187420 07/07/2010 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $2,748.60
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 187420
CHECK DATE: 717/2010
DEPARTMENT A CCOUNT PO NUMBER IN VOICE NUMBE AMOUNT DESCRIPTION
1110 4340701 13115 2,748.60 MEDICAL EXAM FEES
INVOICE
Io Public Safety Medical Services
324 E. New York Street
E Suite 300
X Indianapolis, IN 46204
G Carmel Police Department CARMEPD
Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 06122!2010
O f Invoice 00 -13115
Date Employee Description Amount Balance Due
06114110 Dunlap, Christo her T. Comprehensive Physical $92.82 $92.82
OnMed Program $0.00 $0,00
Res iratorlMedical Review $16.32 $16.32
Health Risk Appraisal Motivation 16.32 $16.32
BIA Bio -Elec Im ed Anal 14.28 $14.28
Flexibility Check $10.20 $10.2 0
Waist/Hi Ratio $3.06 $3.06
Treadmill (PFE) $156.00 156.00
Tonometry $36.72 $36.72
Vital Si ns HT WT BP P R $7.14 $7.14
V' i Titmus $26.
PFT W/Interp $33.66 $33.66
Audiometry 14.28 $14.28
ECG W/ Interp $20.40 $20.40
Urinal sis Dipstick $3, 06 $3.06
Fleming Anna G. Comprehensive Physical $92.82 92.82
OnMed Program $0. 00 $0,00
Res iratorNedical Review $16.32 $16.32
Health Risk Appraisal Motivation 16.32 $16.32
BIA Bio -Elec Im ed Anal 14.28 $14.28
Flexibility Check $10.20 $10.2 0
Waistfflb Ratio $3.06 $3.06
Treadmill (PFE) $156.00 $156.00
Tonometry $36.72 $36.72
Vital Signs HT WT BP P R $7.14 $7.14
Vision Titmus $26.52 $26.52
PFT W/Interp $33.66 $33.66
Audiometry 14.28 $14,28
ECG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 $3,06
Lovitt Richard A. CMP $15.30 $15.30
CBC W /Dill And Plat 1224 $12.24
Li id Panel $15.30 $15.3 0
Venipunc $3,06
HIV 1 2 13.26 $13
Quantiferon Tb Gold $51.00 $51.00
Martin Brian A. Comprehensive Physical $92.82 $92.82
OnMed Program $0.00 $0.00
Respirator/Medical Review 16.32 $16.32
Health Risk Appraisal Motivation 16.32 $16.32
BIA Bio -Elec Im ed Ana! 14.28 $14.28
Flexibility Check $10.20 $10.2 0
Waist/Hi Ratio $3.06 $3.06
Muscle Strength Endurance $26.52 26.52
Treadmill (PFE) $156.00 156.00
Vital Signs 7 HT WT BP P R $7.14 7.14
r,
INVOICE
0 Public Safety Medical Services
324 E. New York Street
'E Suite 300
Indianapolis, IN 46204
c Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 06/22/2010
Invoice 00 -13115
Date Employee Description Amount Balance Due
Vision Titmus $26.52 $26.52
Audiametry $14.28 $14.28
ECG W/ Interp $20.40 $20.40
U rinalysis Dipstick
Pans Mark J. CMP $15.30 $15.30
CBC W /Dill And Plat $12.24 $12.24
Li id Panel $15.30 $15.30
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
Renforth Trevor M. CMP 1530 $15.301
CBC W /Dill And Plat $12.24 1224
Lipid Panel $15,30 $15.3 0
Veni uncture Fee $3.06 $3.06
HIV 1 2 $13.26 $13.26
Quantiferon Tb Gold $51.00 $51.00
HB SAb Quantitative Titer $35.70 $35.70
Comprehensive Physical $92.82 $92.82
Health Risk Appraisal Motivation $16.32 $16.32
OnMed Program $0.00 0.00
Respirator/Medical Review $16,32 $16.32
BIA Bio -El ec Im ed Anal 14.28 $14.28
Flexibility Check $10.20 $10.201
Waist/Hi Ratio $3.06 $3.06
Muscle Strength Endurance $26.52 26.52
Treadmill (PFE) $156.00 $156.00
Tonomet .72 $36.72
Vital Signs HT WT BP P R $7.14 $7.14
Vision Titmus $26.52 $26.52
PFT W/Interp $33.66 $33.66
Audiornetry $14.28 14.28
ECG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 3.06
Smith Troy D. OnMed Program $0.00 $0.00
Respirator/Medical Review $16,32 $16.32
Health Risk Appraisal Motivation 16.32 $16.32
BIA f Bio -Elec Im ed Anal 14.28 $14.28
Flexibility h k $10.20 $10.2
W Rati
Treadmill (PFE) $156.00 $156.00
Tonornetry $36.72 $36.72
Vital Si ns HT WT BP P R $7.14 $7.14
Vision Titmus $26,52 $26.52
PFT W/Interp $33.66 33.66
Audiometry 14.28 $14.28
ECG W/ Interp $20,40 $20.40
w
INVOICE
0, Public Safety Medical Services
324 E. New York Street
E Suite 300
i Indianapolis, IN 46204
0
Carmel Police Department I CARMEPD Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 06122!2010
,m Invoice 00 -13115
Date Employee Description Amount Balance Due
Urinalysis Dipstick $3.06 $3.06
Comprehensive Physical $92.82 $92.82
06116/10 Martin Brian A. CMP $15.30 $15.3 0
CBC WlDiff And Plat $12.24 $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
Total Charges $2,748;60
Total Payments Balance Due ->i $OAO $2,748.60
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date
PreG;�ibed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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))
6/22/10 13115 Payment for officer physicals 2,748. 0
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
Public Safety Med al S rviceR IN SUM OF
324 E. new York street, Suite 300
Indianapolis, IN 46204
2,748.60
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
Po#t or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1110 13115 407 -01 2,748. 0 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
July 1 20 10
Signature
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund