186770 06/23/2010 CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of 1
ONE CIVIC SQUARE CIGNA HEALTHCARE INC
CARMEL, INDIANA 46032 PO BOX 182223 CHECK AMOUNT: $236.67
CHATTANOOGATN 37422 CHECK NUMBER: 186770
CHECK DATE: 6/23/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 236.67 REFUND
r
Date: 06/14/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
ACCOUNT Fg,1,2',-.T0RY
z
Bill To: DEBORAH DAVIDSON ICD -9: 7231 7840 E8131
3620 COLUMBUS
ANDERSON, IN 46013- From: 103RD &MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
I CIGNA 5200
Patient: DEBORAH DAVIDSON 03843262002
3620 COLUMBUS Insurance
ANDERSON, IN 46013- 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
$338.10 $574.77 236.67
CPT
Date Description :Char' es`, CrecJits
04/06/2010 BASIC LIFE SUPP EMERGENCY A0429 $325.00
04/06/2010 MILEAGE A0425 $13.10
05/18/2010 COMMERCIAL INSURANCE PAYMENT $236.67
06/11/2010 COMMERCIAL INSURANCE PAYMENT z $338.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 06/14/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal iD# 356000972
ACCOUNT MSTOrRY
Bill To: DEBORAH DAVIDSON ICD -9: 7231 7840 E8131
3620 COLUMBUS
ANDERSON, IN 46013-
From: 103RD &MERIDIAN ST
To: CLARIAN HOSPITAL NORTH
1 CIGNA 5200
Patient: DEBORAH DAVIDSON U3843262002
3620 COLUMBUS Insurance
ANDERSON, IN 46013- 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
$338.10 $338.10 $0.00
CPT
Date Description Charges Credifs
04/06/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
04/06/2010 MILEAGE A0425 $13.10
05/1.8/2010 COMMERCIAL INSURANCE PAYMENT $236.67
06/11/2010 COMMERCIAL INSURANCE PAYMENT $338.10
06/14/2010 REFUND 236.67
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
ProviderExplarratiotr ofMedical PayrrtentReport Coy
Frovidee Numiber
Provider Name Date through wkllch claims were processed OLIN IS NOT A BILL rage
I 356000972 0000 I CARMEL FIRE DEPT I 05/11/2010 Retain for Your Records 1
Ad usted Ad4usted ud C` a Coiilsurarice DRG $er Diem Per Dietn
Proc See' f
DCcC DI2G
edure I Billed Procedure Cod ',Allowed: No! Covered Decf op Per Plan Benefit N
iLirie. Procedure Dater Procedure Di l 13enetit
q
.Code' Code:: Aitouot Amount Discount Amount At Amounts: cte
Pet. errt Diem
Amount cut Number Amount
f
PATIEkT NAME: DEBORAH 5 DAVIDSON PATIENT 201000969 OPERATION LOCATION /GROUP# 24083 9 2471422 RECEIVE DATE: 04/19/2010 PROCESS DATE: 05/11
I MEMBER NAME: LOUIS J DAVIDSON SUBSCRIBER U36432620 REF 8671011193613 CHECK 00569089981 1
j 1 04062010 AD429 325.00 325.00 0.00 97.50 0.00 0.00 227.50
Z 04062010 A0425 13.10 13.10 0.00 3 -93 O.OQ 0.00 9.17
TOTAL 338.1.0 338.10 236.67
i
j 1 THE $500 IN NETWORK DEDUCTIBLE HAS BEEN SATISFIED FOR 2010
5101.43 HAS BEEN APPLIED TOWARDS THE 510,000 OUT OF NETWORK 'OUT- OF-POCKET LIMIT' FOR 2010
51,791.15 HAS BEEN APPLIED TOWARDS THE $5,000 IN NETWORK 'OUT -OF- POCKET LIMIT' FOR 2010
i
BALANCE 1101.43
WHY WAIT FOR THE MAIL? VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE
i
I i ANYTIME AT HTTP: /WWW.CIGNA.CON /HEALTH /PROVIDER/
PAYMENT OF $236.67 TO CARMEL FIRE DEPT
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P�yLo�$67� QSf11 /E01q 35G000972 0000.,
TWO tiUDIf Di1LLI4IRS AND 67 GENTS
I Pay CARMEL` FIRE bEf';' ►)Mars *236.57
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G2436D 03 -23 -2005 r Provider EOP Summary
I`I 4 II. 8 II L IpI 8 11 9 9 I E
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s e a o m m^ s •m o m 3 s MA m
M &1 Marshall &.11smly D2 7047
Indianapolis, Indiana 2740 .':N 666734
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Ckalln:No:.04331767 Irima. R dL�' an iers Issue Date 060810
IVf=AL INSURA Cl✓ :COILiPr' NY Tom: €d 4 356000972
Policy No. 029005233805
Date of Loss 040610 Irires r ^iry ScGurial> SYUhrtfry Seivice Adjuster ID 424
Agent 002042 W.C. HESS INSURANCE INC Manager [D 548
Insured DAVIDSON JOHN
THIS CLAIM DRAFT IS ISSUER SUBJECT TO THE >APPROVAL.OF THE COMPANY AND,_IS VOID IF NOTTRESENTED WITHIN 60 DAYS FROM ISSUE. DATE
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pAy Three ny_ ei hundredthi ht and 10 /100 DOLLARS *338.10
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PAY TO THE ORDER OF FOR
1 CARMEL EIRE DEPARTMENT PATIENT #201000969 DEBORAH DAVIDSON
2:,C[VIC SQUARE SERVICE DATE .4/6/10
CARMEL, IN 46032
BY
AUTHORIZED REPRESENTATIVE
SIGNAT RE NA5 A COLORED BACKGROUND 13 RUER CONTAINS M GROPRINTING
110 0666 ?34 1:2 ?4❑ ?0 1003176811°
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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
n� Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e_1
Total 3 7
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
IN SUM OF 67'
7VZ Z
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
JUM 20f0
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund