183496 03/16/2010 CITY OF CARMEL, INDIANA VENDOR: 363981 Page 1 of 1
ONE CIVIC SQUARE DENISE WATSON CHECK AMOUNT: $200.00
CARMEL, INDIANA 46032 Po Box 280
ARCADIAIN 46030 CHECK NUMBER: 183496
CHECK DATE: 3/16/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 200.00 OTHER EXPENSES
DENISE N LOGAN ZOH8
BROCK'.A' WATSON Brock kDenise Watson 20-7404/2740
8936 BRYANT NE APT.
IINQIANAPO S,IIN-.46520 3A
L PO Bo 2$0' 1 aaMCHaa
Arcadia IN 46030 DATE
PAS TO THE Cav YYe. f C" I 17-
ORDER OF
C)L7 DOLLARS
la
FOR
1; 2 20138
DENISE N- INATSON;
BROCKA',WATSON' 720� P.O, BOX 280
RCAAIA, IN 46030 A
PAY TO THE DATE
ORDER OF
.1
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DOLLARS' 8 o
o
FOR
5 7
e
20' 74041 2740
9RANGH 23
pENISE;N �yATSON
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ARCADIAr VN p
PAY TO Tl DOLLARS e
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Ha�iantl Llarke
DENISE,N, WATSON
B RO C K A 0 :WATSON 20- 74D4/274 e ANCH 23
P.O. BOX 28'
ARCAOIA, IN 46030 C
'-:r DATE
P�� THE d
ORDER OF
9 er6
DOI�LAILS
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Harigad Glarke
INDIANA TEAMSTERS HEALTH BENEFITS FUN
1233 S['F -1-13Y STREET
WDIANAPOLIS, INDIANA 46203
RECE MA PHONE 317 /639 -3573
FAX 317 639 -3548
LONG DISTANCE 1-800 -859 -6862
EMPLOYER: PLAN NUMBER:
PARTICIPANT:
PROVIDER:
3 �C v i ICI= .�r `r}'.TMC:k� i
21 C _PlrjCt ARE
IN 460322 00
E'XPL`e4N T' ICI ®'F..BE�IEFI�S.0
1.505564
EMPLOYEE ID NUMBER PATIENT DATE
n3N 7_2 fir
a 0J' 1 3
PROVIDER DATE CHARGES ALLOWED DEDUCTIBLE WRITEOFF /GOB BENEFIT CODE
I 1''rr_ r� EP.� GE NICY t /1to fi1
6' 60
S�'{
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CODE
'[3EI7UCTT '4'I'F1i3ON
DEDUCTIBLE TAKEN, THIS BENEFIT YEAR
DEDUCTIBLE TO BE APPLIED ON FUTURE CLAIMS ,0
FAMILY DEDUCTION TAKEN THIS BENEFIT YEAR
PAID BY OTHER CARRIER 31 74
NATIONAL CITY BANK
INDIANA TEAMSTERS 'H //pp pp N�W FUND
�d�LT9� .16�E9�'E��TS. F i.D9\ID DATE
INDIANAPOLIS INDIANA 46255 NUMBER
NU ER
20 -6/740 1233 S F1 E
LBY STREET
INDIANAPOLIS, ;INDIANA 46203 ?5f i 0
15 0 5.516 4
GROUP NO 1'D ::NUMBER COVERED PERSON` CLAIM NO. CLAIMANT ACCOUNT Y
�d ?31i ?9 BKU1 `..r,; 13 I "s ;7 ria3 c
PAYTH REE HUB=' 7z;, T i 'lNI w Q1,;=
VOID,180 DAYS FROM ISSUE
TO THE CARNED FIRE I:iEPARThlE ?a v.
ORDER
OF
'AR L INS 4 6-22 01
ih
AUTHORIZED SIGNATURES
u° 50 S 56411 1:D 7400006 Sao
5D�9830 ?911
Date: 03/12/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bili To: BROCK WATSON ICD -9: 78039 78009
108 N WEST ST P.O. BOX 280
ARCADIA, IN 46030
From: 275 MEDICAL DR
To: ST. VINCENTS HOSPITAL CARMEL
I IND TEAMSTERS /HEALTH BEN
Patient: DENISE N WATSON 7213004696
108 N WEST ST P.O. BOX 280 Insurance
ARCADIA, IN 46030- 2
Patient No: 200901306
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
$351.20 $551.20 200.00
CPT
Date Description Charges
Credits
05/19/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/19/2009 MILEAGE A0425 $26.20
08/28/2009 PAYMENT $50.00
09/25/2009 PAYMENT $50.00
10/23/2009 PAYMENT $50.00
11/20/2009 PAYMENT $50.00
03/10/2010 COMMERCIAL INSURANCE PAYMENT $351.20
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 03/12/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
U N T
sin To: BROCK WATSON ICD -9: 78039 78009
108 N WEST ST P.O. BOX 280
ARCADIA, IN 46030
From: 275 MEDICAL DR
To: ST. VINCENTS HOSPITAL CARMEL
7 IND TEAMSTERS /HEALTH BEN
Patient: DENISE N WATSON 7213004696
108 N WEST ST P.O. BOX 280 Insurance
ARCADIA, IN 46030- 2
Patient No: 200901306
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
$351.20 $351.20 $0.00
CPT
Date Description Charges Credits
05/19/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/19/2009 MILEAGE A0425 $26.20
08/28/2009 PAYMENT $50.00
09/25/2009 PAYMENT $50.00
10/23/2009 PAYMENT $50.00
11/20/2009 PAYMENT $50.00
03/10/2010 COMMERCIAL INSURANCE PAYMENT $351.20
03/12/2010 REFUND 200.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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 No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�mhic sem over ZZx' (5'0
e�zi s a. _s
r'
Total
1 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.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. 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
LIAR 1
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund