HomeMy WebLinkAbout259508 06/14/16 0r G�q"
"� - CITY OF CARMEL, INDIANA VENDOR: 370673
(; 3� ONE CIVIC SQUARE CLIA LABORATORY PROGRAM CHECK AMOUNT: $*******150.00*
;q CARMEL, INDIANA 46032 PO BOX 530882 CHECK NUMBER: 259508
M�TpN��` ATLANTA GA 30353-0882 CHECK DATE: 06/14/16
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
252 5023990 15D2113634 150.00 OTHER EXPENSES
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts u ty Form NO.201 (Kev.9995)
CLIA LABORATORY PROGRAM ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
PO BOX 530882 IN SUM OF$ CITY OF CARMEL
An invoice or bill to be properly itemized must show:kind of service,where performed,dates service
ATLANTA, GA 30353-0882 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc.
$150.00 Payee
Purchase Order#
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Terms
Date Due
PO# ACCT# DATE INVOICE# DESCRIPTION
DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT
15D2113634 50-239.90 $150.00 1 hereby certify that the attached invoice(s),or 6/7/16 15D2113634 $150.00
252 252 252 252
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
Tuesday,June 07,2016
David Haboush
Fire Chief
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—
Cost
20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE&MEDICAID SERVICES
CLIA LABORATORY USER FEES
CLIA ID Number Fees for Certificate of Certificate Period
15D2113634 WAIVER 05/26/2016-05/25/2018
Payment Due Date Total Payment Due
07/15/2016 $150.00
CURRENT CHARGES
Bill Date Description Amount
05/31/2016 CERTIFICATE FEE $150.00
Our records indicate your laboratory requested a Certificate under the provisions of the Clinical Laboratory Improvement
Amendments (CLIA)Program.The CLIA law promotes the quality and reliability of laboratory tests performed throughout the
nation.The law requires CMS to assess fees to cover all costs of administering the program,including registering laboratories,
issuing certificates and conducting onsite surveys,as applicable.
15D2113634 Changes required to your certificate,may be made on the reverse
CARMEL FIRE DEPT side of this form and our
to the state agency listed below.
2 CIVIC SQUARE For more information about CLIA,visit the CMS website at
CARMEL,IN 46032 www.cros.gov/CLIA'or contact the state agency with
any questions.Make payments on-line at www.pay.eov.
State Agency Name and Phone Number to report changes:
INDIANA STATE DEPARTMENT OF HEALTH
DIVISION OF ACUTE CARE SERVICES
2-NORTH MERIDIAN ST RM 4A
INDIANAPOLIS, IN 46204
(317)233-7502
DO NOT SEND PAYMENT TO THE STATE AGENCY
Note: All fees must be paid in full prior to any CLIA inspection or issuance of any CLIA.certificate.Advance billing allows time to
schedule and perform an inspection,if applicable,and allows time to issue the appropriate certificate.When renewing a certificate,if
full payment is not received prior to the begin date of the above certificate period,your current certificate will be terminated and you
may not legally perform testing after this date.Paid Certificates are mailed 30 days prior to the effective date.
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