162484 08/07/2008 CITY OF CARMEL, INDIANA VENDOR: 272800 Page 1 of 1
ONE CIVIC SQUARE RIVERVIEW HOSPITAL
CARMEL, INDIANA 46032 PO Box 220
CHECK AMOUNT: $130.00
NOBLESVILLE IN 46060
CHECK NUMBER: 162484
CHECK DATE: 8/7/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AM OUNT DESCRIPTION
651 5023990 130.00 OTHER EXPENSES
i
Account Number: 800252904 Page 1 of 1
Patient Name: City Of Carmel
Riverview 395 Wesffield Road Statement Date: 07/18/08
s�r cal Noblesville, IN 46060 Amount Due Now: $130.00
Due Date: 07/28/08
Account Balance: $130.00
Patient Accounts Office
(317) 776 -7141
Office Hours
*0 -1733 Riverview Monday through Friday
2 CITY OF CARMEL UTILITIES 11 8:00 a.m. 4:30 p. m.
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
INDIANAPOLIS, IN 46280 Your account is now past due. Please send payment
in full. If you have any questions contact Riverview
Customer Services at 317 776 -7141.
PAST DUE
For Workmed services you received on 6/12/08. As a patient of Riverview
Payments/ Hospital, you expect the finest
Date Description Charges Adjusts Balance level of health care. You have
many choices for your health
ACCOUNT BALANCE 130.00 care needs and we want to
thank you for choosing us.
We hope that our services
exceeded your expectations.
Riverview Hospital does
expect payment in full upon
receipt of your first statement.
If you are unable to meet this
obligation, we offer a variety of
options to assist you. These
options are listed on the
reverse side of this statement.
We rely on you to contact us
immediately if payment in full
will not be made.
Additional important information continued on reverse side-
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Payu nennt Tams
In accordance with Riverview Hospital policy, we are able to offer our patients the following
payment options for your convenience.
Payment in full within 30 days of receipt of statement
Four equal monthly installments no interest
For those needing long term payment options, we offer medical financial contracts
Physician Fees
If you receive radiology, emergency, anesthesia, or pathology services, you will receive a
separate statement from the physician.
Hnnsu it nncce Benefits
If you have questions regarding your insurance benefits or how your insurance company
processed your claim, please contact your insurance company.
Patient Accounts Office IH ou irs
If you have questions concerning your account, you may call Patient Accounting at
(317) 776 -7141. Office Hours are Monday Friday between the hours of 8:00 a.m. and
4:30 p.m. (excluding holidays).
Notice: There will be a $20.00 charge for all checks
returned for non suff icient funds.
Thank you for choosing Rluertliew 1 for i henTthom i7ceds
RIV -501 (05108)
Jul 29 08 03:07p p. 2
RIVERVIEW HOSPITAL
PO BOX 220 07/28/08 OP 0270
NOBLESVILLE, IN 46061
CARMEL, CITY OF 800252904 U 13M 05/09/07 06/12/08 06/12/08 FINAL
CARMEL UTILITIES, CITY OF
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
DETAIL OF CURRENT CHARG
06/12/08 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
TERESA LEWIS
06/12/08 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JEFF KOZLOVICH
TOTAL PHARMACY 130.00
800252904 07/28/08 130.00
Jul 29 08 03:08p p,3
RIVERVIEW HOSPITAL
PO BOX 220 07/28/08 OP 0270
NOBLESVILLE, IN 46061
CARMEL, CITY OF 800252904 U 13M 05/09/07 06/12/08 06/12/08 FINAL
CARMEL UTILITIES, CITY OF
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
=IANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
SUMMARY OF CHARGES
PHARMACY 130.00
SUB -TOTAL OF CHARGES 130.00
PAYMENTS /ADJUSTMENTS NONE
SUBTOTAL PAYMENTS /ADJUS NONE
BALANCE 130.00
800252904 07/28/08 130.00
T
✓OUCHER 08601 -5 WARRANT ALLOWED
?72800 IN SUM OF
RIVERVIEW HOSPITAL
'O BOX 220
gOBLESVILLE, IN 46061
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
'O INV ACCT AMOUNT Audit Trail Code
061208 01- 7042 -05 $130.00
dI
t
Voucher Total $130.00
;ost distribution ledger classification if
Jaim paid under vehicle highway fund
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
272800
RIVERVIEW HOSPITAL Purchase Order No.
PO BOX 220 Terms
NOBLESVILLE, IN 46061 Due Date 7/29/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/29/2008 061208 $130.00
r
iereby certify that the attached invoice(s), or bill(s) is (are) true and
xrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer