HomeMy WebLinkAbout302106 08/22/16 Q
CITY OF CARMEL, INDIANA VENDOR: 370999
ONE CIVIC SQUARE DHP CHECK AMOUNT: $*******304.23*
CARMEL, INDIANA 46032 TWO PIERCE PLACE#1900 CHECK NUMBER: 302106
ITASCA IL 60143 CHECK DATE: 08/22/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 081016 304.23 OTHER EXPENSES
VOUCHER NO. WARRANT NO.
ALLOWED 20
�P
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
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Board Members
PO#or DEPT.# INVOICE NO. ACCT#!TITLE AMOUNT I hereby certify that the attached invoice(s), or
a��3 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
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Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
�r
CITYIEL
JAMES BRAINARD, 1VIAYOR
August 10, 2016
DHP
TWO PIERCE PLACE
SUITE 1900
ITASCA, IL 60143
RE :OVERPAYMENT Account#20144683 ROBERT MCCLURE
Date of Service 09/23/2014 CASE#2313490
Dear DHP:
Humana sent a payment on 11/04/2014 for$304.23 check#25400.
We also received a check from Nationwide Insurance check#4399781
for$380.29 on 01/06/2015. The overpayment will be refiinded to the patient's
health insurance Humana. Refund check must be written to DHP for$304.23.
If you have any questions,please feel free to contact me at (317) 571-2604.
Sincerely,
�X�
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTINIENr
STEVEN A. COUTS HEADQUARTERS
(`.n-, TKT A((12) ll-- 217 C-71 ')Ann P.- 917 C71 71'1
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032-2584
(317) 5712604 Federal ID#356000972
Patient Name: MCCLURE, ROBERT N
ROBERT MCCLURE CARMEL FIRE DEPARTMENT
5564 CASTOR WAY 2 CIVIC SQUARE
NOBLESVILLE , IN 46062-6957 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 08/10/16 990108226
Ticket# : 20144683:1
Date of Service: 9/23/2014
DETACH HERE
DUPLICATE PAYMENT RECEIVED. NATIONWIDE PAID INVOICE IN FULL. REFUND HUMANA ?'
$304.23 THANK YOU
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20144683:1
Online Payment will charge a service fee.
Date.of.Service-,-.; .Description Patient,Name Charges) Date Payment(s)
Charges
9/23/2014 *BASIC LIFE SUP MCCLURE, ROBERT N $375.00
9/23/2014 *MILEAGE MCCLURE, ROBERT N $5.29
---------------------------------
Charge Total: $380.29
Payments
Paid By: Invoice 09/23/14 $380.29
Paid By: HUMANA CHOICE FIRST COMMERCIAL INSURANCE 11/04/14G� �a ($304.23)
�J
Paid By. MCCLURE, ROBERT N COMMERCIAL IN URANCE 01/06/15 ($380.29)
Paid By: HUMANA CHOICE FIRST REFUND 08/10/16 $304.23
BALANCE $0.00
CARMEL FIRE DEPARTMENT
,D 2 CIVIC SQUARE
-s- CARMEL, IN 46032-2584
Cliff (317) 571 2604 Federal ID#356000972
Patient Name: MCCLURE, ROBERT N
ROBERT MCCLURE CARMEL FIRE DEPARTMENT
5564 CASTOR WAY 2 CIVIC SQUARE
NOBLESVILLE , IN 46062-6957 CARMEL, IN 46032-2584
TO ASSURE PROPER CREDIT, RETURNStatement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 08/10/16 990108226
Ticket# : 20144683:1
Date of Service: 9/23/2014
DETACH HERE
DUPLICATE PAYMENT RECEIVED. NATIONWIDE PAID INVOICE IN FULL. REFUND HUMANA
$304.23 THANK YOU
MAKE CHECKS PAYABLE TO:' CARMEL FIRE DEPARTMENT BALANCE
Pay online at www.govpaynet.com with PLC#7487 Run Number 20144683:1
Online Payment will charge a service fee.
Date of Service Description Patient Name " ` P Charges) Date Payments)
Charges
9/23/2014 *BASIC LIFE SUP MCCLURE, ROBERT N $375.00
9/23/2014 *MILEAGE MCCLURE, ROBERT N $5.29
---------------------------------
Charge Total: $380.29
Payments
Paid By: Invoice 09/23/14 $380.29
Paid By: HUMANA CHOICE FIRST COMMERCIAL INSURANCE 11/04/14G� ($304.23)
Paid By: MCCLURE, ROBERT N COMMERCIAL IN URANCE 01/06/15 ($380.29)
t�e
Paid By. HUMANA CHOICE FIRST REFUND 08/10/16 $304.23
BALANCE $0.00