175795 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 363205 Page 1 of 1
ONE CIVIC SQUARE FREDERICK MCBROOM CHECK AMOUNT: $6210
CARMEL, INDIANA 46032 10599 HUNTERSFIELD DR
CARMEL IN 46032 CHECK NUMBER: 175795
CHECK DATE: 8/612009
D EPARTMENT AC COU N T PO NUMBER INVOICE NUMB AMO DESC
102 5023990 62.10 OTHER EXPENSES
Date: 07/21/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
(Bill To: FRED I MCBROOM ICD -9: 78605 7867 7823
10599 HUNTERSFIELD DR
CARMEL, IN 46032
From: 118 MEDICAL DR
To: CLARIAN HOSPITAL NORTH
MEDICARE PART B
Patient: FRED I MCBROOM 306448863A
10599 HUNTERSFIELD DR Insurance
CARMEL, IN 46032 2 MUTUAL OF OMAHA
Patient No: 200901151 74900899
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$388.10 $450.20 -62.10
CPT
Date Description Charges Credits
05/03/2009 ADVANCED LIFE SUPP 1 --EMER A0427 $375.00
05/03/2009 MILEAGE A0425 $13.10
06/30/2009 MEDICARE PAYMENT $310.48
07/07/2009 COMMERCIAL INSURANCE PAYMENT $77.62
07/14/2009 COMMERCIAL INSURANCE PAYMENT $62.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/21/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederallD# 356000972
Bill To: FRED I MCBROOM ICD -9: 78605 7867 7823
10599 HUNTERSFIELD DR
CARMEL, IN 46032
From: 118 MEDICAL DR
To: CLARIAN HOSPITAL NORTH
1 MEDICARE PART B
Patient: FRED I MCBROOM 306448863A
10599 HUNTERSFIELD DR Insurance
CARMEL, IN 46032 2 MUTUAL OF OMAHA
Patient No: 200901151
74900899
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$388.10 $388.10 $0.00
CPT
1 a Description Charges Credits
05/03/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
05/03/2009 MILEAGE A0425 $13.10
06/30/2009 MEDICARE PAYMENT $310.48
07/07/2009 COMMERCIAL INSURANCE PAYMENT $77.62
07/14/2009 COMMERCIAL INSURANCE PAYMENT $62.10
07/21/2009 REFUND -62.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
REPORT GW2232 Explanation of Payment Report PAGE 1
1 Y P PERIOD ENDING DATE 06/30/09
CITY OF CARMEL FIRE DEP DRAFT /CHECK NUMBER: 00892194'
2 chic so United World Life Insurance
DIRECT INQUIRIES TO:
CARMEL IN 46032 UNITED WORLD LIFE
IF YOU HAVE ANY QUESTIONS, CALL: INSURANCE COMPANY
PROVIDER ID: 3316 FARNAM ST
(877) 617 -5587 OMAHA, NE 68175 -0001
CLAIMS PROCESSED UNDER TIN /EIN: 356000972
Insured's Name
Patient
Policy/Plan Number
Cert Number Date of Less Charges
Claim Number Service Submitted Not Covered Less Considered Benefit Balance
Account Number From To Procedure Charges Amount Note Balance Deductible Charges ova Amount Due
ICBROOM /FREDERICK/
.ELF
050309 050309 AMBULANC 375.00
050309 050309 AMBULANC 13.10
49008 -99W 77.62 100 77.62
310.48 1
83322676200 -073
00901151
TOTAL 388.10 77.62
OTAL PAID: 77.62
!RTES:
1 THIS IS THE AMOUNT PAID BY MEDICARE.
1t� 13 AlL J U L Q A 2009
THE'FACE OF THIS DOCUMENT -HAS A COLORED BACKGROUND:ON WHITE PAPER. THE BACK OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATEHMARii MOLD ATAN;14NGLE TO VIEW
r xl 4 x PAYABLE THRU FIRST NATIONAL BANK OF OMAHA 1048
W UNITED ;WORLD LIFE onnaHA :NE sai o2
o, x FREMONT NATIONAL BANK &,TRUST CO x
INSURANCE COMPANY
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GYBS- PO90630230332004303
58 POLICY /'PLAN NUMBER 7490F08 =99W:
CITY OF CARMEL FIRE DEP
2 CIVIC SQ
•r CARMEL IN 46032
SIGNATURE"
II °0089 Z 191,11■ z; 1049000iai: 09 LD393 71I°
K Ae t na P.O. BOX 9107 al
CLAlM �A YMENT
EL PASO TX 79998.1 707
USA
Please Retain for Future Referent'
008341 J280DUN2 023236 CITY OF CARMEL FIRE DEPT. PIN: 000574510
Page 1 of 3
CITY OF CARMEL FIRE DEPT.
2 CIVIC 5Q
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1� P.O. BOX TX 79 EXPLANATION OF BENEFITS
/A EL PASO, TX 79998.1107
1 1 et a 1 usA
Please Retain for Future. Reference
008341 J280DUA2 023237 CITY OF CARMEL FIRE DEPT. PIN: 0005745100
Check No: 09817,
Page 2 of 3
Date Printed :."..07107/2009
CITY OF CARMEL FIRE DEPT. Tax Identification Number: XXXXXXXX0972i:
2 CIVIC SO Check Number: 0981.7/070064538
CARMEL IN 46032 -2584 Check Amount: .$123.15:
III11111IIIII11111II IIIIJ IIIIIIIIII Ii II IIIIlll I1 k11 I1
:R19CEIVED JUL 14 2009
Notes:
Update your address, telephone number, email address and /or NPl information by visiting www.aetna.com /provweb /or
www.aetnadental.com and select Update Personal Information.
Patient Name: FRED R MCBROOM II (Self)
Claim ID: EJFAHTTPX00 Recd: 06/30/09 Member ID: W090177135 Patient Account: 200901 151
Member: FRED R MCSROOM II DIAG: 786057867 7823
Group Name: GANNETT CO., INC. Group Number: 398683 -13 -261 UP DASU)0
Product: Open Choice@ Network ID: 00000
Aetna Life Insurance Company
SERVICE PL "'SERVICE NUM:;: SUBMITTED ALLOWABLE COPAY NOT ^SEE DEDUCTIBLE, GO :::.PATIENT:.. PAYABLE..:',:
DATES CODE :SVCS CHARGES AMOUNT AMOUNT PAYABLE' REMARKS :INSURANCE' 'RESP `:AMOUNT
05103109 41 A0427NH 1.0 375.00 300.00 1 15.00 .15.00
05/03/09 41 A04251 2.0 13.10 10.48 1 0.52 0.52
TOTALS 388.10 310.48 15.52 15.52 62.10
ISSUED AMT: $62.10`
Remarks:
1 This amount was paid by Medicare, which is the primary carver. The member is not responsible for this amount.
ForQuestions Regarding This Claim
P:O. BOX 981107 EL' PASO ;;TX 79998-1107:: Total Patlent:Respbnsiblllty $15.52
CALL (888) 632 7- 3862 FOR ASSISTANCE Claim.Payment $62 10
Not6. .A10n4uiries should reference the,ID:number above for prompt response.
U LI U O; Q
a °Q�
MA r. 0 OD 0
CITY O }ARMEL
JAMES BRAINARD, MAYOR.
July 21, 2009
Mr. Frederick McBroom
1.0599 Huntersfield Dr.
Carmel, IN 46032
RE: INVOICE #200901151/ D.O.S. 5/3/2009
Dear Mr, McBroom:
Enclosed you will find a reimbursement check in the amount of $62.10. On July 7, 2009
we received a check from United World Life for your ambulance transport on May 3,
2009 in the amount of $77.62. On July 14, 2009 we received a check from Aetna for
$62.10 for the same ambulance transport. Since you have 2 secondary insurances, we are
issuing the overpayment to you in the amount of $62.10.
If you have any questions, please feel free to contact me at (317) 571 -2605.
Sincerely,
Becky S. Lannan
Billing Administrator
CAfiNirt. FIRE DFRkHTNILNT
STFIVFN A. Colas Hi ADQuARTEKs
Two CnnC SQUARE, CARNIEL, IN 46032 OHrict_ 317.571.2600, FAx 317.571.2615
Date: 07/21/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
Bill To: FRED I MCBROOM ICD -9: 78605 7867 7823
10599 HUNTERSFIELD DR
CARMEL, IN 46032
From: 118 MEDICAL DR
To: CLARIAN HOSPITAL NORTH
1 MEDICARE PART B
Patient: FRED I MCBROOM 306448863A
10599 HUNTERSFIELD DR Insurance
CARMEL, IN 46032 2 MUTUAL OF OMAHA
Patient No: 200901151 74900899
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$388.10 $450.20 -62.10
CPT
Date Description Charges Credits
05/03/2009 ADVANCED LTFE SUPP 1 -EMER A0427 $375.00
05/03/2009 MILEAGE A0425 $13.10
06/30/2009 MEDICARE PAYMENT $310.48
07/07/2009 COMMERCIAL INSURANCE PAYMENT $77.62
07/14/2009 COMMERCIAL INSURANCE PAYMENT $62.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 07/21/2009
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 FederalID# 356000972
sire To: FRED 1 MCBROOM ICD -9: 78605 7867 7823
10599 HUNTERSFIELD DR
CARMEL, IN 46032
From: 118 MEDICAL DR
To: CLARIAN HOSPITAL NORTH
MEDICARE PART B
Patient: FRED I MCBROOM 306448863A
10599 HUNTERSFIELD DR Insurance
CARMEL, IN 46032 2 MUTUAL OF OMAHA
Patient No: 200901151 74900899
PLEASE FILL OUT THE SURVEY ON THE BACK OF THIS INVOICE AND RETURN WITH YOUR INSURANCE INFORMATION IN THE
ENCLOSED SELF ADDRESSED STAMPED ENVELOPE. THANK YOU.
Total Amount Total Paid Balance
$388.10 $388.10 $0.00
CPT
Date Description Charges Credits
05/03/2009 ADVANCED LIFE SUPP 1 -EMER A0427 $375.00
05/03/2009 MILEAGE A0425 $13.10
06/30/2009 MEDICARE PAYMENT $310.48
07/07/2009 COMMERCIAL INSURANCE PAYMENT $77.62
07/14/2009 COMMERCIAL INSURANCE PAYMENT $62.10
07/21/2009 REFUND -62.10
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
REPORT GW2232 Explanation of Payment Report PAGE 1
Y P PERIOD ENDING DATE 06/30/09
CITY OF CARMEL FIRE DEP DRAFT /CHECK NUMBER: 00892194
2 civic SO United World Life Insurance
DIRECT INQUIRIES TO:
CARMEL IN 46032 UNITED WORLD LIFE
IF YOU HAVE ANY QUESTIONS, CALL: INSURANCE COMPANY
PROVIDER ID: 3316 FARNAM ST
CLAIMS PROCESSED UNDER TIN /ESN: 356000972 (877) 617 -5587 OMAHA, NE 68175 -0001
Insured's Name
Patient
Policy/Plan Number
Cert Number Date of Less Charges Remaining
Claim Number Service Submitted Not Covered Less Considered Benefit Balance
Account Number From To Procedure Charges Amount Note Balance Deductible Charges Amount Due
ICBROOM /FREDERICK/
;ELF
050309 050309 AMBULANC 375.00
050309 050309 AMBULANC 13.10
49008 -99W 77.62 100 77.62
310.48 1
83322676200 -073
00901151
TOTAL 388.10 77.G2
OTAL PAID: 77.62
TOTES:
1 THIS IS THE AMOUNT PAID BY MEDICARE.
RE C;&' JUL 0 7 200
THE FACE OF THIS DOCUMENT -HAS A COLORED BACKGROUND:ON WHITE PAPER. THEiBACK OF TH1900CUMENT CONTAINS AN'ARTIFICIAL WATERMAH HOLD ATAN AT6LzLE TOWIEW
PAYABLE THRU FIRST NATIONAL BANK OF OMAHA tpgg
N 1 zOMAHA :NE 68102`
W
UNITED .WORLD LIFE 'FREMONT NATIONAL BANK &TRUST CO
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INSURANCE COMPANY
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58 POLICY /PLAN'NUMB'ER 749008 99W
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E� PASO, TX 7999 &•1107
Please Retain for Future Referenc
008341 JZ80DUNZ 023236 CITY OF CARMEL FIRE DEPT. I PIN: 000574510
Page i of 3
CITY OF CARMEL FIRE DEPT.
2 CIVIC 5O
CARMEL IN 46032 -2584
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yl 5et USA
Please Retain for Future Reference
008341 -1280DUA2 023237 CITY OF CARMEL FIRE DEPT. 1 PIN: 0005745100
Check No: 09817/070064538
Page 2 of 3
Date Printed: 07/0712009`
CITY OF CARMEL FIRED EPT- Tax Identification Number: XXXXXXXX0972:.
2 CIVIC SQ Check Number:: 09817/070064538
CARMEL IN 46032 -2584 Check Amount: ;..$123.15.
DECEIVED JU 1 4 Z
Notes:
Update your address, telephone number, email address and/or NPI information by visiting www,aotna.com /provweb /or
www.aetnadental.com and select Update Personal Information.
Patient Name: FRED R MCBROOM /I (self)
Claim ID: EJFAHTTPX00 Recd: 06/30/09 Member ID: W090177135 Patient Account: 200901151
Member: FRED R MCBROOM Il DIAG: 786057867 7823
Group Name: GANNETT CO., INC. Group Number: 398683 -13 -261 UP DASU)0
Product: Open Choice® Network 10: 00000
Aetna Life Insurance Company
SERVICE PL SERVICE NUM.: ,SUBMITTED ALLOWABLE COPAY NOT SEE`. 'DEDUCTIBLE CO PATIENT ':PAYABLE;.;i
DATES "6ODE SVCS> CHARGES AMOUNT AMOUNT: PAYABLE'. REMARKS INSURANCE RESP AMOUNT'
05103109 41 A0427NH 1.0 375.00 300.00 1 15.00 15:00 Koo
05/03109 41 A0425NH 2.0 1310 10 49 1 0.52 0.52 210
TOTALS 388.10 310.48 15.52 15.52 fi2:10
ISSUED AMT:. $6210:'
Remarks:
1 This amount was paid by Medicare, which is the primary carder. The member is not responsible for this amount.
For Questions Regarding This Claim
P,O BOX:981.107 EL PASO;TX :79998 1107; :.Total iPatient Responsibility $15 52.`
CpL� (888) 632 3862. FOR' ASSISTANCE Claom Payment $62 10 is
Note AU,Inquiries should reference the lO :number above for prompt response
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
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payeeee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
ev a,<
t<
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. WARiRANT NO.
ALLOWED 20
A&16; IN SUM OF
/059 9i�e�s'e%� ,fir
ON ACCOUNT OF APPROPRIATION FOR
U GC�Q GcC'e GUIGZ- U
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Q���023 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
AUG
F
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund