HomeMy WebLinkAbout196472 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