203676 11/09/2011 CITY OF CARMEL, INDIANA VENDOR: 365795 Page 1 of 1
ONE CIVIC SQUARE RICHARD WHITTON
CARMEL, INDIANA 46032 12999 CHESNEY DR CHECK AMOUNT: $91.48
FISHERS IN 46037 CHECK NUMBER: 203675
CHECK DATE: 11/9/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 91.48 AMBUL REFUND
Oo0 W 1++
000 000 000
CITY �FAP� V IEL
JANmS BRAINARD, MAYOR
October 25, 2011
Mr. Richard Whitton
12999 Chesney Dr.
Fishers, IN 46037
RE: INVOICE #201002635/ D.O.S. 10/07/2010
Dear Mr. Whitton:
Enclosed you will find a reimbursement check in the amount of $91.48. On June 13,
2011 we received a check from MedShield for Mary Wheeler's ambulance transport on
October 7, 2010 in the amount of $91.48 ($107.62 less collection fees of $16.14). On
October 20, 2011 we received a check from Anthem Blue Cross Blue Shield in the
amount of $107.62 for the same ambulance transport. Since this invoice was paid in full,
I am issuing you a refund of $91.48.
If you have any questions, please feel free to contact me at (317) 571 -2605.
Sincerely,
Bec y S. Lannan
Billing Administrator
CARMEL FIRE DEPARTNIENI
STEVEN A. COUTs HEADQUARTERS
Two CIVIC SQUARE, CARNIUL IN 46032 OFFICE 317.571.2600, F. 317.571.2615
Date: 10/25/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: MARY A WHEELER ICD -9: 427.5
C/O WHITTOM 12999 CHESNEY DRIVE
FISHERS, IN 46037
From: 118 MEDICAL DR APT /SUITE# 709
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: MARY A WHEELER 312328801TA
118 MEDICAL DR 709 Insurance
CARMEL, IN 46032 2 ANTHEM BLUE CROSS &BLUE
Patient No: 201002635 UGG921650270
YOUR INSURANCE HAS DENIED THIS CLAIM. COVERAGE WAS NOT IN EFFECT ON THE DATE THE SERVICES WERE RENDERED.
THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$538.10 $629.58 -91.48
CPT
Description Chara"" Credits
z
10/07/2010 ADVANCED LIFE SUPP 2- EMERGENCY A0433 $525.00
10/07/2010 MILEAGE A0425 $13.10
10/28/2010 MEDICARE PAYMENT $430.48
06/13/2011 COLLECTION PAYMENT $91.48
06/13/2011 WRITE OFF- COLLECTION FEE $16.14
10/20/2011 BLUE SHIELD PAYMENT $107.62
10/25/2011 WRITE OFF- COLLECTION FEE -16.14
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/25/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: MARY A WHEELER ICD -9: 427.5
C/O WHITTOM 12999 CHESNEY DRIVE
FISHERS, IN 46037
From: 118 MEDICAL DR APT /SUITE# 709
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: MARY A WHEELER 312328801TA
118 MEDICAL DR 709 Insurance
ANTHEM BLUE CROSS &BLUE
CARMEL, IN 46032 2
Patient No: 201002635 UGG921650270
YOUR INSURANCE HAS DENIED THIS CLAIM. COVERAGE WAS NOT IN EFFECT ON THE DATE THE SERVICES WERE RENDERED.
THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$538.10 $538.10 $0.00
CPT
Date Descript'IOn Chases Credits
10/07/2010 ADVANCED LIFE SUPP 2- EMERGENCY A0433 $525.00
10/07/2010 MILEAGE A0425 $13.10
10/28/2010 MEDICARE PAYMENT $430.48
06/13/2011 COLLECTION PAYMENT $91.48
06/13/2011 WRITE OFF- COLLECTION FEE $16.14
1012012011 BLUE SHIELD PAYMENT $107.62
10/25/2011 WRITE OFF- COLLECTION FEE -16.14
10/25/2011 REFUND -91.48
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
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 g1 Z
2 9 9 q ehes,4 e41
ON ACCOUNT OF APPROPRIATION FOR
8r GU 2ee G nC•t v
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
s
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund