‘SAFE MOTHERHOOD MATERNITY CLINIC (SMMC) } San Pablo City, Laguna, Philippines | TLE Contact No. o93v0162545 7) #47 P. Alcantara St. Brgy. VI Patient name:_Charisse M-Resioales Address ou sec Date and Time Admitted:-444 © 400M _ Date and Time Discharged: 12-24-14 @ "5° ja a Remedig —$@ Final Dingnosis:_Guey (400d) Qu 94 9h wee ing aie enmicintstor First Case Rate Mcpo1 Other Diagnoses: 1, —— Second Case Rate fpecee erare ere ee eer, 3. SUMMARY OF FEES f ] ] ‘Amount of Discounts Phillieaith Benefits | T Place 7 T P. | Actual VAT Senior |__HMO First Case | Second Case articulars Charges | exempt | Citizen/ | DSWD | Rate Amount | Rate Amount Pwo | —DoHoun | Mo | — Others L I HCI Fees Room and Board ae 7 I nooLe | Drugs and Medicines | 750 I { 2200 | Laboratory and | Diagnosties I Delivery Room Fee | Uoo woo. ve Supplies 1300 | Vig00 Others: Pls. Specify | ] | [Subionl Pago |? P P Piacoa Peres Professional Fee's i 3208 3,200 2. 3. [4 | | Ss | [ Subéotal P 3.206 |P P 1 P3205 |P_o.o8 (Total LP 8.900 |p lp ip [p_&0°® |p o-s0 Prepared: Conforme: a 00 Leuma sever ewees mtant Member / Patient / Authorized Representative (Signature over printed name) Date signed: 02-28-2011 Contact no.: 09399462545 (Signature over printed name) Date signed: 02 ->@- 201 Contact n¢