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Home My WebLink About331139 10/17/18 . ��u`-..N,y� �/ � CITY OF CARMEL, INDIANA VENDOR: 372841 ® ONE CIVIC SQUARE CHRISTINE CARLSON CHECK AMOUNT: $*******358.55* 9� ?�, CARMEL, INDIANA 46032 13436 LORENZO BLVD CHECK NUMBER: 331 139 M��TON�, CARMEL IN 46074 CHECK DATE: 10/17/18 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 358.55 OTHER EXPENSES VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) Vendor# 372841 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER CHRISTINE CARLSON IN SUM OF$ CITY OF CARMEL 13436 LORENZO BLVD 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. CARMEL, IN 46074 Payee $358.55 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 $358.55 1 hereby certify that the attached invoice(s),or 10/8/18 0 Reimburse Ambulance Fees $358.55 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 Friday, October 12,2018 2 David Haboush Fire Chief 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 f r CITY ' �R1VIEL J1v.Nirs BR:V\ARI), it<I YOJ� October 8, 2018 Christine Carlson 13436 Lorenzo Blvd Carmel. IN 46074 RE: RUN #2017-00007074:1 DOS 12/20/2017 Tyler Carlson Dear Christine Carlson: Enclosed you.will find a refund check for$358.55. We received your payment check #976 on 06/09/2018for$681.24. IHC your health insurance paid$358.55 on 07/1.6/2018. This created an overpayment of$358.55 Refund to-be issued to Christine Carlson. If you have any questions,.please feel free to contact me at (317) 571-2604. Sincerely, A/14 j n Michelle T. Harrington EMS Billing Administrator CAr::Nr1:r. FiRr' DE ART\11:NT Snmw A. CO UTe HEADQUARTER!, Two CIVIC SQUARE. CAIG\1R, IN 416032 Order 317371.2600, FAx 317.571.2615 CSL CITY OF CARMEL FIRE DEPT -1 2 CIVIC SQUARE P�'.n.3' CARMEL, IN 46032-2584 CL"T l (317)571 2604 Federal ID#356000972 Patient Name: CARLSON,TYLER T TYLER CARLSON CITY OF CARMEL FIRE DEPT 13436 LORENZO BLVD 2.CIVIC.SQUARE WESTFIELD, IN 46074 CARMEL, IN 46032-2584 TO ASSURE.PROPER CREDIT, RETURN Statement Date. Patient lD AMOUNT PAID THIS'PORTION WITH YOUR PAYMENT 10/08/18 990120590 Ticket#: 2017-00007074:1 Date of Service: 1212012017 DETACH HERE REFUND AMOUNT$358.55. PATIENT PAYMENT AND INSURANCE PAYMENT RECEIVED CREATED:AN OVERPAYMENT. MAKE,CHECKS PAYABLE TO: CITY OF CARMEL FIRE DEPT BALANCE Pay online at www.govpaynet-corn with PLC#7487 Run Number 2017-06007074; Online Payment will charge a service fee. -Date-of Service Description Patient'Name Charge(s): Date Payment(s) -Charges 592592.25 12/20/2017 'ADVANCED LIFE CARLSON, TYLER T $$88.99 12/20/20.17 `MILEAGE CARLSON,TYLER T Charge Total: :8681.24 Payments 12/20/17 (8717.09) Paid By: Invoice Reversal Invoice 12/20117 $684:24 Paid By: Paid By: Invoice 12/20/17 8717.09 Paid By: CARLSON, TYLER T Bad Debt 05/17/18 (8681.24) Paid By: CARLSON,TYLER T COLLECTION PAYMENT 06/29/18 ($681.24) -Paid By: CARLSON,.TYLER T Bad Debt Invoice Reversal 06/29/18 $681.24 BALANCE 80.00 CA M- 1 CITY"OF CARMEL FIRE DEPT g 2 CIVIC SQUARE CARMEL, IN 46032-2584 • (31.7) 5712604 Federal ID#356000972 Patient Name: CARLSON,TYLER T TYLER CARLSON CITY OF CARMEL FIRE DEPT 13436-LO RENZO BLVD 2 CIVIC SQUARE WESTFIELD, IN 46074 CARMEL, IN 46032-2584 TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID. THIS PORTION WITH.YOUR PAYMENT 10/08/18 990120590 Ticket#: 2017-00007074:1 Date.of Service:-1212012017 DETACH HERE REFUND AMOUNT$358.65. PATIENT PAYMENT AND INSURANCE PAYMENT RECEIVED CREATED AN OVERPAYMENT. Paid By: IHC STM CLAIMS COMMERCIAL INSURANCE 07/27/18 ($358.55). Paid.By. CARLSON, TYLER T REFUND 10/08/18 $358.55 BALANCE $0.00 rr- TEAM NCE INC. 9Z6 13436 LORENZO BLVD.317.340.6060 CARMEL,IN 46074• 71$69/749 i-lay to M i4 Ord,r'aP X � Vl/J � ��✓ 11 91 /C Oallars �O rre F. rri Tr3tlzo?�:�vlt ForfY/fir � RECEIPT City of Carniel 44848 Fund: 102 Ambulance Fund Fire�vclbap��undReceipt Date: 06/29/2018 Received from: TONI BUTLER/LAW $681.24- For the Sum Of: Six Hundred Eighty One-Dollars And Twenty Four Cents On Account of: TYLER CARISON 2017-00007074 Payment Detail: Check$681.24 Check#: ; Remitter Signature: Authorized Signature:_ I,111.V -�N.I III"I Ni%It JI NKI111I.M 1 01.\`I�'10t IIIPI III 0I% %ANIt 1. :r: page 1 of 4 EBA MIT HOOP Wools W E SWO St Me 1 NJ Exrpianationt Of Ber-lefits RockUdA 61108 T;1,)-, PURPOSES Forwarding Sprvice Requested THIS IS NOT A BILL Cusl,3.mei Service Cali 5 1 -6 Chock No: 4HI86. tARY11 IW 111FAMM WK Nut on III nwwwwe Iww pamm Dam CY pwr 7n"wl Yaw p�,pon 5&Aht'� xi 7YLEn p,_567% "i � s, -- - r;4 TOTA L-S solo PaImnt TYILEP CAPIL50N i st t,,r. r YO % tfj ---- �'j S62 A21 12484 A!A&U'-ANCE TOTA� E51 i5 —Awall Orr tr I Pa a h pwaSe reijet%, NOTICE. 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