STATEMENT OF THE ACCOUNT

SOA Reference No. ___________

Patient Name: __________________________________ Age: _______ Date & Time Admitted: _______________________________
Address: __________________________________________________ Date & Time Discharged: _____________________________
Final Diagnosis: ___________________________________________ First Case Rate: ____________________________________
Other Diagnosis: 1. _______________________________________ Second Case Rate: __________________________________
2. _______________________________________
3. _______________________________________

SUMMARY OF FEES

Amount of Discounts PhilHealth Benefits

Place: Out of
__PCSO Pocket of
VAT Senior __DSWD
First Case Second Case
Particulars Actual Charges exempt Citizen/ PWD __DOH(MAP) Rate Amount Rate Amount Patient
__HMO
__Others:
_______
HCI fees
Room Board
Drugs and Medicines
Laboratory &
Diagnostics
Operating Room Fee
Supplies
Other: Pls. Specify

Subtotal ₱ ₱ ₱ ₱ ₱ ₱ ₱
Professional Fee/s
1. ERLINDA VITAL
2.
3.
Subtotal ₱ ₱ ₱ ₱ ₱ ₱ ₱

Total ₱ ₱ ₱ ₱ ₱ ₱ ₱

Prepared by: Conforme:

NIEVES E. ABIAR _________________________________

Billing Clerk/Accountant Member Patient Authorized representative
(Signature over Printed Name) (Signature over Printed Name)
Date Signed: _____________ Relationship to member of Authorized representative
Contact No: 09558177921 Date Signed: ___________________
Contact No: _______________________________

NOTE:
1. Form out the form legibly
2. The member/patient/authorized representative should not sign a blank SOA
3. Printed copy of SOA or its equivalent should be free of charge