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Home My WebLink About166195 11/24/2008 CITY OF CARMEL, INDIANA VENDOR: T362199 Page 1 of 1 ONE CIVIC SQUARE EQUITABLE LIFE CASUALTY CARMEL, INDIANA 46032 3 TRIAD CENTER CHECK AMOUNT: $61.25 SALT LAKE CT`r UT 84180 CHECK NUMBER: 166195 9M CHECK DATE: 1112412008 DEPARTME ACCOUNT N UMBER INV NUMBE AMOUNT DE SCRIPTION 0 +102 502399 61.25 OTHER.EXPENSES o 0 h III,' 1 5 1 r. d I II l i'�il' III rill l.l_. 'I. I I i;lil I,.:., I Ir I, ®Ifl�ll'' -�J �i IY III le ,::il �,la il�..' II III .i�j S�1L�. r.u'I (I III Ilg I, I� 1p lil ;p N I k. �I,, F� aa: l !9 h I I I i'dlll I I 1 I 4 i' x'41 dI I,'. 7 !'I.. i. 'Ih Ib .1 o'rb,11 6,. I I i I i IL u 1 I 1 IS,,al 1 Q RANGE COMP u I .I' OV� I ^6YLI81�QINVices II'II.,i 6 II I' I Ir {III;II° i11�6198 �ArSv 38.1'72001'IIU. 952. .0 I 1� i,4 '�,rTYlad'enter.•, .;I I.' !d I e li ,p..: 180 iI 111 lr' a 4 oil l;l 11 'I. I' I I :!I IIII I. 6 III I: I III IIIIII I,> V II I III .Y L ke G.f{ U1�h;8,4 1 5alt it II. IIIIIII..:, IIII I S j,li 1 II FI '.I rl a a .II ,1 -II .[11 Y IIII 1„ I!,II II a I '!Ip 56— .ea YI ,'u lal I:�a, ,I:I•r .III LI I ,II f LIi f 1.',. '.IIII rl •IL' I. Iii 1 'I .I,,, �I', d;:ul IIII: 1�44l441: "Il i �l`I I. II IItlI I.; ..I :nhl III Ir, II L1. a•, 1 -I .q I L, I I Iri 'l 1 „.PPY: EXACTLY X61 DOLLARS- A D 25 CENTS PATE annouNT !ill” .I I kill i I�.II .dh_ :�li I kl' fl "I 4,, 17' Qm7r �,k C y III I I61f (IIIIIII I Ir. I,17��Q�00 YII ,I I 'd4EYO�� +r2J P u I rf IgIY�9 4� .r I I I I III rll. ill II. IIII. I.;. ml I I I I u p iil u II III 6 I IIII �ll'!j I! I: l', I II IIII d III lull h IIII 'II 'I IIII u r. CARMEL FIRE DEPARTMENT L ToTH O 2 CARMEL CIVIC SQUARE F�DER OF I VIII I ll i CARMEL IN 46032 I Equltable Life Casualty, Insurance Company I II i(1 III I I I i1 r, II I I it lil l l i �OIiJ 6 MOTI� 1 p l IIII,., rl i ll I'li. plll;! Al I,II,I I� I bl: I'. 111,11.. All ill i,11' 77 7 MP d d Ii I I I IIII II I I 1 I ql I I 11, 11 16r r4 I1�41 j1 V 1I III X111 'h IIII I I I :;a II II IlIU Il l MP 11 I Itl 1 1: 0161 1 III tlll.,� rl I 10 l I •3 I. I I,. '�J�1 b1 I I I t enJ l'1 d,; ll �V'�II _''t 1 11111J.,I,E: -',!!1 I I,• ::1. I Id: I.IE� II ul 1t�r1 I�„ I�I': �I11I 1 -L�� I:IIh IIrDii; °II a, viii i IJ I:, II,I 6 X9 .04.4.L �1541�, 3 II 989� >51I�1 II Ibii •1 n; I:i' lli'I °rl ..III Id Il� .d s'; i. .P9: IIII il'd i -iI 'JIl flll iiJr!II !I III n i .IIII I I I 1,k :I .n I r ll h6 L fln r,ht ri, dl I L I Yl4l. li 11 II ,c 1 r.l1,i1, ,IV o I' it al' Ili, d.. I 1 yfd'. I 1 a' ullp,l 41111 II11 �'76R +11: II i I`I:,l r1a II I ,,,:I I p. Il, 1p 4 F' 4 ll` ;YI,. I I ..I :�IIu' T DETACH HERE T September 30, 2008 11698930 Dear Provider: This is your Explanation of Benefits for payment for services provided to one of our policyowners. if you have any questions, please contact our Claims Department for assistance. We're here to help you because WE CARE. CLAIM 12696833 CLAIMANT: WILLIAM FIGUEROA RECEIVED: 9/23/08 POLICY 3817200 PLAN 952.00 AGENTS: 173270 FAHED M ULAYYET EFFECTIVE 12 15/03 THRU 10/15/08 173270 FAHED M ULAYYET eft SERVICE AfVILlUfll1` M: E D r C A R' RE4SON BENS 1 PROVIDER; BtLl EE} APP Roy .PAYMENT CF7DE AML1111�7 CARMEL FIRE DEPART 7/29/08 7/29/08 300.00 300.00 240.00 51 60.00 CARMEL FIRE DEPART 7/29/08 7/29/08 6.25 6.25 5.00 51 1 ^25 Total. Benefit Amount 61.25 REASONS 51 Your provider accepted assignment of Medicare benefits and cannot charge you more than the Medicare approved amount. REMARKS Patient Account�r 200801869 RECEIVED OC 0 7 2008 FAUltah INSURANCE COMPANY 1 4 F CLAIM NO 14 -2247 -543 POLICY NO 1452- 765 -14 -001 LOSS DATE 07 -29 -2008 PAYMENT NO 1 18 169249 .:Coverage' Descr.i pti6n.a. Amount COL Pa d DA i E 11 MEDICAL PAYMENT $306.25 600 2 AMOUNT $306.25 TIN 14- 356000972 ENTERED BY BURTZOS, TINA AUTHORIZED BY BURTZOS TINA PHONE (866) 648 -0715 REMARKS 7/29/2008 STATE FARM FIRE AND CASUALTY COMPANY 1 18 169249 WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 MPC INDIANA 18 -501 L025 COLUMBUS, OH 11-14-2008 CLAIM NO 14- 2247 -543 INSURED FIGUEROA, WILLIAM DATE M M o o Y r v Y LOSS DATE 07 -29 -2008 ON BEHALF OF WILLIAM FIGUEROA *EXACTLY THREE HUNDRED SIX AND- 251100 DOLLARS *306.2 5 Pay to the Order of.- CARMEL FIRE DEPT,EMERGENCY MEDICAL;: 2 CIVIC SQ CARMEL IN 46032 -2584 APPROVED BY RECEIVED NOV 1 8 2098 CLAIM NO 14- 2247 -543 POLICY NO 1452 765 -14 -001 LOSS DATE 07 -29 -2008 PAYMENT NO 1 18 169249 .I Coverage. Dkcri t i on Amouiat COL Pa Cd DATE 11-14-2008 MEDICAL PAYMENT $306.25 600 2 AMOUNT $306.25 i A 14- 35600097:' S 1"I.3 AUTHORIZED BY BURTZOS, TINA PHONE (866) 648 -0715 REMARKS 7/29/2008 ••STATE FARM FIRE AND :CASUALTY COMPANY WEST LAFAYETTE LN JPMORGANd CHASE BANK, NA 56 1544/441 COLUMBUS; ON m '.MPC INDIANA :18-501,1 025' 1` 1. 08 CLAIM NO 14 2247 -543 INSURED FIGUEROA, WILLIAM DATE M u u x:v v r LOSS DATE 07 29 2008: ONBEHALF OF WILLIAM; FIGUEROA *a"EXACTLY THREE HUNDRED SIX AND 25/100 DOLLARS *306. 2 Pav to the Order of; CARMEL FIRE DEPT EMERGENCY MEDICAL 2 CIVIC SQ CARMEL IN 46032 -2584 1 I AUTHORIZED S16NAiURF 1 1'18i71692'�,911' 1:0 31:52YE29023311m Date: 11/20/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE a CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972a HISTORY Bifl To: WILLIAM FIGUEROA ICD -9: 78652 E8130 7402 SOMERSET SAY UNIT 112 INDIANAPOLIS, IN 46240 From: 136TH &MERIDIAN ST To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: WILLIAM FIGUEROA 315308659A 7402 SOMERSET BAY UNIT 112 Insurance INDIANAPOLIS, IN 46240- 2 EQUITABLE LIFE CASAULTY Patient No: 200801869 3817200 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $306.2.5 $612.50 306.25 CPT Date Description Charges Credits 07/29/2008 BASIC LIFE SUPP— EMERGENCY /x,0429 $300.00 07/29/2008 MILEAGE A0425 $6.25 09/30/2008 MEDICARE PAYMENT $245.00 10/07/2008 COMMERCIAL INSURANCE PAYMENT $61.25 11/18/2008 COMMERCIAL INSURANCE PAYMENT $306.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 11/20/2008' CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE J CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 NT HISTORY Bill To: WILLIAM FIGUEROA ICD -9: 78652 E8130 7402 SOMERSET BAY UNIT 112 INDIANAPOLIS, IN 46240 From: 136TH &MERIDIAN ST To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: WILLIAM FIGUEROA 315308659A 7402 SOMERSET BAY UNIT 112 Insurance INDIANAPOLIS, IN 46240- 2 EQUITABLE LIFE CASAULTY Patient No: 200801869 3817200 PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $306.25 $551.25 245.00 CPT Date Description Charges Credits 07/29/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 07/29/2008 MILEAGE A0425 $6.25 09/30/2008 MEDICARE PAYMENT $245.00 10/07/2008 COMMERCIAL INSURANCE PAYMENT $61.25 11/18/2008 COMMERCIAL INSURANCE PAYMENT $306.25 11/20/2008 REFUND -61.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL ij 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 n l y re v- C� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) bars e m Total J� 1 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 �C �eL, e C 17�[�cI IN SUM OF bl 3 ON ACCOUNT OF APPROPRIATION FOR Board Members POD 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 N OV 2 4 2008 17 Signature Cast distribution ledger classification if Title claim paid motor vehicle highway fund