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HomeMy WebLinkAbout215869 12/25/2012 CITY OF CARMEL, INDIANA VENDOR: 356246 Page 1 of 1 ` ONE CIVIC SQUARE AETNA CHECK AMOUNT: $340.57 CARMEL, INDIANA 46032 PO BOX 981106 9yOM/� EL PASO TX 79998 CHECK NUMBER: 215869 CHECK DATE: 12/25/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 102 5023990 340 . 57 AMBULANCE REFUND P Al u.. CITY COEL JAMES BR_AINARD, MAYOR December 17, 2012 Aetna P.O. BOX 981106 El Paso, TX 79998-1106 RE : Jack Bartz claim ID E3JK18VB200 ID : W460548476 Dear Sir/Madam: Enclosed you will find a reimbursement check in the amount of$340.57. September 6, 2012 we received payment from Aetna Insurance for ambulance transport and on September 11, 2012 for $400.67 from Erie Insurance Auto Claim. Since this was a motor vehicle accident claim, we are issuing Aetna the Health Provider a refund of$340.57. If you have any questions, please feel free to contact me at (3 17) 571-2604. Sincerely, Michelle T. Harrington Billing Administrator CAR:NIEL FIRE DEPARTMENT STEVEN, A. COLTS HEADQUARTERS Two Civic SQUARE, CAP-NIEL, IN 46032 OFFICE 317.571.2600, FAx 317.5712615 P.O.BOX 981106 t n a" .KPLAINA 'IQ:NJVEFITS EL PASO TX 79998-1106 USA Please Retain for Future Referen CITY OF CARMEL FIRE DEPT./PIN:00057451 Check No:09822-0041982 Page 2 of 3(1) 2. 2 Q� <iTX:ideptiP`rrCtI0i3IIVlt»t1" :;`XX7(X!(X;?X0972; CITY OF CARMEL FIRE DEPT. 2 CIVIC Sly CARMEL IN 46032-2584 r �'P Notes: Update your address, telephone number, email address and/or NPI information by visiting www.aetna.com/provider, www.aetnadental.com www.aetnaglobalbenefits.com and select Update Personal Information. Patient Name: JACK BARTZ(spouse) Claim ID:E3JK18VB200 Recd:08/09/12 Member ID:W460548,476 Patient Account:201202007 Member:RENEE:BARTZ DIAG:-784.0,E813A Group Maine'THE DOW CHEMICAL COMPANY -Group Number:479235-31-011-HB'P6<)II Product:AexceIV Plus Aetna Choice®POS 11 Network ID:0000(- Aetna-Life Insurance Company SERVKf P4 9ERVIGE .NUM ',,, 5UBbsITrEO ALLOWABLE', CDFpY NOT SEE. 0.EDUCT�4E",; C9 .'r:.;:?> 'i :`PATIENT ;i'''PAYAAhE';:`;< tlA7ES GG1A S�ICS'`.;.' CHAR;CS AMOUWT ''.< AM©'UN7 PAYABLE: REMAfil43 IN$URANpE RE9P., ': AMdi1N7, 06120112 41 A0429SH 1.0 375.00 56.25,:;':,:;r;;'E'.?'si56;15;`:;;!>'>;;>r,,:,3.18:;7 d 06120112 41 A0425SH 3.0 25.67 TOTAL S 400:67 60;10::::: QI N N r > OC N W >���::��' :I��t1':E.L.✓:<:AMT..::.:.:.:: a'`.7;.., d 'N For Questions Regartii. This Claim N P:,0,::BOX 981't06 EL PA50 TX 79998 1106 Total P*'b'* i.6 h'ti R'6:` slbl]Ity $60 10 CA[ ,(S88) 6 3$!?+ 'FCR A, S[STANt; irie > ere ce<tfis D ti»ber.:above for rani .res'onseI�Iht Payment $ 4G►..5?. !Note:Aq;trigu s should.ref li f n p. pt p pq Pa1,eI1 t:nlalll spouse) Claihi'(D+ET:�42CBVPOO :f2ecd:08113712 Member ID:W175682332 Patient Account:201201,731 Member.:JEWNIZ95120=0 DIAG:'641;91 Group',Name 4BANK=OF,.AMERICA CORPORATION Group;Number:;811380=10=.13 I PC`:P7±.Q81 k 0 Product Aetna Chorc „ 'or ID 000( AetnaW646suiand0; ompan - �::.:".SERVICE;�>s»::<:;:p,aPL:::.:,�•,SERVaCE:::;NUM,:::::.:.:�:.S06A417T£tl<:>;•>;,�,::; i3OWABLE:.:: :::.:ORpAI`:::::.�.•::::.:.NOT:::::::•::::::SEE......_:::DtvUT E.::.....::::::C9..,.:...:.:::,::•::RTa biuhPr:^i�:PA•.A$_:.:: ..:.::.,:.OA1ES;i:'i>;;::,„ :!v;;:. COtlEc.:.::SVC5,...::::::.CNAI�GE9..,�u::::::.�..AM0iJM7::.::::::.::AMOI1NTs;;%:•;>PAYAeLE:..:::ttEtdAR�,,;..:.Y:::;;;;•::•::.;:•::.::.:.>aNSIJftANCE<•;>::;i ss:r r: .. 7:cs:: - - K iti9P: ;I„ AMOtPub. ::...:.:.::....: h - n. - UiIIJ I I ` ..: . .... . :. 375.O0 /2 ? __A0429RH 1%0: 41 0512911? 5.0'2y b :: 3.;,;;•.;. 35:49 4_1_0.49 T OTA LS�I �I .0. 'd l. I I I- I I` _ i, ,I I - I I; I t. 'IU I I. i qd'r :'For:Quesl:i+�n�Regard i laun,. 1407 I G 79 '' :::a::::<•;: Note;.��lldn,ufrEess ould:refere ahe:D:numbec:a Via: or.:: om res se;;;:>.:>>:;:: �la1m<.::a ment.;;:;:: :<>':: :::::::::::.. :::.>:::::•:;;>:>:::r::::. >, :<..,..:,:,::.:i :. 'i':' :: :::;."i:: i>:aC'.:::;::;:;::,:<:;,;<;;:i:;::;;;:;;.:, >:iii>:iif.::;:i::: :i"C>;; vJ'S`;5;:;::;'('a;i ri•. Yi:;:i:.;:>: i I � _....��__.__.�.�oifalPaymen�ty C17'Yf3�CA�'NI��.�JR�_17�1'�'•._.��__�..�. �.�..�.___.. _ . $ 51:46 Continued on Next Page r. y"" t aetna- P.O.BOX 981106 +L�`�lI 9"_A 1 tZV1,i�l1(/ EL PASO TX 79998-1106 USA Please Retain for Future Reference •029565'V1K2PHA•107952• CITY OF CARMEL FIRE DEPT.I PIN:00057451 OC Page 1 of 3(1) ******************AUTO**3-DIGIT 460 16162 1 AT 0.374 65 CARMEL,FIRE DEPTARTMENT 2 CIVIC SQ CARMEL.IN 46032-2584 RECEIVED SE 0 6 2012 Z �o es N � pO� N N � � O O N " r > 0 W S = N o_ rn o N N O N THE ORIGINAL DOCUMENT HAS A REFLECTIVE WATERMARK ON THE BACK-HOLD AT AN ANGLE TO VIEW WHEN CHECKING THE ENDORSEMENT-SECURITY FEATURES DETAILED,ON BACK �i;��, .. h,�I ' iIHP Aetna Life Insurance Com an or;an J p y Affiliated Company tD No:XXXXXXXX0972. Check No: 004,1 k9 6_ as Agent for Specified Payer(s) I'i!� I Itl Sell No:000000004 !Acct 09822 i P.O.BOX 981106 �, .. ,,P 1 I EL PASO TX 79998-1;106,1 CI!I dljj;i;, ;�i „.n• USA ,,,i,l,,,;il�l, 51-44 119 CT til PAYER a,;11,,' ' 'MULTIPLE ,ly,'!'jollil',IIIIijP 08-28-2012 ,djpj, Ial 4,1,1 {I,. h,jl PAY ''''`' Seven Hundred Fifty One Dollars and 061100 TO THE CARMEL FIRE DEPTARTMENT VOID AFTER 51.0 R ORDER OF 2 CIVIC SQ ********$75'1.06 CARMEL IN 46032-2584 Bank of America izl (5,-7aAk ice tro-os1 118001. 1,98 2 26118 Boo b &90044 54 000000009EI 2 20 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. Payee 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 $ 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 DEG 17 2012 4 ZIA - \ 4-�— 1 f--' —17" 0- Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund