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    FLC Reim Fadullon, Renato1 8.5.19

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    Annilyn Velasco Miraballes
    A reimbursement form documents a patient's medical information and a medical expense. It lists the patient's name, ID number, dates of admission and discharge, diagnosis, and that the nature of reimbursement is FMA. It also includes an itemized list of a medical procedure from Mercury Drug on July 16, 2019 costing 1,110 pesos for MUCOFALK. The total reimbursable amount is 1,110 pesos.

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    FLC Reim Fadullon, Renato1 8.5.19

    Uploaded by

    Annilyn Velasco Miraballes
    9 views1 page
    A reimbursement form documents a patient's medical information and a medical expense. It lists the patient's name, ID number, dates of admission and discharge, diagnosis, and that the nature of reimbursement is FMA. It also includes an itemized list of a medical procedure from Mercury Drug on July 16, 2019 costing 1,110 pesos for MUCOFALK. The total reimbursable amount is 1,110 pesos.

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    Flc Reim Fadullon, Renato1 8.5.19

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    A reimbursement form documents a patient's medical information and a medical expense. It lists the patient's name, ID number, dates of admission and discharge, diagnosis, and that the nature of reimbursement is FMA. It also includes an itemized list of a medical procedure from Mercury Drug on July 16, 2019 costing 1,110 pesos for MUCOFALK. The total reimbursable amount is 1,110 pesos.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    9 views1 page

    FLC Reim Fadullon, Renato1 8.5.19

    Uploaded by

    Annilyn Velasco Miraballes
    A reimbursement form documents a patient's medical information and a medical expense. It lists the patient's name, ID number, dates of admission and discharge, diagnosis, and that the nature of reimbursement is FMA. It also includes an itemized list of a medical procedure from Mercury Drug on July 16, 2019 costing 1,110 pesos for MUCOFALK. The total reimbursable amount is 1,110 pesos.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 1

    Date: 8/5/2019

    Name: FADULLON, RENATO


    Company: FILOIL LOGISTIC CORP
    HPPI ID # 16-00001-0035
    Availment Date:
    Admission Date:
    Discharge Date:
    DIAGNOSIS:
    Nature of Reimbursement: FMA

    Name of Supplier / Coverable


    O.R. Date O.R. Number Clinic / Hospital Particulars Price Amount Remarks

    7/16/2019 103351477319 MERCURY DRUG MUCOFALK 1,110.00

    TOTAL 1,110.00

    Prepared by: ANNILYN V. MIRABALLES Approved by: DR BENJAMIN SANCHEZ


    Date 8/5/2019 8/5/2019

    Noted:

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