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Home My WebLink About168082 01/21/2009 CITY OF CARMEL, INDIANA VENDOR: T362442 Page 1 of 1 0 ail ONE CIVIC SQUARE ALBERT KLEINSCHMIDT CHECK AMOUNT: $61.21 CARMEL, INDIANA 46032 14351 QUAIL POINTE DR CARMEL IN 46032 CHECK NUMBER: 168082 CHECK DATE: 1/21/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 61.21 OTHER EXPENSES f a A 20 340 7 3 2 5 ALBERT Ci KLEINSCF M t 769294406 14351 QUAIL POINTE DRIVE rz CARMEL IN 46032 9 /y/ Ib x PAY TO THE V Sj ORDEWOF, S 1' J �`1" .,ax a y a 4y D MEMO b_ N .x...�.. C I STATE FARM EXPLANATION OF REVIEW nw This is not a bill INSURANCE O State Farm Mutual Automobile CLAIM NUMBER 14- 2229 -679 OFFICE NAME Insurance Company Indiana MPC Office ALBERT C. KLEINSCHMIDT CARMEL FIRE DEPT EMERGENCY MEDICAL 14351 Quail Pointe Drive 2 CIVIC SQ Carmel, IN 46032 CARMEL, IN 46032 -2584 DATE OF LOSS 6/2/2008 CLAIM HANDLER Unit Xe Processor NAME INSURED KLEINSCHMIDT, ALBERT C ADDRESS PO Box 2362 Bloomington, IL. 61702 POLICY NUMBER 671096214 PHONE 866 648 -0715 JURISDICTION Indiana TIN 356 -00 -0972 V IP OF SERVICE 46032 BILL REFERENCE DATE NA �v 13 q E RECEIVED 12/17/2008 NUMBER E813.0 MOTOR VEHICLE COLLISION WITH OTHER VEHICLE, INJURING DRIVER DIAGNOSIS CODES OF MOTOR VEHICLE OTHER THAN MOTORCYCLE, 786.52 PAINFUL RESPIRATION i (DRAFT NUMBER 1118913048J LINE DATE OF pOS CPT /HCPCSMOD /TSUNITS SUBMITTED APPROVED REASON SERVICE AMOUNT AMOUNT CODES 1 6/2/2008 6/2/20081 11 A0429 1 300.00 300.00 2 6/2/2008 6/2/20081 11 A0425 1 6.25 6.25 TOTAL SUBMI TTED CHARGES 306.25 TOTAL APPROVED AMOUNT 306.25 AMOUNT NOT PAYABLE 0.00 DEDUCTIBLE 0.00 PPORTIONMENT /PRO RATA 0.00 PAID AMOUNT 306.25 RECEIVED CLAIM,NO 14- 2229 -679 POLICY NO 6710 962 -14E LOSS DATE 06 -02 -2008 PAYMENT NO 1 18 913048 J Coverage:Descri t.ion Amount COL P.a' Cd DATE 12 -18 -2008 MEDICAL PAYMENT $306.25 600 2 AMOUNT 306.25 TIN 14- 356000972 REMARKS 6/2/2008 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 913048 WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 INIU•ANCIO MPC INDIANA 18-501 L025 COLUMBUS, OH 12 -18 -2008 DATE MM DD YYYY CLAIM NO 14- 2229 -679 INSURED KLEINSCHMIDT, ALBE LOSS DATE 06 -02 -2008 ON BEHALF OF ALBERT C. KLEINSCHMIDT rK *EXACTLY THREE HUNDRED SIX AND 2511;OODOLLARS *?306 ':25 Pay to the V16, r� Orderof. CARMEL FIRE DEPT EMERGENCY MEDICAL 2 CIVIC SQ CARMEL IN 46632- 2584rk� ll APPROVED BY ED CLAIM NO 14- 2229 -679 POLICY NO 6710- 962 -14E LOSS DATE 06 -02 -2008 PAYMENT NO 1 18 913048 J coverage. :D escri tion 'Amount COL Pa .Cd DATE 12-1 8-2008 MEDICAL PAYMENT $306.25 600 2 AMOUNT $306.25 TIN 14- 356000972 REMARKS 6/2/2008 A•M' STAATE FAfZM ,MUTUAL AUTOMOBILE I NSIIRANCE COMPA 1 1g 93048 J WEST IN JPMORGAN CHASE BANK,.NA "56 1544/441 5 j UM HOC BUS MPC INDIAIJA .18 507 L025 r r r 1.2 18 2008 DATE MM DD tYYYY a�1M rio 14 2226 9 IN'suRED KLEINS,.CHMiDT ALBE LOSS. DATE 66 -02 2008 ON BHA�F of ;ALBERT; C »KLEINSCHMIDT EXACTLY THREE HUNDRED SIX AND 25 /100 DOLLARS" *306.25 Pay to the Order of..- CARMEL FIRE DEPT EMERGENCY MEDICAL 2 CIVIC SQ CARMEL IN 46032 -2584 Al AUTHORIZED SIG T e o n o 11 l a 17913048l1' 1:04I,I154L,31:626290233112 Date: 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 MOUNT STO Bill To: ALBERT C KLEINSCHMIDT ICD -9: 78652 E8130 14351 QUAIL POINTE DRIVE CARMEL, IN 46032 From: 136TH ST US 31 To: ST. VINCENT CARMEL MEDICARE PART B Patient: ALBERT C KLEINSCHMIDT 351180078A 14351 QUAIL POINTE DRIVE Insurance CARMEL, IN 46032- 2 UNITED HEALTH CARE 740800 Patient No: 200801397 961165159 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $306.25 $612.50 306.25 CPT Date Description Charges Credits 06/02/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 06/02/2008 MILEAGE A0425 $6.25 07/15/2008 MEDICARE PAYMENT $244.83 07/15/2008 ASSIGNMENT MEDICARE $0.21 09/19/2008 PAYMENT $61.21 12/23/2008 COMMERCIAL INSURANCE PAYMENT $306.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 01/09/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederallD# 356000972 ".s.. Bill To: ALBERT C KLEINSCHMIDT ICD -9: 78652 E8130 14351 QUAIL POINTE DRIVE CARMEL, IN 46032 From: 136TH ST US 31 To: ST. VINCENT CARMEL MEDICARE PART B Patient: ALBERT C KLEINSCHMIDT 351180078A 14351 QUAIL POINTE DRIVE Insurance UNITED HEALTH CARE/ 740800 CARMEL, IN 46032- 2 Patient No: 200801397 961165159 YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND IS DUE AND PAYABLE NOW. THANK YOU. Total Amount Total Paid Balance $306.25 $551.29 245.04 CPT Date Description Charges Credits 06/02/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00 06/02/2008 MILEAGE A0425 $6.25 07/15/2008 MEDICARE PAYMENT $244.83 07/15/2008 ASSIGNMENT MEDICARE $0.21 09/19/2008 PAYMENT $61.21 12/23/2008 COMMERCIAL INSURANCE PAYMENT $306.25 01/09/2009 REFUND -61.21 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF i�3 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 6 2 5 Signature Title Cost distribution ledger classification if v claim paid motor vehicle highway fund