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PHILIPPINE GENERAL HOSPITAL The National University Hospital University of the Philippines Taft Avenue, Manila PHIC Accredited

PHILIPPINE GENERAL HOSPITAL

The National University Hospital University of the Philippines Taft Avenue, Manila PHIC Accredited Health Care Provider ISO 9001:2008 Certified

CHARITY IN-PATIENT ACCOUNT RECORD AS OF SEPTEMBER 04, 2017 12:39 PM

Patient Name: DORMENTES, CHRISTIAN JOSEPH PERLAS Address: 37 COCONUT ST., WOOD ESTATE VILLAGE 2, MOLINO 3, BACOOR CITY, CAVITE Discount Type:

Date Admitted: August 05, 2017 Date Discharged: September 04, 2017

Room/Ward/Bed:

nxi

Summary of Charges

Case No.: 4452629 Bill No.: 242895 Age:

Time Admitted: 04:47 PM Time Discharged: 12:39 PM Balance: 0.0

SERVICES DEPARTMENT FEES

Gross

Discount

Amount Due

ANESTHESIA-(40202170-00-439-25)

905.00

-

905.00

CCU-MAT (EQULIFE CONSUMABLES)-(2999999000-173)

3,740.00

-

3,740.00

LABORATORIES-BLOODBANK-(40202170-00-01)

1,500.00

-

1,500.00

LABORATORIES-CLINICAL CHEMISTRY-(40202170-00-01)

2,825.00

-

2,825.00

LABORATORIES-CLINICAL MICROBIOLOGY-(40202170-00-01)

6,735.00

-

6,735.00

LABORATORIES-CLINICAL MICROSCOPY-(40202170-00-01)

555.00

-

555.00

LABORATORIES-HEMATOLOGY-(40202170-00-01)

700.00

-

700.00

LABORATORIES-IMMUNOPATHOLOGY-(40202170-00-01)

430.00

-

430.00

LABORATORIES-SURGICAL PATHOLOGY-(40202170-00-01)

230.00

-

230.00

LCB-OR (ROOM & RATES)-(40202170-001-04B (LCB OR))

1,500.00

-

1,500.00

MEDICINE (SECTION OF PULMONOLOGY)-(40202170-00-06A)

750.00

-

750.00

NICU (MACHINES AND EQUIPMENT)-(4020217000-24)

28,425.00

-

28,425.00

NURSING EDUCATION AND TRAINING(DNET)-(40202990-00-13-2B)

600.00

-

600.00

PGH – PHARMACY-(4020299000-439-7-2)

3,724.50

-

3,724.50

PHARMACY-CONSIGNMENT

3,100.50

-

3,100.50

PHARMACY-REVOLVING FUND

12,930.25

-

12,930.25

PHARMACY-SPECIAL PURCHASE

1,865.00

-

1,865.00

ROOM AND BOARD CHARITY-(40202170-00-23L)

3,500.00

-

3,500.00

TOTAL CHARGES

Php 74,015.25

Php 0.00

Php 74,015.25

LESS: ADJUSTMENTS RETURN. MEDS (CM #ENC) TOTAL ADJUSTMENTS

Php 0.00

Php 0.00

TOTAL CHARGES AFTER ADJUSTMENTS

Php 0.00

PAYMENTS

DATE

OR NUMBER

AMOUNT

-

-

-

TOTAL PAYMENTS:

Php 0.00

LESS:BENEFIT(S)

PHIC-P07.3

Php 11,830.00

PHIC-99432

Php 1,250.00

OUTSTANDING HOSPITAL BILLS PROFESSIONAL FEE(COMPLIMENTARY):

Php 60,935.25

1ST CASE RATE

Php 0.00

2ND CASE RATE

Php 0.00

TOTAL PROFESSIONAL FEE

Php 0.00

NOTED BY:

Printed by:

GOODICO M. YANZON

Chief, Revenue Section

Note: W/ PC 9/4/17 given initial dose of merop 8/21 8pm

FLORES, JEROME D.

Data Encoder

Conforme:

Signature over Printed Name of Member or Representative

Contact Number:

If not the member:

Relation to Member: