245994 06/03/15 CITY OF CARMEL, INDIANA VENDOR: 365641
® t�; ONE CIVIC SQUARE ST VINCENT HOSPITAL CHECK AMOUNT: S********45.54*
CARMEL, INDIANA 46032 HEALTH INFORMATION MANAGEMENT CHECK NUMBER: 245994
94j�t.ON�p'� 2001 W 86TH STREET CHECK DATE: 06/03/15
INDIANAPOLIS IN 46260
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4358200 76052. 45.54 SPECIAL INVESTIGATION
St. Vincent Hospitals Invoice No
Indianapolis,Carmel & Fishers 76052
2001. W. 86th Street
Indianapolis, IN 46260
( 317) 338-2216 Tax ID:35-0869066
Date: 02/12/2015
To: Carmel Police Department
3 Civil Square
Carmel, IN 46032
* * * Duplicate Invoice * * * 85 Days Over Due
Patient: Tyler Lacy
Request No" Invoice No; Medical Record No Date Received- : Date Sent
L183696 76052 0001744732 02/09/2015 02/12/2015 Pages/Time Charges
Photocopy 6 20.00
If this bill has been paid, please send a copy
of the front and back of your cancelled check.
Postage 5.54
Certified 20.00
Sales Tax 0.00
v Total Billed $45.54
Amount Paid 0.00
Balance $45.54
To ensure proper posting of payments, please send Attn: Health Information Services Department
VOUCHER NO. WARRANT NO.
St. Vincent Hospital ALLOWED 20
Health Information Management(PO BOX 409 IN SUM OF$
2001 W. 86th Street
Indianapolis, IN 46260
$45.54
i
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 I 76052 I 43-582.00 I $45.54 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
Fr' ay, May 29, 2015
r
Chief of Police
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))
02/12/15 76052 case#14-44011 $45.54
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