NCC210642_Annual Fee Payment Record_20220315

Action History (UTC-05:00) Eastern Time (US & Canada)
by Workflow 1/29/2022 5:45:30 PM (Workflow Start Event)
Submit by Selkane, Aziza 3/15/2022 3:00:38 PM (2022 Annual Fee Payment Verification for NCC210642-2022)
0 CaroMont Health
• Selkane, Aziza assigned the task to Selkane, Aziza 3/15/2022 3:00 PM
• The task was assigned to DEMLR NCG01 Annual Fee Team. The due date is: March 14, 2022 5:00 PM
1/29/2022 5:45 PM

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Certificate of NCC210642
Coverage (COC) No. * This is passed from the workflow when the invoice is filed.
NC Reference COC NCG01-2021-0642
No. *
Permit Status: Active
Year COC Issued 2021
This field will be hidden.
Check previous years for outstanding fees (years that do not apply will be blank):
2020 Fee Status
2021 Fee Status
Project Name* CaroMont Regional Medical Center- Belmont
Project Address* 1-85 and NC-273, Belmont, NC
Permittee* CaroMont Health, Inc.
County Gaston
Invoice No.* NCC210642-2022
This is passed from the workflow when the invoice is filed.
Annual Fee* $ 100.00
Invoice Date* 2/1/2022
This is passed from the workflow when the invoice is filed.
Invoice Due Date* 3/1/2022
This is passed from the workflow when the invoice is filed.
An automated email reminder is sent to the permittee when the invoice is due. Wait until invoice is 15 days overdue
before proceeding to a Notice of Deficiency.
Days Overdue 14
Wait at least 15 days until proceeding to NOD.
Important: If you change the choice below to Payment NOT RECEIVED, the fee status becomes PAST DUE, and the
permittee will receive a Notice of Deficiency.
Annual Fee Payment • Fee Payment Received or Not Applicable.
Received* Fee Payment NOT RECEIVED.
Date Payment 3/15/2022
Received * Or, if WAIVED or NOT RECEIVED, this is the date that status is recorded.

Method of Payment* electronic
check
other
Check Number* 417759
Fee Status* PAID
Legally Responsible Richard Blackburn
Person (Orig.)
Original Permittee E- [e-mail]
mail *
CONFIRM Permittee [e-mail]
E-mail * Opportunity to modify problem e-mail address or permittee contact info
Original Site Contact [e-mail]
E-mail *
CONFIRM Site [e-mail]
Contact E-mail* Opportunity to correct problem e-mail address or site contact info
Original Billing E-mail [e-mail]
(If available)
CONFIRM Billing E- [e-mail]
mail Opportunity to correct problem e-mail address or billing contact info
Billing Telephone No. 7048342233
Permittee Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow).
Site Contact Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow)
Billing Contact Email [e-mail]
for 30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow).
Project Name for 30- CaroMont Regional Medical Center - Belmont
day Reminder The project name is passed from workflow for the 30-day reminder
Permittee Name for CaroMont Health, Inc.
30-day Reminder The permittee is passed from workflow for the 30-day reminder
County for 30-day Gaston
Reminder The county is passed from workflow for the 30-day reminder
Additional Billing Contact E-mails
Additional E-mail for
CC:
Review Date * 3/15/2022