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Home My WebLink About186738 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: 364276 Page 1 of 1 ONE CIVIC SQUARE JEANNE BARRY CARMEL, INDIANA 46032 759 WOODVIEW DRIVEN CHECK AMOUNT: $206.86 CARMEL IN 46032 CHECK NUMBER: 186738 CHECK DATE: 6/2312010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 206.86 REFUND Date: 06/08/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 ACCOUNT HiSTDY Bill To: JEANNE P BARRY ICD -9: 536.2 759 WOODVIEW DR N CARMEL, IN 46032 From: 759 WOODVIEW DR N To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient: JEANNE P BARRY 306205999A 759 WOODVIEW DR N Insurance CARMEL, IN 46032 2 HARP /UNITED HEALTHCARE Patient No: 00806745512 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $414.30 $414.30 $0.00 CPT Date Description Charges Credits 04/06/2010 ADVANCED LIFE SUPP 1 —EMER A0427 $375.00 04/06/2010 MILEAGE A0425 $39.30 05/05/2010 MEDICARE PAYMENT $207.44 05/20/2010 COMMERCIAL INSURANCE PAYMENT $206.86 06/02/2010 COMMERCIAL INSURANCE PAYMENT $206.86 06/08/2010 REFUND 206.86 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 06/08/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federai iD# 356000972 Bill To: JEANNE P BARRY ICD -9: 536.2 759 WOODVIEW DR N CARMEL, IN 46032 From: 759 WOODVIEW DR N To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient. JEANNE P BARRY 306205999A 759 WOODVIEW DR N Insurance CARMEL, IN 46032 2 AARP /UNITED HEALTHCARE Patient No: 00806745512 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $414.30 $621.16 206:86 CPT Description Charges 04/06/2010 ADVANCED LIFE SUP? 1 -EMER A0427 $375.00 04/06/2010 MILEAGE A0425 $39.30 05/05/2010 MEDICARE PAYMENT $207.44 05/20/2010 COMMERCIAL INSURANCE PAYMENT $206.86 06/02/2010 COMMERCIAL INSURANCE PAYMENT $206.86 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 356000972 -0001 134 501080 05 -17 -10 PAGE 001 wipbs PROVIDER EXPLANATION OF BENEFITS HEALTH INSUFRANCE Wisconsin Physicians Service Insurance Corporation EOB ENHANCEMENTS EFFECTIVE 1/26/05: 1717 W. Broadway -Box 8190 Madison, WI 53708 EOBS CHECKS WILL BE MAILED ON MON. WED. THEY WILL PRINT FRONT TO BACK. (DUPLEXED) I,I„LII „II„ „JL„I,I„LI,IJ�I��L,I „III,.. „LI,I„II If We may be of assistance to you, CARMEL FIRE DEPT lease write Customer Service at 2 CIVIC SQ �.0. Box 8688 Madison, WI 53708 -8688 CARMEL, IN 46032 -2564 or call 608 -221 -1600. Please have the subscriber, group RECEIVED MAY 2 0 2010 number and claim number available. Less Less Less Less Less Rsnl Date(s) of Service Charged Allowed Deductible Copayment Coinsurance Discount Other ANSI Total Service Code Amount Amount Amount Amount Amount Amount Amount Code Payment BARRY, MERTON 759 WOODVIEW NORTH DR, CARMEL, IN 46032 -3423 SUBSCRIBER NUMBER: 000068824 A ZI_FN T: BARRY, JEANNE LOCATION ID#: 0001 1154325579 PATIENT ACCOUNT: 201000965 04 -06 -1 AMBG 375.00 375.00 .00 .00 .00 .00 .00 23 04 -06 -10 AMBG 39.30 39.30 .00 .00 .00 .00 .00 23 LESS AMOUNT PAID BY MEDICARE 207.44- EP CLAIM TOTALS 414.30 GROUP #88- 157640 CLAIM #053070841 .00 TOTAL 206.86 79 -57 SE( "NUM 001057: 759 I CONTROL �134-501OS0 a7�7w ar�onownv aoza1ao 0 CHECK NUMBER MADfSON, wl 53708.8 47599 4 I PAYLG E DATE 05/1.7/10 PAY fO THE ORDER OF CARMEL FIRE DEFT 2 CIVI SO: t CARMFI_ IN 4(3032 2584 DOLLARS CENTS VOID AFTER 100 DAfS °i WWW ASSOCIATEDBANK COM II ■47S9904'n■ I :07S900S7S1: 2213 0El S 9J3 CLAIM REDUCED BECAUSE CHARGES HAVE BEEN PAID BY ANOTHER PAYER AS PART OF COORDINATION OF BENEFITS, WHICH MAY INCLUDE MEDICARE PAYMENTS. COORDINATION OF BENEFITS WITH YOUR PRIMARY PLAN OF COVERAGE MAY RESULT IN EITHER A REDUCED PAYMENT OR NO PAYMENT. EP =ANSI CODE-23 THE IMPACT OF PRIOR PAYER(S) ADJUDICATION INCLUDING PAYMENTS AND /OR ADJUSTMENTS. THESE SERVICES WERE PAID BY MEDICARE. 144 -AAR PC K42. 00302 -001 -00969 UNITED HEALTH CARE If you have questions please contact us at: PO BOX 740819 ATLANTA, GA 30374 -0819 UNITED HEALTH CARE PO BOX 740819 ATLANTA, GA 30374 -0819 TOLL FREE: 1 800 -AARP --789 1- 800 2277 -789 PAGE 1 OF 2 CARMEL FIRE DEPT* r �J C'.C1,pir.JS 2 CARMEL CIVIC SQ J CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: MAY 24, 2010 CHECK AMOUNT: $633.43 For real -time access to claim, check, and member eligibility information please register online at: https://aarpprovideronlinctoot.uhc.com. Please remember to submit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to. criminal and civil penalties. Health Care United HealthCare Insurance Company (and United HealthCare Insurance Options' 0 Company of New York for New York residents) are proud providers to Please detach check below and cash promptly UNITED;HE4LTH C AAE PQ BOX:740819. 62-20 ATLANTA, GA:39374 =0919 Cltibank Delaware One Penn';5 Way New Castle, DE 19720' REPRESENTS PAYMENT FOR MULTIPLE INSUREDS DATE MAY 24 20 T:0 PAY *>ti *`633._43 HUNDRED> THIRTY "THREE. DOLLARS AND. <;CEATTS PAY TO THE ORDER OF CARML;.FIRE ;bEP.T? :.s: 2- CARMEL C I V.I:C Sq CARMEL;:'IN :'<4'6032= :7.543 Security Feah,res on ac 0k1 :293 X00 31116 2 :.L641i� 144 -A A R PC K42. 00302 002.00990 Optio Care United Healthcare Insurance Company (and United Healthcare Insurance Options' Company of New York for New York residents) are proud providers to PAGE 2 OF 2 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS 2 STATEMENT DATE: MAY 24, 2010 RECEIVED J UN a 20 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT* Insured Provider Dates of Amount Medicare Medicare Applied to Benefit Information Service Charged Approved Paid Deductible From To Ar�r�� PATIENT CARMEL 040610 375.00 375.00 176.00 155.00 44.00 CARMEL 040610 39.30 39.30 31:44 7.86 040610 155.00 YOUR CLAIM INDICATES THAT ALL OR A PORTION OF THE MEDICARE PART B DEDUCTIBLE WAS SATISFIED. WE ARE REIMBURSING THE DEDUCTIBLE AS OUTLINED IN YOUR CERTIFICATE OF INSURANCE. TOTAL 206.B61 WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Z is r ,�Ae Total 1 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 P IN SUM OF c*C YW ON ACCOUNT OF APPROPRIATION FOR z&&Jawe Fz LX- Mo 2iQ/m Board Members Po# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. H 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 MI N 2 120 20 d Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund