219563 04/25/2013 CITY OF CARMEL, INDIANA VENDOR: 367102 Page 1 of 1
ONE CIVIC SQUARE W P S MEDICARE
CARMEL, INDIANA 46032 FINANCE DEPARTMENT CHECK AMOUNT: $230.00
PO BOX 1602 CHECK NUMBER: 219563
OMAHA NE 68101
CHECK DATE: 4/25/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4357004 230 . 00 EXTERNAL INSTRUCT FEE
Part B Payment Form
Billing Medicare for Ambulance Transports
AMBJ801
Sheraton Hotel
8787 Keystone Crossing
Indianapolis, IN 46240
May 8, 2013
Registration: 8:30am - 9:00am ET
Seminar: 9:OOam -3:00pm ET
After you register on-line, complete this form and return with payment to:
WPS Medicare
Attn: Finance Department
P.O. Box 1602
Omaha, NE 68101
Provider Information:
Contract: J8- IN, MI
Provider Name: C AI-0 f_ 7 _t-_EC e-_11 r_bm
Provider Number: —Z_(� �(_.Q0(')
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Address: �Y��_._S -----------------
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Phone Number: 51'_- ZL-ZayExt:
Fax Number: W:n_ _,7L21,(�p
Attendees,:
Name: cy i Name: p O
Title: _ ;1 �nj. . torTitle: i L + a' i ri
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E-Mail: r Ci' �l p.r;,;r/E-Mail: q_ ?LM rn
Name: ---------------___— Name: _
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Title: Title:
E-Mail:--------------------- E-Mail:----------------------
Make Checks Payable to WPS-Medicare
Total Amount Enclosed ($115.00 per attendee) $_ �
Check Number
We can no longer accept payment at the door.
Disclaimer: This seminar is intended for Medicare Part B providers billing on the CMS-
1500 claim form or electronic equivalent.
CANCELLATION/REFUND POLICY
All cancellations must be received in our office prior to the date of the scheduled
event. A full or partial refund will be issued based on contractual expenses we
will incur. No refunds will be issued for cancellations received on or after the date
of the event.
03/07/2013 http://www.wpsmedicare.com/ 1
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VOUCHER NO. WARRANT NO.
ALLOWED 20
WPS Medicare
Finance Department IN SUM OF $
PO Box 1602
Omaha, NE 68101
$230.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I I 43-570.04 I $230.00 1 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
APR Ra 9
� 290�,
11h,-17A00 )4,19
�.
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Registration -Mharrington, Udayan $230.00
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
20
Clerk-Treasurer