HomeMy WebLinkAbout157888 04/01/2008 CITY OF CARMEL, INDIANA VENDOR: 361050 Page 1 of 1
ONE CIVIC SQUARE JANET COFFMAN CHECK AMOUNT: $356.00
CARMEL, INDIANA 46032 993 THIRD AV NW
CARMEN IN 46032 CHECK NUMBER: 157888
CHECK DATE: 41112008
DEPARTMENT ACCOU PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 356.00 OTHER EXPENSES
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JANET O 09 os 11s16z�oo
993 3RD AVE'N.'W
CARMEL IN 46032 1390 j DATE"
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INDIANA COMP. HEALTH INS. ASSOC.
3 Admin. By ACS Healthcare Solutions. [nc.
P.O. Box 33009
Indianapolis, IN 46203-0009
Return Service Requested
ALL FOR AADC 462
9965 0.5500 FP 0.373
CARMEL FIRE DEPT 34
2 CARMEL CIVIC SQ
CARMEL IN 46032
R ICEIVED MAR 2 1
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'Box 33009
flldianapolis:, 46203-00W'(800) 552-7921 6
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cD PAY Six Hundred f6rtv Nine &65/100 Dollars
TO THE CARMEL FIRE DEPT
ORDER OF
%'Oil) Ab"I'll"1Z 180 DAYS
Do AR KAS PFiES ENT' N.THE�REVERSE.S AT AN NG
NOT.'CASHIFWATERM 1DE',OFTH1S:DQCUMENT �A
Date: 03/25/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: JANET O COFFMAN ICD -9: 9594 9593 71886 E8859
993 3RD AV NW
CARMEL, IN 46032
From: 993 3RD AV NW
To: ST. VINCENT CARMEL
1 ICHIA /33009
Patient: JANET O COFFMAN 0714900001 -00
993 3RD AV NW Insurance
CARMEL, IN 46032 2
Patient No: 200702531
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
$356.00 $712.00 356.00
CPT
Date Description Charges Credits
11/08/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
11/08/2007 MILEAGE A0425 $6.00
03/07/2008 PAYMENT $356.00
03/21/2008 COMMERCIAL INSURANCE PAYMENT $356.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 03/25/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bill To: JANET O COFFMAN ICD -9: 9594 9593 71886 E8859
993 3RD AV NW
CARMEL, IN 46032
From: 993 3RD AV NW
To: ST. VINCENT CARMEL
1 I C H IA/33009
Patient: JANET O COFFMAN 0714900001 -00
993 3RD AV NW Insurance
CARMEL, IN 46032 2
Patient No: 200702531
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
$356.00 $356.00 $0.00
CPT
Date Description Charges Credits
11/08/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
11/08/2007 MILEAGE A0425 $6.00
03/07/2008 PAYMENT $356.00
03/21/2008 COMMERCIAL INSURANCE PAYMENT $356.00
03/25/2008 REFUND 356.00
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
j J LZ Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
s
fA 4
9 T
law.
Total) t/O.
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.
1 20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
�9 3 Ord 4-Ke 4 Z
35Co, c9t�
ON ACCOUNT OF APPROPRIATION FOR
4n 6a 1 �(f o
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
20
07
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund