159569 05/14/2008 CITY OF CARMEL, INDIANA VENDOR: 272800 Page 1 of 1
ONE CIVIC SQUARE RIVERVIEW HOSPITAL
1 CHECK AMOUNT: $50.00
CARMEL, INDIANA 46032 Po Box zzo
NOBLESVILLE IN 46060 CHECK NUMBER: 159569
CHECK DATE: 5/14/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340702 50.00 SHOTS INOCULATIONS
a
1 2 3a PAT. I id
RIVERVSEW- HOSPITAL .__.RIVERVIEW_HOSPITAL CNTLU 8002342.89 a
b. MED.
PO BOXT*20 PO BOX 220 REC.4 000333132 0131
5 FED TAX NO. 6 STATEMENT COVERS PERIOD 7
NOBLES IN 46061 NOBLESVILLE IN 46060 FROM THROUGH
(317) 776 -7363 (317) 776 -7433 351128943 04/22/2008 04/22/2008
8 PATIENT NAME a 9PATIENT ADDRESS a 10130 RUCKLE ST
b JABLE PATRICIA A t) I INDIANAPOLIS IN d 46280 e
10 BIRTHDATE 11 SEX ADMISSION 1 6 DHR 17 STAT CONDITION CODES 29 ACDT 30
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 2324 25 26 27 28 STATE
06/03/1951 F 0 /22/2008 08 3 1 23 01
31 OCCURRENCE 0 a 33 OCCURRENCE a 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE o o• CODE DATE o 'A=
CODE FROM THROUGH CODE FROM THROUGH
11 04/22/2008
e
38 39 VALUE CODES 41 VALUE CODES
POLICE DEPT, CARMEL CODE AMOUNT o0 o CODE AMOUNT
3 CIVIC SQUARE a
CARMEL IN 46032 b
c
d
42 REV. CO. 43 DESCRIPTION 44 HCPC5I RATE HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49
1 0636 DRUGS REQ DETAILED CODING 90746. 04/22/2008 1 50.00
2 2
3 3
1 4
6 5
6 6
7 7
B 6
9 9
16 0
11 11
12 12
$3 r 13
14 q 14
45 FS
16 16
17 17
1B 16
19 19
20 20
21 21
22 22
nnni PAGE OF CREATION DATE 0.4/_28/_20.0.8 50.00 0.00 23
50 PAYER NAME 51 HEALTH PLAN ID 11 RI ll Es 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
13- 00.823.211
A WORK MED Y Y 50.00 57 351128943 A
w OTHER a
c PRV ID c
56 INSURED'S NAME 59 RREL 60INSURED'S UNIQUE ID 61 GROUP NAME 62. INSURANCE GROUP NO,
0.
JABLE, PATRICIA 08 320422719
e B
c c
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
A A
B B
C
66 68
DX
69 ADMIT 70 PATI ENT 71 PPS 72 1 73
DX REASON DX CODE I ECI
74 PRINCIPAL PROCEDURE a -a w 6, OTHER PROCEDURE
CODE DATE oo a CODE DATE 76 ATTENDING NPI DUAL
OB 710A.0.4A0
LAST FIRST
d. OTHER PROCEDURE
CODE DATE 77 OPERATING NPI OVAL
9 o� o�
LAST FIRST
80 REMARKS 81 C a 78 OTHER NPI
WORK -MED DUAL
3 -CIVIC -SQUARE d LAST FIRST
c 790THER NPI DUAL
d LAST FIRST
U B 114 U A-
-R IN Sp
60 A F OMB NO.093 &0997 printed Orl Recycled Paper Ni]Re- TFP24394689 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
BILLER REP: SHARON PIERCE
US-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATiON
OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR
CIVIL MONETARY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE
FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S),
Submission of this clairn constitutes certification that the billing (b) The patient has repre, that by a reporteci residential address
information as shown on the face hereof is true, accurate and complete. outside a military rnedicai treatment facility catchment area h.e or
That the submitler did not knowingly or recklessly disregard or she does not live within the catchment area of a U.S. rniota"i
misrepresent or conceal material facts. The following certifications or medical treatment facility, or H the patient resides within a
verifications apply where pertinent to this Bill: catchment area of such a facility, a copy of Non-Avai;ab,*,;
Statement (DD Form 1251) is on file, or fire physician has cpahfled
I if third party benefits are indicated, the appropriate assignments by
the insured /beneficiary and signature of the patient or parent or a to a medical emergency in any inslance where a copy of a Non-
Availability Staienieni is root or: ffile.; l egal guardian covering authorization to release information are on file.
Determinations as to the release of medical and financial information (c) The patient or the patients parem or guardian has responded
should be gLlldad by the patient of the patient's legal representative, directly to the provider's request to identify all health Insurance
2. if patient occupied a private roorn or required private nursing for coverage. ana that ail such (aveiage is identified on the "ace of
the clairn except that coverage wh is excliisiveiy supplemental
ryiiedicai necessity, any required certifications are on file. payments, to TR i (,A R E -de lcii ml r ib e�ncfl t
3 Phvskian's ce ar�d if required by contract (dr The amount billed to fIas Leevi ac: suc).
or Federal regulations, are on file. coverage have been, billed and paid eXClLjJ'TQ MKdicaia,and the
4, For Religious Non-Medical facilities, verifications and if necessary re.. amount filled to TRICARE is that remaining ciaim.ed against
certifications of the patient's need for services are on file. TRICARE b enefits;
5. Signature of patient or his representative on certifications, (e) The beneficiary's cost share has not been waived by consent or
authorization to release information, and payment request, as failure to exercise generally accepted billing and collection efforts;
required by Federal Law and Regulations (42 USC 1935f, 42 CFR and,
424.36, 1 D USC 1071 through 1086, 32 CFR 199) and any other (f) Any hospital -based physician under contract, the co_-t of whose
applicable contract regulations, is on file. services are allocated in the charges includad in flair bill, is not an
6. The provider of care submitter acknowledges that the bill is in employee or nierriber of the Uniformed Servicas.'r purpc5e5 of
conformance with the Civil Rights Act of 1964 as amended. Records this certification, an employee of th e Unilornied Services is an
adecluatejy describing services will be maintained and necessary employee, appointed In civil service (refer to 5 USC 2105
information will be furnished to such governmental agencies as including part-time or internnittei enniploye:es. but excluding
required by applicable l3vv. contract surgeons or other personal service contracts. Similarly,
rnember o, the Uniformed Servico�.- does not apply to reserve
7. For Medicare Purposes: If the patient has indicated that other health
insurance or a state medical assistance agency will pay part of members of the Uniforrried nut On a.0tive duly-
his. medical expenses and he!she wants information about (g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
hisiber claim released to them upon request, necessary authorization participating in Medicare rnus, also participate in TF:JCAI_-1E_ tor
is on file. The patient's signature on the provider's request to bill inpatient hospital services provided r_ to admissions to
Medicare medical and non-medical infori including hospitals occurring on or after January 1 987; and
ernploy status, and whether the person has employer group CARE benstits are to be paid in a paficipating sfah s. t,
p (h) If T I
lheaft� insurance which is responsible to pay for the services for submitter of fihis claim agrees to sLbm';' this clainn to, the
this Medicare claim is made. appro TRIZARE claims processor. The pr(,)vi.derL_,f cue
8 For Medicaid purposes: The subrnitter understands that because submitTer also agrees to accept the THICAHE decerminco
arld ��atisfacticx o�� this, cla�?nn %A41 be from Fedeml and ST ate. reasonpN� charge_Is the
ii-incA any faise stmernents, oocurnents, or conceatment of a supplies listedor, ;heclainn :ii
material fact are subject to prosecution under applicable Federal or the TRICARE-determined reasonable charge even 4 it is iess
State, Laws_ than the billed amount, and also agrees to accept III amount
paid by TRICARE combined with the cost-share amount and
9. For TRICARE Purposes: deductible amount, if any, paid by or on bap half of The patient as
(a) The information on the face of this claim is true, accurate and full payment for the listed medical services or supplies. The
complete to the best of the submitter's knowledge and belief, and provider of care subirniiter will not atierript to c.oiiect from the
services were medically necessary and appropriate for the health patient (or his or her parent or guardian) arnounTs over the
of the patient; TRICARE determined reason cable charge. TRICARf-_ %,Mli make
any benefits payable directly to the provider of care, if the
provider of care is a participating prcividier.
SEE FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS
Prescribed by State Board of Accounts City Form No. 241 (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
Riverview Hospital Purchase Order No.
P.O. Box 220 Terms
Noblesville, IN 46061 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4/22/08 payment for hepatits b shot for Pat Jable 50.00
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
R iverview Hospital IN SUM OF
P.O. BOX 220
Noblesville, IN 46061
50.00
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
o�pT. I hereby certify that the attached invoice(s), or
1110 407 02 50.00 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
May 8 20 08
Signature
Chief of Police
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund