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Home My WebLink About179456 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