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Home My WebLink About163224 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 pOV FO tflC J c M5, O HP8 OPd P OF x h- srMONEY MARKET ACCOUN a; FOP y y N.QWNU MEN 936�A�XI5 FlE5FP 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