190260 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