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Home My WebLink About301151 07/25/16 eCHECCITY OF CARMEL, INDIANA VENDOR: 365641 K AMOUNT: $***'""353.00• ONE CIVIC SQUARE ST VINCENT HOSPITAL CARMEL, INDIANA 46032 HIS,ATTN:RELEASE OF INFORMATION CHECK NUMBER: 301 151 9�'fr6 2001 W 86TH STREET,PO Box 40970 CHECK DATE: 07/25/16 INDIANAPOLIS IN 46209 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4358200 1217048 64.75 SPECIAL INVESTIGATION 1110 4358200 1234775 65.25 SPECIAL INVESTIGATION 1110 4358200 13657386 151.00 SPECIAL INVESTIGATION 1110 4358200 13761771 72.00 SPECIAL INVESTIGATION VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) ST VINCENT HOSPITAL ALLOWED 20 ACCOUNTS PAYABLE VOUCHER HIS, ATTN: RELEASE OF INFORMATION IN SUM OF$ CITY OF CARMEL . 2001 W 86TH STREET, PO BOX 40970 An invoice or bill to be properly itemized must show:kind of service,where performed,dates service INDIANAPOLIS, IN 46209 rendered,by whom,rates per day,number of hour;,rate per hour,number of units,price per unit,etc. $353.00 Payee Purchase Order# ON ACCOUNT OF APPROPRIATION FOR Carmel Police 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 MPI#13761771 43-582.00 $72.00 1 hereby certify that the attached invoice(s),or 6/27/16 MPI#13761771 medical records for case#16-37315 $72.00 1110 101 1110 101 MPI#1217048 43-582.00 $64.75 bill(s)is(are)true and correct and that the 6/27/16 MPI#1217048 medical records for case#16-37315 $64.75 1110 101 materials or services itemized thereon for 1110 101 MPI#13657386 43-582.00 $151.00 6/29/16 MPI#13657386 medical records for case#16-37315 $151.00 1110 101 which charge is made were ordered and 1110 101 MPI#1234775 43-582.00 $65.25 received except 6/30/16 MPI#1234775 medical records for case#16-37315 $65.25 1110 101 1110 101 r ~ r Thursday,July 14,2016 Tim Green Chief of Police '- �`'`` 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 distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer T_NV0_ _1_CE_. St Vincent Health DATE:JUNE 30,2016 2001 W 86th Street MPI# 1234775 Indianapolis,IN 46260 317-338-2216 317-338-9559 TO Hamilton Co Prosecuting Attorney Attn.: Detective Nancy Zellers 3 Civic Square Carmel,IN 46032 NAME JUSTIN J KECK —- -- #pages 57 Copy charge - - $41.75 Postage $3.50 I Rush Fee Certification $20.00 Fee Discount Total Due ---rr— ---'- ---_-- $65.25--- Make all checks-payable to St Vincent Health Credit card payments may be made by phone 317-338-2216 Thank you for your business! 4"p . mcent Release of Information Statement Bill To: Patient Details: Recipient Name: Prosecuting Attorney of Hamilton County Patient Name: ANNA KATHLEEN HOOVER Address Line1: Detective Nancy Zellers,Carmel Police Department MPI: 13657386 Address Line2: 3 Civic Square FILE/CLAIM#: City: Carmel State: IN Statement Date: 06/29/2016 Postal/Zip Code: 46032 Country: DOCUMENT SUMMARY Number of Pages: 361 Document Type Documents Pages I I DISCHARGE SUMMARY 1 2 0 MEDICATION RECORD 1 6 } RADIOLOGY REPORT 10 18 EMERGENCY RECORD 4 12 1 Total Amount: $137.50 H&P - PROGRESS NOTES 4 18 CONSENT 2 6 INTERDISCIPLINARY ASSESSMENT 2 3 Rush Fee: $13.50 CUMULATIVE DATA 2 17 I MISCELLANEOUS 5 114 PATIENT INSTRUCTIONS 4 22 ORDERS 2 34 Pre-Payment:. j REGISTRATION SHEET 4 4 LAB REPORT 2 22 PATIENT HLTH PROFILE 1 8 i Amount Owing: $151.00 TREATMENT FLOWSHEET 1 9 CASE MGMNT/UR 1 1 ER NURSING ASSESSMENT 2 4 ' PROCEDURE REPORT 2 3 Submit } NURSING ASSESSMENT 3 39 I TREATMENT PLAN 1 3 I TEACHING TOOL 1 1 } H&P (DICTATED) 1 2 4 } SOCIAL SERVICES 1 3 I&0 FLOWSHEET 1 10 f3 j Ii f I 1 + 6 s f� i { ' I i Staff Name: Staff Title: t. recent Release of Information Statement Bill To: Patient Details: Recipient Name: Hamilton Co Prosecuting Attorney Patient Name: KATHERINE DIANE FILIPOWICZ Address Line1: 3 Civic Square MPI: 13761771 Address Line2: Detective Nancy Zellers FILE/CLAIM#: City: Carmel State: IN Statement Date: 06/27/2016 Postal/Zip Code: 46032 Country: - 1 - DOCUMENT SUMMARY Number of Pages: 85 Document Type Documents Pages ORDERS 2 4 RADIOLOGY REPORT 7 13 EMERGENCY RECORD 6 20 EMERGENCY RECORD (DICTATED) 1 2 Total Amount: $68.50 NURSING ASSESSMENT 3 10 CORRESPONDENCE 2 6 REGISTRATION SHEET 2 2 Rush Fee: $3.50 SOCIAL SERVICES 1 1 CONSENT 2 5 INTERDISCIPLINARY ASSESSMENT 2 2 MISCELLANEOUS 3 10 Pre-Payment: ER NURSING ASSESSMENT 1 3 CUMULATIVE DATA 2 4 H&P - PROGRESS NOTES 1 1 Amount Owing: $72.00 MEDICATION RECORD 1 2 Submit Staff Name: Staff Title: t.Vmcent Release of Information Statement Bill To: Patient Details: Recipient Name: Hamilton Co Prosecuting Attorney Patient Name: JONATHAN CARTER MOORMAN Address Line1: 3 Civic Square MPI: 1217048 Address Line2: Detective Nancy Zellers FILEICLAIM#: City: Carmel State: IN Statement Date: 06/27/2016 Postal/Zip Code: 46032 Country: DOCUMENT SUMMARY I Number of Pages: 56 Document Type Documents Pages REGISTRATION SHEET 2 2 EMERGENCY RECORD 5 11 ER NURSING ASSESSMENT 2 4 PROCEDURE REPORT 1 2 Total Amount: $61.25 NURSING ASSESSMENT 2 6 i INTERDISCIPLINARY ASSESSMENT 1 2 MISCELLANEOUS 3 8 Rush Fee: CONSENT 2 6 $3.50 CORRESPONDENCE 1 4 ORDERS 1 1 EMERGENCY RECORD (DICTATED) 1 3 Pre-Payment: CUMULATIVE DATA 1 4 ROI Invoice 1 1 CONSULTS (DICTATED) 1 1 Amount Owing: $64.75 H&P - PROGRESS NOTES 1 1 Submit I I B Staff Name: Staff Title: