190004 09/14/2010 CITY OF CARMEL, INDIANA VENDOR: T357070 Page 1 of 1
ONE CIVIC SQUARE STATE FARM MUTUAL INS CHECK AMOUNT: $19.65
CARMEL, INDIANA 46032 2550 NORTHWESTERN AVE
o WEST LAFAYETTE IN 47906 CHECK NUMBER: 190004
CHECK DATE: 9114/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 19.65 AMBULANCE REFUND
Date: 09110/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
ACCOUNT
Bill To: CASSANDRA DODD ICD -9: 7231 71946 7840 E8130
955 MARGUERITTA WAY
GREENWOOD, IN 46143
From: US 31 I -465
To: CLARIAN HOSPITAL NORTH
7
Patient: CASSANDRA DODD
955 MARGUERITTA WAY Insurance
GREENWOOD, IN 46143- 2
Patient No: 201002102
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
$344.65 $364.30 -19.65
CPT
Date :Description Charges Credits
08/06/2010 BASIC LIFE SUPP--EMERGENCY A0429 $325.00
08/06/2010 MILEAGE A0425 $19.65
09/08/2010 COMMERCIAL INSURANCE PAYMENT $364.30
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/10/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
.(317)571 -2605 FederalID# 356000972
Bill To: CASSANDRA DODD ICD -9: 7231 71946 7840 E8130
955 MARGUERITTA WAY
GREENWOOD, IN 46143
From: US 31 I -465
To: CLARIAN HOSPITAL NORTH
1
Patient: CASSANDRA DODD
955 MARGUERITTA WAY Insurance
GREENWOOD, IN 46143- 2
Patient No: 201002102
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
$344.65 $344.65 $0.00
CPT
Date s Description Charges Credits
08/06/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
08/06/2010 MILEAGE A0425 $19.65
09/08/2010 COMMERCIAL INSURANCE PAYMENT $364.30
09/10/2010 REFUND -19.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
CLAIM NO 14- 3052 -054 POLICY NO 1638- 816 -14 LOSS DATE 08 -06 -2010 PAYMENT NO 1 18 507388 J
CoverageDescet t;i'on: .Amount COL Pa `Cd' DATE 09 -02 -2010
MEDICAL PAYMENT $364.30 600 2 AMOUNT $364.30
TIN 14- 356000972
REMARKS 8/6/2010
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 507388 J
WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441
COLUMBUS, OH
m MPC INDIANA 18 -501 L025
09 -02 -2010
DATE M M D D Y Y Y Y
CLAIM NO 14- 3052 -054 INSURED DODD, RICHARD
LOSS DATE 08 -06 -2010 ON BEHALF OF CASSANDRA A. DODD
*EXACTLY THREE HUNDRED SIXTY-FOUR ANDt301100 DOLLARS
Pay to the
Order of: CARMEL FIRE DEPARTMENT';.
2 CIVIC SQ
CARMEL IN 46032 -2584
RECEIVED S Cp 0 APPROVED BY
CLAIM NO 14- 3052 -054 POLICY NO 1638 816 -14 LOSS DATE 08 -06 -2010 PAYMENT NO 1 18 507388 J
Covera Deacri Oon 'Amount COL Pa ''Cd DATE 09 -02 -2010
MEDICAL PAYMENT $364.30 600 2 AMOUNT 364.30
TIN 14- 356000972
i�6 9I P t P""q .,«..Y ti, 4` k'— if+ws� D S
RETAIN w' .r s �«w� ii t S s..... �J" 4I '4.,.�r ✓4
REMARKS 8/6/2010
;STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY. 1 :18
WEST LAFAYETTE IN JP.MORGAN AS BANK, NA 56 1544/441
CDCUMBUS OH
MPC LNDIANA ',18 501.'L025
09 02 2010
_r
DATE m D D' ;TY Y Y
aCLAIM NO 14 -3052 -054 INSURED DODD; ,RICHARD
-,LOSS DATE 08 -06 -2010 �ON'.BEHA'LF OF�;CASSANDR'A -A. DODD
I *EXACTLY THREE HUNDRED SIXTY -FOUR AND 30 /100.DOLLARS *364..30
r' Pay to the
f Order of: CARMEL FIRE DEPARTMENT
2 CIVIC S cs
CARMEL IN IN 46032 -2584 w i
AUTHORIZED SIGNATURE
AUTHO D SIGNATURE
Lu
°�8�7507388Ill 1: 0 4 L,I154431:6 25 290 2 3 3lie
STATE FARM
n EXPLANATION OF REVIEW
e 0 This is not a bill
INSURANCE
OO
State Farm Mutual Automobile
CLAIM NUMBER 14- 3052 -054 OFFICE NAME Insurance Company
Indiana MPC Office
CASSANDRA A. DODD CARMEL FIRE DEPARTMENT
955 MARGUERITTA WAY 2 CIVIC SQ
GREENWOOD, IN 46143 -2541 CARMEL, IN 46032 -2584
DATE OF LOSS 8/6/2010 CLAIM HANDLER Unit Xe Processor
NAME INSURED DODD, RICHARD K ADDRESS PO Box 2362 Bloomington, IL.
61702
POLICY NUMBER 163881614 PHONE 866 648 -0715
JURISDICTION Indiana TIN 356 -00 -0972
Z IP OF SERVICE 6032 -2584
BILL REFERENCE NA DATE RECEIVED 8/25/2010
NUMBER
719.46 PAIN IN JOINT, LOWER LEG, 784.0 HEADACHE, E813.0 MOTOR VEHICLE
DIAGNOSIS CODES COLLISION WITH OTHER VEHICLE, INJURING DRIVER OF MOTOR VEHICLE.
OTHER THAN MOTORCYCLE, 723.1 CERVICALGIA
DRAFT NUMBER 1118507388J
LINE DATE OF POS CPT /HCPCSMOD /TS UNITS SUBMITTED APPROVED REASON
SERVICE AMOUNT AMOUNT CODES
1 8/6/2010 8/6/2010 11 A0429 1 325.00 325.00
2 8/6/2010 8/6/2010 11 A0425 3 19.65 19.65
3 8/6/2010 8/6/2010 11 A0429 1 325.00 0.00 99
4 8/6/2010 8/6/2010 111 A0425 3 19.65 19.65
TOTAL SUBMITTED CHARGES 689.30
TOTAL APPROVED AMOUNT 364.30
MOUNT NOT PAYABLE 0.00
DEDUCTIBLE 0.00
PPORTIONMENT /PRO RATA 0.00
PAID AMOUNT 364.30
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
R e
Dn L "l.1 S scti� l�
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.
n ALLOWED 20
IN SUM OF 6 -S
ON ACCOUNT OF APPROPRIATION FOR
Am h1dalt c� f-�e��I/ rp
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), O r
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 13 2010
r
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund