The URL can be used to link to this page

Home My WebLink About172940 05/27/2009 CITY OF CARMEL, INDIANA VENDOR: 362913 Page 1 of 1 ONE CIVIC SQUARE OLIVE MORFORD t CARMEL, INDIANA 46032 12999 N PENN #8103 CHECK AMOUNT: $67.12 CARMEL IN 46032 CHECK NUMBER: 172940 CHECK DATE: 5/27/2009 DEPART A CCOUN T P NUM BER INVOI N UMBER AM OUNT DE SCRIPTION 102 5023990 67.12 AMBUL REFUND A I I II 1 o L nthem v �O1U1750302UU■ I IIIIII'll') II��! I�I�I VIII II��I Ill) I�i�i VIII �III� II�II ��III III I��) 3 of 6' f rn An independent licensee of the Blue Cross and Blue Shield Association. N Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. CARMEL FIRE DEPT.. PROVIDER ID NO: 000000184493. 04/22/09 ®Registered Marks Blue Cross and Blue Shield Association CHECK NUMBER 0305143621 M AY 0 5:2009 CUUtS Vlt'rLKtNUL Muvrvi wvetar AMOUNT INSURED'S NAME MORFORD, OLIVE E INSURED "S ID 54SH55927 PATIENT NAME: MORFORD,OLIVE E FOR INddkf g'tAd PATIENT ACCOUNT#: 200900444 CLAIM NUMBER: 091048098000 RECEIVED pgTE`. S ERVICE PROVIDER NAME: CARMEL FIRE DEPT SERVICE PROVIDER ID: 1154325579 02/14/2009 02/14/200 A0429RH 41 325.00 64.50 .00 0.00 0.00 0.00 2.49 NCP 45, 0 DO 164.50 000 0 2/14/2 9 02/14/29 A0425RH 41 13.10 2.62 0.00 0.00 0.00 0.00 0.00 0.00 2.62 TOTAL: 338.10 67.12 0.00 0.00 0.00 0.00 2.49 0._DO ;67.12 INTEREST PAID 0.00 AMOUNT PAID BY MEDICA E 268 4 I j TOTAL NET PA i _bZ.12 Y I i a.......... t... -LSUYI DBA ANTHEM BLUE CROSS AND BLUE SHIELD A-Ci th em 1351 WILLIAM HOWARD TAFT ROAD CINCINNATI, OH 45206 -1775 1 of 6 .4n independent licensee of the Blue Cross and Blue Shield Association Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc 8 Registered Ma ks Blue Cross and Blue Shield Association I IIIIII I'11I /111'�11IIIII #BWNCQXF p185999999493/DF9# I13 .1 CARMEL FIRE DEPT 1 2 CARMEL CIVIC SQ CARMEL IN 46032 0 r 0 N v tr 0 w 0 r 0 r ANTHEM INSURANCE COMPANIES, INC. CHECK NUMBER 0305143621 DATE 04/ZZ/09 P.O. BOX 37010 PROVIDER NAME CARMEL FIRE DEPT LOUISVILLE, KY 40233 -7010 ADDRESS 2 CARMEL CIVIC SO CARMEL IN 46032 PROVIDERID NO 000000184493 1154325579 TAX ID NO XXXXX0972 PAYMEIJ SUMMAR trio r� GRCSS APPROVED CLAIM AMOUNT 631 r---) IRS WITHHELD 0.00 INTEREST PAID 0.00 i AMOUNT PREVIOUSLY OVERPAID 0.00 AMOUNT DISBURSED 631.25 m NET AMOUNT DUE 631.25 i RECOUPMENT BALANCE 0.00 �o i ma h At YL 5 j DETACH CHECK AT'PERFORATION BEFORE DEPOSITING t,�,em t%. COMP LUE ATLANTA,AGEORGIA 03051 _C 1351 WILLIAM HOWARD TAFT ROAD 0064 1278/0611 i1 CINCINNATI' OH 45206 1775 04ZZA103 01 22- 013282 C006665 "3299777138 D� PROVIDER ID NO TAX ID NO DATE CHECK AMOUNI;` XXXXX0972 04/22/09 5 *63 1 25 c 000000184'493' x =C op3 rr PAY EXACTLY .3E jE jE jE jE *63 1 DOLLARS AND 25 CENTS mgt Z_v i u TO ORDER OF Oz =or. mR CARMEL FIRE DEPT 2 CARMEL CIVIC CARMEL IN 46032 D WIREVI INS URA E C%MPJ1NIES, INC. z Security features included. Details on back. 1:05 1'. 1 2 ?88E: 3 249 138vs X6 00961 *02 *002477 -PO- 09110 -FO- 120 -CN 110 CFPA20- 070705 UNITEDHEALTHCARE INSURANCE COMPANY OLDSMAR SERVICE CENTER United Healthcare P.D. BOX 740800 ATLANTA GA 30374 -0800 A UnitedHealtn GrouoComoany PHONE: 1- 877 842 -3210 DATE: 04/20/09 TIN: 35- 6000972 N P I 1154325579 GROUP 0710593 GROUP NAME: GENERAL AGENCIES OF THE UNITED CHECK NUMBER: Ux 04939760 CHECK AMOUNT: $67.12 CARMEL FIRE DEPT AMBULANCE SVC CARMEL FIRE DEPT AMBULANCE SV PROVIDER CARMEL 4GO32 EXPLANATION OF BENEFITS PATIENT DETAIL PRODUCT MEM. ID PATIENT PAT PATIENT MEMBER CONTROL DATE PROVIDER NAME REL ACCOUNT NAME NUMBER RECEIVED OF SERVICE IND A 919473152 OLIVE MORFORD RR 200900444 OLIVE MORFORD 02151499468 -01 04113109 CARMEL FIRE DEPT AMBU SERVICE DETAIL PATIENT DATES OF DESCRIPTION AMOUNT NOT PROV ADJ AMOUNT DEDUCT/ PLAN PAID TO RMK PATIENT NAME SERVICE OF SERVICE CHARGED COVERED DISCOUNT ALLOWED COPAY COV PROVIDER CD RESP. OLIVE 02114109 AMBULANCE 325.00 2.49 2.49 322.51 250.00 80% 58.01 51 MORFORD 02114109 AMBULANCE 13.10 13.10 80% 9.11 57 SUBTOTAL 338.10 2.49 2.49 335.61 250.00 67.12 TOTAL PAID TO PROVIDER $67.12 REMARKS (51) THE PLAN BENEFIT FOR THESE SERVICES WAS DETERMINED BY USING THE AMOUNT APPROVED BY MEDICARE. THIS PHYSICIAN OR HEALTH CARE PROFESSIONAL HAS AGREED TO ACCEPT THAT AMOUNT. THE PATIENT IS RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE MEDICARE ALLOWED AMOUNT AND THE TOTAL AMOUNT PAID BY BOTH PLANS. (57) WE HAVE PROCESSED THESE CHARGES BY COORDINATING THE BENEFITS YOU RECEIVED FROM YOUR OTHER INSURANCE PLAN WITH THE BENEFITS AVAILABLE UNDER THIS PLAN. UNITEDHEALTHCARE IS IMPROVING SERVICE TO YOU BY ADOPTING ELECTRONIC PAYMENTS STATEMENTS (EPS) AS A STANDARD WAY TO PAY CLAIMS. EPS WILL DRAMATICALLY REDUCE THE TIME AND EFFORT YOUR ORGANIZATION SPENDS ON ADMINISTERING PAPER CHECKS AND EXPLANATION OF BENEFITS. GET A HEAD START AND ENROLL TODAY BY SELECTING THE ELECTRONIC PAYMENTS STATEMENTS LINK FOUND ON THE HOME PAGE OF WWW.UNITEDHEALTHCAREONLINE.COM OR CONTACT US AT 1 866 -UHC -FAST (1 866 842 3278), OPTION 5. FOR MORE INFORMATION ABOUT OUR FREE OR LOW COST SOLUTIONS FOR SUBMITTING CLAIMS ELECTRONICALLY TO UNITEDHEALTHCARE AND OTHER PAYERS, PLEASE CONTACT US TOLL FREE AT 1 800 842 -1109, OPTION 3. *l THIS PAYMENT HAS BEEN ADJUSTED BASED ON THE AMOUNTS PAID BY MEDICARE AND /OR OTHER INSURANCE. _R6 ETlEIVETL) APR 2 4 2009 Detach Check Detach Check l x- 1 S 5D 937 JPMorganrChases Bank N A 2,3 UNITEDHEALTHCARE INSURANCE COMPANY Svraquso,.NY OLDSMAR SERVICE CENT ER" 4 r kP O�BOX 740800 ATLANTA GA 30374 =0800 iFHONE: 877 =842 3210 04/20/09 A..� DATE X6 00961 002477,PO 09110 FO 120 CN`. 110 PLEASE %PRESENT PROMPTLY FOR `P 1 "2 AYMENT CONTRACT 710593 r PAY *SIXTY 12/100. :DOLLARS `PAY CARMELFIRE DEPT AMBULANCE SVC, CARMEL FIRE> DEPT AMBULANCE SV TQ THE 2 CIVIC !SQ ORDER OF CARMEL fPN 46032 3 ;AUTHORIZED.SIGNAiUR° I 1 i i nldhullilill I� Ili I m Ilud6i'iilll i nml IdJil iilud I I d uldllnulii6ululmli udu dlilidudullnnldnnunnlhluildllluliutilllilldii61n6ilulidnln6i611idiilnlullilulullilnlu6ilidiillludlinlllniilliiulhiul6mlliiiilhiillluilliuidllliln 'ililllilliliiili6 dl Iflldulu1611uIIIIILLul6nldl6dlnlnllniiilhiilll li °04939780118 1:0213`093:79(: 81108972bII' wp Date: 05/11/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: OLIVE E MORFORD ICD -9: 9596 71945 E8859 12999 N PENNSYLVANIA ST APT B103 CARMEL, IN 46032 From: 12999 N PENNSYLVANIA ST APT /SUITE# To: ST. VINCENTS HOSPITAL CARMEL 1 MEDICARE PART B Patient: OLIVE E MORFORD 312401648A 12999 N PENNSYLVANIA ST APT B103 Insurance CARMEL, IN 46032 2 ANTHEM BC /BS/ 37010 Patient No: 200900444 YRR545M55927 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $338.10 $338.10 $0.00 CPT Date Description Charges Credits 02/14/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 02/14/2009 MILEAGE A0425 $13.10 04/14/2009 MEDICARE PAYMENT $268.49 04/14/2009 ASSIGNMENT MEDICARE $2.49 04/24/2009 COMMERCIAL INSURANCE PAYMENT $67.12 05/05/2009 BLUE SHIELD PAYMENT $67.12 05/11/2009 REFUND -67.12 APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999 w Date: 05/11/2009 CARMEL FIRE DEPARTMENT EMERGENCY MED SVCS 2 CIVIC SQUARE CARMEL, IN 46032- (317)571 -2605 FederalID# 356000972 Bill To: OLIVE E MORFORD ICD -9: 9596 71945 E8859 =3 12999 N PENNSYLVANIA ST APT 8103 n CARMEL, IN 46032 From: 12999 N PENNSYLVANIA ST APT /SUITE# m To: ST. VINCENTS HOSPITAL CARMEL Patient: OLIVE E MORFORD j ig 12999 N PENNSYLVANIA ST APT B103 Insuran CARMEL, IN 46032 Patient No: 200900444 PLEASE DO NOT PAY! THIS IS NOT AN INVOICE! WE HAVE BILLED YOUR HEALTH INSURANCE. NO PAYMENT IS DUE FROM YOU AT THIS TIME. PLEASE FILL OUT THE SURVEY ON THE BACK SIDE AND RETURN IN THE ENCLOSED ENVELOPE. THANK YOU. Total Amount Total Paid Balance $338.10 $405.22 -67.12 CPT Date Description Charges Credits G 02/14/2009 BASIC LIFE SUPP- EMERGENCY A0429 $325.00 y 02/14/2009 MILEAGE A0425 $13.10 04/14/2009 MEDICARE PAYMENT $268.49 04/14/2009 ASSIGNMENT MEDICARE $2 49 gy 04/24/2009 COMMERCIAL INSURANCE PAYMENT $67 PAYMENT .12 05/05/2009 BLUE SHIELD S67.12 F: 4 T �Y x q ppRO EQ 6 y T N6 ST ATF solqRD Or 'IL �o1<1 �9� 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 �f 0), Ve r� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total 7 1'2— 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. 1 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF 7 Z l 999 e Y�ruQ 4 107 Z 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 MAY 2 2 2009 20 Si ur Cost distribution ledger classification if Title claim paid motor vehicle highway fund