The URL can be used to link to this page

Home My WebLink About160116 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE CARMEL, INDIANA 46032 PO BOX 740819 CHECK AMOUNT: $83.75 s ATLANTA GA 30374 CHECK NUMBER: 160116 CHECK DATE: 5128/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 83.75 REFUND Health Care _e United HcalthCare Insurance Company (and United HcatthCarc Insurance A Options, Company of New York for New York residents) are proud providers to PAGE 3 OF 4 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: APRIL 14, 2008 BENEFIT SUMMARY FOR: CARMEL FIRE DEPT* AzLL''.1ftD AP k 2 2 ZU08 insured I Provider Dates of Amount Medicare I Medicare I Applied to Benefit Information Service Charaed Cnnmvc owl n�a l J MEMBERSHIP O1 "1589087 .CLAI"M; 507269 =.1<. 35 ARMBRIISTER, ":WILLI`AM R h PATIENT 200800479 CARMEL 021508 350.00 350.00 280.00 �O.O( CARMEL 021508 68.75 68.75 55.00 13.7' TOTAL 83.7! AAR0 0 5- 21 910 7 105- AARPCK43- 00958 -001 -02594 UNITED HEALTH CARE If you have questions please contact us at: 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 1 OF 4 CARMEL FIRE DEPT* 2 CARMEL CIVIC SO CARMEL IN 46032 -7543 REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS STATEMENT DATE: APRIL 14, 2008 CHECK AMOUNT: $1,5G3.87 RECEIVED APR 2 2 Z111 For real -time access to claim, check, and member eligibility information please register online aV https: /aarpprovideroin inetool.uhc.com Please remember to sLI`',Tlit your claims on a timely basis. The certificate of insurance includes a time limit for submitting proof of loss. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. United Healtl7Care Insurance Compan} Health Care (and United HealtlhCare In Health C o Cornpany of News York for News York residents) are proud providers to Q 5 Please detach check below and cash promptly UNITED HEALTH CARE PO BOX 740819 62 ATLANTA, GA 30374 -0919 Citibank Delaware 311 One Penn's Way 1 1 1 242 5 0 6 New Castle, DE 19720 REPRESENTS :PAYMENT: FOR MULTIPLE INSUREDS DATE:: APRIL 14 2008 PAY:$ *1,563 *ONE THOUSAND FIVE HUNDRED SIXTY THREE DOLLARS AND .8 7 CENTS PAY TO THE ORDER OF CARMEL FIRE DEPT* 2 CARMEL CIVIC SO CARMEL <IN 46032 -7543 II <124.2506311 1 :03 3.8562 106 4 of 5 CARMEL FIRE DEPT PROVIDER ID NO: 1154325579 04/16/08 CHECK NUMBER: 0303874573 SERVICE DATE(S) SERVICE TOTAL INTEREST YED APR 2 2 ZW8 0.00 TOTAL NET AMOUNT DUE: MEDICARE SELECT 0.00 MEDICARE SUPPLEMENT SERVICE INSURED OTHER SERVICE DATE( S) POS CHARGE ALLOWED DEDUCTIBLE CO -PAY CO- INSURANCE CONTRACTUAL PROVIDER RESP. EXPUANSI RESPONSIBILITY EXPL /ANSI NET PAID CODES DIFFERENCE AMOUNT CODEIS) AMOUNT CODES) SERVICE DATE(S) SERVICE LLOWED DEDUCTIBLE CO -PAY CO- INSURANCE pOS CHARGE A CUMKn LIUnL rrcUVlUen near. ,�L RESPONSIBILITY NtI rAIU CODES DIFFERENCE AMOUNT c CO DEIS) AMOUNT �CODE(S) INSURED'S NAME: ARMBRUSTER,WILLIAM R INSURED'S ID: 757H53676 PATIENT NAME: ARMBRUSTER,WILLIAM R FOR INQUIRIES CALL: PATIENT ACCOUNT#: 200800479 CLAIM NUMBER: 080998249800 RECEIVED DATE: 04/08/2008 (800) 345 -4344 SERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: 1154325579 0211512008 0211512008 A0427RI1 41 350.00 70.00 0.00 0.00 0.00 0.00 0.00 0.00 70.00 02/15/2008 02/15/2008 A0425RH 41 68.75 13.75 0.00 0.00 0.00 0.00 0.00 0.00 13.75 TOTAL: 418.75 83.75 0.00 0.00 0.00 0.00 0.00 0.00 83.75 INTEREST PAID 0.00 AMOUNT PAID BY MEDICARE 335.00 TDIALNELP9I 81.25 AID 0416AI030122- 008358 ANTHEM INSURANCE COMPANIES, INC. 16772 A y� 7} yy DBA ANTHEM BLUE CROSS AND BLUE SHIELD nthem `m 1351 WILLIAM HOWARD TAFT ROAD CINCINNATI, OH 45206 -1775 1 of 5 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. (5 Registered Marks Blue Cross and Blue Shield Association 11IIIIII 'll'�Illtl'IIIIIIIII'lll #BWNCQXF N4428845679///DFS# I13 o CARMEL FIRE DEPT 2 CARMEL CIVIC SQ o CARMEL IN 46032 0 0 V N V O O W O r 0 N ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0303874573 DATE 04/16/08 P.O. BOX 37110 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7110 ADDRESS 2 CARMEL CIVIC SO CARMEL IN 46032 ta® ANTHEM.CDM PROVIDER ID NO 1154325579 TAX ID NO XXXXX0972 PAYMENT SUMMARY GROSS APPROVED CLAIM AMOUNT 303.73 r IRS WITHHELD 0_ 00 INTEREST PAID 0..00 I AMOUNT PREVIOUSLY OVERPAID 0..00 I AMOUNT DISBURSED 303.71 NET AMOUNT DUE 303..71 j RECOUPMENT BALANCE 0.00 tatmeaof tlamecm Iltial® DETACH CHECK AT PERFORATION BEFORE DEPOSITING 1 t�e�le E D. 19. BL ANTHEM INSURANCE COMPANIES, INC. BANK OF AMERICA CHECK NUMBER DBA ANTHEM BLUE CROSS AND UE SHIELD ATLANTA,- GEORGIA 0303874573 o 1351 WILLIAM HOWARD TAFT ROAD 0064- 1278/0611 m CINCINNATI; 014.4520671775 0416AI030122-008358 m 0005618 329977i7I38 r PROVIDER'ID NO TAX ID.NO DATE CHECK AMOUNT' 1154325579 XXXXX0972 7 04/16/08' #303.71 o om x" PAY EXACTLY #�3A3 ;DOLLARS AND 71 CENTS t^D> zz TOI:THE ORDER OF. O w 0X, z <ti F m CARMEL. FIRE. DEPT 2 CARMEL CIVIC SQ CARMEL IN 46032 INSURANtE PANIES, INC. Security features included. Details on back. 3 2 99 b 3auI' Date: 05/12/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: WILLIAM R ARMBRUSTER ICD -9: 8730 7806 78605 E8859 11813 SOMERSET WAY E CARMEL, IN 46033 From: 11813 SOMERSET WAY E To: ST. VINCENT INDPLS 1 MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200800479 YRR757M53676 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME, PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $418.75 $418.75 $0.00 CPT Date Description Charges Credits 02/15/2008 ADVANCED LI7E SUPP 1 -EMER A0427 $350.00 02/15/2008 MILEAGE A0425 $68.75 04/08/2008 MEDICARE PAYMENT $335.00 04/22/2008 BLUE SHIELD PAYMENT $83.75 04/22/2008 COMMERCIAL INSURANCE PAYMENT $83.75 05/12/2008 REFUND -83.75 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 FederalID# 356000972 Bill To: WILLIAM R ARMBRUSTER ICD -9: 8730 7806 78605 E8859 11813 SOMERSET WAY E CARMEL, IN 46033 From: 11813 SOMERSET WAY E To: ST. VINCENT- INDPLS 1 MEDICARE PART B Patient: WILLIAM R ARMBRUSTER 309165441A 11813 SOMERSET WAY E Insurance CARMEL, IN 46033 2 ANTHEM BC /BS/ 37010 Patient No: 200800479 YRR757M53676 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $418.75 $502.50 8 -83.75 CPT Date Description Charges Credits 02/15/2008 ADVANCED LIFE SURD 1 —EMER A0427 $350.00 02/15/2008 MILEAGE A0425 $68.75 04/08/2008 MEDICARE PAYMENT $335.00 04/22/2008 BLUE SHIELD PAYMENT S83.75 04/22/2008 COMMERCIAL INSURANCE PAYMENT $83.75 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 A ea l Purchase Order No. 2o)( 781 9 Terms II rr nn //jj r 4-Waj o 914 3o s7 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) rh b se O 3. a r Total O 7-5 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 P IN SUM OF 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 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund