182985 03/03/2010 CITY OF CARMEL, INDIANA VENDOR: 272800 Page 1 of 1
ONE CIVIC SQUARE RIVERVIEW HOSPITAL
CHECK AMOUNT: $65.00
CARMEL, INDIANA 46032 ao Box zzo
NOBLESVILLE IN 46060 CHECK NUMBER: 182985
CHECK DATE: 3/3/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 800472259 65.00 MATERIALS SUPPLIES
:RIVERVIEW HOSPITAL
PO BOX 220 02/14/10 OP 0270
NOBLESVILLE, IN 46061
TURNER, DAVID L 800472259 M 49 09/05/60 02/10/10 02/10/10 FINAL
CARMEL UTILITIES, CITY OF WORK MED 306782951
ATTN: ACCOUNTS PAYABLE
9609 HAZEL DELL PARKWAY
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
DETAIL OF CURRENT CHARG
02/10/10 WORK REL HEPATITIS A VACC(AD 90632 48500882 1 65.00
800472259 02/14/10 65.00
°RIVERVIEW HOSPITAL
PO BOX 220 02/14/10 OP 0270
NOBLESVILLE, IN 46061
TURNER, DAVID L 800472259 M 49 09/05/60 02/10/10 02/10/10 FINAL
CARMEL UTILITIES, CITY OF WORK MED 306782951
ATTN: ACCOUNTS PAYABLE
9609 HAZEL DELL PARKWAY
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
SUMMARY OF CHARGES 6 5 0 0
PHARMACY 65.00
SUB -TOTAL OF CHARGES 65.00
PAYMENTS /ADJUSTMENTS NONE
SUBTOTAL PAYMENTS /ADJUS NONE
BALANCE 65.00
800472259 02/14/10 65.00
RIVERVIEW HOSPITAL 2 RIVERVIEW HOSPITAL 3a PAT, 800472259
CNTL#
7P_6 BtX 'PO BOX 220 b, MED� UU9350792
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NOBLE "4 6061 NOBLESVILLE IN 460-60 5 FED. TAX NQ 16 STATEMENT COVERS PERIOD
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(31:7Y 77'6-73:4'1� (317Y 77'6 7433 35rl28'9'4'3j2 /'l7G i 0 T0 2 10
6 PATI NAME 9 PATIENT ADDRESS —4'870-U-W-n-3-2
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b I TURNER, DAVID L N
ADMIS CONDITION CODES 129 ACOT 1 30
10 SIRTHDATE 111 SEX 112 DATE 13 HS' i R 7 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE
0 7 9 7 7 0 5 /I:9 60 F R 9'27'170 /'370 FI 6 i i i. I I 3 I I T I I I I 1 1
31 OCCURRENCE 33 OCCURRENCE 35 OCCURRENCE SPAN as OCCURRENCE SPAN 37
0., CODE
CODE DATE 016 DATE CODE FROM THROUGH CODE FROM THROUGH
rl 20 T
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ie CAJ I S, C-fT F 39 VALUE C I ODES 41 VALUE CODES
ATTN ACCOUNTS PAYABLE a CODE AMOUNT m CODE AMOUNT
INDIANAPOLIS IN 46280
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1111 W 1IF-APT1.11 44 HCPGS f RATE I HIPPS CODE 45 SERV. UATE 46 SEAV UNITS 47 TOTAL CHARGE$ NON C-Ellr 14�
0250 PHARMACY 90632 02/10/20 65�00
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21 C)ool PAGE 1 OF 1 CREATION DATE -5/ m 0 1
150 PAYER NAME 51 HEALTH PLAN ID 57 FIL W ASG 55,EST. AMOUNT DUE 56 NPI
0 54PRIqRFAYMENTS
WORK MED Y Y 6t 0-0- A
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PAV 10
58 INSURED'S NAME 59PREL 60INSURED'S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.
TURNER, DAVID 2 0 3'T67 8'2'Y5r A
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63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
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69 ADMIT V053 70 PATI ENT 171 PPS 172 1 73
OX I REASON DX CODE ECI
74 PRINCIPAL PROCEDURE fl br OTHER PROCEDURE '16 76 ATTENDING NPI 1-Z�
CODE DATE oil— CODE DATE El ZABETir
LAST FIRST
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CODE DATE 77 OPERATtNG jNPt QUALl I
TY LAST jFinST
780THER I INPI 1 1
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ATTN ACCOUNTS PAYABLE' b LAST FIRST
9 6 0 9 PARKWAY 79 OTHER -Pl I QUALI I
INI)IANA-POLIS IN 4 628 0 d LAST �FIRST
OB-04 CMS-1450 APPROVED OMB NO. 0938-0997 11-1- BILL AND ARE MADE A PART HEREOF.
UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
CIVIL MONETARY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAIN(S).
sion of this chin; constitutes certification tha t th e billing b) The patient has represented that by a reported residential address
g
Woi oration as shown on the face hereof is hue, accurate and complete, outside a ri medical treatment facility catchment area he or
That the submitter did not knowingly or recklessly disregard or she does not live within the catchirnent area of a, U.S, military
misrepresent or conceal material facts. The following certifications or medical treatment facility, or if the patient resides within a
apply where pertinent to this BiT catchment area of SLKh a faoi!ity, a copy of Non-Availability
I I't,hird party benefits are indicated, the appropriate assignments by Statement (DD Form 1 25 1) is on file, or the physician has certified
the insured /beneficiary and signature of the patient or parent or a to a medical emergency in any instance where a copy of a Non-
legal Guardian covering ar.ithorization to release information are on file. Availability Statement is not on file;
Determinations as to the release of medical and fi nancial information (c) The patient or the patient's parent or guardian has responded
should be guided by the patient or the patient's legal representative. directly to the provider's request to identify all health insurance
2. If patient occupied a private room or required private nursing for coverage, and that all such coverage is identified on the face of
medical necessity, any required certifications are or file. the claim except that coverage which is exclusively supplemental
payrnents to TRICARE- determined benefits
3. certifications and if required by contract (d) The amount billed to TWCARE tias been billed after all such
or Federal regulat are on file. coverage have been billed and paid excluding Medicaid, and the
4. For Religious Non-Medical facilities, verifications and it necessary to- amount billed to TRICARE is that remaining claimed against
certifications of the patient's need for services are on file. TRICARE benefits;
5. Signature of patient or his representative on certifications, (e) The beneficiary's cost share has no; been waived by consent or
authorization to release information, and payment request, as failure to exercise generally accepted billing and collection efforts;
required by Federal Law and Regulations (42 USC 1935f, 42 CFR and,
10 USC 1071 through 1086, 32 GFR 199) and any other
q24 (f) Any hospital-based physician under contract, the cost of whose
applicabie contract regulations, is on file.
services are allocated in the charges included in this bill, is not an
6L The provider of care submitter acknowledges that the bill is in employee or mernber of the Uniformed Services. For purposes of
conforrnanceajfh the Civil Rights Act of 1964 as amended. Records this certification, an employee of the Uniformed Services Is an
adequately describing services will be maintained and necessary employee. appointed in civil service (refer to 5 USC 2105),
rJormation wili be tarnished to such governmental agencies as including part -time or intermittent employees, but excluding
required by appl'tcable law. contract surgeons or other personal service contracts. Similarly,
member of the Uniformed Services does not apply to reserve
7. For Medicare Purposes: If the patient has indicated that other health members of the Uniformed Services riot on active dutv.
insurance or a state medical assistance agency will pay part of
his/her medical expenses and he/she wants information about (g) Based on 42 United States Code 1395co(a)(1)(j) all providers
his/her claim released to them upon request, necessary authorization participating in Medicare must also participate in TRICARE for
is on file. The patient's signature on the provider's request to bill inpatient hospital services provided pursuant to admissions to
Medicare medical and non -rnPdi,-,a1 information, including hospitals occurring on or after January 1, 1987; and
eiriploymerit status, and whether the per has employer group (h) If TRICARE benefits are to he paid in a participating status, the
health insu which is responsible to pay for We service for
�vhich this Medicare claim is macle. submitter of this claim agrees to submit this claim to fl-rE�-
appropriate TRtCARE claims processor. The provider of care
8, For Medicaid purposes The suornitter understands that because subm.11ter also agrees to accept the 7PjCARE dc erriirie_d
and aabstacticriof fiiis ciaim will be from Federal and State rca,�orRbie charge as the total charge for the nred$'eai, or
funds, arty false statements documents, or concealment of a supplies listed on the dRirn form. The provider of care �A/ill accept
materiai fact are subject to prosecution under applicable Federal or the TRICARE-determined reasonable charge even if it is less
State, Laws than the billed amount, and also agrees to accept the amount
paid by TRICARE combined with the cost-share amount and
9. For TRICARE Purposes: deductible amount, if any, paid by or on behalf of the patient as
(a) The information on the tare of this claim is true, accurate and full payment for the listed medical services or supplies. The
complete to the best of the submitter's knowledge and belief, and provider of care submitter will not attempt to collect from the
services were medically necessary and appropriate for the health patient (or his or her parent or guardian) amounts over the
of the patient; TRICARE deter mined reasonable charge. TRICARE will make
any benefits payable directly to the provider of care, if the
provider of care is a participating provider.
SEE h it ww v,! n u b c c, r a,/ FOR MORE INFORMATION ON UB-04 DATA ELEMENTAND PRINTING SPECIFICATIONS
VOUCHER 097385 WARRANT ALLOWED
272$00 IN SUM OF
RIVERVIEW HOSPITAL
PO BOX 220
NOBLESVILLE, IN 46061
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
800472259 01- 7202 -05 $65.00
Voucher Total $65.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)i
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, Kind of service, where
performed; dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
272800•
RIVERVIEW HOSPITAL Purchase Order No.
PO BOX 220 Terms
NOBLESVILLE, IN 46061 Due Date 2/23/2010
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
2/23/2010 800472259 $65.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and
correct and I have audited same in accordance with fC 5- 11- 10 -1.6
Date Qffi r