227472 12/17/2013 CITY OF CARMEL, INDIANA VENDOR: 00350364 Page 1 of 1
ONE CIVIC SQUARE PUBLIC SAFETY MEDICAL SERVICES CHECK AMOUNT: $2,234.49
CARMEL, INDIANA 46032 324 E NEW YORK ST SUITE 300
INDIANAPOLIS IN 46204 CHECK NUMBER: 227472
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CHECK DATE: 12/1712013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4340799 11-10686 1, 037 . 89 OTHER MEDICAL FEES
1120 4340799 21891 151 . 28 OTHER MEDICAL FEES
1120 4340799 21929 1, 045 . 32 OTHER MEDICAL FEES
INVOICE
o Public Safety Medical Services
324 E. New York Street
E Suite 300
iY Indianapolis, IN 46204
HCarmel Fire Department/CARMEFD Terms
_ Attn: Asst Chief David Haboush
Invoice Date 12/03/2013
2 Civic Square
m
Carmel, IN 46032 Invoice# 00-21891
Date Employee Description Amount Balance Due
11/27/13 Knott Bruce A. Respirator/Medical Review $25.00 $25.00
Brief Physical Exam Wellness 70.04 $70.04
EKG W/Interp $21.22 $21.2 2
PFT-Pulmonary Function Test $35.02 $35.02
Vital Signs-HT WT BP P R $0.00 $0.001
Total Charges-> $151.28
Total Payments&Balance Due-> $0.00 $151.28
Please write invoice number on payment check.
Balance due 15 days from invoice
Our Federal Employer Identification Number is 35-2079797 date
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$151.28
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. I ACCT#/TITLE I AMOUNT Board Members
1120 I 21891 I 43-407.99 I $151.28 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
I ' 2013
f
Fire Chief
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))
21891 $151.28
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
o Public Safety Medical Services
= 324 E. New York Street
E Suite 300
W Indianapolis, IN 46204
C Carmel Fire Department/CARMEFD
Terms
Attn: Asst Chief David Haboush
2 Civic Square Invoice Date 12/10/2013
M Carmel, IN 46032 Invoice# 00-21929
Date Employee Description Amount Balance Due
12/03/13 Baskerville Steven M. Chart Review/Completion 85.94 $85.9 4
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
Tonomet Glaucoma Test 38.20 $38.20
Urinalysis-Dipstick $3.19 $3.1 9
EKG W/Inter 21.22 $21.22
Audiornetry $14.86 $14.86
PFT-Pulmonacy Function Test $35.02 $35.02
Vision-Color Ishihara $27.59 $27.59
Vision-Acuity 27.59 $27.5 9
Vital Signs-HT WT BP P R $0.00 $0.001
Chest X-Ray-PA/lAT(Digital) 63.67 $63.671
PSY-Applicant Psych Eval $360.00 $360.001
Total Charges-> $1,045.32
Total Payments&Balance Due-> $0.00 $1,045.32
Please write invoice number on payment check.
Our Federal Employer Identification Number is 35-2079797
Public Safety Medical Services, Inc. ®
324 E. New York
Suite 300 Invoice Number: 11-10686
Indianapolis, IN 46204 Invoice Date: Dec 12, 2013
TIN 35-2079797 Page: 1
Voice: 1-317-972-1180 Duplicate
Fax: 1-317-972-1190
Bill To: Ship to:
Carmel Fire Department Carmel Fire Department
2 Civic Square 2 Civic Square
Carmel, IN 46032 Carmel, IN 46032
Customer ID Customer PO Payment Terms
—I CARMEFD Net 15 Days
Sales Rep ID Shipping Method Ship Date Due Date
Courier 1227/13
Quantity Item Description Unit Price Amount
Applicant Medical-Marcus Nalley-12/12/13 677.89
Psychological Evaluation 360.00
Subtotal 1,037.89
Sales Tax
Total Invoice Amount 1,037.89
Check/Credit Memo No: Payment/Credit Applied
TOTAL 1,037.89
VOUCHER NO. WARRANT NO.
ALLOWED 20
Public Safety Medical Services
IN SUM OF $
324 East New York Street, Ste. 300
Indianapolis, IN 46204
$2,083.21
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#!TITLE AMOUNT Board Members
1120 11-10686 43-407.99 $1,037.89 1 hereby certify that the attached invoice(s), or
1120 21929 43-407.99 $1,045.32 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 16 ton
Fire Chief
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))
11-10686 $1,037.89
21929 $1,045.32
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