The URL can be used to link to this page

Home My WebLink About162257 08/07/2008 CITY OF CARMEL, INDIANA VENDOR: 361671 Page 1 of 1 ONE CIVIC SQUARE WILLIAM ARMBRUSTER 1' CHECK AMOUNT: $76.25 CARMEL, INDIANA 46032 11813 SOMERSET WAY EAST CARMEL IN 46033 CHECK NUMBER: 162257 CHECK DATE: 8/7/2008 DEPARTMENT A CCOUNT PO NU INV OICE NUMB AMOUNT DESCRIPT 102 5023990 76.25 AMBUL REFUND Date: 07/25/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: WILLIAM R ARMBRUSTER ICD -9: 78791 11813 SOMERSET WAY E CARMEL, IN 46033 From: 11813 SOMERSET WAY To: CLARIAN NORTH MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200801279 YRR757M53676 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $381.25 $381.25 $0.00 CPT Date Description Charges Credits 05/20/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 05/20/2008 MILEAGE A0425 $31.25 06/24/2008 MEDICARE PAYMENT $305.00 07/11/2008 BLUE SHIELD PAYMENT $76.25 07/22/2008 COMMERCIAL INSURANCE PAYMENT $76.25 07/25/2008 REFUND -76.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 07/25/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: WILLIAM R ARMBRUSTER ICD -9: 78791 11813 SOMERSET WAY E CARMEL, IN 46033 From: 11813 SOMERSET WAY To: CLARIAN NORTH MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200801279 YRR757M53676 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $381.25 $457.50 -76.25 CPT Date Description Charges Credits 05/20/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 05/20/2008 MILEAGE A0425 $31.25 06/24/2008 MEDICARE PAYMENT $305.00 07/11/2008 BLUE SHIELD PAYMENT $76.25 07/22/2008 COMMERCIAL INSURANCE PAYMENT $76.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 1 nt.11.em r V V. 1351 WILLIAM HOWARD TAFT ROAD CINCINNATI, OH 45206 -1775 1 of 7 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. E) Registered Marks Blue Cross and Blue Shield Association #BWNCQXF o #185999999493/DF9# I04 t CARMEL FIRE DEPT 2 CARMEL CIVIC SQ L CARMEL IN 46032 0 0 0 RCFI�1FD 1111 L L4 W 0 r v N r ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0304091980 DATE 07/02/08 P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SO CARMEL IN 46032 i® ttttttt® PROVIDER ID NO 000000184493 1154325579 TAX ID NO XXXXX0972 PAYMENT SUMMARY GROSS APPROVED CLAIM AMOUNT 630.55 r IRS WITHHELD 0.00 INTEREST PAID 0.00 AMOUNT PREVIOUSLY OVERPAID 0 AMOUNT DISBURSED 630.55 NET AMOUNT DUE 630.55 i RECOUPMENT BALANCE 0.00 t® ttt® s i® t® i® i® j DETACH CHECK AT PERFORATION BEFORE DEPOSITING A y� CHECK NUMBER 1 Orr 1 11 lthema DBA -ANT ATLANTA, C 0304091980 Z 1351 WILLIAM HOWARD TAFT ROAD 0064- 1278/0611 c CINCINNATI''' OH 45206 1775 07D2AI030122- 010060 C002834 %32997771'38 my PROVIDER ID NO TAX ID NO DATE CHECK AMOUNT•,: :�'x 000000.184493:'. XXXXX0972 07/02/08 S *63'0..55 t'.. ZO= Or, PAY EXACTLY *630, DOLLARS AND SS CENTS mzv z o ozi TO T'HE.ORDER OF: �I Aox mm� -or =0f R CARMEL FIRE DEPT 2 2 CARMEL CIVIC SQ CARMEL IN 46032 2 INSURANtE P NIES, INC. x Security features included. Details on back. ��803040919B0116 1:06 1 1 1 2 7881: 3 299777138��° 4 of 7 CARMEL FIRE DEPT PROVIDER ID NO: 000000184493 07/02/08 CHECK NUMBER: 0304091980 MEDICARE SELECT RECEIVED JUL 1 12008 INSURED OTHER SERVICE CONTRACTUAL PROVIDER RESP. EXPL /ANSI EXPLlANSI SERVICE DATE(S) POS CHARGE ALLOWED DEDUCTIBLE CO-PAY CO- INSURANCE RESPONSIBILITY NET PAID CODES DIFFERENCE AMOUNT CODES) COD AMOUNT ES) eno wn-wri rAI I TOTAL: 343.75 68.71 0.00 0.00 0.00 0.00 0.21 I u.uu INTEREST PAID I 00.00 AMOUNT PAID BY MEDICA E 274.83 TO L NET PA 68 INSURED OTHER SERVICE CONTRACTUAL PROVIDER RESP. EXPL /ANSI EXPL /ANSI SERVICE DATE(S) CODES POS CHARGE ALLOWED DEDUCTIBLE CO -PAY CO- INSURANCE DIFFERENCE AMOUNT CODE(S) RESPONSIBILITY CODE(S) NET PAID AMOUNT INSURED'S NAME: ARMBRUSTER,WILLIAM R INSURED'S ID: 757M53676 PATIENT NAME: ARMBRUSTER,WILLIAM R FOR INQUIRIES CALL: PATIENT ACCOUNT#: 200801279 CLAIM NUMBER: 081768162200 RECEIVED DATE: 06/24/2008 SERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: 1154325579 05/20/2008 05/20/2008 A0427RH 41 350.00 70.00 0.00 0.00 0.00 0.00 0.00 0.00 70.00 05/20/2008 05/20/2008 A0425RH 41 31.25 6.25 0.00 0.00 0.00 0.00 0.00 0.00 6.25 TOTAL: 381.25 76.25 0.00 0.00 0.00 0.00 0:00 0.00 76.25 IATEREST PAID 0.00 AMOUNT PAID BY MEDICARE 305:00 OTA L_NET_._PA ID 7 6... 196 -AA R P CK42 02039 001 -06121 UNITED HEALTH CARE If you have questions please contact us at: PO BOX 740819 ATLANTA, GA 30374 -0819 UNITED HEALTH CARE PO BOX 740819 ATLANTA, GA 30374 -0819 TOLL FREE: 1- 800 -AARP -789 1- 800 2277 -789 PAGE 1 OF 3 CARMEL FIRE DEPT* 2 CARMEL CIVIC SQ CARMEL IN 46032 -7543 )RECEIVED JUL 2 2 2006 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: JULY 14, 2008 CHECK AMOUNT: $889.68 For real -time access to claim, check, and member eligibility information please register online at: https://aarpproviderotilinetool.uhc.com 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. Health Care United HealthCare Insurance Company' (and United HealthCare Insurance Options' 0 Company of New York for New York residents) are proud providers to Please detach check below and cash promptly UNITED. HEALTH CARE 3 2_20 PO BOX 740819 Citibank Delaware 311 ATLANTA,:GA 30374 -0819 One Penn's Way 1 1 14 3B:5.8 9 0 New Castle, DE 19720 REPRESENTS PAYMENT: FOR MULTIPLE INSUREDS, DATE: JULY 14., 2008 PAY: *889''. *EIGHT HUNDRED EIGHTY NINE DOLLARS AND 68 CENTS PAY TO THE ORDER OF CARMEL FIRE DEPT* 2: CIVIC SQ CARMEL I'N 46032 -7543 0 11 <'b4165890ti 1;03 L LDO 2091: 38 56 2 L6411' NP 196 -AA R PCK42- 02039- 002 -06122 Health Care United HealthCare Insurance Company (and United HealthCare Insurance Options' Company of New York for New York residents) are proud providers to PAGE 2 OF 3 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: JULY 14, 2008 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT* RE'CE'IVED JUL 2 2 2008 Insured Provider Dates of Amount Medicare Medicare Applied to Benefit Information Service Charged Approved Paid Deductible From To BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. I ARMBRUSTER; 'W ILLIAM R f k MEMBERSHIP 0115$9087: CLAIM 81774 507y9631 w... s.s_F .,r,, M a,. ,TIENT 200801279 CARMEL 052008 350.00 350.00 280.00 70.00 CARMEL 052008 31.25 31.25 25.00 6.25 TOTAL 76.25 a.. s:. v(] nAllarax�]. ra�Sii :asc+2,.ns. :,��.:3',(x::i., L.•nu_..a.. .�,e.,.n ,a., r,...e.am.m.e,...n rr... <:n:vnn'.n:v..9�nc� ...e.xt Y. ':n, Y;n -..n e WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR II I BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE. :005- 219107 Prescribed by State Board of Accounts City Form No. 201 (Rev. 19 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 I r I Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) a_rs o� 1 Total 76 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 IN SUM OF horn e( darm ej Lj 3 -7�o, c) 5 ON ACCOUNT OF APPROPRIATION FOR rr)b LJ e l y4t? Wo n� 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 20a s Signature Title distribution ledger classification if paid motor vehicle highway fund