HomeMy WebLinkAbout194765 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: 365083 Page 1 of 1
ONE CIVIC SQUARE MILDRED SHIELDS CHECK AMOUNT: $66.31
CARMEL, INDIANA 46032 12206 WINDSOR DR
CARMEL IN 46033 CHECK NUMBER: 194765
CHECK DATE: 2116120111
DEPARTMENT AC PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 66.31 AMBULANCE REFUND
Date: 02110/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: MILDRED C SHIELDS ICD -9: 786.50
12206 WINDSOR DR
CARMEL, IN 46033 -3142
From: 12999 N PENNSYLVANIA APT /SUITE# 110
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: MILDRED C SHIELDS 200077255A
12999 N PENNSYLVANIA APT C110 Insurance
CARMEL, IN 46032 2 CORESOURCE /2920
Patient No:
MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN. IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS
INFORMATION. IF NOT, 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
11/05/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
11/05/2010 MILEAGE A0425 $6.55
01/18/2011 MEDICARE PAYMENT $265.24
01/26/2011 PAYMENT $66.31
02/08/2011 COMMERCIAL INSURANCE PAYMENT $66.31
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/10/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bit! To: MILDRED C SHIELDS ICD -9: 786.50
12206 WINDSOR DR
CARMEL, IN 46033 -3142
From: 12999 N APT /SUITE# 110
To: ST. VINCENTS HOSPITAL CARMEL
MEDICARE PART B
Patient: MILDRED C SHIELDS 200077255A
12999 N PENNSYLVANIA APT C110 Insurance
CARMEL, IN 46032 2 CORESOURCE /2920
Patient No:
MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN. IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS
INFORMATION. IF NOT, 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
11/05/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
11/05/2010 MILEAGE A0425 $6.55
01/18/2011 MEDICARE PAYMENT $265.24
01/26/2011 PAYMENT $66.31
02/08/2011 COMMERCIAL INSURANCE PAYMENT $66.31
0211012011 REFUND -66.31
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
-c
Return this portion with your payment
Payable To: CARMEL FIRE DEPARTMENT
201002869 MILDRED C SHIELDS $66.31
Run Date
11/05/2010 Amount Pai
4
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
MILDRED C. SHIELDS 01 -81 1017
12206 WINDSOR DR.
CARMEL, IN 46033 -3142 2 �y 70- 21891719
ll 5840
Dace
Pay the
Order erof
1
For
LO L7
Harlantl Calk,
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CoreSource
PO Box 2920
Clinton_ IA 52733 -2320
f
Forw arding; Service Requested I
LL,
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3 -DIGIT LIED Payment Q uestions? Please refer to the customer
9853 0.7538 AT 0-354 service numbers below
iititlti�lll�tu��IlI�III��IEil�l�ui �iut lll�ri iEill ttlditl.
CARMEL FIRE DEPARTMENT 53
2 CIVIC SQUARE
CARMEL, IN 46032 -2584 Your tlanu; CARMEL. 1' IEt1? ill F'AIt l M};N l` rand tax
A have been verified by the WS
RECEIV P18' 0 8 2011
Tae 11 356000472 h_'PC Draft #106605156 PayintWt 0 eel:.' 5 I'ayntent D 0113112011
L s rvice -e >dt ul' Elti Billed Hiscuuut C)th Kl OPatient Net Payment Messages
ate Descri to,, Code Amount Amount Pa nlent Adj ustment Obligation Amount
Provide r:CAR_NfEL FIRE DEI'"i� AMBUL. Patient Name: MII_DRED C S14FLLDS Group /Check Number: 0503/9796403
Network: Member Number: Customer Service 1 -800- 773 -7725
Patient Acct 4 20100 2869 Cla im Num F0 0 01 8772499 Ad By CoreSgllrce
11/05/10 e \(1429 506 325 00 O.QU (1 {1(1 260 00 0 65.00
042
11/05/10 A 506 6.55 0.00 5.24 0 00 0.00 1131
TOIAI: 331.55 0.00 265.24 0.0(1 0.0o 66.31
Adminis Hv Amuuat Atnnunt PlVtllellt 1dj ther 1'Itlent total Pavmud C'usto4ue,rService•
S Summary Billed Disc.... nthcl f'1 m
1 usttnent Ohhl inou Awou Phunc Numher l
�CoreSource 33155 0.00 265.24 0.00 11.00 66.31 Sdt l id ividunl Claim I
Statement Totals Killed 1)iscounl Other Plan C)fher P::tienl Total 1 ailment
Amount Amount I':nrnellt Adjustment Obligation A4nount
33 3.55 0.011 265.24 OS70 0.00 66.3 t
Exp
Ad By_ Cude 1Description J
CoreSuurce 506 I IIFSE EXPENSES WERE PAID BY MEDICARE AANDIOR YOUR 65 SPECIAL AND ARE NOT F[A(;1111.1; FOR
RI-AMBURSL'MEN 'I.
FOR SECURITWPURPOSES, THE FACE OF THIS DOCUMENT CONTAINS A BLUE BACKGROUND AND MICROPRINTING IN THE BORDER 1
O E �:E` Ekclrnnic men C'leurtrrglr��irse
c nunangrmrUuna
NUi lsrnk ssa3la .DRAFT FeIO. 1116605.156
A Triryrm:�rf. rrm an
P j W'e tl iW 0H 471181
....DRAFT�.DATE:.
3112flt:1
Lam'
k) BOX 926
Ulinton, IA' 52733 -29211
PAYABLE THROUGH Sixti Six 3 1 /100 Dollars AMO
b DRAFT *`s66.31�
?l TO THE CARMEL: FIRE DEPARTMENT
I o ORDER OF
CIVIC SQUARE
CARMEL, IN 46032
DO. NOT CASH IF WATERMARK IS NOT PRESENT ON THE REVERSE SIDE OF THIS DOCUMENT HOLD AT AN ANGLE TO VIEW
1 f•106P-05 15611' I:0►,41 L5 L 2 61: 11. 0 1669508 L 211°
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
&rs em
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
f Io�a�e�L SI'4 �lr�s IN SUM OF CJ�.
1 -2
(�?O ern C_1, 4 1 (o O _R 3
ON ACCOUNT OF APPROPRIATION FOR
1Jni8Gc�Ct.ILL+✓'e �Gu7 d-&,& ,bj'Z�
Board Members
PO# or INVOICE NO. ACCT #/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
FEB 14 Z011
d
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund