HomeMy WebLinkAbout184151 04/14/2010 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
ONE CIVIC SQUARE AETNA CHECK AMOUNT: $370.85
CARMEL, INDIANA 46032 PO BOX 981107
a EL PASO TX 79998 -1107 CHECK NUMBER: 184151
CHECK DATE: 4/14/2010
DEPARTMENT ACCOUNT PO NUMBER I NVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 370.85 OTHER EXPENSES
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1 p °x 9,9110(5 9,9110(5 EXP LANATION C)F BEIVEI�ITS
�A usaASO 7x 79993-1106
Please Retain for Future Referent
006648 J280DUA2 023864 CITY OF CARMEL FIRE DEPT. PIN: 00057451C
Check No: 09817i0741210C
Page 2 of 3
Date Prinied 1111712009'
CITY OF CARMEL FIRE DEPT. Tax Ideniification Number XXXXXXXX0972
2 CIVIC SO
CARMEL IN 46032 -2584
RECEIVED NOV 2 4 �00�
Notes:
Update your address, telephone number, email address and /or NPI information by visiting www.aetna.com /provweb/ or
www.aetnadental.corn and select Update Personal Information.
Patient Name: REBECCA COOLIDGE (self)
Claim ID: EKAAJ6C2800 Recd: 11104/09 Ivlember ID: W1.69390120 P'ifient Account: 200902489
Member: REBECCA COOLIDGE DIAL: 7295 V222 E8181
Group Name: THE CAPITAL GROUP COMPANIES, INC. Group Number: 783362 -13 -006 A V1<%AO
Aetna Life Insurance Company Network ID. Q0000
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10!05109 41 40429SH 1.0 325.00 325 G(
10105109 41 A04255N 7 0 45.85 x
S 370.85 370.8!
ISSUED AMT:`: $320..85
For:Questions Regarding This Claim P. G SOY, 14079 LEXIhJGTON .KY 40512 4079.. Total R.atlent Responsibility. SO.DD
CALL (888:): -3862 FOR ASSISTANCE
Clain Payment
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008648 J28013UN2 023863 cif CITY OF CARMEL FIRE DEPT. PIN: 0005745100
Page 1 of 3
CITY OF CARMEL FIRED EPT.
2 CIVIC SQ
CARMEL IN 46032 -2584
RECEIVED Nov 2
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CARMEL FIRE DEPT AMB SERVICES
2 CIVIC SQUARE
CARME IN 46032 2584
Insurer: ERIE INSURANCE EXCHANGE
Policy No.: 0032411604
Claim No.: 061010610211541
RECEIVED MAR 2 5 2010
Date of Loss: 10 -05 -2009
Check No.: 101790072
CMS No.: JQ90072
Check Amt.: $370.85
For. PARTIAL PAYMENT
PATIENT: REBECCA COOLIDGE, ACCT 200902489
SERVICE DATE: 10 -05 -2009 TO 10 -05 -2009
Erie Insurance offers home, auto, business and life insurance.
Call your local ERIE Agent to learn what is available in your area.
Bank of'Amedca'CustomerOonnection 64 =1276'
Bank of America, N.A.
1 Atlanta, Dekalb County, Georgia
ERIE INSURANCE EXCHANGE CLAIM NO.: 061 01 061 021 1 541 CHECK NO T01790072 m Home Office 100 Erie Ins. PI. Erie, PA 16530 DATE OF LOSS: 10 -05- 2009 DATE ISSUED:. '03-18-2010 r
F PJE CMS'NO J090072 c
0
PAY THREE HUNDRED SEVENTY AND 851100 m
a
OPERATOR 2U8COLEMAN
TO M
THE CARMEL FIRE.DEPTAMBSERVICES
TAX ID No.
ORDER 2 CIVIC SQUARE
OF CARMEL, IN 46032 2584
C_
J I
PARTIAL PAYMENT ERIE INSURANCE EXCHANGE rn
FOR PATIENT: REBECCA COOLIDGE, ACCT 200902489 AUTHORIZED sIGNATURE
SERVICE. DATE: 10 -05 --2009 TO 10 -05 -2009 ENCL
r
11° 10 1 7 9 00 7 2 11' j e06 1 11 2 7881: 3 29999949 2 11'
Date: 03/2912010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federa/1D# 356000972
Bill To: REBECCA M COOLIDGE ICD -9: 7295 V222 E8131
799 BENNETT COURT
CARMEL, IN 46032
From: 131ST ST &ILLINOIS ST
To: ST. VINCENTS HOSPITAL
1 AETNA US HEALTHCARE /981106
Patient: REBECCA M COOLIDGE W169390120
799 BENNETT COURT Insurance
CARMEL, IN 46032- 2
Patient No: 200902489
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
$370.85 $370.85 $0.00
CPT
Date Description Charges Credits
10/05/2009 BASIC LIFE SUP EMERGENCY A0429 $325.00
10/05/2009 MILEAGE A0425 $45.85
11/24/2009 COMMERCIAL INSURANCE PAYMENT $370.85
03/25/2010 COMMERCIAL INSURANCE PAYMENT $370.85
03/29/2010 REFUND 370.85
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 03/29/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederailD# 356000972
,CD a I,
Bill To: REBECCA M COOLIDGE ICD -9: 7295 V222 E8131
799 BENNETT COURT
CARMEL, IN 46032
From: 131ST ST &ILLINOIS ST
To: ST. VINCENTS HOSPITAL
1 AETNA US HEALTHCARE /981106
Patient: REBECCA M COOLIDGE W169390120
799 BENNETT COURT Insurance
CARMEL, IN 46032- 2
Patient No: 200902489
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
$370.85 $741.70 370.85
CPT
Date Description Charges Credits
10/05/2009 BASIC LIFE SUPP— EMERGENCY A0429 $325.00
10/05/2009 MILEAGE A0425 $45.85
11/24/2009 COMMERCIAL INSURANCE PAYMENT $370.85
03/25/2010 COMMERCIAL INSURANCE PAYMENT $370.85
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by Slate 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
e_ 6L Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
70 R5
l
t
Total Y5
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and 1 have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF 9 76 l� 5
go
9 76. }S
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
APR 12 2010
c
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund