184814 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