205214 01/05/2012 CITY OF CARMEL, INDIANA VENDOR: 353569 Page 1 of 1
ONE CIVIC SQUARE NANCY KRUSE
e
CARMEL, INDIANA 46032 840 BENNETi COURT CHECK AMOUNT: $68.08
CARMEL IN 46032 CHECK NUMBER: 205214
CHECK DATE: 1/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 68.08 OTHER EXPENSES
Date. 12/29/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federaim# 356000972
.ACCOUNT HISTORY
Bit! To: MARTHA L DEVINE ICD -9: 829.0
12999 N PENNSYLVANIA
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA
To: IU HEALTH NORTH
1 MEDICARE PART B
Patient. MARTHA L DEVINE 314241996A
12999 N PENNSYLVANIA Insurance
CARMEL, IN 46032 2 AETNA US HEALTHCARE /981106
Patient No: 201102624
W188446050
MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN. IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS
INFORMATION. IF NOT, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$384.82 $384.82 $0.00
CPT
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09/27/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
09/27/2011 MILEAGE A0425 $9.82
11/10/2011 MEDICARE PAYMENT $272.36
11/10/2011 ASSIGNMENT MEDICARE $44.38
11/29/2611 PAYMENT $68.08
12/28/2011 COMMERCIAL INSURANCE PAYMENT $68.08
12/29/2011 REFUND 68.08
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 12/29/2011
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federal ID# 356000972
ACCOUNT HISTORY
Bill To: MARTHA L DEVINE ICD -9: 829.0
12999 N PENNSYLVANIA
CARMEL, IN 46032
From: 12999 N PENNSYLVANIA
To: IU HEALTH NORTH
1 MEDICARE PART B
Patient: MARTHA L DEVINE 314241996A
12999 N PENNSYLVANIA Insurance
CARMEL, IN 46032 2 AETNA US HEALTHCARE/981106
Patient No: 201102624
W188446050
MEDICARE HAS PAID ALL BUT THE BALANCE SHOWN. IF YOU HAVE SECONDARY INSURANCE, PLEASE PROVIDE US WITH THIS
INFORMATION, IF NOT, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$384.82 $452.90 -68.08
CPT
4xE fu b. .:..0
a. k1113N �£.h6. I N. 6 kl f 9111 of ,C 4 .kl k }III �:31xG a�l6i:�.9..:'
:.y1' .F�I41y. .+S y...�,.- i,i y..: yl„ 4°R k�,
Date yl .:.y�, ti n :1, ,,3:, I�, III p ry ,,y H E I a.1 l I', M ~�I ,,,I Mll,
y 91 .�'[t 4:: 'c,Y i R a' ...Q Q ly�'F..1,,!'11,4 a 1h1 ''4^ l l r1 i�� h�pol e �°at rnl. III '.r �ar�es
.4 Y IF!.:.:r :�.h_ 11 �l. 41k p :u:;�!eidl�lll� ln ��s. w�.'.4 3�;nunnr.'...' n
09/27/2011 BASIC LIFE SUPP- EMERGENCY A0429 $375.00
09/27/2011 MILEAGE A0425 $9.82
11/10/2011 MEDICARE PAYMENT $272.36
11/10/2011 ASSIGNMENT MEDICARE $44.38
11/29/2011 PAYMENT $68.08
12/28/2011 COMMERCIAL INSURANCE PAYMENT $68.08
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.
Y P/ayee
/V(,(.y'cw f5 raSe Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
6l,L/Se i' in O/ti- Cog U
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.
VL&W ALLOWED 20
S� IN SUM OF �ako
')G�iCGDoUS,��
110 ',0
ON ACCOUNT OF APPROPRIATION FOR
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
JAN A
1�
20
i,
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund