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225427 10/23/2013
CITY OF CARMEL, INDIANA VENDOR: 367222 Page 1 of 1 f ONE CIVIC SQUARE IU HEALTH WORKPLACE SERVICES LL&ECK AMOUNT: $33,632.86 CARMEL, INDIANA 46032 2046 RELIABLE PKWY CHICAGO IL 60686-0020 CHECK NUMBER: 225427 CHECK DATE: 10/23/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 301 5023990 731669 27, 333 . 50 OTHER EXPENSES 1201 4358800 731718 30 . 00 TESTING FEES 1201 4358800 731720 96 . 00 TESTING FEES 301 5023990 731750 4, 374 . 16 OTHER EXPENSES 301 5023990 731825 1, 799 . 20 OTHER EXPENSES 3--3 ) Indiana University Health Workplace Services, LLC 950 North Meridian Street Suite 200 (City of Carmel) Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice October 1, 2013 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel- Onsite Misc.Onsite/Sept.2013 1 Civic Square Carmel,IN 46032- 1 Invoice# 731825 Proc Code Service Date Description Quantity Charge Receipt Adjust Balance 99070 08/11/2013 Young at Heart Clinic Meds 1.00 234.13 234.13 99070 08/18/2013 Young at Heart Clinic Meds 1.00 120.72 120.72 99070 08/25/2013 Young at Heart Clinic Meds 1.00 174.42 174.42 99070 08/31/2013 Young at Heart Clinic Meds 1.00 141.89 141.89 99070 09/01/2013 Onsite Lab Charges 1.00 966.62 966.62 Augus12013 Labs 99070 09/15/2013 Young at Heart Clinic Meds 1.00 161.42 161.42 CITYCARO Invoice# 731825 Balance Due: 1799.20 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE#ON CHECK I --- Cut and---- with payment ® Please remit 1,799.20 and Make Check Payable to: � VISA INVOICE# 731825 IU Health Workplace Services,LLC MASTERCARD 2046 Reliable Pkwy Chicago,IL 60686-0020 ACCOUNT NO CSv EXP CODE DATE Phone: 317-963-1535 SIGNATURE AMOUNT PAID 5 2 Z� -3°) Indiana University Health Workplace Services, LLC 950 North Meridian Street Suite 200 (City of Carmel) Indianapolis, IN 46204 317-963-1535 Tax I D# 20-0994452 Invoice October 1, 2013 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel-Onsite Nurse Time/Sept 2013 1 Civic Square Carmel,IN 46032- 1 Invoice# 731669 Proc Code Service Date Description Quanti Charge Receipt Adjust Balance 09/03/2013 CONTRACT R.N.DAY 6.00 372.00 372.00 Gwen Kopecky 09/04/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/05/2013 CONTRACT R.N.DAY 4.00 248.00 248.00 Gwen Kopecky 09/06/2013 CONTRACT R.N.DAY 6.25 387.50 387.50 Gwen Kopecky 09/09/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/10/2013 CONTRACT R.N.DAY 6.00 372.00 372.00 Gwen Kopecky 09/11/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/12/2013 CONTRACT R.N.DAY 4.00 248.00 248.00 Gwen Kopecky 09/13/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Given Kopecky 09/16/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/17/2013 CONTRACT R.N.DAY 6.00 372.00 372.00 Given Kopecky 09/18/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/19/2013 CONTRACT R.N.DAY 4.00 248.00 248.00 Gwen Kopecky 09/20/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/23/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecky 09/24/2013 CONTRACT R.N.DAY 6.00 372.00 372.00 Given Kopecky Invoice# 731669(continued)page 2 Proc Code Service Date Description Quanti t Charge Receipt Adjust Balance 09/25/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopeeby 09/26/2013 CONTRACT R.N.DAY 4.00 248.00 248.00 Gwen Kopecky 09/27/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopecly 09/30/2013 CONTRACT R.N.DAY 5.00 310.00 310.00 Gwen Kopec%y NURSEMA 09/03/2013 M.A.Nurse Time 7.00 196.00 196.00 Jennifer Lawson NURSEMA 09/04/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/05/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/06/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/09/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/10/2013 M.A.Nurse Time 6.00 168.00 168.00 Jennifer Lawson NURSEMA 09/11/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/12/2013 M.A.Nurse Time 4.00 112.00 112.00 Jennifer Lawson NURSEMA 09/13/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/16/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/17/2013 M.A.Nurse Time 6.00 168.00 168.00 Jennifer Lawson NURSEMA 09/18/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/19/2013 M.A.Nurse Time 4.00 112.00 112.00 Jennifer Lawson NURSEMA 09/20/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/23/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/24/2013 M.A.Nurse Time 6.00 168.00 168.00 Jennifer Lawson NURSEMA 09/25/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/26/2013 M.A.Nurse Time 4.00 112.00 112.00 Jennifer Lawson NURSEMA 09/27/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson NURSEMA 09/30/2013 M.A.Nurse Time 5.00 140.00 140.00 Jennifer Lawson Invoice# 731669(continued)page 3 Proc Code Service Date Description Quantit Charae Receipt Adjust Balance NURSEMD 09/03/2013 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan NURSEMD 09/04/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/05/2013 MD Staff Time 4.00 700.00 700.00 Dr,Fagan NURSEMD 09/06/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/09/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/10/2013 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan NURSEMD 09/11/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/12/2013 MD Staff Time 4.00 700.00 700.00 Dr.Fagan NURSEMD 09/12/2013 MD Staff Time 4.00 700.00 700.00 Dr.Nadelsarn NURSEMD 09/13/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/16/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/17/2013 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan NURSEMD 09/18/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/19/2013 MD Staff Time 4.00 700.00 700.00 Dr.Fagan NURSEMD 09/20/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/23/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/24/2013 MD Staff Time 6.00 1,050.00 1050.00 Dr.Fagan NURSEMD 09/25/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/26/2013 MD Staff Time 4.00 700.00 700.00 Dr.Fagan NURSEMD 09/27/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan NURSEMD 09/30/2013 MD Staff Time 5.00 875.00 875.00 Dr.Fagan CITYCARO Invoice# 731669 Balance Due: 27333.50 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE#ON CHECK V --Cut and return with payment Please remit 27,333.50 and Make Check Payable to: ❑ YASA VISA INVOICE# 731669 IU Health Workplace Services, LLC MASTERCARD 2046 Reliable Pkwy Chicago,IL 60686-0020 ACCOUNTNO CSV EXP CODE DATE Phone: 317-963-1535 SIGNATURE AMOUNT PAID $Z7 333-S�) 't Indiana University Health Workplace Services, LLC 950 North Meridian Street Suite 200 Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice October 1, 2013 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel-Onsite Onsite Fees/Sept. 2013 1 Civic Square Carmel,IN 46032- Invoice# 731750 Proc Code Service Date Description Quantit Charcie Receipt Adjust Balance CARMBUIL 09/01/2013 City of Cannel Clinic Build Out 1.00 2,574.16 2574.16 CARMLEAS 09/01/2013 City of Carmel Sports Performance 1.00 1,800.00 1800.00 Lease CITYCARO Invoice# 731750 Balance Due: 4374.16 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE#ON CHECK --Cut and return with payment Please remit 4,374.16 and Make Check Payable to: ❑o VISA INVOICE# 731750 lU Health Workplace Services,LLC ❑ MASTERCARD 2046 Reliable Pkwy Chicago,IL 60686-0020 ACCOUNTNO CSV EX CODE DATE Phone: 317-963-1535 SIGNATURE LE PAt�1L Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995) 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)) lam ) 0 73)Wc� )3 2,3) .5Q )o ) �s 31 2S n"isc Total ,Sv� 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 I VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF $ ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or INVOICE NO. ACCT#/TITLE AMOUNT DEPT.# I hereby certify that the attached invoice(s), or 3-01 231 L7,,333_5`, bill(s) is (are) true and correct and that the <, -31 5v 7 `� � 32� ,j� materials or services itemized thereon for SJ which charge is made were ordered and received except 20 l� Signature Cost distribution ledger classification if Title claim paid motor vehicle highway fund Indiana University Health Workplace Services, LLC 950 North Meridian Street Suite 200 (City of Carmel) Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice October 1, 2013 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel- Onsite Onsite/August 2013 1 Civic Square Carmel,IN 46032- Invoice# 731720 Proc Code Service Date Description QUantit Charge Receipt Adjust Balance 08/30/2013 Quick Read UDS/6panel includes 1.00 15.00 15.00 kit 82075 08/30/2013 Evidential Breath Test- 1.00 33.00 33.00 Non-Regulated 96.00 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE#ON CHECK ..Cut and.... with payment Please remit 96.00 and Make Check Payable to: ❑� VISA IU Health Workplace Services,LLC INVOICE# 731720 ❑ _ MASTERCARD 2046 Reliable Pkwy Chicago, IL 60686-0020 ACCOUNT NO CSv EXP CODE DATE Phone: 317-963-1535 SIGNATURE AMOUNT PAID $9L-. vc7 s$� Indiana University Health Workplace Services, LLC 2 950 North Meridian Stret Suite 200 (City of Carmel) Indianapolis, IN 46204 317-963-1535 Tax ID# 20-0994452 Invoice October 1, 2013 Bill to: Barbara Lamb For: City of Carmel-Onsite City of Carmel - Onsite Onsite/Sept. 2013 1 Civic Square Carmel,IN 46032- Invoice# 731718 Proc Code Service Date Descriotion Quantit Charge Receipt Ad US Balance 09/09/2013 Quick Read UDS/6panel includes 1.00 15.00 15.00 kit 30.00 MAKE PAYMENT TO THE BELOW ADDRESS WITHIN 30 DAYS OF INVOICE DATE-PLEASE INCLUDE INVOICE#ON CHECK Cut and return with payment Please remit 30.00 and Make Check Payable to: E] VISA IU Health Workplace Services, LLC INVOICE# 731718 ❑ ,, MASTERCARD 2046 Reliable Pkwy Chicago, IL 60686-0020 ACCOUNTNO Csv FXP CODE DATE Phone: 317-963-1535 SIGNATURE AMOUNT PAID S-3c) - �00 Prescribed by Stale Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995) 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 c� V)c6 Purchase Order No. 0 Terms ( ,cam,.,. � •�� 'O2� Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 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 IN SUM OF $ C"tcrsy� $ ) Zb o© ON ACCOUNT OF APPROPRIATION FOR Board Members PO#or D PT.# INVOICE NO. ACCT#!TITLE AMOUNT I hereby certify that the attached invoice(s), or I `�317Z� c�. bill(s) is (are) true and correct and that the IZ, materials or services itemized thereon for which charge is made were ordered and received except ?0 Signature Title Cost distribution ledger classification if claim paid motor vehicle highway fund