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Home My WebLink About184814 04/27/2010 CITY OF CARMEL, INDIANA VENDOR: 364117 Page 1 of 1 ONE CIVIC SQUARE KEY BENEFIT ADMINISTRATORS CHECK AMOUNT: $270.48 CARMEL, INDIANA 46032 PO Box 55210 INDIANAPOLIS IN 46205 CHECK NUMBER: 184814 CHECK DATE: 4/27/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 270.48 REFUND CLAIM NO 14 -2402 -004 POLICY NO 1766- 090 -14B LOSS DATE 12 -21 -2009 PAYMENT NO 1 18 815780 J Coverage Description Amount COL Pay ''Cd> DATE 04 -16 -2010 MEDICAL PAYMENT $338.10 600 2 AMOUNT $338.10 TIN 14- 356000972 REMARKS 1 2121 /200 9 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 815780 J WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56-1544/441 MPC INDIANA 16-501 L025 COLUMBUS, OH 04 -16 -2010 DATE MM DD Y Y Y Y CLAIM NO 14- 2402 -004 INSURED RUDOW, WILLIAM LOSS DATE 12 -21 -2009 ON BEHALF OF KEVIN RUDOW *EXACTLY THREE-HUNDRED THIRTY -EIGHT AND 10 /10OZOLLARS 4 S` 338. 10 Pa to the Order of- CARMEL FIRE DEPARTMENT 2 CIVIC SQ CARMEL IN 46032 -2584 RECEIVED APR 2 0 2M APPROVED BY CLAIM NO 14 -2402 -004 POLICY NO 1766 090 -14B LOSS DATE 12 -21 -2009 PAYMENT NO 1 18 815780 J Coverage Descri tion Amount COL Pay Cd DATE 04-16-2010 MEDICAL PAYMENT $338.10 600 2 AMOUNT $338.10 TIN 14- 356000972 D REMARKS 12121/2009 "'STATE FARM MUTUAL AUTOMOBILE; `I NSURANCE� COMPANY 1 =1$ p81578 J' WEST LAFAYETTE',;IN JPMORGAN CHASE BANK,, NA 56'= T544/441 MPC. INDIANA 18 -501 /L025 COLUMBUS, rOH. X04 16 2010 DATE "MM DD Y'YYY CLAIM NO 14- 2402 -004 INSURED RUDOW; WILLIAM -LOSS DATE 12-21-2009 ON BEHALF OF KEVIN RUDOW W 1. EXACTLY THREE HUNDRED THIRTY -EIGHT AND 101100 DOLLARS 3 "3 g 10 Pal to the Order of. CARMEL FIRE DEPARTMENT 2 CIVIC SQ CARMEL IN 46032-2584 jr jr AUTHORIZED SIGNATURE '�y AUTHO D SIGNATURE i �I °�8L78�578011° Eo044b�5�4 3 105 2 6 290 2 3 30 Date: 04/20/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 At A -q Bill To: WILLIAM RUDOW ICD -9: 78652 7295 E8130 14370 RAVEN WAY APT 203 NOBLESVILLE, IN 46060 From: GUILFORD &CARMEL DR To: CLARIAN HOSPITAL NORTH 1 SAGAMORE HEALTH Patient: KEVIN RUDOW 415178187 14370 RAVEN WAY APT 203 Insurance NOBLESVILLE, IN 46060- 2 Patient No: 200903126 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $338.10 $608.58 270.48 CPT Date Description Charges Credits 12/21/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 12/21/2009 MILEAGE A0425 $13,10 04/01/2010 COMMERCIPL INSURANCE PAYMENT 5270.48 04/20/2010 COMMERCIAL TNSURANCE PAYMENT $338.10 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 04/20/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: WILLIAM RUDOW ICD -9: 78652 7295 E8130 14370 RAVEN WAY APT 203 NOBLESVILLE, IN 46060 From: GUILFORD &CARMEL DR To: CLARIAN HOSPITAL NORTH SAGAMORE HEALTH Patient: KEVIN RUDOW 415178187 14370 RAVEN WAY APT 203 Insurance NOBLESVILLE, IN 46060- 2 Patient No: 200903126 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $338.10 $338.10 $0.00 CPT Date Description Charges Credits 12/21/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 12/21/2009 MILEAGE A0425 $13.10 04/01/2010 COMMERCIAL INSURANCE PAYMENT $270.48 04/20/2010 COMMERCIAL INSURANCE PAYMENT $338.10 04/20/2010 REFUND 270.48 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 KEY BEN EFITADMINISTRATORS E��l�� genets PO Box 55210 JL) Il i Indianapolis, IN 46205 Provider Copy For►varding Service Requested For Customer Service or 24 -hour Medical Eligibility Verification, please call (81)0} 331 -477 Q 3 -DIGIT 460 N 7991 1.2958 AT D-479 Emplo gee: A1313F.' JOHNSON II'1' 1' I11111t1111 11111111' 111111illltllll "11111 �'11111' 'tlll'l, Patient: KEVIN A RU DOW CARMEL FIRE DEPT /AMBBULANCE Patient 200903126 E civic so sl Group 9084 CARMEL, IN 46032 -25134 Z Group: ME'I'fIODIS'F SP(3R'fS NIEDIC'INE C1 R r-' Location: 01 2D30 Claim 08593654 -01 itZCEa V i,D N►' K Date: 03/22/2010 Check 07574042 1 Send Medical Claims Elec ical1v Service. Description/ Total Negotiated C ode Ineligible Co -pay Deductible Covered Pay Cu Insurance Amount Incurred Dite Chargi,aiuut Charge e D g Payable dBIJLANCE 325.00 0.00 0.00 0.00 0.00 325.00 80 65.00 26o.oU 12/21- 12/21!2009 A%4BULAN�CE 13.10 0.00 0,00 0.00 0 -00 [3.10 90 2.t2J 10.49 12121-12/2 F2009 3 35.1 0 0 .00 0.00 0.0 200 33R.10� G7.62� 270.4$ Other Carrier Payment Antount: 0-0 'total Plan Payment Amount: T 270.E 1'dlessaLes Your 2009 deductible Las been satisfied. "x* ALWAYS USE 1 PAR'1ICI1 PROVIDERS "I'O IIECL':1 VE'F11E i CLA141 REINI BUR SENII::N'I' AND SAVIN( iS. K J` ASE RENIEMBER T'O FOLLOW THE NdAl1.IN(i DIRE'CT'IONS ON THE ID C,aRD FO 1"NSURE'I'IIE PROPER PPO PARTIC'IPA FIND PROVIDER OR NON- PARTICIPATING PROVIDER BENEFIT' I-JAS BEEN PAID. FOR SECURITY PURPOSES', THE FACE OF THIS DOCUMENT CONTAINS A BLUE BACKGROUND AND'MICROPRiNTING IN THE_ BORDER =IV1Ll HC)I)Ib r SPON 15 NIGDIC I1YL.GI N7 E It s z CHECK NO `07574(!42 201 P amsyly m1a Parltua} Siltte 325 Gi oup No soaa �4 4 lnd� ma oils I3� -16280 CIIumNu ')h5(665.4-1)1 Paticnt?.ct: r4o •1 0660312' ISSUE :U� /2� /2 {Tl0 �AM PAY TWO HUNDRED SEVENTY DOLLARS AND 18 CENTS *27 0.48 TO TH E CARMEL FIRE DEPT /AMBBULANCE ORDER OF JJ t HUNTINGTON Void after 90 days Authorized Signature DO NOT CASH4F WATERMARKIS NOT PRESENT ON THE'REVERSE SIDE'OF THIS'. DOCUMENT, HOLDAT AN'ANGLE'TO °.VIEW 1100 7 5 7 40 4 21i` 1.044��51261: 0L40013 S304711Q 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 C 1�K� ✓1 s Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total q? 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. WARRANT NO. ALLOWED 20 IN SUM OF D) X D 5/ D aoS ON ACCOUNT OF APPROPRIATION FOR tv 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 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund