190920 10/13/2010 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $1,916.62
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 190920
CHECK DATE: 10/13/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340701 13693 75.00 MEDICAL EXAM FEES
1120 4340701 13735 531.36 MEDICAL EXAM FEES
1110 4340701 27011 13737 1,310.26 CONTRACT PAYMENTS
INVOICE
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
0
W Indianapolis, IN 46204
Carmel Police Department 1 CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 0912912010
m Invoice 00 -13737
Date Employee Description Amount Balance Due
09/20/10 Kingery.AdamF. Indiana Police /Fire PERF 178.50 $178.50
Chart Review/Completion 52.00 $52.0 0
Chest PAlLAT $61.20 $61.2 0
A licant Health Screen PERF $120.16 $120.16
Drug Screen 7 GC /MS W /MRO $71,40 $71.40
Tb Review Non PSMS 0.00 $0.00
Vital Signs HT WT BP P R $7.14 $7.14
Vision Titmus $26.52 26.52
Color Vision (Ishiharal $26.52 $26.52
PFT WlInterp $33.66 $33.66
u iom k $14,28 $1 4.28
ECG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 $3.06
Tonometry $36.72 $36.72
09/24/10 Barlow, Cody J. Indiana Police /Fire PERF $178,50 178.50
Chart Review/Completion 52.00 $52.00
Chest PA/LAT $61.20 $61.20
Tb Skin Test $7.14 $7.14
ADDlicant Health Screen PERF $120.16 $120.16
Drug Screen 7 GC/MS WlMRO $71,40 $71.401
Vital Si ns HT WT BP P R $7.14 $7.14
Vision Titmus $26.52 $26.52
Colo Vision I hi
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
Tonometry $36.72 J36 72
Total Charges $1,310.26
Total Payments Balance Due $0.00 $1,310.26
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
Prescribed 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. /lJ(�P
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))
9/ 29/10 13737 a ent for applicant physical 1,310.26
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
Puhlic Sa fety Medical Services
IN SUM OF
324 E. new York Street, Suite 300
I ndianapolls, 1N 4
1,310.26
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. 1 hereby certify that the attached invoice(s), or
4 1 13737 407 0fi 1,310.26 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
October 7 20 10
k4a'.a.-D. !7�7�
Si
Chief 6f Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
INVOICE
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
0
iX Indianapolis, IN 46204
C Carmel Fire Department CARMEFD
2 Civic Square Terms
Carmel, IN 46032 invoice Date 09129!2010
m Invoice 00 -13735
Date Employee Description Amount Balance Due
09/20/10 Fisher, Gary L. No -Show Fee 0.00 $0.00
09/24/10 Bailey, Mark E. Comprehensive Physical $99.96 $99.96
OnMed Program $0.00 0.00
Respirator/Medical Review $16.32 $16.32
Health Risk Appraisal Motivation 0.00 $0.00
Treadmill WIFE) 156.00 156.00
Flexibility Check 10.24 10.20
WaistlHi Ratio 3.06 3.06
Muscle Strength Endurance 26.52 26.52
BIA Bio -Elec Im ed Anal 14.28 14.28
Chest P T $61.20 $61
Bladder Cancer Screen $45.90 $45.90
Vital Signs HT WT BP P R $0.00 $0.00
Vision Titmus $26.52 $26.521
PFT W/Interp $33.66 $33.66
AudiometrV $14.28 $14.28
ECG W1 Interp $20,40 20.40
Urinalysis Dipstick $3.06 3 06
Total Charges $531.36
Total Payments Balance Due $0.00 $531.36
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
o Carmel Fire Department 1 CARMEFD
2 Civic Square Terms
Carmel, IN 46032 Invoice Date 0912212010
m Invoice 00 -13693
Date Employee Description Amount Balance Due
09/15110 1 Miller Scott G. Fitness For Duty Level 1 $75.00 $75.00
Total Charges $75.00
Total Payments Balance Due $0.00 $75.00
Please write invoice number on payment check.
Our Federal Employer Identification dumber is 35- 2079797 Balance due 15 days from invoice
date
VOU NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$606.36
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1120 13735 43- 407.01 $531.36 1 hereby certify that the attached invoice(s), or
1120 13693 43- 407.01 $75.00 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
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))
13735 $531.36
13693 $75.00
1 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