Loading...
HomeMy WebLinkAbout196390 04/13/2011 a CITY OF CARMEL, INDIANA VENDOR: 365235 Page 1 of 1 ONE CIVIC SQUARE KELLY HUGUENARD CARMEL, INDIANA 46032 1255 S 900 E CHECK AMOUNT: $351.20 `o ZIONSVILLE IN 46077 CHECK NUMBER: 196390 CHECK DATE: 4/13/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 351.20 AMBULANCE REFUND i E) Q.. f f OQ� `r� Q�; B ©11 CITY MEL jAMFS BRAINARD, MAYOR April 5, 2011 Ms. Kelly Huguenard 1255 S 900 E Zionsville, IN 46077 RE: INVOICE #201003081/ D.O.S. 11/27/2010 Dear Ms. Huguenard: Enclosed you will find a reimbursement check in the amount of $351.20. On March 3, 2011 we received a check from you for Ryan's ambulance transport on November 27, 2010 in the amount of $351.20. On April 5, 2011 we received a payment from United Healthcare 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 $351.20. If you have any questions, please feel free to contact me at (317) 571 -2605. Sincerely, Be y S. Lannan Billing Administrator CARMEI. 'Fim. Dr_PARTNIENT STEVEN A. COUTS HEAnQ (IARTERS Two CIVIC SQUARE: CA104EL, IN 46032 Or -rice 317.571.2600, FAx 317571.2615 Date: 0410512011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 ACCOUNT Bill To: JOHN HUGUENARD ICD -9: 3013 30500 E9600 1255 S 900 E ZIONSVILLE, IN 46077 From: 4120 STERLING BLUFF CT To: RIVERVIEW HOSPITAL 1 UNITED HEALTH INS/30555 Patient. RYAN HUGUENARD 857965932 1255 S 900 E Insurance ZIONSVILLE, IN 46077- 1 Patient No: 201003081 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 $351.20 $702.40 351.20 CPT Date ;:I DescriAtion Charges Cred its 11/27/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 11/27/2010 MILEAGE A0425 $26.20 03/03/2011 PAYMENT $351.20 04/05/2011 COMMERCIAL INSURANCE PAYMENT $351.20 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 ACC'COPUNT HISTORY Bill To: JOHN HUGUENARD ICD -9: 3013 30500 E9600 1255 S 900 E ZIONSVILLE, IN 46077 From: 4120 STERLING BLUFF CT To: RIVERVIEW HOSPITAL 1 UNITED HEALTH INS/30555 Patient: RYAN HUGUENIARD 857965932 1255 S 900 E Insurance ZIONSVILLE, IN 46077- 2 Patient No: 201003081 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 $351.20 $351.20 $0.00 CPT Date Description Charges Credits 11/27/2010 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 11/27/2010 MILEAGE A0425 $26.20 03/03/2011 PAYMENT $351.20 04/05/2011 COMMERCIAL INSURANCE PAYMENT $351.20 04/05/2011 REFUND 351.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Return this portion with your payment Payable To: CARMEL FIRE DEPARTMENT 20100308/ .JOHN HUQUENARD $35120 ECEIVED MAR 0 3 Run Date r� 1 11/ 27Y2010 I Amount Paid APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1999 4 J.E. HUGUENARD THE NATIONAL BANK OF INDIANAPOLIS Q 8 1255 S900 E 20-667-740 ZIONSVILLE, IN 46077 qp PAY TO Date�J f 1 THE ORDER m OF a ll 14 DOLLARS d 5 50a 1 D- 11360'01' 061327- PIM -0 -1 I O *C07ASOBOATOPS STD c02 �]�j UnitedHealthcare Insurance_- �T Company niteidlitet thcare SPRINGFIELD SERVICE CEi AUnietlHea[th Group Company P 0 BOX 30555 SALT LAKE CITY, UT 84130.0555 PHONE: 1-371-B42-3210 DATE: 08128/11 TIN: 35- 6000972 087ROVEOID1136001 NPL 1154325579 CARMEL FIRE DEPT A.MEULANCE SVC GROUP NUMBER: 0712525 CARMEL FIRE DEPT AMBULANCE SV CROUP NAME: JONES LANG LASALLE 2 CIVIC SO CHECK NUMBER: PG 00763250 CARMEL IN 46032 CHECK AMOUNT: X351.20 RUEaVED APR 0 5 2011 PR OVIDER EXPLANATION OF BENEFITS PATlENT::RY,AN HUGUENAR (CH) MEMBER NAME: JOHN HUGUENAPD CONTROL NUMBER: 280872 MEMBER ID: A857065932 DATE RECEIVED: 03/14/11 PRODUCT: CHOYC+ PROVIDER OF SERVICE: CARMEL FiP,E DEPT AMBU PATIENT ACCOUNT: 201003061 I DATE(S)OPI DESCRIPTION OF AMOUNT NOT COVERED PROV ADi AMOUNT DEDUCT COPAY FLAN PAID TO RMK PATIENT RESP SKRVICP SERVICES CHARGED DISCOUNT ALLOWED COV PROVIDER I CD 11 127/10 _AMBULANCES a32.5.OD $32300 I 100% $325.00f 11127/10 AMBULANCE OGWoI $26.20 1 CONTROL 280872283901 :i35i.20 $351.20 $351,20 u $O,OC j. SUBTOTAL: TOTAL PAYABLE TO PROVIDER $351.20{ I PLEASE SEE NE)"T PAGE FOR MORE INFORMATION Page 1 of 2 STD E06-356000972- 14013222 �.Unned4o'4 care.lrstuvance Comoan 5 i 19 SPRlNGcIEL'D SERVICE CENTER Y 5 0 60X <3d5F5 'D0 63 H SALT LAKE CITY UT B4130 -0555 FHONE; 1- 577 -842 -3210 p 03/28/11 DATE Bank of America `.,PLEASE PRESENT.PRCMPTLY FOR FAYVENI Hartford; 'CT 06120 10 �3bo-PM- o -t CONTRACT 0712525 PAY: "351 .20 ."Three Kundred iift.y One Doll33 -S.and Twenty (.0 ntC pAY CARMEL FIRE DEPT AMBULANCE SVC TO THE CARMEL FIRE DEPT AMBULANCE SV 2 CIVIC SQ DRIDER:OF';: CARMEL.IN 46032' AUTrHOP ZED SIrGNATURE rlllndainiihliu11L61111un1 'illnullllEUlhlddll Jtlhililllualmlut dmllullhllilutluliiitlllllnulnlltllluddll ndGilllnf1111unlnHidlitdull ill:Itl111d11€ IIIlhtllldl6ldllddudllnllllillllnlB 1a00007 2� 3 25 0um 51110 2 2 '4000 9 5 25 11 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 e Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) e z em &tw Total 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 S-51- ZO ���r�s✓, /l� �l X77 3s Za ON ACCOUNT OF APPROPRIATION FOR 44�&ACPiIVO A2J 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 APR I S Zft 0 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund