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Hospital Bill - 20250626 - 205200 - 0000

The document is a statement of account for patient Donna Marie Doctolero, who was admitted to St. Clare's Medical Center on June 23, 2025. The total hospital bill amounts to 38,678.90 PHP, which includes charges for emergency room services, laboratories, and professional fees. The patient is a non-member of PhilHealth and is responsible for the full amount due, with instructions for potential refunds from PhilHealth provided in the remarks section.

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norilynalvarez306
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246 views1 page

Hospital Bill - 20250626 - 205200 - 0000

The document is a statement of account for patient Donna Marie Doctolero, who was admitted to St. Clare's Medical Center on June 23, 2025. The total hospital bill amounts to 38,678.90 PHP, which includes charges for emergency room services, laboratories, and professional fees. The patient is a non-member of PhilHealth and is responsible for the full amount due, with instructions for potential refunds from PhilHealth provided in the remarks section.

Uploaded by

norilynalvarez306
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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06/ 26/2025

ST.CLARE'S MEDICAL CENTER, INC. 07:35:42PM


1838 Dian Street, Makati City, Metro Manila
Tel Nos. 831-65-11

STATEMENT OF ACCOUNT

CASE NO 20000160268 ROOM/BED # 28


ROOM RATE 2, 180.00
PATIENT NO 2000073091
ADMITTED Jun 23 2025 10:37PM
PATIENT NAME DONNA MARIE DOCTOLERO
AGE 26 SENIOR CIT. ID NO: DISCHARGE
ATT. PHYSICIAN PHIC Non-Member
ADDRESS 218 Tejeros Garden Bliss Makati City HMO
COMPANY
PERSON RESPONSIBLE FOR THE ACCOUNT: CASE TYPE PC
PATIENT TYPE Out Patient

HOSPITAL BILL AMOUNT DISCOUNT PHILHEALTH CORPORATE DUE FROM


GUARANTOR PATIENT
EMERGENCY ROOM 4, 600.00 4, 600.00
MEDICINES
- - -
13, 802.65 13, 802.65
LABORATORIES 8, 814.65 - - - 8, 814.65
SUPPLIES 11,461.60 - - - 11,461.60

HOSPITAL GROSS CHARGES 38, 678.90 0.00 - - 38, 678.90


Less:
NET HOSPITAL BILL 38, 678.90
PROFESSIONAL FEES AMOUNT DISCOUNT PHIC HMO NET
ESP/PWD/SC
DR. EDNA BERSONDA M. D 2,500.00 38, 678.90
Internal Medicine - -

TOTAL PROFESSIONAL FEES 2,500.00 0.00 38, 678.90

NETAMOUNTDUE 38, 678.90

Impotant: REMARKS:
Please keep this patient's SOA for your copy and present, together with
PHIC issued benefits Payment Notice. Upon refund of PHIC benefits (if
any), you can claim your refund check at the Accounting Office 2 weeks
after submission of complete documents
Releasing of cheques for refund is schedule every wednesday.

Prepared by:
KING ABELLERA

STAFF NURSE
SIGNATURE/OVER PRINTED NAME CONTAC NUMBER/RELATION
PATIENT/REPSENTATIVE TO PATIENT

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