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HomeMy WebLinkAbout319471 12/12/2017 �• CITY OF CARMEL, INDIANA VENDOR: 370673 f5 ONE CIVIC SQUARE CLIA LABORATORY PROGRAM CHECK AMOUNT: $***""150.00` CARMEL, INDIANA 46032 PO BOX 530882 CHECK NUMBER: 319471 vM, ATLANTA GA 30353-0882 CHECK DATE: 12/12/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 252 5023990 15D2113634 150.00 OTHER EXPENSES VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995), ALLOWED 20 ACCOUNTS PAYABLE VOUCHER Vendor# 370673 CLIA LABORATORY PROGRAM IN SUM OF$ CITY OF CARMEL PO BOX 530882 An invoice or bill to be properly itemized must show:kind of service,where performed,dates service rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. ATLANTA, GA 30353-0882 Payee $150.00 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 12/8/17 15/32113634 $150.00 1120 252 1120 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 Friday, December 08,2017 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 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 05/26/2018-05/25/2020 Payment Due Date 01/12/2018 Total Payment Due $150.00 CURRENT CHARGES Bill Date Description Amount 11/28/2017 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 Any required changes to your certificate,must be mailed to CARMEL FIRE DEPT the state agency listed below. 2 CIVIC SQUARE For more information about CLIA,visit the CMS website at CARMEL,IN 46032 www.cros.govlCLIA or contact the state agency with any questions. 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. Fnrm C'MS-RS(i1R/111