HomeMy WebLinkAbout172838 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 362895 Page 1 of 1
0 ONE CIVIC SQUARE TERANCE GARDNER
CARMEL, INDIANA 46032 1216 CLAY SPRINGS DRIVE CHECK AMOUNT: $318.75
CARMEL IN 46032 CHECK NUMBER: 172838
CHECK DATE: 5/27/2009
DEPARTMENT,-, A CCOU N T PO NUMBER IN VOICE NUMBE AMOUNT DESCRIPTIO
102 5023990 318.75 REFUND
Date: 05/18/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federa /ID# 356000972
Bill To: PAM J GARDNER ICD -9: 78079 2512
1216 CLAY SPRINGS DR
CARMEL, IN 46032
From: 1216 CLAY SPRINGS DR
To: ST. VINCENT CARMEL
AETNA US HEALTHCARE /981106
Patient: PAM J GARDNER 00008703903
1216 CLAY SPRINGS DR Insurance
CARMEL, IN 46032 2
Patient No: 200800819
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$375.00 $693.75 318.75
CPT
Date Description Charges Credits
03/25/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
03/25/2008 MILEAGE A0425 $25.00
09/09/2008 PAYMENT $375.00
05/15/2009 COMMERCIAL INSURANCE PAYMENT $318.5
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
CHASE
CHASE ONLINE BILL PAYMENT
PO BOX 260169 f
BATON ROUGE LA 70826 -0169
Septelnber 2 2008
43450 6PC -001 001 08246 91128955 1OF1 N
b
CARMEL FIRE DEPARTMENT
Emergency Med Services o
2Civic Square
Carmel IN 46032 -7543
N
O
O
N
APPLY TO ACCT 200800819
TERANCE GARDNER
1216 CLAY SPRINGS DR
CARMEL IN 46032
$375.00
'Pam Gardner 200800819
RECEIVED SEP 0 9 2008
PLEASE POST THIS PAYMENT FOR OUR MUTUAL CUSTOMER
CIIASE ONLINE BILL PAYMENT APPLY TO ACCT 911289J5
200800819:
PO BOX 260169 25 =37440
TERANCE GARDNER
BATON ROUGE LA 70826 -0169 1216 CLAP SRRINGS DR
.(800) 472 -6236
CARMEL:IN 46032 September 2 2008
$37.00
CHASE e o
Pay THREE HUNDRED SEVENTY -FIVE AND 00 /100 DOLLARS
To CARMEL FIRE DEPARTMENT Check Void After 90 Days
:die Emergency Med Setwices
Older l ne Square
of Caanunel EN:46032 =7143
JPMorgan Chase, NA Columbus, OH 43240
II °9112895511° to04ti000017 6 58 5 3 30 13111,
Date: 05/18/2009
i
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: PAM J GARDNER ICD -9: 78079 2512
1216 CLAY SPRINGS DR
CARMEL, IN 46032
From: 1216 CLAY SPRINGS DR
To: ST. VINCENT CARMEL
AETNA US HEALTHCARE /981106
Patient: PAM J GARDNER 00008703903
1216 CLAY SPRINGS DR Insurance
CARMEL, IN 46032 2
Patient No: 200800819
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$375.00 $375.00 $0.00
CPT
Date Description Charges Credits
03/25/2008 ADVANCED LIFE SUPP 1 -EMER A0427 $350.00
03/25/2008 MILEAGE A0425 $25.00
09/09/2008 PAYMENT $375.00
05/15/2009 COMMERCIAL INSURANCE PAYMENT $318.75
05/18/2009 REFUND 318.75
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
M
�Aetn P.O. BOX 98 „U7 QLAIM„PA YMEIT
EL PASO, TX 79998.1,07 USA
Please Retain for Future R ?ferenc
000128 J]K2PJC 000365 CITY OF CARMEL FIRE DEPT. 1 PIN: OOCF57451 0
Page 1 of 2 (1)
CITY OF CARMEL FIRE DEPT.
2 CIVIC SO
CARMEL IN 46032 -2584
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Aetna Life Insurance Company or an Affiliated Company ID No: X.XXXXXXX0972 CheCk:No: "06811
as Agent for Specified Payer(s) SBCt NO 000000004 ACCt: 09817
,Jd P.O BOX 981107
EL PASO TX 79998-1107
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05 -05 -2009
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VOID AFTER OI',4EiIWEAR
TO THE CARMEL FIRE DEPTARTMENT
ORDER OF 2rCIVIC$Q h a I �ti, 1r $31g 75
CARMEL IN 46032 2584 I "'l
I
Bank of America
IA i 766 (10-02)
I
ia068 1 L'IL' SaIla 1a0 1 Vioo4 °i si: 00'0000'009'8 L'7��°
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
0
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))
of �2 ew au e4o' 7S
G� Lr
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 5/27-!5'
/Cv Claw d r�hgS >0-
`621 e/ Z// Z16 D a
S/9 7S'
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
0 a 5 lg, 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
MAY 2 2 2009
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund