H.M.

CORACHEA GENERAL HOSPITAL

A. Collantes Street, Barangay 7, Tanauan City, Batangas
Tel.No. (043)778-1298

STATEMENT OF ACCOUNT
Date Admitted: 4/2/2017 Attending Physician:
Patient's Name: SABA, PAMPILO Age: 77
Date Discharged: 4/6/2017 DIOGENES CORACHEA M.D.
Rm.No. 222 No. of days confined: 4

LABORATORY & MISCELLANEOUS MEDICINES

QTY ITEM UNIT COST TOTAL QTY ITEM UNIT COST TOTAL
SUPPLIES 1 PLR 1L 1L 170.00 170.00
1 Venoset 120.00 120.00 1 DISTILLED WATER 100.00 100.00
1 Insyte 120.00 120.00 8 CIPROFLOXACIN TAB 35.00 280.00
1 Plaster 65.00 65.00 8 DOXOFYLLIN TAB 20.00 160.00
10 Disposable Syringe & Needles 15.00 150.00 8 ESSENTIAL PAIRS TAB 40.00 320.00
10 Cotton Balls 2.50 25.00 12 COMBIVENT NEB 70.00 840.00
1 MISCELLANEOUS 1,250.00 1,250.00 1 NSS 55.00 55.00
1 NEB TUBE 130.00 130.00 12 CHLORPENAMINE AMP 120.00 1,440.00
12 USE OF NEB MACHINE 50.00 600.00 1 AMINOSEA AMP 300.00 300.00
- 6 QUADMAX TAB 20.00 120.00
- 2 VIT B CAP 15.00 30.00
4 NEUROBION AMP 300.00 1,200.00
LABORATORY 3 AZITHROMICIN TAB 85.00 255.00
1 12 L ECG 250.00 250.00 4 PLNSS 1L 170.00 680.00
1 CHEST XRAY PA 250.00 250.00 -
1 CBC 160.00 160.00 -
1 PLATELET COUNT 180.00 180.00 -
1 BUN 180.00 180.00
1 CREATININE 180.00 180.00
1 SODIUM 310.00 310.00
1 POTASSIUM 310.00 310.00
1 RBS 160.00 160.00
1 URINALYSIS 90.00 90.00
1 APICO VIEW 250.00 250.00
- -
- -
- -
- -
- -
- -

SUB-TOTAL 4,780.00 SUB-TOTAL 5,950.00

PHILHEALTH
SUMMARY ACTUAL DEDUCTION EXCESS Please settle bill on or before_________
4/6/17 til 12pm
ROD FEE 500.00 Otherwise, there will be additional charges.
E.R. FEE 550.00
ROOM 4 1000 4,000.00 AMOUNT
DATE OR NO.
MEDICINE 5,950.00 PAID
LABORATORY & MISC 4,780.00
PROFESSIONAL FEE 12,000.00 4,500.00 7,500.00

SUB-TOTAL 27,780.00
ADD:
MEAL
OTHERS - REMARKS:
LESS DEDUCTIONS: NH
SENIOR CITIZEN (4,960.71) BELOW 96 HOURS
EAB FINAL DIAGNOSIS:
OTHERS IVF SET J18.92-PNEUMONIA MODERATE RISK

TOTAL 22,819.29 15,000.00 7,819.29

Billing Officer:
JANE I. LITCHER
Date/Time billed: 4/6/2017 8:11:15 AM

DISCHARGE SLIP
NURSE: CASHIER: GUARD:
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