165884 11/12/2008 CITY OF CARMEL, INDIANA VENDOR: T362163 Page 1 of 1
0 ONE CIVIC SQUARE MOLLY MORRILL
CARMEL, INDIANA 46032 2535 DEARBORN ST CHECK AMOUNT: $20.00
LAKE STATION IN 46405
CHECK NUMBER: 165884
CHECK DATE: 11/12/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 20.00 REFUND
Date: 11/05/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federat lD# 356000972
OU N
Bill To: MOLLY MORRILL ICD -9: 92401 92400 7295 71945
2535 DEARBORN ST
LAKE STATION, IN 46405
From: 20 3RD AV SW
To: ST. VINCENT CARMEL
MEDICARE PART B
Patient: MOLLY MORRILL 405367192A
2535 DEARBORN ST Insurance
LAKE STATION, IN 46405- 2
Patient No: 200801465
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$306.25 $306.25 $0.00
CPT
Date Charges Credits
Description
06/11/2008 BASIC LIFE SUP EMERGENCY A0429 $300.00
06/11/2008 MILEAGE A0425 $6.25
10/10/2008 PAYMENT $20.00
10/21/2008 MEDICARE PAYMENT $244.83
10/21/2008 ASSIGNMENT MEDICARE $0.21
10/31/2008 ASSIGNMENT MEDICAID $61.21
11/05/2008 REFUND -20.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 1V31/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
ACCOUNT HISTORY
Bill To: MOLLY MORRILL ICD -9: 92401 92400 7295 71945
2535 DEARBORN ST
LAKE STATION, IN 46405
From: 20 3RD AV SW
To: ST, VINCENT CARMEL
1 MEDICARE PART B
Patient: MOLLY MORRILL 405367192A
2535 DEARBORN ST Insurance
LAKE STATION, IN 46405- 2
Patient No: 200801465
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$306.25 $326.25 -20.00
CPT
1`hr 14 iF C se l.H, �e ytl`�AFk9 A i f
yt v ..,Fl
,E. Descrrptlon
zr Credits
R s- i ts, r.. lea. rv. :v, q f' ��a R,.. l r a..:t' ?t; r .t i�� cslF�: s:: a —Y: ;��5fi �.�r,.,
06/11/2008 BASIC LIFE SOPP- EMERGENCY A0429 $300.00
06/11/2008 MILEAGE A0425 $6.25
10/10/2008 PAYMENT $20.00
10/21/2008 MEDICARE PAYMENT $244.83
10/21/2008 ASSIGNMENT MEDICARE $0.21
10/31/2008 ASSIGNMENT MEDICAID $61.21
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
MEDICARE PART B INDIANA MEDICARE PART B PROVIDER REPORT_
NATIONAL GOVERNMENT SERVICES, INC.
P.O. BOX 240
INDIANAPOLIS, IN 46206 CHECK DATE 10/16/08
CHECK NUMBER 123164606
CHECKAMOUNT *9,579.66
PROVIDER NUMBER 1154325579
1000156 MBIDRS2 01571 0000158
CARMEL FIRE DEPARTMENT
2 CARMEL CIVIC SQ
CARMEL, IN 46032 -7543
E D ��,ocr 2, zoos ;x
a 0 0 6
74-1292
;MEDICARE PART B
NATIONAL GOVERNMENT SERVICES„ INC 724
INDIAN- APOLI$ IN 46206 c>S+r�rxs i�aicarf6?uEnrcaosE,eurfs
mEDICAR P"MENT
JPM6r0 Chase Bank C OIUI7lhU5 FOR HEALTH fNSURANCE SOCIAL SECURITY ACT
Columbus, Ohio L 031.64$37
P,AY TO :THE ORDER OF
CAR.MEL FIRE D aROViDER No CHECK.NO
2 �'CARMEL `GTVIC 1154,325579 I`23i6'4606
CARMEL, IN 4;603 -7543 Mo DAY YEAR DOLLARS
.161 *9,579 66
VOID 12 MONTHS FROM :ISSUE',DATE
0 5 ❑311 837 1.0 2t, 129 271: E411.38L,37lip
Electronic Remitance Information
PrintDa�e: 10121108 (EOB) Explanation Of Benefits (EOB)
Payor Id: 00630 Production Date: 10/16/08 Receiver Id No: Z6CX
Payer Information:
NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: 1351840597
PO BOX 6160
INDIANAPOLIS IN 462066160
Payer Contact Info:
PROVIDER ENROLLMENT
($66)250 -5665 TE
Receiver Info:
CARMEL FIRE DEPARTMENT Payee Id: 1154325579
2 CARMEL CIVIC SQ
CARMEL IN 460327543
Payment Info:
Check I EFT Trace No: 123164606 7 3 a y
�TotalPaymentAmount $9,57966
Check Issue Date: 10/16/08
Payment Method: Check
Pt No Patient Name Service Date Procedure Code Line Charge Allowed Total Billed Allowed Pt. Responsible Paid
200801465 MORRILL MOLLY 405367192A 06/11/08 A0429 RH 300.00 239.83 306.25 306.04 61.21 244.83
Claim Control 11082770$0740
A0425 RH 6.25 5.00
Claim Status: Processed as Primary
Claim Remark Codes: MA01, MA07,
Claim Adjustments: Total Adjustments
Patient Responsibility Coinsurance Amount 1.25
Patient Responsibility Coinsurance Amount 59.96
Contractual Obligations Charges exceed your contracted/ legislated fee arrangement. Billed: $306.2 21
Late Filing Fee: 0.00
Pt. Responsible Amt: 61.21
Paid: 244.83
i
=MOLLY L MORRILL Sao 534 5 9
2535 DEARBpRN ST
MAKE STATfpN N9`46405 ;778638221
0 1 '�N.s DATE
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PAY TO- THE �'�r',� {i `'s.:�"f
ORDER OF r 3'"' rg
g
3 x 6 "f� i�a`' DOLRS
)PMorgan Chase Bank
NA
Indfanapohs Indiana 46277
www Chase com
,-1.0 40000
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Report: CRA- 0017 -W INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION DATE: 10/28/2008
Process: FNI03011 INDIANA HEALTH COVERAGE PROGRAMS TIME: 09:09:31
Location: FINJW200 SERVICED BY EDS PAGE: 1
PROVIDER REMITTANCE ADVICE
MEDICARE CROSSOVER PART B CLAIMS PAID
0 12A 6 ...A..1.15A3 5: 57J::::<::::;: a:;: :xwx..:.::.:.:::;:.;:.;.:.
4.......... 0...
C1TY::OF. ECK -EFT N1JM8 :ER 13000000t1�1::::
ENT CH
2 CIVIC SQ
MOIL 1Qi19d8366699.. i1p��95fl33 .526.2n118D1455::< Q611t�8::061149.: >':5I�21 24<83:` Afli...: 36: +:25.....:
,00 6 .21:`.... ..a:
fl a
REV PL PROC MODIFIERS UNITS PROVIDER BILLED PATIENT RESP MCAID PAID
0 41 A0429 RH 1.000 1154325579 061108 061108 300.00 0.00 110.84
0 41 A0425 RH 1.000 1154325579 061108 061108 25......................................... 0�............ .......0...00....... p.
E8
fl 5.. fl 9013 9:018 ..:94.15` <i
Qp> 90 .Q....
002 4021 4209
ARCS 000 23 110.84 132 61.21) 178 61.21
001 45 189.16
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aa
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.
M Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e
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 (2)
_,�aJ�e SlaV, 02 -�Z 5< qOS
cZ.6LO
ON ACCOUNT OF APPROPRIATION FOR
41ULJaA,e
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
NOV 10 2008
20
�Signat��
u�
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund