HomeMy WebLinkAbout177679 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: 363308 Page 1 of 1
ONE CIVIC SQUARE BRAD GUMBERT
CHECK AMOUNT: $103.39
CARMEL, INDIANA 46032 4121 ROLLING SPRINGS DR
CARMEL IN 46033 CHECK NUMBER: 177679
CHECK DATE: 9/29/2009
DEPARTMENT ACCOUNT PO N UMBER IN VOICE NUMBER T AMOUNT DES
102 5023990 103.39 OTHER EXPENSES
Date: 09/28/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: MAUREEN E GUMBERT ICD -9: 95919 92231 7245 E8859
4121 ROLLING SPRINGS DR
CARMEL, IN 46033 From: 1195 CENTRAL PARK DR
To: ST. VINCENTS HOSPITAL CARMEL
1 UNITED HEALTH CARE/ 740800
Patient: MAUREEN E GUMBERT 905792816
4121 ROLLING SPRINGS DR Insurance
CARMEL, IN 46033 2
Patient No: 200901590
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
$344.65 $448.04 103.39
CPT
Date Description Charges Credits
06/21/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
06/21/2009 MILEAGE A0425 $19.65
08/18/2009 PAYMENT $344.65
08/21/2009 COMMERCIAL INSURANCE PAYMENT $241.26
08/24/2009 REFUND 241.26
09/25/2009 COMMERCIAL INSURANCE PAYMENT $103.39
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: D9/28/2009
CARMEL. FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: MAUREEN E GUMBERT ICD -9: 95919 92231 7245 E8859
4121 ROLLING SPRINGS DR
CARMEL, IN 46033
From: 1195 CENTRAL PARK DR
To: ST. VINCENTS HOSPITAL CARMEL
I UNITED HEALTH CARE/ 740800
Patient: MAUREEN E GUMBERT 905792816
4121 ROLLING SPRINGS DR Insurance
CARMEL, IN 46033 2
Patient No: 200901590
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
$344.65 $344.65 $0.00
CPT
Date Description Charges Credits
06/21/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
06/21/2009 MILEAGE A0425 $19.65
08/18/2009 PAYMENT $344.65
08/21/2009 COMMERCIAL INSURANCE PAYMENT $241.26
08/24/2009 REFUND 241.26
09/25/2009 COMMERCIAL INSURANCE PAYMENT $103.39
09/28/2009 REFUND 103.39
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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740
GUMBERT 19639BM
MAUREEN
BRAS M: GUMSERT
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4121. ROLLING SPRINGS D
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CHASE C 1
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Indianapolis, Indiana 46277
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CFPA20- 070705
UNITEDHEALTHCARE INSURANCE COMPANY
UnitedHealtheare
PO BOX 30555 AUniredHealihGroupCompany
SALT LAKE CITY, UT 841300555
PHONE: 1- 877 -842 -3210
DATE: 09/21/09
TIN: 35- 6000972
N P I 1154325579
GROUP 0711712
GROUP NAME: KOM SIGNS, INC
CHECK NUMBER: UY 13502670
CHECK AMOUNT: $103.39
CARMEL FIRE DEPT AMBULANCE
CARMEL FIRE DEPT AMBULANCE SV PROVIDER
CARMEL 46032 EXPLANATION
OF BENEFITS
PATIENT DETAIL
PRODUCT HEM. ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER
NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE
CHOYC+ E 311540257 MAUREEN GUMBERT EE 200901590 MAUREEN GUMBERT 00019258066-51 j 08103109 1 CARMEL FIRE DEPT AMBU
SERVICE DETAIL
PATIENT DATES DF DESCRIPTION AMOUNT NOT PROV ADJ AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT
NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP.
MAUREEN 06121109 HRA PAYMENT 103.39 103.39
GUMBERT SUBTOTAL 103.39 103.39
TOTAL PAID TO PROVIDER $'103.39
Detach Check Detach Check
7 537
r JPMorgan Chase Bank, NN A. 212
UNITEDHEALTHCARE INSURANCE COMPANY Syracuse, NY
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PO BOXt`3O5557;
:SALT LAKE sCI,TY .UT' 841300555.
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PHONE 1 877 -842 32 i o LATE :Q9/21 JQ9
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CONTRACT 71;1712 PAX 1O3 r 3g ,3
*ONE, UNDRED THREE 39,/100 DOLLARS
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PAY CARMEL. FIRE, DEPT AMBULANCE SVC j
TO THE h CARMEL FIRE DEPT AMBULANCE SV is
2 C`I °VI C 'SQ
ORDER OF CARMEL I N 46032
AUTHORIZcO SIGNATURE R
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Prescribed 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
.4ra cl� G`,c1k.Jjer z' Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total a
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
D
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
CEP 2
c
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund