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Home My WebLink About186729 06/23/2010 a CITY OF CARMEL, INDIANA VENDOR: 364275 Page 1 of 1 ONE CIVIC SQUARE AULTRA ADMINISTRATIVE GROUP CARMEL, INDIANA 46032 PO BOX 35276 CHECK AMOUNT: $280.96 CANTON OH 44735 CHECK NUMBER: 186729 SON CHECK DATE: 6/23/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 280.96 REFUND Date: 06/16/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal w# 356000972 HISTORY Bill To: SUSAN C MATHEWS ICD -9: 7231 E8130 11840 HARVARD LANE CARMEL, IN 46032 From: 106TH ST HAVERSTIC To: CLARIAN HOSPITAL NORTH SAGAMORE HEALTH Patient: SUSAN C MATHEWS 0050014195E 11840 HARVARD LANE Insurance CARMEL, IN 46032- 2 Patient No: 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 $351.20 $632.16 280.96 CPT Date Descrrpti06 Char es Credits 11/02/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 11/02/2009 MILEAGE A0425 $26.20 01/05/2010 COMMERCIAL INSURANCE PAYMENT $280.96 06/15/2010 COMMERCIAL INSURANCE PAYMENT $351.20 f APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 06/16/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 QC",,_UN R Bill To: SUSAN C MATHEWS ICD 9: 7231 E8130 11840 HARVARD LANE CARMEL, IN 46032 From: 106TH ST HAVERSTIC To: CLARfAN HOSPITAL NORTH 1 SAGAMORE HEALTH Patient. SUSAN C MATHEWS 0050014195E 11840 HARVARD LANE Insurance CARMEL, IN 46032- 2 Patient No: 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 $351.20 $351.20 $0.00 CPT Date S Descriptlon Charges 11/02/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 11/02/2009 MILEAGE A0425 $26.20 01/05/2010 COMMERCIAL INSURANCE PAYMENT $280.96 06/15/2010 COMMERCIAL INSURANCE PAYMENT $351.20 06/16/2010 REFUND 280.96 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 k- AU 1-TRA AULTRA ADMINISTRATIVE GROUP lf you have questions regatding this cocrespondeuce, please call 330 493 -7278 or 1- 877 -649 -4298. IM F P.O. $OY 3 276 8:011 AM to 5:00 PM EST or visit our website at Carlton, OH 44735.5276 2,0912311 e0 www.atiltragroup. con i Electronic Service Requested SINGLE PIECE Enrollee: SUSAN IVIATHEWS 214 0.3820 SP 0.440 Patient: SUSAN iV1A'i'I E-MS I� 1 �1� II I�� J �I l ��llll�lt�llllll 'I�� Sac Sec: CARMEL FIRE DEPARTMENT 1 Grow OTOLARYNGOLOGY 2 CIVIC SQ ll' w: CARMEL. IN 46032 -2584 Group: RA000070 Claim: 97209421 -01 Patient: Date: 12/28/2009 Expl anation of Benefits for Services Provided By: CARMEL FIRE DEPARTMENT �PrOC. �1'ofal ineli Cat: of Scrvtce t ible Reason Disatunt Covered By I Deductible -I ay l m1Le Paid I avn ent Code Charge Code Amount Plan Amount Amount At Amount 11!02-11/02/2009 A0429 325.00 0.00 0,00 325.00 0.00 0.00 325.00 °x6 80 260.00 11/02. 11/02/2009 1 A0425 26:20 0.00 0.00 26.20 0.00 0.00 26.20 80% 20.96 TOTALS 351.20 _0.00 0!00 351.20 0.00 0.00 351.20 280.96 Other Credits or Adjustments 1 0.00 Total Net Payment 280.96 Patient Responsibility 70.24 RECEIVED JAN 0 ZO�� Affiliation Fee 17 E 601 Messages If Aultra Administrative Group is (he secondary payer, the patient responsibility field may not reflect accurately. Please confirm the amount due with your provider of service. The affiliation fee is a contracted amount between the provider and the leased network- The patient is not responsible for this amount. 4 Your 2009 deductible has been satisfied. This Beoefit DetetTnination has been made in accordance with the Covered Expenses and the Schedule of Benefits sections lbund in your health plan's Sununary Plan Description (SPD). Ifyou disagree in whole or in part with this determination, you have 180 days to appeal this deletnunation. Your appeal must be tiled in writing and specify the reason(s) that you believe this detenninalion is in error. A full description of your rights to appeal may be found in your SPD. Please sand your appeal to: Plan Administrator, c/o Aultra Administrative Group, P.O. Box 35276, Canton, 01-1 44735-5276. FOR SECUFIITY PURPOSES THE FACE OF :THISiDOCUMENTCONTAINS A;BL'UE BACKGROUND AND.,'MICROP,RINTING.IN THE BORDER N FL :A &9 S ,25: W `CHECK NO 50291599 clan; 97209+21 BOx3a726 Pauerit 2ti09(iz74a ISSUE DAVE 12/28/,2009 Canton, 'OH, 4,4735 -5276 5 Patiect N rme,S.usAN Iv1t111i> w5, AMOUNT CC PAY TWO- HUNDRED EIGHTY DOLLARS:AND 96 CENTS *286:96 TO THE CARMEL FIRE DEPARTMENT ORDER OF FIRS•PMERIT BANK N.A. ONE FIRST NATIONAL PLAZA Void 6 Months From Date Of Issue MASSILLON, Off 44647 Authorized Signature Two Signatures Required AO. NOT CASHdIFi. 1NATENMARWJ SfN0 ,TIPRESENT:ON'T,HE SREV.ERSE SIL)E.OF.;gT.HISOOCUMENT; HOLD AT "AWVV NGLETO V1EW;tx'�'+_� 11' SO 29 169911 1 :0 L, 1200 S S SI: 59 1 100 19 1Dim CARMEL FIRE-DEPT AMB SERVICES 2 CIVIC SQUARE CARMEL IN 46032 2584 Insurer: ERIE INSURANCE EXCHANGE Policy No.: 001 1409833 RECEIVED JUN Claim No.: 061010610208459 1 5 2010 Date of Loss: 11 -02 -2009 Check No.: 102036671 CMS No.: JT36671 Check Amt.: $351,20 For: PAYMENT SUSAN MATHEWS MEDICAL PAYMENTS SERVICE DATE: 11 -02 -2009 TO 11 -02 -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 America CustomorConnection 84 -1278 U Bank of America. N.A. t Atlanta, Dekafb County. Georgia ERIE INSURANCE EXCHANGE CLAIM NO.: 061 01 061 0208459 CHECK NO.: 102036671 z Horne Office 100 Erie Ins. Pl. Erie, PA 16530 DATE OF LOSS: 11 DATE ISSUED_: 06 2010 E RIE CMS NO_ JT36671 c PAY THREE HUNDRED FIFTY -ONE AND 201100 ri z OPERATOR 5ORCOLEMAN x TO THE CARMEL FIRE DEPT AMB SERVICES TAX ID NO. z ORDER 2 CIVIC SQUARE OF CARMEL, IN 46032 2584 v a PAYMENT SUSAN MATHEWS ERIE INSURANCE EXCHANGE I FOR MEDICAL PAYMENTS AUTHORIZED SIGNATURE soy a SERVICE DATE: 11 -02 -2009 TO 11 -02 -2009 ENCS =k v 11 L❑ 2 03667 111 I: ❑6 L L 27881: 3 29999949 Dim 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. p Payee YG_ /�`C/,�tarlsS�7i�7✓ C�(}'Lc9 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) /�l Cis P �J/t Total I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and f have audited same in accordance with IC 5- 11- 10-1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 c1fC?t/2�5 <��P (9i'trlc�J IN SUM OF 9l1 ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #(TITLE AMOUNT DEPT. !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 excepJ Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund