164572 10/16/2008 CITY OF CARMEL f INDIANA VENDOR: 356246 Page 1 of 1
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ONE CIVIC SQUARE AETNA
CARMEL, INDIANA 46032 PO BOX 981107 CHECK AMOUNT: $72.50
EL PASO TX 79998 -1107
CHECK NUMBER: 164572
CHECK DATE: 10/16/2008
DE PARTMENT ACCOUNT PO NUMBER INVOICE NU MBE R A MOUNT D
102 5023990 72.50 AMBULANCE REFUND
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XActn a USA EL BOX 981197 CLAIM PA YMENT
EL PA50, TX 79998 -1107
025924 JIKZPJA 074547 (1)
Please Retain for Future
CITY OF CARMEL FIRE DEPT. PIN: 00057451(
Page 1 of 3 (1)
CITY OF CARMEL FIRE DEPT.
2 CIVIC SO
CARMEL IN 46032 -2584
I1InI
RECEIVED OCT o a 4
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as Agent forSpecHled Poyei(s) $eq No 000000004 'Acct 09817
t P U BOX 981107
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1k o P.O. BOX 981107 E XPLANATION OF BENEFITS
Aetna EL PASO, TX 79998 -1107
USA
Please Retain for Future Reference
CITY OF CARMEL FIRE DEPT. PIN: 0x0574510(
Check No: 09817/06146509:
Page 3 of 3 (1)
Patient Name: GLENN H LECKRONE (Seo
Claim ID: EDPADYS7800 Recd: 09/19/08 Member ID: W142786625 Patient Account: 200801683
Member: GLENN H LECKRONE DIAL: 458978627867
Group Name: THE DOW CHEMICAL COMPANY Group Number: 783135 -10 -007 PL D88 00
Product: Open Choice® Network ID: 05000
Aetna Life Insurance Company
SERVICE.. PL ''r.- .SERVICE NUM.. SUBMITTED `'..ALLOWABLE.' COPAY .:NOT SEE:'::. DEDUCTIBLE .CO PATIENT. PAYABLE
DATES .CODE .SVCS CHARGES -a AMDUNT �AMOUNT PAYABLE REMARKS '.INSURANCE RESP AMOUNT
07106108 41 A0427NH 1 350.00 350.00
07106/08 41 A0425NH 2 12.50 12.50
TOTALS 362.50 362.50
Less Amount Paid by Other Health Plan $290.00
ISSUED AMT: $72.50
For Questions.Regarding This Claim
P..O. 80X`9$1109 EL PASO, TX 79998 110.9 Total Patient Responsibility:.] $0.00
CALL (888) 632 3862 FOR ASSISTANCE Clalm Payment: $72.50
Note: Afl Inquiries should reference the ID number above for prompt response.
Total Payment to: CITY OF CARMEL FIRE DEPT. $210.00
Protecting the privacy of member health` information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be
prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna member's ID number.
025924 J1K2PJB 745498
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l` 13 °x 8107 CLAIM PA YMEN7
EL PASO, TX 79998 -1107
USA
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005722 J280DUN2 015935 CARMEL FIRE DEPARTMENT I PIN: 00078252:
Page 1 of 2
CARMEL FIREDEPARTMENT
2 CIVIC 5Q
CARMEL IN 46032 -2584
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kA P L BOX 98107 LANATION O B F ENEFITSetna EL PASO, TX 79998 -1107 EXP
USA
Please Retain for Future Reference
005722 J280DUA2 015936 CARMEL FIRE DEPARTMENT PIN: 0007825233
Check No: 09817/061031678
Page 2 of 2
Date Printed: 09/16%2008
CARMEL FIRED EPARTMENT Tax Identification Number: XXXXXXXX0972
2 CIVIC SO Check Number' m 09817/061031678
CARMEL IN 46032 -2584 Check Amount: $72.50
Notes: The benefits listed below reflect your portion of this payment.
Address, telephone number, e-mail and /or N PI numbers can be added or updated online. Medical: visit https: //vvww.aetna.com /provweb
Dentists: Log in to the www.aetnadental.com secure site and select Update Personal Information.
Patient Name: GLENN H LECKRONE (Selo
Claim ID: PPAACiSK)(00 Recd: 08/29/08 Member ID: W142786625
Member: GLENN H LECKRONE DIAG: 7999
Group Name: THE DOW CHEMICAL COMPANY Group Number: 783135 -10 -007 PL DBB_00
Product: Open Choice® Network ID: 00000
Aetna Life Insurance Company
SERVICE PL SERVICE NUM: 'SUBMITTED ALLOWABLE, COPAY NOT SEE DEDUCTIBLE. CO ;PATIENT PAYABLE:
`DATES CODE SVCS CHARGES :f :AMOUNT PAYABLE 'REMARKS INSURANCE RESP .AMOUNT
07106108 41 A0427NH 1 350.00 350.00
07106108 41 A0425NH 1 12.50 12.50
TOTALS 362.50 362s0
Less Amount Paid by Other Health Plan $290.00
::ISSUED AMT::: $72.50
For Questions Regarding This: Claim:..:
P.O. BOX 981'109 EL PASO TX. 799984109: Total .Patient Responsibility $0.00
CALL (888)
032-3862: .FOR ASSISTANCE Claim Payment. $72.50
Note: All Inquiries should reference the ID number above for prompt. response
Total Payment to: CARMEL FIRE>DEPARTMENT $72.50
Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please bo
prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna member's ID number.
74 RECEIVED SEP 2 3 2008
(-uud
Date: 10/08/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
ACCOUNT I- C)RY
Bill To: GLENN H LECKRONE ICD -9: 4589 7862 7867 E8844
15102 ROMALONG LANE
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA APT /SUITE# 131
To: CLARIAN NORTH
MEDICARE PART B
Patient: GLENN H LECKRONE 364441464A
15102 ROMALONG LANE Insurance
CARMEL, IN 46032- 2 AETNA US HEALTHCARE /981106
Patient No: 200801683 00006471501
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
$362.50 $362.50 $0.00
CPT
Date Description Charges Credits
07/06/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
07/06/2008 MILEAGE A0425 $12.50
08/05/2008 MEDICARE PAYMENT $290.00
09/23/2008 COMMERCIAL INSURANCE PAYMENT $72.50
10/07/2008 COMMERCIAL INSURANCE PAYMENT $72.50
10/08/2008 REFUND -72.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/08/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
11 HISTORY
Bill To: GLENN H LECKRONE ICD -9: 4589 7862 7867 E8844
15102 ROMALONG LANE
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA APT /SUITE# 131
To: CLARIAN NORTH
MEDICARE PART B
Patient: GLENN H LECKRONE 364441464A
15102 ROMALONG LANE Insurance
AETNA US HEALTHCARE /981106
CARMEL, IN 46032- 2
Patient No: 200801683 00006471501
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
$362.50 $435.00 -72.50
CPT
Date Description Charges Credits
07/06/2008 ADVANCED LIFE SUPP 1 —EMER A0427 $350.00
07/06/2008 MILEAGE A0425 $12.50
08/05/2008 MEDICARE PAYMENT $290.00
09/23/2008 COMMERCIAL INSURANCE PAYMENT $72.50
10/07/2008 COMMERCIAL INSURANCE PAYMENT $72.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
A6 '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
Q Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
J
n i
Total 7
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
2 7999�
7,-�). ,!57)
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
Art 1 2 008
(�20
Si�;ature��
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund