218219 03/13/2013 - f CITY OF CARMEL, INDIANA VENDOR: 367009 Page 1 of 1
0 ONE CIVIC SQUARE MARIANA ROJDEV
CARMEL, INDIANA 46032 3663 COACHMAN DRIVE CHECK AMOUNT: $413.82
CARMEL IN 46033 CHECK NUMBER: 218219
CHECK DATE: 311 312 01 3
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 413 . 82 AMBULANCE REFUND
CARMEL FIRE DEPARTMENT
: D 2 CIVIC SQUARE
CARMEL, IN 46032-7543
CLAXTI"� (317) 571 2604 Federal ID# 356000972
Patient Name: ROJDEV, MARIANA
MARIANA ROJDEV CARMEL FIRE DEPARTMENT
3663 COACHMAN DR 2 CIVIC SQUARE
CARMEL, IN 46033 CARMEL, IN 46032-7543
TO ASSURE PROPER CREDIT, RETURN Statement Date Patient ID JAMOUNT PAID
THIS PORTION WITH YOUR PAYMENT 02/28/13 201204037
Ticket# : 20125807:1
Date of Service: 12/25/2012
DETACH HERE
REFUND $413.82
MAKE CHECKS PAYABLE TO: CARMEL FIRE DEPARTMENT BALANCE -.-. ; ; ,''$O;Q0
Pay online at www.govpaynet.com with PLC#7487 Run Number 20125807:1
Online Payment will charge a service fee.
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x Date of;3eivice., D:escri„tion,. Patierits";Name a, :- Char e s -I Date Payment(s)u.;
3-"• ! _ `iaa' -: `t,•- v ,u..:s.• (')' =r_
Charges
12/25/2012 *ADVANCED LIFE ROJDEV, MARIANA $475.00
12/25/2012 *MILEAGE ROJDEV, MARIANA $42.28
---------------------------------
Charge Total: $517.28
Payments
Paid By: Converted Invoice 12/25/12 $517.28
Paid By: ROJDEV, MARIANA Payment 02/04/13 ($517.28)
Paid By: GOLDEN RULE/31374 COMMERCIAL INSURANCE 02/21/13 ($413.82)
Paid By: ROJDEV, MARIANA REFUND 02/28/13 $413.82
BALANCE $0.00
Goa
12--17-
CHASE C i Apply In Arc 201204037 mariana rojdev 238316592
MARIANA ROJDEV 25-3/440
CHASE ONLINE BILL PAYMENT 3663 COACHMAN DR 01-28-2013
PO BOX 15944 CARMEL IN 46033-3817
WILMINGTON DE 19850--594
(800)472-6236 Nil ICI I it O��Isl ICI I III III I IIII II II IiII I)II III�I
Pay FIVE HUNDRED SEVENTEEN AND 28/100 Dollars
68539 B PC 001 001 13028-238316592 1 OF 1 W J
CITY OF CARMEL FIRE DEPARTMENT
To EMS DIVISION 2 CIVIC SQUARE �sEEOe �aNa�•
the CARMEL IN 46032 Check Void After 90 Days
Order Y
of
JPMorgan Chase Bank,N.A.Columbus,Ohio
11° 23831659211° 1:04400003 ?1: 65853301311°
ti:Nr-L-PAIMMO avry srr- r�ca.r��o a a 1-a va9va L
BY YOUR PATIENT'S HEALTH INSURANCE PLAN
A UnitedHealthcare Company
F.O. Box 31374 02/12/2013 If you have any questions
`alt Lake City, Utah 84131-0374
{ 00) 657-8205 about this claim or additional
information you wish us to
review, please contact:
Golden Rule Insurance Company
042e474GPA0120601 P.O. Box 31374
CARMEL FIRE DEPARTMENT Salt Lake City, Utah 84131-0374 =
2 CIVIC SQ Telephone (800) 657-8205
CARMEL IN 46032-2584 7:00 am-6:00 pm (CST)
PAGE 1 OF 1
RECEIVED FEB 2 0 2913
SERVICE PROCEDURE AMOUNT DISCOUNT NOT COVERED DEDUCTIBLE/ PAYMENT PAYMENT REMARK
DATES CODE CHARGED COVERED COPAYMENT AMOUNT CODE'
PATIENT:MARIANA RDJDEV INSURED: MARIANA RDJDEV ACCT.No:201204037 OUR ID:090169764 CLAIM NO:13018-02314-00
2/25/12-12/25/12 A0425-00 42.28 0.00 0.00 42.28 8.46 0.00 33.82
2/25/12-12/25/12 A0427-00 475.00 0.00 0.00 475.00 95.00 0.00 380.00
CLAIM TOTALS: 517.28 0.00 0.00 517.28 103.46 0.00 413.82 D00
PATIF,NT: INSURED: ACCT,NO: OUR ID: CLAIM NO:
CLAIM TOTALS:
TOTAL DRAFT: 413.82
*If a REMARK CODE is listed,see the back of this form. '
as The payment amount may not reflect the total benefits payable.A portion of the benefits may have been paid to another party.
PRV-EOBWC-EXT
PLEASE TEAR ALONG PERFORATED LINE
® THIS DOCUMENT HAS MICROPRINTING IN:BORDER AND NU(v1BER
�. AN ARTIFICIAL WATERMARK ON THE BACK 58544 44 .
A UnrtEdHealthcare Company
0079265873 ,
744o.W00d1andDrlve .BULK'.PROVIDER -
Indlana Ils;IN,46278
i'O:.
Telephone.(8D0):657=8205 NOT NEGOTIABLE AFTER:96'DAYS;.;> 1 ,
FEBRUARY 12, 2013
AT SIGHT.WHEN
:APPROVED CARMEL FIRE' ,DEPARTMENT Ay. :. $'`''`� ''411.82
TO THE ORDER.OF
FOUR HUNDRED THIRTEEN
AND82/100 -------------------------------------------------- ---
JPMorgan'Chase Bank,N.A:
FOR TIN:356000972-00 Columbus; 01-1:43271
PAYABLE THROUGH
110007926Sil73118 .1:04411S44311. .. 6.2388723.911 ,vF
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
MAR 1-12013
&SQ-0.[
20
Signature
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund