PHILHEALTH PATIENTS' BILL

NAME OF PATIENT: Hosp. No.

Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C1"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P 800.00

ER Fee 500.00 375.00

Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 562.00 P 437.00 P 800.00 P 0

Professional Fee:

- -
- -
- -

Total Amount Due P 562.00 P 437.00 P 800.00 P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 125.00

NBB
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C1"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. 850.00 850.00

NBS=550/CD=300 PACKAGE
Operating Room Fee -
Others: P
ER Fee - 1,050.00
Misc. /Supp./X-Ray -
RR Fee - CODE: 99432
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 912.00 P 912.00 P 1,050.00 P -

Professional Fee:

- -
500.00 500.00 500.00
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 -

-
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C2"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P
ER Fee 500.00 250.00
Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 562.00 P 312.00 P - P 312.00

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 250.00

312
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C2"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. 850.00 850.00

NBS=550/CD=300 PACKAGE
Operating Room Fee -
Others: P
ER Fee -
Misc. /Supp./X-Ray -
RR Fee - CODE: 99432
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 912.00 P 912.00 P - P 912.00

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 -

912
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C3"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P
ER Fee 500.00 125.00
Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 562.00 P 187.00 P - P 187.00

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 375.00

187
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"C3"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. 850.00 850.00

NBS=550/CD=300 PACKAGE
Operating Room Fee -
Others: P
ER Fee -
Misc. /Supp./X-Ray -
RR Fee - CODE: 99432
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 912.00 P 912.00 P - P 912.00

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 -

912
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"D"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P
ER Fee 500.00 -
Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 62.00

Sub-Total P 562.00 P 62.00 P - P 62.00

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 500.00

62
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"SC"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P
ER Fee 500.00 400.00
Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 49.60

Sub-Total P 562.00 P 449.60 P - P 449.60

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 112.40

450
 PHILHEALTH PATIENTS' BILL
NAME OF PATIENT: Hosp. No.
Complete Address: Department/Ward:
Date of Admission: Date of Discharge:
Physician:

Particulars Actual Philhealth

Amount after Excess
Charges Discount Benefits

"PWD"

Room and Board days @ P P P -

days @ P - -

Drugs and Medicines / Oxygen -

BHF, Cross Matching, Laboratory Exam. -

PACKAGE
Operating Room Fee -
Others: P
ER Fee 500.00 400.00
Misc. /Supp./X-Ray -
RR Fee - CODE:
HEMODIALYSIS - CATEGORY:
Machines -
R.Card/Env./W.tag 62.00 49.60

Sub-Total P 562.00 P 449.60 P - P 449.60

Professional Fee:

- -
- -
- -

Total Amount Due P P P P

Prepared by: Certified Correct:

JENG JUSTINIANO Narlyn R. Severo

Billing Clerk Head, Billing Section

SIGNATURE:
 PRINTED NAME:
CELLPHONE NUMBER:
RELATIONSHIP TO PHILHEALTH MEMBER: _____________

RIMC-FIN-BIL-FRM-003 REV.1/16-APR-2014
 112.40

450