181365 01/13/2010 t‘f CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $7,966.00
t 't ii CARMEL, INDIANA 46032 3 2 4 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 181365
CHECK DATE: 1/1312010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340701 12250 4,340.00 MEDICAL EXAM FEES
1110 4340701 12251 3,626.00 MEDICAL EXAM FEES
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
IY Indianapolis, IN 46204
o Carmel Fire Department CARMEFD
I 2 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/30/2009
m Invoice 00 -12250
Date Employee Description Amount Balance Due
12/11/09 Bondurant, Jeff S. Funct Move Screen $70.00 $70.00
Collins, Tony A. Funct Move Screen $70.00 $70.00
Conner, Timothy L. Funct Move Screen $70.00 $70.0D
Cromlich. Mark A. Funct Move Screen $70.00 $70.00
DeCrastos, Richard A. Funct Move Screen $70.00 $70.00
DeLonq, Michael T. Funct Move Screen $70.00 $70.00
Edwards, Steven L. Funct Move Screen $70.00 $70.00
Faqin, Timothy D. Funct Move Screen $70.00 $70.00
Gipson, Bruce E. Funct Move Screen $70.00 $70.00
Holden, Adam D. Funct Move Screen $70.00 $70.00
Hughes, Chad L. Funct Move Screen $70.00 $70.00
Lux, Michael T. Funct Move Screen $70.00 $70.00
McNab, John D. Funct Move Screen $70.00 $70.00
Paddock, Ronald D. Funct Move Screen $70.00 $70.00
Reeves, Neil P. Funct Move Screen $70.00 $70.00
Ryan, Christopher D. Funct Move Screen $70.00 $70.00
Smith, Brian E. Funct Move Screen $70.00 $70.00
Young, Kevin M. Funct Move Screen $70.00 $70.00
12/22/09 Allen, Brad A. Funct Move Screen $70.00 $70.00
Baskerville, Anthony A. Funct Move Screen $70.00 $70.00
Castor, Rick S. Funct Move Screen $70.00 $70.00
Crane, Barry L. Funct Move Screen $70.00 $70.00
Crisler, John H. Funct Move Screen $70.00 $70.00
Deitsch, Marc W. Funct Move Screen 570.00 $70.00
Edwards, Daniel E. Funct Move Screen 570.00 $70.00
Fisher, Gary L. Funct Move Screen $70.00 $70.00
Grimes, Jeffrey A. Funct Move Screen $70.00 $70.00
Harrington, Adam C. Funct Move Screen $70.00 $70.00
Haus, Joshua S. Funct Move Screen $70.00 $70.00
Love, Joseph B. Funct Move Screen $70.00 $70.00
Mead Jr, Donald R. Funct Move Screen $70.00 $70.00
Medien, Michael J. Funct Move Screen $70.00 $70.00
Mitchell. James C. Funct Move Screen $70.00 $70.00
Payne, Thomas C. Funct Move Screen $70.00 $70.00
Phillips. Craia M. Funct Move Screen $70.00 570,00
Reeves, Stephen J. Funct Move Screen $70.00 $70.00
Reppert, Ian T. Funct Move Screen $70.00 $70.00
Robinson, Mark G. Funct Move Screen $70.00 $70.00
Robinson, Mitchell L. Funct Move Screen $70.00 $70.00
Rohr, Christopher M. Funct Move Screen $70.00 $70.00
Spelbrinq, James E. Funct Move Screen $70.00 $70.00
Thompson. James L. Funct Move Screen $70.00 $70.00
Viehe, Richard E. Funct Move Screen $70.00 $70.00
Wvant, Andrew D. Funct Move Screen $70.00 $70.00
12123/09 Benbow. Kip S. Funct Move Screen 570.00 $70.00
Cox, Justin M. Funct Move Screen $70.00 $70.00
INVOICE
o Public Safety Medical Services
a 324 E. New York Street
E Suite 300
C4 Indianapolis, IN 46204
o Carmel Fire Department CARMEFD
I 2 Civic Square Terms
C armel, IN 46032 Invoice Date 12/30/2009
Invoice 00 -12250
Date J Employee J Description Amount I Balance Due
Essex, Cory C. Funct Move Screen $70.00 $70.00
Frenzel, Eric C. Funct Move Screen $70.00 $70.00
Haymaker. Samuel K. Funct Move Screen $7000 $70.00
Hoover, Anthony B. Funct Move Screen $70.00 $70.00
Martin, David D. Funct Move Screen $70.00 $70.00
Mulford, David A. Funct Move Screen $70.00 $70.00
Nicley. Wes W. Funct Move Screen $70.00 $70.00
Osborne, Scott K. Funct Move Screen $70.00 $70,00
Ray, Lucas M. Funct Move Screen $70.00 $70.00
Schooler, Dustin D. Funct Move Screen $70.00 $70.00
Sombke, Brad D. Funct Move Screen $70.00 $70.00
Sutton, Sean B. Funct Move Screen $70.00 $70.00
Toney, James D. Funct Move Screen $70.00 $70.00
Whitaker, Charles E. Funct Move Screen $70.00 $70.00
Witsken. Steven J. Funct Move Screen $70.00 $70.00
Young, Andrew S. Funct Move Screen $70.00 $70.00
Total Charges $4,340.00
Total Payments Balance Due $0.00 $4,340.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$4,340.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO ACCT #!TITLE AMOUNT Board Members
1120 12250 43 -407.01 $4,340.00 I 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
JAN 1 1 2010
1 I
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
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.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12250 $4,340.00
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
Clerk- Treasurer
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
a Indianapolis, IN 46204
0 Carmel Police Department/ CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/30/2009
03 Invoice 00 -12251
Date Employee Description Amount Balance Due
12/17/09 McAllister, John W. CMP $16.00 $16.00
CBC W /DiffAnd Plat $13.00 $13.00
Lipid Panel $16.00 $16.00
Venipuncture Fee $3.00 $3.00
HIV 1 2 $13.00 $13.00
PSA $35.00 $35.00
Quantiferon Tb Gold $50.00 $50.00
HB SAb Quantitative Titer $35.00 $35.00
12/21/09 Barlow, James C. No -Show Fee $0.00 $0.00
Bickel. Joseph E. CMP $16.00 $16.00
CBC W /Diff And Plat $13.00 $13.00
Lipid Panel $16.00 $16.00
Venipuncture Fee $3.00 $3.00
HIV 1 2 $13.00 $13.00
HB SAb Quantitative Titer $35.00 $35.00
Quantiferon Tb Gold $50.00 $50.00
Gilbert, William J. Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.00 $16.00
OnMed Program $0.00 $0.00
Respirator /Medical Review $16.00 $16.00
BIA (Bio -Elec Imped Analv) $14.00 $14.00
Waist/Hio Ratio $3.00 $3.00
Muscle Strength Endurance $26.00 $26.00
Flexibility Check $10.00 $10.00
Treadmill (PFE) $153.00 $153.00
Vital Signs HT WT BP P R $7.00 $7.00
Vision Titmus $26.00 $26.00
PFT W /Interp $33.00 $33.00
Audiometry $14.00 $14.00
ECG W/ Interp $20.00 $20.00
Urinalysis Dipstick $3.00 $3.00
Keith, Brett A. Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.00 $16.00
OnMed Program $0.00 $0.00
Respirator /Medical Review $16.00 $16.00
Vital Signs HT WT BP P R $7.00 $7.00
Vision Titmus $26.00 $26.00
Audiometry $14.00 $14.00
ECG W/ Interp $20.00 $20.00
Urinalysis Dipstick $3.00 $3.00
Flexibility Check $10 00 $10.00
Waist/Hip Ratio $3.00 j3.00
Treadmill (PFE) $153.00 $153.00
McAllister, John W. Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.00 $16.00
OnMed Program $0.00 $0.00
INVOICE
O Public Safety Medical Services
324 E. New York Street
E Suite 300
ct Indianapolis, IN 46204
e Carmel Police Department CARMEPD
I 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/30/2009
c0 Invoice 00 -12251
Date I Employee Description I Amount I Balance Due
Respirator /Medical Review $16.00 $16.00
BIA (Bio -Elec Imped Analv) $14.00 $14.00
Waist/Hip Ratio $3.00 $3.00
Flexibility Check $10.00 $10.00
Treadmill (PFE) $153.00 $153.00
Hemoccult $5.00 $5.00
Vital Signs HT WT BP P R $7.00 $7.00
Vision Titmus $26.00 $26.00
Audiometry $14.00 $14.00
ECG W/ Interp $20.00 $20.00
Urinalysis Dipstick $3.00 $3.00
McNair, Harland J. _Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.00 $16.00
OnMed Program $0.00 $0.00
Respirator /Medical Review $16.00 $16.00
BIA (Bio -Elec Imped Analv) $14.00 $14.00
Flexibility Check $10.00 $10.00
Waist/Hip Ratio $3.00 $3.00
Muscle Strength Endurance $26.00 $26.00
Treadmill (PFE) $153.00 $153.00
Vital Signs HT WT BP P R $7.00 $7.00
Vision Titmus $26.00 $26.00
PFT W /Interp $33.00 $33.00
Audiometry $14.00 $14.00
ECG W/ Intern $20.00 $20.00
Urinalysis Dipstick $3.00 $3.00
Myers. Brady R. Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.Q0 $16.00
OnMed Program $0.00 $0.00
Respirator /Medical Review $16.00 $16.00
Flexibility Check $10.00 $10.00
Waist/Hip Ratio $3.00 $3.00
Treadmill (PFE) $153.00 $153.00
Vital Signs HT WT BP P R $7.00 $7.00
Vision Titmus $26.00 $26.00
PFT W /Interp $33.00 $33.00
Audiometry $14.00 $14.00
ECG W/ Intern $20.00 $20.00
Urinalysis Dipstick $3.00 $3.00
Schalburg, Randy S. CMP $16.00 $16.00
CBC W /Diff And Plat $13.00 $13.00
Lipid Panel $16.00 $16.00
Venipuncture Fee $3.00 $3.00
HIV 1 2 $13.00 $13.00
PSA $35.00 $35.00
Quantiferon Tb Gold $50.00 $50.00
HB SAb Quantitative Titer $35.00 $35.00
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
'IX Indianapolis, IN 46204
Carmel Police Department CARMEPD
F 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 12!30/2009
m Invoice 00 -12251
,Date Employee Description Amount Balance Due
Spillman, R. Scott Comprehensive Physical $91.00 $91.00
Health Risk Appraisal (Motivation) $16.00 $16.00
OnMed Program 50.00 $0.00
Respirator /Medical Review $16.00 $16.00
BIA (Bio -Elec Imped Analy) $14.00 $14.00
,Flexibility Check $10.00 $10.00
Waist /Hip Ratio $3.00 $3.00
Treadmill (PFE) j153.00 $153.00
Vital Signs HT WT BP P R $7.00 57,00,
Vision Titmus $26.00 $26.00
PFT W /lnterp $33.00 $33.00
Audiometry $14.00 $14.00
1 ECG W/ lnterp 520.00 $20.00
Urinalysis Dipstick $3.00 $3.00
Stites, William R. CMP $16.00 516.00
CBC W /DiffAnd Plat $13.00 $13.00
Lipid Panel $16.00 $16.00
Venipuncture Fee $3.00 $3.00
HIV 1 2 $13.00 $13.00
HB SAb Quantitative Titer $35.00 $35.00
Quantiferon Tb Gold 550.00 $50.00
PSA $35.00 $35.00
Zellers. Nancy L. Comprehensive Physical $91.00 $91.00
OnMed Program $0.00 $0.00
Respirator /Medical Review $16.00 $16.00
Health Risk Appraisal (Motivation) $16.00 $16.00
Flexibility Check $10.00 $10.00
Waist /Hip Ratio $3.00 $3.00
Treadmill (PFE) $153.00 $153.00
Vital Signs HT WT BP P R _7.00 $7.00
Vision Titmus $26.00 $26.00
PFT W /lnterp $33.00 $33.00
Audiometry $14.00 $14.00
ECG W/ lnterp $20.00 520.00
Urinalysis Dipstick $3.00 $3.00
Zellers, Timothy V. CMP $16.00 $16.00
CBC W /DiffAnd Plat $13.00 $13.00
Lipid Panel $16.00 $16.00
Venipuncture Fee $3.00 53.00
HIV 1 2 $13.00 $13.00
PSA $35.00 $35.00
Quantiferon Tb Gold $50.00 $50.00
Total Charges $3,626.00
Total Payments Balance Due $0.00 $3,626.00
Please write invoice number on payment check.
Balance due 15 days from invoice
date
t INVOICE
t o Public Safety Medical Services
324 E. New York Street
E Suite 300
c4 Indianapolis, IN 46204
o Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/30/2009
Invoice 00 -12251
Date Employee 1 Description I Amount I Balance Due
Our Federal Employer Identification Number is 35- 2079797
Press 1bed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
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.
Payee
Public Safety Medical Services Purchase Order No.
324 E. New York street, Suite 300 Terms
Indianapolis, IN 46204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/30/09 12251 payment for officer physicals 3.626.00
Total
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
Clerk- Treasurer
VO NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services IN SUM OF
324 E. New York street, Suite 300
Indianapolis, IN 46204
3,626.00
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
PO# or INVOICE NO ACCT #/TITLE AMOUNT hereby certify invoice(s), I hereb certi that the attached invoices or
1110 12251 407 01 3,626.00 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
January 6 20 10
.b D
Signature
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund