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Home My WebLink About168036 01/21/2009 CITY OF CARMEL, INDIANA VENDOR: T362450 Page 1 of 1 ONE CIVIC SQUARE GARY HULS CARMEL, INDIANA 46032 6116 NE GARFIELD AVE CHECK AMOUNT: $282.12 PORTLAND OR 97211 CHECK NUMBER: 168036 CHECK DATE: 1/21/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 282.12 AMBULANCE REFUND e a x� Electronic Remitance Information Print Date:09/14/07 (EOB) Explanation Of Benefits (EOB) Payor Id: 00630 Production Date: 09107107 Receiver Id No: Z6CX Payer Information: NATIONAL GOVERNMENT SERVICES Payer Natl Id: Payer Id: 1351840597 PO BOX 6130 INDIANAPOLIS IN 462066130 Payer Contact Info: PROVIDER ENROLLMENT (866)250 -5665 TE Receiver Info: CARMEL FIRE DEPARTMENT Payee Id: 356000972 2 CARMEL CIVIC SQ CARMEL IN 460327543 Payment Info: Check EFT Trace No: 122592509 Total Payment Amount $263 52 Check Issue Date: 09/07/07 Payment Method: Check Pt No Patient Name D.O.B. Gender Procedure Code Billed Allowed Pt. Responsible Amt. Paid 200602474 HULS MARY 316053550D A0429 R 348.00 329.40 65.88 263.52 Claim Control 4607190800060 Claim Status: Processed as Primary Claim Remark Codes: MA02.. Claim Adjustments: Total Adjustments Patient Responsibility Coinsurance Amount 9.60 Patient Responsibility Coinsurance Amount 56.28 Contractual Obligations Charges exceed your contracted/ legislated fee arrangement. 18.60 Pt No Patient Name D.O.B. Gender Procedure Code Billed Allowed Pt. Responsible Amt. Paid 200602474 HULS MARY 316053550D A0429 R 348.00 329.40 0.00 0.00 Claim Control 1106279822330 Claim Status: Processed as Secondary Claim Remark Codes: MA01.. Claim Adjustments: Total Adjustments Patient Responsibility Non covered charge(s). 300.00 Patient Responsibility Non covered charge(s). 48.00 Page 1 MEDICARE PART B INDIANA MEDICARE PART B PROVIDER REPORT NATIONAL GOVERNMENT SERVICES, INC. P.O. BOX 240 INDIANAPOLIS, IN 46206 CHECK DATE 09/07/07 CHECK NUMBER 122592509 CHECKAMOUNT *263.52 PROVIDER NUMBER 317470 1001104 MSIDRS2 05659 0001107 CARMEL FIRE DEPARTMENT 2 CARMEL CIVIC SQ CARMEL, IN 46032 -7543 SEA?, l� MEDICARE PART B 74 -1292 724 NATIONAL GOVERNMENT "SERVICES, INC. 'P.O. BOX 240 INDIANAPOLIS IN 46206. CF�A(MSt- WDWARFSAIEn�ca/ormGr�s MEDICARE PAYMENT JPMOrgan Chase Bank Dearborn FOR HEALTH INSURANCE .SOCIAL SECURITY ACT Dearborn, .Michigan 050259286 PAY TO THE ORDER OF CARMEL FIRE .'DEPARTMENT PROVIDER NO.. CHECK NO 2 .CARMEL CIVIC SQ 3174 -70 122592509 CARMEL, IN 46032 =7543 :MO: :DAY YEAR DOLLARS 09 07 07 VOID: 12.MONTHS- :FROM' ISSUE DATE ,,E SO 2S9 28 6go 1:07 2L, 1 29 2 6 L, IE,38437lie y�"` 7. =�r +�n Y, I 10 75 3 19- 707x/3250 GARRY S HULS 3es1za7ses t w 6116 NE GARFIELD AUE PORN AND OR 97211 l e0 d afie F nt 1 f n j v ys ,A� d. UZ M# 3 75F." fl) i OVLA{Z a fS �r t 4 b -.i Wasloington�nAutual h =ry �h y.• ..nox t A i sx ;fig' r 3 Wash'ngtbn'MUtual 9anl•. x'- y r �a'X y�A f .3` .v= 3�''�r p t x r'"`su 39 2 Bbu,Jev�" OOflee 700¢ d h 1 yz 05 F Y A J£ "Y' u i ,�.POrtla IN nd Oft 97+214e,� s. s X 12 r7 ,,,..i'"r, �'$i Pl i:3'25.070760�: 386 247689 �0 5 Date: 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 C I STOR Bill To: MARY HULS ICD -9: 78079 46 ROSEWALK APT 1 E CARMEL, IN 46032 From: 46 ROSEWALK CIR APT /SUITE# 1E To: ST. VINCENT INDIANAPOLIS MEDICARE PART B Patient: MARY HULS 316053550D 46 ROSEWALK APT 1 E Insurance CARMEL, IN 46032 2 UNITED HEALTHCARE/ 30557 Patient No: 200602474 A825343716 PLEASE UPDATE THIS OFFICE ON THE STATUS OF YOUR MEDICARE APPEAL. THANK YOU. Total Amount Total Paid Balance $348.00 $348.00 $0.00 Date Descriptior CPT Charges Credits 09/18/2006 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 09/18/2006 MILEAGE A0425 $48.00 08/31/2007 PAYMENT $348.00 09/14/2007 MEDICARE PAYMENT $263.52 09/14/2007 ASSIGNMENT MEDICARE $18.60 01/09/2009 REFUND 282.12 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 VOUCHER NO. WARRANT NO. ALLOWED 20 S IN SUM OF AM 6 0 a- 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 JAN Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund 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 l� S Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) r� s u 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 EMEMOTap Date: 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 ACCOUNT FOSTCRY Bill To: MARY HULS ICD -9: 78079 46 ROSEWALK APT 1 E CARMEL, IN 46032 From: 46 ROSEWALK CIR APT /SUITE# 1 E To: ST. VINCENT INDIANAPOLIS MEDICARE PART B Patient: MARY HULS 316053550D 46 ROSEWALK APT 1 E Insurance UNITED HEALTHCARE/ 30557 CARMEL, IN 46032 2 Patient No: 200602474 A825343716 PLEASE UPDATE THIS OFFICE ON THE STATUS OF YOUR MEDICARE APPEAL. THANK YOU. Total Amount Total Paid Balance $348.00 $630.12 282.12 Date Description CPT Charges Credits 09/18/2006 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 09/18/2006 MILEAGE A0425 $48.00 08/31/2007 PAYMENT $348.00 09/14/2007 MEDICARE PAYMENT $263.52 09/14/2007 ASSIGNMENT MEDICARE $18.60 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999