159845 05/28/2008 1 CITY OF CARMEL, INDIANA VENDOR: T361342 Page 1 of 1
s ONE CIVIC SQUARE JAMES CULLEN
CARMEL, INDIANA 46032 12502 MEDALIST PKWY CHECK AMOUNT: $286.88
CARMEL IN 46033
o CHECK NUMBER: 159845
CHECK DATE: 5/28/2008
DEPARTMENT ACCOU P NUMB INVOIC NUMBER AMOUNT DESCRIPTION
102 5023990 286.88 OTHER EXPENSES
i
Date: 05/19/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bill To: BARBARA A CULLEN ICD -9: 71886 79946 E8859
12502 MEDALIST PKY
CARMEL, IN 46033
From: 92502 MEDALIST PKY
To: ST. VINCENT CARMEL
1 ANTHEM BCIBS/ 37010
Patient: BARBARA A CULLEN TQX685A22749
12502 MEDALIST PKY Insurance
CARMEL, IN 46033 2
Patient No: 200800785
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
$337.50 $337.50 $0.00
CPT
Date Description Charges Credits
03/19/2008 BASIC LIFE SUFF- EMERGENCY A0429 $300.00
03/19/2008 MILEAGE A0425 $37.50
04/15/2008 PAYMENT $337.50
05/16/2008 BLUE SHIELD PAYMENT $286.88
05/19/2008 REFUND 286.88
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 05/19/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal m# 356000972
Ds "J R N
sill To: BARBARA A CULLEN ICD -9: 71886 71946 E8859
12502 MEDALIST PKY
CARMEL, IN 46033
From: 12502 MEDALIST PKY
To: ST. VINCENT CARMEL
1 ANTHEM BC /BSI 37010
Patient: BARBARA A CULLEN TQX685A22749
12502 MEDALIST PKY Insurance
CARMEL, IN 46033 2
Patient No: 200800785
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
$337.50 $624.38 286.88
CPT
Date Description Charges Credits
03/19/2006 BASIC LIFE SUPP— EMERGENCY A0429 $300.00
03/19/2008 MILEAGE A0425 $37.50
04/15/2008 PAYMENT $337.50
03/16/2008 BLUE SHIELD PAYMENT $286.88
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
ANTHEM INSURANCE COMPANIES, INC. 10806
Anthe 0 9 DBA ANTHEM BLUE CROSS AND BLUE SHIELD
1351 WILLIAM HOWARD TAFT ROAD
CINCINNATI, OH 45206 -1775 1 of 7
An independent hoansee of the Blue Cross and Blue Shield AssociaVon.
Anthem Biwa Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc
®Registered Marks Blue Cross and Blue Shield Assacuilian
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2 CARMEL CIVIC SQ
CARMEL IN 46032
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%ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0303933433 DATE 05/07/08
P.O..BDX.37010 PROVIDER NAME CARMEL FIRE DEPT
LOUISVILLE, KY ''40233 -7010 ADDRESS 2 CARMEL CIVIC SO
ne
CARMEL IN 46032
PROVIDER ID NO 1154325579
TAX ID NO
PAYMENT SUMMARY
GROSS APPROVED CLAIM AMOUNT 699.41 IRS WITHHELD 0.00
INTEREST PAIL 0.00 l AMOUNT PREVIOUSLY OVERPAID 0.00
1
t 'AMOUNT DISBURSED 699.41
'NE
YAMOU!IT DUE 699,41 RECOUPMENT:BALANCE
..Wi9Y 6 2D0�
DETACH :CHECK AT' PER FORATION'BEFORE'DEPOSITING
ANTHEM :INSURANCE COMPANIES, INC. BANK SOF :AMERICA ' CHECK NUMBBER 3
the m �r:V "DBA ANTHEM BLUE ROSS -AND ,ATLANTA, GEORGIA �a
1351 WILLIAM HOWARD TAFT ROAD 0064 1278/0611 me
CI 38 ui
NCINNATI' OH 45206 1775
0507AI03012Z- 007127 0001799 329977x]1 p
PROVIDER ND y i TAX.ID:ND ''.DATE CHECK flMOUNT I .'m C
t !n C
1154325504 Q5%07/0.8 S #b9'4 41
m
PAY EXACTLY *3E jEdEb 9 9, 1 10LLARS'AND -41 CENTS 2zw
TDi THE ORDER 'OF.
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CARMEL -FIRE DEPT mn
2 :CARMEL CIVIC `SD
CARMEL PN 46032
i -INSURANtE 125GHPANIES, INC.
'Security features
included.
F,Details.on' pack.
K0000195604808K
01z then 0. 01111 iti OillIII 0111$ IlilIII1 II I I lII IIIILII! illl loll 5 o 7
a An independent licensee of the Blue Crass and Blue Shield Association.
.-e Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Compedies, Inc. CARMEL FIRE DEPT
Regisie red M1larks Blue Cross and Blue Shield Association PROVIDER ID NO. 1154325579 05/07/08.,
I
CHECK NUMBER 0303433433
t
j
CEL MAY 2008
MEDICARE SUPPLEMENT
I
eyt
SERVICE INSURED OTHER
1 _77.50_
i
TOTAL APPROVED AMOUNT 7 j3S3.13
TOTAL INTEREST
TOTAL NET 4M6UNT OUF: MEDICARE SUPPLEMENT
BLUE ACCESS 53.73
3
INSURED OTHER -I
SERVICE CONTRACTUAL PROVIDER RESP f: EXPUAN51 EXPI /AN51
SERVICE DATE(S) POs CHARGE ALL DEDUCTIBLE CO PAY .CO INSURANCE RESPONSIBILITY `NET PAID
CODES DIFFERENCE AMOUNT CDDE15) AMOUNT' CODEISI.
INSURED'S NAME: CULLEN,JANES T INSURED'S ID: 685A22749 PATIENT NAM£[ CULLEN BARBARA A I F,i FOR:INgI31TY1RS E1-1 L:
PATIENT ACCOUNTS: 200800785 CLAIM NUMBER:
03/19/2008 03/19/2008 A0425 41 37.50 37.50 0.00 0.00 5.62 000 0 00 5fi2 OPM 2 31.88
03/19/2008 03/19/2008 A0429 41 300.00 300.00 0:00 0.00 45.00 0:00 0 00 45.00: OPM 2 jZ55.00
TOTAL: 337.50 337.50 0.00 0:00 50[62 0:00 0.00 50:52 1 286.88
INTEREST PAID 0 00
TOTAL N ET -PAID i .v SSi�B—
SERVICE DATE(S) CODES POS CHARGE ALLOW
LLOWED DEDUCTIBLE CO -PAY CO- INSURANCE C ONTRACTUA L PRO AMOVNT ESP E CODE($) I R SPAOOUNT� TR E CO .1 I -NEY PAID
PATIENT NAME: NHIT7LE CAROLYN 5 FOR INQUIRIES CAI-el-
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PLEASE POST THIS PAYMENT FOR OUR MUTUAL CUSTOMER
Account:
l .V k��x�1'� ;,k,ni Please Direct Any Questions e1
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:JAME5;"aTr�C�L'LEN'�,�� «7a To: 877-246-7923 56715 1/44
BARB "AR'A AkCULLE,N" Online. Bill Payment Processing Center
-12502 MED`ALIST'IRk- j P.O. BOX 182096 �Qaji v,
CAR MEE 1N�46033 8934, COLUMBUS, OH 43218 2096
Apr11��09, 2008" al,�
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THRE NDRED4HIRTY'SEVEN AND 50 1100 DO
*337:50
CARMEL FIRE DEPARTMENT REMITTANCE VOID IF.NOT CASHED WITHIN 90 DAYS,
To EMERGENCY MED SVCS
'he 2 CIVIC SQ
-der CARMEL, IN 460322584
Of AUTHORIZED SIGNATURE
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 invoice(s) or bill(s))
s PTO
A
it
Total o A 1 1 7
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
Rbi
ON ACCOUNT OF APPROPRIATION FOR
,�&bljdaec rul?&l/Il 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
ig natu re
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund