156340 02/06/2008 CITY OF CARMEL, INDIANA VENDOR: T360788 Page 1 of 1
ONE CIVIC SQUARE JEFFREY THOMAS
CARMEL, INDIANA 46032 6251.BURLINGTON AVE CHECK AMOUNT: $336.00
INDPLS IN 46220 CHECK NUMBER: 156340
CHECK DATE: 2/6/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 336.00 OTHER EXPENSES
I'N\ 31727
U rid e rT),T r G 1 1 la OF
Aetna L-1 insurance CcrnT-jan
SRC- all Aetna Compalm
P.O. Box 23759 1 For Assivance IT'rite or Ctill
Columbia. SC 29224
SRC. an Acina Compim
Forwarding Service Requested PO Box 23759
C011-Imbia- SC 29224-'� 759
E -DIGIT 460 For Providers Insureds
E172 D-7808 AT 0-3
1-88S'-772-9(i82
CARMEL FIRE DEPT AMBULANCE SRV Date: 12/,
CIVIC SQUARE
FOR Nu: 07 123 LAI lof�
CARMEL, IN 46032-25f3H
I Group: 7510'7 CI-AINCY'S M'..
➢dent: 3
Rec Date: 1 0/30/2000
Pavirrient Summary Towis
Charge: 3`4u.('17
Atw: CARMEL FIRE: MTTA.MBULANCE Sl\
350.07
This is an I explanation of mrvment for scrvlccs I eIILL.
cA I N ued Et ct
�::Paiivnt-; 200<0';i 94:..l I FH IFY: M1, 'If 10 N4 As
1),nes tit' Service I CPT Corse j Chan,'" I)iScololl rye-ductillic co-hiv ("o-Insill Otiler Ills ineliLlibiv Plan Fay., ll;t(. kespinis Ref'No. f
09/071/2006 091/07,!20061 A0425 i 36,00 .00 00 0.00� oo 36.00
.00
109/07, 09/07/2006 i AO 4 5 36.00 00 W om 00 :,(,00 00 2
j '(19/07/200t', 09/07/2006 !\0429 300.001 00 1 .00 0(1 300.00
109!07,!2006 09/0712 06 INFFE1 j 14,07 00 00 0 4.0 1 2 1 .00
mol
Claim Totals I 3X6.071 �00 00 mo .00 .00. 36�00. 3S0.0 ool
es
I This is d dUjAiC.Ite charge that was I)IeVIOLISiV 001ISi(JOIC(I
2 We have reconsidered this claim (lite 11) Chil1l2eS in the m0U[) i)km and arc making additional pavinent. li'tims additional povillent results in ovelpilvilleill wQ nsL that
VOU refund Lice member- For the pLlmosz: ot'delerillimilp the bcllCi`1tS JMYal)IC under the (tItpatient I)wpostic and Surgical Services benefit_ in addition to the ofiicc visit
copay, oiil one copin is applied Ior all other services provided during any one visit to ii provid
I 1'243902101
FOR SECUFNTY PURPOSES THE FACE OF THIS DOCUMENIT CONTAINS E A' S;- U E: BACKGFZOUND ANC') M[C 30RC
t H.
na 1, Insuratice'lCtimpany
:cH E ck N Z' '000iu-, ovu�
f S S U —F 'D kT'E. 1
AmOuNT
PAY THREE HUNDRED FIFTY AND417/100 3 5, 0 0 7
17) DOLLARS
—7 TO THE CARMEL FIRE DEPT AMBULANCE SR\17 Administered by: SRC an Aetna Company
(70 ORDER OF CIVIC SQUARE pu B.2-3759
C.I—h SC
C. IN 46032-7543
(1] ffiAHTL DFLAWAR-E
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INTW CA. TLL- T)i 19720
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Date: 01/18/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal tD# 356000972
Bill To: JEFFERY M THOMAS ICD -9: 78079 4019
6251 BURLINGTON AVENUE
INDIANAPOLIS, IN 46220
From: 431 SB LN SO OF 96TH ST
To: ST. VINCENT CARMEL
1 STRATEGIC RESOURCE CO
Patient: JEFFERY M THOMAS 304867710
6251 BURLINGTON AVENUE Insurance
INDIANAPOLIS, IN 46220- 2
Patient No: 200602384
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$336.00 $336.00 $0.00
CPT
Date Description Charges Credits
09/07/2006 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
09/07/2006 MILEAGE A0425 $36.00
11/28/2006 PAYMENT $136.00
12/08/2006 PAYMENT $100.00
12/22/2006 PAYMENT 5100.00
01/15/2008 COMMERCIAL INSURANCE PAYMENT $350.07
01/15/2008 WRITE OFF- TNSURANCE $-14.07
01/18/2008 REFUND 336.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/18/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
Bill To: JEFFERY M THOMAS ICD -9: 78079 4019
6251 BURLINGTON AVENUE
INDIANAPOLIS, IN 46220
From: 431 SB LN SO OF 96TH ST
To: ST. VINCENT CARMEL
1 STRATEGIC RESOURCE CO
Patient: JEFFERY M THOMAS 304867710
6251 BURLINGTON AVENUE Insurance
INDIANAPOLIS, IN 46220- 2
Patient No: 200602384
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$336.00 $672.00 336.00
CPT
Date Description Charges Credits
09/07/2006 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
09/07/2006 MILEAGE A0425 $36.00
11/28/2006 PAYMENT $136.00
12/08/2006 PAYMENT $100.00
12/22/2006 PAYMENT $100.00
01/15 /2008 COMMERCIAL INSURANCE PAYMENT $350.07
01/15/2008 WP.ITE OFF- INSUR -ANCE
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
---/(f Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
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
IN SUM OF
3 --R (a, 6-0 v
ON ACCOUNT OF APPROPRIATION FOR
A bul oAc e Lufi4o& A��o�
!e�y�
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
v
r
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund