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Home My WebLink About176762 09/02/2009 CITY OF CARMEL, INDIANA VENDOR: 363308 Page 1 of 1 0 ONE CIVIC SQUARE BRAD GUMBERT CARMEL, INDIANA 46032 4121 ROLLING SPRINGS DR CHECK AMOUNT: $241.26 CARMEL IN 46033 CHECK NUMBER: 176762 CHECK DATE: 91212009 DEP ARTMENT ACCOUNT P N UMBER INVOICE NUMBER AMOUNT DESCRIPTION '102 5023990 241.26 OTHER EXPENSES Date: 08/24/2009 a CARMEL EIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 RY 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 $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 0812112009 COMMERCIAL INSURANCE PAYMENT $241.26 0812412009 REFUND 291.26 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/24/2009 a CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal 1D# 356000972 y 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 $585.91 241.26 CPT Date Description Charges Credits 06/21/2009 BASIC LTFF- 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 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 V 01270 *003609 PO 09229—FO- 530 —FJ 110 0FPA20- 070705 UNITEDHEALTHCARE INSURANCE COMPANY OLDSMAR SERVICE CENTER UnitedHealtheare PO BOX LA KE CI UwtedHeahh Group Company ,a SALT LAKE CITY, UT 8413Q -0555 PHONE: 1 -877- 842 -3210 DATE: 08/17/09 TIN: 35- 6000972 NP I 1154325579 GROUP 0711711 GROUP NAME: KDM SIGNS, INC. CHECK NUMBER: OW 43408590 CHECK AMOUNT: S241.26 CARMEL FIRE DEPT AMBULANCE SVC CARMEL FIRE DEPT AMBULANCE SV PROVIDER CARMEL 46032 EXPLANATION OF BENEFITS PATIENT DETAIL PRODUCT MEM. ID PATIENT OL T PATIENT MEMBER CONTROL DATE PROVIDER NAME ACCOUNT NAME NUMBER RECEIVED OF SERVICE CHOYC+ A 905792816 MAUREEN GUMBERT EE 200901590 MAUREEN GUMBERT 02245209S47-01109/03/09 CARMEL FIRE DEPT AMBU SERVICE DETAIL PATIENT DATES OF DESCRIPTION AMOUNT NOT PROV ADS AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP, MAUREEN 06121109 AMBULANCE 325.00 325.00 70% 227.50 GUMBERT 06 121109 AMBULANCE 19.65 19.65 70% 13.76 SUBTOTAL 344.65 344.6S 241.26N 103.39 PLEASE NOTE THAT THE PATIENT HAS A CONSUMER ACCOUNT THAT MAY PAY SOME OR ALL OF THIS CLAIM. IF FUNDS ARE AVAILABLE, A CHECK WILL BE SENT TO YOU WITHIN 10 BUSINESS DAYS FROM THE DATE OF THIS TRANSACTION AND CAN BE APPLIED TO REDUCE THE PATIENT'S RESPONSIBILITY. TOTAL PAID TO PROVIDER 5241.26 UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS STATEMENTS (EPS) AS A STANDARD WAY TO PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 —UHC —FAST (1 866 842- 3278), OPTION 5. FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1 800 -842 -1109, OPTION 3. REMARKS l PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM. RECEIVED A 2 12009 r--Detach Check Detach Check v� r srg 51 A4 Fleet National Bank a1s� UNITEDHE'ALTHCARE:INSURANCE COMPANY 154 Windsor Street OLDSMAR SERVICE CENTER "Fc Hartford CT 06120 g qp r 1PD'rBOX 30555 f SALT LAKE CITY, UT ::84130- Q555 i r i PHONE 1' 877 -842 3210 DATE V6 01270-003609 PO 09229 FO 530 FJ 110 'PLE PRESENT "PROMPTLY FOR PAYMENT CONTRACT; 711'7 11 *TWO HLJNDRED'=FORTY;ONE. &'26/100 DbL LA R5 pqy CARMEL FIRE. DEPT:•AMBULANCE, SVC. CARME -L FIRE DEPT AMBULANCE SV 2 Ch;UIC 5Q IORDE R DF. CARMEL I N;. 46032. AUTd-IDF {ZED SIGNATUFE nllnallil rnrlihll lllhl lwll l u riillurlt6i61trlttlnhdn6ilttlul lt l u Lil i i r I nluhihiltl lull iliilnlllrnl llmiihutlhnulrl lldlilulml ilrl llihrllilllliiaulil GllilltluliblrllJrmtllhu llllllhlrllltu ,1 =t,3,D854D!i lo❑ b L9D!044510. 2 24 :'DD.� D 20`�HB �l zo :�68 503 740 MAURE E GUiVlBERT 196696762 BRAD M: GUNIBEFiT a ROLLING SPRINGS DR. 4121 CA EL'IN 46033 C-� �'�t lit- ��e�. CHA St 1` Chase Eank. N:A. IlT �pMorgan Indiana 96277 indlanaQofis ir; .err; 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. It Payee Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) GZG(T t y'a o 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. L ALLOWED 20 YQ 7 IN SUM OF ej Z,R q&022 c2 L 2 6 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 AUG 31 2009 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund