The URL can be used to link to this page

Home My WebLink About186755 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: 364277 Page 1 of 1 0 ONE CIVIC SQUARE KENNETH BROUGHTON CARMEL, INDIANA 46032 742 W 136TH ST CHECK AMOUNT: $85.48 CARMEL IN 46032 CHECK NUMBER: 186755 CHECK DATE: 6/23/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 85.48 REFUND ^ti Date: 06/09/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 'r 5 gyp C. a Bill To: KENNETH R BROUGHTON ICD 9: 786.05 742 WEST 136TH STREET CARMEL, IN 46032 From: 742 W 136TH ST To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient: KENNETH R BROUGHTON 418567224A 742 WEST 136TH STREET Insurance CARMEL, IN 46032 2 UNITED AMERICAN INSURANCE Patient No: 007780430 MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN. IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS INFORMATION. IF NOT, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $427.40 $512.88 -85.48 CPT Date Description Ch" arges Credits 'l. 04/20/2010 ADVANCED LIFE SUPP 1 —EMER A0427 $375.00 04/20/2010 MILEAGE A0425 $52.40 05/25/2010 MEDICARE PAYMENT $341.92 06/03/2010 PAYMENT $85.48 06/07/2010 COMMERCIAL, INSURANCE PAYMENT $85.48 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 06/09/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal m# 356000972 ACCOUNT HIS ORY Bill To: KENNETH R BROUGHTON ICD -9: 786.05 742 WEST 136TH STREET CARMEL, IN 46032 From: 742 W 136TH ST To: ST. VINCENTS HOSPITAL MEDICARE PART B Patient: KENNETH R BROUGHTON 418567224A 742 WEST 136TH STREET Insurance CARMEL, IN 46032 2 UNITED AMERICAN INSURANCE Patient No: 007780430 MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN, IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS INFORMATION. IF NOT, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU, Total Amount Total Paid Balance $427.40 $427.40 $0.00 CPT Date Description Charges Credits 04/20/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00 04/20/2010 MILEAGE A0425 $52.40 05/25/2010 MEDICARE PAYMENT $341.92 06/03/2010 PAYMENT $85.48 06/07/2010 COMMERCIAL INSURANCE PAYMENT $85.48 06/09/2010 REFUND -85.48 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT 201001088 KENNETH R BROUGHTON $85 Run Date RE C E IVED JUN 0 3 201 0412012010 Amount Paid APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL. 1999 z KENNETH R BROUGHTON BARBARA S BROUGHTON 5685 742 W 136th St Ph. 317 843.1716 Carmel, IN 46032 21- 1411,7411 PAY TO THE ORDER O F a s, DOLLARS � FOR A-61 QS405 uni amer insura company Hox 8080 McKinney, Texas 7507045080 May 26, 2010 2 181 CARMEL FIRE DEPARTMENT THIS IS NOT A BILL 2 Carmel Civic Sq Carmel IN 46032 7543 RECEIVED JIM 0 7 2010 Tax ID Number: 356000972 Provider Number: N 1154325579 Check Number: 0054467174 STATEMENT OF MEDICARE PART B SUPPLEMENTAL BENEFITS PATIENT NAME HIC SERVICE POLICY YOUR PATIENT ACCT DATES YOUR MC BILLABLE MEDICARE DOES NOT MEDICARE POLICY NOTE MEDICARE CONTROL POLICY FRGM TO CHARGES ASG CHARGES ALLOWED' COVER PAID PAYS CODE 5 BROUGHTON, KENNETH R 418567224A 1110127041630 007780430 0420 042010 427.40 Y 427.40 427.40 .00 341.92 85.48 XO Total 85.48 In the MC ASG column above, Y means Medicare assignment was accepted and N means it was not accepted. YOUR CHARGES are the charges you submitted to Medicare; BILLABLE CHARGES are amounts Medicare allows you to charge this patient. Notes XO This claim was sent to us electronically, It is not necessary for you to file a paper claim with us for this service. Now providers can verify coverage and inquire about Medicare Supplement claims ONLINE! www.MedicalUA.com Page 1 of 1 DETACH THIS PORTION AT DOTTED LINE BEFORE DEPOSITING CHECK DATE 05 -26 CHECK NO...:0054467174 UNITED AMERICAN :INSURANCE:.. COMPANY sa 441119. -POST OFFICE BOX 8080- MCKINNEY, TEXAS 75070 -8080 PROVIDER CARMEL FIRE,DEPA'RTMENT ;$85..48 `TAXID 356000972' BANK OF. AMERICA WINDSOR, CONNECTICUT PAY TO THE ORDER OF: CARMEL ":F IRE ;bEPARTMENT 2' Car V mel C 'IC .S q Carmel 1N 46032 7543' AUTHaBYZED SIGNATURE i; V010 IF NOT PRESENTED WITHIN 12 MONTHS OF THE DATE SHOWN ABOVE R 5 4 6 7 1 7 4i►' 1:0 b 1 q0❑ 4 4 5I: 0000000 70 10 ?110 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)) a Total 5 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 9 n) l/C �n IN SUM OF 'V ON ACCOUNT OF APPROPRIATION FOR Anbuia.vle/ 12 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 JUN 2:1 2010 r' 20 t Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund