189553 08/31/2010 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
o ONE CIVIC SQUARE UNITED HEALTHCARE CHECK AMOUNT: $63.24
CARMEL, INDIANA 46032 Po BOX 740619
•y r a ATLANTA GA 30374 CHECK NUMBER: 189553
CHECK DATE: 8/31/2410
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 63.24 REFUND
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CI 'ARMED.
JAMES BRAINARD, MAYOR
August 20, 2010
United Healthcare
P.O. Box 740819
Atlanta, GA 30374
RE: Mary Nangle Wit 018897644 /DOS 06/11/2010
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $63.24. On June 11, 2009
Ms. Nangle had a BLS Emergency transport to St. Vincent Hospital in Carmel. The
invoice mistakenly charged for a quantity of 2 instead of 1. Therefore you are due a
refund of $63.24. If you have any questions, please feel free to contact me at (317) 571-
2605.
Sincerely,
Bee S. annan
Billing Administrator
d
Date: 08/20/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNT
x
Bill To: MARY M NANGLE ICD -9: 036.9
4787 ALDERSGATE DR
CARMEL, IN 46032
From: 4787 ALDERSGATE DR
To: ST. VINCENTS HOSPITAL CARMEL
UNITED HEALTHCARE /RR
Patient: MARY M NANGLE MA710120343
4787 ALDERSGATE DR Insurance
CARMEL, IN 46032 2 AARPIUNITED HEALTHCARE
Patient No: 1889764411
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $407.89 -63.24
CPT
Date Description Charges Credits
06/11/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
06/11/2010 MILEAGE A0425 $19.65
07/27/2010 MEDICARE PAYMENT $521.62
07/28/2010 REFUND 252.95
07/28/2010 ASSIGNMENT MEDICARE $8.81
08/16/2010 COMMERCIAL INSURANCE PAYMENT $130.41
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/20/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
{317 }571 -2605 Federal 1D# 356000972
Bill To: MARY M NANGLE ICD -9: 036.9
4787 ALDERSGATE DR
CARMEL, IN 46032
From: 4787 ALDERSGATE DR
To: ST. VINCENTS HOSPITAL CARMEL
UNITED HEALTHCARE /RR
Patient: MARY M NANGLE MA710120343
4787 ALDERSGATE DR Insurance
CARMEL, IN 46032 2 AARPIUNITED HEALTHCARE
Patient No: 1 889764411
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY, THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $344.65 $0.00
CPT
Date Description Charges Credits
06/11/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
06/11/2010 MILEAGE A0425 $19.65
07/27/2010 MEDICARE PAYMENT $521.62
07/28/2010 REFUND 252.95
07/28/2010 ASSIGNMENT MEDICARE $8.81
08/16/2010 COMMERCIAL INSURANCE PAYMENT $130.41
08/20/2010 REFUND -63.24
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
.222 -AA ROCK45. 01121- 002.03147
Health Care
United HealthCare Insurance Company (and. United HealtliCare 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
STATEMENT DATE: AUGUST 10, 2010
BENEFIT SUMMARY FOR: CARMEL FIRE DEPT*
Insured Provider Dates of Amount Medicare Medicare Applied to Benefit
Information Service Charged Approved 90
.65 19.65 15.72 Paid Deductible
From To
PATIENT CARMEL 061110 650.00 632.38 505. 126.48
CARMEL 061110 19 3.93
TOTAL 130.41
WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR
BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE.
UNITED;HEALT}di
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ATLANTA GA :30374'0819 cc 52 311
Cine Penns Way 3 1 `4 J
New Castle, DE 19720
REf�R,13SENTS PAYMENT FDR DNE INSURED DATE AjJG[)ST Q ZQ IQ,'
PAY *I30 41
ONEHUNDRED TH I" RTY :DOLLARS AND CENTS:*
PAY:•
TO THE
ORDER 'OF CARMEL FIRE ;'DE PT*
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Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
r 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//
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e, n,th stirs ,e -n e,c CLPG 2 a w- eta
Or-
c
Total Zp 3,
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
alZ led �eal IN SUM OF
0. "�o, 7 4057
L0 3. �7
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
AUG 3 0 20
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund