188961 08/18/2010 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $696.34
4,,ro CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 188961
CHECK DATE: 8118/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 4340700 13292 155.00 MEDICAL FEES
1125 4340700 13336 65.00 MEDICAL FEES
1110 4340701 13412 476.34 MEDICAL EXAM FEES
r
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
Indianapolis, IN 46204
C Carmel Clay Parks Recreation l CARMELPARK
t 1411E 116th Street Terms
m Carmel, IN 46032 Invoice Date 07/21/2010
Invoice 00 -13292
Date Employee Description Amount Balance.Due
07/12/10 Morical Ma (Cindy) J. Hepatitis B Vaccination #1 $65.00 $65.00
Inmection Fee $0.00 $0.0D
07/13110 Albanez Roberto Hepatitis B Vaccination #1 65.00 $65.0 0
Inmection Fee $0.00 $0.00
Keaveney, Karrie E. HB SAb Quantitative Titer $25.0G $25.00
Total Charges $155.00
Total Payments Balance Due $0.00. 1 $155.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date
JUL 2 2 2010
BY: Purchase S
Description v
P.O.0 P or F
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andget C
Line Descr 1 V
Purchaser Date
Appro val Data��l
INVOICE
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Clay Parks Recreation 1 CARMELPARK
Terms
1411 E 116th Street
Carmel, IN 46032 Invoice Date 07/2812010
m Invoice 4 00 -13336
Date Employee Description Amount Balance Due
07/23/10 Aleksa. John R. Hepatitis B Vaccination #2 $65.00 $65.00
Iniection Fee $0.00 0.00
Total Charges $65.00
Total Payments Balance Due $0.00 $65.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days
from invoice date
q ��5r
Description y LLL( er
P.O.# PO F
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Bu dget A to ctO T-ee S
Purim Date l D
Apps Date.
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ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
00350364 Public Safety Medical Services Terms
324 E. New York Street, Ste 300
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
7121110 00 -13292 Drug screens 155.00
7128110 00 -13336 HBV Vaccine 65.00
Total 220.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and k have audited same in accordance
with IC 5- 11- 10 -1.6
20_
Clerk- Treasurer
I'
Voucher No. Warrant No.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of i
220.00
ON ACCOUNT OF APPROPRIATION FOR
101 -General
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1125 00 -13292 4340700 155.00 1 hereby certify that the attached invoice(s), or
1125 00 -13336 4340700 65.00 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
12 -Aug 2010
Signature
220.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
INVOICE
0 Public Safety Medical Services
I 324 E. New York Street
E ,suite 300
I i Indianapolis, IN 46204
6
Carmet Police Department I CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice irate 08!1112(110
m Invoice 00 -13412
Date Employee Description Amount Balance Due
08/02/10 Gerdt Andrew P. CMP $15.30 $15.30
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 51.60
Harris Robert P. CMP $15.30 $15,30
CBC W /Dill And Plat 1224 $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 $51.0 0
Haymaker William E. CMP $15.30 $15.30
CBC W /Dill And Plat 12.24 $12.24
Lipid Panel $15.30 .15.30
Vent uncture Fee X3.06 $3.0
HIV 1 2 $1126 $13.26
Quantiferon Tb Gold 5 ?.QO 51.00
White Kad E. Clop $15.3 $15.30
CBC W /Dill And Plat S12,24 $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
Total Charges $476.34
Total Payments Balance Due $0.00 $476.34
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))
8/11/10 13412 payment for officer physicals 476.34
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 Medical Services IN SUM OF
324 E. New York Street, Suite 300
Indianapolis, IN 46204
476.34
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 13412 407 -01 476.34 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
August 12c 20 10
Signature
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund