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Home My WebLink About196472 04/13/2011 CITY OF CARMEL, INDIANA VENDOR: 365229 Page 1 of 1 ONE CIVIC SQUARE CATHERINE MUNHOLLAND CHECK AMOUNT: $74 -67 CARMEL, INDIANA 46032 10453 LAKESHORE OR E �MipoN,io. CARMEL IN 46033 CHECK NUMBER: 196472 CHECK DATE: 4113/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 REIMS 74.67 OTHER EXPENSES Date: 03/30/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 ACCOLNT Y Bill To: CATHERINE A MUNHOLLAND ICD -9: 459.0 10453 LAKESHORE DR E CARMEL, IN 46033 From: 10453 LAKESHORE DR E To: IU HEALTH NORTH 9 MEDICARE PART B Patient: CATHERINE A MUNHOLLAND 082126275A 10453 LAKESHORE DR E Insurance CARMEL, IN 46033 2 HARP /UNITED HEALTHCARE Patient No: 201100464 1373767512 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR INSURANCE, NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $421.06 $495.73 -74.67 CPT Date Description Charges Credits 02/08/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 02/08/2011 MILEAGE A0425 $46.06 03/15/2011 MEDICARE PAYMENT $298.70 03/15/2011 ASSIGNMENT MEDICARE $47.69 03/22/2011 COMMERCIAL INSURANCE PAYMENT $74.67 03/251207.1 COMMERCIAL INSURANCE T $74.67 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 03/30/2011 CARMEL. FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 ACCOUNIF HISTORY Bili To: CATHERINE A MUNHOLLAND ICD -9: 459.0 10453 LAKESHORE DR E CARMEL, IN 46033 From: 10453 LAKESHORE DR E To: IU HEALTH NORTH MEDICARE PART B Patient: CATHERINE A MUNHOLLAND 082126275A 10453 LAKESHORE DR E Insurance CARMEL, IN 46033 2 AARPIUNITED HEALTHCARE Patient No: 201100464 1373767512 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $421.06 $421.06 $0.00 CPT Date Description Charges Credits 02/08/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 02/08/2011 MILEAGE A0425 $46.06 03/15/2011 MEDICARE PAYMENT $298.70 03/15/2011 ASSIGNMENT MEDICARE. $47.69 03/22/2011 COMMERCIAL INSURANCE PAYMENT $74.67 03/25/2011 COMMERCIAL INSURANCE PAYMENT $74.67 03/30/2011 REFUND -74.67 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 EXPLANATION OF BENEFITS THE BABCOCK WILCOX CO DRAFT ISSUED 3/16/2011 MARSH AFFINITY GROUP SVCS INSURED— MUNHOLLAND, CATHERINE PO BOX 10432 PATIENT— CATHERINE DES MOINES, IA 50306 -0432 ACCT #201100464 INSURED'S CERTIFICATE 279/49 300 28 15 INSURED'S POLICY ID AGP -6004 COVERAGE SENIOR MEDICAL PLAN AMOUNT NOT MEDICARE. BENEFIT PROVIDER DATE OF SERVICE BILLED ELIGIBLE.APPROVED.DEDUCTIBLE. PAYABLE 1 CARMEL FIRE DEP 2/08/2011— 2/08/2011 421.06 .00 373.37 _00 74.67 DRAFT— 86714956 TOTALS: 421.06 .00 373.37 .00 74.67 r DECEIVED' mu 2 N 2011 QUESTIONS? CALL TOLL FREE: 1 877 -351 -6602 e a a o' o e o a a go a Administered by Seabury Smith on behalf of The Hartford Check No. 86714956 279/49 11074 -9- 004 -05 Date 3/16/2011 50-937 213 THE PAY HARTFORD *SEVENTY —FDU'R AND 67/100 DOLLARS**'* 574.67 JPMorgan Chase Bank NA Syracuse, NY VOID IF NOT CASHED IN 60 DAYS TOTHE CARMEL FIRE DEPARTMENT ORDER 2 C CIVIC SQ OF CARMEL, IN 46032 -7543 Authorized Signature Ila8671495E1IIa 1: 0 2 13 0 R 3 791.6018C. 5163111 077- AARPCK41- 02355. 0 01 -07060 UnitedHealthcare Insurance Company if you have questions please CO ntaCt u 5 at: PO Box 740819 Atlanta, GA 30374 -0819 UnitedHealthcare Insurance Company PO Box 740819 Atlanta, GA 30374 -0819 TOLL FREE: 1 800 -AARP -789 RECEIVED MAR 2 5 2011. 1- 800 2277 -789 PAGE 1 OF 2 CARMEL FIRE DEPT* 2 CARMEL CIVIC SQ CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: MARCH 18, 2011 CHECK AMOUNT: $631.93 For real -time access to claim, checl.:, and member eligibility information please register online at: https.//aarpprovideron Please remember to submit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance company or other person files an application for Insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. j Supplemental and Personal Health 'o Plans insurers in'UnitedHealthcare g Insurance Company rr 1 k Please detach check below and cash promptly ;UnrtedHaalthcare insurance Comperiy. PC Box 240899 62 20 Atlanta:GA 30374 0919: Citibank Delaware:: 311 One Penn's Way 13-5-0356,4 New Castle, DE 19720 :REPRtSENTS PAYMENT FOR MULTIPLE INSUREDS DATE MARCH 18, 2011 PAY:$ *631.93 S I X :::HUNDRED:: TH I'RTY ONE DOLLARS AND 9 3 .CENTS PAY TO THE ORDE R OF:. CARWL :.F`IRE DEPT 2 CARMEL CIV_F:C CARMEL:..-IN <z46032 -7543 ll :b 50 5649ii® b L00.2.09:[.: :3�5� 2 077- AARPCK41.02858- 002.07081 These Plat's carry the AARP nanic and UnitedHe tltcare pays a rovalty fee to AARP [or use of the AARP iniellecittal property. Atnourtts paid arc used for the `„encral purpose of AARP and its members. Neither AARP nor its affiliate is the insurer. Coverage insured by UnitcdHealtltcare Insurance Companv (for Ncvv York residents. Unit:edHealthcure Insurance Compary of Ne-vv York), PAGE 2 OF 2 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: MARCH 1 8 2011 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT* r6 N1Uh1H{3LLAND;° GAT'HERINEA ,�H ,E,," t HI MEEIHERSP #l, 073 675'x. a u x18 R .7 a PAT 1ZNT 201100464 CARMEL 020811 375.00 331.52 265.22 66.30 CARMEL 020811 46.06 41.85 33,48 8.37 TOTAL 74.67 AAR005.21107 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 Prih P Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) �Cc_ ri CSC D vC� Total 0 74-/ (p 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 �Cc lie.r1he Awhollaw� IN SUM OF 7' Z-/. ON ACCOUNT OF APPROPRIATION FOR Ain at�c &//—Vo -Aw ro 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