DAVAO ADVENTIST HOSPITAL OPD STATEMENT

Bangkal, Davao City

Patient: LOSALA, ELOISA KIP BUO

Company:
Insurance: Medicare Type: SSS - DEP
Address: Date Confined: 12/23/2015 07:47AM
Date Discharge: 12/23/2015 09:00AM
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER MINOR ROOM 1,200.00 1,200.00 -
ER SUPPLIES 1,285.00 1,285.00 -
CSR - - -
ECG - - -
LABORATORY - - -
MISCELLANEOUS - - -
MEDICINE - - -
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 2,485.00 2,485.00 - - -
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
Dr. Bardos, Rafael 840.00 840.00 - -
-
-
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 840.00 840.00 - - -
HOSPITAL & PF FEE TOTAL: 3,325.00 3,325.00 - - -
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 3,325.00 3,325.00 - - -
BALANCE DUE: -
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

BRENT LESTER LAMERA

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name
Contact No.
 R& B ADMITTING FEE CSR ECG LABORATORY MISCELLANEOUS
1 3900 300 300 54
2 250 320
3 10 54
4 10 54
5 10
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23 3900 300 580 0 482 0

6,659.00
MEDICINE RADIOLOGY
1397

1397 0
DAVAO ADVENTIST HOSPITAL OPD STATEMENT
Bangkal, Davao City

Patient: VIDAL, ALEXANDER

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 5/6/2018
Date Discharge: 5/6/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ROOM FEE - - - -
EMERGENCY SUPPLIES 1,120.00 - - - 1,120.00
CSR - - - - -
ECG 275.00 - - - 275.00
AMBULANCE FEE 1,500.00 - - 1,500.00
LABORATORY 981.00 - - 981.00
MEDICINE 1,879.15 - - 1,879.15
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 5,755.15 - - - 5,755.15
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 150.00 - - - 150.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 150.00 - - - 150.00
HOSPITAL & PF FEE TOTAL: 5,905.15 - - - 5,905.15
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
1,500.00 1,500.00
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 1,500.00 - - - 1,500.00
GRAND TOTAL 4,405.15 - - - 4,405.15
BALANCE DUE: 4,405.15
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name
Contact No.
DAVAO ADVENTIST HOSPITAL OPD STATEMENT
Bangkal, Davao City

Patient: MAHINAY, ZAIJAN TAYO

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 5/17/2018
Date Discharge: 5/17/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 150.00 - - 150.00
EMERGENCY SUPPLIES 871.10 - - - 871.10
CSR - - - - -
ECG - - - - -
AMBULANCE FEE - - - -
LABORATORY - - - -
MEDICINE 708.48 - - 708.48
RADIOLOGY 1,686.00 - 1,686.00
HOSPITAL SUB-TOTAL: 3,415.58 - - - 3,415.58
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 250.00 - - - 250.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 250.00 - - - 250.00
HOSPITAL & PF FEE TOTAL: 3,665.58 - - - 3,665.58
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 3,665.58 - - - 3,665.58
BALANCE DUE: 3,665.58
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name
Contact No.
DAVAO ADVENTIST HOSPITAL OPD STATEMENT
Bangkal, Davao City

Patient: BANSAL, MIGUELITO BINA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 5/17/2018
Date Discharge: 5/17/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 150.00 - - 150.00
EMERGENCY SUPPLIES - - - - -
CSR - - - - -
ECG - - - - -
AMBULANCE FEE - - - -
LABORATORY - - - -
MEDICINE 120.33 - - 120.33
RADIOLOGY 1,560.40 - 1,560.40
HOSPITAL SUB-TOTAL: 1,830.73 - - - 1,830.73
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 350.00 - - - 350.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 350.00 - - - 350.00
HOSPITAL & PF FEE TOTAL: 2,180.73 - - - 2,180.73
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 2,180.73 - - - 2,180.73
BALANCE DUE: 2,180.73
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name
Contact No.
DAVAO ADVENTIST HOSPITAL OPD STATEMENT
Bangkal, Davao City

Patient: JORGE, PRINCESS NICOLE

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 5/20/2018
Date Discharge: 5/20/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 150.00 - - 150.00
EMERGENCY SUPPLIES 1,562.90 - - - 1,562.90
CSR - - - - -
ECG - - - - -
AMBULANCE FEE - - - -
LABORATORY - - - -
MEDICINE 4,160.39 - - 4,160.39
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 5,873.29 - - - 5,873.29
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 250.00 - - - 250.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 250.00 - - - 250.00
HOSPITAL & PF FEE TOTAL: 6,123.29 - - - 6,123.29
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 6,123.29 - - - 6,123.29
BALANCE DUE: 6,123.29
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: GALLARDO, HILARIO RINOPAL

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 7/19/2018
Date Discharge: 7/22/2018
Tel. No. 298-1692 No. of Days: 3
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 5,400.00 - - 5,400.00
ER FEE 400.00 - - 400.00
CSR 506.30 - - - 506.30
STATION CHARGES 650.00 - - - 650.00
LABORATORY 1,414.00 - - 1,414.00
MEDICINE 8,665.60 - - 8,665.60
RADIOLOGY 7,688.00 - 7,688.00
case rate - 10,500.00 (10,500.00)
SENIOR DISCOUNT - - 4,944.78 (4,944.78)
HOSPITAL SUB-TOTAL: 24,723.90 10,500.00 4,944.78 - 9,279.12
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. ALCASID, MARIO ALEX 100.00 - - - 100.00
DR. PATALINGHUG, GEOVANNI 4,590.00 4,500.00 - 90.00
HOSPITAL SHARE 10.00 10.00
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 4,700.00 4,500.00 - - 200.00
HOSPITAL & PF FEE TOTAL: 29,423.90 15,000.00 4,944.78 - 9,479.12 -
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
LINGAP RAF#18133122 3,000.00 3,000.00
DSWD R1-200336 2,000.00 2,000.00
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 3,000.00 - - - 5,000.00
GRAND TOTAL 26,423.90 15,000.00 4,944.78 - 4,479.12
BALANCE DUE: 4,479.12
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: MENDOZA, KRISTINA MAE

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/3/2018
Date Discharge: 8/7/2018
Tel. No. 298-1692 No. of Days: 4
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 3,460.00 - - 3,460.00
EMERGENCY ROOM 665.00 - - 665.00
MEDICINE 2,693.50 - - - 2,693.50
CENTRAL SUPPLIES 491.75 - - - 491.75
RADIOLOGY 559.00 - - - 559.00
LABORATORY 1,560.00 - - 1,560.00
STATION CHARGES 810.00 - - 810.00
ECG - - -
case rate - 2,800.00 (2,800.00)
SENIOR DISCOUNT - - - -
HOSPITAL SUB-TOTAL: 10,239.25 2,800.00 - - 7,439.25
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. NAVAL, ROSE MARIE 3,360.00 1,200.00 - - 2,160.00
HOSPITAL SHARE 240.00 - - 240.00
VAT 259.20 259.20
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 3,859.20 1,200.00 - - 2,659.20
HOSPITAL & PF FEE TOTAL: 14,098.45 4,000.00 - - 10,098.45
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 14,098.45 4,000.00 - - 10,098.45
BALANCE DUE: 10,098.45
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: CRUZ, DEMETRIO, JIMENEZ

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 7/31/2018
Date Discharge: 8/5/2018
Tel. No. 298-1692 No. of Days: 5
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 6,750.00 - - 6,750.00
EMERGENCY ROOM 965.00 - - 965.00
MEDICINE 9,321.05 - - - 9,321.05
CENTRAL SUPPLIES 2,253.20 - - - 2,253.20
RADIOLOGY 2,984.80 - - - 2,984.80
LABORATORY 11,709.00 - - 11,709.00
STATION CHARGES 2,405.00 - - 2,405.00
ECG 509.00 - 509.00
CASE RATE - 10,500.00 (10,500.00)
SENIOR DISCOUNT - - 7,379.41 (7,379.41)
HOSPITAL SUB-TOTAL: 36,897.05 10,500.00 7,379.41 - 19,017.64
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. ABDURAHMAN, HIEDE 6,750.00 - - - 6,750.00
- - - -
DR. ALCASID, MARIO ALEX 14,390.00 1,890.00 12,500.00
DR. GARCIA, EDWIN PERALTA 6,885.00 1,260.00 5,625.00
HOSPITAL SHARE 625.00 625.00
DR. MARCOS, MERVIN 6,750.00 1,350.00 5,400.00
600.00 600.00
PROFESSIONAL FEES SUB-TOTAL 36,000.00 4,500.00 - - 31,500.00
HOSPITAL & PF FEE TOTAL: 72,897.05 15,000.00 7,379.41 - 50,517.64
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
PARTIAL PAYMENT OR 488622 7,000.00 7,000.00
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 7,000.00 - - - 7,000.00
GRAND TOTAL 65,897.05 15,000.00 7,379.41 - 43,517.64
BALANCE DUE: 43,517.64
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: DAHUYAG, PATRICIA PARAGUYA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 7/31/2018
Date Discharge: 8/6/2018
Tel. No. 298-1692 No. of Days: 7
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 6,055.00 - - - 6,055.00
EMERGENCY ROOM 665.00 - - - 665.00
MEDICINE 5,934.75 - - - 5,934.75
CENTRAL SUPPLIES 1,358.60 - - - 1,358.60
RADIOLOGY 4,705.00 - - - 4,705.00
LABORATORY 12,435.00 - - - 12,435.00
STATION CHARGES 2,135.00 - - - 2,135.00
ECG 509.00 - - - 509.00
CASE RATE - 9,940.00 - - (9,940.00)
SENIOR DISCOUNT - - 6,586.47 - (6,586.47)
HOSPITAL SUB-TOTAL: 33,797.35 9,940.00 6,586.47 - 17,270.88
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. ALCASID, MARIO ALEX 10,000.00 - - - 10,000.00
DR. BASILIO, ORLANDO 865.00 - - - 865.00
HOSPITAL SHARE 86.50 - - - 86.50
DR. GARCIA, EDWIN PERALTA 5,000.00 - - - 5,000.00
HOSPITAL SHARE 500.00 - - - 500.00
DR. PATALINGHUG, GEOVANNI 9,660.00 4,260.00 1,080.00 - 4,320.00
HOSPITAL SHARE 600.00 - 120.00 - 480.00
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 26,711.50 4,260.00 1,200.00 - 21,251.50
HOSPITAL & PF FEE TOTAL: 60,508.85 14,200.00 7,786.47 - 38,522.38
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
PARTIAL PAYMENT 8,000.00 8,000.00
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 8,000.00 - - - 8,000.00
GRAND TOTAL 52,508.85 14,200.00 7,786.47 - 30,522.38
BALANCE DUE: 30,522.38
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: LABARCA, EMILIA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/4/2018
Date Discharge: 8/6/2018
Tel. No. 298-1692 No. of Days: 3
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 7,500.00 - - - 7,500.00
EMERGENCY ROOM 765.00 - - - 765.00
MEDICINE 3,449.60 - - - 3,449.60
CENTRAL SUPPLIES 1,520.25 - - - 1,520.25
RADIOLOGY 1,632.80 - - - 1,632.80
LABORATORY 2,937.00 - - - 2,937.00
STATION CHARGES 600.00 - - - 600.00
ECG 734.00 - - - 734.00
CASE RATE - 6,300.00 - - (6,300.00)
SENIOR DISCOUNT - - 3,467.73 - (3,467.73)
HOSPITAL SUB-TOTAL: 19,138.65 6,300.00 3,467.73 - 9,370.92
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. DIMAANDAL, HENRY JOAN 8,100.00 2,700.00 - - 5,400.00
TAX 648.00 - - - 648.00
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 8,748.00 2,700.00 - - 6,048.00
HOSPITAL & PF FEE TOTAL: 27,886.65 9,000.00 3,467.73 - 15,418.92
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
-
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 27,886.65 9,000.00 3,467.73 - 15,418.92
BALANCE DUE: 15,418.92
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: DALAY, KEONA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/4/2018
Date Discharge: 8/6/2018
Tel. No. 298-1692 No. of Days: 3
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 2,595.00 - - - 2,595.00
EMERGENCY ROOM 765.00 - - - 765.00
MEDICINE 1,185.85 - - - 1,185.85
CENTRAL SUPPLIES 458.95 - - - 458.95
RADIOLOGY - - - - -
LABORATORY 258.00 - - - 258.00
STATION CHARGES 680.00 - - - 680.00
ECG - - - - -
CASE RATE - - - - -
SENIOR DISCOUNT - - - - -
HOSPITAL SUB-TOTAL: 5,942.80 - - - 5,942.80
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. FERNANDEZ, RICO HECTOR 3,960.00 1,800.00 - - 2,160.00
HOSPITAL SHARE 240.00 - - - 240.00
VAT 259.20 - - - 259.20
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 4,459.20 1,800.00 - - 2,659.20
HOSPITAL & PF FEE TOTAL: 10,402.00 1,800.00 - - 8,602.00
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
-
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 10,402.00 1,800.00 - - 8,602.00
BALANCE DUE: 8,602.00
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: LITANG, RODOLFO III

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/4/2018
Date Discharge: 8/6/2018
Tel. No. 298-1692 No. of Days: 3
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 4,395.00 - - - 4,395.00
EMERGENCY ROOM 575.00 - - - 575.00
MEDICINE 1,645.50 - - - 1,645.50
CENTRAL SUPPLIES 697.75 - - - 697.75
RADIOLOGY - - - - -
LABORATORY 2,838.00 - - - 2,838.00
STATION CHARGES 725.00 - - - 725.00
ECG - - - - -
CASE RATE - - - - -
SENIOR DISCOUNT - - - - -
HOSPITAL SUB-TOTAL: 10,876.25 - - - 10,876.25
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. BOLOTAOLO, EVANGELINE 5,910.00 3,510.00 - - 2,400.00
TAX 192.00 - - - 192.00
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 6,102.00 3,510.00 - - 2,592.00
HOSPITAL & PF FEE TOTAL: 16,978.25 3,510.00 - - 13,468.25
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
-
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 16,978.25 3,510.00 - - 13,468.25
BALANCE DUE: 13,468.25
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIS HOSPITAL DAVAO IPD STATEMENT
Bangkal, Davao City

Patient: RESTON, LILIOSA CABANDA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 7/27/2018
Date Discharge: 8/7/2018
Tel. No. 298-1692 No. of Days: 11
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 17,215.00 - - - 17,215.00
EMERGENCY ROOM 915.00 - - - 915.00
MEDICINE 14,410.30 - - - 14,410.30
CENTRAL SUPPLIES 6,214.30 - - - 6,214.30
RADIOLOGY 9,441.00 - - - 9,441.00
LABORATORY 5,910.00 - - - 5,910.00
STATION CHARGES 1,920.00 - - - 1,920.00
ICU 4,160.00 - - - 4,160.00
ECG 462.00 - - - 462.00
CASE RATE - 19,600.00 - - (19,600.00)
SENIOR DISCOUNT - - 11,859.52 - (11,859.52)
HOSPITAL SUB-TOTAL: 60,647.60 19,600.00 11,859.52 - 29,188.08
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. CAMARILLO, MILLAN 800.00 - - - 800.00
HOSPITAL SHARE 100.00 - - - 100.00
DR. ESCALANTE, REX TRIO 21,900.00 8,400.00 - - 13,500.00
HOSPITAL SHARE 1,500.00 - - - 1,500.00
PF DISCOUNT (3,000.00) - - - (3,000.00)
DR. FLORESCA, DOROTHEO 13,500.00 - - - 13,500.00
PR DISCOUNT (3,500.00) - - - (3,500.00)
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 31,300.00 8,400.00 - - 22,900.00
HOSPITAL & PF FEE TOTAL: 91,947.60 28,000.00 11,859.52 - 52,088.08
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DSWD R1-200391 2,000.00 2,000.00
LINGAP RAF#18133178 5,000.00 5,000.00
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 2,000.00 - - - 7,000.00
GRAND TOTAL 89,947.60 28,000.00 11,859.52 - 45,088.08
BALANCE DUE: 45,088.08
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
DAVAO ADVENTIST HOSPITAL IPD STATEMENT
Bangkal, Davao City

Patient: DAHAN, VIC MICHAEL MOLINA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/1/2018
Date Discharge: 8/7/2018
Tel. No. 298-1692 No. of Days: 6
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 5,190.00 - - - 5,190.00
OPERATING ROOM 52,663.20 - - - 52,663.20
EMERGENCY ROOM 665.00 - - - 665.00
MEDICINE 4,291.85 - - - 4,291.85
CENTRAL SUPPLIES 2,424.95 - - - 2,424.95
RADIOLOGY 3,325.40 - - - 3,325.40
LABORATORY 1,019.00 - - - 1,019.00
STATION CHARGES 850.00 - - - 850.00
ICU -
ECG - - - - -
CASE RATE - 14,400.00 - - (14,400.00)
SENIOR DISCOUNT - - - - -
HOSPITAL SUB-TOTAL: 70,429.40 14,400.00 - - 56,029.40
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DR. BASILIO, ORLANDO 24,032.00 4,032.00 - - 20,000.00
HOSP. SHARE 2,000.00 - - - 2,000.00
VAT 2,160.00 - - - 2,160.00
DR. ESCALANTE, REX 2,970.00 2,880.00 - - 90.00
HOSP. SHARE 10.00 - - - 10.00
VAT 10.80 - - - 10.80
DR. GARCIA, EDWIN PERALTA 11,688.00 2,688.00 - - 9,000.00
1,000.00 - - - 1,000.00
1,080.00 - - - 1,080.00
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 44,950.80 9,600.00 - - 35,350.80
HOSPITAL & PF FEE TOTAL: 115,380.20 24,000.00 - - 91,380.20
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
PARTIAL PAYMENT 30,000.00 30,000.00
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 30,000.00 - - - 30,000.00
GRAND TOTAL 85,380.20 24,000.00 - - 61,380.20
BALANCE DUE: 61,380.20
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIS HOSPITAL DAVAO IPD STATEMENT
Bangkal, Davao City

Patient: CARBONILLA, KYRO HANSEN

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: B36 L19 ISAAC ST, SOUTH VILLA CATALUNAN Date Confined: 8/2/2018
GRANDE DAVAO CITY, DAVAO DEL SUR, 8000 Date Discharge: 8/7/2018
Tel. No. 298-1692 No. of Days: 5
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE SENIOR DEISCOUNT INSURANCE PERSONAL
ROOM AND BOARD 4,325.00 - - - 4,325.00
OPERATING ROOM - - - - -
EMERGENCY ROOM 715.00 - - - 715.00
MEDICINE 7,782.15 - - - 7,782.15
CENTRAL SUPPLIES 736.15 - - - 736.15
RADIOLOGY 559.00 - - - 559.00
LABORATORY 381.00 - - - 381.00
STATION CHARGES 1,775.00 - - - 1,775.00
ICU -
ECG - - - - -
CASE RATE - - - - -
SENIOR DISCOUNT - - - - -
HOSPITAL SUB-TOTAL: 16,273.30 - - - 16,273.30
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- - - - -
DR. FERNANDEZ, RICO 8,100.00 4,500.00 - - 3,600.00
HOSP. SHARE 400.00 - - - 400.00
VAT 432.00 - - - 432.00
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - -
PROFESSIONAL FEES SUB-TOTAL 8,932.00 4,500.00 - - 4,432.00
HOSPITAL & PF FEE TOTAL: 25,205.30 4,500.00 - - 20,705.30
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
-
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 25,205.30 4,500.00 - - 20,705.30
BALANCE DUE: 20,705.30
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING DAWN S. BINASAHAN

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: FLORES, ERLINDA

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/7/2018
Date Discharge: 8/7/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 150.00 - - 150.00
EMERGENCY SUPPLIES 1,000.00 - - - 1,000.00
CSR - - - - -
ECG - - - - -
AMBULANCE FEE 1,800.00 - - 1,800.00
LABORATORY - - - -
MEDICINE 2,206.15 - - 2,206.15
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 5,156.15 - - - 5,156.15
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 250.00 - - - 250.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 250.00 - - - 250.00
HOSPITAL & PF FEE TOTAL: 5,406.15 - - - 5,406.15
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 5,406.15 - - - 5,406.15
BALANCE DUE: 5,406.15
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: MATUGUINA, FELIX

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 8/16/2018
Date Discharge: 8/16/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 1,045.00 - - 1,045.00
EMERGENCY SUPPLIES 1,500.00 - - - 1,500.00
CSR - - - - -
ECG - - - - -
AMBULANCE FEE - - - -
LABORATORY - - - -
MEDICINE 1,054.25 - - 1,054.25
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 3,599.25 - - - 3,599.25
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF - - - - -
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL - - - - -
HOSPITAL & PF FEE TOTAL: 3,599.25 - - - 3,599.25
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DSWD DC1-201689 3,500.00 3,500.00
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL 3,500.00 - - - 3,500.00
GRAND TOTAL 99.25 - - - 99.25
BALANCE DUE: 99.25
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: PARASDAS, NELLY

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 7/28/2018
Date Discharge: 7/28/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 4,433.20 - - 4,433.20
EMERGENCY SUPPLIES - - - - -
CSR - - - - -
ECG - - - - -
AMBULANCE FEE 1,800.00 - - 1,800.00
LABORATORY 1,848.56 - - 1,848.56
MEDICINE 2,065.96 - - 2,065.96
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 10,147.72 - - - 10,147.72
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 350.00 - - - 350.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 350.00 - - - 350.00
HOSPITAL & PF FEE TOTAL: 10,497.72 - - - 10,497.72
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
0 - -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 10,497.72 - - - 10,497.72
BALANCE DUE: 10,497.72
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: OTANG, ROBERTO

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 9/18/2018
Date Discharge: 9/18/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 4,789.01 - - 4,789.01
EMERGENCY SUPPLIES - - - - -
CSR - - - - -
ECG - - - - -
AMBULANCE FEE - - - -
LABORATORY 882.90 - - 882.90
MEDICINE 3,884.29 - - 3,884.29
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 9,556.20 - - - 9,556.20
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF 350.00 - - - 350.00
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL 350.00 - - - 350.00
HOSPITAL & PF FEE TOTAL: 9,906.20 - - - 9,906.20
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
0 - -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 9,906.20 - - - 9,906.20
BALANCE DUE: 9,906.20
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: MACASO, BONIFACIO

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 9/28/2018
Date Discharge: 9/28/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE - - - -
EMERGENCY SUPPLIES 2,818.58 - - - 2,818.58
CSR - - - -
ECG - - - - -
AMBULANCE FEE 1,500.00 - - 1,500.00
LABORATORY - - - -
MEDICINE 5,162.09 - - 5,162.09
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 9,480.66 - - - 9,480.66
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF - - - - -
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL - - - - -
HOSPITAL & PF FEE TOTAL: 9,480.66 - - - 9,480.66
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
0 - -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 9,480.66 - - - 9,480.66
BALANCE DUE: 9,480.66
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: MARANGA, BRENT

Company:
Insurance: Medicare Type: SSS - MEMBER
Address: Date Confined: 10/29/2018
Date Discharge: 10/29/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 2,420.00 - - 2,420.00
EMERGENCY SUPPLIES - - - - -
CSR - - - - -
ECG - - - - -
AMBULANCE FEE 731.90 - - 731.90
LABORATORY - - - -
MEDICINE - - - -
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 3,151.90 - - - 3,151.90
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF - - - - -
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL - - - - -
HOSPITAL & PF FEE TOTAL: 3,151.90 - - - 3,151.90
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
0 - -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 3,151.90 - - - 3,151.90
BALANCE DUE: 3,151.90
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

DARLING BINASAHAN
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: TOLENTINO, LEONARDO

Company:
Insurance: Medicare Type: NON-MEDICARE
Address: Date Confined: 11/27/2018
Date Discharge: 11/27/2018
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 300.00 - - 300.00
EMERGENCY SUPPLIES 4,418.05 - - - 4,418.05
CSR - - - - -
ECG 275.00 - - - 275.00
AMBULANCE FEE - - - -
LABORATORY 981.00 - - 981.00
MEDICINE 8,410.50 - - - 8,410.50
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 14,384.55 - - - 14,384.55
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF - - - - -
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL - - - - -
HOSPITAL & PF FEE TOTAL: 14,384.55 - - - 14,384.55
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 14,384.55 - - - 14,384.55
BALANCE DUE: 14,384.55
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

EUNICE RACHEL UY
Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO OPD STATEMENT
Bangkal, Davao City

Patient: DEGORO, PRIMITIVO

Company:
Insurance: Medicare Type: NON-MEDICARE
Address: Date Confined: 1/11/2019
Date Discharge: 1/11/2019
Tel. No. No. of Days: 1
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ER FEE 2,282.80 - - 2,282.80
EMERGENCY SUPPLIES 216.05 - - - 216.05
CSR - - - - -
ECG - - - -
AMBULANCE FEE 1,800.00 - - 1,800.00
LABORATORY 981.00 - - 981.00
MEDICINE 1,238.35 - - - 1,238.35
RADIOLOGY - - -
HOSPITAL SUB-TOTAL: 6,518.20 - - - 6,518.20
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
DORTOR PF - - - - -
- - - -
- -
-
-
-
-
PROFESSIONAL FEES SUB-TOTAL - - - - -
HOSPITAL & PF FEE TOTAL: 6,518.20 - - - 6,518.20
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
- -
- -
- -
-
-
-
DEPOSITS/PAYMENTS SUB-TOTAL - - - - -
GRAND TOTAL 6,518.20 - - - 6,518.20
BALANCE DUE: 6,518.20
Note: Please vacate the room 30 minutes after bill settlement. Cut-off
time is 4PM. Pay this amount to the cashier. Thank you and God bless.

Certified Correct by: Reviewed & Acknowledged by:

IAN RAY E. GUANZON

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.
ADVENTIST HOSPITAL DAVAO IPD STATEMENT
Bangkal, Davao City

Patient: GORIO, JAPHET ANDERS

Room No. 220 1
Company: Case No. 3026
Insurance: Medicare Type: NON-MEDICARE
Address: BLK15 LOT5 WELLSPRING VILLAGE1 Date Confined: 8/19/2019 11:15 AM
CATALUNAN PEQUEÑO, DAVAO CITY Date Discharge: 8/23/2019 3:06 PM
Tel. No. No. of Days:
SERVICES/CHARGES/ADJUSTMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
ROOM AND BOARD 3,460.00 - - 3,460.00
EMERGENCY SUPPLIES 635.00 - - - 635.00
MEDICINE 1,270.15 - - - 1,270.15
CENTRAL SUPPLIES 571.55 - - - 571.55
LABORATORY 2,080.00 - - 2,080.00
PBO CHARGES 400.00 - - 400.00
STATION CHARGES 400.00 - - - 400.00
HOSPITAL SUB-TOTAL: 8,816.70 - - - 8,816.70
PROFESSIONAL FEES TOTAL MEDICARE COMPANY INSURANCE PERSONAL
MARCOS, LEONIDA SALCEDO 5,800.00 3,000.00 - - 2,800.00
PROFESSIONAL FEES SUB-TOTAL 5,800.00 3,000.00 - - 2,800.00
HOSPITAL & PF FEE TOTAL: 14,616.70 3,000.00 - - 11,616.70
DEPOSITS/PAYMENTS TOTAL MEDICARE COMPANY INSURANCE PERSONAL
MEDS RETURN 261.80 261.80
- -
- -
- -
- -

DEPOSITS/PAYMENTS SUB-TOTAL 261.80 - - - 261.80

GRAND TOTAL 14,354.90 3,000.00 - - 11,354.90
BALANCE DUE: 11,354.90

Certified Correct by: Reviewed & Acknowledged by:

BRENT LESTER LAMERA

Billing Clerk Patient/Relatives Signature Relationship
Over Printed Name

Contact No.