179455 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
ONE CIVIC SQUARE UNITED HEALTHCARE
CARMEL, INDIANA 46032 PO BOX 740603 CHECK AMOUNT: $67.12
ATLANTA GA 30374 -0803 CHECK NUMBER: 179455
CHECK DATE: 11/11/2009
DtPARTMFNT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 67.12 REFUND
Date: 10/28/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederaliD# 356000972
Bill To: DOROTHY M WINSTEAD ICD -9: 9593 71943 E8801
8720 YARDLEY COURT APT 204
INDIANAPOLIS, IN 46268
Frain: 1217 S RANGELINE RD
To: ST. VINCENTS HOSPITAL CARMEL
1 THE HARTFORD
Patient: DOROTHY M WINSTEAD CLM #22WBIT2939
8720 YARDLEY COURT APT 204 Insurance
INDIANAPOLIS, IN 46268- 2 AARP /UNITED HEALTHCARE
Patient No: 200901704 015805521111
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
$338.10 $673.71 335.61
CPT
Date Description Charges Credits
07/03/2009 BASIC LIFE SUPP EMERGENCY A0429 $325.00
07/03/2009 MILEAGE A0425 $13.10
09/01/2009 MEDICARE PAYMENT $268.49
09/01/2009 ASSIGNMENT MEDICARE $2.49
09/22/2009 COMMERCIAL INSURANCE PAYMENT $338.10
09/24/2009 ASSIGNMENT MEDICARE -2.49
09/29/2009 COMMERCIAL INSURANCE PAYMENT $67.12
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 10/28/2009
a
CARMEL. FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederalID# 356000972
g 0 r
Bill To: DOROTHY M WINSTEAD ICD 9: 9593 71943 E8801
8720 YARDLEY COURT APT 204
INDIANAPOLIS, IN 46268
From: 1217 S RANGELINE RD
To: ST. VINCENTS HOSPITAL CARMEL
9 THE HARTFORD
Patient: DOROTHY M WINSTEAD CLM #22WBIT2939
8720 YARDLEY COURT APT 204 Insurance
INDIANAPOLIS, IN 46268- 2 HARP /UNITED HEALTHCARE
Patient No: 200901704 015805521111
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
$338.10 $606.59 268.49
CPT
Date Description Charges Credits
07/03/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
07/03/2009 MILEAGE A0425 $13.10
09/01/2009 MEDICARE PAYMENT $268.49
09/01/2009 ASSIGNMENT MEDICARE $2.49
09/22/2009 COMMERCIAL INSURANCE PAYMENT $338.10
09/24/2009 ASSIGNMENT MEDICARE -2.49
09/29/2009 COMMERCIAL INSURANCE PAYMENT $67.12
10/28/2009 REFUND -67.12
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
261- AARPCK42•01171. 001 -03418
UNITED HEALTH CARE If you have questions please contact us at:
PO BOX 740819
ATLANTA, GA 30374 -0819
UNITED HEALTH CARE
PO BOX 740819
ATLANTA, GA 30374 -0819
TOLL FREE: 1- 800 -AARP- 789
1- 800 2277 -789
PAGE 1 OF 4
CARMEL FIRE DEPT*
2 CARMEL CIVIC SQ
CARMEL IN 46032 -7543
REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS
STATEMENT DATE: SEPTEMBER 1 8 2009 RECEil E 9 2009
CHECK AMOUNT: $1,505.93
For real -time access to claim, check, and member eiiVgibility information please register online at.
https://aarpprovideronlinetool.uhc.com
Please remember to submit your claims on a timely basis. The certificate of insurance includes a time limit for
submitting proof of loss.
Any person who knowingly and with intent to defraud any insurance compaliy or other person fifes an
application for insurance or statement of claim containing any materially false information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
Health Care
United HealdiCare Insurance Company (and United Health Care insurance Options
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Company of Nevi York for New York residents) are proud providers to
Q
Please detach check below and cash promptly
aptly
'UNtTED,HEALTH CARE L
Qa i3o' 740819 62 20
ATLANTA =GA 30374 0819 CrtiO Delaware 311
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One
Penn 's 'Way
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New Castle, DE 1.9720
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REPRESENTS PAYMENT; FOR MULTI PLE,INS ORE'DS i= DATE' SEPTEMBER
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PAY 505 93**
ONE THOU:SAND FIVE HUNDRED FIVE. DOLLARS :AND 9.3 CENTS*
PAY
TO THE,
ORDER 'OF
CARMEL.,.FIRE .;DEPT*
2.CARMEL CIVIC SQ
CARMEL TN 46032 =7543
,2:x,10,0 2 2'8118 1 0 3 L L:0:0 ._2 0 91: 38 5 0 2:1 E, 4111,
261- A.ARPC X42- 01171- 002.03419
Health Care
United HealifiCare Insurance Company (and United HcohhCare Insurance Options
Company of New York for NevN York residents) are proud providers to
PAGE 2 OF 4
REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS
STATEMENT DATE: SEPTEMBER 18, 2009
BENEFIT SUMMARY FOR: CARMEL FIRE DEPT*
SEP 2 9 2009
Insured Provider Dates of Amount Medicare Medicare Applied to Benefit
information Service Charged Approved Paid Deductibie
From To
BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE.
4 WINSTEAR, DOROTHY M ,.,'ti r: MEMBERSHIP' 015805521 CLAIM 92446 507'052 1
ATIENT 20�090i704� CARMEL' 070309 325.00 322.51 258.01 64.50
CARMEL 070309 13.10 13.10 10.48 2.62
TOTAL 67.12
800 5-2 1 910 7
The Hartford Central Work Comp
PO Box 14471
Lexington, KY 40512
877 952 -9222 THE
IARTFORD
000950
City Of Carmel Fire Department
2 CIVIC SQUARE
CARMEL, IN 46032
Attention This remittance Encorporates
1 claim payments
Special Handling ID: RM 00
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RE GEIVED S E P 2 2 2009
083718583
HAR -100 -2 e e e e
The Hartford.- Central Work Comp i 56 :154 C heck` Number 1140838571
PO;Bo0447.1 :x441
ss u e? D ate 09 -1' 1 -2009
H E Lexington, KY 40512
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THREE HUNDRED THIRTY -EIGHT DOLLARS AND 10 /100
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2 =ORDER 2 CIU,IC:�SOUARE,�, �xr CC
OF CARMEL, iN 46032
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`AUthorized Signature r
II' b 04083857 �I1' 1:01 1 b54L.31: 63 255973Bo
Bill Control No: THE HARTFORD MEDICAL BILL PROCESSING CTR
0127492877 P.O. BOX 14170 1124
LEXINGTON, KY 40512
EXPLANATION OF REIMBURSEMENT
September 11, 2009
PATIENT: DOROTHY WINSTEAD SOC SEC NO: XXX /XX/2608
CLAIM NO:YKS 05210 C INJURY DATE: 07/03/2009
INSURED: NEW CONCEPTS IN MARKETIN INVOICE NO: 200901704
PAY TO: CITY OF CARMEL FIRE DEPARTMENT INVOICE DATE: 08/17/2009
2 CIVIC SQUARE
CARMEL, IN 46032 TAX ID NO: 356000972
PROCEDURE DESCRIPTION CHARGED PAID
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07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001
A0429 SH AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERG TRA 325.00 325.00
REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE
RATE FOR YOUR GEOrRAPHIC (ZIP CODE) AREA.
m
0 07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001
A0425 SH GROUND MILEAGE. PER STATUTE MILE 6.55 6.55
0
0
REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE
RATE FOR YOUR GEOGRAPHIC (ZIP CODE) AREA.
07/03/2009 TOS: DIAG CD: 959.3 UNITS: 00001
A0425 SH GROUND MILEAGE, PER STATUTE MILE 6.55 6.55
REASON: REIMBURSEMENT IS BASED UPON USUAL, CUSTOMARY AND REASONABLE
RATE FOR YOUR GEOGRAPHIC (ZIP CODE) AREA.
RECEIVED S E F 2 2 2009
CHARGED AMOUNT: 338.10
TOTAL AMOUNT PAID: 338.10
For Reconsideration of this reimbursement determination, the following information MUST be submitted:
Copy of this EOR, copy of the original bill and any supporting documentation to the address above. If
you have any questions regarding this Explanation of Reimbursement (EOR) please call 800- 526 161 1
and reference your Bill Control Number 0127492877•
eon
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
Ar^voice 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 n/
Purchase Order No.
'11 ,),,x 7 zhQ ?Z q Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
S7ZP
Total Z Z
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
r
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM O F �o
Z Z2
6 C 7� Y/ 9
A6/ZA
s l 7. /z
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
N 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund