HomeMy WebLinkAbout228709 1/28/2014 °��,f CITY OF CARMEL, INDIANA VENDOR: 365641 Page 1 of 1
ONE CIVIC SQUARE ST VINCENT HOSPITAL
i,,�`ia CARMEL, INDIANA 46032 HEALTH INFORMATION MANAGEMENT CHECK AMOUNT: $45.54
_oM�0 2001 W 86TH STREET CHECK NUMBER: 228709
INDIANAPOLIS IN 46260
CHECK DATE: 1/28/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4358200 65151 45 . 54 SPECIAL INVESTIGATION
St. Vincent Hospitals Invoice No
Indianapolis,Carmel & Fishers 65141
2001 W. 86th Street
Indianapolis, IN 46260
( 317 ) 338-2216 Tax ID: 35-0869066
Date: 10/31/2013
To: Carmel Police Dept.
3 Civic Square
Carmel, IN 46032
Attn: T.Andrew Zellers
Patient: David Reynolds
Request No Invoice No Medical Record No Date Received Date Sent
R158311 65141 0002293563 12/04/2013 10/31/2013 Pages/Time Charges
Photocopy 3 20.00
To ensure payment is posted
correctly please include copy of Postage 5.54
our invoice and send Attn: Health Certified 20.00
Information Management Department
Sales Tax 0.00
Total Billed $45.54
Amount Paid 0.00
Document Date
Start End Description Balance $45.54
07/27/2013 07/27/2013 Lab Reports
Indianapolis records
To ensure proper posting of payment, please send Attn: Health Information Management
I
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))
01/21/14 65151 medical records $45.54
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.
ALLOWED 20
St. Vincent Hospital
Health Information Management IN SUM OF $
2001 W. 86th Street
Indianapolis, IN 46260
$45.54
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 I 65151 I 43-582.00 I $45.54 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, January 23, 2014
Chief of Police
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund