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Home My WebLink About160117 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE CHECK AMOUNT: $72.50 CARMEL, INDIANA 46032 PO BOX 740819 ATLANTA GA 30374 CHECK NUMBER: 160117 CHECK DATE: 5/28/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 1 72.50 REFUND r. N Anthem r 0 005868030300* I IIIIII VIII VIII VIII VIII VIII VIII VIII VIII VIII VIII VIII IIII IIII 5 of N An independent licensee of the Blue Cross and Blue Shield Association. CARMEL FIRE DEPT Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. PROVIDER ID N0: 1154325579 04!30/08 p) Registered Marks Blue Cross and Blue Shield Association CHECK NUMBER: NUMBER: 0 i I i MEDICARE SUPPLEMENT RECEIVED MAY 20 INSURED OTHER SERVICE CONTRACTUAL PROVIDER RESP. EXPL /ANSI EXPL /ANSI SERVICE DATE(S) POS CHARGE ALLOWED DEDUCTIBLE CO -PAY CO- INSURANCE AMOUNT, RESPONSIBILITY NET PAID CODES DIFFERENCE AMOUNT CODE(S) CODE(S) i AM R R FOR INQVI_AR NAME: ARMBRUSTE,WILLI S_CALL: INSURED'S NAME: ARMBRUSTER,WILLIAM R INSURED'SID: 757M53676 PATIENT PATIENT ACCOUNT#: 200800748 CLAIM NUMBER: 08115BS45300 RECEIVED DATE: 04/22/2008 (800) ;34544344, S ERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: 1154325579 03/17/2008 03/17/2008 A0427RH 41 350.00 70.00 0.00 0.00 0.00 0.00 0.00 0.00 i 70.00 03/17/2008 03/17/2008 A0425RH 41 12.50 2.50 0.00 0.00 0.00 0.00 0.00 0.00 2.50 TOTAL: 362.50 72.50 0.00 0.00 0.00 0.00 0.00 I 72.50 INTEREST PAID 0 -00 AMOUNT PAID BY MEDICARE 72 59 INSURED OTHER SERVICE CONTRACTUAL PROVIDER rnucn n�nurn oLE CO -PAY CO- INSURANCE RESPONSIBILITY NET PAID •••�uRESP EXPL /ANSI EXPL /ANSI .rllnclU COOFISI 03/1 03/1 INTE AMOU ANTHEM INSURANCE COMPANIES, INC. DBA ANTHEM BLUE CROSS AND BLUE SHIELD l l YYl m 1351 WILLIAM HOWARD TAFT ROAD 1 1 1` .AA _I CINCINNATI, OH 45206 -1775 1 of 6 An independent licensee of the Blue Cross and Blue Shield Association Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. kRi Registered Marks Blue Cross and Blue Shield Association I IIIIIIIIIII 'IIIIII1111�IIIIIII' #BWNCQXF #4428845679///DFS# I13 o CARMEL FIRE DEPT CD 2 CARMEL CIVIC SQ CARMEL IN 46032 0 0 tr Ou 0 IN O r 0 r ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0303914124 DATE 04/30/08 P.O. BOX 37110 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233-7110 ADDRESS 2 CARMEL CIVIC SO t® CARMEL IN 46032 t,® ANTHEM.COM PROVIDER ID NO 1154325579 TAX ID NO XXXXX0972 r® PAYMENT SUMMARY GROSS APPROVED CLAIM AMOUNT 615.06 r IRS WITHHELD 0.00 INTEREST PAID 0.00 AMOUNT PREVIOUSLY OVERPAID 0.00 I AMOUNT DISBURSED 615.06 NET AMOUNT DUE 615.06 RECOUPMENT BALANCE 0.00 I r® t� tt ®u tar_m 7, ECEIVED AY Q r® j DETACH CHECK AT PERFORATION. BEFORE. DEPOSITING CHECK NUMBER I O Anthem .0 9 DBA ANT ATLANTA, A GEORGIA 0303914124 Z, 1351 WILLIAM HOWARD TAFT ROAD .0064- .1278/0611 CINCINNATI, OH -45206 -1775 0430AI030122- 007048 C004326 3299777138 y PROVIDERS ID NO TAX ID NO DATE CHECK AMOUNT nx' 1154325579 �XXXXX0972 04/30/08 S *615:'06 �.na PAY .EXACTLY *6'.15 DOLLARS AND 06 CENTS �ZZ, Io'> TO THE ORDER OF mm z m f CARMEL FIRE DEPT m 2 CARMEL CIVIC SQ CARMEL IN 46032 NT I TEt INSURANtE dbMP4NIES, INC. Security features included. rn, Details on back. 003019LLs L2Lty" t:061 1. L2788so 3299777L38va 122 -AA RPCK44- 01550- 003 -04143 United .HealtliCarc insurance Company (and United Hcalil Carc Insurance Care Company of New York for New f 000%00- ork residents) arc proud providers to Options PAGE 3 OF 4 REMITTANCE ADVICE PLEASE RETAIN FOR FOUR RECORDS STATEMENT DATE: MAY 1, 2008 �j P��+ jnj`1j t MAY v RFNFFTT cIIMM4RY FnR C;ARMFI., PTRE DEPTH 1 CQE�u1i. IVEMED 9 2008 �9,.. ARMS_ RUSTER, WI•;LLIAM -R PATIENT 200800748 ;x �MEMBERSH;IP #':011589087 CARMEL 031708 1.,I 350.00 350.00 280.00 CARMEL 031708 12.50 12.50 10.00 70.00 2.50 72.50 i A RODS -21 M7 1 22- AARPCK44- 01550- 001 -04141 UNITED HEALTH CARE li you have questions please contact us at: a� PO BOX 740819 ATLANTA, GA 30374 -0819 UNITED HEALTH CARE PO BOX 740819 ATLANTA, GA 30374-0819 TOLL FREE: 1- 800 -AARP -789 1- 800 2277 -789 PAGE I OF 4 CARMEL FIRE DEPT* 2 CARMEL CIVIC SO CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: MAY 1 2008 CHECK AMOUNT: $1,624.76 E INED MAY For real -time access to claim, check and member elluibility information please register online at: https://aarpprovideronlinetool.uhc.com Please remember to sub nit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Health Care United HealthCare insurance Company (and tinted HealthCare Insurance Options' Company of Ne« York for New York residents) are proud providers to O Please detach check below and cash promptly :UNITED HEALTHCARE PO BOX 740819 Citibank Delaware 311 ATLANTA. GA .30374 -0819 One Penn's Way 11 128 053 8 T New Castle, DE 19720 REPRESENTS :PAYMENT FOR MULTIPLE INSUREDS DATE MAY 1, 200.8 PAY 1,12 4 7:6 *ONE THOUSAND SIX HUNDRED TWENTY FOUR DOLLARS AND 76 `CENTS "PAY TO THE ORDER OF CARMEL FIRE DEPT* 2 CARMEL CIVIC SO CARMEsL- I'N •46032- 7543 110 a 1'.L .28C 5 38 711 6.0 3 I 1 00 20 9Fo 38 5 6 2 rF Date: 05/12/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 r.� T D n �.E��s Bill To: WILLIAM R ARMBRUSTER ICD 9: 27651 78079 11813 SOMERSET WAY E CARMEL, IN 46033 From: 12999 N PENNSYLVANIA APT /SUITE# 132 To: CLARIAN NORTH MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200800748 YRR757M53676 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 $362.50 8362.50 $0.00 CPT Date Description Charges Credits 03/17/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/17/2008 MILEAGE A0425 $12.50 04/22/2008 MEDICARE PAYMENT $290.00 05/09/2008 COMMERCIAL INSURANCE PAYMENT $72.50 05/09/2008 BLUE SHIELD PAYMENT $72.50 05/12/2008 REFUND S -72.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 05/12/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: WILLIAM R ARMBRUSTER ICD -9: 27651 78079 11813 SOMERSET WAY E CARMEL, IN 46033 From: 12999 N PENNSYLVANIA APTlSUITE# 132 To: CLARIAN NORTH MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200800748 YRR757M53676 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 $362.50 $435.00 -72.50 CPT Date Description Charges Credits 03/17/2008 ADVANCED LIFE SUPP 1 —EMER A0427 $350.00 03/17/2008 MILEAGE A0425 $12.50 04/22/2008 MEDICARE PAYMENT $290.00 05/09/2008 COMMERCIAL INSURANCE PAYMENT $72.50 05/09/2008 BLUE SHIELD PAYMENT $72.50 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by Stale 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. Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) _t t i c 2 S i 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. ALLOWED 20 IN SUM OF Z2,5 #0 9 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—� 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund