164799 10/16/2008 CITY OF CARMEL, INDIANA VENDOR: T362019 Page 1 of 1
ONE CIVIC SQUARE ILIYA KOPELEVICH
CHECK AMOUNT: $375.00
CARMEL, INDIANA 46032 131 BLAIRSDEN AVE
CARMEL IN 46032
CHECK NUMBER: 164799
CHECK DATE: 10/16/2008
DE ACCOUNT PO NUMBER INVOICE NUMB AMOUNT DESCRIPTION
102 5023990 375.00 AMBULANCE REFUND
Date: 10/03/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
P
Bill To: ILIYA KOPELEVICH ICD -9: 7802 78009 78079 4589
131 BLAIRSDEN AV
CARMEL, IN 46032
From: 131 BLAIRSDEN AV
To: HEART CENTER OF INDIANA
ANTHEM BC /BS/ 37010
Patient: ILIYA KOPELEVICH YRK543M63085
131 BLAIRSDEN AV Insurance
CARMEL, IN 46032 2
Patient No: 200801938
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
$375.00 $750.00 375.00
CPT
Date Description Charges Credits
08/04/2008 ADVANCED LIFE SUPP 1 —EMER A0427 $350.00
08/04/2008 MILEAGE A0425 $25.00
09/12/2008 PAYMENT $375.00
09/30/2008 BLUE SHIELD PAYMENT $375.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/03/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
�.ax �w w n S
Bill To: ILIYA KOPELEVICH ICD -9: 7802 78009 78079 4589
131 BLAIRSDEN AV
CARMEL, IN 46032
From: 131 BLAIRSDEN AV
To: HEART CENTER OF INDIANA
ANTHEM BC /BS/ 37010
Patient: ILIYA KOPELEVICH YRK543M63085
131 BLAIRSDEN AV Insurance
CARMEL, IN 46032 2
Patient No: 200801938
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
$375.00 $375.00 $0.00
CPT
Date Description Charges Credits
08/04/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
08/04/2008 MILEAGE A0425 $25.00
09/12/2008 PAYMENT $375.00
09/30/2008 BLUE SHIELD PAYMENT $375.00
10/03/2008 REFUND 375.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
ANTHEM INSURANCE COMPANIES, INC. JJJ 20522
DBA ANTHEM BLUE CROSS AND BLUE SHIELD
Anthem s 1351 WILLIAM HOWARD TAFT ROAD
CINCINNATI, OH 45206 -1775 1 of 3
An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
(9) Registered Marks Blue Cross and Blue Shield Association
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#BWNCQXF
#185999999493/DF9# HI01
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ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0304390659 DATE 09/24/08
P.O. BOX 37110 PROVIDER NAME CARMEL FIRE DEPT
LOUISVILLE, KY ,40233 -7110 ADDRESS 2 CARMEL CIVIC SO
CARMEL IN 46032
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PROVIDER ID NO 000000184493 1154325579
800- 345 -4344 TAX ID NO XXXXX0972
PAYMENT SUMMARY
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GROSS APPROVED CLAIM AMOUNT 375.00 r IRS WITHHELD 0.00
INTEREST PAID 0.00 AMOUNT PREVIOUSLY OVERPAID 0.00
f AMOUNT DISBURSED 375.00
NET AMOUNT DUE 375.00 RECOUPMENT BALANCE 0.00
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ID.N_Od "0000001844 09/24/0
Registered Marks Blue Cross and Blue Shield Association PROVIDER 93 8
CHECK 'NUMBER 0304390659
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TO AVOID ANY UNNECESSARY DELAYS IN CLAIMS PROCESSING, PLEASE INCLUDE
CURRENT COORDINATION OF BENEFITS (COB) INFORMATION WHEN SUBMITTING °�I�,jlVltl I h�III
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SERVICE CONTRACTUAL PROVIDER 4ESP EXPUANSI EXPUANSI
SERVICE DATE(S) CODES POS CHARGE ALLOWED DEDUCTIBLE CO-PAY CO- INSURANCE DIFFERENCE "AMOUNT CODE(S( �i�l U�P l i��iI RESAMOUINTLITY CODE(S(I1I1l
1 1 !i111. NETCPAID
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WSURED'S NAME: KOPELEVICH,ILIYA INSURED'S ID: 543M63085 ""`PATIENT NAME KOPELEVIGH ILIYA FORiINQUFf7EAL4:
PATIENT ACCOUNT 200801938 CLAIM NUMBER: 08261EC86800 RECEIVED DATE 09%15/2008' 6800) 1 34_i4 j
S ERVICE PROVIDER NAME: CARMEL FIRE DEPT 'SERVICE PROVIDER 10: 1154325579 p�'�111�11111j11 "'lid 711j1 j1'''I 4 1
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08/04/2008 08/04/2008 A0427RH 41 350.00 350.00 0.00 0.00 0.000.00 0.00 �I '0 00 350.00
08/04/2008 08/04/2008 A0425RH 41 25.00 25.00 0.00 0.00 0.00 0.00, "0.00 0:00 ;25.00
TOTAL: 375.00 375.00 0.00 0.00 0.00 0.00 0.00 0.00 375.00
INTEREST PAID �li illh: 0.00
TOTAL NET PAID 3 a
TOTAL 75.0
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TDTAL APPROVED AMOUNT 375.00
TOTAL INTEREST 1 X111111 �1!' IU' l 0.00
TOTAL NET AMOUNT DUE: HEALTHY INDIANA PLAN 375.00
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GROSS APPROVED CLAIM AMOUNT 375.00
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NET AMOUNT DUE 375.00
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Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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
i U Q �O p e l PYl L Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
u'
Total 75-
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.
ALLOWED 20
_Z, IN SUM OF 27,5
aarmeJ
3 75. 6'U
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
®CT 1 26
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund