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Home My WebLink About188868 08/18/2010 4, CITY OF CARMEL, INDIANA VENDOR: 364568 Page 1 of 1 ONE CIVIC SQUARE THOMAS IRICK o CARMEL, INDIANA 46032 5352 WOODFIELD OR N CHECK AMOUNT: $636.60 CARMEL IN 46033 CHECK NUMBER: 188868 CHECK DATE: 8/1812010 DEPARTMENT ACCOUNT PO NUMBER I NVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 638.60 OTHER EXPENSES r t 1206 rs MR.rI FIQIVI/ISIUI fRIGIC, it f x f" p 1 jh u 5 1 9 Is .IF �'4oP: A R •rrr rgFr•..l' ,a'. ..,ef "C'' �f du kRI]EA i IP FOR RYAN Ni IRICK e CARMEL� aIN 460339154 W PAYTO'IHE 4l ORDfiRQF 7 1, V�' �Od DOLLARS LE w Ti4a niC r p r a i 1 y n 47 rr x rc n a s v 1 �A°2,'f r ra ��'d r p e Pr•7""r£� i 7 MEDICARE PART B INDIANA MEDICARE PART B PROVIDER REPORT NATIONAL GOVERNMENT SERVICES, INC. P.O. BOX 240 INDIANAPOLIS, IN 46206 CHECK DATE 07/29/10 CHECK NUMBER 123847026 0000094 CHECK AMOUNT *10,378.68 PROVIDER NUMBER 1154325579 0000093 20100730 FG431101EKIPDD60 1 OZ D0MFG4B116000" 159067 SP IIIIIIIIt "'lllll 11 ll CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SQ CARMEL IN 46032 RECEIVED AUG 0 3 2010 6r a n 7. a1 '4 -7 a' -•:ate: 'u ioi' i i. x MEDICARE PART 8 74 -1292 NATIONAL GOVERNMENT SERVICES, INC. 724 P.O. BOX 240 INDIANAPOLIS, IN 46206 crvrars, �irxuxFan�mrcarosmmt�s MEDICARE PAYMENT JPMorgan Chase Bank, Columbus FOR.HEALTH.INSURANCE SOCIAL SECURITY ACT Columbus, Ohio 0503847176 PAY'TO THE ORDER OF PROVIDER NO. CHECK NO. CARMEL 'FIRE DEPARTMEN -T 1154325579 1238 2 CARMEL CIVIC MO. DAY YEAR DOLLARS '9` 1D X CARMEL, IN 4603 07 2 10,378..68 2 -754:3 s VOID 12 MONTHS PROM ISSUE DATE A 11 'OS0384717E +1 1 :0724129271: 64b4384371I' Electronic Remitance Information 'Print Date: 08103110 (EOB) Explanation Of Benefits (EOB) Payor Id: 00630 Production Date: 07/29/10 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Nat€ Id: Payer Id: PO BOX 6160 INDIANAPOLIS IN 462066160 Payer Contact Info: NATIONAL GOVERNMENT SERVICES INC, (866)250 -5665 TE Receiver Info: CARMEL FIRE DEPARTMENT Payee ld: 2 CARMEL CIVIC SO CARMEL IN 460327543 Payment Info: Check I EFT Trace No: Total Payment Amount 6 r Check Issue Date: 07/29/10 s�4a Payment Method: Check Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid IRICK RYAN M 03/14/10 A0427 RH 375.00 300.00 401.20 401.20 80 -24 320.96 Claim Control 1110197455740 A0425 RH 26.20 20.96 Claim Status: Processed as Primary Claim Remark Codes: MA01. Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 75.00 Patient Responsibility Coinsurance Amount 5.24 Billed: 401.20 Late Filing Fee: 0.00 Pt. Responsible Amt: 80.24 Paid: 320.96 Electronic Remitance Information Print Date: 08103110 (EOB) Explanation Of Benefits (EOB) Payor Id: Production Date: 07/29/10 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: PO BOX 6160 INDIANAPOLIS IN 462066160 Payer Contact Info: NATIONAL GOVERNMENT SERVICES INC, (866)250 -5665 TE Receiver Info: CARMEL FIRE DEPARTMENT Payee Id: 1154325579 2 CARMEL CIVIC SQ CARMEL IN 460327543 Payment Info: Check EFT Trace No: Check issue Date: 07129/10: Payment Method: Check Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid IRICK RYAN M 31462873401 05/01/10 A0429 SH 325 -00 260.00 397.05 397.05 79.41 317.64 Claim Control 1110197455760 A0425 SH 72.05 57.64 Claim Status: Processed as Primary Claim Remark Codes: MA01, Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 65.00 Patient Responsibility Coinsurance Amount 14.41 Billed: 397.05 Late Filing Fee: 0 -00 Pt. Responsible Amt: 79.41 Paid: 317.64 Date: 08/04/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Y Bill To: RYAN M [RICK ICD -9: 780.02 5352 WOODFIELD DR N CARMEL, IN 46033 From: 5352 WOODFIELD DR N To: ST. VINCENTS HOSPITAL CARMEL 9 MEDICARE PART B Patient: RYAN M (RICK 5352 WOODFIELD DR N Insurance CARMEL, IN 46033 2 Patient No: PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $401.2.0 $722.16 320.96 CPT Date Description Charges Credits 03/14/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00 03/14/2010 MILEAGE A0425 $26.20 06/18/2010 PAYMENT $401.20 07/06/2010 CORRECTION 401.20 07/06/2010 CORRECTION $401.20 08/03/2010 MEDICARE PAYMENT $320.96 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08104/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederaiiD# 356000972 g N k LJ K Bill To: RYAN M IRICK ICD -9: 880.00 5352 WOODFIELD DR N CARMEL, IN 46033 From: 4755E 126TH ST To: COMMUNITY HOSPITAL -NORTH MEDICARE PART B Patient: RYAN M IRICK 5352 WOODFIELD DR N Insurance CARMEL, IN 46033 2 Patient No: PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE, THANK YOU. Total Amount Total Paid Balance $397.05 $714.69 317.64 CPT Date Description Charges Credits 05/01/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 05/01/2010 MILEAGE A0425 $72.05 06/18/2010 PAYMENT S397.05 0710612010 CORRECTION 397.05 07/06/2010 CORRECTION $397.05 08/03/2010 MEDICARE PAYMENT $317.64 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) i 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)) Total `103�', CU� 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 IN SUM OF to 3,9 0 .d l z/ 0L &3,�?ZP 0 ON ACCOUNT OF APPROPRIATION FOR T� 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 AUG 19 28 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund