The URL can be used to link to this page

Home My WebLink About171810 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 $40.19 04/15/2009 REFUND -40.19 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 M zD D. E.. REID Tao 4 9122 K. D..REID 649606472 13997 N POND CIRCLE CARMEL, IN 46032 urd�r o 3 4morgan Chase Bank, N.A. Indianapolis, Indiana 48277 ,M.m.Chase.com M, a >UNIF G 2C) STARFinant�alBank 04198/20g9 Q� y� SERVICES YN7C Anr)ersctat IncUaia !d EN PATI T PERRY REIN :uomtsovAYSi;�xDAm i �'Q Sqx i'0 Yend1'eton iN,.4Gbba 0010 a Phone(800)79] 5837 P4'CIENT IQ ZQD802843 bFtssus c Pi•ovader'$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