186738 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