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Home My WebLink About195245 03/02/2011 f CITY OF CARMEL, INDIANA VENDOR: T0002820 Page 1 of 1 ONE CIVIC SQUARE CIGNA CHECK AMOUNT: $331.55 CARMEL, INDIANA 46032 PO BOX 5200 SCRABTIB PA 18505 CHECK NUMBER: 195245 CHECK DATE: 3/2/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 REFUND 331.55 AMBULANCE REFUND Date: 02/24/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 A yam, C U T I T0 N Bill To: TINA L JORDAN ICD -9: 7245 7231 71941 E8130 11418 LONG LAKE DR INDIANAPOLIS, IN 46235- From: 1 -465 MERIDIAN To: CLARIAN HOSPITAL NORTH 1 CIGNA 5200 Patient: TINA L JORDAN 03324109601 11418 LONG LAKE DR Insurance INDIANAPOLIS, IN 46235- 2 STATE FARM INSURANCE /2362 Patient No: 201002665 CLM #14- 3065 -159 WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $331.55 $663.10 331.55 CPT Date Description Charges Credits 10/11/2010 EASIC LTFE SUPP- EMERGENCY A0429 $325.00 10/11/2010 MILEAGE A0425 $6.55 11/09/2010 COMMERCIAL INSURANCE PAYMENT $331.55 02/23/2011 COMMERCIAL INSURANCE PAYMENT $331.55 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 02/24/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: TINA L JORDAN ICD -9: 7245 7231 71941 E8130 11418 LONG LAKE DR INDIANAPOLIS, IN 46235 From: I -465 &MERIDIAN To: CLARIAN HOSPITAL NORTH 1 CIGNA 1 5200 Patient: TINA L JORDAN 03324109601 11418 LONG LAKE DR Insurance INDIANAPOLIS, IN 46235- 2 STATE FARM INSURANCE /2362 CLM #14- 3065 -159 Patient No: 201002665 WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW 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 10/11/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 10/11/2010 MILEAGE A0425 $6.55 11/09/2010 COMMERCIAL INSURANCE PAYMENT $331.55 02/23/2011 COMMERCIAL INSURANCE PAYMENT $331.55 02/24/2011 REFUND 331.55 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Provider Explati atiozr of Medical Beite fits Report ®tom th e Provider Number Provider Name Date Lhrough wi2iCh Claims were processed THIS IS NOTA BILL Page 356000972 0000 CARMEL FIRE DEPT II /02/2010 Retain forYourl2ecords I Ad us Adjusted i :fed L}tvl DRG DRf 1 I iviced re. Billed ed ti Ato[ C ve d ;�bouct iii roc A11oyti re /Cupay Co surance,': DKG Dtem Per Diem See.. Line; 1,rOCeilureDate: I edurg:, Pcocedureod 1'ei:'Dlem' PerDtem .:Code Amount ;Amount DLSCOnnY Amouiat mount Atn�unt:' t3eaiefik PlanBene €it Noce, Co Amount I:. Ifumbe[ 1... I YID Amo unt PATIENT NAME: TINA JORDAN PATIENT 201002665 OPERATION LOCATION /GROUP# 25521 3174704 RECEIVE DATE: 10/19/2010 PROCESS DATE: 11/0z MEMBER NAME: TINA JORDAN SUBSCRIBER U33241096� REF 765 1029399217 1 1 10112010 A0429 325.00 325.00 0.00 325.00 0.00 0.00 0.00 2 10112010 A0 6.55 6.55 0.00 6.55 0.00 0.00 0 "00 f TOTAL 331.55 331.55 331.55 0 5904.51 HAS BEEN APPLIED TOWARDS THE $4,500 OUT OF NETWORK FAMILY DEDUCTIBLE FOR 2010 i 1904.51 HAS BEEN APPLIED TOWARDS THE $3,000 IN NETWORK FAMILY DEDUCTIBLE FOR 2010 7, 5430.11 HAS BEEN APPLIED TOWARDS THE $10,500 OUT OF NETWORK FAMILY 'OUT -OF- POCKET LIMIT' FOR Ei(1[, I lj[7 NUV 2010 X14/ i Y U S430.11 HAS BEEN APPLIED TOWARDS THE $7,000 IN NETWORK FAMILY 'OUT- OF-POCKET LIMIT' FOR 2010 BALANCE 5331.55 NN NOTES ON BENEFIT DETERMINATION: i MEDICAL PLAN PAYMENT OF S0.00 TO CARMEL FIRE DEPT CHOICE FUND [IRA PAYMENT OF 5331.55 TO CARMEL FIRE DEPT j THIS EXPENSE HAS BEEN APPLIED TO PLAN DEDUCTIBLE OR COPAY IF YOU HAVE ANY QUESTIONS REGARDING THIS CLAIM, PLEASE INCLUDE THE i REFERENCE NUMBER ON INQUIRIES. SYS -BS6 A CIGNA CHOICE FUND HEALTH REIMBURSEMENT ACCOUNT PAYMENT WAS MADE ON THIS CLAIM. A HRA EDP IS INCLUDED IN THIS MAILING. A CIGNA CHOICE FUND HEALTH RKIMBUR.SEHENT ACCOUNT PAYMENT WAS MADE ON f THIS CLAIM. A HRA EDP IS INCLUDED IN THIS MAILING. A FLEXIBLE SPENDING HEALTH ACCOUNT PAYMENT WAS MADE ON THIS CLAIM. I A FSA EDP IS INCLUDED IN THIS MAILING. i WHY WAIT FOR THE MAIL? VIEW ELIGIBILITY, BENEFITS OR CLAIM DETAILS ONLINE ANYTIME AT IITTP: /WWW.CIGNA.COH /HEALTH /PROVIDER/ n A) Fully Paid {ror ot COtV1VLC 11CU1 bl EVEl11 Lll l If5ISI1ltANEsI' EUh1I'ANX t1057899436�i f I AS AGENT FOR 62 2Dr311 CI INA Cgf�P0� DATE ProVlder €i f P�rt_c�c:7 IIf;02,/20I4 356000972<0000 CJGN i THREE MUNb THIRTY ENE Q�� -TAR AND 55 CENTS 3E3E3k3E3E3f3E oLla 331 55 ezly CARMEL FIRE DCP$ v olCl if Ivnt cashed wit 1B D a y S I GARME GxWI Q CA RhfEL to th 'Ifs 46032 254 Occler q. cJf CfILI3AK DLi AtVAftl y i�IEWCAS1Ll; f7FLAWAftI; THE IGINAL bCLIMENT HAS. A FtEF1EC7tVl: WATERMARK 17104 C)N THEBACK HC)LS3 A7 AN ANGLE:;O VIEkN' G2433B 7 -19 -2002 .28 fl& 3();2665 PHOCL Med,cak 1'rovsder JrdS' du "FlHRA Summary a 191�f111! II B 5 7 899 3�1.e 1 .0 3 b b0 o 2 091. X 0008488 11° CLAIM NO 14 -3065 -159 POLICY NO D600- 958 -14C LOSS DATE 10 -11 -2010 PAYMENT NO 1 18 624994 J Coverage Description Amount COL Pa DATE 02-15- Itcl MEDICAL PAYMENT 5331.55 600 2 AMOUNT $3 31.55 TIN 14- 356000872 ENTERED BY POLIN SHERRI AUTHORIZED BY POLIN, SHERRI PHONE (866) 648 -0715 REMARKS 10/1112010 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 13 624994 J WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56-1544/441 COLUMBUS, OH MPC INDIANA 18 -501 L025 02-15-2011 DATE M M D D Y Y Y Y CLAIM No 14- 3065 -159 INSURED JORDAN, TINA LOSS DATE 10 -11 -2010 ON BEHALF OF TINA JORDAN *EXACTLY THREE HUNDRED THIRTY-ONE AND 551/.100 DOLLAFiS *3'3�• 55 o. Pay to the Order of: CARMEL EIRE DEPARTMENT', T 0 2 CIVIC SQ CARMEL IN 46032-2584 r' APPROVED BY CLAIM No 14- 3065 -159 POLICY No D600- 958 -14C LO DATE 10 -11 -2010 PAYMENT NO 1 18 624994 J Coverage Descric)tion Amount COL Pay.Cd DATE 02 -15 -2011 MEDICAL PAYMENT $331.55 600 2 AMOUNT $331.55 TIN 14- 356000972 AUTHORIZED BY POLIN SHERRI PHONE (866) 648 -0715 REMARKS 10111/2010 STATE FARM MUTUAL RUTOMOBI LE' INS, I.JRANC:E `COMPANY >1$ PL�� WEST L'AFAYET,TE IN JPMORGAFf CHASE BANK NA- 56 15 4/441 COLUMBUS', :OH MPC INDIANA 'r18 501 %L025 o 62 1 1 5 2011 CLAIM Ne 14- -3 65 159_ INSURED JORDAN TINA DATE M'M D D v`v vv LOSS DATE 10 -11= 201,0 ON BEHALF OF TI NA JORDAN *EXACTLY THREE HUNDRED THIRTY -ONE AND 55/100 DOLLARS *331..55 Pav to r11e Order of: CARMEL FIRE DEPARTMENT o' 2 CIVIC SO, n CARMEL IN 46032 -2584 CF�uaQi AUTHORIZED SIGNATURE AUTHO D SIGNATURE' li b8 1, 76 2 Fm 26 2 90 23 31° 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. �I Payee 6- Purchase Order No. c Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 4 e a-q /""7 e"tJ -7 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 a fi -::z IN SUM OF ON ACCOUNT OF APPROPRIATION FOR 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 2 8 2 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund