205263 01/05/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
a CHECK AMOUNT: $5,448.60
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 205263
CHECK DATE: 1/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 R4340701 25945 16642 4,401.38 OFFICER PHYSICALS
1110 R4340701 25945 16785 1,047.22 OFFICER PHYSICALS
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
w Indianapolis, IN 46204
o Carmel Police Department CARMEPD
H Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 12/22/2011
m Invoice 00 -16785
Date Employee Description Amount Balance Due
12/14/11 Smiley, Landry D. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation $0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 $156.00
Flexibility Test $10.20 $10.2 0
Body Fat Test BIA Bio -Elec Imp Anal $14.28 $14.28
Waist/Hi Ratio $3.06 $3.06
Infection Fee $10.20 $10.201
Td Tetanus Di htheria Vacc $20.40 $20.4 0
no t [y (Glaucoma Test) 7 .72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity $26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
Audiometry 14.28 $14.28
EKG W/ Interp $20.40 $20.4 0
Urinalysis Dipstick $3.06 $3.06
Zellers. Timothy V. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.32 $16.321
Comprehensive Physical Exam $99.96 $99.96
Flexibility Test $10.20 $10.2 0
B ody Fat Test BIA Bio- lec Imp Anal $14.28 $14.2
Waist/Hi Ratio $3.06 $3.06
Treadmill Submax $156.00 $156.00
Tonomet Glaucoma Test 36.72 $36.72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 26.52 $26.52
PFT Pulmonary Function Test 33.66 $33.66
Audiometry 14.28 $14.28
EKG W/ Interp $20.40 $20.40
Urinalysis Di stick $3.06 $3.06
12/16/11 McNair Harland J. Quantiferon Tb Blood 51.00 $51.0 0
CMP (Comp Metabolic Panel 19.52 $19.52
C m Blood Count) 1 7.
Lipid Panel Blood $20.74 $20.74
Veni uncture $3.06 $3.06
PSA Prostate Specific A Blood $35.70 $35.70
Total Charges $1,047.22
Total Payments &Balance Due $0.00 $1,047.22
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
.W. Indianapolis, IN 46204
o Carmel Police Department CARMEPD
H Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 12/02/2011
m Invoice 00 -16642
Date Employee Description Amount Balance Due
11/21/11 Dixon Micheal R. Treadmill Submax $156.00 $156.00
Quantiferon Tb Blood 51.00 $51.00
CMP (Comp Metabolic Panel $19.52 $19.52
CBC (Comp Blood Count $17.68 $17.68
Lipid Panel Blood 20.74 20.74
Veni uncture $3.06 $3.06
HIV 1 2 Blood 13.26 $13.26
PSA Prostate S ecific A Blood 35.70 $35.70
Tonomet Glaucoma Test 36.72 $36.721
Vital Si ns HT WT BP P R $0.00 $0.00
Vision -A uity $26.52 12U2
PFT Pulmonary Function Test $33.66 $33.66
Audiometry 14.28 $14.28
EKG W/ Inter $20.40 $20.4 0
Urinal sis Dipstick $3.06 $3.06
In ection Fee $10.20 $10.2 0
OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Flexibility Test $10.20 $10.2 0
Body Fat Test BIA Bio -Elec Imp Anal 14.28 $14.28
W i Hi Ratio $3
Td Tetanus Diphtheria) Vacc $20.40 $20.40
Zellers Timothy V. Quantiferon Tb Blood $51.00 $51.00
CMP C mp Metabolic Panel $19.52 $19.52
CBC (Comp Blood Count 17.68 $17.68
Li id Panel Blood 20.74 $20.74
Veni uncture $3.06 $3.06
HIV 1 2 Blood $13.26 $13.26
PSA Prostate Specific A Blood 35.70 $35.70
11/23/11 Bickel. Jose h E. OnMed Program $0.00 $0.00
Health Risk Aooraisal Motivation 0.00 $0.00
Res irator /Medical Review $16.32 $16.32
C omprehensive P i I Exam $99.96
Muscular Strength Endurance Test $26.52 1 $26.52
Flexibility Test $10.20 $10.20
Body Fat Test BIA Bio -Elec Imp Anal 14.28 $14.28
WaisUl-lip Ratio $3.06 $3.06
Treadmill Submax 156.00 $156.00
Tonometr Glaucoma Test 36.72 $36.72
Vital Sign HT WT BP P R $0.00 $0.00
Vision Acuity 26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
Audiometry 14.28 14.28
EKG W/ Inter 20.40 $20.4 0
INVOICE
0 Public Safety Medical Services
324 E. New York Street
Suite 300
W Indianapolis, IN 46204
o Carmel Police Department CARMEPD
F- Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 12102/2011
m Invoice 00 -16642
Date Employee Description Amount Balance Due
Urinalysis Di stick $3.06 $3.06
Green Timothy J. OnMed Pro ram $0.00 $0.001
Health Risk Armraisal Motivation 0.00 $0.00
R esr)irator/Medical Review 1 1 2
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 $156.00
Flexibilitv Test $10.20 $10.20
Body Fat Test BIA Bio -Elec Imp Anal $14.28 $14.28
Waist/Hi Ratio $3.06 $3.06
Tonometr Glaucoma Test 36.72 $36.72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity $26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
Audiometry 14.28 $14.28
EKG W/ Interp $20.40 $20.4 0
r n I Di sti k $3.06 $3.06
Hobson. Phillip L. Audiometry $14.28 $14.28
EKG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 $3.06
OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.0G $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 $156.00
Flexibility Test $10.20 $10.2 0
Bodv Fat Test BIA Bio -Elec Imn Anal 14.28 $14.28
Waist/Hi Ratio $3.06 $3.06
T n m I uco Test) 36 .72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity $26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
Howard Lana M. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Com rehensive Physical Exam $99.96 $99.96
Muscular Strength Endurance Test $26.52 $26.52
Flexibility Test $10.20 $10.2 0
Body Fat Test BIA Bio -Elec Imo Anal 14.28 $14.281
Waist/Hi Ratio $3.06 $3.06
Treadmill Submax $156.00 $156.
Injection Fee $10.20 $10.20
Td Tetanus Diphtheria) Vacc $20.40 $20.40
Tonometr Glaucoma Test $36.72 36.72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
AudiometrV $14.28 $14.28
INVOICE
Public Safety Medical Services
w 324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Police Department CARMEPD
Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 12/02/2011
m Invoice 00 -16642
Date Employee Description Amount Balance Due
EKG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 $3.06
Klein. Marc A. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 $156.00
Flexibility Test $10.20 $10.2 0
Body Fat Test BIA Bio -Elec Imp Anal 14.28 $14.28
Waist/Hi Ratio $3.06 $3.06
Ini ection F e $10.20 $10.2 0
Td Tetanus Diphtheria) Vacc $20.40 $20.40
Vital Signs HT WT BP P R $0.00 $0.00
Vision AcuitV $26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.66
Audiometry 14.28 $14.28
EKG W/ Interp $20.40 $20.4 0
Urinalysis Dipstick $3.06 $3.06
McAllister. John W. Audiometry 14.28 $14.28
EKG W/ Interp $20.40 $20.4 0
Urinalysis Dipstick $3.06 $3.06
OnMed Pro ram $0.00 $0.00
Health Rik Appraisal (Motivati $0.0
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax L11 .00 156.00
Flexibility Test 0.20 10.20
Body Fat Test BIA Bio -Elec Imp Anal .28 14.28
Waist/Hi Ratio .06 3.06
In ection Fee .20 $10.2 0
Td Tetanus Diphtheria) Vacc $20.40 $20.40
Tonomet Glaucoma Test 36.72 $36.72
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 26.52 $26.521
PFT Pulmonary Function Test $33.66 $33
Pirics, John D. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation $0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 156.00
Flexibility Test $10.20 $10.20
Body Fat Test BIA Bio -Elec Im Anal 14.28 $14.281
Waist/Hi Ratio $3.06 $3.06
Tonomet Glaucoma Test 36.72 $36.72
Vital Si ns HT WT BP P R $0.00 0.00
Vision Acuity 26.52 $26.52
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 12/02/2011
m Invoice 00 -16642
Date Employee Description Amount Balance Due
PFT Pulmonary Function Test $33.66 $33.66
Audiornetry $14.28 $14.28
EKG W/ Intero $20.40 $20.40
U rinalysis Di ti k $3.06 $3.0
Zellers Nancy L. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation $0.00 $0.00
Respirator/Medical Review $16.32 $16.32
Comprehensive Physical Exam $99.96 $99.96
Treadmill Submax $156.00 $156.00
FlexibilitV Test $10.20 $10.2 0
Body Fat Test BIA Bio -Elec Imp Anal 14.28 $14.28
Waist/Hi Ratio $3.06 $3.06
Tonomet Glaucoma Test 36.72 $36.721
Vital Si ns HT WT BP P R $0.00 $0.00
Vision Acuity 26.52 $26.52
PFT Pulmonary Function Test $33.66 $33.6
Audiometry $14.28 $14.28
EKG W/ Interp $20.40 $20.40
Urinalysis Dipstick $3.06 $3.06
In ection Fee $10.20 $10.2 0
Td Tetanus Diphtheria) Vacc 20.40 $20.40
Total Charges $4,401.38
Total Payments Balance Due $0.00 $4,401.38
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from
Invoice date
INDIANA RETAIL TAX EXEMPT PAGE
C ®f C armel CERTIFICATE NO. 003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 25
35- 60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, A/P
CARMEL, INDIANA 46032 -2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997 SHIPPING LABELS AND ANY CORRESPONDENCE.
'URCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
12rZ=1 9
Public SO* Medical Services Carmel Police Department
VENDOR SHIP 3 Civic squ=
324 E. Notj York Street, Suite 3M TO Carmel, IN 46
Indianapolis, IN 4004 (W) 571
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account +3-409.09
1 Each Offiier Physicals $3,300.00 $3,300.00
Sub Total: $3,500.00
0'
Send Invoice To:
Carmel Polito Department
Attn: Yemsa Anderson
3 Civic squm
Carmel, IN 46032= PLEASE INVOICE IN DUPLICATE
DEPARTMENT ACCOUNT PROJECT I PROJECT ACCOUNT AMOUNT
Carmel Police Dept. PAYMENT $3150D'C0
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
SHIP REPAID.
THIS APPROPRIATION SUFI IENT TO PAY FOR THE ABOVE ORDER.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED. ORDERED BY
PURCHASE ORDER NUMBER MUST APPEAR ON ALL
SHIPPING LABELS. C 0f Police
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 TITLE b
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
9 4 A .P.V. CLERK- TREASURER
DOCUMENT CONTROL NO. COPY SIGN AND RETURN TO CLERIC'S OFFICE
VOUCHER NO. WARRANT
ALLOWED 20
IN THE SUM OF
e't
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
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__-
20
Signature
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))
12/02/11 16642 officer physicals $4,401.38
12/22/11 16785 officer physicals $1,047.22
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
VOU NO. WARRANT NO.
Public Safety Medical Services ALLOWED 20
IN SUM OF
324 E. New York Street, Suite 30
Indianapolis, IN 46204
$5,448.60
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Prior Year Encumbered I hereby certify that the attached invoice(s), or
25945 16642 43- 407.01 $4,401.38
Prior Year Encumbered bill(s) is (are) true and correct and that the
25945 16785 43- 407.01 $1,047.22
materials or services itemized thereon for
which charge is made were ordered and
received except
Tuesday, January 03, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund