HomeMy WebLinkAbout195944 03/29/2011 CITY OF CARMEL, INDIANA VENDOR: 365200 Page 1 of 1
ONE CIVIC SQUARE HEALTH PORT CHECK AMOUNT: $162.71
CARMEL, INDIANA 46032 PO BOX 409740
ATLANTA GA 30354 -9740 CHECK NUMBER: 195944
CHECK DATE: 3129/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1180 4341999 0086917546 162.71 OTHER PROFESSIONAL FE
ldlea thPort �9� t Invoice 0086917546
P.O. Box 409740 �a 1 ���1�0�' Date: 2/17/2011
Atlanta, Georgia 30384 -9740 I Customer 1361
Fed Tax ID 58 2659941
(770) 754 6000
Ship to: Bill to: r Records from:
WAYNE UHL WAYNE UHL CLARIAN NORTH MEDICAL CENTER
STEPHENSON MOROW AND SEMLER STEPHENSON MOROW AND SEMLER 11700 NORTH MERIDIAN STREET
8710 NORTH MERIDIAN ST 8710 NORTH MERIDIAN ST CARMEL, IN 46032
STE 200 STE 200
INDIANAPOLIS, IN 46260 -2331 INDIANAPOLIS, IN 46260 -2331
Requested By: STEPHENSON MOROW AND SEMLER SSN: *4811
Patient Name: PRYOR BRANDON DOB: 111487
Description Quantity Unit Price Amount
Basic Fee 20.00
Retrieval Fee 0.00
Per Page Copy (Paper) 2 40 0.50 20.00
Per Page Copy (Paper) 3 10 0.00 0.00
Per Page Copy (Paper) 1 336 0.25 84.00
Shipping /Handling 8.07
Subtotal 132.07
Sales Tax 10.64
Certification Fee 20.00
Invoice Total 162.71
Balance Due 162.71
Pay your invoice online at www.HealthPortPay.corn
Terms: Net 30 days Plea r t hi s a m ou nt 162.71 (USD)
HealthPort
P.O. Box 409740
Atlanta, Georgia 30384 -9740
Fed Tax ID 58 2659941
(770) 754 6000
Invoice 0086917546
Check
Payment Amount
Please return stub with payment.
Please include invoice number on check.
-To pay invoice online, please- go to www.HealthPortPay.com or call (770) 754 6000.
Email questions to Collections @healthport.com.
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
Health Port
Purchase Order No.
P. 0. Box 409740
Terms
Atlanta, GA 303$4 -9740
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3 -22 -11 0086917546 Retrieve and provide records for ongoing litigation $162.71
per the attached invoice
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
Health Port IN SUM OF
P. O. Box 409740
Atlanta, Georgia 30384 -9 740
$162.71
ON ACCOUNT OF APPROPRIATION FOR
Department of Law 1180
430 -41999 Other Professional Services
Board Members
D INVOICE NO, ACCT #fDTLE AMOUNT I hereby certify that the attached invoice(s), or
1180 0086917546 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
02 20
ture
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund