331264 10/17/18 +or_c�q�
CITY OF CARMEL, INDIANA VENDOR: 370269
/ \f\ ONE CIVIC SQUARE ZIRMED CHECK AMOUNT: $*******352.25*
�� CARMEL, INDIANA 46032 1311 SOLUTIONS CENTER CHECK NUMBER: 331264
9M,()UN G�d; CHICAGO IL 60677-1311 CHECK DATE: 10/17/18
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4355200 746996 352.25 SUBSCRIPTIONS
VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995)
ALLOWED 20 ACCOUNTS PAYABLE VOUCHER
Vendor# 370269
ZIRMED IN SUM OF$ CITY OF CARMEL
1311 SOLUTIONS CENTER 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.
CHICAGO, IL 60677-1311
Payee
$352.25
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
746996 43-552.00 $352.25 1 hereby certify that the attached invoice(s),or 10/12/18 746996 Billing Fees $352.25
1120 101 1120 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
Friday,October 12,2018
David Haboush
Fire Chief
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
INVOICE Date 10/10/2018
,d.'k sy�� � A U S T A R Invoice# 746996
T Account# 125191
gHJJEHy4 ;YCLL T9CHIJOLOGY For overnight or Due Date 11/9/2018
correspondence ONLY: Customer PO#
Invoice questions?Please call Shipping Code(2)
Waystar
1-844-4WAYSTAR(492-9782) (Option 3) WayAttn: Accounting Dept
Email:billinginquiry@waystar.com 888 W.Market St., Ste 400 -��-za" —6,-sLouisville, KY 40202 Amount Paid
Bill To PLEASE REMIT ONLY PAYMENTS
City of Carmel Fire Department TO THE FOLLOWING:
2 Civic Square ZirMed
Carmel IN 46032 1311 Solutions Center
Chicago, IL 60677-1311
,rte
125191 Zirmed 746996 10/10/2018 11/9/2018
Monthly Professional Claims Management Fee 1 99.00 99.00
Monthly Eligibility System Access Fee 1 100.00 100.00
Monthly Remittance Advice Access Fee 1 25.00 25.00
Patient Payments-Virtual Terminal Fee 1 25.00 25.00
Patient Payments Ecommerce Monthly Portal Fee 1 49.00 49.00
ACH Transaction Fee 60 0.50 30.00
ACH Verification Fee 57 0.25 14.25
ACH Return Fee 2 5.00 10.00
Invoice Total $352.25
352.25 0.00 0.00 0.00 0.00 $352.25
Would you like your invoice via email? Please email billinginquiry@waystar.com