157035 03/05/2008 0i. CITY OF CARMEL, INDIANA VENDOR: T360922 Page 1 of 1
ONE CIVIC SQUARE MARYLYNN DEL DUCO CHECK AMOUNT: $325.60
CARMEL, INDIANA 46032 14940 WARNER TRAIL
WESTFIELD IN 46074 CHECK NUMBER: 157035
CHECK DATE: 3/5/2008
DEPARTMENT ACCOUNT PO NUM INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 325.60 REFUND
1
Date: 02/28/2008
a
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
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Bill To: DARREN D DELDUCO ICD -9: 78039
14940 WARNER
WESTFIELD, IN 46074
From: 13450 N MERIDIAN APT /SUITE# 260
To: ST. VINCENT INDIANAPOLIS
UNICARE ACCESS PPO
Patient: MIA A DELDUCO 558A68304
14940 WARNER Insurance
WESTFIELD, IN 46074- 2
Patient No: 200700665
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
$398.00 $723.60 5- 325.60
CPT
Date Description ChaMes Credits
03/16/2007 ADVANCED LIFE SUPP 1 —EMER A0427 $350.00
03/16;2007 MILEAGE A0425 $48.00
07/13/2007 PAYMENT $398.00
02/26/2008 COMMERCIAL INSURANCE PAYMENT $325.60
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/28/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bill To: DARREN D DELDUCO ICD -9: 78039
14940 WARNER
WESTFIELD, IN 46074
From: 13450 N MERIDIAN APT /SUITE# 260
To: ST. VINCENT INDIANAPOLIS
1 UNICARE ACCESS PPO
Patient: MIA A DELDUCO 558A68304
14940 WARNER Insurance
WESTFIELD, IN 46074- 2
Patient No: 200700665
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
8398.00 $398.00 $0.00
CPT
Date Description Charges Credits
03/16/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
03/16/2007 MILEAGE A0425 $48.00
07/13/2007 PAYMENT $398.00
02/26/2008 COMMERCIAL INSURANCE PAYMENT $325.60
02/28/2008 REFUND 325.60
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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P.O. BOX 4458 ISSUE DATE PAGE C002426
M CHICAGO, IL606BO -4456 02/18/08 00001 OF 00004 006337
Life S Health Insurance Company
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EXPLANATION OF BENEFIT PAYMENTS CHECK NUMBER
0009881132
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EXPLANATION OF BENEFITS SEQUENCE n IS: 1154325579 200800002
H -409 Rev. 01/07 CHECK AMOUNT: S325.60
SEE REVERSE SIDE FOR IMPORTANT INFORMATION
NM67CF 10106 PLEASE DETACH CHECK AT PERFORATION BEFORE DEPOSITING
f 64 -1278 CHECK NUMB
P.O. BOh 4456 oQ: Qg861 1 7 1L
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i NI 1 C' :CHICAGO, IL '606B0 -445
Life Health insurance Company
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PAZ` TO 'CARMEL ;FIP,E :DEP:T AMBULANC February 18, 2008
2.'.CIiVIC SO
CARMEL, 'IN 46032 PAY THIS AMOUNT
1$325.601
THREE HUNDRED TWENTY -FIVE 60/1 DOLLARS
BANK Or AMERICA
BANK OF.4MERICA.CUSTOMER.CONNECTION
.BANK OF AMERICA.N.A.
ATLANT .,,DEKALB'COUNT Y,.GEORGIA
VOID IF NOT CASHED IN 6 MONTHS
`Ll. E' C c J L': C r..• 111
P.O. BOX UNICARE. f
IL -4458 EXP LANATION OF BENEFITS 006338
6 CHICAGO. 4 60680
Life Health Insurance Company
ISSUE DATE PAGE C002426
February 18, 2008 00002 OF 00004
Sequence Number: 1154325579 200800002
CARMEL FIRE DEPT AMBULANC
2 CIVIC S@ Provider ID: 356000972 -100
CARMEL, IN 46032
NETWORK PROVIDER: N o
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FOUNDATION PHYSICIAN: N W
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RECEIVED FEB 2 6 2008
Patient Name: DEL DUCO MIA ID 558A68304 Acct Nbr: 200700665 Group 145194M001
Claim ID: 07097103286
COINSURANCE
SERVICE PROCEDURE UNITS OF BILLED ALLOWED NOT ALLOWED DEDUCTIBLE COPAYMENT CLAIMS
DATE(s) NUMBER SERVICE AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT PAYMENT
03/16/07 A0427 001 350.00 350.00 350.00 0.00
03/16/07 A0425 008 -48.00 -48.00 -48.00 0.00
TOTAL THIS CLAIM 398.00 398.00 0.00 398.00 0.00 0.00
Patient Name: DEL DUCO MIA ID 55BA68304 Acct Nbr: 200700665 Group 145194M001
Claim ID: 07097103286
COINSURANCE
SERVICE PROCEDURE UNITS OF BILLED ALLOWED NOT ALLOWED DEDUCTIBLE COPAYMENT CLAIMS
DATE(s) NUMBER SERVICE AMOUNT AMOUNT AMOUNT AMOUNT AMOUNT PAYMENT
03/16/07 A0427 001 350.00 350.00 70.00/01 280.00
03/16/07 A0425 008 48.00 48.00 9.60/01 38.40
TOTAL THIS CLAIM 398.00 398.00 0.00 0.00 79.60 318.40
This is an adjustment to a previously processed claim, refer to EOB Sequence.No.: 356000972 -100 200700001
FOR INFORMATION CALL: 1- 800- 333 -3304
MESSAGES:
O1 This balance is the member's coinsurance responsibility.
Statutory interest included for delayed payment.
Unicare encourages and supports the submission of electronic transactions. For in-
formation regarding electronic transactions, please contact EDI Services at
www.unicare.com.
T A BM
T 1 N1 0
NM61EF 07/06
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DARREN D. DEL DUCO 122
MARYLYNN B. DEL DUCO 6- 7041/21410
7 6 07
14940 WARNER TRAIL 950
WESTFIELD, IN 46074 DATE
PAY TO THE
ORDER OF
DOLLARS o...
I FOR
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))
Total
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
/ZJ 9410 1, )OYfi 6,��c,
lAoC IV
ON ACCOUNT OF APPROPRIATION FOR
Ar�V- g
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
a received except
_Signati. T
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund