HomeMy WebLinkAbout197084 05/11/2011 CITY OF CARMEL, INDIANA VENDOR: 359345 Page 1 of 1
ONE CIVIC SQUARE BANKERS LIFE CASUALTY CHECK AMOUNT: $22.29
CARMEL, INDIANA 46032 PO BOX 1935
CARMEL IN 46082 CHECK NUMBER: 197084
CHECK DATE: 5/11/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 22.29 REFUND
rl .n, 11 t
QW F EL
AMEs BRAINARD, /1Y0 R
April 26, 2011
Bankers Life Casualty
F.O. Box 1935
Carmel, IN 46082
RE Betty Hart/ID 4206064550/ DOS 02/09/2011
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $22.29. On April 21,
2011 we received a check from you in the amount of S106.43 for Ms. Hart's ambulance
transport on February 9, 2011. Since the Medicare co -pay was only 84.14, we are issuing
you a refund of $22.29. If you have any questions, please feel free to contact me at (3 17)
571 -2605.
Sincerely.
Bee y S. Lannan
Billing Administrator
CATOM. FIRE DHPAItTMENT
STEvTN A. COUis HEAE)QUART06
Two CIVIC SQUARE, CARNIEL, IN 46032 OFFICE 317.5 71.2600, FAZ 317.571.2615
Date: 04/26/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: BETTY HART ICD -9: 298.9
8009 STAFFORD LANE
INDIANAPOLIS, IN 46260
From: 12130 OLD MERIDIAN ST
To: COMMUNITY HOSPITAL -NORTH
1 MEDICARE PART B
Patient: BETTY HART 315308210A
12130 OLD MERIDIAN ST #311 B Insurance
CARMEL, IN 46032 2 BANKERS LIFE &CASUALTY /1935
206064550
Patient No: 201100477
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
$473.15 $473.15 $0.00
CPT
Date Description Charges Credits
02/09/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
02/09/2011 MILEAGE A0425 $98.15
04/05/2011 MEDICARE PAYMENT $336.56
04/05/2011 ASSIGNMENT MEDICARE $52.45
04/21/2011 COMMERCIAL INSURANCE PAYMENT $66.30
04/21/2011 COMMERCIAL INSURANCE PAYMENT $40.13
04/26/2011 REFUND -22.29
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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
S Lfee q- Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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.
ll ALLOWED 20
4ait l'S G� �Q SGc. IN SUM O F cx l 9
V Q Z
ON ACCOUNT OF APPROPRIATION FOR
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
SAY r X
4
20
Signature
Title
Cost distribution ledger classification it
claim paid motor vehicle highway fund