177704 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
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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
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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