HomeMy WebLinkAbout189833 09/14/2010 CITY OF CARMEL, INDIANA VENDOR: 364693 Page 1 of 1
ONE CIVIC SQUARE IN UFCW UNIONS FOOD EMPLOYEES
4 CARMEL, INDIANA 46032 5420 W SOUTHERN AVE SUITE 407 CHECK AMOUNT: $369.47
INDIANAPOLIS IN 46241
CHECK NUMBER: 189833
CHECK DATE: 9/1412010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTI
102 5023990 369.47 AMBUL REFUND
Date: 08/30/2010
CARMEL FIRE DEPARTMENT s
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
FM7
Bill To: ELLEN J HANKINS ICD -9: 786.50
130 NAPPANEE DR
CARMEL, IN 46032
From: 130 NAPPANEE DR
To: ST. VINCENTS HOSPITAL CARMEL
1 ANTHEM BC/BS/ 37010
Patient: ELLEN J HANKINS UF1000286174
130 NAPPANEE DR Insurance
CARMEL, IN 46032 2 MEDICARE PART B
Patient No:
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$394.65 $764.12 369.47
CPT
Date Description Charges Credits
06/07/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
06/07/2010 MILEAGE A0425 $19.65
07/26/2010 COMMERCIAL INSURANCE PAYMENT $369.47
08/27/2010 COMMERCIAL INSURANCE PAYMENT $394.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/30/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bill To: ELLEN J HANKINS ICD -9: 786.50
130 NAPPANEE DR
CARMEL, IN 46032
From: 130 NAPPANEE DR
To: ST. VINCENTS HOSPITAL CARMEL
1 ANTHEM BC /BSI 37010
Patient: ELLEN J HANKINS UFI000286174
130 NAPPANEE DR Insurance
CARMEL, IN 46032 2 MEDICARE PART B
Patient No:
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$394.65 $394.65 $0.00
CPT
Date Description Charges Credits
06/07/2010 ADVANCED LIFE SUPF 1 -EMER A0427 $375.00
06/07/2010 MILEAGE A0425 $19.65
07/26/2010 COMMERCIAL INSURANCE PAYMENT $369.47
08/27/2010 COMMERCIAL INSURANCE PAYMENT $394.65
08/30/2010 REFUND 369.47
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Ntiroeoiauns
IN UFCW UNIONS FOOD EMPLOYERS H &W PL IN UFCW UNIONS FOOD G.h'fPLOYERS H &W
PO BOX 42669 PL
INDIANAPOLIS, IN 46242 -0669
For Customer Service:
(80(1)382 -1799
�mounw�ou
Return Service Requested
CLAW NO 10036 102000167
PLAN NAME: IN IJFCW UMONS F(Y)D
ALL FOR AADC 462 EMPLOYIERS I I &W PL
8988 U 7648 FP U-414 PLAN NO: k059
Il1�I�Il�I��,Blfl' III' ilf�tllll�tllll 'lll�lllllll�Il�Ie�11I'� PARTICIPANT: ELLEN 1 IIAN1hINS
CARMEL FIRE DEPT 143 PATIENT: ELLEN 1IA.NKINS
2 CARMEL CIVIC SQ PAT. ACCOUNT 26101954 t 195008
CARMEL, IN 46032 [U- 1ATIONS1 -11P: PARTICIPANT
RGC [iI VED: 07/15/10
PROC ESSEll: 07/19/10
RECEIVED JU 2 Zq� EXAMINER: D U
0! 00 t I�
E xpl ana tion of Ben efits
5rrvice Providerol semice hargt Network r Nct I Less
p 13alancc Paid
Dates Service I p e Am ount f Discount Covered Deductible Considered At Atnuunt Code
106-07 06 -07 -11 CARMEL FIRE DEPT r1'V113UL. 375.000 375.001 349.821 672
06 -07 66 -07 -10 CARMEL FIRE DF PT AMBUL. 19.65 19.65 100% 19.65 792 1
06- 0706 07 -10 CAI:NIEL F IRE DEPT MESSAGE'- 51311
Totals: 394.65 3 94.6 1 369.47
Deduct M aximums
INDIV €DUAL I1ED[1CTIBLE AMCIIJNT 400.000F 400.00 \CIE "I' FOR 2010
INDIVIDI.1rkL.,%4AJOR�IEDICAL. 22285.52 PAID FORLIFE'FIME'I'O DATE
FriN91L.1' UEDi C[ IBLL �1R401TN7
400_000F 750.00 MET F'OR 2010
INDI VIDUA.L MAJOR \MDI 22285 PAID F OR 2 010 F O DATE
sum Other Irts #Tor Fatd Chrck Ptlent
[�f P t�tnG C4tnCl;cs Itlatnc Ps mettF I'attnettt Tu I�Tutxt4i LI�(titit';
CARAIF L FIRE DEPT 394 -65 369.47 CEUtMEL FIR 2 05232 2518
Remarks
672 MAXIMUM CO- INSURAINICI� AMOUNT HAS BEEN MET
792 ,MAJOR N4EI)ICAL BENEFITS PAYABLE' Al' 100 PER PLAN PROVISIONS
51113 NON CONTRACTED PROVIDER
1'OIJR
PI-AN HAS PRE- NOTIFlC A' 10N REQUIREMENTS.
CONTACT INFORMED AT 1-866 -446 -1318.
Zenith Claim Numbers: 1003620102000167
URPOSE$ THE FACE OF -7HIS DOCUMENT CONTAINS A�BCUE BACKGROUND AND`MICROPRINTING''IN THE BORDER:
FOR SECURITY P
St 1UQ x et, N(? ()()(2(),�3l
1N'UFCW `UN14P[S FORD E 1VTPLOYERS HBrCV PL, tua CHECK IRATE '07/2(1/1.0
34?U W Situthet n:AYc.. Suit( 407`
iazti olis IN 46241 564.'
p
liul
AM OU NT
361
PAY Three Hundred Sixth Tine 47 /100 Dollars.
TO THE ORDER OF: CARMEL FIRE DEPT Void If Not Cashed In 6 Months
xt;Yunnx Claim No: 10036 102000167
Pfau No: K059
Patient Acct:261019541 195008 /l
v' yDO =NOT CASHAF,t NOT -P..RESENTrON THE'REVERSE'SIDE OF`,,THS' DOCUMENT HOLD AT_'ANi'ANGL @;TO'V.IEW
HaODO020S23211' e 24 30 1 00 71. 1,40993SOt,S290
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Check 'Number: 14480 32 3 3 5
D ate: 08/19/2010
NON NEGOTIABLE NON NEGOTIABLE NON NEGOTIABLE N()N- NEGOTIABLE $745.8S******
PAY NON NEGOTIABLE NON NEGOTIABLE NON- NEGOTIABLE NON NEGOTIABLE
To 5/28- 6/7/10
the city Of Carmel Fire Dept Ambulance SE
order 2 ci vic Squar��.7
of Carmel, Tn, 46032
Claimant /Patient Ellen Hankins
Insured: Gary Adams
Date of Loss: 0512812010
Claim Number: 1016143128 -1
Check Nnnibcr: 1448032335
Payment Under Insureds; medical
Correspondence Reference: RSROPZOH01
Reference'NUMber:
r .Ft K t K 'J
t
Tll`,no�s Farmers Insurance Company`' x
CIsun 1t11'fil ;f
Cek` 144$33°
Z5�:t3 South F] fcfi Avenue <11 t X33 X77 k�
Pocxell0 �b 83204`'
Date 08/19f2010
b
PAY Seven Hunclret# Forty Five Dollar`s¢ And Eighty Fl Ve penis
=n a
y_ $745 85'
r
ic) l GC7i7 f�I 1LI1 Sl ibfON(1I5 r
To 5/28 6/7/10
fnyw
the cl ty Of Carmel Fl re Dept grn bul ante "SE
orde'� 2 `C1 VIc Squar,
bf Carmel Tn 46032
44b4n Delaware A �ulaidi iry of C.,ro Ur}) 0119 Pent 's kVaY i lmu Purl DE 1973i1 I
r�THE.'ORIGINAL?DOCUMENT}iAS A: fiEFL ON THE BACK* rsi HOL "O AT�AN F1NCxLE TO_VIEW NHNtCHECKING THEN60RS aa
�+�,503 2335 0 3 1 100 2091: 3 8? 21, 11 5u°
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
It 1� AJ /,,�{146Z'l S 4- r�� �1UP ��'J Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
W s sb e YZ
p!_, E ll t
Total
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 7
ON ACCOUNT OF APPROPRIATION FOR
Z Qmbtdaxoe- h /Ale
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
SEP 3 2010
f
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund