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188645 08/11/2010 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1 ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $2,914.86 INDIANAPOLIS IN 46204 CHECK NUMBER: 188645 CHECK DATE: 8/11/2010 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1110 4340701 13293 110.16 MEDICAL EXAM FEES 1110 4340701 13337 2,804.70 MEDICAL EXAM FEES INVOICE o Public Safety Medical Services 324 E. New York Street E Suite 300 tY Indianapolis, IN 46204 O Carmel Police Department 1 CARMEPD 3 Civic Square Terms Carmel, IN 46032 Invoice Date 07/21/2010 m Invoice 00 -13293 Date Employee Description Amount Balance Due 07(14110 Vanderbeck David R. CMP $15.30 $15.30 CBC W]Diff And Plat $12.24 $12.24 Lipid Panel $15,30 $15.3 0 Veni uncture Fee $3.06 $3.06 HIV 1 2 $13,26 1 §13.26 Quantiteron Tb Gold 51.00 $51.00 'Tot, Charges Total Payments Balance Due $0.00 $110.16 Please write invoice number on payment check. Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice date INVOICE i° Public Safety Medical Services 324 E. New York Street E Suite 300 Indianapolis, IN 46204 o Carmel Police Department I CARMEPD 3 Civic Square Terms Carmel, IN 46032 Invoice Date 0712812010 Invoice 00 -13337 Date Employee Description Amount Balance Due 07119110 Byrne, Timothy L CMP $15.30 $15.30 CBC W /Dill And Plat $12,24 112.24 Li id Panel $15,30 $15.30 Veni uncture Fee $3.06 13.06 HIV 1 2 $13.26 $13.26 Quantiferon Tb Gold $51.00 $51.0 0 Grose James E- CMP $15,30 $15.3 0 CBC W /Dill And Plat $12.24 $12.24 Lipid Panel $15.30 $15.3 0 Veni uncture Fee $3.06 $3.06 HIV 1 2 2 $13.26 Quantiferon Tb Gold $51.00 $51.00 Lvtle, Blake A. CMP $15.30 $15.3 0 CBC W /Dill 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 $51.0 0 Mclnt re Trent A. CMP $15.30 $15.3 0 CBC W /Dill And Plat $12.24 $12.24 Li id Panel $15.30 $15.3 0 Veni uncture Fee 3.06 $3.06 Qu antiferon Tb Gold S51. 151, HIV 1 2 $13.26 $13.26 Morrow, Scott A. CMP $15.30 $15.30 CBC W1Diff 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 Quantiferon Tb Gold $51.00 $51.00 07!23110 Byrne, Timothy L. Comprehensive Physical $92.82 $92.82 Health Risk Appraisal Motivation 1 16.32 $16.32 OnMed Program $0.00 $O.OD Respirator/Medical Review $16.32 $16.3 BIA Bio -Elec Imned Analy) 14.28 $14.28 Flexibility Check $10.20 $10.20 Waist/Hi 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 $33.66 333.66 Audiomet 14,28 $14.28 ECG W/ Inte 20.40 $20.40 Urinalysis Dipstick $3.06 $3.06 Grose James E. OnMed Program so.00 0.00 INVOICE 0 Public Safety Medical Services 324 E. New York Street E Suite 300 i Indianapolis, IN 46204 o Carmel Police Department/ CARMEPD 3 Civic Square Terms Carmel, IN 46032 Invoice Date 07128/2010 Invoice 00 -13337 Date Employee Description Amount Balance Due Res irator /Medical Review $16.32 $16.32 BIA Bio -Elec Im ed Anal 14.28 $14.28 Flexibility Check $10.20 $10.2 0 Waist/Hi RatiQ $3.06 $3.0 Treadmill (PFE) $156.00 $156.00 Tonomet $36.72 $36.72 Vital Signs HT WT BP P R $7.14 $7.14 Vision Titmus $26.52- S'8.52 PFT W/Interp $33.66 $33.66 Audiometry 14.28 $14,28 ECG WI Interp $20,40 $20.4 0 Urinalysis Dipstick $3.06 $3.06 Com rehensive Physical $92,82 $92.82 Health Risk Appraisal Motivation 16.32 $16,32 McIntyre, Trent A. Com rehensive 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 Flexibilitv Check $10.20 $10.20 Waist /Hi Ratio $3.06 $3,06 Treadmill (PFE $156.00 $156.00 Tonometa $36.72 $36.72 Vital S4 ns HT WT BP P R $7.14 $7.14 Vision Titmus $26.52 $26.52 PFT W/Interp $33.66 $33.66 Audiomet 14.28 $14.28 ECG W1 Interp 20.40 $20.4 Urinal sis Dipstick $3.06 $3.06 Morrow, Scott A. Comprehensive Physical $92.82 $92.82 Health Risk Appraisal Motivation $16.32 $16.32 OnMed Proaram $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 $10,20 Waist/Hip Ratio $3.06 $3.06 Treadmill (PFE) $156.00 $156.00 Tonomet 36.72 $36.72 V ital Sin 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 W1 Inter $20.40 $20.40 Urinalysis Dipstick $3.06 $3.06 Spillman, R. Scott Comprehensive Physical 92.82 $92.82 OnMed Program $0.00 $0.0o Respirator/Medical Review $16.32 1 $16.32 INVOICE oo Public Safety Medical Services 324 E. New York Street E Suite 300 Indianapolis, IN 46204 C Carmel Police Department/ CARMEPD E' 3 Civic Square Terms Carmel, IN 46032 Invoice Date 07/28/2010 m Invoice 00 -13337 Date Employee Description Amount Balance Due Health Risk Appraisal Motivation $16.32 $16.32 BIA Bio -Elec Im ed Anal $14.28 $14.28 Flexibilit Check $10.20 $10.20 Waist/Hi Ratio $3.06 $3.06 Treadmill (PFE) $156.00 $156.00 Tonomet 36.72 $36.72 Vital Signs HT WT BP P R $7.14 $7.14 Vision Titmus $26.52 $26.52 PFT Wfinterp $33,66 $33.66 Audiornetry $14.28 $14,28 CG W1 In er p $20AQ $20.4 $20A 0 Urinal sis Dipstick $3.06 $106 Total Charges $2,804.70 Total Payments Balance Due $0.00 $2,804.70 Please write invoice number on payment check. Our Federal Employer Identification Number is 35- 2079797 Balance due 15 Clays from invoice date Prescribed by Slate 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)) 7 21 10 13293 payment for officer physicals 110.16 i 3 lj 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 PU1)lic Safety Medical Services IN SUM OF 324 E. New York Street, Suite 300 Indianapolis, IN 46204 ON ACCOUNT OF APPROPRIATION FOR police general fund A 0-y A-I U Board Members I! PO`# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 1110 13293 407 01 110.16 bill(s) is (are) true and correct and that the 1 C) materials or services itemized thereon for which charge is made were ordered and received except July 29 20 10 Signature Chief of Police Title Cost distribution ledger classification if claim paid motor vehicle highway fund