HomeMy WebLinkAbout202336 09/27/2011 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
ONE CIVIC SQUARE UNITED HEALTHCARE CHECK AMOUNT: $205.76
PO CARMEL, INDIANA 46032
SALT LAKE CITY CHECK NUMBER: 202336
UT 84131
ow
CHECK DATE: 9/27/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 205.76 OTHER EXPENSES
t n
n
n
i
iS
n
n a pe
CITY AI�MEL
AI�s BRAiNARD, MAYOR
September 21, 2011
United Healthcare
P.O. Box 31362
Salt Lake City, UT 84131
RE James ISbeIVID 967013 97920935 -00/ DOS 07/15/2011
Dear Sir /Madam:
Enclosed you will find a reimbursement check in the amount of $205.76. On August 26,
2011 we received a check from you in the amount of $205.76 for Mr. Isbell's ambulance
transport on July 15, 2011. On September 20, 2011 we received a check from Gallagher
Bassett for the total amount of the invoice. Since the workman's comp insurance is
primary, we are issuing you a refund of $205.76. If you have any questions, please feel free
to contact me at (317) 571 -2605.
Sincerely,
Bee y S. annan
Billing Administrator
CARNIEL FIRE DEPARTMENT
STEVEN A, COUTS HEADQUARTERS
Two CMC SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
Date: 09/21/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: JAMES T ISBELL ICD -9: 7802 78009 7804 9925
P.O. BOX 71
FORTVILLE, IN 46040
From: 14455 CLAY TERRACE BLVD
To: ST. VINCENTS HOSPITAL CARMEL
1 SECURE HORIZONS BY UHC
Patient: JAMES T ISBELL 979209350
P.O. BOX 71 Insurance
FORTVILLE, IN 46040- 2 GALLAGHER BASSETTi23812
Patient No: 201101923 CLM #003923 000195 -WC
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
$487.08 $692.84 205.76
CPT L At' �w� .l^wrJ'�k� °8P': a�ux �rt t n,�: ��a ....�,i: r ,l�.d ia� a!J�'vIS�' ✓Lt�: ic
p 2` I Ys d V 5' p4 w 4 MI..�,,i §Ir,Fu,., t _,r' i d
Date I D.escr�pfiia.n Vii.? w.., C.redits
r 6' •a Hs3, •r "ta..�.I ,fx q
i.c:dsa.�uw� �NU�'1� vp!I�Jill,! '�r.a. W �c
07/15/2011 ADVANCED FIFE SUPP 1 -EMER A0427 $475.00
07/15/2011 MILEAGE A0425 $12.08
08/26/2011 MEDICARE PAYMENT $205.76
08/26/2011 ASSIGNMENT MEDICARE $81.32
09/20/2011 COMMERCIAL INSURANCE PAYMENT $487.08
09/20/2011 ASSIGNMENT MEDICARE -81.32
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/21/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: JAMES T ISBELL ICD -9: 7802 78009 7804 9925
P.O. BOX 71
FORTVILLE, IN 46040
From: 14455 CLAY TERRACE BLVD
To: ST. VINCENTS HOSPITAL CARMEL
1 SECURE HORIZONS BY UHC
Patient: JAMES T ISBELL 979209350
P.O. BOX 71 Insurance
FORTVILLE, IN 46040- 2 GALLAGHER BASSETT /23812
Patient No: 201101923 CLM #003923 000195 -WC
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
$487.08 $487.08 $0.00
CPT
='w a 7tl i nL- '..Pal 'Vi' I' I• M'I I.. i�..k1 •W 'li.. Y„ ,T`
hr,�;,�.1 r. <3, a,. a,r, r�, P :a Ir •s.r:; .�r.'�.
D. li �u',�I�r����:, �E'.I• 'k 11 5 �'t� 1
scrip lion
eC�1tS 4r,
anelnra. ss. ti' n�+; ai.'. "kl:tl�, +*�la,.m,r a:asrsu,mratl iw?pu' sky%, M �a�, �Y, r�r" ''v����..'�g.'e.�s•s w:l,s.s
07/15/2011 ADVANCED LIFE SUPP 1 -EMER A0427 $475.00
07/15/2011 MILEAGE A0425 $12.08
08/26/2011 MEDICARE PAYMENT $205.76
08/26/2011 ASSIGNMENT MEDICARE $81.32
09/20/2011 COMMERCIAL INSURANCE PAYMENT $487.08
09/20/2011 ASSIGNMENT MEDICARE -81.32
09/21/2011 REFUND 205.76
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
t I
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
`�or�rlf 5 _1-
Total j 7
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
zllbV ed IN SUM OF
213b Z
7lp
ON ACCOUNT OF APPROPRIATION FOR
b�l e�►� d, e r�
Board Members
Po# or INVOICE NO. ACCT #(TITLE AMOUNT I hereby that the attached invoice or
DEPT. cert y s )e
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 2.1
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund