HomeMy WebLinkAbout159296 05/14/2008 CITY OF CARMEL, INDIANA VENDOR: 361225 Page 1 of 1
(s ONE CIVIC SQUARE LARRY COOPER
CARMEL, DIANA 46032 1108 E 106TH ST CHECK AMOUNT: $302.81
IN
INDIANAPOLIS IN 46280 CHECK NUMBER: 159296
CHECK DATE: 5/14/2008
DE PARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 302.81 REFUND
i
i
I
b
visit us at www 53.co— 1559
LARRY W'COOPER m
EVELYN L COOPER 71.8591749
1108E 106TH ST
INDIANAPOL..IS; IN 46280. U
U+re
'PAY TO
LtOIIDF,2
r _�'DOLLARS CLUB
h Third Bank FIFTY THR
ANA (CENTRAL) IA WOUS, INDNA M,
BfIPRLANO 2�0"
L
0423AI030122 611388
ANTHEM INSURANCE COMPANIES, INC. 22207
�y
OBA ANTHEM BLUE CROSS AND BLUE SHIELD
Aiit��.eyt. 1351 WILLIAM HOWARD TAFT ROAD
CINCINNATI, OH 45206 -1775 1 of 6
An independent licensee of the Blue Cross and Blue Shield Assoc-
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc
6) Ragistated Marks Blue Cross and Blue Snleld Association
�tln�t��n��ru u��nt�t��tittE
#BWNCQXF
#4428845679///DF5# I1.3
o CARMEL FIRE DEPT
2 CARMEL CIVIC SQ
p t CARMEL IN 46032
0
0
V
0
C>
O
W
6
r
n
r
ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER DATE aG/23/08
P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT
LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SO
CARMEL IN 46032
PROVIDER ID NO
®tta,
PAYMENT .SUMMARY
GROSS APPROVED CLAIM AMOUNT 793.90 r--- IRS WITHHELD 0. 00
INTEREST PAID 0.00 I AMOUNT PREVIOUSLY OVERPAID 0.00
I nneawH.r
AMOUNT DISBURSED 793.90
NET AMOUNT DUE 793.90 I R£CDUPM ENT BALANCE 0.00
t i
sr�mro
rQ+m
®n
rm»eta
®cry
.CEw� ivir�l b .2 ;200
t�
DETACH CHECK AT PERFORATION BEFORE.. DEPOSITING
7 ANTHEM INSURANCE COMPANIES, INC. BANK OF AMERICA CHECK NUMBER s
111 thelT yy� 1.,e "z���k DBA.ANTHEEM BLUE CROSS AND BLUE SHIELD ATLANTA, GEORGIA 0303895030 zc
1351 WILLIAM HOWARD.TAFT ROAD
.606 Z 8/0611
mc
CINCINNATI; DH 45206 -1775 0423AI030122- 011388
0007383 "329977.7,138 n y i
.'-PROVIDER Ip NO
04/23/06 - x
oc
m�
PAY EXACTLY 3E jE 3E jE 3f #.7'93 'DOLLARS AND 9Q CENTS zZ�
TO THE ORDER OF iOz
M
O r
in R
f
CARMEL FIRE .DEPT
2 CARMEL CIVIC ':SQ
CARMEL IN 46032 ttTWE* INSURA 13 5 4 H P4NIES, INC. z
x
Security features
included.
009708030300 i I IIIII Illil 11111 11111 Illfl IIII Illli Illl� II it III Illll �!I I IIII Ilg
1 v 1 5 of 5
An em B independent licensee of the Blue Cross and Blue Shield Association.
n CARMEL FIRE DEPT
.4nmem Blue Cross and Blue A n n d B lue Shield Association a the trade name of Arnhem Insurance Companies, Inc.
Registered Marks Blue Cross PROVIDER ID NO: 1154325579 04/23%08
Q� ad B
CHECI. NUMBER: 0
A
,!CIV� fl 2 ZQQB
MEDICARE SUPPLEMENT MAY:
E X PL PAN S
DIFFERENCE AMOUNT CODEISI RESPONSIBILITY CODEISI "NEJ PAID
AMOUNT
03/02/2008 03/02/2008 A0425 41 6.25 6.25 6,00 0.00 0.94 0.00 0.00 .94 OPM 2 5.31
03/02!2008 03/02/2008 A0427 41 350.00 350.00 0.00 0.00 52.50 0.00 0.00 52.50 OPM 2 1297.50
TOTAL: 356.25 356.25 0.00 0.00 53.44 0.00 0.00 53.4 ;302.81
INTEREST PAID
0.00
OIAL_NET PAI X82..8
i
I
'Dmhm: 05/07/2008
C&FlK8EL FIRE DEPARTMENT
EMERGENCY MEDSVC3
2 CIVIC SQUARE
CARMEL|N 40032
(317)571-2609 pvdwe/uD# 358008972
80Tz LAWRENCE COOPER ICD-9: 7802 78009
1108E106THST
INDIANAPOLIS, IN 46280 From: 1108 E 106TH ST
To: HEART CENTER OF INDIANA
ANTHEM BCIBS/ 37010
Patient: LAWRENCE COOPER
1108E106TH3T Insurance
INDIANAPOLIS, IN 46280
Patient No: 208800038
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE. THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW
THANK YOU.
Total Amount Total Paid Balance
CPT
Date Description Charges Credits
03/02/2008 ADVANCED LIFE 3OeP I-EM2D A0427 $350.00
03/02/2008 MILEAGE A0425 $6.25
04/25/2008 PAYMENT $356.25
05/02/2008 BLUE SHIELD PAYMENT $302.81
05/07/2008 REFUND $-502.81
APPROVED ov THE STATE BOARD oF ACCOUNTS FOR CITY oFc*nMEL.1yne
Date: 05/07/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
Bill To: LAWRENCE COOPER ICD -9: 7802 78009
1108 E 106TH ST
INDIANAPOLIS, IN 46280 From: 1108 E 106TH ST
To: HEART CENTER OF INDIANA
1 ANTHEM BC /BS/ 37010
Patient: LAWRENCE COOPER TQX831A22749
1108 E 106TH ST Insurance
INDIANAPOLIS, IN 46280 2
Patient No: 200800636
WE DO NOT FILE CLAIMS FOR YOUR INSURANCE. THIS INVOICE IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW.
THANK YOU.
Total Amount Total Paid Balance
$356.25 $659.06 302.81
CPT
Date Description Charges Credits
03/02/2008 ADVANCED LIFE SDPP I -EMER A0427 $350.00
03/02/2008 MILEAGE A0425 $6.25
04/25/2008 PAYMENT $356.25
05/02/2008 BLUE SHIELD PAYMENT $302.81
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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
rr� U IN SUM OF dam
C6 an as O 6-'s, 1- V6 :—),F6
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. 1 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
o
Signat re
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund