247200 07/15/15 (9,
CITY OF CARMEL, INDIANA VENDOR: 355031
ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH Pa�ROK AMOUNT: $*"****"658.00*
CARMEL, INDIANA 46032 7169 SOLUTION CENTER CHECK NUMBER: 247200
CHICAGO IL 60677-7001 CHECK DATE: 07/15/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 417047 470.00 MEDICAL FEES
1081 4340700 422002 188.00 MEDICAL FEES
_ Community Occupational Health Svs
7169 Solution Center
Chicago, IL 60677-7001 Ij
Phone: 317-621-0341 JUN 22 2015
FEIN: 35-1955223
BY
Invoice
May 04, 2015
Bill to: Lynn Russell For: Carmel Clay Parks &Recreation
Carmel Clay Parks &Recreation 04/15
1411 E. 116th St.
Cannel, IN 46032-
_......... .....
Invoice# 417047
Proc Code ICD9 Date Description QtV Charge Receipt Adiust Balance
746404 04/27/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Gary M Chin Balance Due: 47.00
746404 1)823.80 04/116/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.0.0
2)E883.9
Nancy K Goins Balance Due: 47.00
746404 04/30/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
059/440
Damion M Harris Balance Due: 47.00
746404 04129/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Hansen Huber Balance Due: 47.00
746404 04/29/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Andrew A Jaggers Balance Due: 47.00
746404 04/17/2015 Drug Screen Non NIDA 5 Panel 1.00 47.00 -47.00
Taylor L James Balance Due: 47.00'
746404 04/30/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Sarah A Monaghan Balance Due: 47.00
746404 04%28/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Abigail E Paul Balance Due: 47.00
746404 04/20/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Matthew W Petersen Balance Due: 47.00
746404 04/27/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
i
Natalie F Rumreich Balance Due: 47.00
r Invoice# 417047 (continued)page 2
1
JUN 2 2 2015 Invoice# 417047 Balance Due: 470.00
PLEASE REMIT PAYMENT PROMPTLY
PAST DUE
Cut and return with payment
-----------------------------------------------------------------------------------------------
Please remit 470.00 to Community Occupational Health Services
7169 Solution Center
Please place,invoice number 417047 on check Chicago,IL 60677-7001
Phone: 317-621-0341
a Community Occupational Health Svs
7169 Solution Center
Chicago, IL 60677-7001
Phone: 317-621-0341
FEIN: 35-1955223 _
JUN 22 2015
Invoice ,= JUL
June 17, 2015
Bill to: Lynn Russell For: Carmel Clay Parks &Recreation
Carmel Clay Parks &Recreation - 06/15
1411 E. 116th St.
Carmel, IN 46032-
���� Invoice# 422002
Proc Code Date Description QtV Charge Receipt Adiust Balance
746404 06/12/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Jacob Backes Balance Due: 47.00
746404 05/04/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Elizabeth M Eppler Balance Due: 47.00
746404 06......................_...._.._-------__.._................._........_..__..__......__...._.._..__..__...._..__........
/02/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Thomas A Gerow Balance Due: 47.00
746404 06'/04/2015 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Aimee E Rich Balance Due: 47.00
........................ .... ....... ...... ................................ ......................................
Invoice# 422002 Balance Due: 188.00
PLEASE REMIT PAYMENT PROMPTLY
Purchase _ �v 7—
Description Lv,
P.O.# Por F
G.L.#
Budget
Line Des
ftclll POE5�
Purcha e
Approval Date �O
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
355031 Commu I ity Occupational Health Services Terms
7169 Solution Center
Chicago) IL 60677-7001
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
5/4/15 417047 Pre-employment drug testing $ 470.00
I6/17/15 .422002 Pre-employment drug testing $ 188.00
I
Total $ 658.00
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
I
20_
Clerk-Treasurer
Voucher No. Warrant No.
355031 Community Occupational Health Serviced Allowed 20
7169 Solution Center
Chicago, IL 60677-7001
In Sum of$
$ 658.00
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO#or Board Members
Deptept# INVOICE NO. 4CCT#/TITLE AMOUNT
1081-99 417047 4340700 $ 470.00 1 hereby certify that the attached invoice(s), or
1081-99 422002 4340700 $ 188.00 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
f
I
i
July 9,2015
'PI
$ 658.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund