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Home My WebLink About194357 02/03/2011 CITY OF CARMEL, INDIANA VENDOR: 00351910 Page 1 of 1 c ONE CIVIC SQUARE ST VINCENT CARMEL HOSPITAL INC CHECK AMOUNT: $883.00 CARMEL, INDIANA 46032 9600 RELIABLE PARKWAY Lo CHICAGO IL 60686 -0096 CHECK NUMBER: 194357 CHECK DATE: 2/3/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4340701 2053664876 828.00 MEDICAL EXAM FEES 1201 R4358800 21677 2053664876 55.00 TESTING FEES Plea seiold- alongp erforation- and return -stut w tth -p me ni m ztt .St. Vincent su SER FOR ME Carmel Hospital JOSEPH B LOVE 2001 West 86th Street P.O. Box 40970 SERV CE 11/02/10 S TATEMENT; 01/06/11 Indianapolis, IN 46240 -0970 T M.Tiff PAYMENT EXPECTATION Laboratory 567.00 St. Vincent would appreciate a Emergency Room 316.00 payment in full when you receive your Total Charges 883.00 statement. If you are unable to pay in full, we offer ACCOUNT ACTIVITY payment plans at zero percent Interest with no prequalification. Total Payments /Discounts 0.00 Financial Assistance is available for those that are unable to pay. Contact Customer Service for financial assistance and payment arrangement details. Asa atient of St. Vincent, you have the right to expect the finest level of Health Care. You have man choices for your health care needs and we want to thank you c1 ba r e s- 2cclioost .n om t.L h_e.hc� »P_t.,.t -nu_ s_r ice.. exceeded your expectations. CUSTOMER SERVICE CONTACT INFORMATION Monday through Friday 8:00 AM 4:00 PM 317- 338 -8035 800- 582 -8258 toll free 317 -583 -2737 fax E -Mail: billing(a stvincent.org Account Number Date Amount�Due,F' F: r To Pay Your Bill Online Please Go To: 2053664876 01/27/11 $883.00 www.stvincent.or WORKERS COMPENSATION WAS DENIED PAYMENT NOW DUE We have been notified that this claim will not be covered by Workers Compensation. If you question this information we recommend that you contact your employer. Please pay the amount due by the date indicated above. I 67 20OCT56 kfp2i In addition to your hospital bill, you may also receive separate bills for physician se rvices such as radiology, pathology. can €erg€ ncv gown physicians, or other professional services St. Vincent Health expects prompt payment in full for the services you received. We offer a variety of Payment Programs desig to accomplish this goal while providing you with an op ortunity to pav your obligation over time. We also make available to you a financial assistance program based upon established Federal Guidelines. Please refer to the following information regarding these different programs. O Cash, Check or Credit Card: For your convenience you may pay your balance using the following credit cards by completing the requested information on the Return Payment Stub or calling ustomer Service. American Express Discover MasterCard Visa If you desire to pay by check please write your account number or numbers on your check and complete the information on the Return Payment Stub, Patient Friendly Payment Plans: Are offered at zero percent interest, no minimum amount, no application, guaranteed acceptance, and various payment terms. St. Vincent Hbspitals are committed to assisting� you in y our pay€nent method of choice. Please contact Customer Service at 1 -800 582 -8258 (toll free) or 317 -338 -8035 (local} for processing and details. Short Term Payment Arrangements: If you do not qualify for any of the above programs, you may establish short term payment arrangements by contacting Customer Service. FI MIIV IT Uninsured Discount: If you have no insurance coverage, St. Vincent automatically provides you with a 20% discount off your total charges. Financial Assistance Available: if you are unable to pay your balance, you may apply for the St. Vincent Financial Assistance Program. St. Vincent recognizes that medical bills are not planned expenses and can lace an overwhelming financial burden on our patients. Financial assistance qualification is primarily based upon your household income using Federal Guidelines. See the poverty guideline chart below to see if you qualify. Number in Household Poverty Guideline 1 43,320 2 58,280 3 73,240 4 88,200 5 103,160 6 118,120 7 133,080 8 148,040 Please Contact Customer Service for Details StNincent Health is committed to providing you excellent patient friendly service!- VOUCHER NO. WARRANT NO. ALLOWED 20 St. Vincent Carmel Hospital IN SUM OF 9600 Reliable Parkway Chicago, IL 60686 $883.00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO# l Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members 1120 I 2053664876 43- 407.01 I I hereby certify that the attached invoice(s), or 5��,.oa bill(s) is (are) true and correct and that the 5.--z, materials or services itemized thereon for which charge is made were ordered and received except JAN 3 1 20 l� Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 2053664876 $883.00 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