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Home My WebLink About177704 09/29/2009 CITY OF CARMEL, INDIANA VENDOR: T357065 Page 1 of 1 ONE CIVIC SQUARE HUMANA CHECK AMOUNT: $296.68 CARMEL, INDIANA 46032 PO BOX 14610 LEXINGTON KY 40512 CHECK NUMBER: 177704 CHECK DATE: 9/29/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 296.68 OTHER EXPENSES THE TRAVELERS CLEVELAND CL CLAIM 8 8 3 H 12618537 AUTO LIABILITY CLAIMS PO BOX 94918 CLEVELAND OH 44101 -9734 UCO2164 TRAVELERSJJ DATE: 09/10/09 LOSS DATE: 06/08/09 CARMEL FIRE DEPARTMENT FILE NUMBER: 031 AB UAB6701 A 2 CIVIC SQUARE REFERENCE 0002003565MM CARMEL IN 46032 CLAIMANT: BETH JACOBS ACCOUNT NAME: BETH JACOBS TRAVCO INSURANCE COMPANY EXPLANATION OF PAYMENT MEDICAL PAYMENTS 06/08/09 TO 06/08/09 $370.85 TOTAL PAID $370.85 Prov Inv 200901484 SEP PAYMENT INQUIRIES? EMAIL AUTMRTPI@SPT.COM, FAX 877 749 -0003, PH. 877 838 -7281 253007806 OVRFUNS2- 121225 DETACH CHECK DETACH CHECK On 883H 12618537 3-11 On an k, N.A. TRAVELERS JJ 31 e Penns way New castle DE 99720 PO BOX 94918 THIS CHECK HAS A RED BACKGROUND CLEVELAND OH 44101 -9734 (216)643 -2474 DATE ACCOUNT NUMBER FILE NUMBER VOID IF NOT PRESENTED WITHIN 09/10/09 J98 031 AB UAB6701 A ONE YEAR AFTER DATE OF ISSUE THREE HUNDRED SEVENTY AND 85/100 I PAY: *370.85 MJU PAY CARMEL FIRE DEPARTMENT TO THE 2 CIVIC SQUARE ORDER OF CARMEL IN 46032 002164 U CO2164 AUTH IZED SIGNATURE d. hlduuulld6ldlddlllnn16dm16udllunilddJlllu6nh16ddllim616nnn II' L26L853711° 1:03LL002091 38768300111` I VVt9VD 4VJ37 x� r 4D r r t ft x BANK OF•AMERICA y T i t �'�1iiiTal7Ct �ili�n you need tr moal ATLAN GA 30308 TA a 2, ;14610 LEXINGTON KY rr c ti ''S ea e 4 r CHECK." NO aa�o 1630 +a r ST VINCENT HEALTH INC t z r 3 its 1i r rF z w-z e x GROUP t 590751 4 u PROVIDER TAX ID MUM9FR 356000972 a r- z IHIS'CHECK COVERS ALt CLAIMS ON RE MITTANCEi'STATEM ENT :NUMHE& ;200908150078033 'i M fh =1 ic. i r h PAY 71l0 HUNDRED iNINETY SIX_ kND 58/1D0 DOLLARS i� x x: r i` v t. c k s sl �y�y s r 1 j5 r1. °s. z SPAY TO THE ORDER OEi FRONT B1tiE oPi wHITP./ BACK AIDktINES /E Yn10 1E NOT CASHED VKITHIN QD4YS7_*F T Y t� CARMEL FIRE DEPARTMENT *296 68r ($1414'109 4 2 CIVIC SQUARE r• SFr ;99r CARMEL, IN 46032 k h• y r vj -`r t K a �l y tz- Sr r+ t -r r h^ c r °_0000 X63004' 7061E b�t 2788:: 3 29' 9D 33 348211. r II II 1 0, r HUMANA AUTOMATED REMITTANCE ADVICE >ANY '(3UEST10NS PLEASE:::CONTACT ;::BENEFITS: PAll7 ?TO T; OLGGIWi G:: H UMANA. HUMANA CLAIMS OFFICE CARMEL FIRE DEPARTMENT P.O. BOX 14601 2 CIVIC SQUARE LEXINGTON, KY 40512-4601 CARMEL, IN 46032 Guidwice when youneed itmost OR CALL 1- 866 427 -7478 PROVIDER ID: 134366234975 OR VISIT WWW.HUMANA.COM FEDERAL TAX ID: 356000972 REMITTANCE ID: 200908150078033 PAGE 1 OF 2 CHECK NUMBER: 0000163004 DATE 08/14/09 LINE DATE OF SERVICE SERVICE EXCLUDED ALLOWED BENEFIT FROM TO CODE CHARGE AMOUNT -DISCOUNT =AMOUNT DEDUCTIBLE -COPAY COINSUR AMOUNT PROVIDER NAME: CARMEL FIRE DEPARTMENT MBR ID: 004086681 02 CLAIM NUMBER: 200907243697043 PATIENT NAME: JACOBS, BETH L PAT DOB: 05/29/1951 PAT ACCT: 200901484 SUBSCRIBER NAME: JACOBS, JONATHON R REL CD: SPOUSE GROUP: 590751 i 001 06/08/09 06/08/09 A0429 325.00 0.00 0.00 325.00 0.00 0.00 65.00 260.00 002 06/08/09 06/08/09 A0425 45,85 0.00 0.00 45.85 0.00 0.00 9.17 36.68 CLAIM TOTALS 370.85 0.00 0.00 370.85 0.00 0.00 74.17 296.68 REMARK CODES HIPAA /HUMANA 001 45 /6BO 002 45 /680 EST MBR RESPONSIBILITY 74.17 TOTAL PAID 296.68 SERVICING PROVIDER NAME /ID: CARMEL FIRE DEPARTMENT 134366234975 TOTALS 370.85 0.00 0.00 370.85 0.00 0.00 74.17 296.68 EST MBR RESPONSIBILITY 74.17 TOTAL PAID 296.66 ROLLUP TOTALS FOR REMITTANCE 370.85 0.00 0.00 370.85 0.00 0.00 74.17 296.61 EST MBR RESPONSIBILITY 74.17 TOTAL PAID 296.68 p w A O RECEIVEM AUG 2 1 2009 Form No. EZ4000P 04105 Date: 09/16/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 A G 0 H i O R Bill To: JONATHON JACOBS ICD -9: 78652 E8130 946 3RD AVENUE NW CARMEL, IN 46032 From: 116TH ST &AAA WAY To: ST. VINCENTS HOSPITAL HUMANA CLAIMS OFFICE Patient: BETH L JACOBS 00408668102 946 3RD AVENUE NW Insurance CARMEL, IN 46032- 2 Patient No: 200901484 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $370.85 $370.85 $0.00 CPT Date Description Charges Credits 06/08/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/08/2009 MILEAGE A0425 $45.85 08/21/2009 COMMERCIAL INSURANCE PAYMENT $296.68 09/04/2009 PAYMENT $74.17 09/15/2009 COMMERCIAL INSURANCE PAYMENT $370.85 09/16/2009 REFUND -74.17 09/16/2009 REFUND 296.68 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 a OTE El 2 4% Date: 09/16/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: JONATHON JACOBS ICD -9: 78652 E8130 946 3RD AVENUE NW CARMEL, IN 46032 From: 116TH ST &AAA WAY To: ST. VINCENTS HOSPITAL HUMANA CLAIMS OFFICE Patient: BETH L JACOBS 00408668102 946 3RD AVENUE NW Insurance CARMEL, IN 46032- 2 Patient No: 200901484 YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $370.85 $667.53 296.68 CPT Date Description Charges Credits 06/08/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/08/2009 MILEAGE A0425 $45.85 08/21/2009 COMMERCIAL INSURANCE PAYMENT $296.68 09/04/2009 PAYMENT $74.17 09/15/2009 COMMERCIAL INSURANCE PAYMENT $370.85 09/16/2009 REFUND -74.17 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 7995) 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 Purchase Order No. O L�Lo Terms ex /'n X0 5 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 1p 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. T j ALLOWED 20 .Lmal'I l�— IN SUM OF Z�202 L-692 ynsiz L)�9 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 SEP 1 9 2009 Signa ure Cost distribution ledger classification if Title claim paid motor vehicle highway fund