HomeMy WebLinkAbout173043 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 00351910 Page 1 of 1
ONE CIVIC SQUARE ST VINCENT CARMEL HOSPITAL INC
CARMEL, INDIANA 46032 1207 RELIABLE PARKWAY CHECK AMOUNT: $1,391.00
CHICAGO IL 60686 -0012
CHECK NUMBER: 173043
CHECK DATE: 5/27/2009
DEPA ACC OUNT PO NUMBE INVOICE NUMBER AMOUNT DES
302 5023990 1,391.00 OTHER EXPENSES
a
2 3a PAT
CARMEL-- HOSPITIAL......... ST- VINCENT...- CARMEL....HOSPITAL CNTL# 9
135; x IDS iN S S T 120 RELIABLE PK F EC 4 000000733512 0131
IN 46032 -1456 CHICAGO IL 60686 -0012 5 FED. TAX NO. 8 STATEMENT COVERS PERIOD 7
FROM THROUGH
317) 582 -7380 743107055 0 /18/2008 7/18/2008
8 PATIENT NAME a 9PATIENT ADDRESS a. 1870 E 106TH ST
b ILLY NICHOLAS S b CARMEL G IN d 46032 B
10 BIRTHDATE 11 SEX ADMISSION i6 DHR 17 STAT CONDITION CODES 1 29 ACDT 30
12 DATE 13 HR 14 TYPE 15 SRO 18 19 20 21 22 23 24 25 26 27 28 STATE
03'20/1989 M 0 /18/2008 14 7
31 OCCURRENCE T o JT 33 DCCURRENCE Q''� a 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37
CODE DATE o• -�e• CODE DATE oo e• CODE FROM THROUGH. CODE FROM
0j 7/18/2008
e
38 39 VALUE CODES o o 41 VALUE CODES
CODE AMOUNT oo a _s;. CODE AMOUNT
a 45 14.00
b
C
d
42 REV. Co. 43 DESCRIPTION 44 HCPCS RATE HIPPS CODE 45 SERV DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON COVERED CHARGES a9
1 0272 MED /SURG /STERILE SUPPLY 3 81.00
2 0320 DIAGNOSTIC RADIOLOGY 73590 7/18/2008 1 234.00 3
3. 0450_ EMERGENCY_.ROOM... 12001 7/18/2008 1 545._00 3
0450._- EMERGENCY_ROOM, ._99283 .7/18/2008 .1 _531.00 4
5 6
6 6
7 7
6 6
11 11
12
13 13
14 14
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i6 is
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2/ 21
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23 PAGE OF CREATION DATE 10 g 13 2009.:•°.._' 1 ,391.00 0.00 23
SO PAYER NAME 51 HEALTH PLAN ID 52 REL 53 ASG S INFO aEN. 54 PRIOR PAYMENT SS EST. AMOUNT DUE. NPI 1639124134
A. WORKERS.. COMPENSATION_ Y Y 1391 57 A
B OTHER B
c PRV ID c
58 INSURED'S NAME 59 P.REL 60 INSURED'S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.
A WILLY,_NICHOLAS S. 18 311065149 WORK COMP A
B
c c
63 TREATMENT AUTHORIZATION CODES 64: DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME:
A BROOKSHIRE GOLF A
c
DX QQ ,r
69 ADMIT ICIR
PATIENT T3
71 PPS '72
DX REASON DX CODE EG E9200
74 PRINCIPAL PROCEDURE e a ter,:: b. OTHER PROCEDURE 5 76 ATTENDING NPI OVAL
CODE DATE •0 CODE DATE 1922270933
LAST KU13EK FIRST MICHAEL
o o d OTHER' PROCEDURE o o 77 OPERATING NPI QUAL
o• o• CODE DATE o0 0• 1922270933
LAST KUBEK IFIRST MICHAEL
80 RE R 81CaC 88 OTHER NPI QUAL
BRIHIRE.._GOLF_......_.___
12120_BROOKSHIRE_P.WK b LAST FIRST
c 79 OTHER NPI QUAL
d LAST FIRST
04 CMS -145
U8 -0 APPROVED OMB NO.0938 -0997 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
Printed on Recycled Paper NUBC .q LIC3810506 BILLER REP: MATT HODGSON
U304 Nt}T CE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT IViISREPRESENTATICN OR FALSIFICATION
OF ESSENTIAL fNFORr14ATION AS REQUESTED; BY THIS FOR 10, IMAY SERVE AS THE BASIS FOR
CIVIL hPiONETAFiY PENALTIES AND ASSESSMENTS AND MAY UP014 CONViC" =TION INCLUDE
NNE.-5 ANDIOR li UNDER FEDERAL ANEYOR STATE LAW(S).
i
SU!tri i
of th'is tlf -<:,l'o `.si ii th,� (b)
information as shcxn o n Me face hereof 4 two wocu,ate and COr ttSl.;t, oukke a m0 lay ay medical treatrnem facility catL,nr?ent area he or
That tho submiier did hot knovah ,g'iy or recklessly dlsieca€ o!" sh "'e 'dops not l e within the s „z.chrnerrt are }f a O.S. military
r; linepr,;seN or corneal material facts T fo lo g ceriaficatlOn:; or inedical treatm 'facility, or :f the patient re side s a
verifications apply -.h r+: peninent t th':s gilt' cakhment area of su ch ca facility, a cocy of Non-Availability
hh e+ eri €DD F?!i 12,51) c, k tic.orth nhtl I i =hasCeiofed
1. UAW party hui:c,l(° eu tICIIC't.1f�,C1 the anpitaf appropriate .a`�5(gIIC?BCitE? by
a n1E d G. I rn It. n n arty instance U .hh. e ca. copy of a Nol I
the !t!Sllrud •iJCilef,C �tryr card Sip! sc`ifcl e of the :?cltrt,(.t or parent or Somme! S r!'St ?Ili,.
legal guardbn covering a +uttlorization to release' inform lJon are an fll'c
D e tp i inat on s to ll a rele of rnedicai am fiiianic ai informa C (C` The se patient o it e omtien S 1; r_:i1C or g uardian has resp
d
S OU ',;'ej by to i_+.a;l,V v kv patwent i5 Q1' mpr,....£:, neat y directly to the provider's request st to idu,+ily cliff hr altn insurance
2. H palient of tupi d .I yonvale mom or'G'ClL.ii d c::£-? tit Or c overage and Tat alt such covo a on the "acc.A. of
to N T ekr' Ei ,:Y u? t i r Yr`I i c1 n 1,;s.
3, Ph s cerilficat ons and re-cer': €;it,ations, ,f rerli,n by con !,'a T e le IC billed (CI) aw �ir"loU =1, bil to T �,+1.r?�7 tk' he ?'ci `�C?orl iJI !E {f d {1raii .St1Ci1
or Federal regulations, are on fife.
9 r- �overage h,,t'c baeh nillec! and Pa.:: exaludirc� N^t.d:caid the
-t. For Religious Non Medical facilities. v'erlficailons and 1 necenary re- amount billed to l RIC?iRE is that ren;ain €ng clai Z CgaiI;ot
ccrtif'(.'.ations of the.. patients riff ed t services are-. are-.) file, lc,, RF at. i ts:
5. Sign ere of pat +a or his reor e.Se ntwi`><e or `ertittca`ic.. (u) Th beneficiary' cost sha has nol been waked cum enI or
authorization to release informainn, and payment request as failure to exerC,r:i ?gene caccel ted b l'ng and c lhdion Huns:
rewired by Fede 1_s'?w anci Regulations 2 L)SC 1 935t 4 C :FR anCA
424.:36, 10 LISC 1071 through 1086, 32 CFR 19 and an over (f} Ai hospit<�. b sed physician Linder contract, the cost of whose Y t r n I
applicable contract C sCjUlatlGr',S. is Cn file. ,services are allocated in the ch r. j S included in this f?i!i. iE t ir)t an
6. The Resid of cam 1 n ,sac' s s O i b ill n employee or member of the Uniformed Services, s, r s o
Sla 3 ilftu �iP.oi
'1V_ d;;e i c, hu h, 1:> f'1 S�ra'. r pc.ir�'1..t?; `f
;;i)rafC,rE7Yicir ?Ce G +:3th the Ovll Flights A0 of 1964 as am ended fSeauls Tis cudicmi an c mp!cyc.c: ,')f the Un!Vmned ervicc IS ,.,`t
ark. a ely� descri services wi be Viltr..! and nece`s 'r nployee.. i`cji,J�Anted sn C vl ser (refer i 5 ijSQ, 2 1 f
i bog W&n wiT be iuniished' tc start ijole'"la!l1e :t i agencies a6 -ifoluding pao tine or inileri^t ittenl empioy'i es, but ex rid n
rr .,C, by appik ain t t "J. Contract surgeons of other persona s ervice contracts, Simi larly.
member of the Lini Services does not apply to reserve
T For Medicare l"u+pc sey If the pWAM has ind €cared Met other health members of the Llnirormed Se;ruic;es not cn ac.lve duty.
insuran or a state medical a S'Mian e agenc wall pay prart`, of
e n (C) Based on 42 U nited States ode 1395cc(ra)( )(I) all providers
n,S "hH: medical ?,(,c,a5e:, and nu ,,'1�, war?i5 +hies €'i ?.atiCta ab��L.f
his /her clair n released to therm upon request, necessar authorllatlon partici'pating in Medicare mus' also participate, in TRICA RE for
is an NA.. T he p` h at on T e Ad.. equest o bill inpwiem hcsr +tA services provided p:.irSU<3nt `c admissions, t o
c IPtin< <A,+ t
Tt ed, :a re modic. al and non infor' e, ion, including :osi)itais o: i -"ing on Cr i, 1 198 7 a',nd
employ °'Aus and ov h ethe r he person has employer group i t T d ti
fh, i; F31C�raR� r, t= i. �rt� _o ht >J a par stifus, #f.e
health Insurwme which ch S Napor isiole to pay for In services for
Med m ade of tai, L:di'Y1 ,g?z.,Ms to SUlatrit "T this claim to th
'which this. edicar- cl��.i €,.,s ade.
apprcp-iate TRIC;ARE claims processor. The pro rider of care
B. For Medlcmd purposes The St1bii [tier understands that because ;>ubmber also agrees to accept the I RICARE deteirnined
€?c yra" eM and satisfaction of this clagn wi`.i be Tom 1 and S'.a tc', reasonable charge as the total charge for the medical services c
funds, any false stWernentS, di1mmients, or co n.cea1ment of ;l S upplies listed on the claim form. The provider of care will accept
rn<. eria l to are subject to prospcutlon undle appl,+ ;able Federad i,r the l RCARE tliin reasonable Cha' c ever, if it is less
St Laws, twon she billed amount, and c i yo agrees to accc-,pt the c.mour'i!
r tld b by TIRIGARE combined vviih the cost -share amount
9. For Pit P'.IrE os"S. deductible amoont, if x0 p£a €d by or o n beh all Cif tile pa`,8r3t os
f_... .l t -;7d, on Cv n we A lhis claim is truc.. accurate and fr.!l payment for the l isle'd f' Ct'SL.' l c es or su ~ties, r�M
o ovide of c2 re a'ut t+
r t. i d tE e ut,.., °a.� r k:a�,,��_e ,_,,..a.J belief and t '�t .t
K �r T.. f �t t hi fad parent J jc' r t t q t r
a owe 'iz;; ..�.a tic and ..�r mot f! 2`, ei for Me .i tt€
caso :SEE I„tp__ /vt x v v u 0 ora FOR 1v INFORMATION ON 1-11304 DATA ELEMENT AND PRNTNC SPECIFICATIONS
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
St. Vincent Carmel Hospital Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
r
Total
1 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 NOQ5 f2-2-74ARRANT NO.
St. Vincent Carmel Hospital ALLOWED 20
13500 N. Meridian Street IN SUM OF
$1,391.00
ON ACCOUNT OF APPROPRIATION FOR
GENERAL FUND
1205 Administration
Board Members
PO# or
DEPT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
0 3�lao bill(s) is (are) true and correct and that the
$1 00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
ignatur
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund