HomeMy WebLinkAbout206646 02/28/2012 CITY OF CARMEL, INDIANA VENDOR: 366060 Page 1 of 1
ONE CIVIC SQUARE REBA COOPER
CARMEL, INDIANA 46032 12504 SANDSTONE RUN CHECK AMOUNT: $495.39
CARMEL IN 46033 CHECK NUMBER: 206646
CHECK DATE: 2/28/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 495.39 OTHER EXPENSES
Date: 0211512012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 FederalID# 356000972
ACCOUNT HISTORY
Bill To: WILLAM COOPER ICD -9: 78650 78605 7245 7295
12504 SANDSTONE RUN
CARMEL, IN 46033
From: 12188 N MERIDIAN ST
To: ST VINCENT HEART CENTER
GOLDEN RULE
Patient: REBA COOPER 057880617
12504 SANDSTONE RUN Insurance
CARMEL, IN 46033- 2
Patient No: 201102873
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$495.39 $990.78 $495.39
CPT
94 Ci, i m 'I
J uS �k d I Ai ,r'i l A i a C� 3 �'`har 2s vcs 5d.°
redit s
�5�i 1p h
1
10/21/2011 ADVANCED LIFE SUPP 1- -EMER A0427 $475.00
10/21/2011 MILEAGE A0425 $20.39
02/08/2012 PAYMENT $495.39
02/10/2012 COMMERCIAL INSURANCE PAYMENT $495.39
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 02/15/2012
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032 -7543
(317)571 -2605 Federal ]D# 356000972
ACC HISTORY
Bifl To: WILLAM COOPER ICD -9: 78650 78605 7245 7295
12504 SANDSTONE RUN
CARMEL, IN 46033
From: 12188 N MERIDIAN ST
To: ST VINCENT HEART CENTER
GOLDEN RULE
Patient: REBA COOPER 057880617
12504 SANDSTONE RUN Insurance
CARMEL, IN 46033 2
Patient No: 201102873
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$495.39 $495.39 $0.00
CPT
a La$x!.k,ar,.l .3':;n"':` "alit �1 FJa'i`R tiv;.:.ti,>:r a
d 4i F,�, h"tt I��i J,. _,.i r�:S a> ':'x „d fir ;9 ul M7,. x. 11, 1.- `f Z 44 a 6 il
1d iz r!a li
Date aF'd4 e a F,r aQ D:eSCfr !',tlOn 4 T.a w.F wp, P, ,g y m:�a +u� i t v r �C.flat eS::ip C'�e(�1�5
d arnv�s x Hr�t�&J �Pil. IJ�af; �Ium:f v.. rd,,: aa« l t� 11. Sb �dlly4` aEry SFM
10/21/2011 ADVANCED LIFE SUPP 1 --EMER A0427 $475.00
10/21/2011 MILEAGE A0425 $20.39
02/08/2012 PAYMENT $495.39
02/10/2012 COMMERCIAL INSURANCE PAYMENT $495.39
02/15/2012 REFUND 495.39
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
n Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
nrn,6r�TSe r' eq 5.
Total
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF$ �tq5, 39
q 9 -5. 9 9
ON ACCOUNT OF APPROPRIATION FOR
Ambulagre
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
2012
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund