HomeMy WebLinkAbout168082 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
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ALBERT Ci KLEINSCF M
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14351 QUAIL POINTE DRIVE
rz CARMEL IN 46032 9 /y/
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STATE FARM EXPLANATION OF REVIEW
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INSURANCE
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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