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Home My WebLink About190260 09/29/2010 CITY OF CARMEL, INDIANA VENDOR: 364753 Page 1 of 1 i ONE CIVIC SQUARE LESTER FLEENER CHECK AMOUNT: $77.62 CARMEL, INDIANA 46032 10825 CORNELL INDIANAPOLIS IN 46280 CHECK NUMBER: 190260 CHECK DATE: 9/29/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 77.62 OTHER EXPENSES Date: 09/22/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 AO U N T H US 0 &YS Bill To: LESTER L FLEENER ICD -9: 796.4 786.50 10825 CORNELL INDIANAPOLIS, IN 46280 From: 10825 CORNELL AV To: ST VINCENT HEART CENTER MEDICARE PART B Patient: LESTER L FLEENER 315367173A 10825 CORNELL Insurance INDIANAPOLIS, IN 46280- 2 MUTUAL OF OMAHA Patient No: 201002116 703222 -88 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 $388.10 $465.72 -77.62 CPT [}ate Description Charges Credits 08/08/2010 ADVANCED LIFE SUPP 1 —EMER A0427 $375.00 08/08/2010 MILEAGE A0425 $13.10 09/13/2010 MEDICARE PAYMENT $310.48 09/17/2010 COMMERCIAL INSURANCE PAYMENT $77.62 09/21/2010 COMMERCIAL INSURANCE PAYMENT $77.62 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09/22/2010 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal 1D# 356000972 Bill To: LESTER L FLEENER ICD -9: 796.4 786.50 10825 CORNELL INDIANAPOLIS, IN 46280 From: 10825 CORNELL AV To: ST VINCENT HEART CENTER 9 MEDICARE PART B Patient: LESTER L FLEENER 315367173A 10825 CORNELL Insurance INDIANAPOLIS, IN 46280- 2 MUTUAL OF OMAHA Patient No: 201002116 703222 -88 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 $388.10 $388.10 $0.00 CPT Date Description Charges Credits 08/08/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00 08/08/2010 MILEAGE A0425 $13.10 09/13/2010 MEDICARE PAYMENT $310.48 09/17/2010 COMMERCIAL INSURANCE PAYMENT $77.62 09/21/2010 COMMERCIAL INSURANCE PAYMENT $77.62 09/22/2010 REFUND -77.62 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Ex pl anation of Pa ment Re REPORT ENDING PAGE pl anation P PERIOD ENDING DATE 09/13/10 CITY OF CARMEL FIRE DEP United of Omaha DRAFT /CHECK NUMBER: 00666058 2 CIVIC SO Life insurance Company DIRECT INQUIRIES T0: CARMEL IN 46032 UNITED OF OMAHA LIFE INSURANCE COMPANY IF YOU HAVE ANY QUESTIONS, CALL: MUTUAL OF OMAHA PLAZA (800) 546 -5906 OMAHA, NE 68175 -0001 CLAIMS PROCESSED UNDER TIN /EIN: 356000972 Insured's Name ?atient Policy /Plan Number 'ert Number Date of Less Charges Remaining Maim Number Service Submitted Not Covered Less Considered Benefit Balance 4ccount Number From To Procedure Charges Amount Note Balance Deductible Charges Amount Due LEENER /LESTER /L ELF 080810 080810 AMBULANC 375.00 080810 080810 AMBULANC 13.10 03222 -BBH 77.62 100 77.62 310.48 1 83476195800 -021 01002116 TOTAL 388.10 77.62 OTAL PAIR: 77.62 RLf CEIVED C Erg 2 1 210 OTES: 0 P�11 J1 =�,�J J U 1 THIS IS THE AMOUNT PAID BY MEDICARE. E D B THE FACC O F T1 =116 DOt.UMENT:NfiS A COL BF.CKGROUN[?.ON- WHII'E,PAPER. THE BMCS< OF TMiS DOCUiVIENT'CONTAINS AN'P,RTIFiC1AL WATEfiM�1RK I-fOLDATAN'ANGLcyTO'UIE4V :76.4' PAYABLE THRU FIRST NATIONAL BANK OF C)MgHA i0a9 E. UNITED•i'pF OMAHA FIFE INSURANCE COMPANY wfiHA; 68102 eE A &u L: of 0m,L A COPoIPANY FR�MONT NATIONAL'�BANK &TRUST 60 u 4viutual'ot Omaha €Plaza, Qm t11ii, NL 68175. i` A DATE DRAFT NO M s M1 n 0 0'6 6 6 0.5..$ "7 7 6 2" 6 9 61.3 `0 8:0 81.0' s CLAIM No AMOUNT 58347.61958.0'0.,021! PAY TO THE ORDER OF PLEASE CASH IMMEDIATELY '.A C C T# 2 04 0-02 11'.1 58 POLICY /PLAN ;'NUMBER 7, -03.2,2.2 &8,H CITY OF CARMEL FIRE DEP 2 CIVIC SQ CARMEL IN 46032 AUTHORIZED SIGNATURE 11'0 ❑665058lie 1; 1049000481. 09 10 40 L 7 11' P"160280p2 Central 'Reserve Life Insurance Co P.O. Box 30010 Austin, TX 78755 -3010 20 pp9,147 U If you have any questions about this claim, please contact: Electronic Service Requested Central Reserve Life Insurance Co w Medicare Supplement Claims Department ALL FOR AADC 462 ClientServicesGASB @gafri.conl L802 0.3820 FP 0.414 866 459 -4272 l�ll. l�ll °.I�IIII °1111"II'1�11�11'�ll "'1'111, °I�I'�Ill�lnll11 P -O. Box 30010 w CARMEL FIRE DEPARTMENT ly4 Austin, Tx 78755 -3010 2 CARMEL CIVIC SO w CARMEL, IN 46032 You do not need to submit paper copies of your claim and Medicare Explanation of Benefits/Medicare Summary Notices as we receive all Part A and Part B claims electronically from Medicare. RECEIVED SEP 1 7 2010 Date: 0911112010 Tax ID: 356000972 Check 000848244 Control 1025410223 Service Dates Gilled Medicare Medicare Not Covered Company Remarks From To Charge Approved payment Amount Payment Code tsurrx€ 1) >1 1 ly #�e# #r2#1IIO211 :::flat a4Q16i33 }?6i. fii1t10€ILI6€ 08108/10 -08/08/10 375.00 375.00 300 -00 0.00 75.00 08 -08/08 13.10 13.10 10.48 0.00 2.62 Totals: $388.10 $388 -10 $310.48 $0,001 $77.62 STATEMENT TOTALS: 1 $388.101 $388.10 $31 0.4 8 $0.001 $7 Remarks Code Descriptions If you wish to dispute the company's decision on this claim, you may submit your dispute in writing to the address of the company listed above. The company does not waive any defenses or rights to conduct additional inquiries, nor does the company waive any rights or defenses with regard to the contract or applicable law. I FOR SECURITY PURPOSES THE FACE OF THIS DOCUMENT CONTAINS A BLUE BACKGROUND AND`.MICROPRINTING THE 'BORDER"x 1 Central R�serve'Llfe Tnsurance Co CHECK Al(O 000848244` P O: BOX >300I0 s�aa r AUSTIN TX 7875 3010`\ l t K DATE CHEC 09 /1,il21).EU �-y 866 =459 ¢272 AMOUNT PY-00948631 r7i 1k'k PAY Seventy. Seven 62/100 Dollars 77.62 C D VOID UNI.ESS PRESENTED WITHIN S� TO THE CARMEL FIRE DEPARTMENT 180'DAYS F.ROM DATE HEREOF M ORDER OF 2 CARMEL CIVIC SQ. CARMEL, IN 46032 JP MORGAN CnASE BANK, NA SAN ANGELO TX f I' "DO!NOT CA`SH?IF WATERMARK IS:NOT P. <T•HE'REVERSE ^SIDE OF rTHIS DOCUMENT'�, AT'AWANGLEaTO VIEW- 11.000848 24411° l: L 1 1,3008801: 7 5 4080 7 2 90 v_._. Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An "invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. I Payee 1 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ZPSkv 1� Total 7 (U I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. a ALLOWED 20 IN SUM OF$ 7 7. CoZ Z 77.(-gz 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 r Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund