HomeMy WebLinkAbout204234 12/06/2011 CITY OF CARMEL, INDIANA VENDOR: 365498 Page 1 of 1
ONE CIVIC SQUARE CHRISTIAN GOMEZ
CARMEL, INDIANA 46032 1103 GOLFVIEW DR APT C CHECK AMOUNT: $453.10
CARMEL IN 46032
CHECK NUMBER: 204234
CHECK DATE: 12/6/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 453.10 OTHER EXPENSES
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Date: 12/01/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederallD# 356000972
ACCOUNT HISTORY
Bill To: YARAMI RUVALCABA ICD -9: 780.39
1103 GOLFVIEW DR APT C
CARMEL, IN 46032
From: 1103 GOLFVIEW DR APT /SUITE# C
To: ST. VINCENTS HOSPITAL
MEDICARE PART B
Patient. YARAMI RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201102395 917564896
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
$544.46 $997.56 453.10
CPT
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09/02/2011 ADVANCED LIFE SUPP 1 -EMER A0427 $475.00
09/02/2011 MILEAGE A0425 $69.46
10/03/2011 MEDICARE PAYMENT $365.43
10/03/2011 ASSIGNMENT MEDICARE $87.67
11/01/2011 COMMERCIAL INSURANCE PAYMENT $544.46
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 FederalID# 356000972
ACCOUNT HISTORY
Bill To: YARAMI RUVALCABA ICD 9: 780.39
1103 GOLFVIEW DR APT C
CARMEL, IN 46032
From: 1103 GOLFVIEW DR APT /SUITE# C
To: ST. VINCENTS HOSPITAL
1 MEDICARE PART B
Patient: YARAMI RUVALCABA 634526806A
1103 GOLFVIEW DR APT C Insurance
CARMEL, IN 46032- 2 UNITED HEALTH INS/30555
Patient No: 201102395
917564896
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
$544.46 $544.46 $0.00
CPT
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C-h' vri! a i 5.,r�Y
y Date x�� _r" Descrintion ar es C.redlts
�ax W ^:i9 tih.y tF�i'.+zK. �E.n1�'.�t.:!r. .,.aFrx.m^�.�xk:._... s'�'..t •tMrcr s:�.«:aa.§;Fr�ui
09/02/2011 ADVANCED LIFE SUPP 1 -EMER A0427 $475.00
09/02/2011 MILEAGE A0425 $69.46
10/03/2011 MEDICARE PAYMENT $365.43
10/03/2011 ASSIGNMENT MEDICARE $87.67
11/01/2011 COMMERCIAL INSURANCE PAYMENT $544.46
12/01/2011 REFUND 453.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
—MITIM POK",
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.
N) LL
Payee
U1 s47 G� (Tome Z Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
P.i m b Leis r o 41 q_6'3' o
Total L/ S
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.
n ALLOWED 20
C�r�s��.rl [rD
IN SUM OF
j l n 3 (o l I Tr A p--J- C
aims, W 4, 32-
4531
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
5 4 bi l�"53r�� 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 5 2611
l li —f
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund