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176485 08/19/2009 CITY OF CARMEL, INDIANA VENDOR: 363276 Page 1 of 1 ONE CIVIC SQUARE UNITED COMMERCIAL TRAVELERS 0 CARMEL, INDIANA 46032 PO BOX 159019 CHECK AMOUNT: $69.74 COLUMBUS OH 43215 CHECK NUMBER: 176485 CHECK DATE: 811912009 DEPARTME ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 69.74 REFUND r.. Date: 08/06/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: MARGARET MCGINNIS ICD -9: 78652 71946 E8130 14817 ADIOS PASS CARMEL, IN 46032 From: 146TH ST LOWES WAY To: CLARIAN HOSPITAL NORTH 1 MEDICARE PART B Patient: MARGARET MCGINNIS 337300798B 14817 ADIOS PASS Insurance CARMEL, IN 46032- 2 UNITED COMMERCIAL ALLIANCE Patient No: 200900705 M5640233 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU, Total Amount Total Paid Balance $351.20 $702.40 351.20 CPT Date Desccri ti_on Charges Credits 03/17/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 03/17/2009 MILEAGE A0425 $26.20 05/04/2009 MEDICARE PAYMENT 5278.97 05/04/2009 ASSIGNMENT MEDICARE $2.49 05/19/2009 COMMERCIAL INSURANCE PAYMENT $69.`]4 08/04/2009 COMMERCIAL INSURANCE PAYMENT $351.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 08/06/2009 4 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (397)571 -2605 FederalID# 356000972 Bill To: MARGARET MCGINNIS ICD -9: 78652 71946 E8130 14817 ADIOS PASS CARMEL, IN 46032 From: 146TH ST LOWES WAY To: CLAR!AN HOSPITAL NORTH 1 MEDICARE PART B Patient: MARGARET MCGINNIS 337300798B 14817 ADIOS PASS Insurance CARMEL, IN 46032- 2 UNITED COMMERCIAL ALLIANCE Patient No: 200900705 M5640233 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME, PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU, Total Amount Total Paid Balance $351.20 $632.66 289.46 CPT Date Description Charges Credits 03/1"7/2009 BASIC LIFE SUPP- EMERGENCY Ad429 $325.00 03/17/2009 MILEAGE A0425 $26.20 05/04/2009 MEDICARE PAYMENT $278.97 05/04/2009 ASSIGNMENT MEDICARE $2.49 05/19/2009 COMMERCIAL INSURANCE PAYMENT $69.74 08/04/2009 COMMERCIAL INSURANCE PAYMENT $351.20 08/06/2009 REFUND -69.74 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 CLAIM NO 14 -2320 -954 POLICY NO 1473 371 -14 Loss DATE 03 -17 -2009 PAYMENT NO 1 18 829834 J Co.ver.age:Descri Lion Amount ..,COL Pa >Cd. DATE 07 -30 -2009 MEDICAL PAYMENT $351.20 600 2 AMOUNT $351.20 TIN 14- 35600097, ENTERED BY BRYANT, ADAM !AUTHORIZED BY BRYANT ADAM PHONE (866) 648 -0715 REMARKS 3/17/2009 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 829834 J WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 IMSVAN[1� MPC INDIANA 18 -501 L025 COLUMBUS, OF 07 -30 -2009 DATE MM DD YYYY CLAIM NO 14- 2320 -954 INSURED MC GINNIS, CONRAD t LOSS DATE 03 -17 -2009 ON BEHALF OF MARGARET MC GINNIS EXACTLY THREE HUNDRE D FIFTY ONE AND-20blj,, 0 DO LLARS 35.1.2:0 i Pay to the Order of.- CARMEL FIRE DEPARTME'NT:1 2 CIVIC SO CARMEL IN 46032 2584'. A +t t I APPROVED BY g1�e F1S V L CLAIM NO 14- 2320 -954 POLICY NO 1473 371 -14 LOSS DATE 03 -17 -2009 PAYMENT NO 1 18 829834 J Cover.a e:Descr.i Lion'' ::Amount: COL Pa ;Cd'; DATE 07 30 -2009 MEDICAL PAYMENT $351.20 600 2 AMOUNT $351.20 TIN 14- 356000972 e; I r AUTHORIZED BY BRYANT, ADAM PHONE (866) 648 -0715 REMARKS 3/17/2009 ;;STATE FARM MUTUAL° TT -LE INSURANCE COMPANY t, 1 l$ $29$ 4 WEST LAFAYETFE; IN ilPMORGAN CHASE BANK NA 'S6 1544/447 F MPC INDIANA 18 501 1025 \0 COLUMBUS 'OH.t 7 `30 2009 „ccA N ;14 2320 954 1 NSURED MC GINNIS,, CQ.NRAD' DATE M M'D D v Y v v .LOSS DATE :'.`03 .1'7- 009 ON "BEHALF' >,OF ;M MC'- ;GINNIS "i t EXACTLY THREE HUNDREWFIFTY =ONE AND 20/100' DOLLARS *3 -51.20 Pay to the Order. of CARMEL FIRE DEPARTMENT 2 CIVIC SO CARMEL IN 46032 -2584 AUTHORIZED 'SIGNATURE e ii'b8L782983L,i1' 1 :0L,41L5L,L--31:1, 25 290 2 13if' ri?ssomuai United Commercial Travelers of America If You Have Questions Call Our 1801 Watermark Drive, Suite 100 Customer Service Department at P.O. Box 159019 (800) 848 -01.23 Columbus, OA 43215 -8619 a0903120107 Claim No.: 091252512 -Y EDI Address Service Requested Insured: MARGARET R MCGINNIS w ID M5640233 3 DI6IT 4LO Claimant: MARGARET R MCGINNIS 17462 0-382D AT 0.357 Patient#: 200900705 111' II' 1111 11 111 1 1 111 ll1 Date: 05/11/2009 CARMEL FIRE DEPT AMBULANCE 76 Group: UNITED COMMERCIAL 2 clvlc sa TRAVELERS UNITEM z CARMEL, IN 46032 -2584 STATE L G rou p 0001 EIN 0356000972 EXPLANATIO OF B Line Provider Date(S) Of Service procedure Totnl 114edicare Pd/ Deductible L1C"1' Covered Balance Paid No. Code Billed Excluded Charges Expense By Plan 01 CARMEL FIRE DEPT AMBULANCE 03/17 03/17/2009 A0429 325.00 2.49 0.00 64.50 64.50 02 CARMEL, FIRE DEPT .AMBULANCE 03/17 03/17/2009 A0425 26.20 0.00 0.00 5,24 5.24 TOTALS 351,201 2.49 0.00 69.74 69.74 Ch eck Issued To: Amoun CARMEL FIRE DEPT AMBULANCE 69.74 Claim Remarks Line No. Explanation 1 U( ;ine Ol- 2.4 )THB IS NOT fiBILL. "FIBS IS T(5t UC�E-DT S 1,2 THIS IS THE MAXIMUM AMOUNT OF BENEFIT FOR TLIIS CLAIM. MAY 1 9 2009 1 QR SEGII'RiTY 1?IJRP0SES THE FACE DFTHIS DOCUMENT CONTAINS >A BLUE SgCKGROUN© 4ND MICROPRIIVTINGIWTHE BQRDER 1 7HE ORDEF30F 1 7 56 704/412 t Uh1TEG3.CUMM' ERCJAL TRA1/ OPAMERICA ,CHEEK N0 75656�i6 B32NDRTH PARK STREE7 ;COLUMBUS.OH10,432iS N01 VALIB,AFF> R�Jb`DAYS'l'R�M'1)A3EOF`iSSU1 t: MARGARET�R MCGINN1S CWm# 09.1252572 Y Patient# 200J0(]705 ISSUE'DATE� 1' /2()49 SPAY SIXTY -NINE AND 741100 DOLLARS A7YIOUNT C, TO THE CARMEL. FIRL DEP1 AMBULANCE' BORDER OF 2 CIVICSQ CARMEL, IN 46032 -2554 ^I l:E'f'BaNK COLUMBUS, 011 Authorized Signature DUNOT CASHiIPWATERIUTARK IS?NOT:P,RESENT ONTk3EE'RE:VERSE'.SIDE OF,THISiDOCUMENT rHOLD,AT AWANGLE TC3 IEW 1I'75 5E6F=1I' 1:04 1 20 7 0401: 3 0099 3 00069 211' Prescribed by Slate Board of Accounts City Form No. 201 (Rev. 1995 ACCOUNTS PAYABLE VOUCHER 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 l,C/2�P/,L �Omn�P�C'i'Cc ►�P�Pc�S Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) e, ,bi l�s e I -1c r Pte" i 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. /ji ALLOWED 20 /UCH �Pl� C- �'�/�I�7P�G�r �l� CZI�C',IP/S IN SUM OF Z0 C I 7 90 X /6 go/ 6 11oxh .t s, 0# 3 pis Z 9, 7LI ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or i 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 AUG 17 2009 20 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund