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HomeMy WebLinkAbout194270 02/03/2011 CITY OF CARMEL, INDIANA VENDOR: 365063 Page 1 of 1 ONE CIVIC SQUARE JIM MATTHIESEN CHECK AMOUNT: $66.31 CARMEL, INDIANA 46032 2 TAMARACK DR #20765 JASPER GA 30143 CHECK NUMBER: 194270 CHECK DATE: 2/3/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 66.31 REFUND Date: 01/27/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: JIM MATTHIESEN ICD -9: 780.02 2 TAMARACK DR 20765 JASPER, GA 30143 From: 116TH &DITCH RD To: CLARIAN HOSPITAL NORTH MEDICARE PART B Patient: JIM MATTHIESEN 353149293A 2 TAMARACK DR 20765 Insurance JASPER, GA 30143- 1 CIGNA HEALTHCARE 182223 Patient No: UO3599891 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 $397.86 -66.31 CPT Date Description Charges Credits 11/11/2010 BASTC LIFE SUP EMERGENCY A0429 $325.00 11 /11 /2010 MILEAGE A0425 $6.55 12/21/2010 MEDICARE PAYMENT $265.29 01/11/2011 PAYMENT $66.31 01/25/2011 COMMERCIAL INSURANCE PAYMENT $66.31 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 01/27/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal iD# 356000972 jk Bill To: JIM MATTHIESEN ICO -9: 780.02 2 TAMARACK DR 20765 JASPER, GA 30143 From: 116TH &DITCH RD To: CLARIAN HOSPITAL NORTH MEDICARE PART B Patient: JIM MATTHIESEN 353149293A 2 TAMARACK DR 20765 Insurance JASPER, GA 30143- 2 CIGNA HEALTHCARE 182223 Patient No: UO3599891 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 11/11/2010 BASIC LIFE SUPP -EMERGENCY A0429 $325.00 11/11/2010 MILEAGE A0425 $6.55 12/21/2010 MEDICARE PAYMENT $265.24 01/11/2011 PAYMENT $66.31 01/25/2011 COMMERCIAL, INSURANCE PAYMENT $66.31 01/27/2011 REFUND -66.31 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT -'I� jw� $66.31 JIM MATTHIESEN EV Run Date Amount Paid (e6, 1 111 112 0 1 0 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 JAMES A. MATTHIESEN 9/93 4080 FLORENCE E. MATTHIESEN 64-427/611 2 TAMARACK DR. 20765 JASPER, GA 30143 v Date Pay to the Order of qv�t— Dollars CN�SCENIT 0 CRESCENT CAPITAL BANK JASPER, GA 30 8 0 GUARDIAN AFETY ®DLll E. MR-SA pr ovider EY(7lallati n of alediccal l' ayrtoeyaReport C IGNA ovreter Number Pro, Name Date I[Iro gll w11icl, ciaims were processed TIHIS IS NO f A BILL Page 356000972 0000 ARHEL FIRE DEPT 01/18/2011 R t�,in For Your Records 1 Adjusted 1 7 Per lliern I Per D RG!1'er L)if m Per Diem I 3'rocedure rldlusted E Biked NioFved Not C;o.erc'l �DeduCtlCo )a Ci7mstasiiee Line Prot lure Date i ['Coco ilre 'I PrOCe(lure Cude, h Amoun nount Beneltt PLIn Benefit j ��te Code I Amount I Amount Discount Amount ltnuunL T Aumb Code t AmounL L PATIENT NAME JAMES MATTIIIESEN PATIENTfi: 201002437 OPERATION LOCATION /GROUP° 25757 9 2457482 RECEIVE DATE: 12/18/203,0 PROCESS DATE: 91/18 t1EHBER NAME: JAMES MATTHIESEN SUBSCRIBER#: 003599891 REFa: 9651035299137 JAMES 00583143554 1 11112010 A0429 325.00 325.00 0.00 0.00 0.00 375. Q0 I 0.00 0.00 i 2 11112010 A0425 5 -55 6 -55 0.00 5.55 TOTAL 331.55 331.55 331.55 i 550.00 HAS BEEN APPLIED TOWARDS 1HE $1,200 IN NETWORK 'OUT -OF- POCKET LIMIT' FOP THE POLICY YEAR BEGINNING 07/01/2010 raj 1:I is2 JAN hh 77 VIEW ELIGIBILITY, BENEFITS. AND CLAIM DETAILS AND GET PRECERTIFICATION ANSWE /714 Z01 RS FAST AT THE CIGNA FUR HEALTH CARE PROFESSIONALS 14EBSITE (WWW.CIGNAFORHCP. COM) PAYMENT OF 566.31 10 CARM£L FIRE DEPT AA1 AMB x TIIE ABOVE PAYHENI" AMOUNT INCLUDES ADJUSTMENTS FOR OTHER INSURANCE COVERAGE I 132 4 34(-:08 n 2U06 FROCLAIfv! Medical Provider EOp J' detach on Perforation Below Please Gash Prc Geller t.ilclnsur re>« Gump LrLy" AS A) E.NT! I ()lt CHECK STA I 1 Of' III,ItViIS II 1('IIIRS'il l�)[c I;lii:1L1' CIG A /311 DATE Provider I SIXTY: S1X .DOLL.ARS AND 31: CENTS ,:Q T'ayLoc 9 65 3 56006972. 0000 18/2011: 1'Ij CARMEL FIRE DEPT 11) [klc z CARMEL CIVIC S Doll its #66. 31 j 1 CAR EL' I�! 46®32 -n2584 I'1 Void It Not Cashed Wlthfn 1BQ pays i L." I (1f1IiANh L)I 1 411,1121;" r i N11V17M; h1? bI:I.r1GV.lR[i I 1571iS2 _�4• G24316 06- 28.2D0B PRf ChAIM:Meilic<-d h« rider bP THE ORIGiNA 4D L OCUMENT E HAS A "REFLECTIVE WATERMARK ON Tt BACK -.HOLD AT: ANGLE VIEW i i43554r1° 1 °0 3 1100 2091: �,CJ0084[i8n, I I T claim Provider EOP Summary G24361) 03 -23 -2005 o v n o e r a s 11 111111 III Iii I III! II I Illli I ill III III Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) t CITY OF CARMEL m 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 m es ,K- Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total alp 1p 3 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 /YI(,4k IN SUM OF ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or D PT. INVOICE NO. ACCT #/TITLE AMOUNT 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 JAN .2 Zap ,20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund