Patient Name : PHOKEN,KASHMALA Admission #: 95635306

Admitting Physician : DR. ZEHRA FADOO MR #: 188-80-50

Financial Class : WLF Room / Bed #: B018 - E
Admission Date : 09/12/2009 Discharge Date:
Source : ER

STATEMENT OF PATIENT CHARGES | TOTAL CHARGES

A: HOSPITAL ACCOMMODATION | 110,800.00
98,050.00 |
Bed Charges / Ancillaries 75 day(s)...........................................................................
12,750.00 |
Special Care 1 day(s).........................................................................................
|
B: PROFESSIONAL FEES | 84,030.00
46,830.00 |
Attending Visits...............................................................................................
24,000.00 |
Surgery........................................................................................................
13,200.00 |
Anesthesia.....................................................................................................
0.00 |
Obstetrics.....................................................................................................
0.00 |
Special Consultancy............................................................................................
0.00 |
Special Procedure..............................................................................................
0.00 |
Dietetic Service...............................................................................................
|
C: PHARMACY AND MEDICAL / SURGICAL SUPPLIES | 299,911.00
206,473.64 |
Pharmacy.......................................................................................................
93,437.00 |
Medical / Surgical Supplies....................................................................................
|
D: DIAGNOSTIC TESTS AND PROCEDURES | 342,278.00
210,148.00 |
Laboratory.....................................................................................................
83,960.00 |
Radiology......................................................................................................
8,950.00 |
Physiological Measurement Services.............................................................................
0.00 |
Physiotherapy..................................................................................................
34,320.00 |
Operation Theater..............................................................................................
0.00 |
Delivery Room..................................................................................................
4,900.00 |
Special Procedures.............................................................................................
|
E: OTHERS | 2,290.00
2,000.00 |
Emergency Visit................................................................................................
290.00 |
Convenience Items..............................................................................................
0.00 |
Special Services...............................................................................................
|

TOTAL CHARGES .......................................................................... | 839,309.00

LESS DEPOSIT ........................................................................... | 206,000.00
NET BALANCE / (REFUND) DUE ............................................................. | 633,309.00
|

This is an interim statement and charges reported above are liable to change as they are received in the
billing office. A final statement of charges will be provided at discharge.

Issued By :
PATIENT BUSINESS SERVICES DEPARTMENT

Printed On : 26/02/2010 03:30 PM Page 1 of 1