HomeMy WebLinkAbout194293 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
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ROGER N. OR WINNIE A. NESTLE 09 -89 TO 74 559
11608 EDEN GLEN DR. PH. 317- 848 -4052
CARMEL, IN 46033 IOATE 1
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JPMorgan Chase Bank, N.A.
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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