182126 02/03/2010 �i CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
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6 j. ONE CIVIC SQUARE UNITED HEALTHCARE CHECK AMOUNT: $176.79
y,� CARMEL, INDIANA 46032 PO BOX 30555
rr" SALT LAKE CITY UT 84130 CHECK NUMBER: 182126
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CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 176.79 REFUND
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740
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SPRINGFIELD SERVICE CENTER r I LlrutedHealthcare
P 0 BOX 30555
SALT LAKE CITY, UT 84',130 -0555 Ir go+PCo mAgl v s Six
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PHONE: 1 877 842 -321Q 3 4 ���?�3s
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=TIN j 35 8000972 I r rL ,i
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GROUP N
1 CE4y��1,; •GROUP NAME LI
THE FINISH NE
JAN 2 2010 C HECK NUMBER: UY 82504/70
CHECK AMOUNT $/76.79
CARME FIRE DEPT AMBULANCE SVC
CARMEL FIRE DEPT AMBULANCE SV PROVIDER
CIVIC
CARMELIN 46032 EXPLANATION
OF BENEFITS
PATIENT DETAIL
[PRODUCT MFM. ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER
NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE
CHOYC+ (E 085429654 MARY SPAGNA SP 200902578 LOU SPAGNA 02363366176 01 /2/07/09 CARMEL FIRE DEPT AMBU
SERVICE DETAIL
PATIENT DATES OF DESCRIPTION AMOUNT NOT PROV ADil.. AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT
NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP.
MARY 10/13/09 AMBULANCE 325.00 325.00 79.00 70% 172.20 NJ
SPAGNA 10/13/09 AMBULANCE 6.55 6.55 70% 4.59 NJ
SUBTOTAL 331.55 331.55 79.00 176.79# 154.76
TOTAL PAID TO PROVIDER $176.79
REMARKS
(NJ) YOUR BENEFITS ARE LOWER BECAUSE YOU DID NOT USE A NETWORK PHYSICIAN OR HEALTH CARE PROVIDER.
UN I S IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS STATEMENTS (EPS) AS A STANDARD WAY TO
PA Y CLAIMS. E WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS
AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK
FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 -UHC -FAST (1 -866- 842 3278), OPTION 5.
FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND
OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1- 800 842 -1109, OPTION 3.
PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM.
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UNITEDHEALT INSUR ANCE' COMPANY s
Syracuse, NY r�
SPRINGFIELD "'SERVICE CENTER U. G o<.
P'0 80X'30555
SALT LAKE CITY, UT 84130 -055 DATE 01 /04/10
PHONE': :.:•'1:: 877- 842 =3210
06 01656004691 PQ 10004 JO 354 CN 110 PLEASE PRESENT PROMPTLY FOR PAYMEN
C O N TRACT 715181
PAY$ **176 79 i
N E HUNDRED SEV SIX 79/100 DOLLAR
PAY CARMEL FIRE.;DEPT AMBULANCE SVC.
TO THE CARMEL FIRE :DEPT AMBULANCE SV. di
2 CIVIC 5Q
ORDER OF CARMEL IN 46032
AUTHORIZED SIGNATURE
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II L. 7:011 I;0 2 L3'093 8 b b0 89747117
Date: 01/19/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
ACCOUNT
Bill To: LOU SPAGNA ICD -9: 7242 78652 E8130
13964 INGLENOOK LANE
CARMEL, IN 46032
From: WALTERS ST CLAY TE BLVD
To: ST. VINCENTS HOSPITAL CARMEL
UNITED HEALTH CARE/ 740800
Patient: MARY C SPAGNA 964000065
13964 INGLENOOK LANE Insurance
CARMEL, IN 46032- 2
Patient No: 200902578
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $331. $0.00
CPT
;Date Description Charges Credits
10/13/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
10/13/2009 MILEAGE A0425 $6.55
12/15/2009 PAYMENT $331.55
01/12/2010 COMMERCIAL INSURANCE PAYMENT $176.79
01/19/2010 REFUND 176.79
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/19/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
1 RIv
Bill To: LOU SPAGNA ICD 9: 7242 78652 E8130
13964 INGLENOOK LANE
CARMEL, IN 46032
From: WALTERS ST CLAY TE BLVD
To: ST. VINCENTS HOSPITAL CARMEL
UNITED HEALTH CARE 740800
Patient: MARY C SPAGNA 964000065
13964 INGLENOOK LANE Insurance
CARMEL, IN 46032 2
Patient No: 200902578
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $508.34 176.79
CPT
Date Description Charges Credits
10/13/2009 BASIC LIFE SUPP EMERGENCY A0429 $325.00
10/13/2009 MILEAGE A0425
12/15/2009 PAYMENT $331.55
01/12/2010 COMMERCIAL INSURANCE PAYMENT $176.79
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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
661/ ec,C /Pal VI CZf e Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Pa ipmtes ejn e_.c 1-- °kr VP��a j f.4c. v 4 /7(o. 7 9
cb _5 a_
Total 1%7 7/ 7 9
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
Cam-/ i y P_Gc-�/ Y C_ Q/e IN SUM OF )740. 7
0.4 6
,Sa11- i_a_ge SLcf J 3o
7
ON ACCOUNT OF APPROPRIATION FOR
4 ulalteej /w D j/ )/0
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT hereby certify invoice( s),
DEPT. 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
'FEB 7010
:1.
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund