179456 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: T0002825 Page 1 of 1
ONE CIVIC SQUARE UNITED sE HEALTHCARE CHECK AMOUNT: $67.12
ao CARMEL, INDIANA 46032 o
y~ ion a ATLANTA GA 30374 -0803 CHECK NUMBER: 179466
CHECK DATE: 11/11/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 2 67.12 REFUND
Date: 10/2812009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
A �_4 T OR
Bill To: MARJORIE M ZINTEL ICD -9: 7$04 92410 E8130
25 ROGERS RD
CARMEL, IN 46032
From: 126TH RANGELINE RD
To: ST. VINCENTS HOSPITAL CARMEL
I OHIO CASUALTY
Patient: MARJORIE M ZINTEL CLM #003720500
25 ROGERS RD Insurance
CARMEL, IN 46032- 2
Patient No: 200901779
WE HAVE NOT RECEIVED A PAYMENT FROM YOUR INSURANCE COMPANY. THIS AMOUNT IS NOW YOUR RESPONSIMLITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$338.10 $673.71 335.61
CPT
Date Description Charges Credits
07/06/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
07/06/2009 MILEAGE A0425 $13.10
09/09/2009 COMMERCIAL INSURANCE PAYMENT $338.10
09/11/2009 MEDICARE PAYMENT $268.49
09/11/2009 ASSIGNMENT MEDICARE $2.49
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: 1 012 8120,0 9
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederallD# 356000972
Bill To: MARJORIE M ZINTEL ICD -9: 7804 92410 E8130
25 ROGERS RD
CARMEL, IN 46032
From: 126TH RANGELINE RD
To: ST. VINCENTS HOSPITAL CARMEL
1 OHIO CASUALTY
Patient: MARJORIE M ZINTEL CLM #003720500
25 ROGERS RD Insurance
CARMEL, IN 46032- 2
Patient No: 200901779
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
$338.10 $606.59 268.49
CPT
Date Description Charges Credits
07/06/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
07/06/2009 MILEAGE A0425 $13.10
09/09/2009 COMMERCIAL INSURANCE PAYMENT $338.10
09/11/2009 MEDICARE PAYMENT $268.49
09/11/2009 ASSIGNMENT MEDICARE $2.49
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 -AA R PC K42 -01171-001 -03418
UNITED HEALTH CARL= If you hav 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 SO
CARMEL IN 46032 -7543
REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS
STATEMENT DATE: SEPTEMBER 18, 2009 RI,01 '1� SEP 2 9 2019
CHECK AMOUNT: $1,505.93
For real -time access to claim, check, and member eligibility 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 company or other person files 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 HealthCare Insurance Company (and United HealthCare Insurance Options
Company of New York for New York residents) are proud providers to
rr
Please detach check below and cash promptly
UNITED HEALTH CARE
PO BOX'740819 2 2
s a
ATLANTA `GA 30374 0819 `Citibank Delaware e° 311
One ',Penn's Way OHO G a i
.New "Castle DE "19720
REPRESENTS PAYMENT FDR9MULTIPLE .INSIiREDS
F 0'0
DATE; SEPTEMBER 18 2
*1
*ONE 'THOUSAN'D "FIVE ::HUNDRED ."FIVE 'DOLLARS AND :.9,3` CENTS
;PAY
TO THE
ORDER OF
CARMEL TIRE ;DEPT*
2- CARMEL "CI VIC`.SQ:
CARMEL.`IN "4`6032 -7543
lip L :2 t, I OD 2 2°g`II° 1:0 3 W0;0 2 D °4z: 3 "8 E 2 5 i
26 1 -AARPCK42-01 171 -003 -03420
Health Care
United HcaltllCare Insurance Company (and United HcalthCarc Insuraricc �A Options"
Company of' New York for Ncw York residents) are proud providers to
PAGE 3 OF 4
REMITTANCE ADVICE PLEASE RETAIN FOR YOUR RECORDS
STATEMENT DATE: SEPTEMBER 18, 2009
BENEFIT SUMMARY FOR: CARMEL FIRE DEPT*
Insured Provider Dates of Amount Medicare Medicare Applied to Benefit
Information Service Charged I Approved Paid Deductible
From To
C:
10_: ZINTEL, SMARJORIE M ',ar...;`.... MMS D44532,216 CLAI:M 9.2525 507862,
PATIENT 200901779 CARMEL 070609 325.00 322.51 258.01 64.50
CARMEL 070609 13.10 13.10 10.48 2.62
TOTAL 67.12
WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR
BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE.
TOTAL ki1.55
WHEN YOUR PROVIDER ACCEPTS MEDICARE'S ASSIGNMENT, WE CALCULATE YOUR
BENEFIT BASED ON THE AMOUNT APPROVED BY MEDICARE.
Indiana CHECK REFERENCE CHECK DATE
Insur B. CODE 1006662170 09/04/09
CHECK'ANIOUNT s.- 6CDCK- NUMBER,.
x
R07 *5338 10_ 001.923
4 PAGE 1 OF 1
LOSS DATE 07/06/09
AGENT NAME BROWN BROWN OF INDIANA INC CASE 003720500
AGENT NUMBER 0004531
PAYEE: CARMEL FIRE DEPT AMBULANCE
CLAIM REP: AMBER HALE
PAYEE ADDRESS: CLAIM REP PHONE: 513- 867 -3000
2 CIVIC SQUARE
CARMEL IN 46032
INSURED /CLAIMANT NAME CASE PAYABLE POLICY
WILLIAM ZINTEL 003720500 338.10 PLP4610946
REMARKS: D /O /B 06/17/1931
003720500 MARJORIE ZINTEL $338.10
07/06/2009 THRU 07/06/2009
TOTAL AMOUNT: $338.10
CAREFULLY DETACH CHECK BEFORE DEPOSITING RETAIN STATEMENT FOR YOUR RECORDS
VERIF.Y?THE AUTHENTIGIT,Y OF TiiIS :MULTI- TONE:SECURITY-DOCUMENT 4W H of '8ACKGROUND AREA CHANGES COLO GRADUALLYFROM TOR T,O BOTTOM 3
IUI
10;0 6 6 2 T
"AMC ^0 Q19 `ti k1ACHOVIA BAiJK, N A 64 9,75/612 e
P 8 0 BDX'�461 1x111 0
SAINT�'LOUIS�: MO fi316b 04b'1 04
SAVANNAH, GA x 20799 11553"
urance w
09104%09 a ,Y
B CODE OFFICE PAYMENT IDENTIFICATION *338 Io
P007 003720500 INDIANA INSURANCE COMPANY
VOIE N r NOT PRE-SENTED:V 17HIN
:6 MONT: HSsOr DAT'cOF
PAY THREE `HUNDRED.T,HIRTY•EIGHT AND 10/ 100 DOLLARS *K
THE
CXRME'L .FIRE DEFT AMBULANCE
:ORDER— CIvlc' SQU'A'RE
OF .CAR M.E L 'IN 460
II® 100eS5217011 t00�. 1 20975bia 2079900L-. h l553u° M
w_ ._.._...,.,....x..��• ..r...r_.A.n �nnn �^h:.'Tt G ?i.. .f. `'H.Eti` Te
nr.t LF TOMEW�WHEliE CHECKING,THEiENQORSEMfiIVT.
Prescribed by State 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.
f /Payee
l��/(� jed— /J�C� l Purchase Order No.
0. O k 7 V 0 1 9 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
P for "rte /Z
Total /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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF Z Z/2_
7 5ZC
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
NOV 0 2afm
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund