HomeMy WebLinkAbout199601 07/20/2011 CITY OF CARMEL, INDIANA VENDOR: 365494 Page 1 of 1
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ONE CIVIC SQUARE GENE MYATT CHECK AMOUNT: $423.32
CARMEL, INDIANA 46032 10886 WESTON DRIVE
CARMEL IN 46032 CHECK NUMBER: 199601
CHECK DATE: 7/20/2011
DEPARTMENT ACCOUNT PO NUMBER INV NUMBER AMOUNT DESCRIPTION
102 5023990 423.32 REFUND
Date: 07/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
f) .v l
Bill To: GENE A MYATT ICD -9: 7802 7808 78605 E8888
10886 WESTON DR
CARMEL, IN 46032
From: 10886 WESTON DR
To: IU HEALTH NORTH
UNITED HEALTH CARE/ 740800
Patient: GENE A MYATT 838327495
10886 WESTON DR insurance
CARMEL, IN 46032- 2
Patient No: 201100793
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$423.32 $423.32 $0.00
CPT
bate,Description Charges, Credits
03/13/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
03/13/2011 MILEAGE A0425 $48.32
07/05/2011 PAYMENT $423.32
07/06/2011 COMMERCIAL INSURANCE PAYMENT $423.32
07/12/2011 REFUND 423.32
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 U .Q,
Bill To: GENE A MYATT ICD -9: 7802 7808 78605 E8888
10886 WESTON DR
CARMEL, IN 46032
From: 10886 WESTON DR
To: IU HEALTH NORTH
UNITED HEALTH CARE 740800
Patient: GENE A MYATT 838327495
10886 WESTON DR Insurance
CARMEL, IN 46032- 2
Patient No: 201100793
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW THANK YOU.
Total Amount Total Paid Balance
$423.32 $846.64 423.32
CPT
i]ate Description Charges Credits
03/13/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
03/13/2011 MILEAGE A0425 $48.32
07/05/2011 PAYMENT $423.32
07/06/2011 COMMERCIAL INSURANCE PAYMENT $423.32
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
Bill To: GENE A MYATT ICD -9: 7802 7808 78605 E8888
10886 WESTON DR
CARMEL, IN 46032
From: 10886 WESTON DR
To: IU HEALTH NORTH
UNITED HEALTH CARE/ 740800
Patient: GENE A MYATT 838327495
10886 WESTON DR insurance
CARMEL, IN 46032- 2
Patient No: 201100793
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW THANK YOU,
Total Amount Total Paid Balance
$423.32 $846.64 423.32
CPT
Date Description Charges Credits
03/13/2011 BASIC LIFE SUPP EMERGENCY A0429 $375.00
03/13/2011 MILEAGE A0425 $48.32
0`1/05/2011 PAYMENT $423.32
07/06/2011 COMMERCIAL INSURANCE PAYMENT $423.32
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
ACCC OUN! 11 a r
Bill To: GENE A MYATT ICD -9: 7802 7808 78605 E8888
10886 WESTON DR
CARMEL, IN 46032
From: 10886 WESTON DR
To: IU HEALTH NORTH
UNITED HEALTH CARE/ 740800
Patient: GENE P; MYATT 838327495
10886 WESTON DR Insurance
CARMEL, IN 46032- 2
Patient No: 201100793
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$423.32 $423.32 $0.00
CPT
Date Description Charges Credits
03/13/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
03/13/2011 MILEAGE A0425 $48.32
07/05/2011 PAYMENT $423.32
07/06/2011 COMMERCTAL INSURANCE PAYMENT $423.32
07/12/2011 REFUND 423.32
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached iirvoice(s) or bill(s))
Prnc� e
A
Total 4 a?3 3 2—
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
�G
IN SUM O F$ 5� Z
eo-07l e'l� 1 S D 7
Va3 z
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice 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 8 2011
1
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund