HomeMy WebLinkAbout181439 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