159077 04/30/2008 I
CITY OF CARMEL, INDIANA VENDOR: 00351114 Page 1 of 1
ONE CIVIC SQUARE ST VINCENT HOSPITAL
CHECK AMOUNT: $46.85
CARMEL, INDIANA 46032 ATTN: HEALTH INFORMATION SVS
2001 W 86TH ST CHECK NUMBER: 159077
INDIANAPOLIS IN 46260
CHECK DATE: 4/30/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4358200 26155 46.85 SPECIAL INVESTIGATION
Gti
St. Vincent Hospital .4
p Invoice No
Health Information Management 26155
2001 W. 86th Street
Indianapolis, IN 46260
317 338 -2216 Tax ID:35- 0869066
Date: 04/20/2008
To: Carmel Police Department, Prosecuting Attorney
3 Civil Square
Carmel, IN 46032
Attn: Lana Howard
Please include your invoice number on your check.
Patient:
RequeSt,No Iriuo`ice No Medical Becord,No`Date:Received DateeSent
T53673
26155 0
001068348 04/17/2008 04/20/2008 Pages /Time Charges
Photocopy 11 20.50
Postage 6.35
Certified 20.00
Sales Tax 0.00
Total Billed $46.85
Document Date
Amount Paid 0.00
Start End Description Balance $46.85
11/19/2007 11/19/2007 Complete Copy Of Medical Record
To ensure proper posting of payment, please send Attn: Health Information Services
Invoice No
St. Vincent Hospital
Health Information Management 26155
2001 W. 86th Street
Indianapolis, IN 46260
317 338 -2216 Tax IB:35- 0869066
Date: 04/20/2008
To: Carmel Police Department, Prosecuting Attorney
3 Civil Square
Carmel, IN 46032
Attn: Lana Howard
Please include your invoice number on your check.
Patient:
Request No Invoice No Medical Record No Date Received: Date Sent
T53673 26155 0001068348 04/17/2008 04/20/2008 Pages/Time Charges
Photocopy 11 20.50
Postage 6.35
Certified 20.00
Sales Tax 0.00
Total Billed $46.85
Document Date Amount Paid 0.00
Start End Description Balance $46.85
11/19/2007 11/19/2007 Complete Copy Of Medical Record
To ensure proper posting of payment, please send Attn: Health Information Services
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
St. Vincent Hospital Purchase Order No.
Health Information management
2001 W. 86th Street Terms
Indianapolis, IN 46260
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
4/20/08 26155 payment for information for on—going investigation 46.85
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
St."Vincent Hospital IN SUM OF
Health Information Management
2001 W. 86th Street
Indianapolis, IN 46260
46.85
ON ACCOUNT OF APPROPRIATION FOR
police genera lfund
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1110 26155 582 46.85 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
April 23 lr 20 08
Signature
Chief of Police
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund