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Home My WebLink About163326 09/03/2008 CITY OF CARMEL, INDIANA VENDOR: 361780 Page 1 of 1 ONE CIVIC SQUARE RICHARD NORMAN CHECK AMOUNT: $367.76 CARMEL, INDIANA 46032 4411 DEERVIEW COURT INDIANAPOLIS IN 46268 CHECK NUMBER: 163326 CHECK DATE: 9/3/2008 D EPARTMENT ACCOUNT PO NUMBER INV OICE NUMBER AMOUNT DESCRIPTION 102 5023990 367.76 AMBULANCE REFUND I I i I Date: 08/20/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: RICHARD A NORMAN ICD -9: 78039 78009 2930 7850 4411 DEERVIEW CT INDIANAPOLIS, IN 46268 From: 101E 103RD ST To: ST. VINCENTS HOSPITAL 1 ANTHEM BC /BS/ 37010 Patient: RICHARD A NORMAN CDJ4010843700 4411 DEERVIEW CT Insurance INDIANAPOLIS, IN 46268- 2 Patient No: 200801613 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 $375.00 $742.76 367.76 CPT Description Charges Credits 06/26/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 06/26/2008 MILEAGE A0425 $25.00 07/25/2008 PAYMENT $375.00 08/19/2008 COMMERCIAL INSURANCE PAYMENT $367.76 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/20/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 ACCOUNT..HISTORY Bill To: RICHARD A NORMAN ICD -9: 78039 78009 2930 7850 4411 DEERVIEW CT INDIANAPOLIS, IN 46268 From: 101E 103RD ST To: ST. VINCENTS HOSPITAL 1 ANTHEM BC /BS/ 37010 Patient: RICHARD A NORMAN CDJ4010843700 4411 DEERVIEW CT Insurance INDIANAPOLIS, IN 46268- 2 Patient No: 200801613 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 $375.00 $375.00 $0.00 CPT Date Description Charges Credits 06/26/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 06/26/2008 MILEAGE A0425 $25.00 07/25/2008 PAYMENT $375.00 08/19/2008 COMMERCIAL INSURANCE PAYMENT $367.76 08/20/2008 REFUND 367.76 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 812 74 0225392 RICHARD A- NORMAN 4411 ,DEERVIEW'CT. PH; 317-228-0918 DATE ,NDIANAPoCIS w PAY TO THE J' J Gtr DOLLARS IJ a ORDER OF is �N' �1 a v) v� A NP 7pMorgan Chase Bank, N.A. I Indiana 4627T ndianapolis MEMO r.- www .Ghase,c 0 m 0 2= 2- 53;9.2 -�.3 I INDEPENDENCE BLUE CROSS 1901 MARKET STREET 081 1 UCDS01010001327 PHILADELPHIA, PA 19103 -1480 PAGE 1 OF 2 a Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and OCC Ins. Co., and with Highmark Blue Shield Independent Licensees of the Blue Cross and Blue Shield Association Code: BC 000577 Provider ID: 0445919000 CARMEL FIRE DEPT AMBULANCE 2 CIVIC SQ Please visit our website: www.ibx.com CARMEL IN 46032 -2584 PPO: 1 -800- 332 -2566 HMO: 1 -800- 227 -3119 CHECK NBR 3103813314 DATE 8/11/2008 AMOUNT $367.76 PAYMENT SUMMARY NET CLAIM AMOUNT $367.76 TOTAL AMOUNT DISBURSED $367.76 FOR ANY DRG RELATED pUESTIONS, PLEASE CONTACT YOUR NETWORK COORDINATOR NPI: SHARE YOUR NPI WITH PAYERS, BILLING COMPANIES, AND CLEARINGHOUSES PRIOR TO THE MAY 23 COMPLIANCE DATE TO AVOID DISRUPTION IN CASH FLOW. REMINDER: ALWAYS USE YOUR COMPLETE 10 -DIGIT PROVIDER IDENTIFIER WHEN SUBMITTING CLAIMS. RECEIVED AUG 1 9 Z= I IIIIII VIII VIII VIII VIII III I Ilil Independence Blue Cross offers products directly, through its subsidiaries 60 162 Keystone Health Plan East and OCC Ins. Co., and with Highmark Blue Shield 433 Independent Licensees of the Blue Cross and Blue Shield Association DATE CHECK NUMBER INDEPENDENCE. BLUE CR9 8/11 31 /2008 .038.1.33 K SHELL IS PRINTED ON WHITE PAPER WITH A 19o1'MdRKET STREET BLUE SCREEN. REVERSE SIDE HAS A WATERMARK. g PHILADELPHIA }PA 19103 =1480 PAY TO' CARMEL FIRE DEPT :AMBULANCE 5 THE' 2 CIVIC SO VOID 6 MONTHS FROM ISSUE DATE ORDER' bF CARMEL" IN 46032 -2584 PAY EXACTLY THREE HUNDRED SIXTY SEVEN AND 76/100 DOLLARS PNC BANK, NATIONAL ASSOCIATION JEANNETTE, PA AUTF&IZE15 11 310381331411' 1:04330L6271: LO 1728679L 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 I'M m a.p Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) r -0 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. h ALLOWED 20 IN SUM OF /7Z/ e-1 8(07- 7!� 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 AUG 2 9 2008 20 S1ignAf Ti Title Cost distribution ledger classification if claim paid motor vehicle highway fund