189740 09/14/2010 CITY OF CARMEL, INDIANA VENDOR: 355031 Page 1 of 1
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH
CARMEL, INDIANA 46032 P 0 BOX 19383 GFiECK AMOUNT: $231.00
INDIANAPOLIS IN 46219 CHECK NUMBER: 189740
CHECK DATE: 9/14/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION
1205 4347500 261260 231.00 GENERAL INSURANCE
AUG /31/2010ME 11.11 AM FAX No,3173515476 F. 002
L�=� Cannel Administration
1500 U Sue Coy
SEP 13 20 10 1 Civic Square )2,
HEALTH INSURANCE CLAIM FORM Carmel, IN 46032
APPROVU0 BY NATIONAL UNIFORM CLAIM COMMITTEE 0106
PICA B w�, rF
I MEDICARE WIND TRICAR[ CHAMPVA GROUP FECA OTHER Ia. INSURED'SI.D.NUb1LTER
CHAMPIJS HEALTH 11 E] LUNG (FOR PROGRAM IN ITEA1 i)
:ued�arat) [D **.d f sporrs O ?asSN) (VAFdek) (ssNorlD) E] {sshg ❑g (!OJ
7. PATIENTS NAME iLnt Haw, rYel Neme, Middy i(A81) 1 P TI NT S ��711 DAri S 4, INSUREDS NAME (Lest Naato,Fgs1 Name 00dW WmA
Miser, William C M® F Carmel Administration
T 5.PATIGNTS ADDRESS (Na.Smo B .PATIENrSRELATIONSHIPTOINSLIRED 7. INSURE" ADDRESS(No.,Streeq
5208 Roland Dr seit sp-se aim other X❑ 1 Civic Square
art &TATE PATIENT STATUS CRY STATE
Indianapolis IN slnfe Ira am, X1 Carmel IN
SIP "C6iSE `YECiPilbdl Qrichiearvee�odej ZIPCODE TELEPWONEPKILIDE AREA M)
FL& ima Part-Ttme
46228 317) 254 1055 Employes 81W.M 0 stw.t 46032 (317) 5712465
9. OTHER INSUREDS NAME (Last Name, First Name, Middy Ini¢;d) 1 D. IS PATIENTS CONDITION RELATED TO: 11, INSURED'$ POLICY GROUP OR MA NUMBER
NONE
a OTHEN INSURE7S POLICY OR GROUP NU1AK a, EMPLOYMEN (CURRENT OR OW) a. IN" ED $DAT F BIRTH SE DO YY NO YES N M F
b. OTHER INVED S DATE OF BIRTH SEX b. AUTO A000ENT? PLACE (SW) b. EMPLOYER S NAME OR SCHOOL NAME
DU YY M F YES NO I t
c EMPLOYERS NATAL" DR SCHOOL N4IE c, OTHER ACCZENT9 C. INSURANCE RAN NAME OR PROGRAM NAME
YES NO Citizen's Management Inc.
d. INSURANCE PLAN NAME OR PROGRAM NAME 160, RESERVED FOR LOCAL USE 4. IS THERE ANOTHER HEALTH BENEFIT PLAN?
CLAIM SILL COMPANY YES NO If yas, raun to anO lAn PWI Item 9 a-d.
READ BACK FORM 06 FORE COMPLETING A BIG NING THIS FORM. 13. INSUREDSS OR AUTHORIZED PERSONS SIGNATURE I M*&Ire
1 2, PATIENTS OR AUTHOR>t�QJ PERSONS SIGNATURE I eud&a me tekase d any medal or oft Wowmmlon neowaty purment of medaal bwmfb to me under9gri d O"ictan or suppW 1a
%;;'Dews 0" divn. I also request paYmnl of 9ovorm wo bwelb e6NSt to myself a m tae parer who aaepm asst mnem bcbar, terNees dwAbEd below.
SOF 03 08 2010 SOF
SIGNED DATE SIGNED
14 WE OF CURRENT LLNESS(FirstrMom)OR 19, IF PATIENT HAS HAD S OR SIMILAR ILLN SS, 16.IIATESPAIE UNABLE TOWORRIN CURRENT OO PAT
O 1 C 21 10 =Y I A OR GIVE FIRST DATE MM DD YY
PREGNANCY FROM TO
T7 NAME Of- RC-FE RAM PHYSKWOROTItERSOURCE !7a 18. HOSPITAUZ06TION DATES RELATED TO CURRENT SER4ICES
MM 00 YY MM Do YY
;Th. i'IPI FROM TO
19. RESERVED FOR LOCAL USE 20.OUTSIDE LAD? 5 CHARGES
YE. a ao
21. DLaGNOSIS OR NATURE OF ILLNESS OR INJURY, (RILATE iTEINIS I. ,3 OR d TO ITEM 24E BY LINE) 22. MEDICAID RESUBMtS&ION
847 2 Sprain/stmin lumbar back E$85 9 Fall,slip,trip o CODs owaNUaa.No.
1 3 same Icvcl
Thoracic/lumbosac 23, PRIOR AUTHORIZA NUMBER
2 L 724 4 radiculitis neuritis 4.
74 A DATE(S) OF SERVICE D I C I D PROCEDURES,SERIIGES, OR 6UPR ES E F 0 N I
from To p6m III (E:pb n LAwW Ckwretanoes) O AGNOSIS DAYS OR ?&DT 10. RENDERING
I AM1 OD YY wu op YY $mNice EMO CPrhICPCS MODIFIER POINYEA $CHARGES UNITS ffift DUAL PROMDERID.#
1 N4 Diclofenac Sodium 50mg; #30 013 01048910A
1� 03 01 ]0 I 01 10 i 1 10544 163 -30 1 2 105; 00 1,00
N4 Skelaxin 800mg; #30 013 01048910A
03 01 10 03 01 10 11 60793 -0136.09 1 t z 126 00 1.Qp
NPI
NPI
NPI
i
1I
S. FEDERAL TAX 1,0, NM �VTTAT'S ACCOUNT NO. I 7 28. TOTAL Gt TAMN PAID 30. BALANCE DUE 35- 1955223 Inv 261260 YES NOS S 398 i 0167 i 00 s 231: 00
31. SIGNATURE OFPHYSICIk4ORSUPPUEA 32. SERVICE FACILITY LOCATIONINFORMA (317) 621 -6704 31,kUNG PROVIDER IruoaPHU (317 355 6335
0coro st*M d 4onM0t"wea Occupational Health Carmel Cornmuni 000 a tional Health Services
P cert+Tr Ihaf tAe slalemps on trre reverse eq,ly TY P
10 as bin MdarenuNleaParldlew) 11911 N. Meridian St., Ste. 160 P.O. Box 19383
S. Daftari MD Carmel IN 46032 Indianapolis M 46219
03 08 2010
SIGNED DATE a, 1912229196 b. 7 1912229196 b OB01048910A
NUCC Instruction Manual available at, www,nlacc.org APPROVED OMB -0938 -0999 FORM CMS -1500 (08105)
SYSTOC v7.26 o9REP0RTSICU8T0M11500 CLAIM FORM CUSTOM_ <b >Custorn report by OHA for INDIANCOMM</b>
VOUCHER NO. -'WARRANT NO.
ALLOWED 20
Community Occupational Health Services
IN SUM OF
PO Box 19383
Indianapolis, IN 46219
$231.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Administration
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1205 261260 I 43- 475.00 I $231.00 1 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
Monday, September 13, 2010
Director, Administraion
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
08/31 /10 I 261260 I I $231.00
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
1 20
Clerk Treasurer