319193 11/30/2017 CITY OF CARMEL, INDIANA VENDOR: 372074
'.; � i• ONE CIVIC SQUARE RUSSELL KEATING CHECK AMOUNT: $*******565.24*
` ,?4 CARMEL, INDIANA 46032 845 PENINSULA AVENUE CHECK NUMBER: 319193
9Ml.oN"+� CLAREMONT CA 91711 CHECK DATE: 11/30/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 565.24 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995)
Vendor# 372074 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
RUSSELL KEATING IN SUM OF$ CITY OF CARMEL
845 PENINSULA AVENUE 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.
CLAREMONT, CA 91711
Payee
$565.24
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire 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
0 50-239.90 $565.24 1 hereby certify that the attached invoice(s),or 11/22/17 0 $565.24
1120 102 1120 102
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, November 28,2017
David Haboush
Fire Chief
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
MEN
nn �
CI`IYY b0` 1RNIEL
JAMES BRAINARD, MAYOR
November 21, 2017
Russell Keating
845 Peninsula Ave
Claremont, CA 9171.1
RE: Account#2017-00005922:1 D.O.S. 10/18/2017 Carole Keating
Dear Russell Keating:
Enclosed yodwill find a refund check in the amount of$565.24.
On November 3, 2017'we received your payment for$706.55 Check#108.
On November 13, 2017 Anthem sent us a payment of$565.24.
Anthem paid us direct and the amount due from the patient is $141.31
Issued refund of$565.24 the overpayment to subscriber.
If you have any questions,please feel free to contact me at (317) 571-2604.
Sincerely,
AW d6 J IV4
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPART1bIENT
STEVEN A. COUTS HEADQUARTERS
TWO CIVIC SQUARE, CARbIEL, IN 46032 OFFICE 317.571.2600, Fix 317.571.2615
Claire Status Detail Learn More»
Transaction ID:7987527007,7987527599,7987527615Transaction Date:Nov 21,2017 04:07 PM ESTCustomer ID:319933
$ ,k 3 s 1•r > � r ( �9 r r k'- �K` t ,,4 . :.� '� e � t ' �? 1.:5 � a " .,..
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Subscriber Name: KEATING, RUSSELL BClaim Number: 17300BR5949Check Number: N/A
Subscriber ID: JQU602A74792 Bill Type: N/A Check Date: N/A
Patient Name: KEATING,CAROLE J Voucher ID: N/A Check Addressi: N/A
Patient Account#: 2017-00005922-1 Billed Amount: $706.55 Paid Amount: $565.24
Provider Name: CITY OF CARMEL Claim Processed Date: 10/27/2017 Paid Tol: Provider
NPI: 1154325579 Claim Received Datet: 10/27/2017 Paid To Namet: N/A
DRG : N/A Paid To Tax IDt: 356000972
Authorization Numberr. N/A
Claim Level Status
Status: Finalized/Payment The Claim/Line has been paid.
Claim%Line has been paid.Status Date: 10/27/2017
P.O.Box 105187
Atlanta, GA 30348
Service Line Status-
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w4mv�-A- ,
10/18/2017 10/18/2017 A0429 N/A SH 1 $689.25 $689.25 $137.85 $0.00 $0.00 $551.40 $0.00
Status: Finalized/Payment The Cfaim/Line has been paid.
Claim/Line has been paid.Status Date: 10/27/2017
Remarks: 00067:This balance is the member's coinsurance responsibility.
00947:You can learn more about the services listed by calling the customer service phone number on the back of your ID card.We can tell you the diagnosis...
10/18/2017 10/18/2017 A0425 N/A SH 1 $17.30- $17.30 $3.46 $0.00 $0.00 $13.84 $0.00
Status: Finalized/Payment The Claim/Line has been paid.
Claim/Line has been paid.Status Date: 10/27/2017
Remarks: 00067:This balance is the member's coinsurance responsibility.
OEM
Other Insurance Information
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N/A $0.00,
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