199475 07/20/2011 CITY OF CARMEL, INDIANA VENDOR: 365498 Page 1 of 1
ONE CIVIC SQUARE CHRISTIAN GOMEZ CHECK AMOUNT: $541.62
CARMEL, INDIANA 46032 1103 GOLFVIEW DR APT C
`pc CARMEL IN 46032
«o„ CHECK NUMBER: 199475
CHECK DATE: 7/20/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 541.62 OTHER EXPENSES
Date: 07/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
v 0 sir gi S(E O'F f, v
Bill To: YARAMI RUVALCABA ICD -9: 796.4
1103 GOLFVIEW DR APT C
CARMEL, IN 46032- r
From: 12400 N MERIDIAN ST
To: ST. VINCENTS HOSPITAL
9 MEDICARE PART B
Patient: YARAMI RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201101171 917564896
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$424.83 $689.33 264.50
CPT
Date Description Charges Credits
04/26/2011 BASIC LIFE SUPP— EMERGENCY A0429 $375.00
04/26/2011 MILEAGE A0425 $49.83
06/02/2011 MEDICARE PAYMENT $301.44
06/02/2011 ASSIGNMENT MEDICARE $48.03
06/28/2011 COMMERCIAL INSURANCE PAYMENT $339.86
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/1212011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
,dy. x U g 5 T a re a g
Bill To: YARAMI RUVALCABA ICD -9: 796.4
1103 GOLFVIEW DR APT C
CARMEL, IN 46032
From: 12400 N MERIDIAN ST
To: ST. VINCENTS HOSPITAL
I MEDICARE PART B
Patient: YARAMI RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201101171
917564896
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU,
Total Amount Total Paid Balance
$424.83 $424.83 $0.00
CPT
Date Description Charges Credits
04/26/2011 BASIC LIFE SUPP— EMERGENCY A0429 $375.00
04/26/2011 MILEAGE A0425 $49.83
06/02/2011 MEDICARE PAYMENT $301.44
06/02/2011 ASSIGNMENT MEDICARE $48.03
06/28/2011 COMMERCIAL INSURANCE PAYMENT $339.86
07/12/2011 REFUND 264.50
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
A ininvoice 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.
AA Payee
i
a/"l QfY/�7 Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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.
ALLOWED 20
IN SUM OF J0
1102 401f L
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
,]U
r
r
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Date: 07/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federai m# 356000972
N T H T C R
Bill To: YARAMI RUVALCABA ICD -9: 780.02 787.01
1103 GOLFVIEW DR APT C
CARMEL, IN 46032
From: 1103 GOLFVIEW DR APT /SUITE# C
To: ST. VINCENTS HOSPITAL
MEDICARE PART B
Patient: YARAMI RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201101199 917564896
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$445.22 $722.34 277.12
CPT
Date
Description Charges Credits
04/29/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
04/29/2011 MILEAGE A0425 $70.22
06/02/2011 MEDICARE PAYMENT $316.26
06/02/2011 ASSIGNMENT MEDICARE $49.90
06/28/2011 COMMERCIAL INSURANCE PAYMENT $356.18
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
A C U N"
Bill To: YARAMI RUVALCABA ICD -9: 780.02 787.01
1103 GOLFVIEW DR APT C
CARMEL, IN 46032
From: 1103 GOLFVIEW DR APT /SUITE# C
To: ST. VINCENTS HOSPITAL
MEDICARE PART B
Patient. YARAM! RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201101199 917564896
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$445.22 $445.22 $0.00
Date
CPT
Description Charges Credits
04/29/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
04/29/2011 MILEAGE A0425 $70.22
06/02/2011 MEDICARE PAYMENT $316.26
06/02/2011 ASSIGNMENT MEDICARE $49.90
06/28/2011 COMMERCIAL INSURANCE PAYMENT $356.18
07/12/2011 REiuND 277.12
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 207 (Rev. 1995)
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
�II /I
C__J? r/ 5 an 90/7 e Z Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
6 min coke,,- /2 Z
�Ct
Total 7 Z Z
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
C/JfI6 Z9-12 ��i�i�Z IN SUM OF 7
�fl�D32-
7�1
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
JUL 18 2011
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund