HomeMy WebLinkAbout202154 09/27/2011 CITY OF CARMEL, INDIANA VENDOR: T357065 Page 1 of 1
ONE CIVIC SQUARE HUMANA CHECK AMOUNT: $352.98
CARMEL, INDIANA 46032 PO BOX 14610
LEXINGTON KY 40512 CHECK NUMBER: 202154
CHECK DATE: 9/27/2011
DEPARTMENT ACCOUNT P O NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 352.98 AMBULANCE REFUND
Date: 09/21/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederaiiD# 356000972
ACCOUNT HISTORY
Bill To: CHALA LAGONI ICD -9: 7840 78702 E8130
6021 CHESTNUT DR
ANDERSON, IN 46013
From: 10101 N MERIDIAN ST
To: ST. VINCENTS HOSPITAL CARMEL
HUMANA CHOICE FIRST
Patient: CHALA LAGONI 004374986011
6021 CHESTNUT DR Insurance
ANDERSON, IN 46013- 2
Patient No: 201101906
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU
Total Amount Total Paid Balance
$407.47 $733.45 325.98
CPT
IJpaa' +.p rs,.;� In u;,p J_ "IZk idi {H a. dyl���I .I:,`E 'Ur'S -.�f3i r "s i�M: ,�J't'x k. a., x
i Descr•IptIon M r Y {,I; M :r ul E 7 Char4es X' {n' Credits
Date g
t i b l�� r s I I�r!"7
07/13/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
07/13/2011 MILEAGE A0425 $32.47
08/16/2011 COMMERCIAL INSURANCE PAYMENT $325.98
09/08/2011 COMMERCIAL INSURANCE PAYMENT $382.55
09/15/2011 COMMERCIAL INSURANCE PAYMENT $24.92
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/21/2011
i
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federaim# 356000972
ACCOUNT HISTORY
Sill To: CHALA LAGONI ICD -9: 7840 78702 E8130
6021 CHESTNUT DR
ANDERSON, IN 46013
From: 10101 N MERIDIAN 5T
To: ST. VINCENTS HOSPITAL CARMEL
1 HUMANA CHOICE FIRST
Patient: CHALA LAGONI 00.4374986011
6021 CHESTNUT DR Insurance
ANDERSON, IN 46013- 2
Patient No: 201101906
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$407.47 $407.47 $0.00
CPT
Y�rt:�ti�, c erra.m:n �q i v :i, ix ,s k dl �I llq �3s!If �m�t,+n n e•. =17x3 yn S a,ulipj,
Date fi d4^ i 4, D'escrlption III .,b I ti �1 Cflaraes )I Credlf's
E- .r.,._ ,7 Jr�i�fi ��,�t.��` �"�S H,y ff: i`:a @F1.�1111�11 77 c$ �.il l4�il���l��r ':��I�'Y�'�J nF by ^ui. iuu .,us�� .v ��ie .i.,
y
07/13/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
07/13/2011 MILEAGE A0425 $32.47
08/16/2011 COMMERCIAL INSURANCE PAYMENT $325.98
09/08/2011 COMMERCIAL INSURANCE PAYMENT $382.55
09/15/2011 COMMERCIAL INSURANCE PAYMENT $24.92
09/21/2011 REFUND 325.98
I
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
Z21') a- Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
sem
-o
Total 35
I hereby certify that the ittached 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 9
ex,'g a Yom 12-
ON ACCOUNT OF APPROPRIATION FOR
Board Members
P09 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
SEP 2 014
s� n
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund