305763 12/07/16 ,Coq .
4+ �f
,z% ,J CITY OF CARMEL, INDIANA VENDOR: 355031
j; ® `I ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH%19ROK AMOUNT: $...*.**282,00*
,� CARMEL, INDIANA 46032 7169 SOLUTION CENTER CHECK NUMBER: 305763
+,,,.,_, CHICAGO IL 60677.7001 CHECK DATE: 12/07/16
ETON�
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 473242 282.00 MEDICAL FEES
Voucher No. Warrant No.
355031 Community Occupational Health Services Allowed 20
7169 Solution Center
Chicago, IL 60677-7001
In Sum of$
$ 282.00
ON ACCOUNT OF APPROPRIATION FOR
108 ESE
PO#or INVOICE NO. ACCT#/TITLE AMOUNT Board Members
Dept#
1081-99 473242 4340700 $ 282.00 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
November 30, 2016
Signature
$ 282.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
C,mm,rnty Occupatignal hiealth Sus r
� �1�2Solufsiori_Center`
f' Chica �—
D
Phone. 317-621-0341
FEIN: 35-1955223 NOV 21 2010
Y:
Invoice
jg,ov
Bill to: Lynn Russell For: Carmel Clay Parks &Recreation
Carmel Clay Parks &Recreation 11/16
1411 E. 116th St.
Carmel, IN 46032-
nvoice#� 473242
..._......._..._........_............._................._.... _....w._.._..._.w......__.___.__....._._. --
Proc Code ICD Date Description Qtv Charge Receipt Adjust Balance
746404 11/04/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Summer Church Balance Due: 47.00
746404 1) 11/02/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
S30.81IA
2)
Y04.1 XXA
Nathaniel Hillyer Balance Due: 47.00
746404 11/09/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Tracy L McQueen Balance Due: 47.00
746404 11/09/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Jarrod W Moon Balance Due: 47.00
746404 11/04/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Chelsea L Redmond Balance Due: 47.00
746404 11/11/2016 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Jeremiah A Ward Balance Due: 47.00
Invoia 4 473242 Balance Due:. 282 0
Please remit payment promptly