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
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AS A) E.NT! I ()lt CHECK
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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