRICE= $12.09
BARTELL DRUGS PRICE= $10.99
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WITH XPS THE AMOUNT DUE$6.35 / ,-
BARTELL DRUGS#45
BARTELL DRUGS#45 (425)793-1015
(425)793-1015 4700 NE 4TH STREET
4700 NE 4TH STREET RENTON,WA 98059
RENTON,WA 98059
THANK YOU
THANK YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU
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DATE: 06/18/08 N (425)271-1515 NAME: CHARLES G OR (425)251-5110
NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306
1414 MONROE AVE NE#306
CEPHALEXIN 500MG CAPSULE(*LU
00093-0752-10 ATENOLOL 50MG TABLET(*TEVA)
68180-0122-02 86632232 86422883
REFILL REFILL NO QUANTITY 30.00
NO QUANTITY 28.00 BARTELL DRUGS PRICE_
BARTELL DRUGS PRICE= $23.89 )Lf.O ' $13.49
WITH XPS THE AMOUNT DUE-
WITH XPS THE AMOUNT DUE- 14.01 -� g,gg ��
BARTELL DRUGS
BARTELL DRUGS#45 (425)793-1015#45 ��
(425)793-1015 4700 NE 4TH STREET
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RENTON,WA 98059 RENTON,WA 98059
THANK YOU
THANK YOU WE TRULY gppRECIATE YOUR •gUSINESS. TO PROVIDE YOU
WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WITH THE BEST SERVICE
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 POSSIBLE PLEASE ORDER YOUR
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BARTELL DRUGS
RX# Washington's Own�rujatores_...,.��
45-406676 E DR. FLO, GAYLE
1 BARTELL DRUGS DATE: 07/04/08 R (425)251-5110
------washingtodsOwn DingWOrein NAME: CHARLES GOODWIN
45-433333 E DR• GRIFFITH,ALIDA 1414 MONROE AVE NE#306
DATE: 06/26/08 R (425)899-3123
NAME: CHARLES GOODWIN GEM- B•OZIL 600MG TABLET(*TE
0009 067 -05
1414 MONROE AVE NE#306 87696204
AGGRENOX CAP 200/25 REFILL NO QUANTITY 180.00
00597-0001-60 86680337
BARTELL DRUGS PRICE_ $91.78
REFILL 3 QUANTITY 60.00 WITH XPS THE AMOUNT DUE: 72.51 Ta.Si
BARTELL DRUGS PRICE= $195.99 10'1(P
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WITH XPS THE AMOUNT DUE 4149.16 / 4700 NE 4TH STREET
BARTELL DRUGS#45 RENTON,WA 98059
(425)793-1015
4700 NE 4TH STREET THANK YOU
RENTON,WA 98059 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
L REFILLS 24-48 HOURS IN ADVANCE
THANK YOU
WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
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Rxx 45-406696 E DR. FLO, GAYLE DATE: 07/20/08 R (425)899-3123
DATE: 07/12/08 N (425)251-5110 NAME: CHARLES GOODWIN
NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306
1414 MONROE AVE NE#306 AGGRENOX CAP 200/25
ATENOLOL 50MG TABLET(*TEVA) 00597-0001-60 88523061
00093-0752-10 87970736 REFILL 2 QUANTITY 60.00
REFILL 5 QUANTITY 30.00 BARTELL DRUGS PRICE= $195.29
BARTELL DRUGS PRICE= $13.49 (.a/ WITH XPS THE AMOUNT DUE-$149.16 /0
WITH XPS THE AMOUNT DUE 46.88 / BARTELL DRUGS#45(425)793-1015
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BARTELL DRUGS#45 470( 25 4TH9STREET
(425)793-1015 RENTON,WA 98059
4700 NE 4TH STREET
RENTON,WA 98059 THANK YOU
THANK YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU REFILLS 24-48 HOURS IN ADVANCE
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
REFILLS 24-48 HOURS IN ADVANCE
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RX# 45- 381218 E DR. LORCH,GERALD
DATE: 07/25/08 R (425)251-5110 NAME: CHARLES GOODWIN
1414 MONROE AVE NE#306
NAME: CHARLES GOODWIN
1414 MONROE AVE NE#306 AMLODIPINE 5MG TABLET(*LUP)
68180-0751-09
ALLOPURINOL 100MG TABLET(*PA
49884-0602-10 88921456 REFILL 6 QUANTITY 30.00
REFILL NO QUANTITY 30.00 BARTELL DRUGS PRICE= $54.49
BARTELL DRUGS PRICE= $10.99 2 WITH XPS THE AMOUNT DUE: 4J2 a
WITH XPS THE AMOUNT DUE 46.35 �p.3C BARTELL DRUGS#45
(425)793-1015
BARTELL DRUGS#45 / 4700 NE 4TH STREET
(425)793-1015 RENTON,WA 98059
4700 NE 4TH STREET
RENTON,WA 98059 THANK YOU
WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
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DATE: 08/10/08 R (425)899-3123
NAME: CHARLES GOODWIN
1414 MONROE AVE NE#306
CARBIDOPA/LEVODOPA 25MG/100M
00093-0293-01 1407961288709
REFILL 3 QUANTITY 540.00
BARTELL DRUGS PRICE= $388.99 3(0 II
WITH SR THE AMOUNT DUE-$361.76 l/
BARTELL DRUGS#45
(425)793-1015
4700 NE 4TH STREET
RENTON,WA 98059
THANK YOU
WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU
WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR
REFILLS 24-48 HOURS IN ADVANCE
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'Nu■'' SEND CLAIM TO: '''.0' City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton,WA 98057
U4 Y Ott
- N-V° CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE a,V p v 47--2, 4,2 d O6
2) DISABILITY RETIREE'S NAME (print) <fOtlit 1—. F? ,'&
3) ADDRESS 0 3 5 — 3 A V 7ôi i U/Q 1,il We , 3'!q
4) DISABILITY AT TIME OF RETIREMENT Th 4e.Ii yr,,f/
)U ,71 sf e,,S''€
rat"4t_ t-1"-rwi !'ce-rsarr44-1xie P.-14 11"15
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.)
rnie,i; ciiie -Pio1,--- ST-c, itah ,4 A -71, x ) ely Pro iknt5
1 •/ryt-e ms y Pert t o •wt,0 Ti.), a n 4 64-Qx W tt S
6) TOTAL AMOUNT OF CLAIM: $ .9 1,
Amount of total claim (above)that is related to the Retirement Disability: $ ,,, S:)O
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: 4)•,0 e ,,/
,‘
Note: Supp• ing documentation must be attached.
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124415th Ave.,Longview,WA 98632 Ph.(36 SAVE FOR INSURANCE
OR TAX RECORDS —
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Rd C793384 For. JOHN PARKS (-)0) n
7.01-08 CRN:A9085831703891 1335 3RD AVE#109 I...z� LoLONGVIEW,WA 98632 (360) 577-6684 a.*o N
ALPRAZOLAM 0.5MG TAB *** W Z, 44.#60 NDC: 59762.3720.03 W oI
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Value atthe ammo.'0.
'41t0' 1 ' - DRUG RECEIPT
1244 15th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVEFor JOHN PARKS
FOR INSURANCE
Ha OR TAX RECORDS
'i
7-20-08 CRN:A4086023719461 1335 3RD AVE#109
LONGVIEW,WA 98632 1360) 577-6684
PREDNISONE 10MG ***
#28 NDC: 00143-1473-10
DR. KUTELIA,RAJDEN ZHA COPAY: $1.25
11111 1111111111111111111311111111111111100 Price
J
Value atthe smiling'0'
latO ! ' - DRUG RECEIPT
124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
Rab 807735 OR TAX RECORDS
For. JOHN PARKS
7-20.08 CRN:A1086020439561 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577-6684
SPIRIVA HANDIHALER
#30 NDC: 00597-0075-41
DR. KUTELIA,RAJDEN ZHA COPAY: $36.77
11111111111111111111111111111110111111111 Nice
k Value atths RECEIPT
124415th Ave.,Longview WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE
8077362008 OR TAX RECORDS
+Y For JOHN PARKS
Rrz
7 CRN:A0086023720151 1335 3RD AVE#109
LONGVIEW,WA 98632 (360) 577-6684
ALBUTEROL SULF HFA A INH
#8.50 NUC: 59310-0579-20
DR. KUTELIA,RAJDEN ZHA COPAY: $7.84
111111 11100111111111111111111111111111111111111 Price
J
P 1
Now SEND CLAIM TO: ,.r'' City of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton, WA 98057
U4 0
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE — -6 g
2) DISABILITY RETIREE'S NAME (print) AAA!
tti
3) ADDRESS 1 L am¢ t n. `�- / V .,
4) DISABILITY AT TIME OF RETIREMENT
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
Ilan,source or insurance coverage. Supporting documentation for all must be attached.)
^K
_clikviodAreamtimp
6) TOTAL AMOUNT OF CLAIM: $ '' "
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. v
SignatureLP
:
Note: Supporting documentation must be attached.
YDS
)atabase Edition:83.information Expires 08/21/2008
SAM'S CLUB (425)"3-7937 $18.54 SAM'S CLUB(425)793-7937 $18.54
901 SOUTH GRADY WAY 901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000' Pharmacy RENTON,WA 98055-0000
STROM,KARL B 05/05/2008 NEW STROM,KARL B 05/05/2008 NEW
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6678271 Ref#4 QTY:30 DAW: 0 DS:60 RX:6678271 Ref#4 QTY:30 DAW:0 DS:60
NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
83087851 83087851
pi Patient Pay $4.41 ESI Patient Pay $4.41
5 STROM
KARL B
J m 15616 SE 143RD
_r J RENTON,WA 98055
(425)271.8373 4 79312 41149 9
^ • 05/05/2008 (425)793-7937
/+ Y Signature Required N RX:6678271 REF=4 OC#655 923 865 776 592 884 107 659 238
07/23/2008 03:35:17 PM ESI
Page No : 1 of 2 TOTAL: $4.41
Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB sol5)793 3
SOUTH9GRADY WAY $7.32 SAM'S CLUB(42 )793-7937
901SOUTHGRADY WAY $7.32
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 05/03/2008 REFILL STROM,KA L B 05/03/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6669776 Ref#0 QTY:60 DAW:0 DS:30 RX:6669776 Ref#0 QTY:60 DAW:0 DS:30
NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
83688041 83688041
ESI Patient Pay $6.32 ESI Patient Pay $6.32
2 KARLOM B
D m 15616 SE 143RD
RENTON,WA 98055
—I (425)271-8373 4 79312 41145 1
A 05/03/2008 (425)793-7937
1) Y Signature Required N RX:6669776 REF=0 OC#155 923 896 676 592 884 107 659 238
07/23/2008 03:35:33 PM ESI
Page No : 1 TOTAL: $6.32
Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB (425)
01 SOUTH GRAD/WAY $10.78 SAM'S CLUB(425)793-7937 $10.78
901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 05/03/2008 REFILL STROM,KAF;iL B 05/03/2008- REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6672060 Ref#8 QTY:60 DAW:0 DS:30 RX:6672060 Ref#8 QTY:60 DAW:0 DS:30
NDC:00378-0018-01 METOPROLOL 25MG TAB MYL NDC:00378-0018-01 METOPROLOL 25MG TAB MYL
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
83986041 83986041
ESI Patient Pay $3.00 ESI Patient Pay $3.00
r
STROM
D m 15616 SE 143RD
X -1 RENTON,WA 98055
_ CC (425)271-8373 4 79312 41146 8
^ Y 05/03/2008 (425)793-7937
,! L Signature Required N RX:6672060 REF=8 OC#355 923 871 076 592 884 107 659 238
07/23/2008 03:35:44 PM ESI
Page No : 1 of 2 . TOTAL: $3.00
.
17 N-i.e.; 2
Database Edition:83.Information Expires 08/21/2008 *w *are
SAM'S CLUB 901 SOUTH�GRADY WAY 7 $52.62 SAM'S CLUB 901 SOUTH GRADY WAY $52.62
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 05/03/2008 REFILL STROM,KARL B 05/03/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6661062 Ref#P QTY:90 DAW:0 DS:90 RX:6661062 Ref# P QTY:90 DAW:0 DS:90
NDC: 00781-2052-01 TERAZOSIN 2MG CAP SAN NDC:00781-2052-01 TERAZOSIN 2MG CAP SAN
GRAVES,DANIEL NABP:4930613 GRAVES,DANIEL NABP:4930613
83287041 83287041
ESI Patient Pay $11.00 ESI Patient Pay $11.00
STROM
L
5 m 15618 SE 143RD
- J RENTON,WA 98055
•
pC (425)271-8373 4 79312 41147 5
'^ Q 05/03/2008 (425)793-7937
++ Y Signature Required N RX:6661062 REF#P OC#055 923 411 076 592 884107 659 238
07/23/2008 03:35:56 PM ESI
Page No : 1 TOTAL: $11.00
Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB (425)793-7937 $9.72 SAM'S CLUB(425)793-7937 $9.72
901 SOUTH GRADY WAY 901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 05/03/2008 REFILL STROM,KARL B 05/03/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6673783 Ref#0 QTY:90 DAW:0 DS:30 RX:6673783 Ref#0 QTY:90 DAW:0 DS:30
NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL
MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613
83748041 83748041
ESI Patient Pay $8,72 ESI Patient Pay $8;,72
i
KARLOM B III III 1 11111 1 11
0 CO 15616 SE 143RD
RENTON,WA 98055
(425)271-8373 4 79312 41148 2
r^ Q 05/03/2008 (425)793-7937
V/ Y Signature Required N RX:6673783 REF=0 OC#755 923 833 676 592 884107 659 238
07/23/2008 03:36:08 PM ESI
Page No : 1 of 2 TOTAL: $8.72
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`4w00 SEND CLAIM TO: 'ill.' of Renton
Finance Dept.-Fire Pension
1055 South Grady Way
Renton,WA 98057
4cY 0
Y
CITY OF RENTON
FIREMEN'S PENSION BOARD
Pharmacy/Medical Claim Reimbursement Request
1) DATE
2) DISABILITY RETIREE'S NAME (print) /2-( � •I'lkd'41
3) ADDRESS __P ( L�— iQ J � � '7' C7&-4`e--) 47:87
4) DISABILITY AT TIME OF RETIREMENT
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.)
(1,a-c-g-x-rj (t-s—
S4-/Ks-
Sm/9-Aii 'FA
s 30 9a
S',4)-,l u �
6) TOTAL AMOUNT OF CLAIM: $ I 7-7
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.
011.7)
Signature: I
Note: Supporting documentation must be attached.
PCU
Database Edition:83.Information Expires 08/21/2008
411111011, ,fthe
SAM'S CLUB (42 SOUTH GRADY WAY $7.32 SAM'S CLUB(425)793-7937
$7.32
901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 03/31/2008 REFILL STROM,KAI L B 03/31/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6669776 Ref#0 QTY:60 DAW:0 DS:30 RX:6669776 Ref#0 QTY:60 DAW:0 DS:30
NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
81551073 81551073
ESI Patient Pay $6,32 ESI Patient Pay $6.32
KAR OB
D m 15616 SE 143RD
RENTON,WA 98055
- J Er (425)271-8373 4 79312 33318 0
'^ 03/31/2008 (425)793-7937
/! Y• Signature Required N RX:6669776 REF=0 OC#155 923 896 676 592 884 107 659 238
07/23/2008 03:33:54 PM ESI
Page No : 1 TOTAL: $6.32
Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB )793-7937
901 SOUTH GRADY WAY $9.72 SAM'S CLUB 901 SOUTH GRADY WAY $9.72
Pharmac RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 03/31/2008 REFILL STROM,KARL B 03/31/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6673783 Ref#0 QTY:90 DAW:0 DS:30 RX:6673783 Ref#0 QTY:90 DAW:0 DS:30
NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL
MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613
81519073 81519073
ESI Patient Pay $8,72 ESI Patient Pay $8.72
KTOM
ARL B
D m 15616 SE 143RD
J RENTON,WA 98055
(425)271-8373 4 79312 33319 7
^ 03/31/2008 (425)793-7937
n Y• Signature Required N RX:6673783 REF=0 OC#755 923 833 676 592 884 107 659 238
07/23/2008 03:34:09 PM ESI
Page No : 1 of 2 TOTAL: $8.72
)atabase Edition:83.Information Expires 08/21/2008
SAM'S CLUB (425)793-7937 $38.46 SAM'S CLUB(425)793-7937 $38.46
901 SOUTH GRADY WAY 901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 03/31/2008 REFILL STROM,KARL B 03/31/2008. REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX: 6670338 Ref#0 QTY:30 DAW:0 DS:30 RX:6670338 Ref#0 QTY:30 DAW:0 DS:30
NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
81567073 81567073
ESI Patient Pay $4.41 ESI Patient Pay $4.41
57 STROM
D m 15616 SE 143RD
J RENTON,WA 98055
E
(425)271-8373 4 79312 33320 3
03/31/2008 (425)793-7937
Y• Signature Required N RX:6670338 REF=0 OC#655 923 865 776 592 884 107 659 238
07/23/2008 03:34:22 PM ESI
Page No : 1 of 2 TOTAL: $4.41
PACE 1,
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Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB 901)SOUT-7937 H GRADY WAY $9'72 SAM'S CLUB 9015SOUTH GRADY WAY)793-7937 $9.72
Pharmacy RENTON,WA.98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/17/2008 REFILL STROM,KARL B 06/17/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6673783 Ref#0 QTY:90 DAW:0 DS:30 RX:6673783 Ref#0 QTY:90 DAW:0 DS:30
NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL
MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613
86521159 86521159
ESI Patient Pay $8.72 ESI Patient Pay $0.72
i
KARLOM B 111 11 I I 11111111
O m 15616 SE 143RD
• J RENTON,WA 98055
(425)271-8373(425)793-7937 4 79312 51210 3
Q 06/17/2008
N Y Signature Required N RX:6673783 REF=0 OC#755 923 833 676 592 884 107 659 238
07/23/2008 03:30:55 PM ESI
Page No : 1 of 2 TOTAL: $8.72
Database Edition:83.Information Expires 08/21/2008
SAM'S CLUB 901 SOUTH GRADY WAY)793-7937 $7.32 SAM'S CLUB 901 SOUTH GRADY WAY)793-7937 $7.32
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/17/2008 REFILL STROM,KARL B 06/17/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6669776 Ref#0 QTY:60 DAW:0 DS:30 RX:6669776 Ref#0 QTY: 60 DAW:0 - DS:30
NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN NDC:00591-5543-01 ALLOPURINOL 100MG TAB DAN
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
86920159 86920159
ESI Patient Pay $6.32 ESI Patient Pay $6.32
STROM
KARL
D m 15616 SE 143RD
RENTON,WA 98055
x u- (425)271-8373 4 79312 51208 0
,^ a 06/17/2008 (425)793-7937
J/ Signature Required N RX:6669776 REF=0 OC#155 923 896 676 592 884 107 659 238
07/23/2008 03:31:07 PM ESI
Page No : 1 TOTAL: $6.32
PkW 3
Database Edition:83.Information Expires 08/21/2008 C
SAM'S CLUB 5)793-7937
901 SOUTH RADY WAY $10.78 SAM'S CLUB(25SOTH RADY WAY $10.78
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/17/2008 REFILL STROM,KARL B 06/17/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6672060 Ref#8 QTY:60 DAW:0 DS:30 RX:6672060 Ref#8 QTY:60 DAW:0 DS:30
NDC:00378-0018-01 METOPROLOL 25MG TAB MYL NDC:00378-0018-01 METOPROLOL 25MG TAB MYL
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
86221159 86221159
ESI Patient Pay $3.00 ESI Patient Pay $3.00
D STRM
KARLB
m 15616 SE 143RD
X J RENTON,WA 98055
CC (425)271-8373 4 79312 51209 7
Y 06/17/2008 (425)793-7937
4 Signature Required N RX:6672060 REF=8 OC#355 923 871 076 592 884107 659 238
07/23/2008 03:32:13 PM ESI
Page No : 1 of 2 TOTAL: $3.00
•
)atabase Edition:83.Information Expires 08/21/2008
SAM'S CLUB 9015S0 T-H9GRADYWAY $18.54 SAM'S CLUB(425S793-H7937
GRADY WAY $18.54
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/17/2008 REFILL STROM,KA L B 06/17/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6678271 Ref#4 QTY:30 DAW:0 DS:60 RX:6678271 Ref#4 QTY:30 DAW:0 DS:60
NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV NDC:00093-7153-98 SIMVASTATIN 10MG TAB TEV
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
86222159 86222159
ESI Patient Pay $4.41 ESI Patient Pay $4.41
?` STROM III II I 1 1111111111
m 15616 SE 143RD
RENTON,WA 98055
r CC (425)271-8373 4 79312 51211 0
^ 06/17/2008 (425)793-7937
/+ Y Signature Required N RX:6678271 REF=4 OC#655 923 865 776 592 884107 659 238
07/23/2008 03:32:31 PM ESI
Page No : 1 of 2 TOTAL: $4.41
i , .
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SAM'S CLUB (425)793-7937 Meow $10.72 SAM'S CLUB(425)793141110 $10.72
901 SOUTH GRADY WAY 901 SOUTH GRADY WAY
Pharmacy RENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KARL B 06/26/2008 NEW STROM,KARL B 06/26/2008 NEW
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6682146 Ref#P QTY:30 DAW:0 DS:30 RX:6682146 Ref#P QTY:30 DAW:0 DS: 30
NDC:00378-1809-01 LEVOTHYROXIN 100MCG TAB MYL NDC:00378-1809-01 LEVOTHYROXIN 100MCG TAB MYL
GRAVES,DANIEL NABP:4930613 GRAVES,DANIEL NABP:4930613
86312487 86312487
ESI Patient Pay $3.00 ESI Patient Pay $3.00
SKAAR oB a0.
J m 15616 SE 143RD
E J RENTON,WA 98055
_
CC (425)271-8373 4 79312 53533 1
A 06/26/2008 (425)793-7937 >
,+ Y Signature Required N RX:6682146 REF#P OC#355 923 871 076 592 884 107 659 238 •L
06/26/2008 06:33:43 PM ESI G
Page No : 1 of 2 TOTAL: $3.00 a
SAM'S CLUB 9401 SOUTH GRADY WAY $6•46 SAM'S CLUB 9011 SOUTH GRADY WAY $6.46
PharmacyRENTON,WA 98055-0000 Pharmacy RENTON,WA 98055-0000
STROM,KRL B 06/28/2008 NEW STROM,KARL B 06/28/2008 NEW
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6682262 Ref#0 QTY:30 DAW:0 DS:30 RX:6682262 Ref#0 QTY:30 DAW:0 DS:30
NDC:00517-0130-05 CYANOCOBALAM 1000MCGINJ AME NDC:00517-0130-05 CYANOCOBALAM 1000MCGINJ AME
YU,YAHUA NABP:4930613 YU,YAHUA NABP:4930613
86260185 86260185
ESI Patient Pay $5.46 ESI Patient Pay $5.46
STROMP.
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^ 06/28/2008 (425)793-7937 ,
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Y Signature Required N RX:6682262 REF=0 OC#755 923 855 376 592 884 107 659 238 •6.
06/28/2008 02:29:56 PM ESI
Page No : 1 TOTAL: $5.46 a.
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SAM'S CLUB 901 SOUTH GRADY WAY 425)793-7937 $13.78 SAM'S CLUB 901 SOUTH GRADY WAY(425)793-7937 $13.78
P QNfK RL BENTON,WA 98055-0000 07/15/2008 NEW SPT upk RENTON,WA 98055-0000
15616 SE 143RD RENTON,WA 98055 15616 SSE 143RD REO ,WA 980557/15/2008 NEW
RX:6683461 Ref#5 QTY:60 DAW:0 DS:30 RX:6683461 Ref#5 QTY:60 DAW:0 DS:30
NDC:54458-0976-07 ALLOPURINOL 100MG TAB INT NDC:54458-0976-07 ALLOPURINOL 100MG TAB INT
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
87674388 87674388
ESI Patient Pay $7.00 ESI Patient Pay $7.00
,
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M+ J RENTON,WA 98055II C
CC CC 07/15!2008 ((425)271.8373 4 79312 57788 1
425)793-7937 >
1/,
Signature Required N RX:6683461 REF=5 OC#455 923 821 076 592 884 107 659 238 •C
07/15/2008 01:21:30 PM ESI G
Page No : 1 TOTAL: $7.00 d
Database Edition:83.Information Expires 08/21/2008
(42425)
-7937
SAM'S CLUB
9015 SOUTH GRADY WAY)793-7937 $9.72 SAM'SS CLUBt � 901 SOUTH GRADY WAY $9.72
P,1 FfOIVf,kARL BRENTON,WA 98055-0000 07/15/2008 NEW Show BENTON,WA 98055-0000 07/15/2008 NEW
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:6683460 Ref#3 QTY:90 DAW:0 DS:30 RX:6683460 Ref#3 QTY:90 DAW:0 DS:30
NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL NDC:00378-0232-01 FUROSEMIDE 80MG TAB MYL
MARTIN,MICHAEL M NABP:4930613 MARTIN,MICHAEL M NABP:4930613
87658298 87658298
ESI Patient Pay $8.72 ESI Patient Pay $8.72
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RENTON,WA 98055I C
(425)271-8373 4 79312 57664 8 5../^ Y 07/15/2008 (425)793-7937
It
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07/15/2008 01:21:18 PM ESI
Page No : 1 of 2 TOTAL: $8.72 a
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SAM'S 13� LU�!B )793-7937
9015SOUTH GRADY WAY $19.84
SAM'S CLUB )793-7937
9021 SOUTH GRADY WAY $19.84
PSTROM,KARL BRENTON,WA 98055 �� 07/17/2008 REFILL STROM KARL BRENTON,WA 98055-0000 07/17/2008 REFILL
15616 SE 143RD RENTON,WA 98055 15616 SE 143RD RENTON,WA 98055
RX:4411869 Ref#0 QTY:90 DAW:0 DS:30 RX:4411869 Ref#0 QTY:90 DAW:0 DS:30
NDC:00406-0357-05 HYDROCO/APAP5-500MG TAB MAL NDC:00406-0357-05 HYDROCO/APAP5-500MG TAB MAL
BROCKENBROUGH,ANDREW T NABP:4930613 BROCKENBROUGH,ANDREW T NABP:4930613
87294698 87294698
ESI Patient Pay $1.5,20. ESI Patient Pay $15,20
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Y Signature Required N RX:4411869 REF=0 OC#655 923 457 076 592 384 107 659 238 '0
07/17/2008 04:50:23 PM ESI •2
Page No : 1 of 2 TOTAL: $15.20 a
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aDepartment of Veterans Affairs
E60 L COAO98I0N WAY
WA 98108-1532 STATEMENT OF MEDICAL CARE COST RECOVERY ACCOUNT ACTIVITY
SEATTLE
NAME OF FACILITY
AGENT CASHIER (136MCCR) VA PUGET SOUND HEALTH CARE SYSTEM (663)
FOR QUESTIONS ABOUT YOUR ACCOUNT, PLEASE PHONE THE
BELOW NO. 1-866-290-4618
For written inquiries concerning your account please send them
093276 - 032408 to the MCCR or Revenue Office at the facility address above.
KARL B STROM JR Payments received after 03/20/2008 will be on
201 UNION AVE SE UNIT 142 your next statement.
RENTON WA 98059-5177
11.10
CALL WITH YOUR HEALTH INSURANCE INFORMATION
'tient Name: KARL B STROM JR Account No: 663-000000-7237347-STROM Stmt Date: 03/24/2008
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i)ts�A�.:tE�11f::P4JS.:�p..::::.:::::::.::::.:::::::::::..:::.:::.:.:::::::..:...::::..::prra�f�l..:.:.(3i�k. : :.:.:.:...:.:..:.:.:.::::.::::... ... .:: .. ;
02/19/2008 OVERPAYMENT REFUND 24.00- 663-K8023NY
02/25/2008 COPAY RX:4245408A FD:02/23/2008 24.00 663-K8033QK
DRUG:AMIODARONE HCL (PACERONE) 200MG TAB
DAYS:90 QTY:90 PHY:WICHER,JOHN B CHG:$24.00
03/18/2008 COPAY RX:4793341 FD:03/14/2008 24.00 663-K8033QK
DRUG:INSULIN REG HUMAN 100 UNIT/ML NOVOLIN R
DAYS:90 QTY:9 PHY:WICHER,JOHN B CHG:$24.00
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MDepartment of Veterans Affairs
E60 L COAO98I08 WAY
WA 98108-1532 STATEMENT OF MEDICAL CARE COST RECOVERY ACCOUNT ACTIVITY
SEATTLE
NAME OF FACILITY
AGENT CASHIER (136MCCR) VA PUGET SOUND HEALTH CARE SYSTEM (663)
FOR QUESTIONS ABOUT YOUR ACCOUNT, PLEASE PHONE THE
BELOW NO. 1-866-290-4618
For written inquiries concerning your account please send them
0 9 4 7 3 4 - 052408 to the MCCR or Revenue Office at the facility address above.
KARL B STROM JR Payments received after 05/20/2008 will be on
201 UNION AVE SE UNIT 142. your next statement. IMMIOMMI
RENTON WA 98059-5177 —
CALL WITH YOUR HEALTH INSURANCE INFORMATION
tient Name: KARL B STROM JR Account No: 663-000000-7237347-STROM Stmt Date: 05/24/2008
.. .. ..:...:....,.............................................. . #�;t_ ;:.;;:.;:.;:.;:.>:.;;;:.>;:.;:.::,::::.:.�:::::.::::::::;:.:::::.:::..:::.:;:.;:.,>::>:::;.>ll@.9t�UnFF'...............81LL►N�.:;�it"FMF3.... .....
03/25/2008 RX CO-PAYMENT/NSC VET 24.00- 663-K8033QK
04/04/2008 PAYMENT (04/03/2008) 24.00- 663-K8033QK •
05/02/2008 COPAY RX:1603848I FD:04/29/2008 24.00 663-K804PJD
DRUG:INSULIN NPH HUMAN 100 UNIT/ML NOVOLIN N
DAYS:90 QTY:6 PHY:WICHER,JOHN B CHG:$24.00
05/20/2008 COPAY RX:4245408A FD:05/23/2008 24.00 663-K804PJD
DRUG:AMIODARONE HCL (PACERONE) 200MG TAB
DAYS:90 QTY:90 PHY:WICHER,JOHN B CHG:$24.00
( ted
ov' 144
SUMMARY OF
MONTHLY ACTIVITY
48.00 48.00- 48.00 48.00
PLEASE DETACH THIS COUPON BELOW AND RETURN WITH PAYMENT. DO NOT INCLUDE ANY CORRES'v •. • "ITH PAYMENT.
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