HomeMy WebLinkAbout162681 08/20/2008 CITY OF CARMEL, INDIANA VENDOR: T361704 Page 1 of 1
ONE CIVIC SQUARE LISA CHANEY
CARMEL, INDIANA 46032 11294 APALACHIAN WAY
CHECK AMOUNT: $295.00
4. FisHFRS IN 46037 CHECK NUMBER: 162681
CHECK DATE: 812012008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBE AMOUNT DESCRIPTION
102 5023990 295.00 AMBULANCE REFUND
e
Date: 08/11/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MEC SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal !D# 356000972
Bill To: JEAN CHANEY ICD -9: 78031 7806 7862 7850
11294 APALACHIAN WAY
FISHERS, IN 46037
From: 14250 CLAY TERRACE BLVD
To: CLARIAN NORTH
I ANTHEM BC /BS137010
Patient: COLE CHANEY IWW849055519
11294 APALACHIAN WAY Insurance
FISHERS, IN 46037- 2
Patient No: 200801361
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 $663.75 295.00
CPT
Date Description Charges Credits
05/29/2008 ADVANCED LIFE SUPP 1 —EMER A0427 $350.00
05/2.9/2008 MILEAGE A0425 $18.75
08/05/2008 PAYMENT $368.75
08/08/2008 BLUE SHIELD PAYMENT $295.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date. 08/11/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federally# 356000972
Bill To: JEAN CHANEY ICD -9: 78031 7806 7862 7850
11294 APALACH IAN WAY
FISHERS, IN 46037
From: 14250 CLAY TERRACE BLVD
To: CLARIAN NORTH
ANTHEM BC1BS137010
Patient: COLE CHANEY IWW849055519
11294 APALACHIAN WAY Insurance
FISHERS, IN 46037- 2
Patient No: 200801361
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
05/29/2008 ADVANCED LIFE SUPP 1 --EMER A0427 $350.00
05/29/2008 MILEAGE A0425 $18.75
08/05/2008 PAYMENT $368.75
08/08/2008 BLUE SHIELD PAYMENT $295.00
08/11/2008 REFUND 295.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
PIPE P1
JEAN PHILIP CHANEY OR a�"� 3645
M LISA E CHANEY
Fiche r s,IpN 46037
hian Way 7-30 Fishes, IN 4
DATE
PAY TO THE 3 7 f
w O D ROF �J
m
0 7�-
DOLLARS
vv
®A/L E I
G ®NS pie
FOR ?-()Oro 13 6 l 'car, C6mt Vr
4
—
5'
r
t
DB361 R E0U15j0.0B 10
12 9 9 347
BlueCross BlueShield.
of Illinois
70- 2382 CHEGK,:NO..OU38ZS94
A Division of Heelth Service Corporation, 7.1.9
:.Mutual Legal Reserve Company
an Independent' Licensee of the.
BIus Cross and Blue Shield Association
�PLEASE f NEGOTIATE PROMPTLY
300 East-Rand olph THIS CHECK IS VOID�ONE (1) YEAR AFTER DATE-OF ISSUE
Chicago, Illinois 60601 -5099
DATE CHECK'ISSUED PAYEE :NUMBER
PAY TO THE ORDER OF HCMS3 07,/3'010,8` 115432'5579
AMOUNT
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE 52:95,
CARMEL IN.46032 -2584
p�.talu.w'Q
The Northern -Trust Company o
Chicago; IL
Payable Through
Oakbrook Terrace, IL
'i 38 78 9 40 SP 1:D7 1 9 238 28 3 1 1 9 5 400 nl
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
S l-// Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
D
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.
�j ALLOWED 20
IN SUM OF 95. 6Y
Z ZL Q/a l�
r-2 95. (k)
ON ACCOUNT OF APPROPRIATION FOR
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
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund