HomeMy WebLinkAbout179445 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