183917 03/29/2010 "e, CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
i ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 CHECK AMOUNT: $4,928.06
324 E NEW YORK ST SUITE 300
_off `o INDIANAPOLIS IN 46204 CHECK NUMBER: 183917
CHECK DATE: 3/29/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340701 12247 4,160.00 MEDICAL EXAM FEES
1110 4340701 12664 768.06 MEDICAL EXAM FEES
4' INVOICE
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
Indianapolis, IN 46204
Carmel Fire Department 1 CARMEFD
F 2 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/2912009
m Invoice 00 -12247
Date Employee Description Amount Balance Due
11/25109 Crane Barry L. Low Back Ortho Eval $80.00 $80.00
Crisler, John H. Low Back Ortho Eval $80,00 $80.0 0
Deitsch Marc W. Low Back Ortho Eval $80.00 $80.00
Love Joseph B. Low Back Ortho Eval $80.00 $80.00
Medlen Michael J. Low Back Ortho Eval $80.00 $80.D0
S elbrin James E. Low Back Ortho Eval 80.00 80.00
11130109 Buttler James N. Low Back Ortho Eval $80.OD $80.0 0
DeLong, Michael T. Low Back Ortho Eval $80.00 $80,0 0
Horner David W. Low Back Ortho Eval $80.00 $80.00
Paddock Ronald D. Low Back Ortho Eval $80.00 $80.00
Small Thomas D. Low Back Ortho Eval $8000 $80.
Stroup, Scott A. Low Back Ortho Eval $80.00 $80.00
12/01/09 Brant Kenneth E. Low Back Ortho Eval $80.00 $80.00
Ca shave Jeffrey A. Low Back Ortho Eval $BO.00 $80.00
Davis James M. Low Back Ortho Eval 80.00 $80.00
Ellison. Christopher M. Low Back Ortho Eval $80.00 $80.00
Haymaker, Samuel K. Low Back Ortho Eval $80.00 $80.0 0
Mead David L. Low Back Ortho Eval 180.00 $80.00
Osborne Scott K. Low Back Ortho Eval $80.00 80.00
Sharp, Adam C. Low Back Ortho Eval $80,00 $80.00
Steele Jeffrey A. Low Back Ortho Eval $80.00 $80. 00
12/03/09 Baskerville Steven P. Low Back Ortho Eval $80.00 S80.0 0
E x Low Back Ortho Eval $80.0
Frenzel, Eric C. Low Back Ortho Eval $80.00 $80.00
Gu el Mark E. Low Back Ortho Eval $80.00 $80.00
Hutchison Brian P. Low Back Ortho Eval $80.00 $80,00
Lenze Theodore A. Low Back Ortho Eval $80.00 $80.00
t rson Vernon A. Low Back Ortho Eval 80.00 80.0 mer Charles J. Low Back Ortho Eval 80.00 80.00
u Kent C. Low Back Ortho Eval 80.00 80.00
n Brad A. Low Back Ortho Eval $80,00 $80.00
Callahan Mark Low Back Ortho Eval 80.00 $80.0 0
Foster James R Low Back Ortho Eval 80.00 $80.0 0
H rrin ton Adam C. Low Back Ortho Eval $80. $80
Hensle y. Robert P. Low Bapk Ortho Eval $80.00 $80.00
Payne Thomas C. Low Back Ortho Eval $80.00 $80.00
Phillips Craig M. Low Back Ortho Eval $80.00 $80.00
Platt, Jace P. Low Back Ortho Eva! $80.00 $80.00
Reeves Stephen J. Low Back Ortho Eva[ $80.00 $80.00
12/09/09 F e. Steven R. Low Back Ortho Eval $80.00 $80.00
Haboush David G. Low Back Ortho Eval $80.00 $80.0 0
Ryan, Christopher D. Low Back Ortho Eval $80.00 80.00
Low Back Ortho Eval $80.00 $80.00
Steele Jeffrey A. Low Back Ortho Eval 80.00 $80.0 0
Stindle Kevin P. Low Back Ortho Eval $80.00 80.00
12115!09 Fa in Timothy D. Low Back Ortho Eval 80.00 $80.1
INVOICE
0 Public Safety Medical Services
t 324 E. New York Street
E Suite 300
m Indianapolis, IN 46204
Carmel Fire Department f CARMEFD Terms
F 2 Civic Square Invoice Date 12/29/2009
M Carmel, IN 46032
Invoice 00 -12247
Date Employee Description Amount Balance Due
12/21/09 Bailev, Mark E. Low Back Ortho Eval $BO.00 $80.0 0
Brandt Gary D. Low Back Ortho Eval $80.00 80.00
Cox Justin M. Low Back Ortho Eval 80.00 180.0 0
D fek Gary J. Low Back Ortho Eval $80.00 0
Mason, Bryan L. Low Back Ortho Eval $80.00 $80.00
Utzi Chad M. Low Back Ortho Eval $80.00 $80.00
Total Charges 1 $4,160:001
Total Payments &Balance Due,- $D.00 $4,160.0D
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 dad's from Invoice
date
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))
12247 $4,160.00
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
VOUCHER NO. WARRANT NO.
Public Safety Medical Services ALLOWED 20
IN SUM OF
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$4,160.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO4 Dept. INVOICE NO. ACCT /TITLE AMOUNT
Board Members
1120 12247 43 407.01 $4,160.00 1 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
MAR 2 S ??1�
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
Ix Indianapolis, IN 46204
Carmel Police Department 1 CARMEPD Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 03/24/2010
m Invoice 00 -12664
Date Employee Description Amount Balance Due
03/15/10 Collins, Willie H. CMP $15.30 $15.30
CBC WlDiff And Plat $12.24 12.24
Lipid Panel $15.30 1530
Veni uncture Fee 3.06 $3.06
HIV 1 2 $13.26 $13.26
PSA $35.70 $35.70
Quantiferon Tb Gold $51.00 51.00
Flaming, Anna G. HB SAb Quantitative Titer $35.70 $35,70
Hasty, Zachery R. CMP $15.30 $15.3 0
CBC W /Diff And Plat S12,24 $12.24
Lipi Panel $15.30 15.30
Veni uncture Fee $3.06 $3.06
HIV 1 2 $13.26 $13.26
Quantiferon Tb Gold $51.00 $51.0 0
HB SAb Quantitative Titer 3570 $35.70
Jent. Danny N. CMP $15.30 1530
CBC W /Diff And Plat $12.24 12.24
Lipid Panel 15.30 $15.30
Veni uncture F 3.D6 $3.0
H 1 2 13.26 113.26
uantiferon Tb Gold $51.00 51.00
Robbins Todd CMP 15,3G 15.30
Q BC W Diff And Plat $12. $12.24
Lipid Panel $15.30 $15.30
Veni uncture Fee $3.06 $3.06
HIV 1 &2 $13.26 $13.26
Quantiferon Tb Gold $51,00 $51.00
VanNatter Shane R. CMP $1530 $15.30
CBC WlDiffAnd Plat $12.24 $12.24
Lipid Panel $15.30 15.30
Veni uncture Fee $3.06 $3.06
HIV 1 2 1 113.26 $13.26
Quantiferon Tb Gold 51.00 $51.0 0
03118(10 Dietz Aaron K. GMP $15.30 $15.3 0
CBC W Diff And Plat S12.24 $12.24
L4 id Panel $15.30 $15.30
Veni uncture Fee $3.06 $3.06
HIV 1 &2 $13,26 $13.26
Quantiferon Tb Goid $51.00 $51.00
Total Charges $768.06
Total Payments Balance Due $0.00 $768.06
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from Invoice
date
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
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))
3/24/10 12664 payment for officer physicals 768.06
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
P ublic Safety Medical Services IN SUM OF
324 E. New York street, Suite 300
Indianapolis, IN 46204
768.06
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1110 12664 407 01 768.06 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
�A
March 26 20 1.0
Signature
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund