171810 04/29/2009 CITY OF CARMEL, INDIANA VENDOR: 362835 Page 1 of 1
ONE CIVIC SQUARE D E REID CHECK AMOUNT: $40.19
CARMEL INDIANA 46032 13997 N SPRINGMILL POND CIRCLE
41,4oH.do CARMEL IN 46032 CHECK NUMBER: 171810
CHECK DATE: 4/29/2009
'I D EPAR T MENT ACCOUNT PO NUMBER INVOICE NUMBER AMO DESCRIPTION
102 5023990 40.19 OTHER EXPENSES
Date: 04/1512009
i
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal iD# 356000972
R
PP
Bill To: DAVID E REID ICD -9: 7802 78009
13997 SPRINGMILL PONDS CIRCLE
CARMEL, IN 46032
From: 13997 SPRINGMILL PONDS CIR
To: ST. VINCENTS HOSPITAL CARMEL
1 UNIFIED GROUP SERVICES
Patient: PERRY G REID 038100031800
13997 SPRINGMILL PONDS CIRCLE Insurance
CARMEL, IN 46032- 2
Patient No: 200802843
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $384.84 -40.19
CPT
Date Description Charges Credits
11/25/2008 BASIC LIFE SUPP EMERGENCY A0429 $325.00
11/25/2008 MILEAGE A0425 $19.65
02/27/2009 PAYMENT $344.65
04/14/2009 COMMERCIAL INSURANCE PAYMENT S40.19
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 04/15/2009
i
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal iD# 356000972
fi
'r r y t
Bill To: DAVID E REID ICD -9: 7802 78009
13997 SPRINGMILL PONDS CIRCLE
CARMEL, IN 46032
From: 13997 SPRINGMILL PONDS CER
To: ST. VINCENTS HOSPITAL CARMEL
1 UNIFIED GROUP SERVICES
Patient: PERRY G REID 038100031800
13997 SPRINGMILL PONDS CIRCLE Insurance
CARMEL, IN 46032- 2
Patient No: 200802843
YOUR INSURANCE HAS APPLIED THIS CLAIM TO YOUR DEDUCTIBLE. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $344.65 $0.00
CPT
Date Description Ch„ arges Credits
11/25/2048 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
11/25/2008 MILEAGE A0425 $19.65
02/27/2009 PAYMENT $344.65
04/14/2009 COMMERCIAL INSURANCE PAYMENT $40.19
04/15/2009 REFUND -40.19
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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D. E.. REID Tao 4 9122
K. D..REID 649606472
13997 N POND CIRCLE
CARMEL, IN 46032
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4morgan Chase Bank, N.A.
Indianapolis, Indiana 48277
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a >UNIF G 2C) STARFinant�alBank 04198/20g9 Q�
y� SERVICES YN7C Anr)ersctat IncUaia
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PATI T PERRY REIN
:uomtsovAYSi;�xDAm i
�'Q Sqx i'0 Yend1'eton iN,.4Gbba 0010
a Phone(800)79] 5837
P4'CIENT IQ ZQD802843 bFtssus
c Pi•ovader'$ene7:'�t Faxback[(888) 2392940
.Internet'Info h€tps %lwww.ugsweb.com r PAYJRIS AMOUNT
FORTY `DOLLARS AND 19 CENTS $4Q.19.
d
PAY CARMEL FIRE`DEPT AMBULANCE SER
s THE 2 CIVIC SQUARE
a OF CARMEL IN 46032 7543
u°03807905um I:04490L6721: u°LL0 37L62uQ
393 EXPLANATI OF BE NEFITS 04/08/2009 03807905
ADMINISTERED BY GROUP CLAIMANT U
UNITIED GROP 3810 318
SERVICES, INC. RYOBI DIE CASTING PLAN A ENVISION ENCORE CLAIM FOR PERRY REID
SON
P.O. Box 10 Pendleton, IN 46064 -00I0 PATIENT ACCT 200802843
Phone (800) 291 -5837
Provider Benefit Faxback (888) 239 -2940 CLAIM NUMBER 2009- 84000235- 0
Lntemet lnfb: https: /www.ugsweb.com
CLAIMS SUMMARY
DAVID E REID TOTAL AMOUNT COVERED $344.65
13997 SPRINGMILL POND CIRCLE PAID BY OT14ER INSURANCE CO $0.00
TOTAL PAID BY PLAN $40.19
CARMEL, IN 46032 EMPLOYEE'S RESPONSIBILITY 5304.46
PROVIDER(S)
356000972 -0 Deductible Remaining -Flan $0.00
CARMEL FIRE DEPT AMBULANCE SER
2 CIVIC SQUARE Out of Pocket Remaining Plan 51,359.33
CARMEL, IN 46032 -7543
100 Out -of- Network Repricer ANTIUAL ACCUMULATION 540.19
CJIS#7i eats:
P PO Zero Pricing (Not Covered Under Cont
TYPEOFSERVICE llATESOFSERVICE TOTAL NOT NEGOTIATED ELIGIBLE Co-Pay I)EDUCTIBLE PAID BENEFITS
CHARGE COVERED SAVING OR PENALTY EXPENSE APPLIED AT PAID
AMBULANCE GROUND 21125/08 11/25/08 $325.00 $0.00 $0.00 $325 -00 $0.00 5300.00 90 $22.50
AMBULANCE GROUND 1 1/25/08 11125108 519,65 $0.00 50.00' 519.65 50.00 $0.00 90 517.69
RECE D APR 14 2009
�t9
MD e
TOTALS $344.65 $0.00 50.00 5344.65 $0.00 $300.00 540.19
Remarks on Back
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
y 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.
/1
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
b s el� y
r
Total
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
L� IN SUM OF
1 9 q 7 IV Gll'!'G1 w4 6
C-G� d _Z .A/ j0
�ZO. q
ON ACCOUNT OF APPROPRIATION FOR
Board Members
O# or INVOICE O ACCT /TITLE AMOUNT
EPT. 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
1 which charge is made were ordered and
received except
PR 2
20
Signature
Cost distribution ledger classification it Title
claim paid motor vehicle highway fund