163634 09/17/2008 CITY OF CARMEL, INDIANA VENDOR: T361833 Page 1 of 1
0 ONE CIVIC SQUARE KEITH BOLAND CHECK AMOUNT: $337.50
4' CARMEL, INDIANA 46032 10 SHORE CIRCLE
CARMEL IN 46033 CHECK NUMBER: 163634
CHECK DATE: 911712008
D EPARTMENT ACCOUNT PO NUMBER INVOICE NUM BER AMOUNT DESCRIPTION
102 5023990 337.50 OTHER EXPENSES
,c
Date: 09104/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
H
Bill To: 'KEITH D BOLAND ICD -9: 9048 7295 E8842
10 SHORE CIR
CARMEL, IN 46033
From: 10 SHORE CIR
To: ST. VINCENTS HOSPITAL CARMEL
1 ANTHEM BC /BS/ 37010
Patient: LORI S BOLAND BFE903025085
10 SHORE CIR Insurance
CARMEL, IN 46033 2
Patient No: 200801765
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE, THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW.
THANK YOU.
Total Amount Total Paid Balance
$375.00 $712.50 337.50
CPT
Description Charges Credits
0°1/1.7/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
07/17/2008 MILEAGE A0425 $25.00
08/19/2008 PAYMENT $375.00
09/03/2008 BLUE SHIELD PAYMENT $337.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/04/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
Bin To: KEITH D BOLAND ICD -9: 9048 7295 E8842
10 SHORE CIR
CARMEL, IN 46033
From: 10 SHORE CIR
To: ST. VINCENTS HOSPITAL CARMEL
ANTHEM BC /BS/ 37010
Patient: LORI S BOLAND BFE903025085
10 SHORE CIR Insurance
CARMEL, IN 46033 2
Patient No: 200801765
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE. THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW.
THANK YOU.
Total Amount Total Paid Balance
$375.00 $375.00 $0.00
CPT
Date Description Charges Credits
07/17/2008 ADVANCED LIFE SUPP I —EMER A0427 $350.00
07/17/2008 MILEAGE A0425 $25.00
08/19/2008 PAYMENT $375.00
09/03/2008 BLUE SHIELD PAYMENT $337.50
09/09/2008 REFUND 337.50.
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
I'
J
7248
KEITH D. BOLAND
OR LO S..BOLANfD 20 7/ 7 40
to stiORE clla. Date' saia
CARMEL, IN 46033 -3640
Pay to the order ofA�® Ni15 Dollars 8
Hunting n
hurtfington.com
For
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j
An Independent Licensee
of the Blue Cross end
Biue Shieid Association
e7
BlueCrossBlucShield
of Tennessee
801 Pine Street
Chattanooga, Tennessee 37402
CARMEL FIRE DEPT �EP 200
2 Civic Sq Ji C.�` VED
Carmel IN 46032
BCBST Provider No. 3128641 NPI Number 1154325579
The Federal Government requires BlueCross BlueShield of Tennessee" to report to the Internal Revenue
Service a providers earnings that exceed $600 in a taxable year.
Your Tax Identification Number(TIN) on file with us is 356000972
Attention: If this number and name are correct, please do not return this form. If either is not correct, please
complete the form below and mail or tax to address below:
BlueCross BlueShield of Tennessee •An Independent Licensee
Provider Management Department 3TC of the BlueCross and
601 Pine Street Chattanooga, TN 37402 -2555 Fax: 423 -535 -5808 BlueShield Association
Name (if joint names, list first and circle the name of the person or entity whose number you enter below)
Business Name
Please check appropriate Entity.
Address (Number, Street, and Apt or Suite Number) IndividuallSole Proprietor
Corporation Partnership
City, State, and Zip Code Other
Tax Payer Identification Number (TIN)
Enter your TIN in the appropriate area below. For individuals, this is your Social Security Number (SSN).
For other entities, it is your Employer Identification Number (EIN).
Social Security Number Employer Identification Number
Effective Date Tax Payer Identification Number (TIN) Went Into Effect:
Under penalties of perjury, l certify that the number shown on this form is my correct taxpayer identification number
(or I am waiting for a number to be issued to me.)
Sign Here Date:
If notified by the IRS that the reported tax number and name do not match their file, we will notify and request from you verification of the
Name and TIN Number as registered with the Internal Revenue Service. Failure to comply may result in Backup Withholding procedures.
Thank You. W...:
FACE OF THIS CHECK HASH COLORED BACKGROUND -NOT A. WHITE, GRAY OR FADED BACKGROUND 61 -1.278
An Independent Licensee- bll
of.the BlueCross and
`fi BlueShield Association
s� m
3
'B1u n eCrossBlueSh eld DATE: 08/27/200e N 014447.85
of Tennessee ,DOLLARS. I CENTS
-Three Hundred Thirty Seven And 50/100-----
PAY TO THE
ORDER OF: PROVIDER ND. 3128641
CARMEL FIRE DEPT
2 Civic Sq
Carmel IN 46032
BANK OF AMERICA, DEKALB COUNTY GA
PROFESSIONAL LINE OF BUSINESS BC01
REMITTANCE ADVICE REMIT /CHECK DATE 08 /27 /2008
BCBST PROVIDER NUMBER 3128641
B1ueCrossBlueShield CARMEL FIRE DEPT
NPI NUMBER 1154325579
of Tennessee 2 Civic Sq TAX IDENTIFICATION NUMBER 356000972
An Independent Licensee of the Carmel IN 46032 CHECK NUMBER 014447853
Blue Cross and Blue Shield Association
REMITTANCE NUMBER 2008082711200689
PAGE NUMBER 1 OF 1
PATIENT INFORMATION CLAIM INFORMATION PAYMENT INFORMATION
LAST NAME FIRST NAME CLAIM DATE OF PROCEDURE PATIENT N N PATIENT OTHER CLAIM PAID
TOTAL CONTRACT PATIENT PATIENT
NUMBER NON- 0 0 DED/ INSURANCE/
PATIENT SERVICE CHARGES T WRITE OFF T COINS INTEREST OWES
ACCOUNT MEMBER ID RECVD O V E E FROM /THRU MODIFIER COVERED COPAY MEDICARE
SERV PR PAID
BLUE NETWORK..P-
BOLANa: LORI2S EXTSQPSZ4408 8737- 071709
200801765 90302508501,,, 08/,19/2008 071770 71708 A0427RH 350 00 00 00, 35 00 D 315,00
i1543?5579 0717 ;071769 110425RN 25. $0 08 9$ i 3 5U $ix 'c2.50
CLAIM TOTAL 375 00, 00 00 00, 37.50 .00 337. s0„ 37.50
G t� D S P 008
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xx
TOTALS: 375.00 .00 .00 .00 37.50 00 337.50 37.50
INTEREST: .00
REMITTANCE TOTAL 337.50
PLEASE RETAIN FOR YOUR RECORDS
Visit BlueAccess at www.bcbsLcom to view this information and more.
For your service questions or issues call 1 -800- 924 -7141
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�m r
�227 5�
'U
1 p
4
Total
9
S 7 S
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.
l ALLOWED 20
C) IN SUM OF 7 SO
i o ors
me), -Z �6o 3
ON ACCOUNT OF APPROPRIATION FOR
�Xj �Iko 4,
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice 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
S
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund