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Home My WebLink About195616 03/16/2011 CITY OF CARMEL, INDIANA VENDOR: 365178 Page 1 of 1 ONE CIVIC SQUARE PHILLIP POLIVKA CARMEL, INDIANA 46032 1320 GOLDFINCH DR CHECK AMOUNT: $384.06 CARMEL IN 46032 CHECK NUMBER: 195616 CHECK DATE: 3/16/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 384.06 OTHER EXPENSES Date: 03/10/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: PAULINE S POLIVKA ICD -9: 786.05 1320 GOLDFINCH DRIVE CARMEL, IN 46032 -1190 From: 12999 N PENNSYLVANIA To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: PAULINE S POLIVKA 207097160D 12999 N PENNSYLVANIA APT C304 Insurance OLYMPIC HEALTH MANAGEMENT CARMEL, IN 46032 2 202001499MSEL Patient No: 201100130 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 $384.06 $768.12 384.06 CPT Date Description Charges Credits 01/04/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 01/04/2011 MILEAGE A0425 $9.06 01/20/2011 PAYMENT $384.06 02/03/2011 CORRECTION $0.00 02/23/2011 MEDICARE PAYMENT $271.80 02/23/2011 ASSIGNMENT MEDICARE $44.31 03/08/2011 COMMERCIAL INSURANCE PAYMENT $67.95 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 03/10/2011 CARMEL FIRE DEPARTMENT EMERGENCY IVIED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 E "F T Bill To: PAULINE S POLIVKA ICD -9: 786.05 1320 GOLDFINCH DRIVE CARMEL, IN 46032 -1190 From: 12999 N PENNSYLVANIA To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: PAULINE S POLIVKA 207097160D 12999 N PENNSYLVANIA APT C304 Insurance CARMEL, IN 46032 2 OLYMPIC HEALTH MANAGEMENT Patient No: 201100130 202001499MSEL 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 $384.06 $384.06 $0.00 CPT Date Description Charges Credits 01/04/2011 BASIC LIFE SUPP EMERGENCY A0429 $375.00 01/04/2011. MILEAGE A0425 $9.06 0112012011 PAYMENT $384.06 02/03/2011 CORRECTION $0.00 02/23/2011 MEDICARE PAYMENT $271.80 02/23/2011 ASSIGNMENT MEDICARE $44.31 03/08/2011 COMMERCIAL INSURANCE PAYMENT $67.95 03/10/2011 REFUND 384.06 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT 201100130 PAULINE S POLIVKA RECE"NED JAN $384.06 Run Date 01/04/2011 Amount Paid 0 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 PAULINE S. POLIVKA 1040 PHILLIP E. POLIVKA 1320 GOLDFINCH DR. CARMEL, IN 46032-1190 70-2189/'719 070 Date Pay to the Order of 7 1 7. x x Dollars o7i Tn IN For iO Bankers Life and Casualty Company �T �T �7 PO Box 5348 EX LA ATI OF PAYMENT T Bellingham WA 98227 -5348 Keep This Notice For Your Records 1 -800- 688 -0010 i 002598- 000001 -002598 2076807 1420OMS 1 CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SQ CARMEL, IN 46032 -7543 STATEMENT DATE: 02/24/2011 PAGE: 1 of 1 DOC 4: 02283170 F `'a t�v%'H o +�D 2 i PROVIDER 4: 1079954 TAX ID 356000972 CHECK 4: 00/736655 CHECK AMOUNT: 567.95 p U THIS IS A SUMMARY OF CLAIMS PROCESSED PP_ IENT. NAM PP_TIENT .POLICY_.. PP_TIENT ACCOUNT 'k DP TES OF SERVICE CLAIM BILLED MEDIC Ai2E- MEDICAP.E SUPPLEMENT PaTIENT FROM TO D7UN7BER P�SOUNT` ALLOWED PAID 'P AID LIABILITY .,.CODE POLIVKA, PAULINE S 5206683 9 _01100130 01/04/2011 01/04/2011 0069911017 9.06 8.23 5.58 1.65 .00 01/04/2011 01/04/2011 0069911016 375.00 331.52 265.22 66.30 .00 SUMMARY TOTALS: 384.06 339.75 271.30 67.95 .00 Thank you for the opportunity to be of service to you. Please notify us of any changes to your Tax Identification Number, Medicare Provider Number, address or phone number. If you have any questions, please contact our Customer Service Department from 5:00 a.m. to 8:00 p.m., Pacific Time, Monday through Friday: 1- 800 -688 -0010 SEOU -1 FEATURES ON THIS DOCUMENT INCLUDE P MIORO-IIJT llOE.ER AND VOID RAIJTOGRAPH ON FALL AND A RULED PATTERN AND WHITE WATERIAARK ON 8ACK e�nkers Lflfe end Casualty 19- 10'/ 1250: 0 0173 655 13an1< t CH K I D I ATE "0 i z 24 =Hour Banking 2%24/2011 PO 534'8 1 800 -673 3555 EC MONTHS VOID AFTERI6 Is Bellingham WA 98227 =5348 ,I 1- 800 688 -0010 $'67 95 PAY' Sixty Seven and .95/100 TO CARMEL FIRE DEPARTMENT. THE 2 Carmel civic Sq ORDER CARMEL;, IN 46032- 7543 OF,' AUtti ized.Signat OMS in c Check. Is i MICR Enod g Not Presenf� 11 L 7 366 5 Sii I: L 2 5000 LO 5lio L 5 3 50 5 54864 Lila NATIONAL GOVERNMENT SERVICES INC,PART B PO BOX 6160 REMITTANCE INDIANAPOLIS, IN 462066160 NOTICE CARMEL FIRE DEPARTMENT NPI V 1154325579 2 CARMEL CIVIC SQ DATE: 02/17/2011 CARMEL, IN 460327543 CHECK /EFT V 123974436 PAGE V 1 REND PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP /RC -AMT PROV PD NAME POLIVKA, PAULINE HIC 207097160D ACNT 201100130 ICN 1111038496850 ASG Y MOA MA01 MA18 1154325579 0104 010411 41 1 A0429 EH 375.00 331.52 0.00 66.30 CO -45 43.48 265.22 1154325579 0104 010411 41 1.20 A0425 EH 9.06 8.23 0.00 1.65 CO -45 0.83 6.58 PT RESP 67.95 CLAIM TOTALS 384.06 339.75 0.00 67.95 44.31 271.80 ADJ TO TOTALS: PREV PD INTEREST 0.00 LATE FILING CHARGE 0.00 NET 271.80 CLAIM INFORMATION FORWARDED TO: OLYMPIC HEALTH MANAGEMENT SYSTEM Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee �/1 �l✓ P �Dl✓ �/h Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 4, 1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 V�Q INSUMOF$ 3 ?q- ea"-Mel, y-[o D3 a 3 06 ON ACCOUNT OF APPROPRIATION FOR 4 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 M 14 zD» 2 0 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund