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247449 07/15/15 LAq - ';" CITY OF CARMEL, INDIANA VENDOR: 369556 ® it ONE CIVIC SQUARE QUEST DIAGNOSTICS CHECK AMOUNT: $*****...75.00* s : CARMEL, INDIANA 46032 PO Box 740709 CHECK NUMBER: 247449 ATLANTA GA 30374-0709 CHECK DATE: 07/15/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1125 4340700 9159765450 75.00 MEDICAL FEES '6<V Quest Invoice/Statement Diagnostics PoBOX 740709 ATLANTA,GA 30374-0709 06/25/2015 $75.00 AB 01 013297 66163 H 58 E ::: , Client Number Lab Code 15085427 NDA 9159765450 _ 15085427 NDA CARMEL CLAY PARK AND RECR JUL5LYNN RUSSELLClient Name; CARMEL CLAY PARK ANQ RECR 1411 E 116TH ST Terms: 30 Days CARMEL, IN 46032-3455 I3 • __ Protocol Number: N/A PO Number: N/A �II ��I11�1�111�11�111�1 �1'��I��II'�II"�i'llllll�ill •a o .Ot�4 OG u� o� _ . ® You may pay online at the website listed below or by telephone. • Your payment stub is attached below. Please include your client number, Invoice numbers and amounts paid on your check stub, Invoice discrepancies must be identified In writing by fax or through elnvoice using the fax number or web link below. Payment is due for the undisputed balance. • We report payment history to credit agencies. Unless a valid dispute Is identified, open invoices beyond our terms are reported as past due. c • This bill is final unless discrepancies are reported within 30 days. M • This invoice reflects the total net fee for laboratory services rendered. If you are required to report items or s services to Medicare or Medicaid, you must report the total net fee either on the applicable cost report or other reporting documentation required by the Medicare or Medicaid programs. © For Billing Inquiries: Weekdays 9AM -4:30PM EST Phone: 1-800-345-2455 Fax: 484-676-5464 -Or visit our website at HTTPS://QUESTDIAGNOSTICS.-COM/EINVOICE �I,,, : .. Lab Tax ID: #38-2084239 ®kn QL eSt. Invoice/Statement ® Uiaynost]CS POBox740709 A ATLANTA,GA 30374-0709 0 • = 06/25/2015 $75.00 AB 01 013297 66163 H 58 E �_ F_ Client Number Lab Code 15085427 NDA 9159765450 15085427 NDA CARMEL CLAY PARK AND RECR JUL 0 LYNN RUSSELL I Client Name: CARMEL CLAY PARK AND RECR 1411 E 116TH STTerms: 30 Days £3Y: Protocol Number: N/A CARMEL, IN 46032 3455 PO Number: N/A r�llrrll�illlrlrllrllllllllllrrr�l'��I��II'�II"�I'IIiIII�IrII • a o 0 You may pay online at the website listed below or by telephone. • Your payment stub is attached below. Please include your client number, invoice numbers and amounts paid on your check stub. Invoice discrepancies must be identified in writing by fax or through elnvoice using the fax number or web link below. Payment is due for the undisputed balance, • We report payment history to credit agencies. Unless a valid dispute is identified, open invoices beyond our terms are reported as past due. e • This bill is final unless discrepancies are reported within 30 days. • This invoice reflects the total net fee for laboratory services rendered. If you are required to report items or s services to Medicare or Medicaid, you must report the total net fee either on the applicable cost report or other reporting documentation required by the Medicare or Medicaid programs. For Billing Inquiries: `i Weekdays 9AM -4:30PM EST Phone: 1-800-345-2455 Fax: 484-676-5464 Or visit our website at HTTPS://QUESTDIAGNOSTICS.COM/EINVOICE 12�. q-0-1 00 :I: Lab Tax ID: #38-2084239 '7-1I✓ � 2 ♦Please fold and tear along perforation and remit with payment In the envelope provided. Lab Code: NDA ® QLIeSt Current Invoice Balance: $0.00 0 Diat;'I ostics Past Due Balance: $75.00 a • a $75.00 LOG ON NOW. Pay your statement online securely at Statement Date:06/25/2015 Invoice-'Number: 91'59765450 HTTPS://QUESTDIAGNOSTICS.COM/EINVOICE or call 1-800-345-2455. Client Number: 15085427 ffamdo'=101M $ MAIL PAYMENTS TO: ; QUEST DIAGNOSTICS Please make checks payable to QUEST DIAGNOSTICS. ; PO BOX 740709 Be sure to include invoice number on your check. ATLANTA-, GA-30374-0709 ❑ Check here if address has changed. Please provide your new address information , I I r i l l r l I r r l l .I r l 11 11 11 11 . I I r l on the back. II I �I I� I I� II 1 III I �� I� IIS QUEST DIAGNOSTICS reserves the right to assign this receivable to any of its affiliates. 9159765450015085427500000000000DB d Quest Statement Page 1 o(1 Diagnostics PO BOX 709 ® ATLANTAANTA,,GA 30374-0709 06/25/2015 $75.00 Lab Tax ID: #38-2084239 Client Number Lab Code 15085427 NDA CARMEL CLAY PARK AND RECR 15085427 Client Name: CARMEL CLAY PARK AND RECR LYNN RUSSELL Terms: 30 Days Protocol Number: N/A 1411 E 116TH ST PO Number: N/A CARMEL, IN 46032.3455 • G3�c�J ' Invoice Invoice Invoice Payments Transfer Other Debits/ Invoice Number Date Amount Credits Credits Balance 9159765450 05/26/15 $75.00 $0.00 $0.00 $0.00 $75.00 BALANCE $75.00 M Invoice Specimen Patient Transaction Description Prior Balance s Number Number Name Date $75.00 9159765450 CURRENT MONTH AMOUNT $0.00 BALANCE $75.00 w A N A For Billing Inquiries: Weekdays 9AM -4:30PM EST Phone: 1.800-345-2455 Fax: 484-676-5464 Or visit our website at HTTPS://QUESTDIAGNOSTICS.COM/EINVOICE _..- ------ ------ ....._... - Statement Aging Current 30 Days 60 Days 90 Days 120 Days 150 Days 180 Days and over $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 Quest o Diagnostics REQUEST FOR DRUG TEST ADJUSTMENTS Client Number: 15085427 Statement Date: 06/25/15 Client Name: CARMEL CLAY PARK AND RECR Invoice Number: 9159765450 If additional space is needed, form may be duplicated. Ratient,�I.D.or, ;:. r•Je Specimen# Amount"' . . Reason for Adjustment If'Pricing Problems. Patient_Name Incorrect Correct TOTAL AMOUNT: `: s *Note: Pricing adjustments are contingent upon approval from sales representative. Comments: Adjustment Address Change/Correction: Requested by: Date: Phone Number: Attn: Fax Number: Please mail or fax request for adjustment to: QUEST DIAGNOSTICS MAIL CODE MR152 PO BOX 740709 Fax: 484-676-5464 ATLANTA, GA 30374-0709 * * * ATTACH ALL DOCUMENTATION * * * ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of bill to be properly itemized rate must show;h urkind of service, ice,where uniprice perforper med, dates service rendered, by whom, rates per day, number of hour , Payee Purchase Order No. Terms Quest Diagnostics P.O. Box 740709 Atlanta, GA 30374-0709 Invoice Invoice Description PO# Amount Date Number (or note attached invoice(s)or bill(s)) $ 75.00 6125115 9159765450 Out of State employee drug test Total $ 75.00 orrect and I have audited same in accordance I hereby certify that the attached invoice(s),or bill(s)is(are)true and c with IC 5-11-10-1.6 20 Clerk-Treasurer Voucher No. Warrant No. Quest Diagnostics Allowed 20 P.O. Box 740709 Atlanta, GA 30374-0709 In Sum of$ $ 75.00 ON ACCOUNT OF APPROPRIATION FOR 101 -General Fund PO#or Board Members Deptept# INVOICE NO. CCT#/TITL AMOUNT 1125 9159765450 4340700 $ 75.00 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 July 9, 2015 Signature $ 75.00 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund