216477 01/15/2013 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: $842.68
INDIANAPOLIS IN 46204 CHECK NUMBER: 216477
CHECK DATE: 1115/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4350900 19492 407 . 80 OTHER CONT SERVICES
1120 4350900 PRE-133112-0 434 . 88 OTHER CONT SERVICES
JAN/07/2013/MON 03: 51 PM PUBLIC SAFETY MED FAX No. 9721190 P. 002
Public Safety Medical Services, Inc.
324 E, Now York INV016""'
Suite 300 invoice Number: PRE423112-0
Indianapolis, IN 46204 Invoice Date: Dec 31,2012
—T-I-N_352-07979
Page:
Voice, 1-317-972-1180
Fax: 1-317-972-1190
Carmel Fire Department
2 Civic Square
Carmel, IN 46032
MEN',VISA,
CARMEFD Net 30 Days
H W-M TIQ"Mll r,
ED 11,00, IM, 0,16"Irp"M
LID
Courier
j 1/30/13
LEM
Jim Toney-Wellness physical (Jan. 17,
.2013)
Comprehensive physical 10246
On Med
Health Risk Appraisal
Respirator/Med. Review 16.73
Treadmill 159.90
Body fattest(BIA) 14,64
Waist/hip ratio 3.14
Flexibility Test 10.46
Muscular strength endurance 27.18
Vitals
Vision-Acuity .27.18
PFT(pulmonary function test) 34,50
Audiometry 14.64
EKG 20.91
Urinalysis-dipstick 3.14
Subtotal 434.88
Sales Tax
Total Invoice Amount
Check/Credit Memo No: Payment/Credit Applied
NAP
R
INVOICE
0 Public Safety Medical Services
w 324 E. New York Street
E Suite 300
w Indianapolis, IN 46204
o Carmel Fire Department/CARMEFD
Terms
Attn: Accounts Payable
Invoice Date 12/30/2012
2 Civic Square
m
Carmel, IN 46032 Invoice# 00-19492
Date Employee Description Amount Balance Due
12/21/12 Brant Kenneth E. 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
Vital Signs-HT WT BP P R $0.00 $0.001
Vision-Acuity 27.18 $27.18
FT-Pul m onary Function t $34.50 $34,50
Audiometry $14.64 $14.64
EKG W/Interp $20.91 $20.91
Urinalysis-Dipstick $3.14 $3.14
Total Charges-> $407.70
Total Payments&Balance Due-> $0.00 $407.70
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797
Balance due 15 days from invoice
date
'rescribed 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
vhom, 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))
19492 Brant $407.80
PRE-133112-0 Toney $434.88
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
$842.68
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
POO/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 19492 $407.80 I hereby certify that the attached invoice(s), or
1120 PRE-133112-0 $434.88 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
JAN 1 4 2013
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund