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Home My WebLink About179799 11/24/2009 y VENDOR: 358229 CITY OF CAt�nnEL INDIANA NICOLE PASS/NEAU 0 ONE CIVIC SQUARE CIO DOCS CARMEL, INDIANA 46032 CHECKgly UNT: Pag 3s of -1 CHECK NUMBER: 20 CHECK DA 7-E 1 79 799 1'I 124/2009 DEPARTMENT ACCO PO NUMBER INVOICE NUMBE AMOUNT DESCRIPTION 1192 4341999 139.20 OTHER PROFESSIONAL FE i Date of Birth LAKEVIEW FAMILY MEDICINE, LLC GLEN LEER, DO 204 W. Main Street, PO Box 383 Arcadia,'IN 46030 Office: (317)984-8811 Fax: (317)984-5862 �7 Za- C HIA RG OFFICE PROCEDURES NEW ESTAB INJECTIONS LABS/TESTS 'Op D E Level One 99201 99211 Immunization Injection 90471 ABI I PPG Level Two 99202 99212 Therapeutic Injection 90772 Accucheck 82962 Level Three 99203 99213 Arthrocentesis, sm. joint 20600 Breathing Treatment 94640 Level Four 99204 99214 Arthrocentesis, med. font 20605 CBC w/ Differential 85025 Level Five 99205 99215 Arthrocentesis, Ig. joint 20610 CMP 80053 Aristozparn, per 5mg J3303 EKG 93000 Up to 1 Year 99381 99391 Cefiriaxone, per 250mg J0696 Event Monitor 93270 '1 -4 Years 99382 99392 Dexamethasone, per 1mg J1100 Finger Stick 36416 _11 Ye ars 99383 99393 Influenza Vaccine, 3 years+ 90658 Lipid Profile 80061 12-17 Years 99384 99394 Hyalgan, per 20-25mg dose J7321 Hernocult 82270 18-39 Years 99385 99395 Hydroxyzine, up to 25mg J3410 Hemoglobin, glycated 83036 40-64 Years 99386 99396 Ketorolac, per 15mg J18851 Holter Monitor 93230 65 and Over 99387 99397 Nalbuphine, per 1 Orng J2300 IMicroalburnin 82044 2 1 Penicillin, up to 600,000 units J2510 10ximetry, Ear or Pulse 94760 99080 rn Form(s), Number of pages Pneuococcal Vaccine, 2years+ 9073 Pap (Thin Prep) 88142 Missed Appointment 1 291 1 Pronnethazine, up to 50mg J2 Pregnancy Test 81025 OSTEOPATHIC MANIPULATION CODE OTHER PROCEDURES CODE Spirometry 94010 1-2 Body Regions 98925 Cardioplethesmagraphy ICG 93701 6trep test 87880 13-4 Body Regions 98926 Cardioplethesmography Total 93720 Thyroxine, Total, T-4 84436 5-6 Body Regions 98927 Cerunnen Removal 69210 TSH 84443 7-8 Body Regions 98928 Destruction of Warts, <1 4 17110 Uric Acid 845501 9-10 Body Regions 98929 Digital Nerve Block 64450 Urinalysis, Culture 87086 Excision, 'all I Nail Matrix 11750 U rinalysis, Dip 7 I I ill&.A Simple 10060 lenipuncture 364151 1 DIAGNOSIS CODE DIAGNOSIS CODE DIAGNOSIS CODE Abdominal Pain 789.0 Fatigue, Weakness 780.79 Peripheral neuropathy Acne 706.1 Fever 780.6 Peripheral Vascular Disease 443.9 Abnormal Weight Gain 783.1 GERD 530.81 Pharyngitis 462 Abnormal Weight Loss 783.21 Hearing Loss 389.00 Physical, Annual P7 2 ADHD 314.01 Heart Palpitations 785.1 Physical; CIJUSports 70 3 Allergic Rhmitis 477.9 Hematuria 599.7 Physical, Pap /Pelvic V7r3l Anemia 285.9 Hypercholesterolemia 272.0 Physical, Employment V70.5 Anemia, Pernicious 281.0 Hyperlipidernia 272.4 Physical, Well-Child V20.2 Angina 413.9 Hypertension, Benign, W/O CHF 402.10 Pneumonia 486 Anxiety 300.00 Hypertension, Benign, W/ CHF 402.11 Prostate Hypertrophy 600.90 Arthritis 716.9 Hypertension, Malign, W/O CHF 402.00 Rash 782.1 Arthralgia 719.40 Hypertension, Malign, W/ CHF 402.01 Rectal Bleeding 569.3 Asthma 493.90 Hyperthyroidism 242.90 Renal Insufficiency 593.9 Atrial Fibrillation 427.31 Hypothyroidism 244.9 Restless Leg Syndrome 33199 Bronchitis, Acute 466.0 Hypermenarrhea 626.2 Rheumatoid Arthritis 714.0 B ursit is Other 727.3 Insomnia 780.521 1 Rhinitis 472.01 1 CAR 414.00 Influenza 487i Sciatica 724.3 CephaigiatHeadache 784.0 Irritable Bowel Syndrome 5641 Shortness of Breath 786.05 a Cerumen Impaction 380.4 Infection, Skin 686.9 Sinusitis 461.9 Chest Pain, Unspecified 786.50 Laryngitis, Acute 464.0 Sleep Apnea 780.57 Chest Pain, Noncardiac 78&59 Lymphadenopathy 785.6 Somatic Dysf, head 739.0 I CHF 428.0 Mass, Breast 611.72 cervical 739.1 Colon Polyps 211.3 Mental Status Change 780.99 thoracic 739.2 C 1 Conjunctivitis, Acute 372.00 Migraine 346 -90 lumbar 739.3 Constipation 564.00 Muscle Strain 848.91 sacral 739.41 1 COPID 496 Myalgia/Fibromyalgia 729.1 pelvic 739.51 1 Cough 786.2 Nasal Congestion 478.1 lower extremities 739.6 Depression 311 Nausea 787.02 upper extremities 739.7 Dermatitis 692.9 Neurotransmitter Abnorm. 348.9 costal 739.8 Dehydration 276.5 Osteoarthritis Unspec. 715.90 abdomen/other 739.9 Diabetes IDDM, uncont 250.03 shoulder region 715.91 Sprain, Cervical 847.0 Diabetes NIDDM, uncont 250.02 upper arm 715.921 Sprain, Lumbar 847.2 Diabetes Mellitus-IDDM 250.01 forearm 715.93 Sprain, LumbosacTal 846.0 Diabetes Mellitus-NIDDM 250.00 hand 715.94 Sprain, Thoracic 847.1 Diarrhea 787.91 pelvic/thigh 715.95 Strap Throat 034.0kj Dizziness 780.4 lower leg 715.96 Syncope 780.2 Dyspnea 786.09 ankle/foot 715.97 Tendinitis 726.90 Eczema 692.9 other specified 715.98 TIA 435.9 Edema 782.3 Onychomycosis 110.1 Upper Respiratory Infection 465.9 Electrolyte Imbalance 276A Osteoporosis 733.00 Urinary Incontinence 788.30 Elevated Blood Pressure 796.2 Otitis Externa 380.1 Urinary Tract Infection 599.0 Emesis 787.031 1Otitis Media 382.9 Vaccine, Influenza VO4-81 I Epididymitis 604.91 1 Pain, Back 724.5 Vaccine, Pneumococral VOU3.82 Erectile Dysfunction 6 07 84 P a i n 0719.46 Vascular Disease 459.9 Eustachian Dy sfunct ion ia uslach,an Tube Il, jI, r t,- 782.0 Viral illness 079.9 99 E n, 780-8 Peptic Ulcer Disease i 9 9 nction 3 Pa as e E x cessi ve S weati ng 536.91 Warts 078.11 1 CO Indiana Department of Revenue CDL -PHY Medical Examination Report for State Form #49867 Commercial Driver Fitness Determination (R3/10-04) Commercial Driver's License, Medical Section *Social Security Number 5252 Decatur Boulevard, Ste. R, This state agency is requesting disclosure of your Indianapolis, IN 46241 Social Security number, under IC 4- 1 -8 -1, in order Telephone: (317) 615 -7335 Fax: (317) 821 -2340 to perform its statutory function. Disclosure is voluntary, and you will not be penalized for refusal. 1. MEtE= Driver completes this section Driver's Name (Last, First, MI) Address 0 City, State, Zip Code Age Sex New Certification Work. Tel: ❑Vl Recertification (3 0 5'71 t(" rN �1>�r 3u Follow Up Home Tel: V v1 (3), (c�5� 3N J Social Security No. Birthdate (MM DD YYYY) Date of Exam (MM DD YYYY) 1 11 7 1q 13 1 I I 0 State of Issue Driver License No. License T e CDL Class: CH OR B I (K) CDL C 2. Driver com1iieies this section, but medical examiner is encouraged to discuss with driver. Yes No Yes No Yes No j Any illness or injury in last 5 years? Liverdisease a Digestive problems f-Head /brain injuries, disorders or illnesses Diabetes or elevated blood sugar controlled by: Seizures, epilepsy diet pills insulin Medication 16 Nervous or psychiatric disorders, e.g.; severe depression WLEye disorders, or impaired vision (except Medication corrective lenses) Loss of, or altered consciousness Ear disorders, loss of hearing or balance Fainting, dizziness E6-Heart disease or heart attack; other Sleep disorders cardiovascular condition History of sleep apnea. Treatment Medication Pauses in breathing while asleep a Heart surgery (valve replacement/bypass, Daytime sleepiness including with driving angioplasty, pacemaker or IC defibrillator) Narcolepsy High blood pressure Loud Snoring Medication Insomnia /deprivation of sleep (1- Muscular disease Stroke or paralysis 1- Shortness of breath Missing or impaired hand, arm, foot, leg, finger, toe 4 Lung disease, emphysema, asthma Spinal injury or disease Chronic low back pain a Chronic bronchitis Regular, frequent alcohol use If Kidney disease, dialysis rif Narcotic or habit forming drug use For any YES answer, please indicate onset date, diagnosis, treating physician's name and address and any curr nt limita- tions. List all medications (including over the counter medications) used regularly or recently. rrlLt I certify that the above info/ m`otio`n Is comp ete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical E in�r's�Ce c I uthorize this informati t r� ed to the Indiana Department of Revenue. Z river's Signaturcs Date Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over the counter medications, used while driving) CDL -PHY Page 1 of 4 Driver's Nam N t C l SSt n�a� DLA Testing (Medical Examiner completes Section 3 through 7) Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 peripheral in hori- zontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate. Instructions: When other than the Snellen chart is used, give test results in Snellen- comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 2 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified. Numerical readings must be provided. Horizontal Complete this section if vision testing is done by Acuity Uncorrected Corrected Field of Vision an Ophthalmologist or Optometrist. Right Eye 20/ 20/ J Right Eye 0 Left Eye 20/ 20/ QC Left Eye Both Eyes I 20/ I 20/ 1 Date of Examination Telephone No. Applicant can recognize and distinguish among Name of Ophthalmologist or Optometrist (Print) traffic control signals and devices showing standard red, green and amber colors? Yes No Signature Applicant meets visual acuity requirement only when wearing: Corective Lenses Monocular Visions: Yes No License No. /State of Issue 4. Standard: a) Must first perceive forced whispered voice 5 feet with or without hearing aid, or b) Average hearing loss in better ear 40dI3 Check if hearding aid used for tests. Check if hearing aid is required to meet standard. Instructions: To convert audiometric test results from ISO to ANSI, -14dB from ISO for 50011z, -10dB for 1,000 Hz, -8.5dB for 2,0001-1z. To average, add the readings for 3 frequencies tested and divide by 3. Numerical readings must be recorded. a) Record distance from individual at which Right Ear Left Ear forced whispered voice can first be heard. Feet: Feet: .b) If audiometer is used, record hearing Right Ear Left Ear loss in decibels. (acc.1o.ANSI Z24.5-; 500Hz 1000Hz 20001-1z 500Hz 1000Hz 2000Hz 1951) Average: Average: J jjj% umerical readings must be recorded. Medical Examiner should take two readings to confirm BP Blood y Diastolic Reading Categor E irationDate Recertification Pressure /O 140 159/90 -99 Stage 1 1 year 1 yearif< 140!90 One -time certificate for 3 months Driver qualified if 140/90. if 140- 159/90 -99 Pulse Regular 160 17.9!100 -109 Stage One -time certificate for 3months I year from date ofcxam if< 140/90 Rate Irregular 180110 State 3 6 mono from date ofexam if 6 months if <140/90 140/90 Record Pulse Rate: Medical examiner should take at least 2 readings to confirm blood pressure. 6. e Numerical readings must be recorded. Urinalysis is required. Protein, blood or sugar in the urine may be an indication that further testing is needed to rule out any underlying medical problem. Urine SP. GR. Protein Blood Sugar Specimen: Other Testing (Describe and record): CDL -PHY Page 2 of 4 Driver's Name t-�� `}S• a1u _DL# 111919 "P1 Height V (iu.) Weight (lbs.) The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if the condition, if neglected, could result in a more serious illness that might affect driving. Check yes if there are any abnormalities. Check no if the body system is normal. Discuss any yes answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance. Body System Check for: Yes No 1. General Appearance Marked overweight, tremor, signs of alcoholism, problem drinking,or drug abuse. 2. Eyes Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos. Ask about retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate. 3. Ears Scarring of tympanic membrane, occlusion of external canal, perforated eardrums 4. Mouth and Throat Irremediable deformities likely to interfere with breathing and swallowing. 5. Heart Murmurs, extra sounds, enlarged heart, pacemaker, in lantable defibrillator 6. Lungs and chest, not including Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath breast examination sounds including wheezes or alveolar rales, impaired respiratory function, cyanosis. Abnormal findings on physcial exam may require further testing such as pulmonary tests and /or xray of chest. 7. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness. 8. Vascular system Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins. 9. Genito- urinary system Hernias. 10. Extremities Limb impaired. Loss or impairment of leg, foot, toe, arm, hand, finger. Perceptible limp, Driver may be subject to SPE deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Certificate if otherwise qualified. Insufficient grasp and prehension in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly. 11 Sine, other musculoskeletal Previous sur deformities, limitation of motion, tenderness. 12. Neurological Impaired equilibrium, coordination or speech pattern; paresthesia asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinski's reflexes, ataxia. Comments Note rtification status here. See Instructions to the Medical Examiner guidance. eets standards in 49 CFR 391.41; qualifies for 2 -year certificate Wearing corrective lenses Meets standards, but periodic evaluation required. Wearing hearing aid Due to driver qualified only for: Driving within an exempt intracity zone 3 months 6 months 1 year Other (see 49 CFR 391 -62) Qualified by operation of 49 CFR 391.64 (See page 3 of instructions) Skills Performance Evaluation (SPE) Certificate Does not meet standards (See page 3 of instructions) Accompanied by a waiver /exemption Driver must present exemption at time of certification. Temporarily disqualified due to (condition or medication) Return to Medical Examiner's office for follow up on Medical Examiner's Name (Print n Lam: Q.0. Medical Examiner's Signatur Telephone Numbe t 1 `I t Address �0 Lt A G 1 ��1 Q If meets DOT standards, complete the DOT Medical Examiner's certificate according to 49 CFR 391.43 (h). CDL -PHY Page 3 of 4 Driver's Name n�� DL# Notice for all CMV drivers: Drivers must carry one of the Medical Examiner's Certificate when operating a commercial vehicle. To the Medical Examiner: Complete only one of these Medical Examiner Certifications. DOT Medical Examiner's Certificate to be completed if the driver meets Federal Motor Carrier Safety Regulations 49 CFR 391.41- 391.49 DOT I ters at M jc E iner s Certificate I certify that I have examined 2 In accordance with the FedL.al Motor Carrier Safety Regulations (49 CFR 391.41- 391.49) and with knowledge of the driving duties, I find this person is qualified; and if applicable, only when: Wearing corrective lenses Driving within an exempt intracity zone (49 CFR 391.62) Wearing hearing aid Accompnaied by a Skill performance Evaluation Cert. (SPE) Accompanied by a waiver /exemption Qualified by operation of 49 CFR 391.64 The information I have provided regarding this physical examination is true and complete. A complete DOT (Interstate) examination form with any attachment embodies my findings completely and correctly, and is on file in my CP (Operator's) office. CH (Chauffeur's) Medical Certificate Expiration Date IVIM DD YYYY CDL (Commercial (Not the Medical Examiner's state license certificate Driver's License expiration date) J� e 2 Interstate) S' re edical Exa Date T e o e Medical Examiner's Name (please print) MD O Chiropractor C ,Fti e L. FE Physician Assistant Advanced Practice Nurse Medical Examiner's: Issuing State License or Certificate No. Sign re of Driver Driver's License No. State dress of D er This card to be issued to a CDL -K Intrastate license holder only. Indiana CDL Intrastate Medical Examiner's Certification I certify that I have examined in my medical opinion this examinee did not have at the time of this examination any medical disorder or physical condition which was likely to interfere with his /her ability to safely operate a commercial motor vehicle or a motor vehicle used to convey public passengers. The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office. Medical Certificate Expiration Date NM DD YYYY Indiana (Intrastate) (Not the Medical Examiner's state license certificate (K) CDL (Commercial expiration date) 0 1 N Driver's Signature of Medical Examiner Date Telephone License Intrastate) Medical Examiners Name (please print) C] MID DO Chiropractor Physician Assistant Advanced Practice Nurse Medical Examiner's: Issuing State License or Certificate No. Signature of Driver Driver's License No. State Address of Driver Please make two copies. Send one copy to the Department and keep a copy for your records. Medical Examiner's Certificate must accompany the Medical Examination Report (Medical Long Form) when filing with the Indiana Department of Revenue, Motor Carrier Services, CDL Section. CDL -PHY Page 4 of 4 r DATE PATIENT NAME URINE DIP STICK RESULTS LEUKOC'Y'TES /NEGATIVE TRACE SMALL MODERATE LARGE 4 NITRITE (nG T`IVE POSITIVE URORILINOGEN 0.2 1 2 4 8 PROTEIN f `NEGATIVE TRACE 30 100 300 2,000 OR MORE +-f- PH 5.0 6.0 6.5 7.0 7.5 8.0 8.5 BLOOD NEG C MODERATE TRACE SM MOD LG NONFIEMOLYZED HEMOLYZED r l SPECIFIC GRAVITY 1.000 1.005 1.010 1.015 1.020 1.02 1.030 i KETONE (NEG/ TRACE SM MOD LARGE 5 15 40 80-160 DDLIRUDIN (7)G SMALL MODERATE LARGE GLUCOSE NE 100 250 500 1000 >2,000 P. O. Box 383 204 West Main Street Arcadia, Indiana 46030 317-984-8811 Fax: 317- 984 -5862 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)) 11/16/09 Med. Exam for CDL $139.00 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 VO UCHER NO.. WARRANT N O. ALLOWED 20 Nichole Passineau IN SUM OF c/o One Civic Square Carmel, IN 46032 $139.00 ON ACCOUNT OF APPROPRIATION FOR Carmel DOCS Department PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members 1192 2- 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 Friday, November 20, 2009 ire Title Cost distribution ledger classification if claim paid motor vehicle highway fund