The URL can be used to link to this page

Home My WebLink About164572 10/16/2008 CITY OF CARMEL f INDIANA VENDOR: 356246 Page 1 of 1 w c� ytif 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 e r e 3 a §r a c 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 c Aetnn Ufe Insui once Company of on Affiliated Company :SID NO XXXXXXXX0972 CheekiNo 061465095 as Agent forSpecHled Poyei(s) $eq No 000000004 'Acct 09817 t P U BOX 981107 EL PASO TX 79998 ir-v v ,l"15A /�i T ,.fi x tea. q; e i :.'.i�Ni %hi �IP� Py ryI �9P 4 3. r/ r� ire ✓f r dA� IIIIa. 'i ��If ��nIWF II�IIi, ��l Y.:. 51 44.- a x,f f yy t x ::g l fFy ✓lr 71N 'IV �i� 'tliPo�a I� .ICI... I I�I� .aa r xl 118 CTS �B rm r s II �II� -r I I NJI'p a ys -s v $c ..ark �C s�w� ..rl ,d$� 1"4`' Ilpa IIIII� I P i� `��II 'IY r t� NN POLICYHOLDER MULTIPLE 1 e �IIIIIIp p p IIQC IdPI x 9 frs8i3 m11y s 411IVh' II I jl,��m II r `.N I' r1I� 3 �h �IIIII s';'U.r I�III :�_v .�r.4�''n�N�'a•.. li; r;- �I..I�tl� o.=Hundr d _Ten�DoUars- and:.00 /100 I II ta n VIII „I�uif �Ilfl° 3 11 :II 'GiII d t�� hI��I� IIu uOID uR �WEAR TOTI�E�,� GARME FIREDEPTARTMENT 0 ERfC7F ui�r V ��ru m �I�I u�IIVIIII'�New q PI k *,k N o, '��YI VIII Illli S ..:0 �i�lll VIII '.O 1RMELl 46Q, ;22584 ill illlnu4�' i�;� �IIIII� :1/ 9> „�r r WI C HII�II�II-0 4... ,::4,IIhd I I IIIIIn "�I�� ,"r 7 Bonk s r✓G� r a' w4 -I�liy II�iIOIi b �1 a a il m sue- i F,. x i./ i !I�II!h k I f 1 1VIlii Idih (10. 1 1 i �p i +II ;Iiilillll�illGk�Illllll II i� r' ue a 1' dtlllllp'lil ii Ilgll �d�y' li I i hp r 7 r Iiil �jP� ihII �II�IIII 1 I II ,VIN °II �I awIII I� k e y ,pl�il VIII I� II� Cl4� ail; �IIII�II' li a� I� °06 ��,65095`II �.0 �`°L9DDLl` °451. 000000'0098 17P M 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. $210.00 Protecting the privacy of member health` information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna member's ID number. 025924 J1K2PJB 745498 .-i l` 13 °x 8107 CLAIM PA YMEN7 EL PASO, TX 79998 -1107 USA Please Retain for Future Referen 005722 J280DUN2 015935 CARMEL FIRE DEPARTMENT I PIN: 00078252: Page 1 of 2 CARMEL FIREDEPARTMENT 2 CIVIC 5Q CARMEL IN 46032 -2584 �t�rl�r��tt��n tt��ttl�r�ti��r�i�i�i•� n�r��rl n •�i��n EC SLR cmvaw� nom, Aetna Llfe 6isurance Company of an Affillated:Compeny ID No XXXXXXXX0972 Check:No :061 Q316Z$: 'as Agent tor: 1pPClfied Paver(s) $eq NO 00007431 Q1CCt 09817: P. O BOX 981107 DEL PASO 1'X 79998 11.07 p ry X 1 a �IIn I t.': i nt i, 1 s_ st aa ai g y /C vp z II ,I �UI III Il ,IIIV �q.l' tt9 r' a s +III�IIp i 11�IIII •??�w`., /as% YY �Iql POLICYHOLDER THE DQNCCHI L CO PA f EM G A M,NY n 09 lars 1 �nd 551-00 �.1101" J, w�aM 1 �I llu, Ilp P.z'�.n4 p 4w:��i.�l�l9 .h.111 �4;` �u": nl ��I w T� 1�„ c u� IIIIV JI� 1 p6' -1 tllQ Vl�� WOID fFPER N YEAR TO THE CAARMEL :FIRE DEPARTMEN f ai, x e. qua., 4*�P �Plnll)( �I ORD,,.ER OF.., 2 CIV.I,C i ,I .I �IJ Il: I, �M 1 .m 111:�h1 N p. N,�li I 'R °M �II t tl� c, .0 DA MEI1 6� 2 256x', I V �u I 4 I I F'r,� rn ._i��il ul�� I�il 4 •,67 �,..n4�b... a ��lpllll �A Bank of Amencn sx t�t yea Ito-oz> s IIIVIII 1��':q:V�l ,rhl ��ih11111:p1iI :Illlt"'�'I� JII IIII III I I Iy m4 II IIII y 1111111 r ��a 1 �1� 1 1� 1 i 11 1 1�1w. 'tr'D 6 1 0.3' 5:7 8.u� I a>0 L 9 0 0 4'�, 5a a 0 0'0 0 0'D" 00 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