188868 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
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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
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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
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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