The URL can be used to link to this page

Home My WebLink About177433 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: T362010 Page 1 of 1 ONE CIVIC SQUARE UNITED HEALTHCARE INS CO CHECK AMOUNT: $351.20 CARMEL, INDIANA 46032 PO eox 30555 SALT LAKE CITY UT 84130 CHECK NUMBER: 177433 CHECK DATE: 9/15/2009 DEPARTMENT ACCOU PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTI 102 5023990 351.20 OTHER EXPENSES Date: 09702/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- {317 }571 -2605 Federal 1D# 356000972 sill To: REGINA THOMPSON ICD -9: 7231 E8130 4766 N. COUNTY RD. 300E FRANKFORT, IN 46041 From: MERIDIAN ST 1 465 To: CLARIAN HOSPITAL NORTH 1 UNITED HEALTH INS/3D555 Patient: REGINA S THOMPSON 912767573 4766 N. COUNTY RD. 300E Insurance FRANKFORT, IN 46041- 2 Patient No: 200901442 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 $351.20 $702.40 351.20 CPT Date Description Charges Credits 06/04/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/04/2009 MILEAGE A0425 $26.20 08/18/2009 COMMERCIAL INSURANCE PAYMENT $351.20 08/28/2009 COMMERCIAL INSURANCE PAYMENT $351.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 09702/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 AkCC'e"OUNT Hl, Bill To: REGINA THOMPSON ICD -9: 7231 E8130 4766 N. COUNTY RD. 300E FRANKFORT, IN 46041 From: MERIDIAN ST 1 465 To: CLARIAN HOSPITAL NORTH I UNITED HEALTH INS/30555 Patient: REGINA S THOMPSON 912767573 4766 N. COUNTY RD. 300E Insurance FRANKFORT, IN 46041- 2 Patient No: 200901442 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 $351.20 $351.20 $0.00 CPT Date Description Charges Credits 06/04/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/04/2009 MILEAGE A0425 $26.20 08/18/2009 COMMERCIAL INSURANCE PAYMENT $351.20 08/28/2009 COMMERCIAL INSURANCE PAYMENT $351.20 09/02/2009 REFUND 351.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 7 P 70-23Z E Xts',11. NSUIRA, C-E�'e -DRA, LINQIS 61558 j 0: V 1,0 3 ii 8�r s aftd 2 0 Void ifnoL presented for Z ARkE ,T ,L7 �Rt",,DEPT 11 9 I j 114 S d RE D R"kUNT z o NO 0, 1' 0 9 z 8 DATE 0 F, LOSS` 0',, 6� G,4,/ 0 9 PAyAIlLE,,TjfROUGH THE HERGET NATIONALBANK OF PFION ILLIN 2 2 2 2 L 6 13 itm 1 :0 7 1 10 2 3 2 21: 00 h 911 THE E fiF kqlNA EfC��U M N !L� I�L �Xkfj I T, E R F. L C T I V E 1� A-K EWZ P�Q�Nq kESFRT Ll� H Detach and Keep for Your Records PAYMENT RECORD F 22C-21 68 DATE 08/24/09 INSURED R HUNT CLAIM NO. OW10986 DATE OF LOSS 06/04/09 ADJ NO. V2 AMOUNT $351.20 BI MEDICAL PAYMENT PATIENTS NAME: REGINA S. THOMPSON PATIENTS 200901442 RUN DATE: 06/04/09 Auu z CARMEL FIRE DEPT AMBULANCE SERVICE 2 CIVIC SQUARE CARMEL IN 46032-7543 200E 08105 W5- 01277 *01 *003987 -PO 09222 FO^ 530 FJ 110 CFPA20- 070705 UNITEDHEALTHCARE INSURANCE COMPANY UnitedIeatthcare OLDSMAR SERVICE CENTER PO BOX 30555 A UnitedHeahh Group Company SALT LAKE CITY, UT 84130 -0555 PHONE: 1 -977- 842 -3210 DATE: 08/10/09 T 35- 6000972 NP I 1154325579 GROUP 0712475 GROUP NAME: WESLEY MANOR CHECK NUMBER: OW 41594770 CHECK AMOUNT: $351.20 CARMEL FIRE DEPT AMBULANCE SVC CARMEL FIRE DEPT AMBULANCE SV PROVIDER 2 CIVIC SQ EXPLANATION CARMEL IN 46032 OF BENEFITS PATIENT DETAIL PRODUCT HEM, ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE CHOYC+ .4 912767573 REGINA THOMPSON EE 200901442 REGINA THOMPSON 02238064697 01 07124109 CARMEL FIRE DEPT AMBU SERVICE DETAIL PATIENT J DATES OF I DESCRIPTION AMOUNT NOT PROV ADJ I AMOUNT DEDUCT/ J PLAN J PAID TO RMi( I PATIENT NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP, REGINA 06/04/09 AMBULANCE 325.00 325.00 100% 325.00 THOMPSON 06/04/09 AMBULANCE 26.20 26.20 100% 26.20 SUBTOTAL 351.20 351.20 3S1.20# TOTAL PAID TO PROVIDER $351.20 UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS &-STATEMENTS (EPS) AS A STANDARD WAY TO PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1- 866 -UHC -FAST (1- 866 842 3278), OPTION 5. FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1 -800- 842 -1109, OPTION 3. REMARKS PAYMENT OF BENEFITS HAS BEEN MADE IN ACCORDANCE WITH THE TERMS OF THE MANAGED CARE SYSTEM. VED AUG 1.8 20ffi Detach Check Detach Check '51w44 Fieet National"Bank 1is z UNITEDHEALTHCARE INSURANCE :COMPANY 150. Windsor Street Hartford, CT 06120 OW, Y 1 OLDSh7AR:<SERVICE..cEENTER- PQ BDX 30555 y T `LAKE-,CITY UT 84,T30 "0555: DATE 08/1 0]09 PHONE;; .1 $N77 842 -3210 W5 Oi277 003987 'PO 09222 =F0 530 -F�. 110 PLEASE PRESENT PROMPTLY FOR PAYMENT° hCONTRACT 712475 L PAY:. *THREE HUNDRED FIFTY ONE: &.20 /'100"DOLLARS CARMEL FIIR,E ,DEPT AMBULANCE SVC P 4Y CARMELIFIRE :DEPT AMBULANCE :SV D THE 2.'CIVr SQ I I ORDER ';OF CARMEL .I N 46032 'AUTHORIZED SIGNATI`1RE 1 1 II' II' lidllnilllinlnlli 1 i dlllhlihidlliil6 lnlluillluuilillllhlll IuhuLl dullnl 1Ghilllllllplllll{ 111113111111EIIiIEIIIIIIIIIIIIIIli111111111111illllllllillllll11111111111lIIIIIIIIIIII[ IIIIIIIIIIIIIIIIt111111Ilflllllllllllllllllllllllllll�lflllll1111l111111111111111111111€ 111111lIIIIIIpllllllllllllllll111illlllllllllllllllllllilllllllllllllllllllllllllllPlllll 111 �g '1: 0 1 9 0.0 L, 'S t: 2 2 1, DE 1 0 2 0 9 lie Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL ;\n 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/" I 4 P ayeer Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) e i A IDGcfs eM e-J r 614 0^_ e ha- ama6ort Total�5� O 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 o 40 ON ACCOUNT OF APPROPRIATION FOR ,4m6a"e �,Y_1Xo 4 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 SEP 14 70p Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund