HomeMy WebLinkAbout173250 06/10/2009 CITY OF CARMEL, INDIANA VENDOR: 362934 Page 1 of 1
ONE CIVIC SQUARE JOHN CALLEY
CARMEL, INDIANA 46032 9673 WILD CHERRY LANE CHECK AMOUNT: $275.72
INDIANAPOLIS IN 46280
CHECK NUMBER: 173250
CHECK DATE: 6/10/2009
DEPAR ACCOUNT PO NUM I NVOICE NUMBER AMO DESCRIPTI
102 5023990 275.72 REFUND
An IncirpcndcTii LkUTISCC Of the Bitiv Cross and Blue Shield Association 02556 7254499 005112 008389 00001 /00002 k02556
94, FOR RELATED INQUIRES
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PLEASE CALL OR WRITE:
ANTHEM BLUE CROSS AND BLUE SHIELD
P.O. BOX 6199
INDIANAPOLIS, INDIANA 46206 -6199
866- 814 -3739
>02556 7254499 001 092013 PROVIDER NUMBER TAXID
CARMEL FIRE DEPT 1154325579 356000972
2 CARMEL CIVIC SQ
CARMEL IN 46032 REFERENCE NUMBER PAYMENT DATE
124682598 05122/2009
PROVIDER VOUCHER
SERVICE PROCEDURE TOTAL ALLOWED OTHER PROVIDER'S SUBSCRIBER'S APPROVED AMOUNT RSN
DATES CODE CHARGES AMOUNT INSURANCE LIABILITY LIABILITY TO PAY PAID (CODE
FROMITO CVD /NCVD DOLLARS
*1* P PO P A I D Q L A I M S
SUB ID: dNO0474940 PATIENT: CALLEY INELEN
CLAIM 260913439509 0 PATIENT ACCT /PRESCRIPTION 200900428
02/12/09 1 9 B A0429 $325.00 $325.00 $0.00 $0.00 $65.00 $260.00 $260.00
02/12/09
02/12/09 9 B A0425 $19.65 $19.65 $0.00 $0.00 $3.93 $15.72 $15.72
02/12/09
CLAIM TOTAL $344.65 $344.65 $0.00 $0.00 $68.93 $275.72 $275.72 A
A -A COINSURANCE OF $68.93 WAS REQUIRED.
TOTAL F O N T I I U
PAGE 1 OF 3 03335936 0041 630
OU CHECK NO. 124682598 6222
.o-An Independent Licenser of Lftr (Slur Cross arul131ur Shield Asocialion
TAX ID: 356000972 311
ANTHEM BLUE CROSS AND BLUE SHIELD DATE PAYEE NO. CHECK REF.
P.O. BOX 6199
INDIANAPOLIS, INDIANA 46206 -6199
05122109 1154325579 037400785
VOID 180 DAYS AFTER DATE AMOUNT
PAY CARMEL FIRE DEPT Q 3E 4 3 6 7 7
TO THE 2 CARMEL CIVIC SO
ORDER CARMEL IN 46032
THE SUM OF FOUR HUNDRED THIRTY SIX DOLLARS AND 77/100
WOchovia Bank, AU T H ORIZED SIGNATURE
National Association
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