166970 12/11/2008 CITY OF CARMEL, INDIANA VENDOR: 362270 Page 1 of 1
ONE CIVIC SQUARE CLAUDE ZOOK
s CARMEL, INDIANA 46032 12981 206TH ST CHECK AMOUNT: $250.00
NOBLESVILLE IN 46060 CHECK NUMBER: 166970
CHECK DATE: 12/11/2008
DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
5023990 250.00 AMBULANCE REFUND
Electronic Remitance Information
Print Date: 11107108 (EOB) Explanation Of Benefits (EOB)
Payor Id: 00630 Production Date: 10/31/08 Receiver Id No: Z6CX
Payer Information:
NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: 1351840597
PO BOX 6160
INDIANAPOLIS IN 462066160
Payer Contact Info:
PROVIDER ENROLLMENT
(866)250 -5665 TE
Receiver Info:
CARMEL FIRE DEPARTMENT Payee Id: 1154325579
2 CARMEL CIVIC SQ
CARMEL IN 460327543
Payment Info:
Check /EFT Trace No: 123184855 Total,Payment Amount $7,075100 4
Check Issue Date: 10/31/08 };t
Payment Method: Check
Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid
200801711 ZOOK CLAUDE 1 311402591A 07/11/08 A0429 SH 300.00 240.00 312.50 312.50 62.50 250.00
Claim Control 1108294202920 A0425 SH 12.50 10.00
Claim Status: Processed as Primary
Claim Remark Codes: MA01, MA18,
Claim Adjustments: Total Adjustments
Patient Responsibility Coinsurance Amount 60.00
Patient Responsibility Coinsurance Amount 2.50
Billed: 312.50
Late Filing Fee: 0.00
Pt. Responsible Amt: 62.50
Paid: 250.00
MEDICARE PART B INDIANA MEDICARE PART B PROVIDER REPORT
NATIONAL GOVERNMENT SERVICES, INC.
P.O. BOX 240
INDIANAPOLIS, IN 46206 CHECK DATE 10/31/08
CHECK NUMBER 123184855
CHECKAMOUNT *7,075.00
PROVIDER NUMBER 1154325579
1000151 MBIDRS2 45185 0000154
CARMEL FIRE DEPARTMENT
2 CARMEL CIVIC SQ
CARMEL, IN 46032 -7543
RECEIVED NOV .0 .7 2008
74 -1M MEDICARE PART B
:NATIONAL GOVERNMENT SERVICES, INC-.
:P.O. BOX 240'
('FrV1FXS for MF02i7PF6MmKA10.CF7P ►V11E5
INDIANAPOLIS, IN 46206
MEDICARE PAYMENT
JPMOrgan Chase Bank COlumbuS FOR HEALTH: INSURANCE SOCIAL SECURITY ACT
Columbus, Ohio 05.03185106
PAY TO`THE -ORDER OF
CARMEL F;LRE DEPARTMENT PROVIDER CHECK N(..
-2 CARMEL CIVIC SQ'. 11`54325579 .1:23.18.4_:855
CARMEL, IN :46032- 7.54:3 mo_ oay vEaR
:..,DOLLARS
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Date: 11/25/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNTHIS
Bill To: CLAUDE I ZOOK ICD -9: 78097 78079 2930
12981 206TH STREET
NOBLESVILLE, IN 46060
From: 11825 N PENNSYLVANIA
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: CLAUDE I ZOOK 311402591A
12981 206TH STREET Insurance
NOBLESVILLE, IN 46060- 2 ANTHEM BC /BS/ 37010
Patient No: 200801711 YRP776M62273
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
$312.50 $312.50 $0.00
CPT
Date Description Charges Credits
07/11/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
07/11/2008 MILEAGE A0425 $12.50
10/10/2008 PAYMENT $312.50
10/14/2008 CORRECTION 312.50
10/14/2008 CORRECTION $312.50
11/07/2008 MEDICARE PAYMENT $250.00
11/25/2008 REFUND 250.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 11/25/2008
r"
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
0 L) N' RY
Bill To: CLAUDE I ZOOK ICD -9: 78097 78079 2930
12981 206TH STREET
NOBLESVILLE, IN 46060
From: 11825N PENNSYLVANIA
To: ST. VINCENTS HOSPITAL CARMEL
MEDICARE PART B
Patient: CLAUDE I ZOOK 311402591A
12981 206TH STREET Insurance
NOBLESVILLE, IN 46060- 2 ANTHEM BC /BS/ 37010
Patient No: 200801711 YRP776M62273
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
$312.50 $562.50 250.00
CPT
Date Description Charges Credits
07/11/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
07/11/2008 MILEAGE A0425 $12.50
10/10/2008 PAYMENT $312.50
10/14/2008 CORRECTION 312.50
10/14/2008 CORRECTION $312.50
11/07/2008 MEDICARE PAYMENT $250.00
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
Ar 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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
TotalQ
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
n�l�s V�ll� 201 o
ON ACCOUNT OF APPROPRIATION FOR
4t�zl- e
Board Members
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
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund