HomeMy WebLinkAbout313685 07/18/17 `� ��'b CITY OF CARMEL, INDIANA VENDOR: 355031
�O ONE CIVIC SQUARE COMMUNITY OCCUPATIONAL HEALTH WAQK AMOUNT: $********94.00*
,?4 CARMEL, INDIANA 46032 7169 SOLUTION CENTER CHECK NUMBER: 313685
_Sy..o„- . CHICAGO IL 60677-7001 CHECK DATE: 07/18/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 495897 94.00 MEDICAL FEES
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t Community Occupational Health Svs
7169 Solution Center
Chicago, IL 60677-7001 F X Tf'�
Phone: 317-621-0341
FEIN: 35-1955223 AL 1 2017
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Invoice
July 05, 2017
Bill to: Lynn Russell For: Carmel Clay Parks & Recreation
Carmel Clay Parks &Recreation 06/17
1411 E. 116th St.
Carmel, IN 46032-
- Invoice# 495897
Proc Code ICD Date Description Qt( Chancre Receipt Adjust Balance
746404 1) 06/22/2017 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
580.01XA
2)Y93.F9
Katherine M Bentivoglio Balance Due: 47.00
746404 06/20/2017 Drug Screen-Non NIDA 5 Panel 1.00 47.00 47.00
Eve Weifenbach Balance Due: 47.00
Invoice# 495897 Balance Due: 94.00
Please remit payment promptly
.. Cut and return with payment