Loading...
HomeMy WebLinkAbout172710 05/27/2009 CITY OF CARMEL INDIANA VENDOR: 356246 Page 1 of 1 ONE CIVIC SQUARE AETNA CARMEL, INDIANA 46032 PO BOX 981107 CHECK AMOUNT: $64.19 EL PASO TX 79998 -1107 CHECK NUMBER: 172710 CHECK DATE: 512712009 VEPARTME A CCOUNT PO NUMBE I NVOICE NUMBER AMOUNT DESCRIPTION ,02 5023990 64.19 OTHER EXPENSES Date: 05/18/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: FRED I MCBROOM ICD -9: 78009 2512 7808 78079 10599 HUNTERSFIELD DR CARMEL, IN 46032 From: 10599 HUNTERSFIELD DR To: CLARIAN HOSPITAL NORTH 1 MEDICARE PART 8 Patient: FRED I MCBROOM 306448863A 10599 HUNTERSFIELD DR Insurance CARMEL, IN 46032 2 MUTUAL OF OMAHA Patient No: 200900511 74900899 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $401.20 $465.39 -64.19 CPT Date Description Charges Credits 02/22/2009 ADVANCED LIFE SUPP 1 -EHER ,A,0427 $375.00 02/22/2009 MILEAGE A0425 $26.20 04/21/2009 MEDICARE PAYMENT $320.96 05/05/2009 COMMERCIAL INSURANCE PAYMENT $64.19 03/05/2009 COMMERCIAL INSURANCE PAYMENT $80.24 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 05/18/2009 I CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 ,t Bill To: FRED I MCBROOM ICD -9: 78009 2512 7808 78079 10599 HUNTERSFIELD DR CARMEL, IN 46032 From: 10599 HUNTERSFIELD DR To: CLARIAN HOSPITAL NORTH MEDICARE PART 6 Patient: FRED I MCBROOM 306448863A 10599 HUNTERSFIELD DR Insurance CARMEL, IN 46032 2 MUTUAL OF OMAHA Patient No: 200900511 74900899 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $401.20 $401.20 $0.00 CPT Date Description Charges Credits 02/22/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00 02/22/2009 MILEAGE A0425 $26.20 04/21/2009 MEDICARE PAYMENT $320.96 05/05/2009 COMMERCIAL INSURANCE PAYMENT $64.19 05/05/2009 COMMERCIAL INSURANCE PAYMENT $80.24 05/18/2009 REFUND -64.19 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 REPORT GW2232 Explanation of Payment Report PAGE 1 PERIOD ENDING DATE 04/21/09 CITY OF CARMEL FIRE DER DRAFT /CHECK NUMBER: 00945958 4 2 CIVIC SO United World Life Insurance DIRECT INQUIRIES TO: CARMEL IN 46032 UNITED WORLD LIFE IF YOU HAVE ANY QUESTIONS. CALL: INSURANCE COMPANY PROVIDER ID: 3316 FARNAM ST (877) 617 -5587 OMAHA, NE 68175 -0001 CLAIMS PROCESSED UNDER TIN /EIN: 356000972 lsured's Name 'atient 'olicy Number :ert Number Date of Less Charges Remaining ;laim Number Service Submitted Not Covered Less Considered Benefit Balance ,ccount Number From 7 Procedure Charges Amount Note Balance Deductible Charges Amount Due :BROOM /FREDERICK/ :LF 022209 022209 AMBULANC 375.00 022209 022209 AMBULANC 26.20 !9008 -99W 80.24 100 80.24 320.96 1 53322676200 -050 )0900511 TOTAL 401.20 80.24 ITAL PAID: 80.24 )TES: 1 THIS IS THE AMOUNT PAID BY MEDICARE. RECEIVED MAY 6 5 2699: THE'FAC OF S DOCUPlEI iT`F Au F, COLO tEU k0 CCxFtOIJfv�s� 01I WFkITE FAF'EFt. T'-iE €3ACI. THl �)r THES:Dt)r Ui'diEN f CG)IdTAIlVS Ai f hi1T{Fi 'iAL L fr�3 iivlF.ni N0I_D AT Aid AIvC,E s TO- VIE441 ..PAYABLE THRU =;FIRST-NATIONAL -BANK OF'OMAHA 1049> CD 101MAHA, NE 68102 UNITED`WORLD LIFE •FREMONT NATIONAL BANK &TRUST CO a INSURANCE COMPANY z 'DATE­­, DRAFT NO APR 21 '2.009 00945958.. 009459'58 8024 34385 .2209 CLAIM;NO. 4 AMOUNT F 5833'22676200; 050 80.14 PAY TO THE ORDER OF PLEASE CASH IMMEDIATELY ACCT 2 58 POLICY /PLAN NUMBER 74 99 W CITY OF CARMEL FIRE DEP 2 CIVIC SQ CARMEL IN 46032 AUTHORIZED SIGNATLIRE n °0094 5 9 S8 110 1: 1049000481[0 ❑g L0 1 4 4 7n� 000165 JIK2PJD 000438 C� �a P.O. BOO 961107 EXPLANATION O i BENEF►T na et EL PASO, TO 79998.1107 1 11 USA Please Retain for Future Reference CITY OF CARMEL FIRE DEPT. I PtN: 0005745100 Check No: 096171067872853 Page 2 of 3 (1 Date Printed: 0412812009. CITY OF CARMEL FIRE DEPT, Tax Identification Number:' sXXXXXXXX 2 CIVIC SQ Check.Number. .098171067872853 CARMEL IN 46032 -2584 GheckAmount. $396.91 I l" IM11I11111111111I1L11111111 [loll 11l,1lllls11 fit ItIll1I W IVED MAY 0 5 2009 Notes: Update your address, telephone number, email address and /or NPI information by visiting www.aetna.com /provweb/ or www.aetnadental.com and select Update Personal Information. Patient Name: FRED R MCBROOM (Self) Claim ID: EOPAG22C400 Recd: 04/21/09 Member ID: W090177135 Patient Account: 200900511 Member: FRED R MC'BROOM It DIAL: 78009 2512 7808 Group Name: GANNETT CO., INC. Group Number: 398683 -13 -261 UP DASU)0 Product: Open Choice@ Network ID: 00000 Aetna Life Insurance Company :;SERVICE :?PL SERVICE.. NUM:' SUBMITTED 3'':ALLOWABLE :COPAY NOT, „i_ 'SEE DEDUCTIBLE CO'r: PATIENT PAYABLE DATES 7 CODE "SVCS CHARGES AMOUNT(: AMOUNT .:'PAYABLE REMARKS :1MSURANCE„ RESP "'AMOUNT 02122/09 41 A0427RH 1.0 37500 300.00 1 15.00 15.00 6000 02122109 41 A0425RH 4.0 26.20 2096 1 1.05 1:05 419 TOTALS 401.20 320.96 16.05 ''16 5 :64:19 ISSUEi7:AMT: $6419 Remarks: I -This amount was paid by Medicare, which is the primary carrier. The memberis not responsible for this amount. For Questions, Regarding Thls:Claim P.''O BOX 981 EL PASO TX :79996 1107:. Total .Patient: Responsiblllty. $16.05` CA (88U632 3862 FOB ASSISTANCE Clalrn Payment $64:19 .Note AlLanqurnesshould reference fhe 1D number above for prdmpf response Patient Name: JAMES E SHAW (son) Claim ID: EQ34G2MGC00 Recd: 04/20/09 Member ID: W142786992 Patient Account: 200900494 Member: MICHAEL C SHAW DIAG: 780097845 30550 Group Name: THE DOW CHEMICAL COMPANY Group Number: 783135 -35 -001 AS D7 «60 Product: Aexcel@ Plus Open Choice@ Network ID: 00000 Aetna Life Insurance Company SERVICE pl SERVICE NUM" SUBMITTED ALLOWABLE COPAY .C: NOT SEE .I: DEDUCTIBLE CO PATIENT PAYABLE >DATES 'CODE 'SVCS CHARGES.: :AMOUNT AMOVNT PAYABLE REMARKS !�INSURANCE'�: "IRESP AMOUNT 02/20/09 41 A0429RH 1.0 325.00 48.75 48.75 275.25 02/20109 41 A0425RH 10.0 65 9.83 9 83 ':55.67 TOTALS 390.50 58.58 58.58 ;:331.92 ISSUED AMT $331:92 Continued on Nnrt Parrp X P.O, BOX 981107 r f�q g�pgLp� EL PASO, TX 79998 -1107 L,LA1 I I �VI E tl T 1 g USA Please Retain for Future Referent¢ 0110]65 J1K2PJC OOU437 CITY OF CARMEL FIRE DEPT. PIN: 0005745101 Page 1 of 3 (1) CITY OF CARMEL FIRE DEPT. 2 CIVIC SO CARMEL IN 46032 -2584 MAY waa rr us�rsg n ux FAfti r a yrnvar�sn..wr, Aetna Life fnsurence Company or an Affiliated Company ID No:.'XXXXXXXX0972 frheC{( 067872853.:. X gent f s asAgent.tor S eci6ed Pa el Seq`Na: 000OOOD04 Acct:' 09817 p y EL PAS TX 79998-1107 4 r�'''I r y'"al�'( l.h I 4 r R C4 ri s 119 CT �'1�1. �V }`I i4Vi�ff�V 4 POLICYHOLDER MULTIPLE M'a I'li �lalg �uk qq.. r,a�R' ri 1 x yak +nu k '04 -28 -2009 I tlr`�ip':" r1.I x'19 �rl:y a •?7R,,1 iiq i' r. k "'i a 7 �ruqq'�,,r a °r,.a71" ,�r•,7,a a.- :II r Ra.'�' ,t'; M �s.Yir.�l lq. ,'1i�m• r �,�fi �1 1 �i 9 t. 04 J1d 1.., �.r„ fyGY,'�!,9y'f, hr. il,,:.'d� o t,ay. �ri N 1 T ;f F.. F �f rC 1 d�.1, rw�d7:,r,�' s 'ri�adM�: .Y, PAY.; 6x11,,. hree Hundred M1nery Six Dollars and .1/100; A fr t,� ht 1Ft c k ',f y �9 a, �c k m rw V1 u,a a ui N ,r Is 1 r�G;O,iu +V.:�:; l yt11 r r• rf. 'V r y x �i�.r�ti 1.h °'NAr :�y rBl riMr t 'r Ir 14 a',,,. 1 1 .9 1t 1 111 ti s'`4 6, i =r �I au ',t. I y i II,T�,'V ^NI r i x r x ay a �x x�s;,;,� 6 d �1 I r r '4N FIB, d 1 lllt f l �fi dy�UOID A�F.ER ON NEAR TO THE CARMEL FIRE DEPTARTMENT ORDER OF 2 5Qyr <i i i u N r�ff4�rro rro qlr C� °nw:,. 9 m y 2 1 CA' RMEL IN4603^L 2584. HJf�I t I;. 1 iNfy I �Ct �rpf:l wS r ,11, P R dl Ll Y lNd. �A snl Bank a1Am f �1M II J! I�wp 611 tµ� I a 7eG (10.021 i Al i a:r a'Ai �SI1, hl'11d u�lhl r1�;, ,uf d t ,lp lal dyNulil'�� µi�1� dfI111 l k Ir w' ha II °;0 6 7 8 7 28 5 3 Rio t o 01 b "9 0b L. '[-."5 t: 0 O'©0 0 0'D PSescribed 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. k4V2 Pa yee Q Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) ern e fir O ✓er 42 a44 m r- Total 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 IN SUM OF 2046x 9o('110 ,C- �Q���X 7 9'? ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or �Z 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 MAY 2 2 2009 P Alp 20 i Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund