179103 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1
ONE CIVIC SQUARE AETNA CHECK AMOUNT: $344.65
CARMEL, INDIANA 46032 PO BOX 981107
EL PASO TX 79998-1107 CHECK NUMBER: 179103
CHECK DATE: 11111/2009
bEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 344.65 OTHER EXPENSES
I
000892 JiK2PJP 007075
k Aetna
S 081107 E XP LANATION wF BEiV E ..3
kAet ..a�L �L USAA50, Tx 79998-1107
Please Retain for Future Reference
CITY OF CARMEL FIRE DEPT. 1 PIN: 0005745100
Check No 098161001836342
Page 2 of 2 (1)
Date Printed: 09/29/2009
CITY OF CARMEL FIRE DEPT. Tax Identification Number: XXX,XXXXX0972
2 CIVIC SQ Check Number: 098161001838342
CARMEL IN 46032-2584 Check Amount: $344.65
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Notes:
Update your address, telephone number, email address and/or N PI information by visiting www.aetna.com /provweb/ or
www.aetnadental com and select Update Personal Information.
Patient Name: BRAD KAPLAN (sore)
Claim ID: EAJKJNH6J00 Recd: 09/14/09 Member ID: W156397617. Patient Account: 200902216
Member: MICHAEL KAPLAN a I DIAG: 7231 7241 E9172
Group Name: FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM (FEHBP) Group Number: 800106 -32 -223 EA DB40WO
Product: Aetna HealthFundO Open Choice® PPO Network ID: 00000
Aetna Life Insurance Company
'""'sue SERVICE PL :SERUIGt NUM:'s 5UGMITTEO 'I'RLLONIA9tE- :COPAY NOT SEE ?I. 0EDl1GTISLE CO J'PATIEPIL :I PAYABLE
04TE5 CODE SVGS CHARGES FU 40UMT'<' PrlOUNT PAYABLE INSURANCE F.EaF AtdOUhIT,
98129109 41 A0429SH 1.0 32500 32500
08129109 41 A0425SH 3.0 1965 10 65
TOTALS 344.65 344.65
ISSUED AMT: $344.65
For Questions Regarding This Claim
P.O. BOX 981109 EL PASO, TX 79998 -1109 Total Patient Responsibility: $0.00
CALL (888) 632 3862 FOR ASSISTANCE Claim Payment: $344.05
Note: All inquiries should reference the ID numberabove for prompt response.
Total Piymdht.'to:: CITY OF CARMEL FIRE DEPT: $344.65
Protecting the privacy of member health information is a top priority at Aetna. When contacting us about this statement or for help with other questions, please be
prepared to provide your Aetna provider number, tax identification number (TIN), or Social Security number (SSN), in addition to the Aetna mernber's ID number.
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P.O. BOX 981107 �`I lA /i Y �p r/� JT
)(Aetna
USA
79998.1107 '4/L/`1I1U1 !i Y1VIC/
USA
Please Retain for Future Reference
000892 J1K2PJ0 007072
CITY OF CARMEL FIRE DEPT. l PIN: 0005745100
Page 1 of 2 (1)
CITY OF CARMEL FIRE DEPT.
2 CIVIC SQ
CARMEL IN 46032 -2584
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PHTLADELPHIAINDEMNITY INSURANCE COMPANY
DATE. CHECK NUMBER
CLAIMS ACCOUNT
PHILADELPHIA,PA
ONE GALA PLAZA'
suTrEloa 3 .so 10/28/2009 1110740802
'•EALA CYNWYD, PA 19004'.. :I 310
POLICY HOLDER FIVE SEASONS COUNTRY CLUBS, INC. AMOUNT
CLAIM PHHF09090418462 DOI. 08!29/2009
POLICY NUMBER PHPK367105 PAYMENT PARTIAL 3 4 4 5 5
TYPE LOSS:;
PAY Three hundred forty four and 65 1100 Dollars
PAY TO CARMEL FIRE DEPARTMENT
THE ORDER
OF
sm
TWO SIGNATURES: REQUIRED IF OVER'SI0,000
oe o
11 L L LEI? 1,08D 2no 1:0 3 L000 50 31: 2 L0000 3 119 L 9 3 711
YOUR INVOICE NUMBER
(if applicable)
COMMENTS
patient: Brad Kaplan
Date of trip 08/29/09
Patient no. 200902216
MAIL TO
CARMEL FIRE DEPARTMENT
2 CIVIC SQUARE
CARMEL, IN 46032
RECEIV NOV a 3 2G,
IF THERE ARE ANY QUESTIONS CONCERNING THIS PAYMENT CONTACT OUR CLAIMS DEPARTMENT AT 1 -800- 765 -9749, PLEASE REFERENCE THE CLAIM NUMBER WHEN CALLING.
Date: 11/05/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ID# 356000972
R
Bill To: MICHAEL KAPLAN ICD -9: 7231 7241 E9172
677 BEAVERBROOK DR
CARMEL, IN 46032
From: 1300E 96TH ST
To: CLARIAN HOSPITAL NORTH
9 AETNA US HEALTHCARE /981106
Patient: BRAD KAPLAN VV1 563976 1 7
677 BEAVERBROOK DR Insurance
CARMEL, IN 46032- 2
Patient No: 200902216
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
$344.65 $344.65 $0.00
CPT
Date Description Charges Credits
08/29/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
08/'29/2009 MILEAGE A0425 $19.65
10/06/2009 COMMERCIAL INSURANCE PAYMENT $344.65
11/03/2009 COMMERCIAL INSURANCE PAYMENT $344.65
11/05/2009 REFUND 344.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL. 1999
Date: 11/05/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ►D# 356000972
Bill To: MICHAEL KAPLAN ICD -9: 7231 7241 E9172
677 BEAVERBROOK DR
CARMEL, IN 46032
From: 1300E 96TH ST
To: CLARIAN HOSPITAL NORTH
1 AETNA US HEALTHCARE /981106
Patient: BRAD KAPLAN VV156397617
677 BEAVERBROOK DR Insurance
CARMEL, IN 46032- 2
Patient No: 200902216
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
$344.65 $689.30 344.65
CPT
Date Description Charges Credits
08/29/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
08/29/2009 MILEAGE A0425 $19.65
10/06/2009 COMMERCIAL INSURANCE PAYMENT $344.65
11/03/2009 COMMERCIAL INSURANCE PAYMENT $344.65
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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))
5
0J-L
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
X 5 2 0 YEZ/ 0 7
Za -!�k), 76 WI,?
ON ACCOUNT OF APPROPRIATION FOR
2k bu /Q�c�e /7diVO
j 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
NOV 71109
9C
I LZd
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund