161437 07/11/2008 CITY OF CARMEL, INDIANA VENDOR: T361522 Page 1 of 1
Q� ONE CIVIC SQUARE MAE KLINAR
CARMEL, INDIANA 46032 12999 N PENSYLVANIA APT 4028 CHECK AMOUNT: $68.71
o CARMEL IN 46032 CHECK NUMBER: 161437
CHECK DATE: 7/11/2008
DEPARTMENT AC COUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 68.71 OTHER EXPENSES
Date: 07/01/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federa]ID# 356000972
Bill To: MAE P KLINAR ICD -9: 71945 7295 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# 4028 Insurance
CARMEL, IN 46032 2 BANKERS LIFE CASUALTY /222
Patient No: 200800996 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 Description Charges Credits
04/17/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
04/17/2008 MILEAGE A0425 $43.75
06/06/2008 MEDICARE PAYMENT $274.86
06/06/2008 ASSIGNMENT MEDICARE $0.21
06/06/2008 WRITE OFF- INSURANCE -0.03
06/24/2008 COMMERCIAL INSURANCE PAYMENT $68.71
06/27/2008 COMMERCIAL INSURANCE PAYMENT $68.71
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/01/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: MAE P KLINAR ICD -9: 71945 7295 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# 4028 Insurance
CARMEL, IN 46032 2 BANKERS LIFE CASUALTY /222
Patient No: 200800996 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
04/17/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
04/17/2008 MILEAGE A0425 $43.75
06/06/2008 MEDICARE PAYMENT $274.86
06/06/2008 ASSIGNMENT MEDICARE $0.21
06/06/2008 WRITE OFF- INSURANCE 0.03
06/24/2008 COMMERCIAL INSURANCE PAYMENT $68.71
06/27/2008 COMMERCIAL INSURANCE PAYMENT $68.71
07/01/2008 REFUND -68.71
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
CHECK NO.
0075742639 v._
mP B^NKERS LIFE AND CASUALTY COMPANY' MS
11825 N. PENNSYLVANIA ST, CARMEL„ IN 46032. MELLON BANK N.A.
PHILADELPHIA, PA 62_4
PAYABLE THROUGH MELLON.BANK WE). HILMINGTON, DE 311
PAY SIXTY -EIGHT AND 711100
T O CARMEL FIRE DEPARTME DATE CHECK AMOUNT
THE 2 CIVIC SQUARE 06/23/2008 *68 71
ORDER CARMEL, IN 46032
OF
VOID AFTER 780 DAYS AUTHORIZED SIGNATURE
11° 007S742639 1 :0 3 1 10004 71: 26. 969 SSBIl°
CHECK NUMBER: 0075742639 CHECK DATE: 06/23/2008 BLC /BCBBA /BCB
PATIENT NAME PAT.NO. BILLED APPRVD DEDUCT CO -!NS PAID
KLINAR MAE P 2oo800996 343.75 343.54 .00 68.71 68.71
200280822- 580823 SERV.DT.- o4 -17 -2008
DATE: 06/21/08 CONTROL NO. 00016255 TOTAL PAID 68.71
RtCBIVED JUN 2 7 2008
HOP uorxomina, mni/
;—V Admioim:rt�d8y: Co/eSounce.|nc
PO Bo.x 1761
Lancaster. PA |76()Q'|764
n/is isu."`pi"=ool lit' lit' bellem"v,pu,v.uo.
'i�pu�xxv�. n,="m�,mm,,n^,m
�onrxrdin�5crviccQ�)ocw�cd /u/m,m»,"=x/ml. n.,
v"m^vos/u",/"/111.","o.,/""ill:
MIXED AAo[ ,k2 /-mx-ro'nzx
�513 1'757L MB O.vgu
c^pncL rznc ncpr AneuL^
2 czvrc sm
CAnnsL, IN 4L032-25ov
67f/j i Is 68.71
oET wu:
uvp oso/xr
c/ixc:wo. :54199811
I NS
FYI L
�A(1429-Rll [al I Wo X j�7-
507 n*"pmxxnoR HAS ACCEPT ASmowwswTmowumxcaxc YOU ARE /mm, um,1umsnln PAY nw[,rTxc DIFFERENCE" xnn'cuw
TxsusmcAxcxnnov El) »moum'F^mmnswoxcAxEm,mcwl.
mo THESE EXPENSES *ExcwuoormuuICxnsyx/xoxYooxoxrccaLAwnxxcnnTs1uomEpoxxs/mmmxcmcmz
RRECEIVED JUN 2 4 2009
5419 80
Adminiqel-ed 13v
PA I t.
Em
PO 138x f 764'
NIAl" 110"
Sixt)� Eight 7 Dollars
OO nx/^�rruumou`m
]x}ID0 C&R�BL 8R£ DEPT &NBULA
�w
ORDER 2C[\/|CS0
OF
CA-RN£L. IN 46032
�ommnrf0^nmswmTsn MARK /awmrpREnsmrom THE RsysosE a/u=,urz*;soomomEw��xnuo�nAxwmsLennV
o"5�1 n:[]S P[]OO1, 131:990 30 3 L. 3:"
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
U n ails Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Mac S
K
Total �q 8
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
oa- IN SUM OF 1p J
s l laku
6Y7I
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. 1 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 a
[Nature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund