182135 02/03/2010 CITY OF CARMEL, INDIANA VENDOR: 363870 Page 1 of 1
j ,i 4 ONE CIVIC SQUARE LINDA WEISS
1z a CARMEL, INDIANA 46032 10329 N NEW JERSEY STREET CHECK AMOUNT: $236.79
-4,, o o INDIANAPOLIS IN 46280 CHECK NUMBER: 182135,
CHECK DATE: 2/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 236.79 AMBULANCE REFUND
i
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
rx'
Bill To: RONALD WEISS ICD -9: 7802 78079 7231 78702
10329 N NEW JERSEY ST
INDIANAPOLIS, IN 46280
From: 10329 N NEW JERSEY ST
To: ST. VINCENTS HOSPITAL CARMEL
1 SAGAMORE HEALTH
Patient: LINDA WEISS 0198138E
10329 N NEW JERSEY ST Insurance
INDIANAPOLIS, IN 46280 2
Patient No:
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
$394.65 $631.44 236.79
CPT
Date Description Charges Credits
10/29/2009 ADVANCED LIFE SUPP 1 -EMIR A0427 $375.00
10/29/2009 MILEAGE A0425 $19.65
12/23/2009 PAYMENT $394.65
01/20/2010 COMMERCIAL INSURANCE PAYMENT $236.79
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/21/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 113# 356000972
y G
8111 To: RONALD WEISS ICD 9: 7802 78079 7231 78702
10329 N NEW JERSEY ST
INDIANAPOLIS, IN 46280
From: 10329 N NEW JERSEY ST
To: ST, VINCENTS HOSPITAL CARMEL
1 SAGAMORE HEALTH
Patient: LINDA WEISS 01981388
10329 N NEW JERSEY ST Insurance
INDIANAPOLIS, IN 46280 2
Patient No:
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
$394.65 $394.65 $0.00
CPT
Date Description Charges Credits
10/29/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
10/29/2009 MILEAGE A0425 $19.65
12/23/2009 PAYMENT $394.65
01/20/2010 COMMERCIAL INSURANCE PAYMENT $236.79
01/21/2010 REFUND 236.79
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
20 -fi373 1 S
'LINDA "'R WE�SS 1 08 127276561
ISS
I30I�lALD A;
10329 N:NEW JE RSEY ST. DATE
INDIANAPOLIS IN '4 6 280 ]359
PAY TOTE
ORPEROF"
�0. iur
HCH Adnlinititratjon
Innovative Solutions ancf Quality Service
P.O. Box 1986
Peoria- IL 61656 -1986
20IOUI1SUt:3
Forwarding Service .Requested if you have auty questions, pkcase call customer sea-vice
at
3 -DIGIT 46L] (31)9) 673 -7331) or (81)0) 447 -3227 m
9947 U•38ZU AT U•3S7
III' II' I In II1II Irt!' t1 IIlil1IiIs i iIII,i iIIIIi1 IIInuJhuihiii( Ern! )IoVee: RONAI.,D w .jss s
CARMEL FIRE DEPT AMBULANCE Patient: LINDA WEISS i
CARMELC IN 46032 -2584 a3 Group: IVY'I ECI -I COMM4JNTI'Y COLLEGE
Group ASI1'CC
Claim 07613872 -03
^ems 9I1�1, 1 Account#:
f a ,;w.� T' LDate: 04/]2/2010
Explanation of Benefits for Services Provided By:
CARMEL FIRE DEPT AMBULANCE
UatesorSenlce Ser�trc CPT 1 footh roll I Not hRersun D,scowitt Covered I3�' l Duluctible C:o -Puy Balanct Paid Payment f
C`., e Cole �nurxhet� Amount I Cored uaIr- Pint* Attnoun[ Atnouut At Amount fl
10/29- 10I29f2009�53 A0427 375 -00' 000 0.00 375.00 0.00 0.00 375.00 60% 225.00
10/29- 10/29/2009 53 A0425 1965 0.00 ()OU 19.65 0.00 0.00 19.65 60% 11.79
TOTALS j 394.65 (1.60 394.65 O.00I O.6Ol 394.65 236.79
Otlter Insurance Credits or Adjustments 0.00
total Nel Payment L 236.791
Patient Kesponsibiiity to Provider 157.86
Service Code
Messages
For electronic claim suhmissioa to Emdeon, use payer number 371 1 L Please allow 3 weeks following submission of a claim to follow -up on its
status.Ll hank you.
1,
r1 .F G #�Y1
r} -t'S z -:iii +t,�. r
s .F;r� irs. N �WY�t
tk 3.-� 3.:{r 5� tk r r f st. �xk t ,f �f r 1I
Z `fiy s. rs. r `Sr
zs "'�1.: z t:p si wry x x �f3•c s g„ t r ,x S% '?.k; i a, F ^`y t� xa .r.. ,,��_v' 3' Y �F%- 's�'.�'"'�.
t r r wr aaYs tt 3 ='c s°t��. i,. S'"� .i �a s$?�"�1w a:.'? t '�_ru �i .�a r�' .;Y''
t1x�Erz 7 _.ili.�. J :,.�fk zr ..:el r �gq:r� en�kne;�"a c �z._. r .t y,frRt: 'd' b ,�w x:.:^� z !$C f F t �'nt"� -�::y. �...v
a- :rtt xs' u r r
'�4t v l r,s r F r ai a`, r r fir:: i t
a
4 x1-1 �i�
�FOpASEC RII1$1'1#F�.U.RPOS,S�TyHE FACE DOCUM4T;tCD1+lTA'tfilS t1A 8L'UE 9l_iGICC4l�dQiV 0 Ab[CIfMICRCJPIIN7f1V4 RkkfC8ClR13E y t
�v .,}r' *7 tf j'' v ,�ii5 1 I :I- 7ii I. t 1' ''w rv1.,;°N, i�... '3 N i.l -.i r v f'i I �'''',r�`&�.l�.f l.�
'1( m li
i 1 zi 1 .r t
it Ll`Eg15tS�C11L11]rT1ls1I1'all CQinpany� a �l r'^a{ t 4��� I! i 6o,295Y'= 1
Insureds �Narn RONALI) WEISS 3 f ]I]S 't i tE y_ T 'j i I '3
t ISSUE DATE t 01/12/2014
1?attentlslfalne .'�';?Y;INI�A Vi!EI55 �:C.latm; '0.76= 43$72 -03:.,'. i,
Aceottnt'NumbCr200902.706 VOti) Ih NOT CASHIa) W1 rHIN 120 »AYS AMOUNT
PAY.TWO HUNDREDTEEIRTY -SIX DOLLARS AND 79 CENTS
TO THE CARMEL FIRE DEPT AMBULANCE
ORDER OF 2 CIVIC SQ L 1
CARMEL IN 46032 -743
&T ItAN1:
A1;1'OONA, PA 16601 Authorized Signature
j DO` NOT- CASH'IFWA7Ef3MARiEIISiNOT PRESENT "ON;aT,MEREUER5E51DE OF THIS(DOCUMENT;;;,HOL'D AT AN *ANGGETO:YI =W
11 °OOOOBb6011° ta0 02955t: 98433 ?069411°
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
S S Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
,uhota_ fe, SS
Total '$02 36, 7 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.
I ALLOWED 20
2dik I,() ef's IN SUM OF 36. 7
)03 29 /V A le1 eisev St
r7O(.; a f iDto 5 1- Flo z ,Rd
2 ea. 7
ON ACCOUNT OF APPROPRIATION FOR
�rltbJaILC'� Fir?/A/O /9 70
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify 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
FEB -12010
7
b
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund