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Home My WebLink About181399 01/13/2010 CITY OF CARMEL, INDIANA VENDOR: 363776 Pag �I, e 1 of 1 ONE CIVIC SQUARE GARY SUMMERS CHECK AMOUNT: $388.10 4 CARMEL, INDIANA 46032 601 W 77TH N DRIVE INDIANAPOLIS IN 46260 CH NUMBER: 181399 CHECK DATE: 1/13/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 388.10 REFUND Date: 01/05/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 Bill To: CATHERINE G SUMMERS ICD 9: 81390 71943 E8888 301 EXECUTIVE DR CARMEL, IN 46032 From: 301 EXECUTIVE DR To: ST. VINCENTS HOSPITAL CARMEL MEDICARE PART B 1 Patient: CATHERINE G SUMMERS 312125225A 301 EXECUTIVE DR Insurance CARMEL, IN 46032 AARP /UNITED HEALTHCARE Patient No: 200902367 0930415351 WE CANNOT BILL MEDICARE WITHOUT AN AUTHORIZED SIGNATURE ON FILE. PLEASE SIGN IN SECTION 1 OR 2 AND RETURN iN THE ENCLOSED ENVELOPE PROMPTLY, THANK YOU. Total Amount Total Paid Balance $388.10 $388.10 $0.00 CPT Date Description• Charges Credits 09/17/2009 ADVANCED LIFE SUPP 1- En7ER. A0427 $375.00 09/17/2009 MILEAGE A0425 $13.10 11/24/2009 PAYMENT $388.10 12/08/2009 MEDICARE PAYMENT $310.48 12/29 /2009 COMMERCIAL INSURANCE PAYMENT $77.62 01/05/2010 REFUND 388.10 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 356000972 Bill To: CATHERINE G SUMMERS ICD -9: 81390 71943 E8888 301 EXECUTIVE DR CARMEL, IN 46032 From: 301 EXECUTIVE DR To: ST. VINCENTS HOSPITAL CARMEL MEDICARE PART B 1 Patient: CATHERINE G SUMMERS 312125225A 301 EXECUTIVE DR Insurance CARMEL, IN 46032 2 HARP /UNITED HEALTHCARE Patient No: 200902367 0930415351 WE CANNOT BILL MEDICARE WITHOUT AN AUTHORIZED SIGNATURE ON FILE, PLEASE SIGN IN SECTION 1 OR 2 AND RETURN IN THE ENCLOSED ENVELOPE PROMPTLY. THANK YOU. Total Amount Total Paid Balance $388.10 S776,20 388.10 CPT Date Description Charges Credits 09/17/2009 ADVANCED LIFE SUP? 1 -EMER A0427 $375.00 09/17/2009 MILEAGE A0425 $13.10 11/24/2009 PAYMENT $388.10 12/08/2009 MEDICARE PAYMENT $310.48 12/29/2009 COMMERCIAL INSURANCE PAYMENT $77.62 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 9 E 1 d i7 x :_v -sf,C i..- 'mz J- .3'-3_3a r,ie.- -i,` L•i i ('v 'tw., i „.v... krt-'yy 'fo, .._..;B ,,r i6-K. ,v,v.* a p i t ,,1 21--.1 43 1 CATHERINE G. SUMMERS OR GARY G. SUMMERS 740 9 8 ,7 4 8 93 4 6 4 01 9 S 4 601 W 77TH N' D �a l DATE l 6 a INDIANAPOLIS, IN 46260 /4/ I I PA THE /V s` 3 G70 iC 4 O R DDER OF •f. l Q E. ar } }M A MEMO f I J A w- -3 st r a rVZ1. VWfiti7^`�,..e W .ter. fss .vxn3:�15MAmViV:dt;._..• a+sv. 4e<,a�,3 ci ,1 7 Electronic Remitance Information Print Date: 12/08/09 (EOB) Explanation Of Benefits (EOB) Payor Id: 00630 Production Date: 12/03/09 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Nati Id: Payer Id: 1351840597 PO BOX 6160 INDIANAPOLIS IN 462066160 Payer Contact Info: NATIONAL GOVERNMENT SERVICES INC, (866)250 -5665 TE Receiver Info: CARMEL FIRE DEPARTMENT Payee Id: 1154325579 2 CARMEL CIVIC SO CARMEL IN 460327543 Payment Info: Check EFT Trace No 123649662 Payment Check Issue Date: 12/03/09 7ota1 Amour t 4 $10,223 73 Payment Method: Check Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid 200902367 SUMMERS CATHERINE G 312125225A 09/17/09 A0427 EH 375.00 300.00 388.10 388.10 77.62 310.48 Claim Control 1109324338880 A0425 EH 13.10 10.48 Claim Status: Processed as Primary Claim Remark Codes: MA01, MA18, Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 75.00 Patient Responsibility Coinsurance Amount 2.62 Billed: 388.10 Late Filing Fee: 0.00 Pt. Responsible Amt: 77.62 Paid: 310.48 MEDICARE PART B INDIANA MEDICARE PART B PROVIDER REPORT NATIONAL GOVERNMENT SERVICES, INC. P.O. BOX 240 INDIANAPOLIS, IN 46206 CHECK DATE 12/03/09 CHECK NUMBER 123649662 0000117 CHECK AMOUNT *10 223.73 PROVIDER NUMBER 1154325579 0000115 200912CH ELOKH101EK1PDO6O 1 02 DOM ELOKH10000" 155 BP 111111111 I I I I I II I IuII1 1 1 1 11 11111 {11111 CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SQ CARMEL IN 46032'5='. i c V iii DEC ZU S q, h ri,Lau ��.£t T ROWS i i. r� c y/p� ra 2_ iQI V �+I i 7 !all�[� Z tM- 4��Y:,..- VS MEDICARE:PART B 74, 292 NATIONAL GOVERNMENT SERVICES, INC. rr y a` P.0 BOX 240 INDIANAPOLIS, IN 46206. r-FA'TUrsauerg'rrAr.E. Mrnre41°sERv'cFs MEDICARE PAYMENT JPMorgan Chase Bank, Columbus- FOR HEALTH INSURANCE SOCIAL SECURITY ACT Columbus, =Ohio 0503649850 PAY TO THE ORDER OF 1 PROVIDER NO CHECK NO. CARMEL FIRE DEPARTMENT 1154325579. 123649662 2 CARM CIVIC S Q MO. DAY YEAR DOLLARS 12 03 *10,223.7 CARMEL, IN 46032-7543 I s VOID 12 MONTHS FROM ISSUE DATE i ti1/4 4 721,:i I sue. EoO r 2 2.R 27E: 3 kL ?i� 351 1?PCK45- 00435 -002 -01170 Ut�itcd Hc�;fthCar�� irrs�tr,in Health Care oitroin (�it� �irtitc I Ic:iltlrCa1-c lnstir:uicc Options' Company of ;•vcw for New r siu'rni;; ,Irc proud nrovidcr s PAGE 2 OF 3 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: DECEMBER 17, 2000 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT' Information ovider From rvice To lZharr ed Approved j r aii 1 Dedo t V Benefit Medi^ re Medicare plied to Paid �cinie f I WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR 931 BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. SUMMERS, CATHEPI,NE G CARMEL M iEERSh 09:3DII1535 r CLAIM 3�.:5 50 a7nl 1 091709 '_T_ =,N`F' 20090236. EU 375.00 375.00 n 30v.00 75.00 CARMEL 0 Q17 9 13.10 13.10 10.48 TOTAL 77.62 WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. CARMEL 110109 45.55 45.85 i 3.08 i7� TOTAL 34,171 WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, W. u CALCULATE YOUR BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. 14 h j 2J[9 X05.21 007 35 AARPCK45 -00435 -001 -01169 UNITED HEALTH CARE If you have questions please contact us at: PO BOX 740819 ATLANTA. GA 30374 -0819 UNITED HEALTH CARE PO BOX 740819 ATLANTA, GA 30374 -0819 TOLL FREE 1 -800- AARP -789 1 800- 2277 -789 PAGE 1 OF 3 CARMEL FIRE DEPT* 2 CARMEL CIVIC SO CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE DECEMBER 1 7 2009 r r Cy CHECK AMOUNT $1 049 .86 1 a_. r^ L v 1 For real time access to claim check, and member eliLribiliry information please register online at: haps://aarpprovideronlinetool.uhc.com Please remember to submit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Health Care United 1- te-althCarc Insurance Company (and United HealthCarc Insurance- Options Company of New York for New York residents) arc proud providers to Please detach check below and cash promptly EJNIT -D HEA CARE PO BO? 740619 62 20 ATLA�fTt uA 30374 0818 Citibank Delaware 2'6'031' gS 4 One Penn's Way 1 x" 4 New Castle, DE 197213 REPRESENTS PAYMENT F3R MULTIPLE INSUREDS DATA DECEMBER PAY "THOUSAND .FORTY NINE DOLLARS AND' 8 6 CENTS SAY ORDER .OF CARMEL r �s RMEL FIR- DEPT 2 CARMEL CIVIC 5O CARMEL 'ITS 46032 -7543 t,- ;1!` -3 r P.. 118 .e P 'n n I, iJ s e. a '_i -3 %J 3 E Prescribed by State Board of Accounts Clty 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 a .(21 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ei'in..,b btr3 r 0 y er 4 2ge?, /,0 Total 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. ALLOWED 20 C� 0 pti /ClriIr1 PA'S IN SUM OF 6o/ 40,77 k fir, ,o '88./O ON ACCOUNT OF APPROPRIATION FOR 4h4, u/Qite I-bcn d/A10 felre i't� Board Members PO# or INVOICE NO. ACC(TITLE AMOUNT hereby certify T I hereb certif that the attached invoice(s), 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 6.3e 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund