177454 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: T361280 Page 1 of 1
ONE CIVIC SQUARE R L WILLIAMS CHECK AMOUNT: $107.23
CARMEL, INDIANA 46032 846 ENCLAVE CIRCLE
+M, ron CARMEL IN 46032 CHECK NUMBER: 177454
CHECK DATE: 9115/2009
DEPARTME ACCOUNT PO NUMB IN NUMBER AMOUNT DE
102 5023990 107.23 OTHER EXPENSES
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BlueCross BlueShield A Division of I-lealth Care Service Corporation,
of Illinois a Mutual Legal Reserve Company PROV C LAIM SUMMARY
an Independent Licensee of the
Blue Cross and Blue Shield Association
DATE*: 08/24/09
300 East Randolph PROVIDER NUMBER: 1154325579
Chicago, Illinois 60601 3099
(800) 972 -8088 CHECK NUMBER: 47059459
TAX IDENTIFICATION NUMBER: 356000972
CARMEL FIRE DEPARTMENT
2 CARMEL CIVIC SQ
CARMEL IN 46032
II I l I I II II Ill II I I III II I I I I I II I II I I III I I I Ifl 110111 ill
Reminder: If you enrolled in ERA /EPS...
Your paper PCS will be discontinued 30 days
after you begin receiving your ERA /EPS riles.
ANY MESSAGES WILL APPEAR ON PAGE 1
PATIENT: RAYMOND WILLIAMS THIS IS AN ADJUSTMENT TO A PREVIOUSLY CONSIDERED CLAIM
AGE: 84 IDENTIFICATION NO: 44350- WVE841731051
CLAIM NO: 000091595159835OX PATIENT N0: 200901015
FROM TO PROC AMOUNT AMOUNT DEDUCTIONS /OTHER SERVICES
DATES PS TS* CODE BILLED PAID INELIGIBLE NOT COVERED
04/18- 04/18/09 05 OOK A0429 325.00 64.50 258.01 21 2.49 1)
04/18 04/18/09 05 OOK A0425 19.65 3.93 15.72 2 0.00
344.65 68.43 273.73 2.49
AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $34.21
*DEDUCTIONS /OTHER INELIGIBLE
CONTRACT COINSURANCE; PORTION ELIGIBLE FOR PAYMENT BY ANOTHER CARRIER /MEDICARE: 273.73
DEDUCTIONS /OTHER INELIGIBLE: $273.73
TOTAL SERVICES NOT COVERED: 2.49
PATIENT "S SHARE: $0.00
AMOUNT BILLED: $344.65 AMOUNT OF SERVICES NOT COVERED: $276.22
AMOUNT FAID TO PROVIDER: $34.21 AMOUNT PREVIOUSLY PAID: $34.22
AMOUNT PAID TO SUBSCRIBER: $0.00 NUMBER OF CLAIMS: 1
RECOUPMENT AMOUNT: $0.00 NET AMOUNT PAID TO PROVIDER: $34.21
*TYPE OF SERVICE (TS) I *PLACE OF SERVICE (PS)
OOK. AMBULANCE. I 05. OTHER.
MESSAGES:
1). PAYMENT CANNOT EXCEED THE ALLOWABLE CHARGE DETERMINED BY MEDICARE.
2). A CONTRACT COPAY /DEDUCTIBLE HAS BEEN TAKEN. EXPENSES MAY BE ELIGIBLE
FOR PAYMENT BY ANOTHER CARRIER /MEDICARE. C
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n ■4705945811■ x;0 7 19 236 281: 31195400n°
B1ueCross B1ueShield A Division or Health Care Service Corporation,
of Illinois a Mutual Legal Reserve Company, 1 PROVIDER CLAIM IM S M /Pr RY
an Independent Licensee or the �.rL/' iW1VA �7{./�y* IYO/'-5fi
Blue Crass and Blue Shield Association
DATE: 08/24YO9
300 East Randolph
Chi PROVIDER NUMBER: 1154325579
Chicago, Illinois 60601 5099
(800) 972 -8088 CHECK NUMBER: 47059458
TAX IDENTIFICATION NUMBER: 356000972
CARMEL FIRE DEPARTMENT
2 CARMEL CIVIC SQ
CARMEL IN 46032
IIIlI III II IIIIIIIII II IIIIlIIIIIII III IIIl�IIlI III III
Reminder: If you enrolled in ERA EPS...
Your paper PCS will he discontinued 30 days
after you begin receiving your ERA /EPS files.
ANY MESSAGES WILL APPEAR ON PAGE 1
PATIENT: FLORENCE WILLIAMS THIS IS AN ADJUSTMENT TO A PREVIOUSLY CONSIDERED CLAIM
AGE: 81 IDENTIFICATION NO: 44350
CLAIM NO: 000091405173531OX PATIENT NO: 200900752
FROM TO PROC AMOUNT AMOUNT DEDUCTIONS /OTHER SERVICES
DATES PS TS* CODE BILLED PAID INELIGIBLE NOT COVERED
03/22 03/22/09 05 OOK A0427 375.00 75.00 300.00 1 1) 0.00
03/22- 03/22/09 05 OOK A0425 13.10 2.62 10.48 1 0.00
388.10 77.62 310.48 0.00
AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $38.81
*DEDUCTIONS /OTHER INELIGIBLE***
CONTRACT COINSURANCE; PORTION ELIGIBLE FOR PAYMENT BY ANOTHER CARRIER /MEDICARE: 310.48
DEDUCTIONS /OTHER INELIGIBLE: $310.48
PATIENT`S SHARE: $0.00
AMOUNT BILLED: $388.10 AMOUNT OF SERVICES NOT COVERED: $310.48
AMOUNT PAID TO PROVIDER: $38.81 AMOUNT PREVIOUSLY PAID: $38.81
AMOUNT PAID TO SUBSCRIBER: $0.00 NUMBER OF CLAIMS: 1
RECOUPMENT AMOUNT: $0.00 NET AMOUNT PAID TO PROVIDER: $38.81
*TYPE OF SERVICE (TS) I *PLACE OF SERVICE (PS)
OOK. AMBULANCE. I 05. OTHER.
MESSAGES:
1). A CONTRACT COPAY /DEDUCTIBLE HAS BEEN TAKEN, EXPENSES MAY BE ELIGIBLE
FOR PAYMENT BY ANOTHER CARRIER /MEDICARE.
p SC F V 'Z D sEP o l Zoflg
46 747 356000972T PAGE: 1 OF 1 THIS IS THE LAST PAGE OF THIS DOCUMENT
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ff■470594S7110 r :D7 19 2 38 281: 31 19540Uno
BlueCross BlueShield A Division of Health Care Service Corporation,
of Illinois PROVIDER a Mutual Legal Reserve Company, ®Rj CL IM SUMMARY
0 an Independent Licensee of the R v e1 i'� 9
Blue Cross and Blue Shield Association
DATE: 08/241,09
300 East Randolph PROVIDER NUMBER: 1154325579
Chicago, Illinois 60601 5099
(800) 972 -8088 CHECK NUMBER: 47059457
TAX IDENTIFICATION NUMBER: 356000972
CARMEL FIRE DEPARTMENT
2 CARMEL CIVIC SQ
CARMEL IN 46032
Illlllllll1111lll111llIlllIIIIIIII III IIIIIIIIIIIIIII
Reminder: If you enrolled in ERAIEPS...
Your paper PCS will be discontinued 30 days
after you begin receiving your ERA /F.,PS files.
ANY MESSAGES WILL APPEAR ON PAGE 1
PATIENT: FLORENCE WILLIAMS THIS IS AN ADJUSTMENT TO A PREVIOUSLY CONSIDERED CLAIM
AGE: 81 IDENTIFICATION NO: 44350- WVE841731051
CLAIM NO: 000091115172702OX PATIENT NO: 200900465
FROM TO PROC AMOUNT AMOUNT DEDUCTIONS /OTHER SERVICES
DATES PS TS* CODE BILLED PAID INELIGIBLE NOT COVERED
02/18 02/18/09 05 OOK A0429 325.00 64.50 258.01 1 2) 2.49 1)
02/18 02/18/09 05 OOK A0425 19.65 3.93 15.72 1 2 0.00
344.65 68.43 273.73 2.49
AMOUNT PAID TO PROVIDER FOR THIS CLAIM: $34.21
*DEDUCTIONS /OTHER INELIGIBLE
CONTRACT COINSURANCE; PORTION ELIGIBLE FOR PAYMENT BY ANOTHER CARRIER /MEDICARE: 273.73
DEDUCTIONS /OTHER INELIGIBLE: 5273.73
TOTAL SERVICES NOT COVERED: 2.49
PATIENT'S SHARE: 50.00
---7----------------------------------------------------------------------------------------------------
AMOUNT BILLED: $344.65 AMOUNT OF SERVICES NOT COVERED: $276.22
AMOUNT PAID TO FROVIDER: $34.21 AMOUNT PREVIOUSLY PAID: $34.22
AMOUNT PAID TO SUBSCRIBER: $0.00 NUMBER OF CLAIMS: 1
RECOUPMENT AMOUNT: $0.00 NET AMOUNT PAID TO PROVIDER: 534.21
*TYPE OF SERVICE (TS) I *PLACE OF SERVICE (PS)
OOK. AMBULANCE. I 05. OTHER.
MESSAGES:
1 1). PAYMENT CANNOT EXCEED THE ALLOWABLE CHARGE DETERMINED BY MEDICARE.
1 2). A CONTRACT COPAY /DEDUCTIBLE HAS BEEN TAKEN. EXPENSES MAY BE ELIGIBLE
FOR PAYMENT BY ANOTHER CARRIER /MEDICARE.
R E CEI VED SEP
46,746 356000972T PAGE: 1 OF 1 THIS IS THE LAST PAGE OF THIS DOCUMENT
16144 OS107 4462
KELM
20 =6150 4094
R. L. OR VALUE WILLIAMS 12-88 740 62626613
846 ENCLAVE CIRCLE
�J CARMEL, IN 46032. DATE
PAYTOTHF
ORDEROP
DOLLARS
Nabom icR y A
nm
p� m
i
Date: 09/02/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
r MQ—"'
Bill To: RAYMOND L WILLIAMS ICD -9: 37991 37992
846 ENCLAVE CIR
CARMEL, IN 46032
From: 846 ENCLAVE CIR
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: RAYMOND L WILLIAMS 310204503A
846 ENCLAVE CIR Insurance
CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010
Patient No: 200901015 WVE841731051
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $344.65 $0.00
CPT
Date Description Charges Credits
04/18/2009 BASIC LIFE SUPP EMERGENCY A0429 $325.00
04/18/2009 MILEAGE A0425 $19.65
06/09/2009 MEDICARE PAYMENT $273.73
06/09/2009 ASSIGNMENT MEDICARE $2.49
06/16/2009 BLUE SHIELD PAYMENT $34.22
06/23/2009 PAYMENT $34.21
09/01/2009 BLUE SHIELD PAYMENT $34.21
09/02/2009 REFUND -34.21
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/02/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal !D# 356000972
C O i»,.4" iNy l R
Bill To: RAYMOND L WILLIAMS ICD -9: 37991 37992
846 ENCLAVE CIR
CARMEL, IN 46032
From: 846 ENCLAVE CIR
To: ST. VINCENTS HOSPITAL CARMEL
MEDICARE PART B
Patient: RAYMOND L WILLIAMS 310204503A
846 ENCLAVE CIR Insurance
CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010
Patient No: 200901015
WVE841731051
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $378.86 -34.21
CPT
Date Description Charges Credits
04/18/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
04/18/2009 MILEAGE A0425 $19.63
06/09/2009 MEDICARE PAYMENT $273.73
06/09/2009 ASSIGNMENT MEDICARE $2.49
06/16/2009 BLUE SHIELD PAYMENT $34.22
06/23/2009 PAYMENT $34.21
09/01/2009 BLUE SHIELD PAYMENT $34.21
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/02/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal ►D# 356000972
C 0 U 1 V3 TF R
Bill To: FLORENCE V WILLIAMS ICD -9: 7842 7821 78609 9953
846 ENCLAVE CIRCLE
CARMEL, IN 46032
From: 846 ENCLAVE CIR
To: ST. VINCENTS HOSPITAL CARMEL
MEDICARE PART B
Patient: FLORENCE V WILLIAMS 308268923A
846 ENCLAVE CIRCLE Insurance
CARMEL, IN 46032- 2 ANTHEM BC/BS/ 37010
Patient No: 200900752 VVVE840731051
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$388.10 $388.10 $0.00
CPT
Date Description Charges Credits
03/22/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
03/22/2009 MILEAGE A0425 $13.10
05/22/2009 MEDICARE PAYMENT $310.48
06/02/2009 MEDICARE PAYMENT $38.81
06/19/2009 PAYMENT $38.81
09/01/2009 BLUE SHIELD PAYMENT $38.81
09/02/2009 REFUND -38.81
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/02/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
O R
Bill To: FLORENCE V WILLIAMS ICD -9: 7842 7821 78609 9953
846 ENCLAVE CIRCLE
CARMEL, IN 46032
From: 846 ENCLAVE CIR
To: ST. VINCENTS HOSPITAL CARMEL
I MEDICARE PART B
Patient: FLORENCE V WILLIAMS 308268923A
846 ENCLAVE CIRCLE Insurance
CARMEL, IN 46032- 2 ANTHEM BC /BS/ 37010
Patient No: 200900752 VVVE840731051
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN, THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$388.10 $426.91 -38.81
CPT
Date Description Charges Credits
03/22/2009 ADVANCED LIFE SUPP 1 —EMER A0427 $375.00
03/22/2009 MILEAGE A0425 $13.10
05/22/2009 MEDICARE PAYMENT $310.48
06/02/2009 MEDICARE PAYMENT $38.81
06/19/2009 PAYMENT $38.81
09/01/2009 SLUE SHIELD PAYMENT $38.81
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/02/2009
CARMEL. FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317 )571 -2605 FederalID# 356000972
ACCOUNT�
Bill To: FLORENCE V WILLIAMS ICD -9: 7842 9953
846 ENCLAVE CIRCLE
CARMEL, IN 46032
From: 846 ENCLAVE
To: ST. VINCENTS HOSPITAL CARMEL
1 MEDICARE PART B
Patient: FLORENCE V WILLIAMS 308288923A
846 ENCLAVE CIRCLE Insurance
CARMEL, IN 46032- 2 ANTHEM BC /BS/ 37010
Patient No: 200900465 WNA845679875
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND 1S DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $344.65 $0.00
CPT
Date Description
CharOes Credits
02/18/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
02/18/2009 MILEAGE A0425 $19.65
04/21/2009 MEDICARE PAYMENT $273.73
04/21/2009 ASSIGNMENT MEDICARE $2.49
05/05/2009 BLUE SHIELD PAYMENT $34.22
05/15/2009 PAYMENT $34.21
09/01/2009 BLUE SHIELD PAYMENT $39.21
09/02/2009 REFUND -34.21
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 09/02/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
N RY
Bill To: FLORENCE V WILLIAMS ICD -9: 7842 9953
846 ENCLAVE CIRCLE
CARMEL, IN 46032
From: 846 ENCLAVE
To: ST. VINCENTS HOSPITAL CARMEL
MEDICARE PART B
Patient: FLORENCE V WILLIAMS 308268923A
846 ENCLAVE CIRCLE Insurance
CARMEL, IN 46032- 2 ANTHEM BC /BS/ 37010
Patient No: 200900465 WNA845679875
YOUR INSURANCE HAS PAID ALL BUT THE BALANCE SHOWN. THIS AMOUNT IS YOUR RESPONSIBILITY AND IS DUE AND
PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$344.65 $378.86 -34.21
CPT
Date
Description Charges Credits
02/18/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00
02/18/2009 MILEAGE A0425 $19.65
04/21/2009 MEDICARE PAYMENT $273.73
04/21/2009 ASSIGNMENT MEDICARE $2.49
05/05/2009 BLUE SHIELD PAYMENT $34.22
05/15/2009 PAYMENT $34.21
09/01/2009 BLUE SHIELD PAYMENT $34.21
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
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.
Payee
L L� r S Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
0
r'
f J
y N
u
Total
e
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
VOOCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF IQ 7,,:;-' 3
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
SEP 14 UP
c
r.
r_
t
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund