155491 01/10/2008 CITY OF CARMEL, INDIANA VENDOR: 272800 Page 1 of 1
ONE CIVIC SQUARE RIVERVIEW HOSPITAL
li CHECK AMOUNT: $2,015.00
CARMEL, INDIANA 46032 Po Box zzo
a NOBLESVILLE IN 46060 CHECK NUMBER: 155491
CHECK DATE: 1110/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
5023990 S11005 122007 2,015.00 HEPATITS VACCINES
��t
RIVERVIEW HOSPITAL
PO BOX 220 12/20/07 OP 0270
NOBLESVILLE, IN 46061
CARMEL, CITY OF 800188978 U 07M 05/09/07 12/12/07 12/12/07 FINAL
CARMEL UTILITIES, CITY OF WORK MED
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
DETAIL OF CURRENT CHARG
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
CHRISTOPHER A. STUBBS
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
E. CRAIG CARTER
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JORDAN KLEINSMITH
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
RANDY MASSINGILL
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
ROBBIE KINKEAD
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
DAVID L. DYE
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JOSEPH FAUCETT
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
MICAH W. BECK
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
TERESA LEWIS
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
PAUL ARNONE
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
DARRYL BELL
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
CALVIN L. COOPER-JR.
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
NORMAN D. RILEY
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
GARY D. LAFOLLETTE
12/12/07 WORK REL HEPATITIS A'VACC(AD 90632 48800882 1 65.00
W. EDWARD WOLFE
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
DAVID W. HUMPAL
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
800188978 12/20/07
RIVERVIEW HOSPITAL
PO BOX 220 12/20/07 OP 0270
NOBLESVILLE, IN 46061
CARMEL, CITY OF 800188978 U 07M 05/09/07 12/12/07 12/12/07 FINAL
CARMEL UTILITIES, CITY OF WORK MED
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
LARRY L. EIDSON
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
RALPH E. GRUWELL
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
ERIC S. ROBINSON
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
PETER R. BRENNAN
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
HAROLD B OLIVER
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JEFF KOZLOVICH
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
DENNIS RUSS
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JEFFREY W. COOPER
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
KEVIN BUHMANN
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
BART CHAFIN
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
LARRY D. SCHIMMEL
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
LONNIE J. PATTON
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
GREGORY A EPP
12/12/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
AARON HOOVER
12/13/07 WORK REL HEPATITIS A VACC(AD 90632 48800882 1 65.00
JON L. OSBORN
800188978 12/20/07 2015.00
RIVERVIEW HOSPITAL
PO BOX 220 12/20/07 OP 0270
NOBLESVILLE, IN 46061
CARMEL, CITY OF 800188978 U 07M 05/09/07 12/12/07 12/12/07 FINAL
CARMEL UTILITIES, CITY OF WORK MED
9609 HAZEL DELL RD
ATTN: TERESA LEWIS
INDIANAPOLIS, IN 46280
HANRAHAN, ELIZABETH J
SUMMARY OF CHARGES 2015.00
PHARMACY 2015.00
SUB -TOTAL OF CHARGES 2015.00
PAYMENTS /ADJUSTMENTS NONE
SUBTOTAL PAYMENTS /ADJUS NONE
BALANCE 2015.00
800188978 12/20/07 2015.00
1 2 3a PAT.
._RIVERVIEW_HOSP_I.TAL CNTL4 8 -0- 018-8 9 7 Ig
b. MED.
PO'-BOX-220 REO. 0- 0- 03 -2.5 6 5.6
o STATEMENT COVERS PERIOD 7 01 Al
NOBLESV _ILLE___.._.IN_._4 5 FED. TAX NO. .6.0 -6.1- FROM THROUGH
8 PATIENT NAME a 9 PATIENT ADDRESS a
6- 09— HAZEL_D- ELL_RD
b CARM-EL,, ADMISSION IND-IANAP- OL.I.S CONDITION CODES 1 1 1 29 ACCT 3 e
10 BIRTHDATE 11 SEX 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE
05-09- 2.0.0_7
31 OCCURRENCE v j 1 X 4 5 9 N 33 OCCURRENCE 0 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE o0 0• CODE DATE o0 0 CODE FROM THROUGH CODE FROM THROUGH
1 12120
b
38 39 VALUE CODES m 00 41 VALUE CODES
CITY CODE AMOUNT 00 o CODE AMOUNT
9609 HAZEL DELL RD a 81 100
INDIANAPOLIS, IN 46280 b
C
d
42 REV. Co. 43 DESCRIPTION 44 HCPCS l RATE HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON COVERED CHARGES 49
0636 DRUGS /DETAIL CODE 90632 121207 30 1950.00
2 0636 DRUGS /DETAIL CODE 90632 121307 1 65:00 2
3 3
4 4
5 5
fi 8
7 7
B 8
9 B
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 /8
19 19
20 2D
21 21
22 22
t3 PAGE OF CREATION DATE
REL 59450 IL-2
50 PAYER NAME 51 HEALTH PLAN ID INFO BEN. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NW 1�0 -n o o' 7
A WORK MED Y Y 57 351128943 A
B OTHER B
c w PRV ID c
58 INSURED'S NAME 59 P. REL 60 INSURED'S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.
A CARMEL CITYOF 2 351128943 A
B e
L c
63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME
A
B B
c c
66 68
DX N 7 0 -5-3
09 ADMIT 70 PATIENT 71 PPS 72 73
DX C REASON DX CODE EG
74 PNINurAL PROCEDURE E6 0 o o b. OTHER PROCEDURE
CODE DATE ob 5 CODE DATE 76 ATTENDING NPI QUAL
AT
IS o o o d. OTHER PROCEDURE
0 9 o CODE DATE o 0 77 OPERATING NPI DUAL
LAST FIRST
80 REMARKS 81 CC 78 OTHER -PI DUAL
W WM3- WM- WM- S- WM -1 a B-3-2-8-2-N-0-0-000
WORK —MED b LAST FIRST
c 790THER NPI DUAL
d LAST FIRST
UB-04 CMS -1450 APPROVED OMB NO, 0938-0997 Printed on Recycled Paper 'NUBC` TFP24394669 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
PRINTED: 12/20/07 PAGE: 240 PRINTED BY: TJG
LIB -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 claim constitutes certification that the billing (b) The patient has represented that by a reporied residential address
information as shown on the face hereof is true, accurate and complete. outside a military medical treatment facility catchrnent area he or
That the submitter did not knowingly or recklessly disregard or she does not live within the catchment area of a U.S. military
mi:.srepresent or conceal n aterial facts. The following certifications or medical treatment facility, or if the patient resides within a
v�-rifications apply where pertinent to this Biii: catchrnent area of such a faciiity. a copy of Non .Availability
Statement (DD Form 1251) is on file, or the physician has cerlified
1. If third party ncnrfiis are indicated, the appropriate assignments by to a medical emergency in any instance where a. copy of a Non
the insured /beneficiary and signature of the patient or parent or a Availability Statement is not on tile;
iegal guardian covering authorization to release information are on file.
Determinations as to the release of nedica! and financial information (c) The patient or the patient's parent or guardian has responded
should be guided by the patient or the patient's legal representative. directly to the provider's request to identity all health insurance
coverage, and that all such coverage is identified on the face of
2. if patient essi a private room or required private nursing for the claim except that coverage which is exclusively supplemental
medical neccessity, any required certifications are on file. payments to TRICARE determined benefiis
3 f-t ySiclI -i h s ce Ifi cations nd re cer ific,:7"t )ns, if io ui(erj icy CGntrelC': j T flB artf'V7r.i�''t 1);i! d tiJ !R It',Ai''sL hay b een F1111c1t attic' alr >UCr1
Federal rer.Ir.Aaticns, are can file. coverage have been billed and paid exciuding Medicaid, and the
4. For Religious Non Medical facilities, verifications and if necessary re- amount billed to T RICARE is that remaining claimed against
certifications of the patient's need for services are on file. TRICARE benefits;
5. Signature of patient or his representative on certifications, (e) The beneficiar cost share has not been 1.vaived 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, 10 USC 1071 through 1086, 32 CFR 199) and any other
applicable contract regulations, is on file. (f) Any hospital-based physician uradsr coritrac{;;the cost of whose
services are allocated in the charges included in this bill, is not an
6. The provider of care submitter acknowledges that the bill is in employee or member of the Uniformed Services. For purposes of
conformance with the Civil Rights Act of 1964 as amended. Records this certification, an employee of the Uniformed Services is an
adequately 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 intermittent emp!oyees, but excluding
required by applicable iaw. contract surgeons or other personal service contracts. Similarly,
member of the Uniformed Services does not apply to re serve
7. For Medicare Purposes: If the patient has indicated that other health members of the Uniformed Services not on active duty.
insurance or a state medical assistance agency will pay part of
his/her medical expenses and he /she wants information about (g) Based on 42 United States Code 1395cc(a);1)(j) ail providers
his. /her claim released to them upon request, necessary authorization participating in Medicare must also participate in TRICARE for
is on file. The patient's signature on the provider's request to bill inpatient hospital services provided pursuant to admissions to
Medicare medical and non medical information, including hospitals occurring on or after January 1, 1987; and
employment status. and whether the person has employer group (h) If TRICARE_ benefits are to be paid in a participating status, the
health insurance which is responsible to pay for the services for subnitter of this claim agrees to submit this claim to the
which this medicare claim is n-rade• appropriate "TRiCARE claims processor. The provider of care
8. For Medicaid purposes: The submitter understands that because subrriitter also agrees to accept the TRICARE. deterrnincd
payment and satisfaction of this claim will be from Federal and State reasonable charge as the total ch v far the media +I serv:,r
funds, any false statements. documents, or concealment of a supplies listed on 111e c;aim form,. i t1e provkjer of car'P ,v!q acceN
rrafsoai fact are subi -A U? presec ;st!or! ur;der applicable Federal or the TRICARE determined reasonable charge even if it is less
tf y than the billed amount, and also agrees to accept the amount
paid by TRICARE combined with the cost share amount and
9. ForTRICARE Purposes: deductible amount, if any, paid by or on behalf 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 submitter will not attempt to collect from the
services were medically necessary and appropriate for the health patient (or his or her parent or guardian) amounts over the
of the patient; TRICARE determined reasonable charge. TRICARE will make
any benefits payable directly to the provider of care, if the
provider of care is a participating provider.
SEE ho��. /www.nubc FOR MORE INFORMATION ON UB -04 DATA ELEMENT AND PRINTING SPECIFICATIONS
Dear_ Work Med Company,
Attached is a claim for services rendered. We are requesting
prompt payment at this time. Please reference the patient control
number on the check or attach a copy of the claim.
If you have any questions regarding this bill, please call me at
317 776 -3851.
Sincerely,
Christine Sheeks
Riverview Hospital Occupational Health
VOUCHER 077006 WARRANT ALLOWED
272800 IN SUM OF
RIVERVIEW HOSPITAL'
"PO BOX 220
NOBLESVILLE, IN 46061
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
122007 01- 7040 -01 $585.00
122007 01- 7042 -05 $1,430.00
O�
e�
Voucher Total $2,015.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER s
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 12/29/2007
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/29/200; 122007 $2,015.00
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
i
Date Officer