186008 05/26/2010 a CITY OF CARMEL, INDIANA VENDOR: 364204 Page 1 of 1
s ONE CIVIC SQUARE LEO WERTMAN CHECK AMOUNT: $69.79
CARMEL, INDIANA 46032 75 ROSEWALK CIR APT #1G
CARMEL IN 46032 CHECK NUMBER: 186008
CHECK DATE: 5/26/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 69.79 OTHER EXPENSES
L
Re turn this portion with your payment
Payable To: CARMEL FIRE DEPARTMENT
201000496 LEO WERTMAN $69.79
Run Date I?EOLIT
02/14/2010 %-,TJ.L VED MAY 0 7 2010 Amount Paid 6'7. 7 c/
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMLL, 1999
1469
LEO W. WERTMAN 10-05 740
7:� ROSE WALK CIRCLE, APT eV j.C 1OJ185696
CARMEL, IN 46032
DATE
PAY TO THE
ORDER F 7
DOLLARS
20
MEMO
:
W6- 01486 *03 *004186 -PO- 10130 -80- 017 -FJ 110
CFPA20. 070705
UNITEDHEALTHCARE INSURANCE COMPANY �y ,,7}
RAILROAD CUSTOMER SERVICE CTR. U T7 nitednalalthCare
PO BOX 30304 A UnitedHealth Group Company
SALT LAKE CITY, UT 84130-0304
PHONE: 1- 877 842-3210
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DATE: 05/10/10
TIN:
RECEIVED MAY 1 7 Z018 GROUP 0023111
GROUP NAME: RAILROAD EMPLOYEES
CHECK NUMBER: OF 16425420
CHECK AMOUNT: $69.79
CARMEL FIRE DEPT AMBULANCE
CARMEL FIRE DEPT AMBULANCE SV PROVIDER
2 CIVIC EXPLANATION
CARMEL IN N 46032
OF BENEFITS
PATIENT DETAIL
PRODUCT MEM, ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER
NAME LL ACCOUNT NAME NUMBER RECEIVED OF SERVICE
INQ LED WERT14AN JR RR LEO WERTMAN JR 02496128841 -01 04/21/10 CARMEL FIRE DEPT AMBU
SERVICE DETAIL
PATIENT DATES OF DESCRIPTION AMOUNT NOT PROV ADJ AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT
NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED CDPAY COV PROVIDER CD RESP.
LEO 02114110 AMBULANCE 325.00 alai 8.81 316.19 100% 69.79 51
WERTMAN JR 02/14/10 AMBULANCE 32.75 32.75 .00 59
SUBTOTAL 357.75 alai 8.81 348.94 69.79# F
TOTAL PAID TO PROVIDER $69.79
REMARKS
(51) THE PLAN BENEFIT FOR THESE SERVICES WAS DETERMINED BY USING THE AMOUNT APPROVED BY MEDICARE. THIS PHYSICIAN OR
HEALTH CARE PROFESSIONAL HAS AGREED TO ACCEPT THAT AMOUNT, THE PATIENT IS RESPONSIBLE FOR THE DIFFERENCE BETWEEN
THE MEDICARE ALLOWED AMOUNT AND THE TOTAL AMOUNT PAID BY BOTH PLANS.
(59) THE BENEFIT FOR THESE SERVICES IS BASED ON THE AMOUNT PAID BY MEDICARE. THE PATIENT IS RESPONSIBLE FOR THE
DIFFERENCE BETWEEN THE MEDICARE ALLOWED AMOUNT AND THE TOTAL AMOUNT PAID BY BOTH PLANS.
UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS 6 STATEMENTS (EPS) AS A STANDARD WAY TO
PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS
AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS 6 STATEMENTS LINK
FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 -UHC -FAST (1-866- 842 3278), OPTION 5.
FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND
OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1 800 842 -1109, OPTION 3.
PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM.
THIS PAYMENT HAS BEEN ADJUSTED BASED ON THE AMOUNTS PAID BY MEDICARE AND /OR OTHER INSURANCE.
Detach Check
II� Detach Check
5144
Bank of America 119
UNITEDHEALTHCARE INSURANCE COMPANY 150 Windsor Street
RAILROAD CUSTOMER,: SERVICE CTR. Hartford,. CT 06720
PO BOX 30304
SALT LAKE CITY UT' 84130 0304 6
PHONE '.1 87 -842 .3210.
.DATE 06 /1;0 /1
W6-,01486 op4ia6 -PO -10 130 =s0 -017 d fip' PLEASEi PRESENT PaOMPTLY :FOR PAYMENT
CONTRACT 0231 11 PAY 69..7;9
*SIXTY NINE *:x
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PAY CARMEL FIRE DEPT AMBULANCE "S VC
TO THE CARMEL FIRE DEPT AMBULANCE SV
2 CIVIC SO
ORDER I]Fz CARMEL-IN 46032
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Date: 05/19/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
5 --CCOUNT HISIFORY
Bill To: LEO WERTMAN ICD -9: 78609 7862
75 ROSEWALK CIR APT 1G
CARMEL, IN 46032
From: 75 ROSEWALK CIR APT /SUITE# 1G
To: CLARIAN HOSPITAL NORTH
1 UNITED HEALTHCARE /RR
Patient: LEO WERTMAN A051221153
75 ROSEWALK CIR APT 1 G Insurance
CARMEL, IN 46032 2 UNITED HEALTHCARE
Patient No: 800012331
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
$357.75 $427.54 -69.79
CPT
Date Description Charges Credits
02/14/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
02/14/2010 MILEAGE A0425 $32.75
04/26/2010 MEDICARE PAYMENT $279.15
04/26/2010 ASSIGNMENT MEDICARE $8.81
05/07/2010 PAYMENT $69.79
05/17/2010 COMMERCIAL INSURANCE PAYMENT $69.79
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 05/19/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032
(317)571 -2605 FederallD# 356000972
Bill To: LEO WERTMAN ICD -9: 78609 7862
75 ROSEWALK CIR APT 1 G
CARMEL, IN 46032
From: 75 ROSEWALK CIR APTlSUITE# 1 G
To: CLARIAN HOSPITAL NORTH
1 UNITED HEALTHCARE /RR
Patient: LEO WERTMAN A051221153
75 ROSEWALK CIR APT 1G Insurance
CARMEL, IN 46032 2 UNITED HEALTHCARE
Patient No: 800012331
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
$357.75 $357.75 $0.00
CPT
Date Description Charges Credits
02/14/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
02/14/2010 MILEAGE A0425 $32.75
04/26/2010 MEDICARE PAYMENT $279.15
04/26/2016 ASSIGNMENT MEDICARE $8.81
05/07/2016 PAYMENT $69.79
05/17/2010 COMMERCIAL INSURANCE PAYMENT $69.79
05/19/2010 REFUND -69.79
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
�0 1� (x Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
60
Total l� 7
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
IC-22 l IN SUM OF 79
&979
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
MAY 2
20`,
fi
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund