206785 02/28/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $601.60
INDIANAPOLIS IN 46204 CHECK NUMBER: 206785
CHECK DATE: 2/2812012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 4340700 17196 65.00 MEDICAL FEES
1110 4340701 17197 536.60 MEDICAL EXAM FEES
INVOICE
H Public Safety Medical Services
324 E. New York Street
Suite 300
tY Indianapolis, IN 46204
C Carmel Clay Parks Recreation CARMELPARK
1411E 116th Street Terms
Carmel, IN 46032 Invoice Date 02/16/2012
m Invoice 00 -17196
Date Employee Description Amount Balance Due
02/06/12 Edwards Michael Hepatitis B Vaccination #3 $65.00 $65.00
Injection Fee $0.00 $0.00
Total Charges $65.00
Total Payments Balance Due $0.00 1 $65.00
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797
Balance due 15 days from invoice
date
Purchase n Q S
Description 1 Vv D LOS
P.O. P or F FEB 2 1 2012
3 yo70o
Budget
Line Descr C ate Z /Z I r
Z BY:
Purchaser
Approval Date
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
00350364 Public Safety Medical Services Terms
324 E. New York Street, Ste 300
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
2/16/12 17196 Medical fees 65.00
Total 65.00
I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20_
Clerk- Treasurer
Voucher No. Warrant No.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of$,
65.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. A CCT #/TITLE AMOUNT Board Members
Dept
1125 17196 4340700 65.00 1 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
23 -Feb 2012
Signature
65.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
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 02/16/2012
m Invoice 00 -17197
Date Employee Description Amount Balance Due
02/06/12 Bodenhorn, Wendy M. Quantiferon Tb Blood $52.28 $52.28
CMP (Comp Metabolic Panel 20.01 $20.01
CBC (Comp Blood Count 18.12 $18.1 2
Lipid Panel Blood 21.26 $21.26
Veni uncture $3.14 $3.14
Moore. Scott L. CBC Com p Blood Count 18.12 $18.1 2
Lipid Panel Blood 21.26 $21.26
Veni uncture $3.14 $3.14
HIV 1 2 Blood 13.59 $13.59
PSA Prostate S ecific A Blood 36.59 $36.59
Qua ntiferon Tb (Blood) 2. 2.
CMP Com p Metabolic Panel M21.26 $20.01
Sedber Jeffrey T. Quantiferon Tb Blood 52.28
CMP (Comp Metabolic Panel $20.01
CBC (Comp Blood Count 18.12
Lipid Panel Blood 21.26
Veni uncture $3.14
HIV 1 2 Blood 13.59 $13.59
Williams. Ashley L. Quantiferon Tb Blood 52.28 $52.28
CMP Com Metabolic Panel 20.01 $20.01
CBC Com Blood Count 18.12 $18.12
Li id Panel Blood 21.26 21.26
Venipunct r 3.14 .14
HIV 1 2 Blood $13.59 $13.59
Total Charges $536.60
Total Payments Balance Due $0.00 $536.60
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from invoice
date.
a
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))
02/16/12 17197 officer physicals $536.60
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$536.60
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1110 17197 43- 407.01 $536.60
I hereby certify that the attached invoice(s), or
I I
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, February 24, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund