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HomeMy WebLinkAbout199860 08/03/2011 CITY OF CARMEL, INDIANA VENDOR: 365512 Page 1 of 1 ONE CIVIC SQUARE TUYET BURKE CARMEL, INDIANA 46032 10914 COLLEGE PLACE DRIVE CHECK AMOUNT: $38.56 INDIANAPOLIS IN 46280 CHECK NUMBER: 199860 CHECK DATE: 8/3/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBE AMOUNT DESCRIPTION 102 5023990 38.56 AMBULANCE REFUND Date: 07/20/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 C- b 1 1 1hi S T 0 R Y Bill To: SCOTT A BURKE ICD -9: 8730 7840 E8160 10914 COLLEGE PLACE DR INDIANAPOLIS, IN 46280- From: COLLEGE 110TH To: IU HEALTH NORTH 1 ANTHEM BLUE CROSS BLUE Patient: TUYET T BURKE FTQAN1899309 10914 COLLEGE PLACE DR Insurance INDIANAPOLIS, IN 46280- 2 Patient No: 201101593 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 $385.57 $771.14 385.57 CPT Date Description Charges Credits 06/06/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 06/06/2011 MILEAGE A0425 $10.57 07/11/2011 BLUE SHIELD PAYMENT $347.01 07/11/2011 PAYMENT $38.56 07/19/2011 COMMERCIAL 1NSURF.NCE PAYMENT $385.57 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 07/20/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571- 2605 FederallD# 356000972 Sill To: SCOTT A BURKE ICD -9: 8730 7840 E8160 10914 COLLEGE PLACE DR INDIANAPOLIS, IN 46280 From: COLLEGE 110TH To: IU HEALTH NORTH 1 ANTHEM BLUE CROSS BLUE Patient: TUYET T BURKE FTQAN1899309 10914 COLLEGE PLACE DR Insurance INDIANAPOLIS, IN 46280- 2 Patient No: 201101593 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 $385.57 $385.57 $0.00 CPT Date Description Charges Credits 06/06/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 06/06/2011 MILEAGE A0425 $10.57 07/11/2011 BLUE SHIELD PAYMENT $347.01 07/11/2011 PAYMENT $38.56 07/19/2011 COMMERCIAL INSURANCE PAYMENT $385.57 07/20/2011 REFUND 347.01 07/20/2011 REFUND -38.56 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 07/20/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal m# 356000972 P IDR tom¢ te e �P „w tax P R Y Bill To: SCOTT A BURKE ICD -9: 8730 7840 E8160 10914 COLLEGE PLACE DR INDIANAPOLIS, IN 46280 From: COLLEGE 110TH To: IU HEALTH NORTH 1 ANTHEM BLUE CROSS BLUE Patient: TUYET T BURKE FTQAN1899309 10914 COLLEGE PLACE DR Insurance INDIANAPOLIS, IN 46280- 2 Patient No: 201101593 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 $385.57 $771.14 385,57 CPT Date Description Charges Credit's 06/06/2011 BASIC LIFE SUPP EMERGENCY A0429 $375.00 06/06/2011 MILEAGE A0425 $10.57 07/11/2011 BLUE SHIELD PAYMENT S347.01 07/11/2011 PAYMENT $3$.56 07/?9/2011 COMMERCIAL INSURANCE PAYMENT $385,57 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 07/20/2011 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 "s r I� RY Bill To: SCOTT A BURKE ICD -9: 8730 7840 E8160 10914 COLLEGE PLACE DR INDIANAPOLIS, IN 46280- From COLLEGE 110TH To: IU HEALTH NORTH 1 ANTHEM BLUE CROSS BLUE Patient: TUYET T BURKE FTQAN1899309 10914 COLLEGE PLACE DR Insurance INDIANAPOLIS, IN 46280- 2 Patient No: 201101593 WEE 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 $385.57 $385.57 $0.00 CPT 1 4 Description Charges Credits 0610612011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00 06/06/2011 MILEAGE A0425 $10.57 07/11/2011 BLUE SHIELD PAYMENT $347 07/11/2011 PAYMENT $38 07/19/2011 COMMERCIAL INSURANCE PAYMENT $385.57 07/20/2011 REFUND 347.01 07/20/2011 REFUND -38.56 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 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 Z !.(-y e T l t-I'/'S c Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) bum ern oY D� �3 5�0 Total 1 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. X ALLOWED 20 IN SUM OF 3S`.,56' �c6�a�lj -oan =2Z/ wo z� ON ACCOUNT OF APPROPRIATION FOR 14m6u4wekund- Lnlo Aeery 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 An 12011 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund