163224 09/03/2008 CITY OF CARMEL, INDIANA VENDOR. 361768 Page 1 of 1
ONE CIVIC SQUARE CANDY HABECK
CARMEL, INDIANA 46032 14139 CHARITY CHASE CIRCLE CHECK AMOUNT: $371.25
WESTFIELD IN 46074 CHECK NUMBER: 163224
CHECK DATE: 913/2008
DEPARTMENT A CCOUNT PO NU MBER INVO NUMBER AM OUNT DESCRIPTION
102 J 5023990 371.25 REFUND
C'
Date: 08/25/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
Bill To: JEROME HABECK ICD -9: 94420 7295 E8981
14139 CHARITY CHASE CIR
WESTFIELD,IN 46074
From: 14177 CHARITY CHASE CIR
To: ST. VINCENTS HOSPITAL
1 ANTHEM BC /BS/ 37010
Patient: CANDY L HABECK MWP219M61938
14139 CHARITY CHASE CIR Insurance
WESTFIELD,IN 46074 2
Patient No: 200801682
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
$412.50 $783.75 371.25
CPT
Date Description Charges Credits
07/05/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
07;05/2008 MILEAGE A0425 $62.50
07/29/2008 PAYMENT $412.50
08/22/2008 BLUE SHIELD PAYMENT $371.25
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 08/25/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972A!ry
Bill To: JEROME HABECK ICD -9: 94420 7295 E8981
14139 CHARITY CHASE CIR
WESTFIELD,IN 46074
From: 14177 CHARITY CHASE CIR
To: ST VINCENTS HOSPITAL
1 ANTHEM BC /BS/ 37010
Patient: CANDY L HABECK MWP219M61938
14139 CHARITY CHASE CIR Insurance
WESTFIELD,IN 46074 2
Patient No: 200801682
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
$41250 $412.50 $000
CPT
Date Description Charges Credits
07/05/2008 ADVANCED LIFE SOPP 1 -EMER A0427 $350.00
07/05/2008 MILEAGE A0425 $62.50
07/29/2008 PAYMENT $412.50
08/22/2008 BLUE SHIELD PAYMENT $371.25
08/25/2008 REFUND 371.25
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
rit *II0III0966III4020II1II01* 1 of. 2
R ichmond, Be �m 27 nl II IIVI I I W III IlVlul III ��III VI �I 22102
B 21339101
PROFESSIONAL PROVIDER REMITTANCE VOUCHER
PROVIDER NUMBER: 0000000629307
III ItLIIt, IliiiellltttLllllllJtLdliLliltlLiiiiLltLlll RECOVERY APPLIED. $000
o MBMNCXMF IRS WITHHOLD AMOUNT: $000
o CARMEL FIRE DEPARTMENT
CHECK AMOUNT: $37125
r 2 CIVIC SQUARE
CARMEL, IN 46032 -0000
DATE: 08/19/2008
Illlittillltilllliilllllllttlllllllliilllltillltltllillltltlli PACE: 1
U
n D Peuent R
Pm�ider a Mudif!, Amount Otbur DedueLbk I e
nic
Amhanvhnn Clnnn Det, of i For HALO Amount ppc Insuu nce Piaal Petim 1 i
Niunher Number Sen Charged Domed Paid Cnpay Payment Payment
.ARMEL FIRE DEPAR 219161938 S213602830000 7/05/08 1 0427 350.00 350.00 EYC 0.00 35.00 315.00 35.00 AC 7
1ABECK CANDY H 0.00 0.00
:ARMEL FIRE DEPAR 219X61918 213602830000 7/05/08 104042S 62.50 62.50 EYC 0.00 6.25 56.25 6.2 AC 7
1ABECK, CANDY H 0.00 0.00
SUBTOTAL 2 412.50 412.50 0.00 41.25 371.25 41.25
0.00 0.00
-CLAIMS PAID- 2 412.50 412.50 0.00 41.25 371.25 41.2
0.00 0.00
-TOTAL ENTRIES-- 2
NETWORK IDENT FIERS B SUBTO ALS
7 NON PAR 371.25
R CEI D A 22
H -403 Rev. 5/06
66 -7270
2560
Anthem V B 21339101
Anthem Blue Cross and Blue Shield
is the trade name of Anthem health Plans of Virginia, Ina DATE 08 194 2008
An independent {¢enseeof the Blue Ciuss end Blue Shield Aawoetion
PAY THREE HUNDRED SEVENTY ONE AND 25/100 DOLLARS
$371.25
TO THE ORDER OF CARMEL FIRE DEPARTMENT VOID AFTER 180 DAYS
2 CIVIC SQUARE
CARMEL, IN 46032 -0000
WACHOVIA BANK. N.A
R' 2 13 3910 in' '1C 2 5607 2 70 il: 20 7 990006 79 6 III-
s 1
2 5-2440
q
JEROME C. HABECK
CANDY L. HABECK
14139 CHARITY CHASE CIRCLE i
WESTFIELD, I 6074
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Premnbed 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.
/1
Payee
L?n du /ti Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
n se a_ S
Total 3 71
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 3 71 oZ5
3 9 C ase Grp /e
37/. d5
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
A UG 2 9 7008 20
u
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund