HomeMy WebLinkAbout192597 12/08/2010 a CITY OF CARMEL, INDIANA VENDOR: 354180 Page 1 of 1
ONE CIVIC SQUARE SHEPHERD INSURANCE AGENCY CHECK AMOUNT: $331.55
CARMEL, INDIANA 46032 1200 CARMEL DRIVE
CARMEL W 46032 CHECK NUMBER: 192597
CHECK DATE: 121812010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 331.55 REFUND
Date: 12/01/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federat m# 356000972
Bill To: NICOLE L STRACK ICD -9: 78039 78907
15407 BLOOMFIELD CT
WESTFIELD,IN 46074
From: 1200 W CARMEL DR
To: ST. VINCENTS HOSPITAL CARMEL
1 ENCORE HEALTH
Patient: NICOLE L STRACK 035050000500
15407 BLOOMFIELD CT Insurance
WESTFIELD, IN 46074- 2
Patient No: 200902162
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
$331.55 $663.10 331.55
CPT
Date Description Charges Credits
08/24/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
08/24/2009 MILEAGE A0425 $6.55
01/20/2010 COMMERCIAL INSURANCE PAYMENT $331.55
11/29/2010 COMMERCIAL INSURANCE PAYMENT $331.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 12/01/2010
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
4 mss. U N
Bill To: NICOLE L STRACK ICD -9: 78039 78907
15407 BLOOMFIELD CT
WESTFIELD, IN 46074
From: 1200 W CARMEL DR
To: ST. VINCENTS HOSPITAL CARMEL
1 ENCORE HEALTH
Patient: NICOLE L STRACK 035050000500
15407 BLOOMFIELD CT Insurance
WESTFIELD, IN 46074- 2
Patient No: 200902/62
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
$331.55 $331.55 $0.00
CPT
Date Description Charges Credits
08/24/2009 BASIC LIFE SUPP EMERGENCY A0429 $325.00
08/24/2009 MILEAGE A0425 $6.55
01/20/2010 COMMERCIAL INSURANCE PAYMENT $331.55
11/29/2010 COMMERCIAL INSURANCE PAYMENT $331.55
12/01/2010 REFUND 331.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Y m m m m m m' m a
m m s
d
k 0 STAR Financiat.Bank DATE 1I'%22/2010 r 0046EJ
i
Aderson Indtaita
ti n RATIENT NIGGLE L STRACK z'1 1b7/7a9
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VOmFB� r{ DATE
0t 7 'SBrV.IC HS OF IS SUE
Pa a 10, need „n by erVI eS `,PATIENT ID 200902162
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PAY TH[S AMOUNT
PAY: THREE.HUNDRED THIRTY ONE DOLLARS #ND 55 CENTS :S331.55
PAY CARMEL FIRE DEPT AMBULANCE SER
TO;
2 CIVIC SQUARE
OE CARMEL, IN 46032- 7543 S16MTuRi
T
1iI0440468 bu® n:07490 b67 21: 1i® I b0 32 16 2ii°
154 EXPLANATION OF BENEFITS 1 1/22/20 10 04404681
ADMINISTERED BY GROUP CLAIMANT
3505 5
TILSON FIR INC 80 ENCORE PLAN CLAIM FOR NICOLE L STRACK
U OR i f 1 Ica d SELF
Group services
PO Box 10, Pendleton, IN 46064 -0010 PA'rIENT ACCT 200902162
Phone RECEIVED NOV 2 9 M- i
dGrp.c o nn
www.Unified Grp.cm
CLAIM NUMBER 2010-30000054t- 0
CLAIMS SUMMARY
NICOLE L STRACK TOTAL AMOUNT COVER FD 5331.55
P O BOX 426 PAID BY OTHER INSURANCE CO $0.00
TOTAL PAID BY PLAN 5331.55
ELWOOD, IN 46036 E,N1IPLOYEE'S RESPONSIBILITY $0.00
PROVIDER(S)
356000972 -0 Deductible Remaining Plan $2,000.00
CARMEL FIRE DEPT AMBULANCE SER In Network 50.00
2 CIVIC SQUARE Out or Pocket Remaining Plan 56,000.00
CARMEL, IN 46032 -7543 In Network 50.00
100 In- nel-rrark benefit applied ANNUAL ACCUMULATION $0.00
Comments:
3175712605 BECKY S LANNAN
TYPE OF SERVICE DATES OF SERVICE CH TOTAL F ARGE COVERED SAVING OR PENALTY EX C.Pay DEDPP S PAID 1 BEiNEE STS
A MBULANCE GROUND 08/24/09 08/24/09 $325.00 50.00 $0.00 $325.00 50.00 $0.00 100 5325.00
MBULANCE GROUND 08/24/09 08/24/09 56.55 50.00 $0.00 S6 -55 $0.00 $0 -00 100 56.55
TOTALS $331.55 50.00 50.00 5331.55 50.00 50.00 5331.55
Remarks on Back
SHEPHERD INSURANCE
lndcpendeRl FINANCIAL SERVICES INC. FIRST FINANCIAL BANK, N -A.
IHOBO 1200 WEST CARMEL DRIVE
AQEnI, CARMEL, IN 46032 56•91l422
(317) 846 -5554
AMOUNT'
PAY
TO THE
ORDER
OF:
1 tgHr�
2 b o 7 G
1I 1 00 L0 5 O x:04 2 2009 LOI: 00 3 98 6 9 6801m
Shepherd Insurance Financial Services, Inc.
00105:
r
C• L lu
Prescribedby 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.
Payee
eoh n.S(lc /ZL' P_ Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�iI G(OS
Total 4 S21'��y
1 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 20
IN SUM OF
2-,?l 55
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
DEC c 2010
r ti
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund