207201 03/13/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $2,382.37
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
«o INDIANAPOLIS IN 46204 CHECK NUMBER: 207201
CHECK DATE: 3/13/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1091 4340700 16784 25.00 MEDICAL FEES
1110 4340701 17265 256.80 MEDICAL EXAM FEES
1120 4340701 17324 15.00 MEDICAL EXAM FEES
1110 4340701 17325 2,085.57 MEDICAL EXAM FEES
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
d
b� Indianapolis, IN 46.204
o Carmel Clay Parks Recreation CARMELPARK Terms
1411E 116th Street Invoice Date 12/2212011
m Carmel, IN 46032 Invoice 00 -16784
Date Employee gescription, Amount Balance•Due,
j 12/14/11 Raver Jordan L. HB SAb Quantitative Titer $25.00 $25.00
Veni uncture $0.00 0.00
,Total Charges $25:00;.
Total,Pe',ments &.Balance >Due 'c 30.00 $25:00
Please write invoice number on payment check.
i
Our Federal Employer Identification Number is 35- 2079797
FEB 2 2 2012
BY
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Purchase
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Purchase
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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
12/22/11 16784 Medical fees 25.00
Total 25.00
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
Voucher No. Warrant No.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of
25.00
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #[TITLE AMOUNT Board Members
Dept
1091 16784 4340700 25.00 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
8 -Mar 2012
I
Signature
25.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
INVOICE
F-
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
O Carmel Police Department CARMEPD
I-' Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 02123/2012
C3 Invoice 00 -17265
Date Employee Description Amount Balance Due
02/13/12 Hasty, Zachery R. Quantiferon Tb Blood $52.28 $52.28
CMP (Comp Metabolic Panel $20.01 $20.01
CBC (Comp Blood Count $18.12 $18.12
Li id Panel Blood $21.26 $21.26
Veni uncture $3.14 $3.14
HIV 1 2 Blood 13.59 $13.59
02(16(12 Loveall Gregory A. Quantiferon Tb Blood 52.28 $52.28
CMP (Como Metabolic Panel 20.01 $20.01
CBC (Comp Blood Count 18.12 $18.12
Li id Panel Blood 21.26 $21.26
VQniouncture S314 14
HIV 1 2 Blood $13.59 $13.59
To Charg $256.80
Total Payments Balance Due $0.00 $256.80
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
INVOICE
0 Public Safety Medical Services
324 E. New York Street
E Suite 300
d
W Indianapolis, IN 46204
C Carmel Police Department CARMEPD
t 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 02/29/2012
m Invoice 00 -17325
Date Employee Description Amount Balance Due
02/24/12 Bodenhorn Wendy M. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
Treadmill Submax $159.90 $159.90
Flexibility Test $10.46 $10.4 6
Body Fat Test BIA Bio -Elec Imp Anal 14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
Tonomet Glaucoma Test 37.64 $37.64
Vital Si ns HT WT BP P R $0.00 $0.001
Vision -A uity 7.1 27 1
Audiometry $14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Collins. Shane P. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
Treadmill Submax $159.90 $159.90
Flexibility Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal 14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
nmt [y (Gl Tes 7.64 $37.
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity $27.18 $27.18
Audiometry $14.64 $14.64
EKG'W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Hasty, Zachery R. No Show Fee Patient Sick 0.00 $0.00
Love 11. Gregory A. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Res irator /Medical Review $16.73 $16.73
Com rehensive Physical Exam $102.46 102.46
Treadmill Submax $159.90 $159.90
Flexibility Test $10.46 $10.461
Body Fat Test BIA Bio -Elec Imp Anal $14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
Injection Fee 1 $10.46 $10.46
Td Tetanus Diphtheria) Vacc $20.91 $20.91
Tonomet Glaucoma Test 37.64 1 $37.64
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 27.18 $27.18
Audiometry 14.64 $14.64
EKG W/ Inter 20.91 20.91
Urinal sis Di stick $3.14 $3.14
Troyer, Darin M. OnMed Pro ram $0.00 1 so.00
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
d
X Indianapolis, IN 46204
C Carmel Police Department CARMEPD
3 Civic Square Terms
Carmel, IN 46032 Invoice Date 02/29/2012
m Invoice 00 -17325
Date Employee Description Amount Balance Due
Health Risk Appraisal Motivation 0.00 $0.00
Respirator/Medical Review $16.73 $16.73
Com rehensive Physical Exam $102.46 $102.4 6
Treadmill Sub max $159.90 $159.9
Flexibility Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal $14.64 $14.64
Waist/Hi Ratio $3.14 3.14
Tonomet Glaucoma Test $37.64 $37.64
Vital Signs HT WT BP P R $0.00 $0.0 0
Vision AcuitV $27.18 $27.18
AudiornetrV $14.64 $14.64
EKG W/ Intem $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Williams Ashley L. OnMed Program $0.00 $0.00
Health Risk Aopraisal Motivation 0.00 $0.00
Re it t r dic I Review $16.73 1 $16.7
Comprehensive Ph sical Exam $102.46 $102.46
Treadmill Submax $159.90 $159.90
FlexibilitV Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal $14.64 $14.64
WaisUHi Ratio $3.14 $3.14
Tonomet Glaucoma Test 37.64 $37.64
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 27.18 $27.18
Audiometry 14.64 14.64
EKG W/ Intero $20. 20.91
Urinalysis Di stick $3.14 3.14
Total Charges $2,085.57
Total Payments Balance Due $0.00 $2,085.57
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
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))
02/23/12 17265 officer physicals $256.80
02/29/12 17325 officer physicals $2,085.57
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
Public Safety Medical Services
IN SUM OF
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$2,342.37
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members
1110 17265 43- 407.01 $256.80 I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
1110 17325 43- 407.01 $2,085.57
materials or services itemized thereon for
which charge is made were ordered and
received except
Friday, March 09, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
INVOICE
H Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
a Carmel Fire Department CARMEFD
f Attn: Accounts Payable Terms
Invoice Date 02/29/2012
2 Civic Square
m Invoice 00 -17324
Carmel, IN 46032
Date Employee Description Amount Balance Due
02/24/12 Alverson Jonathan L. Medical Records Request 15.00 1 $15.00
Total Charges 1 $15.00
Total Payments Balance Due $0.00 1 $15.00
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35- 2079797 date
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))
17324 $15.00
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$15.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT
Board Members
1120 I 17324 I 43- 407.01 I $15.00 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
MAR 12 2012
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund