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Home My WebLink About181439 01/13/2010 CITY OF CARMEL, INDIANA VENDOR: 363778 Page 1 of 1 ONE CIVIC SQUARE LUCY WORTH CHECK AMOUNT: $420.85 4, CARMEL, INDIANA 46032 9616 DAY DRIVE ors INDIANAPOLIS IN 46280 CHECK NUMBER: 181439 CHECK DATE: 1/13/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 420.85 AMBULANCE REFUND Date: 01/05/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal lD# 356000972 Bill To: ERNEST M WORTH ICD -9: 78907 78079 78791 9616 DAY DR INDIANAPOLIS, IN 46280 From: 9616 DAY DR To: COMMUNITY HOSPITAL -NORTH 1 MEDICARE PART B Patient: ERNEST M WORTH 304280505A 9616 DAY DR Insurance INDIANAPOLIS, IN 46280 2 BANKERS/5348 Patient No: 203046964 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $420.85 $841.70 420.85 CPT Date Description Charges Credits 09/25/2009 ADVANCED LIFE SOPP 1 -ENRR A0427 $375.00 09/25/2009 MILEAGE A0425 $45.85 11/03/2009 PAYMENT $420.85 11/13/2009 MEDICARE PAYHENT $336.68 11/20/2009 COMMERCIAL INSURANCE PAYMENT $84.17 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 01/05/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal 1D# 356000972 Bill To: ERNEST M WORTH ICD -9: 78907 78079 78791 9616 DAY DR INDIANAPOLIS, IN 46280 From: 9616 DAY DR To: COMMUNITY HOSPITAL -NORTH 1 MEDICARE PART B Patient: ERNEST M WORTH 304280505A 9616 DAY DR Insurance INDIANAPOLIS, IN 46280 2 BANKERS /5348 Patient No: 203046964 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $420.85 $420.85 $0.00 CPT Date Description Charges Credits 09/25/2009 ADVANCED LIFE SUPS 1 —EMER A0427 $375.00 09/25/2009 MILEAGE A0425 $45.85 11/03/2009 PAYMENT $420.85 11/13/2009 MEDICARE PAYMENT $336.68 11/20/2009 COMMERCIAL INSURANCE PAYMENT $84.17 01/05/2010 REFUND 420.85 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Bankers Life and Casualty Company EXPLANATION OF PAYMENT ENT PO Box 5348 l� 1 g Y j� Bellingham WA 98227 534& Keep This Notice For Your Records *'i 1-800-688-0010 004922 -OODOO Q01922 OMS12042509 CARMEL FIRE DEPARTMENT STATEMENT DATE: 11/12/2009 of 2 CARMEL CIVIC SQ PP_GE: 40 1 CARMEL, I N 46032 -7543 DO r' g 9 0& 8 2 PROVIDER ii: 1079954 TAX ID 256000972 CHECK If: 00166978/ CHECK AMOUNT: $84.17 THIS IS A SUMMARY OF CLAIMS PROCESSED PA`1'TtNT g 1JA- itiL'p,�^ p i' t �s,� i 0 T i0 ICY e r i u ,:i a N r T ACCOU� DS1TES cP S E'RV I CE CLP I.M 0 B ILL E D o N N1r, DICA t, 3 0 0ICARE SU ,�,It E N FOM tr 4 T.O a E NTT1' k a P t 1 AM001'7 „a 4 1. KLi OWEL9 v?sIL+ s.bA: E�!' LIPBI:1 LI 0ODn WORTH, ERNEST M 5239790 200902413 09/25/2009 09/23/2009 0064449342 45.95 45.85 36.60 9.17 .00 09/25/2009 09/25/2009 0054449347 375.00 373.00 300.00 75.00 .00 SUGARY TOTALS: 420.83 420.95 336.68 84.17 .00 RECETATED NOV 2 0 2009 Thank you for the opportunity to be of service to you. Please notify us of any changes to your Tax Identification Number, Medicare Provider Number, address or phone number. If you have any questions please contact our Customer Service Department from 5:00 a. m. to 8:00 p.m., Pacific Time, Monday through Friday: 1- 800 -688 -0010 1 Bankers Life and Casualty -io 1250 0016697 81 Company us Bank 24 -Hour Banking CHECK DATE 11/12/2009 ND Box 5348 1- 800 673 3555. Beflingharn WA 98227-5348 VOID AFTER 6 MONTHS 1 1-800-688-0010 $84 .17* PAY Eighty Four and 17/100 i ,7 TO CARMEL FIRE DEPARTMENT /J THE 2 Carmel Civic 5q ORDER CARMEL, IN 46032 -7543 L OF Authorized Signature MS *Check_ Is_ Voided lf MICR- Encoding. Not Present' aen- arauE.m: c6.:- :aa=Grs: e S C.neit:'. 3 na:: at1.. 5umme4eam:. 25: x,:u._].sl:ram,,,az.': ^:..mr.^ mzsarL.. s:.noc.raG sr. rs cy n Kt+' :t�xII R.u.HxGSIIyr. v_.. Pg 000 4 76 kli` 1 7,425000®051:®5 5055L,Eir;4 ir e MEDICARE PART B INDIANA MEDICARE PART E. PROVIDER REPORT NATIONAL GOVERNMENT SERVICES. INC. P.O. BOX 240 INDIANAPOLIS. IN 46206 CHECK DATE 11/06/09 CHECK NUMBER 123621988 00(10119 CHECK AMOUNT **-6.772.29 PROVIDER NUMBER 1154325579 00001'f'• 2009110? EKOHK101EKiPDDOO 1 OZ DOMEKOXKIODCO^ 159067 BP I 111 111 I ICI I11 IIIII II 11111IfIIIIII`IIIIIII {II 1 CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SQ ,ate CARMEL IN 46032�,ni. E E° ku.�.3v._�� e:sv ��ew.1S.,.; ''a- z.s .i y� r4, ry MEDICARE. PART B 74-1292 NATIONAL GOVERNMENT'SERVICES. INC. ,v" 72,4 INDIANAPOLIS, IN 46206. "shY"'- .a.a -s Q77`.4 "sm" -r.. MEDICARE PAYMENT JPMorgan Chase Bank, Columbus FoR, HEALTHINSURANCE SOCIAL SECURITY ACT Columbus,' Oh'lo 0503622153 PAY TO THE ORDER. OF PROVIDER•NO. CHECK NO CARMEL FIRE DEPARTMENT 1154325579 123621988 2 'CARMEL .:CIVIC SQ MO. DAY YEAR DOLLARS CARMEL, IN 46032 75.43 06: 6,.77:?:,2 VOID 12'. MONTHS FROM ISSUE DATE a E ;6=-- t :0 r ELI P s_71: SEL. 70' Electronic Remitance Information Print Date: 11/13/09 (EOM Explanation Of Benefits (EOB) Payor Id: 00630 Production Date: 11/06/09 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: 1351840597 PO BOX 6160 INDIANAPOLIS IN 462066160 Payer Contact Info: NATIONAL GOVERNMENT SERVICES INC, (866)250 -5665 TE t Receiver lnfo: CARMEL FIRE DEPARTMENT Payee Id: 1154325579 2 CARMEL CIVIC SQ CARMEL IN 460327543 Payment Info: Check EFT Trace No 123621988 Total Payment Amount $6;772 29 Check Issue Date: 11/06/09 Payment Method: Check Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid 200902413 WORTH ERNEST M 09/25/09 A0427 RH 375.00 300.00 420.85 420,85 84.17 336.68 Claim Control 1109299042170 A0425 RH 45.85 36.68 Claim Status: Processed as Primary Claim Remark Codes: MA01, MA18, Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 75.00 Patient Responsibility Coinsurance Amount 9.17 Billed: 420.85 Late Filing Fee: 0.00 Pt. Responsible Amt: 84.17 Paid: 336.68 Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER 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 ll L C, r3() rA'k_ Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) gin-Lb arsem? Qk r nverrpa�rn� -/-ef f ,?5" it._ to 1,cJ or Total Q 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 VOUCHER NO. WARRANT NO. r/ l ALLOWED 20 1.L& L�Ortl -/2 IN SUM OF "7 9/0110 1 aid �r di an aF6 i.n q6,-)80 ON ACCOUNT OF APPROPRIATION FOR in LJPubC e �u»ci/Uo*pro Board Members Po# or INVOICE NO. ACCT# /TITLE AMOUNT hereby certify invoice( s), DEPT. a I hereb certif that the attached invoices 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 JAN 11 2010 .r.. Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund