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Home My WebLink About194765 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, H7.6501d 1U: CoreSource PO Box 2920 Clinton_ IA 52733 -2320 f Forw arding; Service Requested I LL, .4 2 lfI" C Ut'1 L c !1 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