208012 04/10/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $3,856.10
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 208012
CHECK DATE: 4/1012012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 17499 3,727.70 MEDICAL EXAM FEES
1110 4340701 17548 128.40 MEDICAL EXAM FEES
INVOICE
H Public Safety Medical Services
w 324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Police Department/ CARMEPD
F 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 03/22/2012
m Invoice 00 -17499
Date Employee Description Amount Balance Due
03/14/12 Tilson. Travis C. Quantiferon Tb Blood 52.28 $52.28
CMP (Comp Metabolic Panel $20.01 $20.01
CBC (Comp Blood Count 18.12 $18.12
Lipid Panel Blood 21.26 $21.26
Veni uncture $3.14 $3.1 4
HIV 1 2 Blood 13.59 $13.59
03/16112 Collins Willie H. OnMed Program $0.00 $0.0 0
Health Risk Appraisal Motivation 0.00 $0.00
Res irator /Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.4
Muscula Strenat
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
Treadmill Submax $159.90 $159.90
Tonomet Glaucoma Test 37.64 $37.64
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiometry 14.64 $14.64
EKG W/ Inte 20.91 $20.91
Urinalysis Di sti k 3.14 $3.14
M iller. I I G. OnMed Proaram $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
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
Treadmill Submax $159.90 $159.9 0
Tonomet Glaucoma Test 37.64 $37.64
Vital Si ns HT WT BP P R $0.00 $0.00
Vision Acuity 27.1 27.1
PFT Pulmonary Function Test $34.50 $34.50
Audiometry 14 14
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Moore Scott L. 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
Muscular Strength Endurance Test $27.18 $27.18
Flexibility Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal 14.64 $14.64
WaisUHi do $3.14 $3.14
Treadmill Submax $159.90 $159.90
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 03/22/2012
m Invoice 00 -17499
Date Employee Description Amount Balance Due
Tonomet Glaucoma Test 37.64 $37.64
Vital Si ns HT WT BP P R $0.00
Vision Ac uit 27.18 $27.1
PFT P I Test
Audiometry $14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Robbins' Todd OnMed Pro ra $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Res irator /Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
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
Treadmill Submax $159. $159.90
T (Glaucoma 4
Vital Si ns HT WT BP P R $0.00 $0.00
Vision Acuity $27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiomet $14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Dipstick $3.14 $3.14
Sedberry. Jeffrey T. OnMed Program $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Res irator /Medical Review $16.73 $16.73
C omxehensive Physical Exam $102.46 $102.46
Muscular Strength Endurance Test $27.18 $27.18
Flexibi5tv Test $10.46 $10
Body Fat Test BIA Bio -Elec Imp Anal $14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
Treadmill Submax $159.90 $159.90
Tonometr Glaucoma Test 37.64 1 $37.64
Vital Signs HT WT BP P R $0.00 $0.00.
Vision Acuity 27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiometry 14.64 $14.64
EKG W/ Interp $20.91 $20.91
Urinalysis Di stick $3.14 $3.14
S trona, David C. OnMed Pro ram $0.00 $0.00
Health Risk Armraisal iv
Respirator/Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
Muscular Strength Endurance Test $27.18 $27.18
Flexibility Test $10.46 10.46
Bod Fat Test BIA Bio -Elec Imp Anal 14.64 14.64
Waist/Hi Ratio 3.14 3.14
Treadmill Submax 159.90 159.90
INVOICE
F 0 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 03/22/2012
m Invoice 00 -17499
Date Employee Description Amount Balance Due
Tonomet Glaucoma Test 37.64 $37.64
Vital Signs HT WT BP P R $0.00 $0.00
Vision Acuity 27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiometry 14.64 $14.641
EKG W/ Intero $20.91 $20.91
Urinalysis Di stick $3.14 $3.14
Tilson Travis C. onmed Pro`ram $0.00 $0.00
Health Risk Appraisal Motivation 0.00 $0.00
Res irator Medic I Review $16.73 $16.73
Comi)rehens Physical 1 02.46 $102.4
Flexibilitv Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal 14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
Treadmill Submax $159.90 $159.90
Tonomet Glaucoma Test 37.64 $37.64
Vital Si ns HT WT BP P R $0.00 $0.0 0
Vision Acuity 27.18 $27.18
PFT Pulmonary Function Test $34.50 $34.50
Audiometry 14.64 $14.64
EKG W/ Intern $20.91 $20.911
Urin I is Dipstick $3.14 $3.14
W ieaman. Chad R. OnMed P
Health Risk Appraisal Motivation $0.00 $0.00
Respirator/Medical Review $16.73 $16.73
Comprehensive Physical Exam $102.46 $102.46
Flexibilitv Test $10.46 $10.46
Body Fat Test BIA Bio -Elec Imp Anal 14.64 $14.64
Waist/Hi Ratio $3.14 $3.14
Treadmill Submax 159.90 $159.90
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
U rinalysis $3.14 $3
Total Charges $3;727.70
Total Payments Balance Due $0.00 $3,727.70
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from
Invoice 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))
03/22/12 17499 officer physicals $3,727.70
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
$3,727.70
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1110 I 17499 I 43- 407.01 I $3,727.70 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
Wednesday, March 28, 2012
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
INVOICE
�o Public Safety Medical Services
324 E. New York Street
E Suite 300
X Indianapolis, IN 46204
o Carmel Police Department CARMEPD
H 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 03/28/2012
m Invoice 00 -17548
Date Employee Description Amount Balance Due
03/19/12 Stein Amy J. Quantiferon Tb Blood 52.28 $52.28
CMP (Comp Metabolic Panel 20.01 $20.01
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
Total Charges $128.40
Total Payments Balance Due $0.00 $128.40
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35- 2079797 Balance due 15 days from
Invoice date
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 7995)
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
Public Safety Medical Services Purchase Order No.
324 E New York Street Suite 300
Indpls, IN 46204 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3/28/12 17548 officer physical 128.40
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
Public Safety Medical Services IN SUM OF
324 E New York St Suite 300
Indianapolis, IN 46204
128.40
ON ACCOUNT OF APPROPRIATION FOR
police general fund
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
1110 17548 407 -01 128.40 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 2, 2012
Signature
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund