218290 03/13/2013 CITY OF CARMEL, INDIANA VENDOR: 367015 Page 1 of 1
ONE CIVIC SQUARE KARLA GOSCHE WILLIAMS
CARMEL, INDIANA 46032 10475 TREBAH CIRCLE CHECK AMOUNT: $468.27
CARMEL IN 46032
CHECK NUMBER: 218290
CHECK DATE: 3/13/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 468 . 27 AMBUL REFUND
CITY U~ ' ARMEL
JANIES BRAINARD, MAYOR
March 4, 2013
Karla Gosche-Willaims
10475 Trebah Circle
Carmel, IN 46032
RE: INVOICE #20125752:1 /D.O.S. 12/21/2012
Dear Karla Gosche-Williams:
Enclosed you will find a reimbursement check in the amount of$468.27.
On January 15, 2013 we received your credit card payment for your ambulance transport
on December 21, 2012 in the amount of$520.30.
On January 23, 2013 we received a check from Anthem in the amount of$468.27 for the
same ambulance transport.
Since you paid this invoice in full, I am issuing you a refund of$468.27.
If you have any questions, please feel free to contact me at (317) 571-2604.
Sincerely,
Michelle Harrington
EMS Billing Administrator
CARbIEL FIRE DEPARTINIENT
STEVE, A. CouTs HEADQUARTERS
Two CIVIC SQUARE. CARINNIEL. IN 46032 OFFICE 317.5712600, FAx 317.5712615
CARMEL FIRE DEPARTMENT
� ARTMENT
D 2 CIVIC SQUARE
CARMEL, IN 46032-7543
11 ' (317) 571 2604 Federal ID#356000972
Patient Name: GOSCHE-WILLIAMS, KARLA
KARLA GOSCHE-WILLIAMS
10475 TREBAH CARMEL FIRE DEPARTMENT
CIR 2 CIVIC SQUARE
CARMEL, IN 46032 CA _
CARMEL, IN 46032 7543
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID AMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 02/28/13
Ticket# : 20125752:1 201203991
Date of Service: 12/21/2012
DETACH HERE
E:7- REFEUND $468.27
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE
. - :$0:00
Pay online at www.govpaynet.com with PLC#7487
Online Payment y nt will charge a service fee. Run Number 20125752:1
:`Date'of Service -, Description Patient Name 1
^� Charge(s) "'Date I?ayment(s) "
Charges : . .
12/21/2012 *ADVANCED LIFE GOSCHE-WILLIAMS, KARLA
12/21/2012 *MILEAGE $$45.00
G �
OSCHE-WILLIAMS, KARLA $45.30
--------------------
Charge Total:
$520.30
Payments
Paid By: Converted Invoice
12/21/12 $520.30
Paid By. PAYMENT 01/15/13
($520.30)
Paid By: ANTHEM BLUE CROSS & BLUE BLUE SHIELD PAYMENT 02/07/13
($468.27)
Paid By: GOSCHE-WILLIAMS, KARLA REFUND 02/28/13
$468.27
BALANCE $0.00
Date: 01/15/2013
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-7543
(317)571-2604 FederallD# 356000972
ACCOUNT MST®RY
Bill To: KARLA GOSCHE-WILLIAMS ICD-9: 7245
10475 TREBAH CIR
CARMEL, IN 46032
From: 10475 TREBAH CIR
To: IU HEALTH NORTH
ANTHEM BLUE CROSS & BLUE
Patient: KARLA GOSCHE-WILLIAMS RYL637A24281
10475 TREBAH CIR Insurance
CARMEL, IN 46032 2
Patient No: 201203991 J
qZ
YOUR ACCOUNT IS PAID IN FULL.THANK YOU!
Total Amount Total Paid Balance
$520.30 $520.30 $0.00
c ®ate �` Descrtptlon_ ' x CPTChh rgesT �� C�etllts
♦i�''
12/21/2012 ADVANCED LIFE SUPP 1—EMER A0427 $475. 00
12/21/2012 MILEAGE A0425 $45. 30
01/15/2013 PAYMENT CAj�64,F ( ;,,_�i 6 17W 5- $520.30
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
6
CARMEL FIRE DEPT
PROVIDER ID NO: 000000184493 01/23/13
CHECK NUMBER: 0308374034
MEDICARE SUPPLEMENT -
SERVICE DATE(S) SERVICE POS CHARGE
CODES ALLOWED DEDUCTIBLE CO-PAY CO-INSURANCE CONTRACTUAL PROVIDER RESP.. EXPUANSI INSURED OTHER
INSURED'S NAME:
DIFFERENCE AMOUNT CODE(S) RESPONSIBILITY EXPUANSI NET PAID PATIENT ACCOUNT#: INSURE D'S 10:
CLAIM NUMBER: 13016800A000 PATIENT NAME: AMOUNT CODE(5)
FOR INQUIRIES CALL:
SERVICE PROVIDER NAME: CARMEL FIRE DEPT RECEIVED DATE: 01/12/2013
SERVICE PROVIDER ID: 1154325579 (888) 290-9160
EX PL CD: MD2
1112012012 1112012012 A0429RH 41 375.00
1112012012 1112012012 A042RH 66.23 0.00 0.00 0.00 0.00
41 33.22 6.19 0.00 43.85 MCP 23 0.00
TOTAL: 0.00 0.00 0.00 2.29 MCP 23 66.23
INTEREST PAID 408.22 72.42 0.00 0.00 0.00 0.00 46.14 0.00 6.19
AMOUNT PAID BY MEDICA E 0.00 72 42
?7TAL_NELP_AI➢ 0.00
289.66
SERVICE DATE(S) SERVICE pOS CHARGE Z2 47
CODES ALLOWED DEDUCTIBLE CO-PAY CO-INSURANCE CONTRACTUAL PROVIDER RESP. EXPUANSI INSURED OTHER
DIFFERENCE AMOUNT CODE(S) RESPONSIBILITY EXPUANSI NET PAID
INSURED'S NAME: T` dusomw PATIENT ACCOUNT#: INSURED'S ID:
400 AMOUNT CODE(S)
CLAIM NUMBER: 13018BS8D PATIENT NAME:
SERVICE PROVIDER NAME CARMEL FIRE DEPT RECEIVED DATE: 01/18/2013 FOR INQUIRIES CALL:
SERVICE PROVIDER ID: 1154325579 (888) 290-9160
EX PL CD: MD2
1211012012 1211012012 A0427EH 41 475.00
1211012012 1211012012 A042EH 78.65 0.00 0.00 0.00 0.00 81.76 MCP 23
41 55.87 10.40 0.00 0.00 78.65
TOTAL: 0.00 0.00 0.00 3.85 MCP 23
INTERE57 PAID 530.87 89.05 0.00 0.00 0.00 10.40
0.00 0.00 85.61
AMOUNT PAID BY MEDICA E 0.00 89.05
TQIAL_NET_PAID 0.00
356.21
TOTAL APPROVED AMOUNT
TOTAL INTEREST 390.02
BLUE ACCESS _ TOTAL NET AMOUNT DUE: MEDICARE SUPPLEMENT 0.00
390.02
SERVICE DATE(S) SERVICE pOS CHARGE ALLOWED DEDUCTIBLE CO-PAY CO-INSURANCE
CODES CONTRACTUAL PROVIDER RESP. EXPUANSI INSURED OTHER
INSUREDS NAME: GOSCHENILLIAMS,KARLA K DIFFERENCE AMOUNT CODE(S) RESPONSIBILITY EXPUANSI NET PAID
PATIENT ACCOUPIT/�: 201203991 INSURED'S ID: 637A24281 AMOUNT CODE(S)
CLAIM NUMBER: 2013014QA3055 PATIENT NAME: GOSCHENILLIAMS,KARLA K ±'R
SERVICE PROVIDER NAME: SERVICE PROVIDER ID: 1 15 43 25 579 RECEIVED DATE: 01/14/2013
EXPL CD: MD2
1212112012 12/2112012 A0427 yl i
12/21/2012 12/21/2012 A0425 475.00 475.00 0.00 0.00 47.50
41 45.30 45.30 0.00 0.00 0.00 0.00 47.50 OPM 2
TOTAL: 4.53 0.00 I 0.00 7.50 i
INTEREST PAID 520.30 520.30 0.00 0.00 4.53 OPM T 0.77
52.03 000 0.00 52.03 ALNELP�II) 8.27
0.00
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 I hereby certify hat the attached invoice(s), or
DEPT.# y y
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
MAR 1-1 2u13
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund