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PHILIPPINE GENERAL HOSPITAL

The National University Hospital


University of the Philippines
Taft Avenue, Manila
PHIC Accredited Health Care Provider
ISO 9001:2008 Certified

CHARITY IN-PATIENT ACCOUNT RECORD


AS OF JUNE 08, 2017 09:59 AM

Patient Name: CARBAJAL, JASON BOURNE AVILA Case No.: 4403773


Address: B2 L10A DOA PAZ SUBD. PULANG LUPA 2 LAS PIAS CITY Bill No.: 208387
Discount Type: Age:
Date Admitted: May 05, 2017 Time Admitted: 07:46 PM
Date Discharged: June 08, 2017 Time Discharged: 09:59 AM
Room/Ward/Bed: NXI Balance: 0.0

Summary of Charges

SERVICES DEPARTMENT FEES Gross Discount Amount Due


ECG-(40202170-00-03B) 140.00 - 140.00
LABORATORIES-BLOODBANK-(40202170-00-01) 2,600.00 - 2,600.00
LABORATORIES-CLINICAL CHEMISTRY-(40202170-00-01) 1,240.00 - 1,240.00
LABORATORIES-CLINICAL MICROBIOLOGY-(40202170-00-01) 2,920.00 - 2,920.00
LABORATORIES-CLINICAL MICROSCOPY-(40202170-00-01) 470.00 - 470.00
LABORATORIES-HEMATOLOGY-(40202170-00-01) 675.00 - 675.00
MEDICINE (SECTION OF PULMONOLOGY)-(40202170-00-06A) 1,500.00 - 1,500.00
ORL-(40202170-00-439-161) 200.00 - 200.00
PHARMACY-CONSIGNMENT 395.00 - 395.00
PHARMACY-REVOLVING FUND 2,092.75 - 2,092.75
PHARMACY-SPECIAL PURCHASE 533.00 - 533.00
ROOM AND BOARD CHARITY-(40202170-00-23L) 3,500.00 - 3,500.00
TOTAL CHARGES Php 16,265.75 Php 0.00 Php 16,265.75

LESS: ADJUSTMENTS
RETURN. MEDS (CM #ENC) Php 0.00
TOTAL ADJUSTMENTS Php 0.00
TOTAL CHARGES AFTER ADJUSTMENTS Php 0.00
PAYMENTS
DATE OR NUMBER AMOUNT
- - -
TOTAL PAYMENTS: Php 0.00
LESS:BENEFIT(S)
PHIC-P07.3 Php 11,830.00
MSS Php 2,000.00
PHIC-99432 Php 1,250.00
OUTSTANDING HOSPITAL BILLS Php 1,185.75

PROFESSIONAL FEE(COMPLIMENTARY):
1ST CASE RATE Php 0.00
2ND CASE RATE Php 0.00
TOTAL PROFESSIONAL FEE Php 0.00

NOTED BY: Printed by:

GOODICO M. YANZON CANTOS, ABIGAIL TAEDO


Chief, Revenue Section Data Encoder

Note: issued initial dose merop 5/13

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