HomeMy WebLinkAbout205724 01/31/2012 CITY OF CARMEL, INDIANA VENDOR: T362678 Page 1 of 1
ONE CIVIC SQUARE JANE SENN
CARMEL, INDIANA 46032 10790 CENTRAL AVE CHECK AMOUNT: $400.00
INDIANAPOLIS IN 46280 CHECK NUMBER: 205724
CHECK DATE: 1131/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 400.00 AMBUL REFUND
Date: 01/19/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederallD# 356000972
A CCOUNT HISTORY
Bill To: JANE SENN ICD -9: 78907 78701 7804 78791
10790 CENTRAL AV
INDIANAPOLIS, IN 46280
From: 10790 CENTRAL AV
To: IU HEALTH NORTH
1 ANTHEM BLUE CROSS BLUE
Patient: JANE SENN XEAJ02978680
10790 CENTRAL AV Insurance
INDIANAPOLIS, IN 46280 2
Patient No: 201101478
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS, PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$498.41 $898.41 400.00
CPT
`4ni x( jx.., ,.:'s -,r 'ate 7 uL -ark'
ate Y,,z,T� Syr "r, D:escrifion f��� r
u4 1 x r Charges
D X6 26 Credits
...a.:t, ..:e..,. .i.. ,.uT,... 4As_"_�!..:L� �.�•.•.:s �°zi:_ ��c'azs,x.e..s c"+ ,.a. fr n#.r.ya,..._:s -�t,_n
05/25/2011 ADVANCED LIFE SUPP 1 —EMER A0427 $475.00
05/25/2011 MILEAGE A0425 $23.41
10/13/2011 PAYMENT $100.00
11/15/2011 PAYMENT $100.00
01/04/2012 PAYMENT $200.00
01/18/2012 BLUE SHIELD PAYMENT $498,41
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/19/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederallD# 356000972
Bill To: JANE SENN ICD -9: 78907 78701 7804 78791
10790 CENTRAL AV
INDIANAPOLIS, IN 46280
From: 10790 CENTRAL AV
To: IU HEALTH NORTH
ANTHEM BLUE CROSS BLUE
Patient: JANE SENN XEAJ02978680
10790 CENTRAL AV Insurance
INDIANAPOLIS, IN 46280 2
Patient No: 201101478
THANK YOU FOR YOUR RECENT PAYMENT ON YOUR ACCOUNT. YOUR NEXT PAYMENT IS DUE IN 30 DAYS. PLEASE NOTIFY US
IF THERE WILL BE A PROBLEM. THANK YOU.
Total Amount Total Paid Balance
$498.41 $498.41 80.00
CPT
xf:ww mot...°
x �:s�..��: t�� Charges
_..�,;v cow*: ,s.± ��n tS.S�h -ice. P��''- 3s.. _...�nt±y:cew sa..::::r�. :.L.:� ��t3r;. r. r'. tk.,,. 5?'$�m�k5' %?��?�iP'L.�...,s�a s v
05/25/2011 ADVANCED LIFE SUPP 1 -EMER A0427 $475.00
05/25/2011 MILEAGE A0425 $23.41
10/13/2011 PAYMENT $100.00
11/15/2011 PAYMENT $100.00
01/04/2012 PAYMENT $200.00
01/18/2012 BLUE SHIELD PAYMENT $498.41
01/19/2012 REFUND 400.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL. 1999
escribed 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
ao e S'!!y)/-L Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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
I NO. WARRANT NO.
d ALLOWED 20
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
bid aA-0e IV12 o >9
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 3 0 2012
r
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
S