The URL can be used to link to this page

166033 11/13/2008 CITY OF CARMEL, INDIANA VENDOR: T361522 Page 1 of 1 ONE CIVIC SQUARE MAE KLINAR CHECK AMOUNT: $68.71 CARMEL, INDIANA 46032 12999 N PENSYLVANIA APT 4028 M o CARMELw46032 CHECK NUMBER: 166033 CHECK DATE: 1111312008 DEP ARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AM OUNT DE SCRIPTIO N 1°x;)2 5023990 68.71.. OTHER EXPENSES. Date: 11/05/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 19' t Bill To: MAE P KLINAR ICD -9: 88100 E8888 12999 N PENNSYLVANIA APT# 402B CARMEL, IN 46032 From: 12999 N PENNSYLVANIA ST To: ST. VINCENT- INDPLS UNITED HEALTHCAREIRR Patient: MAE P KLINAR WD396014 12999 NI PENNSYLVANIA APT# 402B Insurance CARMEL, IN 46032 2 BANKERS LIFE CASUALTY/222 Patient No: 200801471 200 -280 -822 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 $343.75 $412.46 -68.71 CPT Date DescripEion Charges Credits 06/12/2008 BASIC LIFE SUPP— EMERGENCY A0429 $300.00 06/12/2008 MILEAGE A0425 $43.75 09/30/2008 MEDICARE PAYMENT $274.83 09/30/2008 ASSIGNMENT MEDICARE $0.21 10/15/2008 COMMERCIAL INSURANCE PAYMENT $68.71 10/31/2008 COMMERCIAL INSURANCE PAYMENT $68.71 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 11/05/2008 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal lo# 356000972 A 0 e," 9 �g 3: �RU; f' ;yep RY Bill To: MAE P KLINAR ICD -9: 88100 E8888 12999 N PENNSYLVANIA APT# 402B CARMEL, IN 46032 From: 12999 N PENNSYLVANIA ST To: ST. VINCENT- INDPLS 1 UNITED HEALTHCARE /RR Patient: MAE P KLINAR WD396014 12999 N PENNSYLVANIA APT# 402B Insurance CARMEL, IN 46032 2 BANKERS LIFE CASUALTY /222 Patient No: 20080/471 L 200 280 -822 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 $343.75 $343.75 $0.00 CPT Date Description Charges Credits 06/12/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 06/12/2008 MILEAGE A0425 $43.75 09/30/2008 MEDICARE PAYMENT $274.83 09/30/2008 ASSIGNMENT MEDICARE $0.21 10/15/2008 COMMERCIAL INSURANCE PAYMENT $68.71 10/31/2008 COMMERCIAL INSURANCE PAYMENT $68.71 11/05/2008 REFUND -68.71 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 CHECK NO 0076713649 nnP BANKERS'LIi:FE AND CASUALTY COMPANY °M.S t IIB25 N..PENNSYLYANIA ST, CARMEL, !IN,46032 THE BANK OF NEW YORK NELLWN L- PHILADELPHIA, PA 62 -4 311 PAY SIXTY -EIGHT AND 711100 DATE CHECK AMOUNT TO CARMEL FIRE DEPARTME 10/20/2008 *68.71 i 1 THE 2 CIVIC SQUARE ORDER CARMEL, IN 46032 OF i i f I VDID AFTER'480 DAYS ..'AU7HbRIZED SIGNATURE I 11'00767 L36490 1:03 L L000 2969 SS811' CHECK NUMBER: 0076713649 CHECK DATE: 10/20/2008 BLC /BCBBA /BCB PATIENT NAME PAT.NO. BILLED APPRVD DEDUCT CO —INS PAID KLINAR MAE P 2oo8ol471 343.75 343.54 .00 68.71 68.71 200280822- 441154 SERV.DT.— 06 -12 -2008 DATE: 10/18/08 CONTROL NO. 00020441 TOTAL. PAID 68.71 RECEIVED OCT 2 4 2M IE"C rr32r UW)K HOP 110P Administration Unit •a�bw Administered By CoreSource, Inc. PO Box 1764 Lancaster- PA 17608 -1764 1 200830080106 This is an explanation o f benefits p ayahle under the tq? patient's plan. Please refer to the remark section for any Forwarding Ser vice R equested ineligible information. For questions regarding this Claim, contact us at: p 1- 800.773 -7725 5 -DIGIT 46032 3215 0.3840 AV 0.324 II "�[`I II° 1I�[ I° I[ 1�' II��IIS `tl�l��lll�l��llfll'�II111 °I'll" ENIP1,0YEENAAM E-ST OF PA CARMEL FIRE DEPT A1IBULA PATIENT: US OF NIAE.11 IANAR 2 civic so 15 GROUP 115113 z CARMEL, IN 46032 -2584 .'ROLIP NAME: PSE,RS PA'T'IENT ACCOUNT NO: 200801471 PRON!II)ER OF SERVICE: ARMEL FIRE ))EPT.AMBIILA PROVIDER TIN: 35-6(100972-99999 ('I..AI NI th E000 1 06443 7 8 (AIF-C.'K #l: 5788586 ISSUED I)ATE: 110/07/2008 PAN'MENT MADE' TO: CARN1EL FIRE 1) EPT AMIIIILA fi Explanation of Bene NFLIGII3LE TI*IEL1EzIBh.L S R 'tCE T�1 Z .I..1 i 1 5E 31v,i1 1 113 ?�b10Uiu 1 hClTtN T Z Ct?yT 32E4? QF OLIC 1'113 F GUPAY °4 PAR) PI Aid` [vlr'1 �)1 11 l)ATT OF EEiVI Ir IOt tNi 130. Gt713L i lvli.0(�I3E Ah1E]iIN 1` 131 N1 C1I 1 ST'ONtil131i 106/12/08 A0429 -RH 1300.00 1.21 1239.83 159.96 59.96 507 506 06/12/08 I A0425 -RI-1 143.75 135.00 18.75 18.75 506 Total 1343.75 �.21 274.83 68.71 1 0.00 j0-o0 168.71 10.00 507 THE PROVIDER 11,4S ACCEPTED ASSIGNMENT FROM NICI)ICARE. YOGI ARE LEGALLY' 0131,1C;ATE ©'1'O I'AY ONLN' 'I'IiE DIFFERENCE BE1'Wir 1 N THE MEDICARE APPROVED Ah10UNT ANT) THE MEDICARE PAYNILNT_ 506 TiIF,SE EXPENSES N4 /ERf? PAID BY A AND/OR YOUR 65 SPECIAL -.AND ARE NOT I ?I,iGIBLE FOR 12EIAdBiJRSEn RECEIVED OCT 1 5 2008 FOR SECURITY PURROSES THE FACE OF_THIS DOCUMENT CONTAIN$ A BLUE BACKGROUND AND' INTHE BORDER 117.KT II ark �7li85RG HIQ�FIUT'Adumstra i(m -Llm t 7 "11 i in Ac}muusiered l :ColeSource tnc Rio 3altunoa ,r C1 D >C� Boy i 76 >7 rl�r t AIr4! rrtElurr I .nlcastei f'A 1.7,08 ].7G r 5'r of NIAE 1 6LTNAR ]EST OF 1b1Ar 11,1 IN R T"� UMPA TkY N }l►lTZ h L'T NUSIR C7 01 P, 0 5 03- 01 0111 E0001 0644378 S A, t�t1E '.>gllt 71 /100 Doll�ics A AM0 Y 70/07 6 8.71 VOI D AFTER 90 DAYS (Y) TO THE CARMEL FIRE DEPT AMBULA ORDER CIVICS Q OF' CARMEL,..1N 46032 r p.. ......u. F r ...:fit. a gF :•x•i� w �OCNOT 'a:C SENT ©h'.TFIE REUER$E SIOE;Q TFIIS'�I?OC1JMl"NT HC3E;D Ae AN'A'NGL_TCa Y1c.W,�� A Ila S 788 58 611° 1:0S 2000 11 31:990 30 38 311' 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 l) 0-i Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) e; r)-) mss 4 g. It Total k. 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 VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF Z 9 9 q Al �P'jwg�l��r�, s :7 ON ACCOUNT OF APPROPRIATION FOR ujC'c12 e Board Members Po# or INVOICE NO. ACCT #/TITLE AMOUNT DEPr. 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 NOV 10 2008 l r r 20 Signature tom_ Cost distribution ledger classification if Title claim paid motor vehicle highway fund