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HomeMy WebLinkAbout195954 03/29/2011 CITY OF CARMEL, INDIANA VENDOR: T357065 Page 1 of 1 0 ONE CIVIC SQUARE HUMANA CHECK AMOUNT: $320.54 i CARMEL, INDIANA 46032 PO BOX 14610 LEXINGTON KY 40512 CHECK NUMBER: 195954 CHECK DATE: 3/29/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE N AMOUN DESCRIP 102 5023990 320.54 OTHER EXPENSES Date: 03123/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 ACCOUNT HiSTORY Bill To: JUDITH A CLARK ICD -9: 9593 7295 E8130 3780 GRAY HEATHER LANE WHITESTOWN, IN 46075 From: 1303 W 116TH ST To: ST. VINCENTS HOSPITAL CARMEL HUMANA CHOICE FIRST Patient: JUDITH A CLARK 00557940801 3780 GRAY HEATHER LANE Insurance WHITESTOWN, IN 46075- 2 METLIFE AUTO HOME/410450 Patient No: 201100269 CLM #SLC97254ED 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 $400.67 $721.21 320.54 CPT Date Descrlptlon Char.Ae Credits 01/20/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 01/20/2011 MILEAGE A0425 $25.67 02/17/2011 COMMERCIAL INSURANCE PAYMENT $320.54 03/14/2011 COMMERCIAL INSURANCE PAYMENT $400.67 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 03/23/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Biii To: JUDITH A CLARK ICD -9: 9593 7295 E8130 3780 GRAY HEATHER LANE WHITESTOWN, IN 46075 From: 1303 W 116TH ST To: ST. VINCENTS HOSPITAL CARMEL 1 HUMANA CHOICE FIRST Patient: JUDITH A CLARK 00557940801 3780 GRAY HEATHER LANE Insurance WHITESTOWN, IN 46075- 2 METLIFE AUTO HOME /410450 Patient No: 201100269 CLM #SLC97254ED 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 $400.67 $400.67 $0.00 CPT Date Description C_h_ames Credits 01/20/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 01/20/2011 MILEAGE A0425 $25.67 02/17/2011 COMMERCIAL INSURANCE PAYMENT $320.54 03/14/2011 COMMERCIAL INSURANCE PAYMENT $400.67 03/23/2011 REFUND 5- 320.54 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 0000258421 11 1 BANK OF :,AMERICA 64 ;1278 ��u/duii Ck'. u�lien vnu iSccd ia most ATLANTA,, GA 30308 1 P.O. BOX 146 LEXINGTON, KY 40512 -4610 r CHECK N O. 0 ST. VINCENT HEALTH, INC. GROUP. 9'590751 PROVIDER„TAX ID NUMBER 356000972' THIS CHECK COVERS ALL :CLAIMS ON REMITTANCE STATEMENT NUMBER :201102120078991 PAY: THREE HUNDRED TWENTY AND 54%1p0 DOLLARS PAY TO THE ORDER OF: FaoNT a UE ON WHITE $ACK LAID bNES? VOID IF NOT CASHED WITHIN 90 DAYS CARMEL FIRE DEPARTMENT *'0 2. 54. `�'2 2 CIVIC SQUARE CARMEL, IN 46032 ur Z�n�"dA'bTT�Tv n•04000 2 2.08.E 611° x.;0'6 i. L 2.7:8810 3 2`9 9.03 3.1 2u7 HUMANA AUTOMATED REMITTANCE ADVICE ANY;4IUFSTIONS r PLEASE:;: CONTACT ;BENEFETS_ PAID »TO TtiE<:.OLLOWING l� T�G HUMANA CLAIMS OFFICE CARMEL FIRE DEPARTMENT P.O. BOX 14601 2 CIVIC SQUARE LEXINGTON, KY 40B12-4601 CARMEL, IN 46032 �iuiC1¢71Ceu-hcnyaunccdicmo.E OR CALL 1- 865- 427 -7478 PROVIDER ID: 134366234975 OR VISIT MANA,COM FEDERAL TAX ID: 2061 PAGE 1 OF 3 CHECK NUMBER: 0000220866 DATE 02/11/11 LINE DATE OF SERVICE SERVICE EXCLUDED ALLOWED BENEFIT FROM TO CODE CHARGE -AMOUNT DISCOUNT AMOUNT DEDUCTIBLE -COPAY COINSUR =AMOUNT PROVIDER NAME: CARMEL FIRE DEPARTMENT MBR ID: 005579408 01 CLAIM NUMBER: 201101313646739 PATIENT NAME: CLARK, JUDITH A PAT DOB: 07/22/1954 PAT ACCT: 201100269 SUBSCRIBER NAME: CLARK, JUDITH A REL CD: EMPLOYEE GROUP: 590751 001 01/20/11 01/20/11 A0429 375.00 0.00 0.00 375.00 0.00 0.00 75.00 300.0( 002 01/20/11 01/20/11 A0425 25.67 0100 0.00 25.67 0.00 0.00 5.13 20.5 CLAIM TOTALS 400.67 0.00 0.00 400.67 0.00 0.00 80.13 320.5 REMARK CODES HIPAA HUMANA 001 45 /6BO 002 45 /6B0 EST MBR RESPONSIBILITY 80.13 TOTAL PAID 320.54 SERVICING PROVIDER NAME /ID: CARMEL FIRE DEPARTMENT 134366234975 TOTALS 400.67 0.00 0.00 400,67 0.00 0.00 80.13 320.5 EST MBR RESPONSIBILITY 80.13 TOTAL PAID 320.54 ROLLUP TOTALS FOR REMITTANCE 400.67 0.00 0.00 400.67 0.00 0.00 80.13 320.54 EST MBR RESPONSIBILITY 80.13 TOTAL PAID 320.54 CJ w 1. O m Farm No. E24000P 04/05 1 916 L O BOX 1529 NY 12110 Auto to Home MetLife Auto ��Home is a brand of Home I Metropolitan Property and Casualty Insurance Company and its Affiliates. Warwick, RI 1916 SLC972540 CP.RMEL FIRE DEPARTMENT 2 CIVIC SQUARE C.'-',2MEL, IN 46032 3 C i MAR 1 d 2Q1� INSURED: JUDITH A CLARK CLAIMANT: JUDITH A CLARK CHECK NUMBER: 003711428 CHECK AMOUNT: $400.67 Four hundred and 67/100 Dollars MED PAY PYMT DOS 01/20/2011 JUDITH A CLARK #201100269 ED AU 1034325 4 1u:�' H aM�' n894 sa aoi3, i p PO BOXc1529, METROPOLITAN GROUP PROPERTY 8 CASUALTY INS CO !'I LATNAM NY i 2110 nn�D Ppy PrMT Check Number JUDLTF{ A CLARK �12011602fi9='` 00371 428;: Claim No.. Not,Valid:Beiore- SLC972540 03 -07 -201:1 '66i hundred. and 67/100 •Dollars va,d N;ne (s) Mon,r Pay to the Order. af:: After Thrs ArT10Unt:': oi CARNI'EL FIRE DEPARTMENT *400.67 ;_1 2 CIVIC SQUARE` Citibank :N.A CARMEL 1N OneRenns Way,.., Newt astle, 19720 GDSICNATDRC' Y fl °00'3 b:�,.2811° am0 3 L.�O 209. 38,'�'S 58 3 411 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 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ire 6 wseln ek -kr &Yep 0 L- Total Q 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 IN SUM OF 3 o a o..s ON ACCOUNT OF APPROPRIATION FOR Board Members PT INVOICE NO. ACCT #ITITLE AMOUNT 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 WARM x©11 Ic r 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund