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Home My WebLink About173554 06/10/2009 CITY OF CARMEL, INDIANA VENDOR: 356277 Page 1 of 1 ONE CIVIC SQUARE SUBURBAN HEALTH ORGANIZATION CARMEL, INDIANA 46032 Po eox sozsso CHECK AMOUNT: $286.20 oN `a INDIANAPOLIS IN 46250 CHECK NUMBER: 173554 CHECK DATE: 6/10/2009 D EPARTMENT ACCOUNT PO NUMBE INVOI NUMBER AMOUNT DESCRIPTION 102 5023990 286.20 OTHER EXPENSES r� Date: 06/04/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federal ID# 356000972 Bill To: CATHY BURSICK ICD -9: 78652 7840 7231 E8131 1135 WHEATFIELD COURT CARMEL, IN 46032 From: 146TH ST LOWES WAY To: CLARIAN HOSPITAL NORTH 1 PHCS PRIVATE Patient: LACY BURSICK HP8016815600 1135 WHEATFIELD COURT Insurance CARMEL, IN 46032- 2 Patient No: 200900704 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 $357.75 $357.75 $0.00 CPT Date Description Charges Credits 03/17/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 03/17/2009 MILEAGE A0425 $32.75 05/19/2009 COMMERCIAL INSURANCE PAYMENT $286.20 05/27/2009 COMMERCIAL INSURANCE PAYMENT $357.75 06/04/2009 REFUND 286.20 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 06/04/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 I C Bill To: CATHY BURSICK ICD -9: 78652 7840 7231 E8131 1135 WHEATFIELD COURT CARMEL, IN 46032 From: 146TH ST LOWES WAY To: CLARIAN HOSPITAL NORTH PHCS PRIVATE Patient: LACY BURSICK HP8016815600 1135 WHEATFIELD COURT Insurance CARMEL, IN 46032- 2 Patient No: 200900704 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 $357.75 $643.95 286.20 CPT Date Description Charges Credits 03/17/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 03/17/2009 MILEAGE A0425 $32.75 05/19/2009 COMMERCIAL INSURANCE PAYMENT $286.20 05/27/2009 COMMERCIAL INSURANCE PAYMENT $357.75 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 tl vaeniozanoi Suburban Health Organization P. O. Box 502530 Indianapolis, IN 46250 zuovusiaoioh if �'OU 1ti1Ve C]LleSt1011S, please Call Return Service Requested 596 -5929 or Toll Free 866 8734516. O 3 -DIGIT 460 For on -line claim status, go to www.emcs- indy.conl 18196 0.3820 AT 0.357 'hhlllll'1lll'I'Ilillulll' Ill 'Illll'lllllf' Tar ID: 356000972 CARMEL FIRE DEPARTMENT 72 Date Paid: 05113109 2 CIVIC SQUARE �z CARMEL, IN 46032 -2584 Check No: 166994 w Service llates llx Proc -Mod tlmts Billed Contract Member COB Adjust Re ap" WHold Amount brom I'o Amount I Amount Resp L Paid Code Amount Paid I Provider: CARMEL FIRE DEPARTMENT Patient Acct 200900704 Claim Number: 09114EO3486 Member Name: B URSICK, LACY Member ID: HP8016915601 H ealth Plan Al-IP 111 0 3/17/09- 03/17/09 786.52 A04 11-1 5 3 2575 32575 6555 0.(10 0.00 101( F 0.00 26 357.75 357.75 71.55 0.00 0.00 0.00 286.20 A4ember Resp" includes copay, coinsurance and /or deductible. F Fee For Service, C Capitated Service. Claim Total: 2 86.20 Additional explanation of how this claim was processed: Payment to Out of Network Provider Summary Hilted Contract Member COB Adjust WHold Amount Health Plan Amount Amount 1 Resp Paid Amount Paid IAHY 357.75 357.75 1 71.55_ 0.00 0.00 1__0.00 l 286.20 Statement Totals Total Total from Total from Total Total total Prev total Billed Contract Member COB Adjust WHold Bal Paid 35 35775 71.55 0.00 _0.00 0.00 0.00 1 286.20 Remi Code and Description RO 102 Paid at a percentage of the contract amount. RECEIVED MA 1 9 2009 FOR 11RITY URPOSES E FACE OFT S CUMENT O INS A BLUE BACKGROUND AND'MICROPRINTING.INTHE BORDER: Iv U. r 6 zot CHEGLf Ix0 16\994 CHECK DATE :'05 /13/09 �Q flr b AIVLOUNT:.� `286 2 L0 PAY Two-Hundred Eighty Siz "201100 Dollars 0 TO THE CARMEL FIRE DEPARTMENT 00 ORDER OF M CHASE ONE, NA Indianapolis, Indiana Q IO °NOT4CASH IF, WATERMARK. IS; NOT�PRESENT `ONTHE''REVERSE�SIDE'OFTHIS? DOCUMENT HOLD-ATANANGLETOWIEW 11 1.6699411° 1:0740000101: 64 CLAIM NO 14- 2320 -954 POLICY NO 1473- 371 -14 LOSS DATE 03 -17 -2009 PAYMENT NO 1 18 481249 J Coverage :Descri ti:on :Amount COL Pa td: DATE 05 -20 -2009 MEDICAL PAYMENT $357.75 600:= 2 AMOUNT $357.75 1� TIN 14- 356000672 REMARKS 3/1712009 1 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 18 481249 0 WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56-1544/441 MPC INDIANA 18-501 L025 COLUMBUS, OH INSY��NCI 05 -20 -2009 DATE MM DD Y Y Y Y CLAIM NO 14- 2320 -954 INSURED MC GINNIS, CONRAD LOSS DATE 03 -17 -2009 ON BEHALF OF LACY BURSICK *EXACTLY THREE HUNDRED FIFTY-SEVEN AND 75/1:0,0 DOLLARS *3'57..75 Pay to the Order of.- CARMEL FIRE DEPART'MEN 2 CIVIC SO CARMEL IN 46032 -2584 rxtd4"a APPROVED BY CLAIM NO 14- 2320 -954 POLICY NO 1473- 371 -14 LOSS DATE 03 -17 -2009 PAYMENT NO 1 18 481249 J Coverage Description Amount COL .Pa Cd DATE 05 -20 -2009 MEDICAL PAYMENT $357.75 600 2 AMOUNT $357.75 TIN 14- 356000972 ..w.. 'a.. REMARKS 3/17/2009 r ,rt� 'STATE FARM MUTUAL AUTOMOBI LE INSURANCE COMPANY 48124 94 WEST LAFAYETTE IN JPMORGAN: CHAS E BANK NA 56 144/441 COLUMBUS 'OH M i 0 MPC INDIANA 18 501 C`025 c%IM ND 14 -2320 =954 [NSURED MC, GINNIS, CONRAD TE �.M D D v x Y v Di1 LOSS DATE 17- 2009; ON •BEHA1f OF LACY.BIJRSICK z *'EXACTLY THREE HUNDRED'FIFTY' =SEVEN AND 75/100 DOLLARS *357.75 Pay to the 'Order of: CARMEL FIRE DEPARTMENT 2 CIVIC SO CARMEL IN 46032 -2584 r AU(+;6RI�tD SIGNATURE r eo o o k1 e- 18 1748 L 2L. 9ill 1:044 L :544 31:6 2 6 290 2 13 Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by t whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. J Payee 6 a ,,A— Y�� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 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 waw oc) �s y z5 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 JUN 20 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund