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