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Home My WebLink About159917 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: T361363 Page 1 of 1 ONE CIVIC SQUARE NATALIE HORGUS CHECK AMOUNT: $213.75 CARMEL, INDIANA 46032 422 3RD AVE NW CARMEL IN 46032 CHECK NUMBER: 159917 i�ow i CHECK DATE: 5/28/2008 DEPA RTMENT ACCOUNT PO N UMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 213.75 OTHER EXPENSES I i i i I INDIANA CARPENTERS WELFARE FUND INDIANA CARPENTERS WELFARE FUND P Em O BOX 421729 ry INDIANAPOLIS, IN 46242 For Customer Service: (8011)700-675-6 r... 4 Return Service Requested IG -AI.M .NO 10016 08121 143 1PI..AN NAMI_" INDIANA CARPENTERS MIXED AADC 462 21861 0. 9468 MB 0 360 41TLAN NO: K6 30 `IIII "I' III"" 1�IIIIItIItIIIIII' IIII ItIIIIIIIIIIIII '11111 III 1,4E:iMli.ER: MLIJAI\4 M HOROUS CITY OF CARMEL FIRE DEFT 103 PA !JEN7 NATA[,:11E HO RCi1.1S 2 CIVIC SQUARE PAT- ACCOUNT 260810265494008 CARMEL, IN 46032 -2584 RI?LATIONSFIIP: V1 RE. ClJvf "I): 04/14/08 PR0CES S 04I30I0S i E.'XAMINER: D M S I Explanation of Benefits Service provider o! service Char e Nehtiorh r Not l,es ilanee 1 aid Iseuefit i Rem nk llates Servrce I pe Amount Discount (:`ovcral Deduclittic (ortsidrrul At Anu,arnt Lock 132.14 02 -14 -08 C'i FS OF CARMEL FIR 4"IRUL. 350.00 70.00 2£ 0 011 75� 21 f1.00 68L 02- 1402 -14 -08 C[IY�OFCARA9H1..FIR A%'mt,L. 6.25 1.25 �O(1 75�n 3 -75' 6SL 02-14 02 -14 -0$ C[ 1'1 OF CAR FIR MESS,A I 75 0 4402 -i4 -0K CI TY OF 51 M SSA GE 1 251 =9_� I 13 13 Tota I J ls: 356. <5 7 �R�.00 1...5 Sutttmn lsiet 4rk Qfh r Ins Uu r 1?:atd Chick P �tcnt: �lfX'fl< C4tki,es s ..I�Itt P si.�me nt Pd` >ttiutik Io 3`+ luntlxt Li ilttk'j CI I OF CARNIEL FIR 356.25 213.7> CITY OF CA 595862 Remarks 681, THE PLAN'S HENEFI'I' IS 75 OF COVERED CHARGES 75X BENEFITS ARE REllL1CGD 20% FOR NON- PARTICII'AT10N' 1'RO 5BH NON- C0f\ PROVIDER R., 7 FDR SE=CURITY P'URRDS'ES THErFACE OF�THIS` :DDCUMENT CONTAINS BABKGROUND AND '1MICRDpR1N71NG.INTiiE,'BOfiDER xu CHECIh I`f'O 000598862 An tana Carpenters Welfare Fund 7�0 ti ECh ;D.AT•E: �oolol_108 yPb Boi. 421729., r rte hidtanapolis IN 46242 AMOUNT PAY Two Hundred Thirteen Dollars THP,,0'U)E1k0F: CITY OF CARME l- FIRE DEPT Void fl 'Not Cashed In 6 Months N A'noNAL CI I Y HANS Claim No: 10036 08121 1=433 PlanNr K630 Patient Acct:2608 1 0265 4N4008 l v„ DOCNOT,,GASFi IF WA7ERMARK.ISiNOT PRESENT- ON,THE.REVERSG,S1DEnOF,TH15 aOCUMEN} Hp A7,AWANGLETO VIeW 0000S98 a I. 211m i:071,0000C St: 03 24 h 289L,11° WILLIAWN1. H OROUS 1147 NATALIE JO HORGU5. I z c 422`3RD.AVE NW E�1 �C 2a- 7403/2740 CARMEL, IN 46032 Date f 3 C. i e hx a �2 P to the r m ��Q j Orde o� Dollars P.O 96x50736 ,3 F OR UM lndianaOohs IN 46250' 73$ e cRE❑i U 10n r xc b x s 2 k Fi NP v For � m Date: 05/12/2008 j CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federai ID# 356000972 Bill To: WILLIAM HORGUS ICD -9: 7245 7840 78701 7804 422 3RD AVE NW APT 8 CARMEL, IN 46032 From: 11911 N MERIDIAN ST To: CLARIAN NORTH 4 ANTHEM BC /BS/ 37010 Patient: NATALIE HORGUS CZP000335844 422 3RD AVE NW APT 8 Insurance CARMEL, IN 46032- 2 Patient No: 200800473 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 $356.25 $356.25 $0.00 CPT Date Description Charges Credits 02/14/2008 ADVANCED LINE SUPP 1 -EMER A0427 $350.00 02/14/2008 MILEAGE A0425 $6.25 05/07/2008 PAYMENT $356.25 05/07;2008 COMMERCIAL INSURANCE PAYMENT $213.75 05/12/2008 REFUND 213.75 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 Federal !D# 356000972 Bill To: WILLIAM HORGUS ICD -9: 7245 7840 78701 7804 422 3RD AVE NW APT 8 CARMEL, IN 46032 From: 11911 N MERIDIAN ST To: CLARIAN NORTH 1 ANTHEM BC /BS/ 37010 Patient: NATALIE HORGUS CZP000335844 422 3RD AVE NW APT 8 Insurance CARMEL, IN 46032- 2 Patient No: 200800473 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 $356.25 $570.00 213.75 CPT Date Description Charges Credits 02/14/2008 ADVANCED LIFE SUPP 1 -EMER A0427 5350.00 02/19/2008 MILEAGE A0425 S6.25 05/07/2008 PAYMENT S3356.25 05/07/2068 COMMERCIAL INSURANCE PAYMENT $213.75 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 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)) 017 Z2 rs -for O e c s Total 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 IN SUM OF 9 7n Y,2 2 2 >r AIW ON ACCOUNT OF APPROPRIATION FOR A& L-)d�e 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 20 oy S nature Cost distribution ledger classification if Title claim paid motor vehicle highway fund