226789 12/03/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES
I` 1 324 E NEW YORK ST SUITE 300 CHECK AMOUNT: $2,452.64
CARMEL, INDIANA 46032
INDIANAPOLIS IN 46204 CHECK NUMBER: 226789
CHECK DATE: 12/3/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1081 4340700 21719 37 . 14 MEDICAL FEES
1091 4340700 21719 84 . 91 MEDICAL FEES
1120 4340799 21773 1, 285 . 27 OTHER MEDICAL FEES
1110 4341999 31365 21774 1, 045 . 32 PSYCHOLOGICL EVALS
INVOICE
o Public Safety Medical Services
r 324 E. New York Street
E Suite 300
W
w Indianapolis, IN 46204
o Carmel Clay Parks & Recreation/CARMELPARK
F— Attn: Jeff Kramer Terms
1411 E. 116th Street Invoice Date 11/13/2013
m Invoice# 00-21719
Carmel, IN 46032
Date Employee Description Amount Balance Due
11104/13 Koch,Carol C. Veni uncture $0.00 $0.00
_
Hep B Titer SAb-Quantitative Blood $37.14 $37.14
Wright,Paula A. Hepatitis B Vacc#2 $74.29 $74.2 9
In ection Fee $10.62 $10.6 2
Total Charges-> $122.05
Total Payments&Balance Due->1 $0.00 1 $122.05
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797 ,(r F T ]D
/ NOU .1 �4 2013
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Purchas T
Approval ------ 7
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ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
00350364 Public Safety Medical Services Terms
324 E. New York Street, Ste 300
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO# Amount
11/13/13 21719 Medical fees $ 37.14
11/13/13 21719 Medical fees $ 84.91
Total $ 122.05
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.
00350364 Public Safety Medical Services Allowed 20
324 E. New York Street, Ste 300
Indianapolis, IN 46204
In Sum of$
$ 122.05
ON ACCOUNT OF APPROPRIATION FOR
108 ESE / 109 Monon Center
PO#or INVOICE NO. ACCT#[TITLE AMOUNT Board Members
Dept#
1081-99 21719 4340700 $ 37.14 1 hereby certify that the attached invoice(s), or
1091 21719 4340700 $ 84.91 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
27-Nov 2013
Signature
$ 122.05 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
INVOICE
� Public Safety Medical Services
= 324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
G Carmel Police Department/CARMEPD
E- 3 Civic Square Terms
Carmel, IN 46032 Invoice Date 11/20/2013
m Invoice# 00-21774
Date Employee Description Amount Balance Due
11/15/13 Roemke Brian A. Chart Review/Completion $85.94 $85.94
Indiana PERF Exam $193.13 $193.13
Drug Screen 9 +Opiates&Ox codone $42.45 $42.4 5
Applicant Blood Panel-PERF $121.84 $121.84
Tb Skin Test $7.43 $7.43
Veni uncture $3.19 $3.19
Chest X-Ray-PA/LAT(Digital) 63.67 $63.6 7
Tonomet Glaucoma Test 38.20 $38.2 0
Urinal sis-Dipstick $3.19 $3.19
EKG W/Intero $21.22 $21.22
Audiometry 14. 6 $14.86
PFT-Pulmonary Function Test $35.02 $35.02
Vision-Color Ishihara $27.59 $27.59
Vision-Acuity $27.59 $27.59
Vital Si ns-HT WT BP P R $0.00 $0.00
PSY-Applicant Psych Eval $360.00 $360.00
Total Charges-> $1,045.32
Total Payments&Balance Due-> $0.00 $1,045.32
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 date
CiINDIANA RETAIL TAX EXEMPT PAGE
ty ®f Car Me� CERTIFICATE NO.003120155 002 0 PURCHASE ORDER NUMBER
FEDERAL EXCISE TAX EXEMPT 3M
35-60000972
ONE CIVIC SQUARE,' THIS NUMBER MUST APPEAR ON INVOICES,A/P
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
11114=13
Public 60etV Medical SerVicGo Cannel Folic@ Department
VENDOR TOHIP 3 CIVIC sgu2m
324 E. Nit Mott Sfraof, Buie 3M CwmGI, IN 46
Indlmnapolis, IN 462U (317)671-259
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
Account QUANTITY �y UNIT
g�OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Account 43-419.M
1 Each psychological evaluation $370.93 $370.93
1 Each p"icel for applicant $875.19 $675.19
Sub Total: $1,045.32
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Send Invoice To: '
Carmel Police Department
Attn:Tomsa Anderson
3 CIVIC Square
Camel, IN 462- PLEASE INVOICE IN DUPLICATE
DEPARTMENT 0_7 ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
Carmel Police Dept. �2) PAYMENT $1,Q45,32
A/P VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THEAPROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS I HEREBY CERTIFY/THATTHERE IS AN UNOBLIGATED BALANCE IN
•SHIP REPAID.
THIS APPRO JT� SUFFICIENT TO Y FOR THE ABOVE ORDER.
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED.
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS.
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE /���n i i1T pibllam
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. V
q CLERK-TREASURER
DOCUMENT CONTROL NO. 3 1 3 6 5 A.P.V. COPY-SIGN AND RETURN TO CLERK'S OFFICE
VOUCHER WARRANT NO.
ALLOWED 20
IN THE SUM OF$
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#[TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received
—-----------------------------
..................................................................................... ............................................... ....................................................
Signature
......................................................................-.................................... .................. ..........................
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$1,045.32
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
_31365 I 21774 I 43-419.99 I $1,045.32 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
Tuesday, November 26, 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))
21774 Brian Roemke $1,045.32
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
INVOICE
to Public Safety Medical Services
r 324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
o Carmel Fire Department/CARMEFD
E- Attn: Asst Chief David Haboush Terms
Invoice Date 11/20/2013
2 Civic Square
m Invoice# 00-21773
Carmel, IN 46032
Date Employee Description Amount Balance Due
11/11/13 Jenkins John W. Tb Read $0.00 $0.00
Wilson Carlos A. Chest X-Ray-PA/LAT(Digital) $63.67 $63.67
PSY-Applicant Psych Eval $360.00 $360.00
Chart Review/Completion $85.94 $85.94
Indiana PERF Exam $193.13 $193.13
Drug Screen 9 +Opiates&Ox codone $42.45 $42.4 5
Applicant Blood Panel-PERF $121.84 $121.84
Tb Skin Test $7.43 $7.43
Veni uncture $3.19 $3.191
Tonomet Glaucoma Test 38.20 $38.2 0
Urinalysis-Di stick $3.19 $3.19
EKG W/Interp $21.22 $21.22
Audiometry $14.86 $14.8 6
PFT-Pulmonary Function Test $35.02 $35.02
Vision-Color Ishihara 27.59 $27.5 9
Vision-Acuity 27.59 $27.5 9
Vital Signs-HT WT BP P R $0.00 $0.00
11/12/13 Foster James P. Brief Physical Exam Wellness 70.04 $70.0 4
Chest X-Ray-PA/LAT(Digital) 63.67 $63.67
EKG W/Interp $21.22 $21.22
PFT-Pulmonary Function Test $35.02 $35.0 2
Vital Signs-HT WT BP P R $0.00 $0.00
11/13/13 Wilson Carlos A. Tb Read $0.00 $0.00
11/15/13 Anderson,Donovan C. Respirator/Medical Review $25.00 $25.00
Love,Joseph B. 1 Respirator/Medical Review $25.00 1 $25.00
Total Charges-> $1,285.27
Total Payments&Balance Due-> $0.00 $1,285.27
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 � (� e
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$1,285.27
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I 21773 I 43-407.99 I $1,285.27 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
�/H f
l
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
'rescribed by State Board of Accounts City Form No.201(Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
\n 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))
21773 $1,285.27
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