227083 12/11/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $377.64
=o CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 227083
CHECK DATE: 12/11/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340799 21829 352 . 60 OTHER MEDICAL FEES
1110 4341999 21830 25 . 04 OTHER PROFESSIONAL FE
INVOICE
10 Public Safety Medical Services
324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Police Department/CARMEPD
Terms
3 Civic Square
Carmel, IN 46032 Invoice Date 11127/2013
m Invoice# 00-21830
Date Employee Description Amount Balance Due
11/18/13 Roemke.Brian A. Tb Read $0.00 $0.00
11/20/13 Roemke, Brian A. Repeat Glucose. Fasting Blood $21.85 $21.85
Veni uncture $3.19 $3.19
E± Total Charges-> $25.04
Total Payments&Balance Due-> $0.00 1 $25.04
I, Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 date
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))
11/27/13 21830 partial physical/Roemke $25.04
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
Public Safety Medical Services
IN SUM OF $
324 E. New York Street, Suite 300
Indianapolis, IN 46204
$25.04
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#!TITLE AMOUNT Board Members
1110 21830 43-419.99 $25.04
I hereby certify that the attached invoice(s), or
I I I
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
Wednesday, December 04, 2013
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
INVOICE
o Public Safety Medical Services
:. 324 E. New York Street
E Suite 300
ix Indianapolis, IN 46204
C Carmel Fire Department/CARMEFD
Attn: Asst Chief David Haboush Terms
Invoice Date 11/27/2013
2 Civic Square
m
Carmel, IN 46032 Invoice# 00-21829
Date Employee Description Amount Balance Due
11/18/13 Drake.Carl D. Respirator Medical Review $25.00 $25.00
Brief Ph sisal Exam Wellness $70.04 $70.04
EKG W/Interp $21.22 $21.2 2
PFT-Pulmonary Function.Test $35.02 $35.0 2
Vital Si ns-HT WT BP P R $0.00 $0.00
Witsken.Steven J. Respirator/Medical Review $25.00 $25.0 0
11/20/13 Wilson.Carlos A. Repeat Glucose Fasting Blood 21.85 $21.85
Veni uncture $3.19 $3.19
11/22/13 VanVoorst Robert J. Respirator/Medical Review $25.00 $25.001
Brief Ph sisal Exam Wellness 70.04 $70.0 4
KG W In ten) 21. 2 $21.2 2
PFT-Pulmonary Function Test $35.02 $35.02
Vital Signs-HT WT BP P R $0.00 $0.00
Total Charges-> $352.60
Total Payments&Balance Due-> $0.00 $352.60
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 date
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))
21829 $352.60
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.
Public Safety Medical Services ALLOWED 20
IN SUM OF $
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$352.60
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. I ACCT#/TITLE AMOUNT Board Members
1120 I 21829 I 43-407.99 I $352.60 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
DEC - 9 2013
JA—/1741,
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund