183356 03/16/2010 CITY OF CARMEL, INDIANA VENDOR: 363978 Page 1 of 1
ONE CIVIC SQUARE CHERRONDA JOHNSON -BEY CHECK AMOUNT: $298.40
,a CARMEL, INDIANA 46032 13555 HEROIC WAY
FISHERS IN 46037 CHECK NUMBER: 183356
CHECK DATE: 3116/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 298.40 REFUND
Date: 03/04/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
U v Z. w:
Bill To: CHERRONDA JOHNSON -BEY ICD -9: 7840 78079
13355 HEROIC WAY
FISHERS, IN 46037
From: 11595 N MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
CIGNA 1 5200
Patient: CHERRONDA JOHNSON -BEY U3311842104
13355 HEROIC WAY Insurance
FISHERS, IN 46037- 2
Patient No: 200902588
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$331.55 $331.55 $0.00
CPT
Date Description Charges Credits
10/15/2009 BASIC LICE SOPP- EMERGENCY A0429 $325.00
10/15/2009 MILEAGE A0425 $6.55
02/09/2010 PAYMENT $331.55
03/02/2010 COMMERCIAL INSURANCE PAYMENT $298.40
03/04/2010 REFUND 298.40
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 03/04/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032
(317)571 -2605 FederalID# 356000972
Bill To: CHERRONDA JOHNSON -BEY ICD -9: 7840 78079
13355 HEROIC WAY
FISHERS, IN 46037
From: 11595 N MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
1 CIGNA 15200
Patient: CHERRONDA JOHNSON -BEY U3311842104
13355 HEROIC WAY Insurance
FISHERS, IN 46037- 2
Patient No: 200902588
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$331.55 $629.95 298.40
CPT
Date Description Charges Credits
10/15/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
10/15/2009 MILEAGE A0425 $6.55
02/09/2010 PAYMENT $331.55
03/02/2010 COMMERCIAL INSURANCE PAYMENT $298.40
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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Pi oviderEx lancatiQn o Medica an
l Payment
Understanding this Benef Statement
This page provides a summary of the payments made this period.
The accompanying pages give more detail on the claims we processed for this period. Please review both the Front and back of each page to see how the
benefit anioun is in the Provider Explanation of Medical Pm
aveiit Report were determined.
In the event a claim is denied......
Rights o fReview and Appeal For Physiciaii or Health Care Provider
1f)'011 have questions or disagree with the paymen L iden tifed e u aa
on this Explanation of Medical Payment Report, yo rry ask to have it reviewed.
If you have a contMCLL131 agreement with CIGNA Healthcare, please refer to the procedural guidelines associa ted with your CIGNA 1lealihCare.
contract, or call our office for assisrmce.
Rights o fReview and Appeal For Employee
Call Meniber Services at the toll free nunrher on this GAplanation of Benefits (LOB) or your ID card if you have questions regarding
this LOB.
If you're not satisfied with this coverage decision, you can start the Appeal process by submitting subitting a written request to the address
listed in your plan materials within 1$0 days of receijpt of this 1:013 (1-1171 iss a longer tune is permitted by your plan
Send a copy of this EOB along with any relevant additional inforinaticm (e.g. benefit documents, clinical records) which helps to
demonstrate that your claim is covered under the plan. Contact lvleniber Services if you need further instructions on how and
where to send your request For review.
Be sure to include your 1) ]lame, 2) Operation Location /Group Number, 3) Enrplovee/Patient Ill number, 4) Name of the patient
and relationship, and 5) Attention: Appeals Unit" on all supportili documents.
You ar entitled o receive free upon request access to, and copies of, all documents, records and other information relevant to
vour claim for benefits
Vou will be notified of the final decision in a timely manner as described in your plan materials. If your plan is governed by
FRISA, you also have the right to bring legal action under Section 5 ofERISA following our review.
Payment Slainin.airy
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order N
t Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s)) pp
Total 1_�
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARnANT NO.
ALLOWED 20
IN SUM OF$
g y
ON ACCOUNT OF APPROPRIATION FOR
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
REAR 15.2010
f a
r
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund