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HomeMy WebLinkAbout320538 01/11/18 CITY OF CARMEL, INDIANA VENDOR: 365641 !@ i! ONE CIVIC SQUARE ST VINCENT HOSPITAL CHECK AMOUNT: $********75.92* CARMEL, INDIANA 46032 ATT:HIM DEPARTMENT CHECK NUMBER: 320538 9'�+i�TON-�o•a 2001 W 86TH STREET CHECK DATE: 01/11/18 INDIANAPOLIS IN 46260 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4358200 75.92 SPECIAL INVESTIGATION VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) Vendor# 365641 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER ST VINCENT HOSPITAL IN SUM OF$ CITY OF CARMEL ATT: HIM DEPARTMENT An invoice or bill to be properly itemized must show:kind of service,where performed,dates service 2001 W 86TH STREET rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. INDIANAPOLIS, IN 46260 Payee $75.92 ON ACCOUNT OF APPROPRIATION FOR Purchase Order# 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 0 43-582.00 $75.92 1 hereby certify that the attached invoice(s),or 1/3/18 0 medical records $75.92 1110 101 1110 101 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 Monday,January 8,2018 Jim Barlow 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 Submit] %FStNilncent I AICENSION Patient Details: Release of Information Invoice Patient Name: KEVIN RICHARDSON MPI: 210226550 Bill To: Facility: St Vincent Hospital Recipient Name: Judge of the Hamilton Superior Court 6 Address Lina!: 2nd Floor,Hamilton Judicial Center Request Type: AC-Certified Attorney Address Line2: - Statement Date: 20 December 2017 8:50 AM CRY: Noblesville State: IN Postal0p Code: 4606o Country: DOCUMENT SUMMARY Number of Pages: 146 A member of Document Type j:g ®L Documents Pages Number of Documents: 4 LAB REPORT @*�® 4 146 &SCENSION HDA�TM OEC 2 LC�� Payment Type: Payment Date: �-00"E Payment Amount: Cole Values t,Iwi+�Y�10" We are called to: Total Amount: $83.75 Service of the Poor Generosity Certification Fee: Of spirit, Postage Fee: $B,77 especially for Rush Fee: persons ° most in need. Labor Fee: Reverence Supplies Fee: Respect and Discount: $14.60 compassion for Pre-Payment: the dignity and diversity of life. Amount Owing:. $75.92 Integrity Please include a copy of this Inspiring trust through personal invoice with your payment. leadership. Submit Wisdom Integrating excellence and STV stewardship. St Vincent Hospital CERTIFIED Requested Medical Records will be Creativity HIM Department mailed upon receipt of payment Courageous 2001 W 86th Street innovation. Indianapolis,IN 46260 Dedication Phone 317-338-2216 Affirming the Fax 317-338-9559 hope and joy Tax ID 35-0869066 of our ' 29D09-1710-MC-007999 ministry, DOC Document Filed Staff Name: Stephanie 1767999 I l I Staff Title: IIIIIIII�IIII�lllllflll�ll��l�� I �Ill��l