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Home My WebLink About196272 04/13/2011 CITY OF CARMEL, INDIANA VENDOR: 365221 Page 1 of 1 0 ONE CIVIC SQUARE FAY BURGE CHECK AMOUNT: $70.69 'zo CARMEL, INDIANA 46032 12656 CERROMAR COURT CARMEL IN 46033 CHECK NUMBER: 196272 CHECK DATE: 4/1312011 DEPARTMENT ACCOUNT PO NUMBER INV OICE NUMBER AMOUNT DESCRIPTION 102 5023990 70.69 AMBULANCE REFUND i i p o p 'v l CITY OF CARMEL JAMEs BRAINARD, MAYOR April 5, 2011 Mrs. Fay Burge 12656 Cerromar Ct. Carmel, IN 46033 RE: INVOICE 4201100468/ D.O.S. 02/08/2011 Dear Mrs. Burge: Enclosed you will find a reimbursement check in the amount of $70.69. On March 29, 2011 we received a check from you for Mr. Burge's ambulance transport on February 8, 2011 in the amount of $70.69. On March 31, 2011 we received a payment from United of Omaha for the same ambulance transport in the same amount. Since you had previously paid the balance in full, I am issuing you a refund of $70.69. If you have any questions, please feel free to contact me at (317) 571 -2605. Sincerely, Beck. S. Lannan Billing Administrator CARAH1 i. Fiat. DEPARTMENT STEVEN A. CouTs HEADQUUTEas Two Civic SQUARE, CARMEL. IN 46032 OrrEcr 317.571.2600, FAx 317.571.2615 Date: 04/05/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032 (317)571-2605 FederalID# 356000972 ACCOUN Bill To: RICHARD L BURGE ICD -9: 869.1 12656 CERROMAR CT CARMEL, IN 46033 From: 1390 KEYSTONE WAY To: ST. VINCENTS HOSPITAL CARMEL 9 MEDICARE PART B Patient: RICHARD L BURGE 292324289A 12656 CERROMAR CT Insurance CARMEL, IN 46033- 2 MUTUAL OF OMAHA Patient No: 201100468 70680388 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $399.16 $469.85 -70.69 CPT Date Description Charges Credits 02/08/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 02/08/2011 MILEAGE A0425 $24.16 03/15/2011 MEDICARE PAYMENT $282.78 03/15/2011 ASSIGNMENT MEDICARE $45.69 03/29/2011 PAYMENT $70.69 03/31/2011 COMMERCIAL INSURANCE PAYMENT $70.69 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 04/05/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317 )571 -2605 FederalID# 356000972 ACCOUNT HISTORY Bill To: RICHARD L BURGE ICD -9: 8691 12656 CERROMAR CT CARMEL, IN 46033 From: 1390 KEYSTONE WAY To: ST. VINCENTS HOSPITAL CARMEL I MEDICARE PART B Patient: RICHARD L BURGE 292324289A 12656 CERROMAR CT Insurance CARMEL, IN 46033- 2 MUTUAL OF OMAHA Patient No: 201100468 70680388 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM, THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $399.16 $399.16 $0.00 CPT Date I; Description Ch6rQes Credits 02/08/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 02/08/2011 MILEAGE A0425 $24.16 03/15/2011 MEDICARE PAYMENT $282.78 03/15/2011 ASSIGNMENT MEDICARE $45.69 03/29/2011 PAYMENT $70.69 03/31/2011 COMMERCIAL INSURANCE PAYMENT 04/05/2011 REFUND -70.69 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Rewrn this portion with your paymer Payable To: CARMEL FIRE DEPARTMENT 201100468 RICHARD L BURGE $70.69 MAR 2 9 2011 Run Date 02108/2011 Amount Paid APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 g &G Rz' hard L. or FqYi M. Burge 1928 12656 Gerromar-Q. 20-1041740. IN 46033-8204 927 Pav to the 4 Order of t c- F0 11:28 Harland Dlorko 'JEWELED ELEG-CE Explanation of Payment Report REPORT ENDING PACE P p PERIOD ENDING DATE 03/21/11 CTTY --A(IME; =IRE DEP United of Omaha DRAFT /CHECK NUMBER: 00865033 2 CIVIC SO Life Insurance C ompany DIRECT INQUIRIES TO: CARMEL IN 46032 UNITED OF OMAHA LIFE INSURANCE COMPANY IF YOU HAVE ANY QUESTIONS, CALL: MUTUAL OF OMAHA PLAZA (800) 546 -5906 OMAHA, NE 68175 -0001 CLAIMS PROCESSED UNDER TIN /EIN: 356000972 nsured's Name 7 atient policy /Plan Number 'ert Number Date of Less Charges Remaining aaim Number Service Submitted Not Covered Less Considered Benefit Balance 4ccount Number From To Procedure Charges Amount Note Balance Deductible Charges Amount Due URGE /RICHARD /L ELF 020811 020811 AMBULANC 375.00 020811 020811 AMBULANC 24.16 06803 -88H 70.69 100 70.69 282.78 1 45.69 2 83548938800 -009 01100468 TOTAL 399.i6 70.69 OTAL PAID: 70.69 i THIS IS THE AMOUNT PAID BY MEDICARE. 2 PROVIDER ACCEPTED MEDICARE ASSIGNMENT. YOU ARE NOT LIABLE FOR THIS. -2 /G _11 F j OF THIS' iDCICUMEN4T CONi%RMS.Pll''i�i+fFDi ad lc.lvAFYi- I�GLi) ,L_, ?L'':111E'i7y; C 76- 4% PAYABLE'THRU FIRST NATIONAL BANK OF OMAHA- 1049. UkD.:OF OMAHA 1FE INSURANCE COMPAiVY OMAHA 68102 iTE W :tl IVlUTUAL of OFtnHn.CoMrnN1 FREMONT,NATIONAL BANK TRUST CO Mutual ol Omaba- Plaza, Omaha, NE 68173 Munrm�Omaxa 4•' DATE DRAFTNO MAR Fo-a8 6' 3 1; 00'8650`33', 706.9 532`92 0:20811. CLAIM NO. AMOUNT 58:3.5489388`00 0:09: �,,_�;�:,`70.'6 "9 PAY TO THE ORDER OF PLEASE CASH IMMEDIATELY ACCT #20 58 POLICY /PLAN NUM °BE,R 706.803 88H CITY OF CARMEL FIRE DEP 2 CIVIC SQ CARMEL IN 46032 AUTHORIZED SIGNATURE y 11 1:40L'90001181: 09 a0"0 a 711° Explanation of Payment Report P EPORT ERIOD ENDING ENDING PAGE 1 DATE 03/21/.11 CITY OF CARMEL FIRE DEP United of O maha DRAFT /CHECK NUMBER: 00865033 2 CIVIC SC Life Insurance Company DIRECT INQUIRIES TO: CARMEL IN 46032 UNITED OF OMAHA LIFE INSURANCE COMPANY IF YOU HAVE ANY QUESTIONS, CALL: MUTUAL OF OMAHA PLAZA (800) 546 -5906 OMAHA, NE 68175 -0001 CLAIMS PROCESSED UNDER TIN /EIN: 356000972 nsured's Name patient =olicy /Plan Number �ert Number Date of Less Charges Remaining Maim Number Service Submitted Not Covered Less Considered Benefit Balance account Number From To Procedure Charges Amount Note Balance Deductible Charges /a Amount Due URGE /RICHARD /L ELF 020811 020311 AMBULANC 375.00 020811 020811 AMBULANC 24.16 06803 -88H 70.69 100 70,69 282.78 1 45.69 2 83548938800 -009 01100468 TOTAL 399.16 70.69 OTAL PAID: 70.69 y .OTES: 1 .-i� ei t:Sx� 1 THIS IS THE AMOUNT PAID BY MEDICARE. 2 PROVIDER ACCEPTED MEDICARE ASSIGNMENT. YOU ARE NOT LIABLE FOR THIS. -1/0 THS t=ACE OF THIS D. CUMENT HA: A COLORiED BACKGROLINI) i�lHIT PAPER. THE BACK OF I H-.E DOCUiIVL,1 r*N IAi-M* AN ART: F tfr.J':,D AT AN ANGLE Ti3 ViEJJ 1 76-4 PAYABLE THRU FIRST-NATIONAL BANK OF OMAHA 1049 NI�ED; bF LIFE l� CE COMPANY OMAHA, NE 68102 A Mu of ON[nr[n,CoMPnNY :FAEMONT NATIONAL BANK TRUST'CO r' Mumai9Qnaxa Nfutu Ll of =Omaha Plaza, Omaha, NE .68 L75 DATE DRAFT NO 'S i 00'86.503:3 ?7;069 53.29'2. 02'081 CC AIMNO s:; AMOUNT 5835489388`00 009.:' :70.:69 PAY TO THE ORDER OF PLEASE CASH IMMEDIATELY ACCT Z0'1 10 �O 4 6 58 POLICY /,P.LAN NUM'BE :R :7068' "03 -8'8H_ CITY OF CARMEL FIRE DEP -A- 2 CIVIC SQ CARMEL IN 46032 AUTHORIZED SIGNATURE II "0086 SO 3 311 0 bO t, 9000 4al.' 09 YD f Iitl 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 GQ Gt/� Purchase Order No. V Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total Q 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 u1� IN SUM OF 7a 9 ON ACCOUNT OF APPROPRIATION FOR wm zz &Clf GC/2X 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 P 1 r r— .17 OIL. &I- 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund