The URL can be used to link to this page

Home My WebLink About304049 10/10/16 CITY OF CARMEL, INDIANA VENDOR: 367222 ONE CIVIC SQUARE IU HEALTH WORKPLACE SERVICES LLCCHECK AMOUNT: $....48,543.96* r. /g CARMEL, INDIANA 46032 2046 RELIABLE PKWY CHECK NUMBER: 304049 9y�TON�. CHICAGO IL 60686-0020 CHECK DATE: 10/10/16 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER -AMOUNT DESCRIPTION 301 5023990 082416 665.54 OTHER EXPENSES 301 5023990 752169 4,374.16 OTHER EXPENSES 301 5023990 752200 36,078.22 OTHER EXPENSES 1201 4358800 752310 754.00 TESTING FEES 1205 4347500 752606 729.60 GENERAL INSURANCE 301 5023990 752674 4,992.75 OTHER EXPENSES 301 5023990 752684 949.69 OTHER EXPENSES VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) IU HEALTH WORKPLACE SERVICES LLC ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 2046 RELIABLE PKWY IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service CHICAGO, IL 60686-0020 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $46,394.82 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# 301 Medical Fund Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 752200 50-239.90 $36,078.22 1 hereby certify that the attached invoice(s),or 9/30/16 752674 Sept Onsite Misc $4,992.75 301 301 301 301 752169 50-239.90 $4,374.16 bill(s)is(are)true and correct and that the 9/30/16.. 752684 Sept Supply $949.69 301 301 materials or services itemized thereon for 301 301 752674 50-239.90 $4,992.75 9/30/16 752169 Sept Onsite Fees $4,374.16 301 301 which charge is made were ordered and 301 301 752684 50-239.90 $949.69 received except 9/30/16 752200 Sept Onsite Staff Time $36,078.22 301 301 301 301 Tuesday, October 04,2016 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- -1.6 ,20- Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer Indiana University Health Workplace Services,LLC 950 North Meridian Street Suite 950 (City of Carmel) Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice September 30, 2016 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel-Onsite Staff Time/Sept.2016 1 Civic Square Carmel,IN 46032- Invoice# 752200 Service Date Description Quanti Charge Recei Aft-sl Balance 09/01/2016 MD Staff Time 4.00 700.00 700.00 Dr.Fagan 09/01/2016 Health Coach Staff Time 4.50 288.00 288.00 Marissa Grant 09/01/2016 R.N.Staff Time 3.75 232.50 232.50 Mareesa Martin 09/01/2016 M.A.Staff Time 4.00 112.00 112.00 Kimberly Pride 09/02/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan 09/02/2016 Health Coach Staff Time 3.50 224.00 224.00 Marissa Grant 09/02/2016 R.N.Staff Time 4.00 248.00 248.00 Mareesa Martin 09/02/2016 M.A.Staff Time 4.50 126.00 126.00 Kimberly Pride 09/06/2016 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan 09/06/2016 M.A.Staff Time 6.50 182.00 182.00 Kimberly Pride 09/06/2016 R.N.Staff Time 7.00 434.00 434.00 Mareesa Martin 09/07/2016 M.A.Staff Time 9.50 266.00 266.00 Kimberly Pride 09/07/2016 N.P.Staff Time 8.50 957.78 957.78 Tina Nitsos 09/07/2016 R.N.Staff Time 9.25 573.50 573.50 Mareesa Martin 09/08/2016 MD Staff Time 4.00 700.00 700.00 Dr.Fagan 09/08/2016 M.A.Staff Time 4.00 112.00 112.00 Jasmine Oliver FOCTSUblmnitted To 0 4 2016 Clerk `treasurer Invoice# 752200(continued)page 2 Service Date DescriptionQuant! Charae Receip Adiusl Balance 09/08/2016 Health Coach Staff Time 4.50 288.00 288.00 -Marissa Grant 09/08/2016 R.N.Staff Time 5.25 325.50 325.50 Mareesa Martin 09/09/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan 09/09/2016 M.A.Staff Time 5.00 140.00 140.00 Aesha Zavala 09/09/2016 Health Coach Staff Time 4.50 288.00 288.00 Marissa Grant 09/09/2016 R.N.Staff Time 6.25 387.50 387.50 Mareesa Martin 09/12/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan 09/12/2016 N.P.Staff Time 6.00 676.08 676.08 Tina Nitsos 09/12/2016 Health Coach Staff Time 3.00 192.00 192.00 Marissa Grant 09/12/2016 R.N.Staff Time 9.25 573.50 573.50 Mareesa Martin 09/12/2016 M.A.Staff Time 8.00 224.00 224.00 Rita Boyles 09/13/2016 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan 09/13/2016 M.A.Staff Time 6.50 182.00 182.00 Kimberly Pride 09/13/2016 R.N.Staff Time 7.00 434.00 434.00 Mareesa Martin 09/14/2016 M.A.Staff Time 9.50 266.00 266.00 Kimberly Pride 09/14/2016 N.P.Staff Time 8.00 901.44 901.44 Tina Nitsos 09/14/2016 R.N.Staff Time 9.50 589.00 589.00 Mareesa Martin 09/15/2016 MD Staff Time 4.00 700.00 700.00 Dr.Fagan 09/15/2016 M.A.Staff Time 4.50 126.00 126.00 Kimberly Pride 09/15/2016 Health Coach Staff Time 6.50 416.00 416.00 Marissa Grant 09/15/2016 R.N.Staff Time 5.75 356.50 356.50 Mareesa Martin 09/16/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan 09/16/2016 M.A.Staff Time 6.50 182.00 182.00 Kimberly Pride 09/16/2016 Health Coach Staff Time 3.50 .224.00 224.00 Marissa Grant Invoice# 752200(continued)page 3 Service Date DescriptionQuant! Charae Recei Ad"Us Balance 09/16/2016 R.N.Staff Time 6.75 418.50 418.50 Mareesa Martin 09/19/2016 M.A.Staff Time 9.25 259.00 259.00 Kimberly Pride 09/19/2016 R.N.Staff Time 9.25 573.50 573.50 Mareesa Martin 09/19/2016 N.P.Staff Time 4.50 507.06 507.06 Tina Nitsos 09/19/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan 09/19/2016 Health Coach Staff Time 3.00 192.00 192.00 Marissa Grant 09/20/2016 M.A.Staff Time 7.00 196.00 196.00 Kimberly Pride 09/20/2016 R.N.Staff Time 7.00 434.00 434.00 Mareesa Martin 09/20/2016 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan 09/21/2016 M.A.Staff Time 9.25 259.00 259.00 Kimberly Pride 09/21/2016 R.N.Staff Time 9.25 573.50_ 573.50 Mareesa Martin 09/21/2016 N.P.Staff Time 8.00 901.44 901.44 Tina Nitsos 09/22/2016 M.A.Staff Time 4.50 126.00 126.00 Kimberly Pride 09/22/2016 R.N.Staff Time 5.00 310.00 310.00 Mareesa Martin 09/22/2016 MD Staff Time 4.00 700.00 700.00 Dr.Fagan 09/22/2016 Health Coach Staff Time 5.00 320.00 320.00 Marissa Grant 09/23/2016 M.A.Staff Time 5.50 154.00 154.00 Kimberly Pride 09/23/2016 R.N.Staff Time 5.25 325.50 325.50 Mareesa Martin 09/23/2016 N.P.Staff Time 6.00 676.08 676.08 Tina Nitsos 09/23/2016 Health Coach Staff Time 4.00 256.00 256.00 Marissa Grant 09/26/2016 M.A.Staff Time 9.25 259.00 259.00 Kimberly Pride 09/26/2016 R.N.Staff Time 9.25 573.50 573.50 Mareesa Martin 09/26/2016 N.P.Staff Time 4.50 507.06 507.06 Tina Nitsos 09/26/2016 MD Staff Time 5.00 875.00 875.00 Dr.Fagan Invoice# :752200(continued)-page 4 Service Date Description Quantily Charge. Receip Agus Balance 09/26/20.16 . . Health"Coach.Staff Time, 3.00: 192.00 192.00, Marissa"Grant 09/27/2016 . M.A..StaffTime: 7:00 196.00 196.00. Kimberly Pride. . . 09/27/20.16 R.N:Staff Time 7.00 434.00 .' . ' 434.00. Mareesa Martin. 09/27/2016 MD Staff:Ti'me. 6.00. 1,050.00 1050.00. Dr.:Fagan . 09/28/2016 . M.A.Staff Time 9:25 259.00 259.00 Kimberly Pride. 09/28/2016 '.R.N.Staff Time 9.25. 573.50 573.50. Mareesa Martin 09/28/20.16 N.P.Staff Time 8.50: .957.78 957.78" . Tina Nitsos. 09/29/2016 M.A.Staff Time4:50 126.00 126.00 Kimberly Pride 09/29/2016• R.N.Staff Time 5.00 310.00 3.10.00" . Mai eesa Martin. 09/29/2016 9/29/20 6 MD Staff.Time 4.00 .700.00 700 00 . Dr.Fagan" 09/29/2016 . " Health:Coach Staff Time: . 6:00 384.00 384.00: Marissa Grant 09/30/2016 M.A.-Staff Time 5.25. '. : " 147.00 . . 147.00. " Kimberly Pride . 0.9/30/20.16 . ' : R.N..StaffTime 5.25. 325.50 325.50. . Mareesa Martin .09/30/2016 : MD Staff Time . 5.00 875.00 875.00: " Dr.Fagan CITYCARO Invoice# 752200 Balance Due: : 36078.22 MAKE PAYMENT TO THE BELOW.ADDRESS WITHIN.30 DAYS OF INVOICE.DATE_PLEASE INCLUDE INVOICE#ON CHECK --Cut and return withpayment . - .. - .. - - . it Make Check e � Please rem' 36,078:22 and Payable to: 0 VISA INVOICE# 752200 Health Workplace•Services;LLC. 0 MASTERCARD 2046 Reliable Pkwy. Chicago,IL 60686-0020 ACCOUNT NO EXP. . CODE. HATE Phone: 317=963-1535 .SIGNATURES. AMOUNT"PAID - . Indiana University Health Workplace Services,,LLC 950 North Meridian Street Suite:950 Indianapolis,.IN 46204 .31.7-9637-1535. Tax ID.# 20.- 0994452 . ..'• Invoice.' September 30,2016 Bill to: Barbara Lamb For: . .City.of Carmel Onsite City of Carmel Onsite Onsite Fee's/Sept.2016 1 Civic Square' Cannel,IN 46032- - Invoice#: •752169 Service'Date Description QuantitV. Charge', "Receipt -Ad"us Balance 09/01/2016 . City.of Carmel Sports Performance ' 1.00:' 1,800.00. '1800.00 " Lease 09/01/2016' City.of Carmel"Clinic Build Out 1.00 2,574:16 2574.16 " CITYCARO' Invoice# 752169 Balance Due:: . 4374.16 MAKE PAYMENT TO THE BELOW'ADDRESS."WITHIN,30 DAYS OF_INVOICE DATE•-PLEASE INCLUDE INVOICE#ON CHECK Subalitted To OCT 04 2016 wk i rasu9"e r . Cut and return with payment Please remit 4,374:16 and Make Check Payable;to: VISAINVOICE#_752169 IU.Health Workplace Services,LLC.' Q MASTERCARD 2046 Reliable Pkwy: " Chicago,IL 60686-0020 ACCOUNT No Csv. EZP" : Phone:. 317-963-1535 . - CODE . .. DATE SIGNATURE. AMOUNTPAID. - " 'Indiana University Health Workplace Services,LLC '950 North Meridian Street• . Suite 950'(City of Carmel). � Indianapolis,:IN 46204: .?� '31:7;-963.- 1535. . " Tax ID•# 20-0994452 . .. . Invoice September 30,2016. Bill to:: Barbara Lamb For: City ofCarmel'-.Onsite Ci of Carmel Onsite Misc.Onsit ty e/Sept.2016 1 Civic Square Carmel,IN 46032- Inv'ice#752674 Service'Date Description uan i , Charge Recei Aldus 'Balance. 08/01/2016 : Onsite Lab Charges 1.00: • 3,653:42 3653.42 " August'2016Labs. 09/06/2016 . Young at Heart Clinic Meds1:00, 1,189:40 :1189.40 09/07/2016 Young at Heart Clinic Meds: . 1.0.0: ' 149.93 . .149.93 CITYCARO Invoice#. 752674 Balance Due: 4992.75 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS.OF INVOICE DATE'-PLEASE,INCLUDE INVOICE#ON CHECK Submitted T6 0CT:64.20:16 . • Clerk Treasurer' Cut and return with payment Pleaseremit 4,992'5.an&Make Check Payable to: El VISAINVOICE#752674 IU Health Workplace Services;LLC 0 MASTERCARD 2046 Reliable Pkwy- Chicago,IL 606.86.0020. . . ACCOUNT NO CSV a ERP CODE DATE Phone: 317=963-1535 . SIGNATURE AMOUNTPAID.. . . . ersi Health Workplace Servic 1 Iridiana Univ tY HeaI es, LLC 3?. 950 North Meridian.Street . Suite 950 (City of Carmel) Indianapolis,:IN 46204' . • -31.7-96371535. 963-1535. . Tax[D.# 20.0994452 . •. Invoice September 30, 2016 Bill.to:: Barbara Lamb. . For: City of Carmel'-.Onsite City of Carmel-Onsite Supply Billing"/Sept.2016. I Civic Square Carmel,IN 46032- Invoice#: 752684 ServiceDate Description. ua i Charge Recei Ad'us . Balance 09/01/2016 Onsite,Operating Supplies : . 1.00. 949.69 949:69 September 2016.Supplies .,CITY CARO Invoice# 752684 Balance Due: 949:69 MAKE PAYMENT TO THE BELOW ADDRESS.WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE.#ON CHECK d To OCT 0.4 20.16. clerk T rarer VOUCHER NO. WARRANT NO. Prescribed by State Board of-Accounts City Form No.201(Rev.1995) ILl HEALTH WORKPLACE SERVICES LLC ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 2046 RELIABLE PKWY IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service CHICAGO, IL 60686-0020 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $729.60 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# General Administration Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 752606 43-475.00 $729.60 1 hereby certify that the attached invoice(s),or 9/30/16 752606 $729.60 1205 101 1205 101 bill(s)is(are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Tuesday,October 04,2016 I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 20 Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer L Indiari,a University Health Workplace Services,.LLC � . . . � . .. '950 North Meridian Street. .- Suite 950 (City of Carmel),. Indianapolis,:IN 46204 . 31:7=963-1535. .: - • .• Tax I,D.# •20.0994452 .•..' .. In .voice. Se0tember30, 2016. Bill.'to:: Barbara Lamb For: City.of Carmel'-.Onsite .City of Carmel Onsite EAP Services/Sept.;2016 1'Civic Square.. Cannel,IN 46032- Inyoice#: 752606 , Service'Date Des&iptio QuantiChaW. rge . Recei i4d'us Balance 09/01/2016' EAP Services. .'608 .00: 72960. : : . 729:60 CITYCARO : Invoice##. 752606 Balance Due:.' 729.60 MAKE PAYMENT TO THE BELOW.ADDRESS WITHIN 30 DAYS OF INVOICE DATE—PLEASE INVOICE#ON CHECK Cut"'and return with payment' VOUCHER NO. WARRANT NO. Prescribed by State Hoard of Accounts City Form No.201(Rev.1995) IU HEALTH WORKPLACE SERVICES LLC ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 2046 RELIABLE PKWY IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service CHICAGO, IL 60686-0020 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $754.00 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# Human Resources Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 752310 43-588.00 $754.00 1 hereby certify that the attached invoice(s),or 9/30/16 752310 $754.00 1201 101 1201 101 bill(s)is(are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Tuesday, October 04,2016 I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 _'20— Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer Invoice.# :7523.10(continued)page'5' Service Date Descriptlon Quainti Cha�ae. : :Recei d u 'Balance 09/20/2016" . Quick.Read UDS/66anel,includes. ' . " : : .1.00: 15:00 15.00. kit: . ' 754.60" " MAKE PAYMENT TO THE BELOW ADDRESS WITHIN-3"0 DAYS.OF INVOICE DATE-PLEASE.INCLUDE INVQICE#ON.CHECK �". . . .. " Indiana University Health Workplace Services, LLC 950 North Meridian Street Suite 950 (City of Carmel) \2� Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice September 30, 2016 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel-Onsite Occupational Drug Screens 1 Civic Square Carmel,IN 46032- Invoice# 752310 Service Date Description Quanti Charge Receip Aaus Balance 09/22/2016 Quick Read UDS/6panel includes 1.00 15.00 15.00 kit 22.00 Invoice# 752310(continued)page 2 Service Date Description Quantily Charge Recei Adj-USA Balance 09/26/2016 Quick Read UDS/6panel includes 1.00 15.00 15.00 kit 30.00 Invoice# 752310(continued)page 3 Service Date Description Quanti Charge Recei Ad"Us Balance 09/27/2016 Quick Read UDS/6panel includes 1.00 15.00 Invoice# 752310(continued)page 4 Service Date Description Quanti Charge Recei AdLs Balance 09/29/2016 Quick Read UDS/6panel includes 1.00 15.00 15.00 kit 15.00 -- - - - - ----- .... . .... VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) IU HEALTH WORKPLACE SERVICES LLC ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 2046 RELIABLE PKWY IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service CHICAGO, IL 60686-0020 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $665.54 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# 301 Medical Fund Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 08.24.16 50-239.90 $665.54 1 hereby certify that the attached invoice(s),or 8/24/16 08.24.16 To Correct healthcare overcharge to employee $665.54 301 301 301 301 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 Tuesday, October 04,2016 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 Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer Payabl-e�to�'IN:DIANA=UNIVERS'ITY HEALTHI Please deliver check to Sue Wolfgang in Human Resources [ubmitted�To OCT 05 2016 ��C� e reaS A9'�B September 14,2016 Billing Statement for: Indiana University Health. PATENT: ACCT#:9356734 s t8 : � • s• -e • s • • • • e ° y:4-•n•a�:�F t ,•� +r;,�^¢,�;yt ^r,,-n��?'a��,'F'F'z;11n .y\' �,. _ ,.1„\W.��tt�k.� \,. "A'�+ �t+7! � \�•y��\' ,•'n ��y�y,,�. ,,,y`n r"pty+ x r -. t {Y , F� qR.• 't 3)4 't `�1 `r., Q � '1,.�g )46„1 1'C W.. ..�.,, ,.. .F✓•..u;)T�. Y'?.' „i. , ;C:� `,t c�`'} a"`;' t� ` 1'` �3t' v.t 4.a...• r"• o, t\ .. �.i.. --ow :.�' .,�;�,. �' •tk9t �'` �ti:��,,\�'�;>`_� ah �`Yd�� •"�. �\', `-�� tr.rr.e. •+� .rdv. ,t.Ai•. . a .�r� �ba 1�. �.'�w:. ,Rtr,'t,hF.,•4�k .,� } k\. 455250597-08/09/16 IU Health North Medical Center 1,590.00 0.00 2,255.54 Outpatient-CAT Scan , NFw 08/2412016 Insurance Cnntrartual Adjustment{Anthem Blue Ar, $1,650.00 NEW 08124/2016 Insurance Payment(Anthem Blue Access PPO) -$984.46 40019104-08/09/16 IU Health Physicians 223.00 0.00 0.00 Group No:22-Provider:LISA YOUNGBLOOD MO ` NEW 08/24/2.016 ANTHEM/BOBS PAYMENT -$108.60 NEW OB/24/2016 Insurance Contractual Adjustment(ANTHEM/BCSS PA -$114.40 40062403-08/09/16 1U Radiology Associates 251.00 0.00 0.00 Group No:20-Provider:KEVIN SMITH MD NEW 08/31/2016 ANTHEM/BOBS PAYMENT -$101.89 NEW 08/31/2016 Insurance Contractual Adjustment(ANTHEM/BOBS PA -$149.11 38845286.05125116 11.1 Health Physicians 156.00 0.00 0.00 Group No:26-Provider:CARY N MARIASH MD l 06/0812016 Adjustment(ANTHEM/BOBS PAYMENT) _$95.00 t NEW 08/11/2016 BNK CHECK -$61.00 TOTAL $2,220.00 $0.00 $2,255.54 mHAT YOU RENTLY OWEBY,Octob• �1C.^• i2 >do` w '1.;.z.,+rle.C$:`.r`�i;9S`.W�`r.a��w,.c..,�.k-.,r�.1.,..+r;$.t�`.T,\.LY5w�:�6.v.$,s6Kri+,.c.S.,�1•'m3x\:a'`k,�_;r.}+l�.4a?hJ+,..�: nh{Cil+ t^� Y �i:.1�w:+ . "�F 4\ 1n} {a Lt+W7.`S�%�Jji!�yam`;J..1i".y.t't'`C�1�i c�.'\A.s`aa\�l,,g�`p•c'�\@„d•.n.t��i.t:',}r^Ynlr1�.t^1'�M.n��_zz''t.l.i`,lC+T'�„,r.vr'•"v'�5} \ ''•” .h ). 54"l \ S(J;aF�;.\'�..','N`,F r�S.V^a ... iut `5. ..?c:t.`-,�iv1P.•�..,...._*.ti}5S}^ =.�i,.;nM�l a r:,, .G. ' y/. o 912812016 Group Health Plan Claims Detail Page Q 1101T.E. OFAI(Is ;A HELP 0 LOGUFF Anthem. Gup Health Plan Services BlueCross BlueShield roCo. You are here: GHP Home>Claim Search>Claim Search Summary,>Claim Detail Subscriber Name: 1111100�111Ill' Group Name: City of Carmel Subscriber ID Number:ANNIMI Group Number: 004007834 b46p 'i t claim's JPCP Infot ion screr 0anden Claim Summary Member Name: Claim Number: 20162300114000 Member Relation: Adjudicated Date: 08/19/2016 Member Gender: Type: Facility Member Birthday: Payee: Provider Provider Name: INDIANA UNIVERSITY HEALTH NORT Claim Detail Lines 'Charge Deductible Coinsuranca Co- Subscriber Approved Status Flw', Liabilib., to Pay 0010 08109/2016- Outpatient $1,590.00 $2,255.54 $0.00 $0.00 $2,255.54 $984.46 Approved 08/09/2016 Facility Totals $1'590.00 $2,255.54 $0.00 $0.00 $2,255.54 $984.46 N®R • -I- IEvil ME a W (D-Registered marks Blue Gross and Blue Shield Association.@2016 copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield is the trade name for the following: In Connecticut:Anthem Health Plans, Inc.In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Indiana:Anthem Insurance Companies, Inc. In Kentucky:Anthem Health Plans of Kentucky, Inc, In Maine:Anthem Health Plans of Maine, Inc.In Nevada: Rocky Mountain Hospital and Medical Service, Inc.In New Hampshire:Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia:Anthem Health Plans of Virginia, Inc. Independent licensees of the Blue Cross and Blue Shield Association.Serving residents and businesses in Indiana, Kentucky,Ohio,Colorado,Nevada,Connecticut, Maine, New Hampshire and Virginia(excluding the city of Fairfax,the town of Vienna and the area east of State Route 123). Use of the Anthem Web Sites constitutes your agreement with our Terms of Use httpsl/pd2.secure.anthem.com/nep/CCServiet