HomeMy WebLinkAbout204138 12/06/2011 CITY OF CARMEL, INDIANA VENDOR: T359686 Page 1 of 1
ONE CIVIC SQUARE ANTHEM BLUE CROSS BLUE SHIELD CHECK AMOUNT: $313.03
CARMEL, INDIANA 46032 1351 WILLIAM HOWARD TAFT TD
s� CINCINNATI OH 45206 CHECK NUMBER: 204138
CHECK DATE: 12/6/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 313.03 OTHER EXPENSES
Date: 12/01/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: CHARLES HOTCHKISS ICD -9: 789.00
12130 OLD MERIDIAN ST #103
CARMEL, IN 46032
From: 12130 OLD MERIDIAN
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: CHARLES HOTCHKISS 383346594A
12130 OLD MERIDIAN ST #103 Insurance
CARMEL, IN 46032 2 ANTHEM BLUE CROSS BLUE
Patient No: 201102648 UGD921570488
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$380.29 $693.32 313.03
CPT
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09/30/2011 BASIC LIFE SUPP EMERGENCY A0429 $375.00
09/30/2011 MILEAGE A0425 $5.29
11/10/2011 BLUE SHIELD PAYMENT $380.29
11/22/2011 MEDICARE PAYMENT $269.06
11/22/2011 ASSIGNMENT MEDICARE $43.97
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 12/01/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federal 1D# 356000972
ACCOUNT HISTORY
Bill To: CHARLES HOTCHKISS ICD -9: 789.00
12130 OLD MERIDIAN ST #103
CARMEL, IN 46032
From: 12130 OLD MERIDIAN
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: CHARLES HOTCHKISS 383346594A
12130 OLD MERIDIAN ST #103 Insurance
CARMEL, IN 46032 2 ANTHEM BLUE CROSS BLUE
Patient No: 201102648 UGD921570488
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$380.29 $380.29 $0.00
CPT
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09/30/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
09/30/2011 MILEAGE A0425 $5.29
11/10/2011 BLUE SHIELD PAYMENT $380.29
11/22/2011 MEDICARE PAYMENT $269.06
11/22/2011 ASSIGNMENT MEDICARE $43.97
12/01/2011 REFUND 313.03
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.
11 Payee
_41&MJLe_ ODS S Ct�GL &eSA �C Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
X 3/3 D
ab rle-s S
Total 6 3
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
�h�hilu� �iassv �C�ceS�i,elG� IN SUM OF
36 l Gcl ill. a a, l- 0waa a f4 k
ON ACCOUNT OF APPROPRIATION FOR
u laic u�4X Ao Apon)
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Z ��3�7 313.3 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
DEC -a
.A
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund