The URL can be used to link to this page

Home My WebLink About180034 12/08/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND e CHECK AMOUNT: $807.60 CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK NOBLESVILLE IN 46060 CHECK NUMBER: 180034 CHECK DATE: 12/8/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 807.60 COBRA INSURANCE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Dec -09 Donald: Medicare Part B $96.40 Amount due for December 2009 Humana Choice PPO 44.00 Total Don 140.40 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 950.12 85% 807.60 Portion paid by City 15% 142.52 ANTHEM BCBS IN INDIVIDUAL INDI -MB1 KY0303A645 001528 1351 Wm Howard Taft Anth em 1 V Cincinnati, OH 45206 -1775 Au i d r—Jrnl l --n ul tllc. bloc C.— z,d bL IC. Slndd .A—mriun. Aml—u blur C— bluc Jlucld is the a i, uauc ..t Ihc. Amlicln Insln Cunp.wic lec. aJH c�islcrnl nvrks blur (_rosy auJ (Slur S11i11J Adsuviat;uu. IUENTWICA 01 SM62629 1 111 Jv 1% b1.22347 ININCI 1526 01 Due Date: 12 -01- 2009 Billing Date: 11 -10 -2009 #BWNCQXF Coverage Period From: 12 -01 -2009 CD o #AIM0 O00 O0000DS0 #INDI -MB 1 KY0303A645 Coverage Period Through: 12 -31 -2009 Cleveland, Barbara L 01) 141 Ston Creek Overlook Total Amount Due: $809.72 Noblesville, IN 46060 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in making your payment over the phone'? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your payment. Please list your 9 -digit Identification Number on your check, include the lower portion of this page and mail to the address specified. If you pay by check, Anthem Blue Cross and Blue Shield charges a "Non Sufficient Funds” (NSF) fee of $20 for returned, unpaid checks. IMPORTANT NOTICE: If you have received a reminder notice from Anthem regarding a past due payment, this bill includes all amounts that. you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amount Due listed on this bill must be received by the Due Date. Anthem's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay prentirnWs in a timely manner. Payments recently mailed may not be reflected. I)E':'ACII AND RETURN TINS SECT ION WITH YOUR P AYMENT- DO NOT STAPLE MAKE CHECKS PAYABLI TO ANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber Ill From Date I 'Through Date Due Date 018M62629 12/01/21109 t2/31/2009 12/01/2009 Amount Due Amount Paid $809.72 7 Unit No. 002 INDI -MBI 3 0 0,9 5'? "`7 {VI 11111 {I IIIIIII11 I11 {1 {IIII11 {111 {11{ {111 {VII I IIIIII Y10090 3 ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262971201200900000809720028 your 2oo5i anth[y Premcums fG-r ed[care Part A (Hospital Insurance) Monthly Premium Most people don't pay a Part A premium because they paid Medicare taxes while working. You pay up to $443' each month if you don't get premium -free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly Income Is You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $96.40' $85,001— $107,000 $170,001— $214,000 $134.90" $107,001 $160,000 $214,001— $320,000 $192.70' $160,001 $213,000 $320,0014426,000 $250.50" above $213,000 above $426,000 $308.30' Dote: If you get a monthly benefit payment from Social Security, the RRB, or the Civil Service, you must have your Part B premiums deducted from your monthly benefit payment. If you don't get any of these benefit payments and choose to sign up for Part B, you will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179 -0355. If you get a bill from the RRB, mail your premium payments to RRB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197 -9024. -::ion Drug Plan) Part u' en espafW FI 1\ A Al ed ica re Toll -free: 1 800 372 2147 u itoa y ou need it „iest TTY users: 1 877 833 4486 il I t Print This Pag Enlarge Text ff] Help Return to Previous Screen Pear Details Humana Choice PPO Plans PPO R5826 -008 Monthly Plan Premium: $44.00 PI n Premiums for Peo with Extra Help Rx Coverage: Annual Part D Deductible $0.00 Annual Medical Deductible: $0.00 Maximum Medical Out -of- $5,000.00 Pocket: Prescription Drug Coverage: Amount you pay per prescription Type of Drug Stage 1 Stage 2 Stage 3 Stage $0 -$295 $296- Over 4 $2700 $2700 Over $4350 Preferred $7 $7 100% 5% Generic Preferred $40 $40 100% 5% Brand Non Preferred $65 $65 100% 5% Brand Specialty 33% 33% 100% 5% Physician Detail: Option to see physicians in- or out- of the plan's network. No referrals required. F You pay more for out -of- network services. Doctor Office Visits: Primary Care Physician: $15.00 Copay Specialist: $35.00 Copay Hospitalization: $800.00 per admit https: /www.humana- medicare. com/ SeniorWizardNET /PianDetails.aspx 3/27/2009 Fifth Third Bank I Manage Accounts I Credit Card Account Activity Page 1 of 1 f� R'?; �Ii� TH��L3'BAI�CK`v Th things Nye do for dreams_ 1 11 d IE Account Balances Account Nicknames Account Activity Welcome, DONALD H CLEVELAND Thursday December 3 2009 Account Activity I Account Summary Account Statements Export History Account: Statement Period: Current Statement Posted Transactions ( Advanced Search: Keyword 1 11 ON Posting Date Transaction Date Debit Credit Description Action 12/02/09 11/30/2009 $809.72 ANTHEM BCBS INS PMT IN 866 649 -2034 OH 12/02/09 12/01/2009 $66.31 CBSA 952 5936471 MN 11/26/09 11/25/2009 $809.72 MAIL PAYMENT BRANCH CINCINNATI OH 1 11/24/09 11/23/2009 $44.00 HUMANA HEALTH PLAN INC 800 992 -2551 KY Transactions and other information that appear on this page have occurred since your last statement cycle date. Please select another statement period to review previous account activity. Disclosure /Error Resolution Copyright 0 2009 Fifth "T "hind Bank, Member FDIC, Equal Housing Lender, All Rights Reserved Contact us Service Center I Help I FA Qs I Privacy Security https: /www.53.com/servlet /efsonline/ account history. html ?TransSortCode= DATE,REV E... 12/3/2009 PrAscribed'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)) Total 1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in a c c ordance with IC 5- 11- 10 -1.6. S� 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 D0,12 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR Board Members Po# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or �U2 J 2 0/ o9 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 Director o B eras ons Cost distribution ledger classification if Title claim paid motor vehicle highway fund