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Home My WebLink About161817 07/23/2008 CITY OF CARMEL, INDIANA VENDOR: T361551 Page 1 of 1 ONE CIVIC SQUARE LEANN FERRY CHECK AMOUNT: $258.13 CARMEL INDIANA 46032 1813 EAGLE TRACE DR GREENWOOD IN 46143 CHECK NUMBER: 161817 CHECK DATE: 7/23/2008 DEPARTMENT ACCOUNT PO N UMBER INVOICE NUMBER AMOUNT DES CRIPTI ON 102 5023990 258.13 OTHER EXPENSES t� Date: 07/14/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 Bill To: CHRISTOHPER G FERRY ICD -9: 7802 7804 1813 EAGLE TRACE DR GREENWOOD, IN 46143 From: 1465 31 MM To: CLARIAN NORTH 1813 EAGLE TRACE DR Insurance GREENWOOD, IN 46143- 2 Patient No: 200800783 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 $368.75 $626.88 258.13 CPT Date Description Charges Credits 03/20/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/20/2008 MILEAGE A0425 $18.75 06/27/2008 PAYMENT $368.75 07/11/2008 BLUE SHIELD PAYMENT $258.13 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 07114/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 l,' .r Bill To: CHRISTOHPER G FERRY ICD -9: 7802 7804 1813 EAGLE TRACE DR GREENWOOD, IN 46143- From: 1465 31 MM To: CLARIAN NORTH 1813 EAGLE TRACE DR Insurance GREENWOOD, IN 46143- 2 Patient No: 200800783 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 $368.75 $368.75 $0.00 CPT Date Description Charges Credits 03/20/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00 03/20/2008 MILEAGE A0425 $18.75 06/27/2008 PAYMENT $368.75 07/11/2008 BLUE SHIELD PAYMENT $258.13 07/14/2008 REFUND 258.13 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 t M 1366061 FERRY r' PAULETTA LEANN a 1813;EAGLETRAC a GREENWOOD IN 46143 a a 0 mem /E(l r Ea� y AAnthe \may/ DBA ANTHEM BLUE CROSS AND BLUE SHIELD nthem ,r vt 1351 WILLIAM HOWARD TAFT ROAD v CINCINNATI, OH 45206 -1775 1 of 7 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. BJ Registered Marks Blue Cross and Blue Shield Association e #BWNCQXF o #185999999493/DF9# I04 w CARMEL FIRE DEPT L4 2 CARMEL CIVIC SQ L CARMEL IN 46032 0 0 o JUL 1 1 W W t,t 0 V N F ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0304091980 DATE 07/02/08 P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SQ CARMEL IN 46032 PROVIDER ID NO 000000184493 1154325579 TAX ID NO XXXXX0972 PAYMENT SUMMARY GROSS APPROVED CLAIM AMOUNT 630.55 IRS WITHHELD 0.00 INTEREST PAID 0.00 AMOUNT PREVIOUSLY OVERPAID 0.00 I AMOUNT DISBURSED 630.55 0.0 1 NET AR40UNTDUE 630.55 t 2ECOUPMENT BALANCE 0 t r DETACH CHECK AT PERFORATION BEFORE DEPOSITING a CHECK NUMBER i ANTHEM INSURANCE COMPANIES, INC. BANK OF AMERICA DBA ANTHEM BLUE CROSS AND .BLUE SHIELD ATLANTA, GEORGIA, oR Anthem 0304091980 ZC 1351 WILLIAM '.HOWARD TAFT ROAD 006471278/0611 xg CINCINNATI OH 45206 1775 0702AI030122- 010060 C002834:. 3299777138 PROVIDER ID NO I =''TAX ID NO 'DATE CHECK,AMOUNT'±;' .:nnC D00000184493'` XXXXX0972 07/02/08 #630 55 xxC t #63U, DOLLARS AND 5'S CENTS PAY EXACTLY Zz� TO T:HE ORDER OF: O z R r. m0 rt CARMEL FIRE DEPT mn 2 'CARMEL CIVIC SQ G ZX CARMEL IN 46032 z 1 INSURANtE CFGMPANIES, INC. z Security features included. Details an back. i Anthem o •A 0000339304726 1 1 11111 IIIII IIIII IIIII IIIII IIIII IIIII IIIILIIIII IIIII IIIII IIIII IIIILIIII IIBI sof7� N An independent licensee of the Blue Cross and Blue Shield Association, CARMEL FIRE DEPT Anthem Marks us Cross and B Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. PROVIDER ID NO o. 0 00000184493 07/02/�OS tered Bllue Shield Regis Association CHECK NUMBER. 0304091980 MEDICARE SUPPLEMENT r I I TOTAL APPROVED AMOUNT 144.96 TOTAL INTEREST 0.00 TOTAL NET AMOUNT DUE: MEDICARE SUPPLEMENT 144.96 BLUE ACCESS INSURED OTHER SERVICE CONTRACTUAL PROVIDER RESP .EXPL /ANSI EXPL /ANSI SERVICE DATE(S) POS CHARGE ALLOWED DEDUCTIBLE 'CO -PAY CO- INSURANCE RESPONSIBILITY NET PAID CODES DIFFERENCE AMOUNT CODE(S) AMOUNT:- CODE(S) _I WSURED 'S NAME: FERRY, CHRIS G INSURED'S ID: 859A66247 PATIENT NAME: .FERRY,PAULETTA L FOR INQUIRIES CALL: PATIENT ACCOUNTS: 200800783 CLAIM NUMBER: 200817SKGO110 RECEIVED DATE. .•06/23/2008; (800) 765 2588 SERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: XXXXX0972 03/20/2008 03/20/2008 A0425 41 18.75 18.75 0.00 0.00 5.62 0.00. 0.00 5.62 OPM2 ��13.13 03/20/2008 03/20/2008 A0427 41 350.00 350.00 0.00 0.00 105.00 0.00 0.00 105:00 OPM 2 245.00 TOTAL: 368.75 368.75 0.00 0.00 110.62 0.00 0.00 110.62' 258.13 INTEREST PAID 0.00 TOT NET P VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF l ON ACCOUNT OF APPROPRIATION FOR -fie C,, 9 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 2(,k o� Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund 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)) e E 1f yv f n •7 Total n5 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 i