HomeMy WebLinkAbout156705 02/21/2008 i
CITY OF CARMEL, INDIANA VENDOR: T360857 Page 1 of 1
6 ONE CIVIC SQUARE SUSAN FORD- MCCARTHY
CARMEL, INDIANA 46032 12619 PLUM CREEK BLVD CHECK AMOUNT: $318.40
CARMEL IN 46033
CHECK NUMBER: 156705
CHECK DATE: 2/2112008
DEPARTMENT ACCO PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 318.40 AMBULANCE REFUND
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Date: 02/12/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972yy g
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Bill To: SUSAN E FORD MCCARTHY ICD -9: 7802 2930 2512
12619 PLUMCREEK BLVD
CARMEL, IN 46033
From: 12619 PLUMCREEK BLVD
To: COMMUNITY HOSPITAL -NORTH
1 ICHIA 33730
Patient: SUSAN E FORD MCCARTHY 05312793300
12619 PLUMCREEK BLVD Insurance
CARMEL, IN 46033 2
Patient No: 200702505
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU,
Total Amount Total Paid Balance
$398.00 $716.40 318.40
CPT
Date Description Charges Credits
11/05/2007 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
11/05/2007 MILEAGE A0425 $48.00
01/31/2008 PAYMENT $398.00
02/12/2008 COMMERCIAL INSURANCE PAYMENT $318.40
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/12/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
S A T�
Bill To: SUSAN E FORD MCCARTHY ICD 9: 7802 2930 2512
12619 PLUMCREEK BLVD
CARMEL, IN 46033
From: 12619 PLUMCREEK BLVD
To: COMMUNITY HOSPITAL -NORTH
1 ICHIA 33730
Patient: SUSAN E FORD MCCARTHY 05312793300
12619 PLUMCREEK BLVD Insurance
CARMEL, IN 46033 2
Patient No: 200702505
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$398.00 $398.00 $0.00
CPT
Date Description Charges Credits
11/05/2007 ADVANCED LIFE SUPP 1 —EMER A0427 5350.00
11/05/2007 MILEAGE A0425 $48.00
01/31/2008 PAYMENT $398.00
02/12/2008 COMMERCIAL INSURANCE PAYMENT $318.40
02/12/2008 REFUND 318.40
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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SUSAN FORD= MCCARTHY 4703
12619P1umCreekBlvd 20 la21/7ao
Cannel; IN '46033` r
Date
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INDIANA COMP. HLALTH INS.ASSOC.
Adnim. B\, ACS Hcalllicm Sohiiions. inc.
P.O. Box 33001)
indEmapolis, INI 462W-000
ff Nott ha-'2c a mtcscion
I picase, Contact its at:
spar
Return Service Requested wivw.1CHiA.m
idcphone: 317 Local
MM T011 Free,
ALL 0R AADC
7380 D.384D FP D.373
CAPMEL FIRE DEPT =i D at c: W /0 /2001)
CARMFL Che6k.. 9: 0 1 OW"2 I S I
CAIRMEL, T
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Check moun t: I h. 40
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Dates of, Prot-viiur'. Subellitted Not Reason iWolved Deductible Co-Vavi I Oflier Piall! intert-st I Pa� Inclu
Service I Modifier I Amount Alimied Codes amount Amount Coill Faid
i Al000W
11!(r�- A04- R H 35000 0.00 .3 �omo 1 o, 00, 70,00j ().(mi,
1i05/07-1 1. .\04')� 101 4)i.00 omo� 4,�. 00 0. 00 9,601 0.00; 0.00: 4
Claim Sub- Totak i 3Q8.00 I 0 0 1 00 0. 79.60' 00! ow i o
qiblc
N o! A I i o i et 1 Dvdlo, Uo-VaN/ I 0ther Plan' I ifterc,, Plo olent
Statement Totals Amount Ahowcd
oills. Paid -Ailloollt I Alloolloll
i 39"".00 OMO 79�60
0 mi 0.00:
A1).11 S 1\1 I'N'TTO 1' U.S 0.00
PAYN11 N F] ()*1 A1,S I X 40
Ft T1 A)l 0.O0
Reasoll Code Descriwions
20'
P1 c i i d i i e I i i I i,� n cori S001 16C I I C C 1 0 L [.�l 0 11 w n i j c I 3ox 3 6
T 7 lul "1 6
BLUE BACKGP0; VD ANED NMCROPRINITEM�� IN 7 1 E;0 0=
iS DOICUMEN p -F
ECK'DATE:
IN 'OAIPI�:EHENSIN/E,,HEAL't'H,INS[J,F,,A
IPO I A A N(t NSSOC
Cli
Admin. '13v /ACS .1 icalthcar� Solutions ht
?:MOUNT
P 0: 3,001) -12,2
111di'lliapolls, P\I�j 0-?0' (SOO) -7921 318.40
hund Ei-titeen 40/100 D01
PAY Three h
TO TH L CARMEL FIRE DEPT
ORDER OF
IN0 DAYS A
DD ENT E -M- G `:H! !V1+GL-=T0 ViEW
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
C Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
O'
c
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.
n
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
G Q.ILL' �1U7 o r�
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 4�
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund