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Home My WebLink About158802 04/30/2008 CITY OF CARMEL, INDIANA VENDOR: T361187 Page 1 of 1 A ONE CIVIC SQUARE ROBERT BERWANGER CHECK AMOUNT: $337.50 CARMEL, INDIANA 46032 1312 HELFORD LANE CARMEL IN 46032 CHECK NUMBER: 158802 CHECK DATE: 4130/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION 102 5023990 337.50 OTHER EXPENSES i Date: 04/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal iD# 356000972 Bill To: ROBERT M BERWANGER ICD -9: 9569 71947 E8859 1312 HELFORD LANE CARMEL, IN 46032 From: 1900 W 116TH ST To: ST. VINCENT INDPLS ANTHEM BC /BS/ 37010 Patient: ROBERT M BERWANGER BLB574A71278 1312 HELFORD LANE Insurance CARMEL, IN 46032- 2 Patient No: 200800360 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 $337.50 $675.00 337.50 CPT Date Description Charges Credits 02/03/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 02/03/2008 MILEAGE A0425 $37.50 03/25/2008 PAYMENT $337.50 04/15/2008 BLUE SHIELD PAYMENT $337.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 04/18/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 C) U' 1 F',Y Bill To: ROBERT M BERWANGER ICD -9: 9569 71947 E8859 1312 HELFORD LANE CARMEL, IN 46032 From: 1900 W 116TH ST To: ST. VINCENT- INDPLS 1 ANTHEM BC /BS/ 37010 Patient: ROBERT M BERWANGER BLB574A71278 1312 HELFORD LANE Insurance CARMEL, IN 46032- 2 Patient No: 200800360 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 $337.50 $337.50 $0.00 CPT Date Description Charges Credits 02/03/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 02/03/2008 MILEAGE A0425 $37.50 03/25/2008 PAYMENT $337.50 04/15/2008 BLUE SHIELD PAYMENT $337.50 04/18/2008 REFUND 337.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 1387 20-1 227 Tao BERWANGER 07-06 72n 1 ROBERT M. EN L• BERWpNGER KAR D ATE I I 1312 HELFCRD GL CARMEL, IN 7` S j91 PAY TO THE �OO LLARS Iw oaDEROF DO CHAS nk. NA. ,r— ,(fi/Jy1 AR y,l 0 Indiangan Chase Ba v I o IndianaQolis,�m�� 86277 .Chase. ends l7�' 3b D7EM0 �---�mm sue 6 of 8 CARMEL FIRE DEPT PROVIDER ID NO: 1154325579 04/02/08 CHECK NUMBER: 0303832637 MEDICARE SUPPLEMENT CSI VED APR 1 5 200 TOTAL APPROVED AMOUNT 142.46 TOTAL INTEREST 0.00 TOTAL NET AMOUNT DUE: MEDICARE SUPPLEMENT 142.46 BLUE ACCESS SERVICE INSURED OTHER CODES SERVICE DATE(S) POS CHARGE ALLOWED DEDUCTIBLE CO -PAY COI DIFFERENCE AMOUNT CODE(S) CO-INSURANCE CONTRACTUAL PROVIDER RESP. EX E(S) i RESPONSIBILITY EXPLIANSI NET PAID AMOUNT CODE(S) INSURED'S NAME: BERWANGER, ROBERT INSURED'S ID: 574A71278 PATIENT NAME: BERWANGER,ROBERT FOR INQUIRIES CALL: PATIENT ACCOUNT 200800360 CLAIM NUMBER: 2008086KGO022 RECEIVED DATE: 03/24/2008 (877) 526 3425 S ERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: 000000184493 02/03/2008 02/03/2008 A0425 41 37.50 37.50 0.00 0.00 0100 0.00 0.00 0.00 37.50 02/03/2008 02/03/2008 A0429 41 300.00 300.00 0.00 0.00 0.00 0.00 0.00 0.00 300.00 TOTAL: 337.50 337.50 0.00 0.00 0.00 0.00 0.00 0.00 337.50 INTEREST PAID 0.00 TOTAL NET PAID 37 5 SERVICE INSURED OTHER GROSS APPROVED CLAIM AMOUNT 863.55 TOTAL INTEREST 0.00 NET AMOUNT DUE 863.55 EXPL CODES EXPLANATION MCP THE CHARGE EXCEEDS THE MEDICARE ALLOWABLE AMOUNT FOR THIS SERVICE. MOD MEDICARE DENIED THIS SERVICE, SERVICE IS NOT COVERED 807 AMOUNT WAS APPLIED TO MEMBER'S DEDUCTIBLE. ANIHLM 1NSURANCL CUMVANILJ, 1Mt.. DBA ANTHEM BLUE CROSS AND BLUE SHIELD A nthem. -•.0 1351 WILLIAM HOWARD TAFT ROAD r CINCINNATI, Oil 45206 -1775 1 of 8 i 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 Registered Marks Blue Cross and Blue Shield Association II IIII IIII II �IIIIIIIII I�IIII'll� #BWNCQXF o #4428845679///DFSN III ro CARMEL FIRE DEPT N 2 CARMEL CIVIC SQ CARMEL IN 46032 r 0 0 0 0 N UI N U1 O W O O D ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0303832637 DATE 04/02/08 P.O. -BOX 37010 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC S0 CARMEL IN 46032 PROVIDER ID NO 1154325579 TAX ID NO XXXXX0972 PAYMENT SUMMARY .GROSS APPROVED CLAIM AMOUNT 863.55 r -IRS WITHHELD 0.00 INTEREST PAID 0.00 AMOUNT PREVIOUSLY OVERPAID 0.00 .I AMOUNT DISBURSED 863.55 t® 1 NET AMOUNT DUE 863:55 I RECOUPMENT BALANCE •0.00 .o �o ic'EUVE. APB 20�fi DETACH CHECK AT'PERFORATION 'BEFORE. DEPOSITING 4 A nthem CHECK NUMBER a 'Y!•• V DBA SSA ANDSBLUE ATLANTA, GEORGIA ;K 0303832637 1351 WILLIAM HOWARD TAFT ROAD 0064- .1278/0611 me CINCINNATI; OH 45206 1775 0402AIQ301Z2 .010255' :0002145 3 299777138 PROVIDERIIDrN0 TAX'iD'NO ':DATE CHECK AMOUNTG r 1 0. 115432557.9 X ^XXXX0972 04/02/08 a >03 �o m -PAY EXACTLY DOLLAkS'AND 55 CENTS zz� TO ,.THE ORDER OF: tmm� Or Z F` CARMEL FIRE'DEP:T 2 CARMEL CIVIC ,`SQ' z CARMEL' IN 4603 2 `N S�£ INSURA E ObMPKNIES, INC. Security features included. .Details on back. Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) 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 �r an Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) S r s Total P I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 D JPr7 �E7�%�GUQh IN SUM OF S37,50 Car l -n =IV zlra o 3- s ON ACCOUNT OF APPROPRIATION FOR ,141; Jac e AQ2M Board Members PO# or DEPT. INVOICE NO. ACCT #/TITLE AMOUNT 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 gnature Title Cost distribution ledger classification if claim paid motor vehicle highway fund