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Home My WebLink About179445 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 363570 Page 1 of 1 0 ONE CIVIC SQUARE TRICARE NORTH CHECK AMOUNT: $143.25 CARMEL, INDIANA 46032 Po sox 870141 SURFSIDE BEACH SC 29587 CHECK NUMBER: 179445 CHECK DATE: 11111112009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMO UNT DESCRIPTION 102 50239 '90 143.25 REFUND Date: 10/28/29 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 Federaim# 356000972 �,PP Bill To: CORY MEYER ICD -9: 71943 E8130 211 SECOND STREET NE CARMEL, IN 46032 From: 116TH ST ROLLING S DR To: CLARIAN HOSPITAL NORTH 1 HEALTHNET FEDERAL Patient: ROBERTA N MEYER 314046726 211 SECOND STREET NE Insurance CARMEL, IN 46032- 2 Patient No: 200901662 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 $344.65 $487.90 143.25 CPT Date Description Charges Credits 06/27/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 06/27/2009 MILEAGE A0425 $19.65 09/01/2009 MEDICARE PAYMENT $143.25 09/01/2009 ASSIGNMENT MEDICARE $201.40 10/06/2009 COMMERCIAL INSURANCE PAYMENT $344.65 10/20/2009 ASSIGNMENT MEDICARE 201.40 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 Date: 10/28/2,&,19 j CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: CORY MEYER ICD -9: 71943 E8130 211 SECOND STREET NE CARMEL, IN 46032 From: 116TH ST ROLLING S DR To: CLARIAN HOSPITAL NORTH HEALTHNET FEDERAL Patient: ROBERTA N MEYER 314046726 211 SECOND STREET NE Insurance CARMEL, IN 46032- 2 Patient No: 200901662 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 $344.65 $344.65 $0.00 CPT Date Description Charges Credits 06/27/2009 BASIC LIFE SCPP- EMERGENCY A0429 $325.00 06/27/2009 MILEAGE A0425 $19.65 09/01/2009 MEDICARE PAYMENT $143.25 09/01/2009 ASSIGNMENT MEDICARE $201.40 10/06/2009 COMMERCIAL INSURANCE PAYMENT $344.65 10/20/2009 ASSIGNMENT MEDICARE 201.40 10/28/2009 REFUND 5- 143.25 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1999 Correspondence Address: ezSEOO OELZLZ TRICARE NORTH REGION CLAIMS CORRESPONDENCE NP, P.O Box 870141 TRICARE SUMMARY PAYMENT VOUCHER SURFSIDE BEACH, SC 29587 -9741 Health Net Questions? T R I C A R E Federal Si www.myTRICARE.com by PGBA aervces North OR 1- 877 874 -2273 Date of Remittance: AUGUST 25, 2009 Provider Number: 356000972 Check Number: 0010623248 NN9 Page Number: 0001 of 0002 PatienlAccounlNumbw Rendering Dates of Service Patient's Provider SSN Procedure APC c Total Charges Allowed Covered Reason Message TRICARE Patient's Name NPI Begin End Srvcs Charges Code Code Cost Share 7 Copay Payment 200901662 062709 062709 A0429 SH000000 001 325.00 129.00 P7001 1,2 0.00 0.00 129.00 MEYER 062709 062709 A0425 SH000000 003 19.65 14.25 P7001 1,2 0.00 0.00 14.25 ROBERTA TOTALS FOR CLAIM NUMBER 9229WO229 -00 -00 344.65 143.25 0.00 0.00 143.25 PATIENT'S RESPONSIBILITY 0.00 Total Charges Allowed Covered Cost Copay Deductible TRICARE Charges Share Payment 0 0 344.65 143.25 0.00 0.00 0.00 143.25 0 TRICARE Payment 143.25 0 0 Interest 0.00 W A W Federal Tax Withheld 0.00 Offset 0.00 Check Amount 143.25 1% VCF,jVED sEP 0 1 2uU9 N N 7 THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND-NOT A WHITE BACKGROUND. TRICARE Payment 8 433 a33 PNC Bank, Natfonal Association JEAN NETTE; PA TRICARE North Region No, 09-10623248 9 t 1 1 A P, O. Be. 870141 i DATE Health N Surfaide Beach, SC 29587 -8741 T R 1 C A R E AMOUNT Federal Services 1 18771 874 -2273 08 -25 -09 MCS810 356000972 North rn CASHIER PAY TO THE ORDER OF: For your protection, require two 10s from payee. c CARMEL FIRE DEPT AMBULANC ':2 CIVIC SQUARE fCARMfL IN_ 46032 i VOID 120 DAYS FROM DATE OF ISSUE 272731 003101 AS TREASURER CLAIM NO 14- 2349 -811 POLICY ND 6859 883 -141 LOSS DATE 06 -27 -2009 -PAYMENT NO 1 18 434001 J C over aJe; Des [ri' ti.on Amount COL Pa Cd,', DATE 09- 3Q MEDICAL PAYMENT $344.65 600 2 AMOUNT 344.65 TIN 14-356000972 ENTERED BY SCHROEDER, PATSY AUTHORIZED BY SCHROEDER, PATSY PHONE (866) 648 -0715 REMARKS 6/2712009 ...M STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 1$ 434001 3 WEST LAFAYETTE, IN JPMORGAN CHASE BANK, NA 56- 1544/441 «sp.. «gym MPC INDIANA 18 -501 L025 COLUMBUS, OH 09 -30 -2009 CLAIM NO 14- 2349 -811 INSURED MEYER, CORY DATE MM DO Y Y Y Y LOSS DATE 06 -27 -2009 ON BEHALF OF ROBERTA N. MEYER *EXACTLY THREE HUNDRED FORTY -FOUR AND 651 100 DOLLARS Pay to the Orderof CARMEL FIRE DEPARTMENT 2 CIVIC SG CARMEL IN 46032- 2584' APPROVED BY 1.,. v CLAIM NO 14- 2349 -811 POLICY NO 6859 883 -141 LOSS DATE 06 -27 -2009 PAYMENT NO 1 18 434001 J Covera eiDescr.i Lion Amount -COL Pa Gd DATE 09 -30 -2009 MEDICAL PAYMENT $344.65 600 2 AMOUNT 344.65 TIN 14- 356000972 AUTHORIZED BY SCHROEDER, PATSY PHONE (866) 648 -0715 REMARKS 6/27/2009 ....A.- 'STATE FARM MUTUAL AUTOMOB I LE' I NSURANCE COMPANY 1 1S '43 001 .J WEST •LAFAYETTE I N JP..MORGAN'. CHASE 56, 1544/441 COLUMBUS .OH MM INDIANA -18 501 %L025 09 30-2009 b %DATE MM D D `'YY Y Y 1-- CLAIM NO 14 -2349 811 ttisuRED NIEYfR, CORY LOSS. DATE, 06- 27- 20091,. 1 oN'.BEHALF °,or ROBERTA N. "MEYER *EXACTLY THREE HUNDRED FORTY -FOUR AND 651100 DOLLARS *3.44'.:65 Pay, to the to Order of CARMEL FIRE DEPARTMENT 2 CIVIC SCI r CARMEL IN 46032 -2584 AUTHORIZED SIGNATURE rt ZmaL2 Kam 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 ifemized 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 CQ.�� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total ,25' 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 /v orb IN SUM OF a 701, ,2-2�5 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 9 2009 Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund