HomeMy WebLinkAbout198408 06/22/2011 a CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
ONE CIVIC SQUARE AETNA CHECK AMOUNT: $382.55
CARMEL, INDIANA 46032 PO BOX 981106
EL PASO TX 79998
CHECK NUMBER: 198408
CHECK DATE: 6/22/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 382.55 AMBULANCE REFUND
I
Date: 06/10/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: KRISTY L NEWETT ICD -9: 7840 V222 E8130
14576 LANSING PLACE
FISHERS, IN 46038
From: CARMEL DR &MERIDIAN ST
To: IU HEALTH NORTH
AETNAINSURANCE
Patient: KRISTY L NEWETT W16938860001
14576 LANSING PLACE Insurance
FISHERS, IN 46038- 2
Patient No: 201101196
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
$382.55 $382.55 $0.00
CPT
Date Description Charges Credits
04/29/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
04/29/2011 MILEAGE A0425 $7.55
06/02/2011 COMMERCIAL INSURANCE PAYMENT $382.55
06/07/2011 COMMERCIAL INSURANCE PAYMENT $382.55
0611012011 REFUND 382.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 06/10/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ►D# 356000972
Bill To: KRISTY L NEWETT ICD -9: 7840 V222 E8130
14576 LANSING PLACE
FISHERS, IN 46038
From: CARMEL DR &MERIDIAN ST
To: IU HEALTH NORTH
AETNAINSURANCE
Patient: KRISTY L NEWETT W16938860001
14576 LANSING PLACE Insurance
FISHERS, IN 46038- 2
Patient No: 201101196
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
$382.55 $765.10 382.55
CPT
Date Description Charges Credits
04/29/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
04/29/2011 MILEAGE A0425 $7.55
06/02/2011 COMMERCIAL INSURANCE PAYMENT $382.55
06/07/2011 COMMERCIAL INSURANCE PAYMENT $382.55
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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CITY OF ARMEL
,JAMES BRAINARD, MAYOR
June 10, 2011
Aetna
P.O. Box 981106
El Paso, TX 79998
RE Kristy Newett/ID 9W169388600/ DOS 04/29/2011
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $382.55. On June 2, 2011
we received a check from you in the amount of $382.55 for Ms. Newett's ambulance
transport on April 29, 2011. On June 7, 2011 we received a check from Nationwide
Insurance for the same amount. Since the auto insurance is primary, we are issuing you a
refund of $382.55. If you have any questions, please feel free to contact me at (317) 571-
2605.
Sincerely,
�,a
Beck S. Lannan
Billing Administrator
CARINIFL FIRE DEPARTMENT
STEVEN A. COUTS HEADQUARTERS
Two CIVIC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
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.
^I-- Payee
G1 Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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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
,4 e9- IN SUM OF
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ON ACCOUNT OF APPROPRIATION FOR
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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
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26
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Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund