ANNEX A

ANNEX A-1
 ANNEX D
BAGUIO GENERAL MEDICAL HOSPITAL
Baguio General Hospital Driveway, Baguio City
Telephone No.: (074)661-7910

Patient Name: VICKY Y. TIMA Room Accommodation: PR - 04

Address: #5 TRANCOVILLE, BAGUIO CITY Admission Date: October 1, 2018
Discharge Date: October 31, 2018

STATEMENT OF ACCOUNT
Particulars Actual PF EXCESS
DISCOUNT

Hospital Charges
Room Charges (P1000/day) 30,000.00 15,000.00 15,000.00
Operating Room Fee 2,000.00 1,000.00 1,000.00
Medicines-RF 30,000.00 - 30,000.00
X-Ray 1,600.00 - 1,600.00
Use of Equipments 5,200.00 - 5,200.00
Emergency Room Fee 200.00 200.00 -
Recovery Room Fee 500.00 500.00 -
Supplies-RF 3,000.00 - 3,000.00
Laboratory Examination 3,500.00 1,500.00 2,000.00
Supplies 800.00 - 800.00
Admission Fee 50.00 - 50.00
Procedure Fees 750.00 - 750.00
Medical Certificate 50.00 - 50.00
Charging of Electronic Devices 75.00 - 75.00
Nursing Supplies 500.00 - 500.00 0
TOTAL 78,225.00 18,200.00 60,025.00

Professional Fee
HANNIGAN, Mike 15,000.00 7,000.00 8,000.00
INSTRUMENTATION FEE 10,000.00 - 10,000.00
RALDI, Gen E. 7,000.00 2,000.00 5,000.00
32,000.00 9,000.00 23,000.00

TOTAL HB & PF 110,225.00 27,200.00 83,025.00

DIAGNOSIS

T/C CEREBRAL CONCUSSION; R/O SKULL FRACTURE

Prepared by: Checked by: Verified by: Approved by:

Ar D. How Ica M. Mon Chan D. Bing Phoe B. Buffay

Billing Clerk Administrative Officer IV Accountant III Chief Administrative Officer

Payment Received by:

4567 / Oct. 31,2019

Joe Y. Adams Official Receipt No. / Date

Administrative Officer V
 ANNEX D

4567
October 31, 2018
Vicky Y. Tima

Eighty-three thousand twenty-five pesos only (PhP 83, 025.00)

Settlement of hospital bill

PhP 83, 025.00 Joe Y. Adams

PhP 83, 025.00
 ANNEX C

BAGUIO GENERAL MEDICAL HOSPITAL

Baguio General Hospital Driveway, Baguio City
Telephone No.: (074)661-7910

MEDICAL CERTIFICATE
Hospital No. ______________
982765 ___________________
October 31, 2018
Date

TO WHOM IT MAY CONCERN:

VICKY Y. TIMA
The undersigned do certify that _________________________________ 59 years old, and
_____
#5 TRANCOVILLE, BAGUIO CITY
currently residing at ____________________________________________ CONFINED
is _____________________
October 1, 2018
in the hospital from ____________________________ October 31, 2018
to ________________________ and found the
following:

>>T/C CEREBRAL CONCUSSION; R/O SKULL FRACTURE

Duration of sickness will take _______ days for the above lesions to heal in the absence of
complication.
VICKY Y. TIMA
This certification is issued upon request of ________________________________ to be used
REFERENCE/S
exclusively for ____________________________ purposes.

Respectfully submitted:
Not valid without
hospital seal.
Mike Hannigan
License No.: 98265
 Republic of the Philippines
ANNEX E
CITY OF BAGUIO
Barangay Trancoville
OFFICE OF THE LUPONG TAGAPAMAYAPA

VICKY YU TIMA,
Complainant,
Barangay Case No.: 88743
-against- For: Serious Physical Injuries

AKHI UY SADO,
Respondent.

x------------------------------------------------------------------------------------------------------------------x

CERTIFICATION TO FILE ACTION

This is to certify that complainant VICKY YU TIMA has requested this office to
help her amicable settle with respondent AKHI UY SADO. There had been a personal
confrontation between the parties before the Punong Barangay but mediation failed.
The Pangkat ng Tagapagkasundo was constituted but the personal confrontation before
the Pangkat likewise did not result into a settlement. Therefore, the corresponding
complaint for the dispute may now be filed in court.

This certificate is issued on DECEMBER 10, 2018 upon the complainant’s

request as a condition precedent for the filing of action in court.

MONICA G. BING
Lupon Secretary

Attested by:

RACHEL KAREN GREENE

Lupon / Pangkat Chairman

Noted by:

ROSS E. GELLER
Punong Barangay