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Home My WebLink About164485 09/30/2008 CITY OF CARMEL, INDIANA VENDOR: 361938 Page 1 of 1 l% ONE CIVIC SQUARE ANITA WHEELER CARMEL, INDIANA 46032 1630 SOUTH L STREET CHECK AMOUNT: $368.75 ELWOOD IN 46036 CHECK NUMBER: 164485 CHECK DATE: 9130/2008 DE PART M ENT ACC PO NUMBER I NVOICE NUMB AMOUNT DESCRIPTION 102 5023990 368.75 AMBULANCE REFUND nap E o no •70 q-o o e q The padlock ioomis printed with ink that responds to warmth: Breathe on d the image will fade and reappey. A'RNI S, 1N,'C Check No: 1837 220,0 EL'IVIWOOD- AVENUE Claim No. UVS5534'5 LAFAYETTEBANK•ANDTRUST GrOUp NO 1 6OO 25 MAIN STREET LAEAYETTE IN 47904 LAFAY,ETTE N 47901 Print Date Q5 30 08 Patient Acct No 200800424 PAY TO THE ORDER OF: *368:75 Three Hundred Sixty Elght Dollars Seventy Flve Cents #BWNCQWH #P /TUDAAAWVB6# voib AFTER so DAYS CARMEL FIRE DEPT. AMBULANCE 2 CIVIC SID CARMEL IN 46032 -7543 I m )x83711' 1:07490 L0091: L 29496!!' PLEASE FOLD AND TEAR ALONG LINE PROCEDURE OTHER PYMT I PATIENT /REVENUE DATES OF SERVICE TOTAL PROVIDER INELIGIBLE NOTES APPLIED APPLIED BEN. CARRIER'S MADE BY RESPOW CODE CHARGES DISCOUNT AMOUNT TO DED. TO COPAY PYMT PLAN SIBILITY A0427 02 -09 -08 02 -09.08 350.00 100 350.00 0.00 A0425 02 -09 -08 02 -09 -08 18.75 100 18.75 0.00 TOTALS 36835 368.75 0.00 Processed Under Medical Claim No: WS55345 Participant: BARRY S WHEELER Plan For Services Provided By Check Amount ID No: 70031 55354 CARMEL FIRE DEPT. AMBULANCE 1837 $368.75 Address: 10751 BUNKERHILL DR 2 CIVIC SQ CARMEL IN 46032 CARMEL IN 46032 -7543 Deductible Accumulations for 2008 Patient: BARRY S WHEELER TIN: 356000972 Individual 400.00 of 400.00 Employer: ARNI'S, INC. Group No: 12344.600 Processed On: 05 -30 -08 By: LEF NOTES Patient Acct. No: 200800424 Individual co- insurance met; benefits limited to policy specifications. Internal rules, guidelines, protocols and /or other similar criterion were relied upon in determining benefits. A copy will be provided free of charge upon written request. You have the right to appeal a claim denied in whole or part by written request within 180 days. To appeal this decision, write to us at Meritain Health, P.O. Box 27267, Minneapolis, MN 55427 -0267. We are accepting claims electronically through ClaimLynx, Claimsnet, or WebMD. Our Payor ID is 41124. PROVIDERS: You can view eligibility, benefit information, and claims status on line at your convenience! To gain access, logon to http: /www.meritain.com /providers. RE C I ED St' 1 fl 2008 IF YOU HAVE ANY QUESTIONS ABOUT THIS EXPLANATION OF BENEFITS CALL CLAIMS CUSTOMER SERVICE: 952 546 -0062 800 925 -2272 or 24 HOUR AUTOMATED CLAIM INFORMATION: 952 593 -6560 800 566 -9311 12055 71- 167/749< ANITA L WHEELER BRANCH 050 1630' SOUTH L STREET: ELWOOD, INDIAN )V 46036- 2841° DATE i K RAY TO THE l S ORDER OF L r+ �./7 /E" r 7.S DOLLARS Financial Bank 1o0 7a p L57 2 s; L 28 04587u L 2055 r Date: 09/17/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 O N ii Bill To: BARRY S WHEELER ICD -9: 78650 71941 7295 78702 10751 BUNKER HILL DRIVE CARMEL, IN 46032 From: 13500 N MERIDIAN ST To: HEART CENTER OF INDIANA SAGAMORE HEALTH Patient: BARRY S WHEELER 7003155354 10751 BUNKER HILL DRIVE Insurance CARMEL, IN 46032- 2 Patient No: 200800424 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 $368.75 $368.75 $0.00 CPT Date Description Charges Credits 02/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 02/09/2008 MILEAGE A0425 $18.75 05/30/2008 PAYMENT $368.75 09/16/2008 COMMERCIAL INSURANCE PAYMENT $368.75 09/17/2008 REFUND 368.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09/17/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: BARRY S WHEELER ICD -9: 78650 71941 7295 78702 10751 BUNKER HILL DRIVE CARMEL, IN 46032 From: 13500 N MERIDIAN ST To: HEART CENTER OF INDIANA SAGAMORE HEALTH Patient: BARRY S WHEELER 7003155354 10751 BUNKER HILL DRIVE Insurance CARMEL, IN 46032- 2 Patient No: 200800424 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 $368.75 $737.50 368.75 CPT Date Description Charges Credits 02/09/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 02/09/2008 MILEAGE A0425 $18.75 05/30/2008 PAYMENT $368.75 09/16/2008 COMMERCIAL INSURANCE PAYMENT $368.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 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. /Palyee ,Q 4` a_ liAC e,— Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 7 e eJ e- y 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. J ALLOWED 20 12i y GZ GcJ� �C�/ IN SUM OF 76 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 SEP 2 9 70 20 igJairet Cost distribution ledger classification if Title claim paid motor vehicle highway fund