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Home My WebLink About194974 03/02/2011 �aF CITY OF CARMEL, INDIANA VENDOR: 365126 Page 1 of 1 a 1 ONE CIVIC SQUARE C D C CORPORATION CHECK AMOUNT: $286.20 ps CARMEL, INDIANA 46032 1101 KESSLER BLVD W DR INDIANAPOLIS IN 46228 CHECK NUMBER: 194974 CHECK DATE: 312!2011 DEPARTMENT ACCOUNT PO NUMBE INVOICE NUMB AMOUNT DESCRIPTION 102 5023990 286.20 AMBULANCE REFUND Date: 02/25/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 A 3. C U tNi k �R Bill To: JOHN OLENICK ICD -9: 292.9 4558 WOODHAVEN DR ZIONSVILLE, IN 46077 From: 4558 WOODHAVEN DR To: ST, VINCENTS HOSPITAL 1 MEDICARE PART B Patient: JOHN OLENICK 202180564A 4558 WOODHAVEN DR Insurance ZIONSVILLE, IN 46077 2 Patient No: 201003294 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $357.75 $357.75 $0.00 CPT Date Description Charges Credits 12/19/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 12/19/2010 MILEAGE A0425 $32.75 01/11/2011 PAYMENT $357.75 02/04/2011 CORRECTION $0.00 02/23/2011 MEDICARE PAYMENT $286.20 02/25/2011 REFUND 286.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 02/25/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 Bill To: JOHN OLENICK ICD -9: 292.9 4558 WOODHAVEN DR ZIONSVILLE, IN 46077 From: 4558 WOODHAVEN DR To: ST. VINCENTS HOSPITAL 1 MEDICARE PART B Patient: JOHN OLENICK 202180564A 4558 WOODHAVEN DR Insurance ZIONSVILLE, IN 46077 2 Patient No: 201003294 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $357.75 $643.95 286.20 CPT Date Description Charges Credits 12/19/2010 BASIC LIFE SUPP EMERGENCY A0429 $325.00 12/19/2010 MILEAGE A0425 $32.75 01/11/2011 PAYMENT $357.75 02/04/2011 CORRECTION $0.00 02/23/2011 MEDICARE PAYMENT $286.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 NATIONAL GOVERNMENT SERVICES INC,PART B PO BOX 6160 REMITTANCE INDIANAPOLIS, IN 462066160 NOTICE CARMEL FIRE DEPARTMENT NPI 1154325579 2 CARMEL CIVIC SQ DATE: 02/17/2011 CARMEL, IN 460327543 CHECK /EFT 1: 123974436 PAGE 1 REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP /RC -AMT PROV PD NAME OLENICK, JOHN HIC 202180564A ACNT 201003294 ICN 111103S496B30 ASG Y MOA MA01 1154325579 1219 121910 41 1 A0429 RH 325.00 325.00 0.00 65.00 260.00 1154325579 1219 121910 41 5 A0425 RH 32.75 32.75 0.00 6.55 26.20 PT RESP 71.55 CLAIM TOTALS 357.75 357.75 0.00 71.55 0.00 286.20 ADJ TO TOTALS: PREV PD INTEREST 0.00 LATE FILING CHARGE 0.00 NET 286.20 Medicare Part B INDIANA MEDICARE PART PROVIDER REPORT National Government Services, Inc. P.Q. Box 6160 Indianapolis, IN 46206.6160 CHECK DATE 0 CHECK NUMBER 123974436 0000040 CHECK AMOUNT 10 4 98 46 PROVIDER NUMBER 1154325579 0000035 20110216 G52WQ1011KlPOD501 OZ D0MGB2WQ10000 159067 BP CARMEL EIRE DEPARTMENT 2 CARMEL CIVIC SQ Jr ED CARMEL IN 46032 �`p` LII�� l 2 7 c op i Medicare PartB o��l4.�J�d :National Government Services, Inc., P.Q. Box 616D csurtaysn.hretxc�sFS ummnrnsoevx�s Ihdianapolss,l.Nf 46206.6160.: US BAN`K,. MEDICARE: (PAYMENT HAVFtE, M ONTANA IF WHEALTH INSURANCE SOCIAL'SECURJTY ACT 80 1769L815 PAY 498.D.Q -AR _'AND 4�6 VOID. 12 MONTHS FROM ISSUE DATE' TO. THE <ORDER.Or PROVIDER NO_ INTERNAL CHECK No. 1154325579 123974436` CARMEL FIRE DEPARTMENT M:O., DAY YEAR DOLLARS. 02. <17 11 X10,4`98.46. 2 CARMEL CIVIC SQ CARMEL, IN 46032 -7543 v �c 13 °0 S0 39 7 4 S 1011 Ao0 8 i 5 1 69 3 b 5 2 30 20 170080 Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT 201003294 JOHN OLENICK $357.75 "R F ED JAN 2010 Run Date 12119/2010 Amount Paid APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 2742 CDC CORPORATION 1101 KESSLER BLVD. W. DR. INDIANAPOLIS, IN 46228 l (317) 696 -0857 Date r 20 -1 -740 I Pay Lo the order of 3 v"V— Dollars I JPMORGAN CHASE BANK, N.A. INDIANAPOLIS, INDIANA 46277 WWW.CHASECOM For_ -___W 11 2 7 4 211' 1:0 740000 LOI: ?0996? 20 2110 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) 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 C� �TA ®YC�4�in Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) .n bccfS e P /YI &A_� �O a� e Total��, a(� 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. nn ALLOWED 20 IN SUM OF Z0 1l o Xe-ss ler, 5 l,-) 2Y ON ACCOUNT OF APPROPRIATION FOR ciakee Z��o Ap 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 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund