HomeMy WebLinkAbout206442 02/14/2012 CITY OF CARMEL, INDIANA VENDOR: 366020 Page 1 of 1
ONE CIVIC SQUARE RON SMITH
CHECK AMOUNT: $35.00
CARMEL, INDIANA 46032 517 CAMELOT MANOR
PORTAGE IN 46368 CHECK NUMBER: 206442
CHECK DATE: 2/14/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 35.00 AMBUL REFUND
Date: 01/31/2012
CARMEL FIRE DEPARTMENT
EMERGENCY IVIED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federal m# 356000972
ACCOUNT HISTORY
Bill To: RON SMITH' ICD -9: 78650 78605 7808 78079
517 CAMELOT MANOR
PORTAGE, IN 46368
From: 320 W GERSHWIN DR APT /SUITE# 312
To: IU HEALTH NORTH
1 EDS -HCFA 1500 CLAIMS
Patient: RON SMITH 105297280799
517 CAMELOT MANOR Insurance
PORTAGE, IN 46368- 2
Patient No: 201102079
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
$518.04 $553.04 -35.00
CPT
na .d, ..vs}": enry,4 t -k; s +t,^r.Yxsx s •,y,
Date sr Descr:Iption .fiK,�, ����;�s .Gharges Credits
v,::a�. -x.rv. rr:a+- _rx_._...c r a r., is :sm?i nrli Q, '1-a e r.+�? i 7' w .93._ :r
E•ni:� a., yt, y A^,� i� �n� y N"S,
07/29/2011 ADVANCED LIFE SUP-, 1 —EMER A0427 $475.00
07/29/2011 MILEAGE A0425 $43.04
08/16/2011- PAYMENT $25.00
11/21/2011 PAYMENT $10.00
01/19/2012 MEDICAID PAYMENT $176.68
01/19/2012 ASSIGNMENT MEDICAID $341.36
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 01/31/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: RON SMITH ICD 9: 78650 78605 7808 78079
517 CAMELOT MANOR
PORTAGE, IN 46368
From: 320 W GERSHWIN DR APT /SUITE# 312
To: IU HEALTH NORTH
EDS -HCFA 1500 CLAIMS
Patient: RON SMITH 105297280799
517 CAMELOT MANOR Insurance
PORTAGE, IN 46368- 2
Patient No: 201102079
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
$518.04 8518.04 $0.00
CPT
;X e 5 �x t
<5 yt
Date E Descrlptlon z Sri
Char es Credits
M:s.zi x ��iR- ..y.a,.MSxn-,, s,.4fir+*.:_.,.:�_,s_ rr... 'a �'`3 *y ,C F'�" t
r a tS', x, a J r'.4t ✓.:,�'`a. -..sn ..r#5�,:' "i..zs x� ^a. f,..��.,.a: a4.a: �rnc:� �l 1
07/29/2011 ADVANCED 'LIFE SUPP 1 -ENTER A0427 $475.00
07/29/2011 MILEAGE A0425 $43.04
08/16/2011 PAYMENT $25.00
11/21/2011 PAYMENT $10.00
01/19/2012 MEDICAID PAYMENT
01/19/2012 ASSIGNMENT MEDICAID 5341.36
01/31/2012 REFUND -35.00
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. 1995)
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
k on 'j A Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
v Vim,
Total '35
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.
ALLOWED 20
�m i IN SUM OF
Sl 7 4 �Cm dol 1 Or
ON ACCOUNT OF APPROPRIATION FOR
Ia e 126/! o &�rU
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
FEB 13 %Nt2
u
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund