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Hosp Bill323423

The document is a statement of account for patient Perla Bello Escario, who was admitted on June 10, 2024, with a total hospital bill of 16,814.71 PHP after discounts and payments. The charges include various medical services such as X-ray, pharmacy, and professional fees, with a balance due of 16,814.71 PHP. The statement also includes details of the attending doctor and the patient's guarantor information.

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lydiabrooks007
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175 views1 page

Hosp Bill323423

The document is a statement of account for patient Perla Bello Escario, who was admitted on June 10, 2024, with a total hospital bill of 16,814.71 PHP after discounts and payments. The charges include various medical services such as X-ray, pharmacy, and professional fees, with a balance due of 16,814.71 PHP. The statement also includes details of the attending doctor and the patient's guarantor information.

Uploaded by

lydiabrooks007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MCU-FDT Medical Foundation Inc.

Run Date and Time 6/20/2024 9:58:30 AM


Samson Road, Edsa Caloocan City Philippines SOA Reference No.: 2024-750454 0667-2031 to 45
Emergency

STATEMENT OF ACCOUNT
PID 271387
Name of Patient: Escario, Perla Bello Age: 68Y7F13D Date & Time Admitted: 6/10/2024 9:00 AM
Address: 549 P. Sevilla St 2nd Ave. Barangay 44 Caloocan City , Metropolitan Date & Time Discharge:
Attending Doctor(s): Rivera, Caferino Hospital Plan: Self-Pay Admission/Case No 132380
Final Diagnosis/es and iCd 10 Code’s: Room No
Surgical Procedures and Rvs Codes, if Applicable: First Case Rate:
Second Case Rate:

HOSPITAL BILL PARTICULARS CHARGES PAYMENT/CN


X-Ray 1,942.00
Central Supply Room 1,942.00
Pharmacy – Main 2,583.34
Emergency Room 5,193.96
Dept of Clinical Laboratories 5,163.68
Pulmonary Section 2,383.06
CT – Scan 6,200.00
Professional Fee 2,666.67
Senior Citizen Discount 1,240.00
Payment 9,960.00

16,814.71 11,200.00

BALANCE DUE>>>>>>>> 16,814.71


PROFESSIONAL FEES PARTICULAR
DOCTOR(S) CHARGES INSTRU OTHER DISCOUNT SR/PWD PAYMENT HMO ADJUSMENT PHILHEALTH BALANCE
FEE AMT DISC
ADAN, FATIMA LIMBA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
LINGATING, REFERINO LIMBA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
RIVERA, CAFERINO L 2,666.67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,666.67
Total Professional fee
P H I L HE A L T H D E T A I L S GUARANTOR DETAILS
PARTICULARS AMOUNT COVERED GURANTOR NAME Hospital Bill Professional
Fee
ROOM AND BOARD
DRUGS AND MEDEICINE
XRAY / LAB / OTHERS
OPERATING ROOM FEE
TOTAL AMOUNT GUARANTEED TOTAL AMOUNT 0.00

Note: This SOA also serves as your invoice NET REFUND 0.00

Prepared By: Aponte, Veronica Gasapo Verified By: Sandra Sams Bello 6/20/2024
Designation: Billing Clerk / A/R Clerk Printed Name and Signature of Member/Representative Date Signed
Date Signed: 6/20/2024 Relationship to member: Daughter Contact no.: +63281235467

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