HomeMy WebLinkAbout237805 10/08/14 CITY OF CARMEL, INDIANA VENDOR: 368717
ONE CIVIC SQUARE JOSEPH CLARKE CHECK AMOUNT: $**R***►440.40'
CARMEL, INDIANA 46032 49 CRICKS 48OL CHECK NUMBER: 237805
,oN CHECK DATE: 10/08/14
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 440.40 OTHER EXPENSES
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JAMES BRAINARD, MAYOR
October 6, 2014
Mr. Joseph Clarke
49 Cricket Knoll Lane
Carmel,IN 46033
RE: INVOICE#20142141:1 /D.O.S. 05/02/2014
Dear Mr. Joseph Clarke:
Enclosed you will fmd a reimbursement check in the amount of$ 440.40.
On July 26, 2014 we received your credit card payment for$ 550.50.
On September 9, 2014 we received payment from Cigna. Your health insurance
reprocessed the claim and paid $ 440.40 and$ 110.10 is coinsurance.
If you have any questions,please feel free to contact me at(3 17) 571-2604.
Sincerely,
Michelle Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEvEN A. CouTs HEADQUARTERs
Two Cmc SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
' CARMEL IN 46032-7543
(317) 571 2604 Federal ID#356000972
Patient Name: CLARKE,JOHN
JOHN CLARKE CARMEL FIRE DEPARTMENT
C/O JOSEPH CLARKE 2 CIVIC SQUARE
49 CRICKET KNOLL LANE CARMEL, IN 46032-7543
CARMEL , IN 46033
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 10/06/14 990106861
Ticket# : 20142141:1
Date of Service:-5/2/2014
DETACH HERE
ON JULY 26, 2014 YOU PAID$550.50 AND ON SEPTEMBER 9, 2014 CIGNA PROCESSED YOUR
CLAIM AND PAID$440.40 YOUR `
CO PAY IS $110.10. REFUND $440.40
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE $0000
Pay online at www.govpaynet.com with PLC#7487 Run Number 20142141:1
Online Payment will charge a service fee.
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Date,of Service Description xPatient Name, Charges Date;Y Payment(s) ;
Charges
5/2/2014 *ADVANCED LIFE CLARKE, JOHN $475.00
5/2/2014 *MILEAGE CLARKE, JOHN $75.50
---------------------------------
Charge Total: $550.50
Payments
Paid By: Invoice 05/02/14 $550.50
Paid By: CLARKE, JOHN Credit Card Payment 07/26/14 ($550.50)
Paid By: CIGNA/ 182223 COMMERCIAL INSURANCE 09/09/14 ($440.40)
Paid By: CLARKE, JOHN REFUND 10/06/14 $440.40
BALANCE $0.00
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
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
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
OCA 6 M4
° 20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund