HomeMy WebLinkAbout191236 10/27/2010 CITY OF CARMEL, INDIANA VENDOR: 364844 Page 1 of 1
ONE CIVIC SQUARE DANNY HUBBARD
0 CHECK AMOUNT: $6.55
CARMEL, INDIANA 46032 12110 N GRAY ROAD
CARMEL IN 46033 CHECK NUMBER: 191236
CHECK DATE: 10/27/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 6.55 OTHER EXPENSES
Date: 10/13/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
ACCOU H R
Bill To: DANNY N HUBBARD ICD -9: 78652 9110 E8130
12110 NORTH GRAY RD
CARMEL, IN 46032
From: 96TH &KEYSTONE
To: CLARIAN HOSPITAL NORTH
CIGNA 5200
Patient: DANNY N HUBBARD U09512681
12110 NORTH GRAY RD Insurance
CARMEL, IN 46032 2
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
$338.10 $344.65 -6.55
CPT
Date Description Charges Credits
05/19/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/19/2010 MILEAGE A0425 $13.10
08/05/2010 COMMERCIAL INSURANCE PAYMENT $331.55
09/02/2010 PAYMENT $6.55
10/13/2010 COMMERCIAL INSURANCE PAYMENT $6.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/13/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal w# 356000972
Bill To: DANNY N HUBBARD ICD -9: 78652 9110 E8130
12110 NORTH GRAY RD
CARMEL, IN 46032
From: 96TH &KEYSTONE
To: CLARIAN HOSPITAL NORTH
9 CIGNA /5200
Patient: DANNY N HUBBARD U09512681
12110 NORTH GRAY RD Insurance
CARMEL, IN 46032- 2
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
$338.10 $338.10 $0.00
CPT
Date Description Charges Credits
05/19/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
05/19/2010 MILEAGE A0425 $13.10
08/05/2010 COMMERCIAL INSURANCE PAYMENT $331.55
09/02/2010 PAYMENT $6.55
10/13/2016 COMMERCIAL INSURANCE PAYMENT $6.55
1011312010 REFUND -6.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
v Return this portion with your payment
Payable To: CARMEL FIRE DEPARTMENT
DANNY N HUBBARD $6.55
Run Date KECEIVED SEP 0 2 2010
05/19/2010 Amount Paid
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
PAMELA S. HUBBARD 3042
DANNY N. HUBBARD
12110 N. GRAY RD_ 70.21891719
CARMEL, IN 46033- 9635 �'�ro 070
Date
Pay to tEie w
Order of
r�S t -�7 irn /1C DolEars
For L3vsCt� •`IC�Q c:r mr
3042
CONTROL 26102010756302 BILL ID: ESIEDI- 07/20/2010- 0199 =0022
EXPLANATION OF REVIEW INDEX CCO0772392
COVENTRY WORKER'S COMP SERVICES DATE PROCESSED: 10/4/2010
4511 WOODLAND CORPORATE BLVD. INFO 1:
TAMPA, FL 33614 -0000 INFO 2:
PHONE: (800) 810 -4881 BRANCH: ESIS Medical Only 498
FAX: (813) 806 -2614 DATE OF INJURY: 5/19/2010
PROVIDER NAME AND ADDRESS: PATIENT NAME: DAN HUBBARD
PATIENT ID:
CARMEL FIRE DEPARTMENT PATIENT ACCT MISSING
2 CIVIC SQ PAYOR RECEIPT DATE: 8/5/2010
CARMEL, IN 46032 COVENTRY RECEIPT DATE: 8/5/2010
CLAIM C494C1647503
COVERAGE: C DRG:
JURISDICTION: IN REP /SUP: 501 685
PROVIDER TAX ID: 356000972 ICD9 PX (1) (2)
NPI: (3)
ICD9 DX (1) 786.5 (2) 911.0 EMPLOYER: THE QUIKRETE COMPANIES INC
(3) E813. (4)
DATE OF BLLD /RVWD UNITS BILL BILL RVW NTWRK OON
"'SERVICE PROCEDURE 1I CHARGES RDCTNS RDCTNS RDCTNS
6DESCRIPTION OF SERVICE NOTES ALLOWANCE
H �� L=-----------------------------------
Q05/19/10 A0425 0000002 13.10 0.00 0.00 0.00
°GROUND MILEAGE, PER S 13,10
X05/19/10 A0429 0000001 325.00 0.00 0.00 0.00
oAMB. SERVICE, BLS, EM 325.00
N
O
a
TOTALS: 338.10 0.00 0.00 0.00
338.10
NOTES /MESSAGES: BREC: 00000000 PPOA: 00000000
Payment of $331.55 was previously issued for this claim. The payment should
have been $338.10. (Z989)
7
I THIS MULTI TONE'AREA
OF THE DOCUMENT CHANGES COLOR` GRADUALLY AND EVENLY FROM `DARK TO,LIGHT WITH DARKER AREAS BOTH-TOP AND „BOTTOM.
nc>: usA
IVC638836U5
ACE Pm ei and'Casaalty Insurance Company
'and- Affiliated Insurers:
Wells Fargn 9enk OA o N a',l 56 392
1 195.HOSPIIaI �rlve
FILE ib van wart, OHa589t -'DATE 412
I. PLEASE
49 pEP051T•^
4c t 647503'.. 1 o /oj% 1 o o�.�ASH
THIN 90 DAY
'POLICY
DOLLARS
HOLDER THE'. QU 1 KRETE :COMPAN 1 ES,` I NC 6 .,55
**SIX DOLLARS AND 55 CENTS**
FOR ®'SERVICES FROM 05/19/10 THRU 05/19/10 MISSING
PAY TO THE ORDER OF
CARMEL FIRE DEPARTMENT
AUTHORIZED SJ NATURE sPPCIALHaNDUN¢
2 C I V I C SQ CLAIM OFFICE ES I S SOUTHF] ELD MED' ONLY 00
CARMEL IN 46032
CLAIMANT HUBBARD; DAN N.
NRS- IGS -12.'
rI 26388360SII' 1:0 L, 1 2 318 a 960005246111°
ff J :THE.ORIGINAU. DOCUMENT `H'AS':kREF.LECTIVE'WATERM'ARK ON'.THE.BACK: HOLD:AT`AN'ANrl F'Tn wi4FOU'ruFrttinir .TUO -Cf tnnoccAnr-nrr NE
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
_D tk-b b ar d Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
r io Kerpowm eAl
s d
r
Total S�
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 J 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
rnbuJow uj?aC IV O 14aaro
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
OCT 2
20
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund