182146 02/03/2010 CITY OF CARMEL, INDIANA VENDOR: 363872 Page 1 of 1
rtt ONE CIVIC SQUARE HOWARD ZIEGLER
t i� CARMEL INDIANA 46032 3029 ROLLING SPRINGS DRIVE CHECK AMOUNT: $77.62
CARMEL IN 46033 CHECK NUMBER: 182146
CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 77.62 REFUND
4
Date: 01/19/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal10# 356000972
ACCOUNT HISTORY
Bill To: HOWARD W ZIEGLER ICD 9: 78650 7231
3029 ROLLING SPRINGS DRIVE
CARMEL, IN 46033
From: 3242 E 106TH ST
To: HEART CENTER OF INDIANA
MEDICARE PART B
Patient: HOWARD W ZIEGLER 304282885A
3029 ROLLING SPRINGS DRIVE Insurance
CARMEL, IN 46033 2 PRINCIPAL LIFE INS 10826
Patient No: 200902789 N86558-19708
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
$388.10 $465.72 77.62
CPT
Date Description Charges Credits
11/10/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
11/10/2009 MILEAGE A0425 $13.10
12/31/2009 MEDICARE PAYMENT $310.48
01/12/2010 COMMERCIAL INSURANCE PAYMENT $77.62
01/15/2010 COMMERCIAL INSURANCE PAYMENT $77.62
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/D# 356000972
A ''a 0 .i d S O r
Bill To: HOWARD W ZIEGLER ICD 9: 78650 7231
3029 ROLLING SPRINGS DRIVE
CARMEL, IN 46033
From: 3242E 106TH ST
To: HEART CENTER OF INDIANA
1 MEDICARE PART B
Patient: HOWARD W ZIEGLER 304282885A
3029 ROLLING SPRINGS DRIVE Insurance
CARMEL, IN 46033- 2
PRINCIPAL LIFE INS 10826
Patient No: 200902789 N86558
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 SfDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU
Total Amount Total Paid Balance
$388.10 $388.10 $0.00
CPT
Date Description Charges Credits
11/10/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
11/10/2009 MILEAGE A0425 $13.10
12/31/2009 MEDICARE PAYMENT $310.48
01/12/2010 COMMERCIAL INSURANCE PAYMENT $77.62
01/15/2010 COMMERCIAL INSURANCE PAYMENT $77.62
01/19/2010 REFUND -77.62
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
I oo7'_O28o
Principal Life insurance Company .v,-
P.O. Box 10826 Customer Service
Clearwater. FL 33757 -8826 1- 800 447 -4701
Please visit our website to verify eligibility
Forwarding Service Requested and obtain claim status information: I;46.41;
http /service.iasadmin.com /pfq.asp 0
ALL FOR AADC 462
I-17 1 5 0 7797 FP 0.414 Pay To: CARMEL FIRE DEPARTMENT
11 III I 'IIii'I "I Voucher 10068845 7
C ARMELEFIRIVIEPARRTMENT 137 Check 09298501
CARMEL, IN 46032 Amount: $77.62
Date: 01/06/2010
tQ� �l 1 6. nl t ryl fzl
Explanation of Supplemental Insurance Benefits
#nsure Claim 3l Medi ar 1? B Polrcy mbs
pefe of S etince Medicat 0 duc €Ibte �Ga� nsura Tatal ftematk Cod
Gtil nce
:Patient Ac tfi Totai Charg Allowed Oi.(1P Paid P P ai d Paid
ZIE HOWARD W 21655826 -01 8655819708
11110109 1 1/10/09
375.00 375.00 0 00 0.011 0.00 75 00 75.00 11
11/10/09 11/10!09 13.10 13.101 0.00 0.00 0.00 2.62 2,62 11
200902789
Claim Totals 388.10
388.101 OAO 0.001 0.00 77.62 77.62
E Voucher Totals 7 388.10 388.101 0.00 0.00 0.00 77.62 77 62
De gf Re C
1 1 CLAIM REFLECTS MEDICARE AND /OR POLICY TERMS
ATTENTION HEALTHCARE PROVIDERS Did you know we offer you the option to receive claim payments and EOBs electronically? Register today for
EFT (Electronic Funds Transfer) ERA (Electronic Remittance Advice). Go to the website shown in the upper right hand corner of the EOB. Register
yourself as a -user, check the box for HIPAA transactions and follow the steps for 835 enrollment. If you have any questions, please contact the provider
relations department at 727 584-8128 Ext 2150. Apply for your NPI at https: /nppes.cros.hhs.gov/
EOB Original provider HCFA /UB04 or RX receipts required for claims consideration. Photocopies are not acceptable.
;FOR S ECURITY' PURPOSES THE :FACE OF THIS= T
DOCUMENCONTAINS 1 A BLUE BACKGROUND AND'1NICROPRINTING`IN THE !BORDER
r E
Pr al •Llfe"I
rnci ns urance Com an
P p y CHECK Duetsche Bank many
k Trust�Cop 2
P:Q 10826 .DATE Wilmington peleware
Cle FLz3 3 7 5 7 8 26
62 38!311
1-800-4477o1 01/061 AMOUNT
$77.6
PAY Seventy Seven 621100 Dollars valo aFTI=_R sa DAYS-
co TO THE CARMEL FIRE DEPARTMENT 1._,:..n. h
fl ORDER OF 2 CARMEL CIVIC SC AUTHORIZED SIGNATURE
CARMEL IN 46032 -7543
2nd signature required it $25,000 or more.
r DO NOTIC'l1SH irwATERmARK,IS =NOT- 'P.RESENT: -ON: THE RIEVERSE'SIDE °DOCUMENT `,HOLD AT,AN ANGLE70UIEW
11 9 29850 Lu° I :0 3 L LOO 3801: 00S3591,511°
TAetna n .o. Box 98 „06 EXPLANATION OF. BENEFITS USA ASO TX 79998-1106
Please Retain for Future Reference
CITY OF CARMEL FIRE DEPT. 1 PIN: 0005745100
Check No: 09817/075579812
Page 3 of 3 (1)
tient Name: HOWARD ZIEGLER (self)
Coo. it): F,IPAK0192N00 Recd: 12/30/09 Member ID: W144251965 Patient Account: 200902789
Meirli er: HOWARD ZIEGLER DIAG: 78650 7231
Group Name: CBS CORPORATION Group Number: 820408 -41 -016 XR CAROYO
Product: radnio Choice() Network ID: 00000
Aetna Life Insurance Company
��PVICE PL RVICE NUM. SUBMITTED ALLOWABLE COPAY NOT .....SEE DEDUCTIBLE:. CO PATIENT PAYABLE
DATES -,ODE SVCS CHARGES AMOUNT AMOUNT PAYABLE ';REMARKS INSURANCE• RESP AMOUNT
11/10109 41 A0427SH 1 0 375.00 300 00 1 75:00
11 /10109 41 A0425SH 2 0 13.10 10.48 1 2 -62
TOTALS 388.10 310.48 77:62
I SSUED.AMT: $77.62
Remarks:
1 This amount was paid by P.4edicare, which is the primary carrier. The member is not responsible for this amount.
For Questions Regarding This Claim P.O. BOX 14079. LEXINGTON; KY.-40512,4079 Total .Patient Responsibility: $0:00
CALL (888) 632 -3862 FOR.ASSISTANCE
Note, All Inquires should reference the ID numherabove for prompt response, Clalm Paymont $77 62
Total Payment to .CITY .OF' FIRE D EPT
Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be
prepared to provide your Aetna provider number, tax identification number (TIN), or Snciai Security number (SSN), in addition to the Aetna member's ID number.
025787 J1k2PJ8 712428
1 16 LAIM PAYMENT.
k A etna P.o. sox 987 TX 79998-1106
USA
Please Retain for Future Re *rents
125787 J1K2p.ra. 071241 CITY OF CARMEL FIRE DEPT. I PIN: 0005145100
Pagel of3(1)
CITY OF CARMEL FIRE DEPT.
2 CIVIC SQ w
CARMEL IN 46032 -2584
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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
AkWard_ I et- Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1/14r- 5 ee 7 j yycp a yin eid 7 7 Co
Total 4- 7
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.
l ALLOWED 20
IN SUM OF 7 7, 7
GZ 1()J/i)77 4ri /75s
darrnei,T /4-e
Z
ON ACCOUNT OF APPROPRIATION FOR
ya e1-1a7 //t/u
42,'o
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
Kg -1 Sig
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund