174400 07/08/2009 CITY OF CARMEL, INDIANA VENDOR: 363023 Page 1 of 1
ONE CIVIC SQUARE JUN KURAMOTO CHECK AMOUNT: $525.00
CARMEL, INDIANA 46032 14219 LAURA VISTA DRIVE
CARMEL IN 46033 CHECK NUMBER: 174400
CHECK DATE: 71812009
DEPARTMENT A CCOUNT PO NUM BER INVOICE NUMBER AMO D
102 5023990 525.00 REFUND
b
l`Y
C�
Date: 07/01/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
4
Bill To: JUN KURAMOTO ICD -9: 4275
14219 LAURA VISTA DR
CARMEL, IN 46033
From: 14129 LAURA VISTA DR
To: ST. VINCENTS HOSPITAL CARMEL
1 UMR
Patient: RAY KURAMOTO 12603188
14219 LAURA VISTA DR Insurance
CARMEL, IN 46033 2
Patient No: 200900648
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
$544.65 $1,069.65 525.00
CPT
Date Description Charges Credits
03/11/2009 ADVANCED LIFE SUPP 2— EMERGENCY A0433 $525.00
03/11/2009 MILEAGE A0425 $19.65
05/15/2009 COMMERCIAL INSURANCE PAYMENT $19.65
06/05/2009 PAYMENT $525.00
06/26/2009 COMMERCIAL INSURANCE PAYMENT $525.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/01/2009
r
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: JUN KURAMOTO ICD -9: 4275
14219 LAURA VISTA DR
CARMEL, IN 46033
From: 14129 LAURA VISTA DR
To: ST. VINCENTS HOSPITAL CARMEL
1 UMR
Patient: RAY KURAMOTO 12603188
14219 LAURA VISTA DR Insurance
CARMEL, IN 46033 2
Patient No: 200900648
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
8544.65 $544.65 $0.00
CPT
Date Description Charges Credits
03/11/2009 ADVANCED LIFE SUPP 2- EMERGENCY A0433 $525.00
03/11/2009 MILEAGE A0425 $19.65
05/15/2009 COMMERCIAL INSURANCE PAYMENT $19.65
06/05/2009 PAYMENT $525.00
06/26/2009 COMMERCIAL INSURANCE PAYMENT $525.00
07/01 /2009 REFUND 525.00
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
f
JUN 'K 71- 959/749
14219. LAURA DR. 7653317698
CARMEL,.IN 46033 o
Date
Pay rde to the
Or of �a (iLn•2 I �i ti U�DaL�lti+ f p �Z�
Dollars LI
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0026611
11129 001
FM099
If returning this check, please 009723.
UMR send to address at left.
PO BOX 30541
SALT LAKE CITY UT 84130 -0541
www.umr.com
11129 CPV19
CARMEL FIRE DEPT Check No. 01007913
2 CIVIC SQ Check Date 06 -18 -09
CARMEL IN 46032 -2584
Check No. 01007913
ADMINISTERED BY UMR
SMC CORPORATION OF AMERICA
06 -18 -09
AFO100 (9/04)
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TO The 3!•, ti u u! I h :II M �I ie v” :II li �r I rt I
Order Of CARMEL:` FIRE .-DEPT *'52
80 Y MD VOID AFTER 18�D DAYS
�l+; u:,:i 9 tbw';rl,!9 .r C IIA ,a"L 1 S a r t" .v 7�;wcyu 1141:FO..� T I....II uiI rs.r°': o{ ;a.....I Ifl rc°.�"3a .'l¢7 •rv.1::.,.,,"�'r, r
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`AUTHOR IZI GNAT U-R- E:,+ °Sf xr �o ,r,,.�• .a.. •`t`
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II 0 10079 1 311 1:0 7 50000 5 11: 00 1� 58--f 9 6 6 7 511'
0026612
11129 002
Remittance Advice for Period Ending 06 -18 -09
UMR
PO BOX 30541 SALT LAKE CITY LIT 84130 1- 866 795 -6662
OPTIONS PPO
SMC CORPORATION OF AMERICA SELF INSURED
Visit our web -site at
www.umr.com
CARMEL FIRE DEPT Federal ID No. 35-6000972 to obtain eligibility, benefit, and
2 CIVIC SQ claim Information on behalf of your
CARMEL IN 46032 patients 24 hours /day, 7 days /week.
Discount
Dates Service Charged Allowed ANSI Patient
From/To Code Amount Amount Deductible Cops} Coinsurance Managed Ineligible Withheld OC Code Paid Responsibility
Care Adjust
EMPLOYEE:.KURAMOTO JUN PATIENT: KURAMOTO RAY ID# 12603188
ACCOUNT NUMBER: 200900648 CLAIM NUMBER: 09113002635
031109 A0433RH 525.00 505.35 .00 .00 .00 .00 19.65- 00 01 505.35 .00
CORRECTION PREVIOUSLY CONSIDERED 18
031109 A0425RH 19.65 19.65 .00 .00 .00 .00 .00 03 19.65 .00
CORRECTION
TOTAL 544.65 525.00 .00 .00 .00 .00 19.65- 00 525.00 .00
OPTIONS PPO
JUN 2 6 2009
SUB TOTAL 544.65 525.00 .00 .00 .00 .00 19.65- 00 525.00 00
PROVIDER TOTAL 544.65 525.00 .00 .00 .00 .00 19.65- 00 525.00 00
CPV19 1800030903 0001007913
CF0038 06 -04
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
j a gmat? Os Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
e,' b
Total �5
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
IN SUM OF aS'
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
JUL 6 2009
2
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund