156270 02/06/2008 CITY OF CARMEL, INDIANA VENDOR: T360780 Page 1 of 1
ONE CIVIC SQUARE TERRI NASH
CARMEL, INDIANA 46032 5302 IVY HILL DR CHECK AMOUNT: $41.00
CARMEL IN 46033 CHECK NUMBER: 156270
CHECK DATE: 2/6/2008
DEPARTMENT A CCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
j 102 5023990 41.00 OTHER EXPENSES
I
I
Date: 01/18/2008
CARMEL FIRE DEPARTMENT r
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
Bill To: RICHARD NASH ICD -9: 78650 78605 7851
5302 IVY HILL DRIVE
CARMEL, IN 46033
From: 5302 IVY HILL DR
To: INDIANA HEART HOSPITAL
1 UNITED HEALTH INS130555
Patient: TERRI L NASH 804432963
5302 IVY HILL DRIVE Insurance
CARMEL, IN 46033 2
Patient No: 200702168
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$410.00 $410.00 $0.00
CPT
Date Description Charges Credits
09/2-7/2007 ADVANCED LIFE SUPP 1 7 -ME,R A0427 $350.00
09/27/2007 MILEAGE A0425 $60.00
12/11/2007 COMMERCIAL INSURANCE PAYMENT 5369.00
12/21/2007 PAYMENT 541.00
01/15/2008 COMMERCIAL INSURANCE PAYMENT 541.00
01/18/2008 REFUND -4 OG
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
APPRUVED BY 1 HL 6 1 A 1 t BUAKU Ur AUUUUNI 5 F UI I Y OF OARMEL, 1 999
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RICHARD M. NASgi 2 8152/2710 83 .3
TERRI LEA NASH
5302 NYHILLDR. PH.317 346 597
CARMEL, IN 46033
Pay ro
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V5- 01443 *01 *003407 -PO- 08007 -BO- 354 -CN 110
CFPA20- 070705
UNITED HEALTHCARE INSURANCE COMPANY
SPRINGFIELD SERVICE CENTER �initedliealthcare
P 0 BOX 30555
N UnrzedHealfn Grow Comm
SALT LAKE CITY, UT 84130 -0555
PHONE: 1 -877- 842 -3210
DATE: 01/07/08
TI 35- 6000972
NP I 1154325579
GROUP 0189391
GROUP NAME: AAR CORP
CHECK NUMBER: UT 60698960
CHECK AMOUNT: 541.00
CARMEL FIRE DEPT AMBULANCE SVC
CARMEL FIRE DEPT AMBULANCE SV PROVIDER
2 C SQ EXPLANATION
CARMEL IN 46032
PATIENT DETAIL
PRODUCT MEM. ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER
NAME i REL i ACCOUNT NAME NUMBER (RECEIVED OF SERVICE
SEL /EP+ 80 TERRI NA.Cf) I.Sp 200702169 RICHARD NASH IO175R657505— OiIf1119107 CARMEL FIRE DEPT AMBU
SERVICE DETAIL
PATIENT !DATES OF DESCRIPTION AMOUNT NOT PROV ADJ AMOUNT DEDUCT! PLAN PAID TO RMK PATIENT
NAME iSERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED I COPAY 1COV PROVIDER, I CD RESP.
TERRI 09127107 AMBULANCE 350.00 350.00 100% 350.00 22
HASH 09127107 AMBULANCE 60.00 60.00 100"5 60.00 22
09/27/07 AMBULANCE 369.00 —369.00 100% 369.00 22
SUBTOTAL 41.00 41.00 41.00 22
TOTAL PAID TO PROVIDER $41.00
REMARKS
(22) WE HAVE RECEIVED MORE INFORMATION AND RECONSIDERED THESE CHARGES.
Detach Check Detach Check
5o -217
The Chase Manhattan Bank z
.UNITED HEALTHCARE INSURANCE COMPANY Syracuse NY
SPRINGFIELD SERVICE CENTER UT 6 0 8
P G .BOX .30555
SALT LAKE'C. UT 84130 -05S5 DATE Oi, SOS
PHONE: 1- 877 -842 -3210
VS- 01443 003407- PO-08007 -BO- 359 CH 110 PLEASE PRESENT PROMPTLY FOR PAYMENT
CONTRACT.: 189391 PAY *4j, ()o
*FORTY ONE 00/100 DOLLARS
PAY CARMEL FIRE DEPT AMBULANCE SVC
TO 'THE CARMEL FIRE DEPT AMBULANCE SV
2'CIVIC SQ
ORDER OF CARMEL IN 46032
AUTHORIZED SIGNATU
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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.
Payee
i' Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
lieri- Qsti
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
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
20<
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund