214052 10/23/2012 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
CHECK AMOUNT: $1,133.57
y /o CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 214052
CHECK DATE: 10/23/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4340701 19025 1, 133 . 57 MEDICAL EXAM FEES
INVOICE
o Public Safety Medical Services
w 324 E. New York Street
Suite 300
I Indianapolis, IN 46204
o Carmel Police Department/CARMEPD
- 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 10/17/2012
m Invoice# 00-19025
Date Employee Description Amount Balance Due
10/08/12 Brady, Sean P. PSA-Prostate Specific A Blood 36.59 $36.59
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 $3.14
HIV 1 &2 Blood 13.59 $13.59
Horner Jeffrey J Quantiferon-Tb Blood 52.28 $52.28
CMP(Comp Metabolic Panel 20.01 20.01
CBC(Comn Blood Count 18.12 $18.12
I-Oid Panel BI 21. 2 6
Veni uncture $3.14 $3.14
HIV 1 &2 Blood 13.59 13.59
PSA-Prostate Specific A Blood $36.59 $36.59
10/09/12 Myers, Brady R. 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 3.14
HIV 1 &2 Blood 13.59 $13.59
10110112 Gossett Lucas A. Chart Review/Completion $84.67 $84.67
Indiana PERF Exam $190.28 $190.28
Tb Skin Test $7.32 $7.32
Applicant Blood Panel-PERF $120.04 $120.04
Drug Screen 7 GC/MS W/MRO $41.82 $41.82
Veni uncture $3.14 $3.14
Chest X-Ray-PA/LAT(Digital) 62.73 $62.73
Vital Signs-HT WT BP P R $0.00 $0.00
Vision-Acuity 27.18 $27.18
Vision-Color Ishihara 27.18 $27.18
PFT-Pulmonary Function Test $34.50 $34.50
Audiometry 14.64 $14.64
EKG W/Intero $20.91 $20.91
Urinalysis-Di stick $3.14 $3.14
Ton met I m $37.64 4
Total Charges-> $1,133.57
Total Payments&Balance Due-> $0.00 $1,133.57
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797
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))
10/17/12 19025 officer physicals $1,133.57
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
$1,133.57
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 _l 19025 I 43-407.01 I $1,133.57 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
Friday, October 19, 2012
i
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund