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    Screenshot 2024-04-20 at 3.34.10 PM

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    Screenshot 2024-04-20 at 3.34.10 PM

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    28 views2 pages
    Ghcf

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    Screenshot 2024-04-20 at 3.34.10 PM

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    28 views2 pages

    Screenshot 2024-04-20 at 3.34.10 PM

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    Online Payment

    STATEMENT OF ACCOUNT
    Patient No: 180023140428 SA Number: IPC100348341 Room No.: S09
    Patient Name: DABAN, MARIA SOLPOT Telephone No.: 09556125983 Room Rate: 950
    DOB: 02/06/1960 Date Admitted: 04/15/2024 Time: 0410PM
    Address: STAVRI RESIDENTIAL COMP. 615-4 TORMIS EXT Date Discharged: Time: 1030AM
    Sambag II (Pob.) Cebu City Cebu 6000
    Responsible JOHANNES KARSTEN DABAN
    Party:
    Attending DR. MARISSA GO CUENCO / DR. SHAREE ANN BAJAMUNDE DESQUITADO / DR. CHRISTOPHER TING GO / DR.
    Physician: MICHAEL JEREMY DIAZ TABALOC

    Final Diagnosis First Case Rate:


    Second Case Rate:
    1. ABSCESS, RIGHT LOWER LEG
    HOSPITAL BILLS
    Charges:
    Bloodbank 541.00
    Cardio Unit 1,076.40
    Central Sterile Processing Unit (CSPU) 262.02
    Central Supply Room 2,017.95
    Emergency Room 3,558.06
    Laboratory 16,589.00
    Operating Room 18,336.58
    Post Anesthesia Care Unit 2,256.84
    Pharmacy 23,591.31
    X-Ray 1,019.00
    Room Accommodation 4,750.00
    Ultrasound 0.00 73,998.16
    Add:
    0.00
    Less:
    Partial Payments 39,000.00
    39,000.00
    PHIC Deductions: First Case 0.00
    Second Case 0.00 0.00
    Adjustments:
    DISCOUNT - SENIOR CITIZEN (10,224.16) (10,224.16)

    Amount Due - Hospital Bill 24,774.00


    PROFESSIONAL FEES

    Amount Due - ( PROFESSIONAL FEE ) 0.00

    Total Amount Due 24,774.00

    Rundate: 4/20/2024 3:33:57 PM This serves as statement of account and not as proof of payment. The hospital
    Page 1/2 reserves the right to bill and collect from you: 1. additional charges
    actually incurred which were not initially billed 2. Philhealth claims
    deducted in this statement of account but underpaid or denied by Philhealth
    such as but not limited to - benefit already exhausted, violation of Single
    Period Policy, double filing. For possible Philhealth refund, please
    coordinate with our Refund/Billing Section (30) days after receipt of payment
    confirmation from Philhealth.
    Online Payment

    STATEMENT OF ACCOUNT
    CLAIM DETAILS
    Relationship to the Member
    Signature over Printed Name of Contact Number Signature over Printed Name of
    Member / Patient / Authorized Billing Clerk
    Signature

    Rundate: 4/20/2024 3:33:57 PM This serves as statement of account and not as proof of payment. The hospital
    Page 2/2 reserves the right to bill and collect from you: 1. additional charges
    actually incurred which were not initially billed 2. Philhealth claims
    deducted in this statement of account but underpaid or denied by Philhealth
    such as but not limited to - benefit already exhausted, violation of Single
    Period Policy, double filing. For possible Philhealth refund, please
    coordinate with our Refund/Billing Section (30) days after receipt of payment
    confirmation from Philhealth.

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