183245 03/16/2010 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH M& AMOUNT: $167.00
CARMEL, INDIANA 46032 P 0 BOX 19383
INDIANAPOLIS IN 46219 CHECK NUMBER: 183245
CHECK DATE: 3/16/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1192 4347000 261260 167.00 WORKMEN'S COMPENSATIO
PLEASE
DO NOT Carmel Administratlon
STAPLE
sue coy RECEDED
IN TIHIS 1 Civic Square MA 1 I1vl
AREA Carmel, IN 46032
PICA HEALTH INSURANCE CLAIM FORM
nmmwmn�mm�anans
I"? MEDICARE I MEDICAID CHAMPLIS CHAMPWA. GROt,' EECA 0TkE. la. iNSURED'S f L'.i Ufv'idLR i F� �1
{Meaicarekl L 1 (Medicaid�l El (Sponsor's SSW 11 tVA File 4) 1:1 '(3SNror'n7j LAN %6� UNG (ID1 312 64 567.E
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PA 6FNL YIRTP DATE SEX 4. INSURED'S NAME (Last Name,First Name,Middle Initial)
Miser William C 09: 26 1955 M® F Carmel Administration
PA IENT'S ADDRESS (No. Streeq 6. PATIENT'S R ELATIONSHIP TOINSURED 7. INSURED'S ADDRESS (No., Street)
5208 Roland Dr self Spouse Child Other I Civic Square
C ITY STATE B. PA FIFNI STATUS CITY STATE
Indianap IN Single Married❑ Other [E Carmel IN
ZIP CODE TELEPHONE (Include Area Code} ZIP CODE TELEPHONE (INCLUDE AREA CODE)
Full Time Part -Time
46228 317 254 1055 Emplo Student El Student 46032 317 571 2465
9, OTHER INSURED'S NAME (Last Name, First Name. Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
NONE
a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT CURRENT 0 .PREVIOUS) a. INSURED'S DATE OF BIRTH SEX
NONE YES El NO naNa, Do YY M F
b. OTHER INSURED'S DATE OF BIRTH SEX b. AUTO ACCIDENT? PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME
MIA DD YY
M F YES NO
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME
YES NO Citizen's Management Inc.
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
BILL, COMPANY YES NO If yes, return to and complete Item 9 a -d.
READ BACK FORM BEFORE COMPLETING SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or o!her information necessary payment of medical benefits to the undersigned physician yr supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. services described below.
SIGNED SOS' DATE 03 08 2010 SIGNED SOP
14. DF; OF &URgNT: ILLNESS (First symptom) OR 5. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16, DATES PATIENT UNABLE TO WORK IN CURRENT OCCtJPATIOfJ
l t I D 1 INJURY(Accident)OR PAM 00 YY N1M DD YY Mm D� YY
01 2 1 2010 PREGNANCY U IP GIVE FIRST DATE FROM T O
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 1$. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
DIM DU YY MIA DD YY
FROM TO
19. RESERVED FOR LOCAL. USE 20, OUTSIDE LAB? S CHARGES
0 YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 7V 22, MEDICAID RESUBMISSION
CODE ORIGINAL REF NO.'
1. t 847.2 Sprain /strain lumbar back 3 t E885.9 Fall,slip,trip on same level
23, PRIOR AUTHORIZATION NUMBER
2. L 724.4 Thoracic /lumbosacradiculitis,neuritis 4.
24. A B C D E F G H I J K
DATE(SJ OF SERVIC Place Type PROL'ED JRES SERVICES OR SUPPLIES DIAGNOSIS DAYS EPSDT RESERVED FOR
From To of 0f (Explain Nusual Circumstances] CODE CHARGES OR Family EMG COB LOCAL USE
MM DO YY N1M DO YY Service Servic CPT /HCPCS MODIFIER UNITS Plan
NDC# 00591- 0338 -01 1 1 .2
1 03 01 2010 03 01 2010 11 92 Diclofenac Sodium 50mg; #330 105 00 1.00 01048910A
NDC4 60793- 0136 -05 1,2
03 01 2010 03 01 2010 11 9 Sketaxin 800mg; #30 126 1.00 01048910A
99202 1 2
03 01 '2010 03 012010 i'1 1 First Visit Expandcd, Problem Focused 167 :00 1 1.00 01048910A
i
25. FEDERAL TAX I,D. NUMBER S5N BIN 26. PATIENT'S ACCOUNT N0. 27. ACo�goPT�LS eNMoECNx4? 28. TOTAL CHARGE 29. AMOUNT PAID 30. BALA NC E DUE
35- 1955223 Inv 261260 �f YES NO 398 ;00 0 :00 3W00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, NAME AND ADDRESS OF FAGILI FY WHERE SERVICES WERE 33, PHYSICIAN'S, SUPPLIE' 'S BILLING NAME, ADDRESS, ZIP LODE
INCLUDING DEGREES OR CREDENTIALS RENDERED (It other than home or office) 8 PHONE Community Occupational I lealth Services
(I certify that the stalemenis on the reverse apply MedCheck Carmel P.O. Box 19383
to this bill and are made a part thereof.)
S. DBt8r1 MD
11911 N. Meridian St., Ste.] 50 Indianapolis, IN 46219
Carmel, IN 46032
03/08/2010 Ph: 317-355-6335
SIGNED DATE Ph: 317- 621 -6704 PIN# GRP# 0104891.OA
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE BW) PLEASE PRINT OR TYPE APPROVED QMB- 0936 -9008 FORM HCFA -1500 (12 -900 FORM OWCP -1500 FORPI RRB -1500
o: \REPORTS \BILLING \HCFA 1500v7.23#0599 APPROVED OMB- 1215 .0055 FORM OINCP -1500, APPROVED Or,10-9?20 0001 (CHAMIIUSr
VOUCHER NO. WARRANT NO.
ALLOWED 20
Community Occupational Health Services
IN SUM OF
P.O. Box 19383
Indianapolis, IN 46219
$167.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS Department
PO# Dept. INVOICE NO. ACCT# /TITLE AMOUNT
Board Members
1192 261260 43- 470.00 $167.00 1 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
Monday Mar h 15, 2 0
,c
Dir, or, DOCS
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
r.+
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
03/11/10 261260 Bill for Craig Miser $167.00
I
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
1 20
Clerk- Treasurer