HomeMy WebLinkAbout165962 11/12/2008 CITY OF CARMEL, INDIANA VENDOR: 360209 Page 1 of 1
C ONE CIVIC SQUARE ST VINCENTS HOSPITAL CARMEL
CARMEL, INDIANA 46032 4685 REIABLE PARKWAY CHECK AMOUNT: $465.D0
CHICAGO IL 60686 -0046
CHECK NUMBER: 165962
CHECK DATE: 1111212008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1150 4340799 465.00 OTHER MEDICAL FEES
4
Oct. 30. 2008 41AM C PROMS No. 9338 P. 2/2
1 BROOxszR P KWY j'A-a� C y
Bob CARMEL IN 46033 n
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HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08106 PICA FTJ 1
2 PICA
1, MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER to ENSIIRED'S I.D. NUMBER (For Pmgrdmm Item l)
CHAMPU9 HEALTH PLAN BLKLUNG
{Mod %care D IM001card Aq F-1 (Sponsor's 551v) (AAemba tom% (SSN or 11)) (SSM) E (to) 31 1065149
2, PATIENT'S NAME (Last Name, Grel Na me, Middle Initial) P 71ENT5 BIR'T'H y�, TE SEX 4, INSUREO'S NAME (Luel Name. Fiml Name. Middle Initial)
WILLY NICHOLAS S F WILLY NICHOLAS
5. PATIENT'$ ADDRESS (No.. SV890 5. PATIENT RELATIONSRIP TO INSURED 7, IN5URED'S ADDRESS (No.. Streel)
1870 E 106TH ST Seu®Spousa ChndF� Other 1870 E 106TH' ST
LSIAT 8. PATIENT STATUS CITY STATE z
C17Y IN 0
CARMEL SlnOm Married olhprl l CARMEL r
I ZIP CODE TELEPHONE Include Area Code) Q
TELEPHONE (Include Aree Code)
ZIP CODE ti
Full•Tima Pan -Firms 4 6 0 3 2 E HON 8 4 4- 4 4 3 3 p
46032 (317 84 4 4 4 3 3 Employed L1 5wdenl 5ludanl
9. OTHER INSURED NAME (Less Name. Firel Nikmo, Middle Initial) 10. 19 PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER 2
n
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e. EMPLOYMENY? (Cuaent OF FNAQU51 a, INSURE DATE OF BIRTH SEX
e• OTHER INSUREDS POLICY OR GROUP NUMBER
b. O INS SEX
ATE OF BIRTH SEK b- AUTO ACCIDENT? PLACE (Slele) b. EMPLOYER'S NAME OR SCHOOL NAME Z
M❑ F[] YES N I BROOKSHIRE GOLF CLUB a
C. EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? c. (NSURANOE PLAN NAME OR PROGRAM NAME W
®NO GENERIC WORK COMP
El YES
a
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFIT PLAN? fl
YES NO r(yes, return to and complete item 9 a-d,
READ BACK. OF FORM BEFORE COMPLETING SIGNING THIS FORM, 13. INSURED S OR AUTHORIZE PERSON'S SIGNATIJR!� I aurnonee
12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorise the release of any medlcel or okhcr intolfir lon npoesaary peympnl Of medleel benpfils to the undersigned ohysiden Or ouppller for
10 V'Oc;pgt 11518clelm. I alsv request payment of govemmanl benefits ellller to mYyall Of 10 the Pady wno aoceplS asslgnrn6n1 aervlces da5�rbed below.
below.
SIGNED SIGN O N FIDE DATE _10 29 08 SIGNED- SIGN O N FILE
14. DATE OF URpE�N(T: ILLNESS (First symptom) OR 15, IF PATIENT HAS HAD SAME OR S ILLNESS. 18. DATES PAITIENC UNABLEYO WORK IN CUP85NT OGCUPATIOY
LJ 1 i tyY INJURY (Ac4ldertl) OR GIVE FIRST DATE 1°IFA FROM I DO i TO DD
PREGNANCY(IJAP)
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 178. 1B. HOSPIT
DD DATES RELATED TO CURRENT ODERVICE YY
I
17b. NPI-------- FROM TO I
19. RES °EPVED FOR LOCAL USE 20. OUTSIDE LAS? S CHARGES
1 E NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (A.91210 IlemB 1, 2.3 9r4 to (ism 24E Iry Line) 22. COD£ A ID RESUBMISSION ORIGINAL REF. NO.
1. 1 891 0 j
23. PRIOR AUTHORIZATION NUMBER J4 z
24. A OATE(S) OF SERVICE B. C. D. PROCEDU S, SERVICES, OR SUPPLIES E• F DA s p AENOFRING Q
From TO PLACE OF (ExplalmUnueualCi"nistances) DIAGNOSIS OR
MM DO 1 (y MM DO YY SERVCE EMG CPTIHGPCS MODIFIER POINTER SC14AAGES UNITS P ANAL. PROVIDER1D.s
1 07118 OS 07 181 08 23 99283 25 1 196.0'IO 1 NaIV 19222'10933 0
LL
2 071 18. 06 07.18, 08 23 12001 i 1 269.00 1 Hal �9222TT(5333 w
J
3 I i 1 NPI
NPI O
Z
5 I 1 V
NPI
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y
NPI
N I'{ M M
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT'5 ACCOUNT NO- 27. ED IT A l S 66pedeh) T? 28 TOTAL CHARGE 29. AMOUNT PAID L,e0- BALAN CE: DUe
351175224 e06431919 ❑YE$ C]NO S 465 s 465'
31, SIGNATURE OF PHYSICIAN OR SUPPLIER 3Z. SERVICE FACILITY LOCATION INFORMATION 33, BILLING PROVIDER INFO PH M 8 U 2 3 T4 O
CLUDINGDEGREESOR the re TIALS
(I cpnify Ih811ne elatempnlS o the ST VINCENT HOSPITAL CARMEL ST VINCENT ER PHYSICIANS
(I
Mp1 landaremadeapanthereol.) 13500 NORTH MERIDIAN ST 4685 RELIABLE PARKWAY
KUSEK DO i CARMEL IN 46032 -1456 CHICAGO IL 60686 -0046
SIGNED 10/29/2008 DATE 1 116391-24134 b. a� 1306891700 bG2
SIGNED
Manual available at: www nucc.Grg PL EASEPR/NTOR TYPE APPROVED OMG-0938.0999 FORM CMS -1500 (08 -06)
NUCC 47 /woR /P
Prescribed by Slate 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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1
Total Zo
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
INS
c��g Ccada(e P
/L
ON ACCOUNT OF APPROPRIATION FOR
Board Members
.PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT..# I hereby certify that the attached invoice(s), or
c/'f p qg bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
i
received except
A
20
Signature Y e Ad.
Cost distribution ledger classification if Title Director of Golf
claim paid motor vehicle highway fund