226476 11/19/2013 a- CITY OF CARMEL, INDIANA VENDOR: 365641 Page 1 of 1
ONE CIVIC SQUARE ST VINCENT HOSPITAL CHECK AMOUNT: $69.54
CARMEL, INDIANA 46032 HEALTH INFORMATION MANAGEMENT
2001 W 86TH STREET CHECK NUMBER: 226476
INDIANAPOLIS IN 46260
CHECK DATE: 11!19/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4358200 R158311 69 . 54 SPECIAL INVESTIGATION
10/31/2013
St. Vincent Hospitals
Indianapolis,Carmel & Fishers
2001 W. 86th Street
Indianapolis IN 46260
Prosecuting Attorney of Hamilton County Indiana
3 Civic Square
Carmel, IN 46032
T.Andrew Zellers
Patient David Reynolds-
Your request for medical records has been received. Prepayment
is required before we complete your request. If we do not receive
a response within 30 days your request will be cancelled and you will
need to resubmit your request.
Please notify us promptly if you need additional time to submit
prepayment.
Request No Date received Page Count Charges
R158311 10/15/2013 66 44.00
taxid Postage 5.54
35-0869066
Certified 20.00
Pages on disc
Total charges $59.54 i
Amount Paid 0.00
Amount Due $69.54
To ensure your prepayment is posted correctly please include a
copy of this invoice and send Attn: Health Information Management
To pay by cr it card call 17-338-2216 between 8 am and 4:30 pm.
Release of Information
( 317 ) 338-2216
VOUCHER NO. WARRANT NO.
ALLOWED 20
St. Vincent Hospital
IN SUM OF $
Health Information Management
2001 W. 86th Street
Indianapolis, IN 46260
$69.54
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 I R158311 I 43-582.00 ( $69.54 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
Thursday, November 14, 2013
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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))
10/15/13 R158311 medical records request $69.54
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