161817 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
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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
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GREENWOOD IN 46143
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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
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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
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DETACH CHECK AT PERFORATION BEFORE DEPOSITING
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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
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INSURANtE CFGMPANIES, INC. z
Security features
included.
Details an back.
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Anthem o •A 0000339304726 1 1 11111 IIIII IIIII IIIII IIIII IIIII IIIII IIIILIIIII IIIII IIIII IIIII IIIILIIII IIBI
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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
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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))
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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
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