HomeMy WebLinkAbout230577 03/26/14 ��p�' CITY OF CARMEL, INDIANA VENDOR: 368087
b r ONE CIVIC SQUARE AMINA PIERSON CHECK AMOUNT: $*******402.18*
?� CARMEL, INDIANA 46032 10724 MORRISTOWN COURT CHECK NUMBER: 230577
, _roN, CARMEL IN 46032 CHECK DATE: 03/26/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 402.18 AMBUL REFUND
04
T
CITY OFn EL
F
JAMES BRAINARD, MAYOR
March 24, 2014
Amina Pierson
10724 Morristown Ct
Carmel, IN 46032
RE: INVOICE # 20134877:1 DOS 10/31/2013
Dear Amina Pierson:
Enclosed you will find a refund check for $402.18.
This account was closed on March 7, 2014 when you paid the invoice in full
with check# 1147. State Farm also processed the claim. Duplicate payment received on
March 18, 2014 from State Farm Insurance check# 1 18 732752 J.
If you have any questions, please feel free to contact me at (3)17) 571-2604.
Sincerely,
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
Two CIVIC SQUARE, CARMEL; IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
SOYT ARt
A/R Detail
Type Transaction Adjudication Entered Amount Reference Memo Status
Date Date Date Number
Invoice 10/31/13 10/31/13 11/05/13 $402.18 Posted
Payment 03/07/14 03/07/14 03/07/14 ($402.18) CK 1147 Posted
Payment 03/18/14 03/18/14 03/18/14 ($402.18) CK 1 18 732752 J STATE FARM MUTUPPosted
Credit 03/24/14 03/24/14 03/24/14 $402.18 CK 1147 AMINA PIERSON Posted
StateFarm EXPLANATION OF REVIEW
® This is not a bill
®.
Claim Number: 14-363G-210 Date of Loss: 10-31-2013 Office Name: State Farm Mutual Automobile
Insurance Company
GLZ MPC Office
Patient: Aliya Malcom Provider: Carmel Fire Department
10724 MORRISTOWN CT 2 CIVIC SQ
CARMEL, IN 46032-9339 CARMEL, IN 46032-7543
Claim Handler: Olwen Chapman-Miller Named Insured: PIERSON, DANIEL
Address: P.O. Box 661011 Policy Number: 3235-313-14
Dallas, TX 75266-1011
Phone: (855) 758-7642 Ext: 6305414299
Date Received: 02-27-2014 TIN: 356000972
Jurisdiction: Indiana Payment Number: 118732752J
Bill Reference
Number: NA Zip of Service: 46032-7643
Diagnosis Codes: 959.9- Injury, other and unspecified, unspecified site
CPT/ Submitted Approved
Ln Date of Service POS HCPC MOD/TS Units Amount Amount Reason Codes
1 10-31-2013 11 A0429 1.00 $375.00 $375.00
2 10-31-2013 11 A0425 1.00 $27.18 $27.18
Total Submitted Charges: $402.18
Total Approved Amount: $402.18
Amount Not Payable: $0.00
Deductible: $0.00
CoPay: $0.00
;Aavortionment:i=P_ro-Rata:__ ---,$0.00----
Offset: $0.00
Paid Amount: $402.18
Explanations
Procedure Guide
A0425-Ground mileage, per statute mile
A0429-Ambulance service, basic life support, emergency transport(BLS, emergency)
DATE: 03-10-2014 14-363G-210 Professional
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
c\ IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
MAR z 4 2014
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund