HomeMy WebLinkAbout203114 10/25/2001 a „�f CITY OF CARMEL, INDIANA VENDOR: 365724 Page 1 of 1
ONE CIVIC SQUARE SHOBHA PAREDDY
INDIANA 46032 CHECK AMOUNT: $60.78
CARMEL
665 WOODBINE DR E
CARMEL IN 46033 CHECK NUMBER: 203114
CHECK DATE: 10/25/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 60.78 REFUND
Date: 10/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: DAYAKAR R PAREDDY ICD 9: V714 E8130
665 WOODBINE DR
CARMEL, IN 46033
From: 146TH &GRAY RD
To: ST. VINCENTS HOSPITAL CARMEL
1 AETNA US HEALTHCARE /981106
Patient: VIKESH R PAREDDY 00041738101
665 WOODBINE DR Insurance
CARMEL, IN 46033- 2
Patient No: 201100725
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
$405.20 $465.98 -60.78
CPT
Date m Descrlption f TM
i
Credits
03/05/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
03/05/2011 MILEAGE A0425 $30.20
04/05/2011 COMMERCIAL INSURANCE PAYMENT $344.42
05/20/2011 PAYMENT $60.78
09/30/2011 COMMERCIAL INSURANCE PAYMENT $60.78
OF ACCOUNTS FOR C1TY OF CARMEL, 1999
PQQ�p�E�
Date: 10/12/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
ACCOUNT HISTORY
Bill To: DAYAKAR R PAREDDY ICD 9: V714 E8130
665 WOODBINE DR
CARMEL, IN 46033
From: 146TH &GRAY RD
To: ST. VINCENTS HOSPITAL CARMEL
AETNA US HEALTHCARE /981106
Patient: VIKESH R PAREDDY 00041738101
665 WOODBINE DR Insurance
CARMEL, IN 46033- 2
Patient No: 201100725
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
$405.20 $405.20 $0.00
CPT
Description CHarc Credits
N
03/05/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
03/05/2011 MILEAGE A0425 $30.20
04/05/2011 COMMERCIAL INSURANCE PAYMENT $344.42
05/20/2011 PAYMENT $60.78
09/30/2011 COMMERCIAL INSURANCE PAYMENT $60.78
10/12/2011 REFUND -60.78
FPPRO�JEO 8Y 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
a: Ckre Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
�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
WARRANT NO.
ALLOWED 20
IN SUM OF
60 7 1
ON ACCOUNT OF APPROPRIATION FOR
5.
r
�2C� f`LC�GL D
Board Members
,t. PT. INVOICE NO. ACCT #/TITLE AMOUNT 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
OCT 24 2099
t t
r
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund