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Home My WebLink About194293 02/03/2011 CITY OF CARMEL, INDIANA VENDOR: 365065 Page 1 of 1 p ONE CIVIC SQUARE ROGER NESTLE CHECK AMOUNT: $16.05 CARMEL, INDIANA 46032 11608 EDEN GLEN DRIVE CARMEL IN 46033 CHECK NUMBER: 194293 CHECK DATE: 2/3/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESC RIPTION 102 5023990 16.05 REFUND Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT WINIFRED A NESTLE RECEIVED �C�� JAN 1 2 20 Run Date c 10/05/2610 Amount Paid D APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 _...w.� N u- '�fi.r x.. ��,f 3`i�. 7M.umiCYAtYk�^ wencaunnnnur „�n..+.zr�p+m xw.�aeirfaHt+nv7�::xrwttuar a r e, arc, tmm�aa +mnaius�a�:mpurerszaanm��* 201 ROGER N. OR WINNIE A. NESTLE 09 -89 TO 74 559 11608 EDEN GLEN DR. PH. 317- 848 -4052 CARMEL, IN 46033 IOATE 1 -J t CHASE+ JPMorgan Chase Bank, N.A. www.Chase.com 33' S'�"SP i t� k 2 m�' Y ry j 5. l P. USA A °X X ExPLA NATION OF BENEFI �et�JI.� A'�[JT; {jrtq�.>i8- ,lrlti Please F,etain for Future Referenc CITY OF CAF,Pl1EL FIFE DEPT F',N: 0005745 k 0 Check No: 0931 7- 035SO445 Pane 3 of 3 Patient Name: W A NESTLE (SpGuse) Claim ID: EPAAP23G300 Recd: 12123/10 Member ID: W1 0061 91 1 1 Patient AcCOLlnt: 201002615 Pvlember: ROGER N NESTLE DIAL: 78002 Group Name: THE DOW CHEMICAL COMPANY Group Number: 479235-17-156 Y CAS] +0 Product: Traditional ChoiceQ Network ID: 00000 Aetna Life Insurance C01111)any SEt'JIGE PL SER'lICE (41i,1. AL TXELL CCPR( HOT SEE GEDUCTIME C0 PATIENT PAY't'U 1114 i, COC1E WC, r;FIARGES AF:IOUDIT A!i0l4iT FRYAELE °EIAA.NK:: 111;7URAI !CE RFP ?!,I!)1111T 101051110 41 A,042lRH 1.0 375.00 75.00 I 6CYi 1010500 41 P,OdZGRH 40 1' 5.24 1 A 1r 1 TOTALS 401.20 M24 64.19 64.19 2 6.r, Lss Amouiii Paid by Oihet He:dlh Plrin 240 72 ISSUED XVIT: $16.05 A Remarks: You have agreed to accept the amount Medicare approved as payment in full ferthis service. The memberis not legally responsible to pay amounts area(erEhan Medicare's approved amount. 065 For Questions Regarding This Claim P.O. BOX 901106 EL PASO. TX 79993 -110(3 Total Patient Responsibility. X64.19 CALL (888) 632 3862 FOR ASSISTANCE Claim Payment :1:16.05 Note, Alt Inquiries should reference the 10 number above for prompt res.rjonse. Date: 01/19/20V CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571- 2605 Federal ID# 356000972 7' H Bill To: WINIFRED A NESTLE ICD -9: 780.02 11608 EDEN GLEN DR CARMEL, IN 46033 From: 11608 EDEN GLEN DR To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: WINIFRED A NESTLE 4413469856 11608 EDEN GLEN DR Insurance CARMEL, IN 46033 2 AETNA US HEALTHCARE /981106 Patient No: 000069960 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 $401.20 $401.20 $0.00 CPT Date Description Charges Credits 10/05/2010 ADVANCED L1-FE SUPP 1 -EMER A0427 $375.00 10/05/2010 MILEAGE A0425 $26.20 11/15/2010 MEDICARE PAYMENT $320.96 01/10/2011 COMMERCIAL TNSURANCE PAYMENT $16.05 01/12/2011 PAYMENT $80.24 01/19/2011 REFUND -16.05 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 01/19/201.1 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal iL)# 356000972 Bill To: WINIFRED A NESTLE ICD -9: 780.02 11608 EDEN GLEN DR CARMEL, IN 46033 From: 11608 EDEN GLEN DR To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: WINIFRED A NESTLE 441346985B 11608 EDEN GLEN DR Insurance CARMEL, IN 46033 2 AETNA US HEALTHCARE /981106 Patient No: 000069960 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 $401.20 $417.25 -16.05 CPT Date Description Charges Credits 10/05/2010 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00 10/05/2010 MILEAGE A0425 $26.20 11/15/2010 MEDICARE PAYMENT $320.96 01/10/2011 COMMERCIAL INSURANCE PAYMENT $16.05 01/12/2011 PAYMENT $80.24 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 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. Payee I p 2S'�I L Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 4 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. ALLOWED 20 aver 1Us -lam U N SUM OF �O S J l 6 D A J/0 ON ACCOUNT OF APPROPRIATION FOR 14r /-u Board Members Po# or INVOICE NO. ACCT4/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 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund