190227 09/29/2010 CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of 1
ONE CIVIC SQUARE CIGNA HEALTHCARE
CARMEL, INDIANA 46032 ONE CIGNA DR CHECK AMOUNT: $298.52
BOURBONNAIS IL 60914 CHECK NUMBER: 190227
CHECK DATE: 9/29/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 298.52 OTHER EXPENSES
Date: 09/15/2010
CARK0EL FIRE DEPARTMENT
EMERGENCY MED SVCS
2CiV|C SQUARE
CARMEL. IN 40032-
(317)571'2605 redera/uD# 356000972
B0 To: DWIGHT FREEMAN IrD-9: 9593 7231 7295 E8131
0S3GREENFORD TRAIL NO
CARMEL.|N 46032' From 96TH MERIDIAN
To: ST. VINCENTS HOSPITAL CARMEL
Patient: JILL FREEMAN
8A3GREENFORD TRAIL NO Insurance
CARMEL.|N 46032
PatienCNo 201002175
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
|s DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
CPT
Date Description Charges Credits
08/13/20I0 BASIC LIFE SO-PP-21MEoGEwC, A0428 $325.00
08/13/20l0 MILEAGE A0425 $26.20
09/1.4/2010 COMMERCIAL TmSUuAmCE e8YMENT $554.89
APPROVED B, THE STATE BOARD oF ACCOUNTS FOR CITY Oro*RMEL.19OS
Date: 09/15/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bill To: DWIGHT FREEMAN ICD -9: 9593 7231 7295 E8131
693 GREENFORD TRAIL NO
CARMEL, IN 46032
From: 96TH &MERIDIAN
To: ST. VINCENTS HOSPITAL CARMEL
CIGNA 5200
Patient: JILL E FREEMAN 01908871902
693 GREENFORD TRAIL NO Insurance
CARMEL, IN 46032- 2
Patient No: 201002175
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
$351.20 $256.37 $94.83
CPT
Date Description Charges Credits
08/13/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
08/13/2010 MILEAGE A0425 $26.20
09/3.4/2010 COMMERCIAL ?NSURANCE PAYMENT $554.89
09/15/2010 REFUND 298.52
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Pr-ov4der Explarsatiota o fMedical Payrnez'rtReport D SEP 1 4
za
Provider Number i Provider rdanle Date through svhich claims were proc TI�iS IS NOT A 131 LL
ige
j 356000972 0000 CARMEL FIRE DEPT 09/02/2010 Retain for Your Records 3
Procedr 1Itii
ue Adjusted gilled.`' adjusted _111oived Not Covered/ Deduct /Co a Coinsurance 1�Pc j DRG1 DRG /Per Diem DRG/
Line Procedure Date Procedure
Proceiure Cod' Q iam. Per Diem I 1'Br DiF m See
\mount. �tnounr I
Code Amount Discount Amount amount Amount Be] t t'lan B-1411 vote
1 er
Code I'
k
i i T;'Pe: I Number i Amoun
i
PATIENT NAME: JILL E FREEMAN PATIENT 201002175 OPERATION LOCATION GROUP# 31909- 9- 320358D RECEIVE DATE: 08/23/201.0 PROCESS DATE: 09/62
MEMBER NAME: DWIGHT FREEMAN SUBSCRIBER U19088719 REFR: 8651023602472 CHECK 00232410853
1 081.42010 A0429 325.00 325.00 0.00 48.75 0.00 0.00 276.25
2�� 08142010 A0425 26.20 26.20 0.00 3.93 0.00 0.00 22 -27 i
j TOTAL 351.20 351.20 298.52 1
$351.20 HAS BEEN APPLIED TOWARDS THE $750 OUT OF NETWORK DEDUCTIBLE FOR 2010
j THE $500 IN NETWORK DEDUCTIBLE HAS BEEN SATISFIED FOR 2010
5351.20 HAS BEEN APPLIED TOWARDS THE $3,000 OUT OF NETWORK 'OUT OF POCKET LIMIT' FOR 2010
$899.26 HAS BEEN APPLIED TOWARDS THE 51,000 IN NETWORK 'OUT -OF- POCKET LIMIT' FOR 2019
BALANCE $52.68
WHY WAIT FOR THE MAIL? VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE
ANYTIME AT HTTP /WWW.CIGNA.COM /HEALTH /PROVIDER/
PAYMENT OF $298.52 TO CARMEL FIRE DEPT
AA1 HAM
PATIENT NAME: JILL E FREEMAN PATIENT 201002175 OPERATION LOCATION /GROUP# 31900 9-3203580 RECEIVE DATE: 08/Z3/Z010 PROCESS DATE: 09/02
MEMBER NAME: DWIGHT FREEMAN SUBSCRIBER U19088719 REF 8651023602473 CHECK 00232410853
3 08132010 A0429 325.00 325.00 0.00 419.59 41.31 0.00 G.00 234.10 i
4 08132010 A0425 26.20 26.20 0.00 3.93 0.00 0.00 22.27
TOTAL 351.20 351.20 49 -59 256.37
THE $500 IN NETWORK DEDUCTIBLE HAS BEEN SATISFIED FOR 2010
$642.89 HAS SEEN APPLIED TOWARDS THE 51,000 IN NETWORK 'OUT OF POCKET LIMIT' FOR 2010
BALANCE S94.83
PAYMENT OF $256.37 TO CARMEL FIRE DEPT
AA1 MAN
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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
2 a- Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
_7
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.
,a-
ALLOWED 20
(21-) IN SUM OF
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
SE7 E
SEP 2 7 ZPAP
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund