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    This document is a request for payment from the Mauban District Hospital in Quezon, Philippines. It lists the patient's name and admission/discharge dates, as well as line items for medicines, oxygen, medical supplies, laboratory tests, procedures, fees, and donations. The total amount owed is noted at the bottom. The request is prepared by the pharmacist and noted by the billing clerk.

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    Request for Payment

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    This document is a request for payment from the Mauban District Hospital in Quezon, Philippines. It lists the patient's name and admission/discharge dates, as well as line items for medicines, oxygen, medical supplies, laboratory tests, procedures, fees, and donations. The total amount owed is noted at the bottom. The request is prepared by the pharmacist and noted by the billing clerk.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    20 views1 page

    Request For Payment

    Uploaded by

    KC Palattao
    This document is a request for payment from the Mauban District Hospital in Quezon, Philippines. It lists the patient's name and admission/discharge dates, as well as line items for medicines, oxygen, medical supplies, laboratory tests, procedures, fees, and donations. The total amount owed is noted at the bottom. The request is prepared by the pharmacist and noted by the billing clerk.

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    © All Rights Reserved
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    Republic of the Philippines Provincial Government of Quezon

    Provincial Government of Quezon MAUBAN DISTRICT HOSPITAL


    MAUBAN DISTRICT HOSPITAL Mauban, Quezon
    Mauban, Quezon
    REQUEST FOR PAYMENT
    REQUEST FOR PAYMENT
    Patient’s Name: _________________________________________
    Patient’s Name: _________________________________________ Date Admitted: ___________ Date Discharged: __________
    Date Admitted: ___________ Date Discharged: __________ ◻ General ◻ Pay ◻ Medicare ◻ OPD
    ◻ General ◻ Pay ◻ Medicare ◻ OPD
    Medicines (RF: ________ CS :_______).................Php
    Medicines (RF: ________ CS :_______).................Php Oxygen fee…………………………………………………. _________
    Oxygen fee…………………………………………………. _________
    Medical supplies (RF: ________ CS :_______)………….._________
    Medical supplies (RF: ________ CS :_______)………….._________ _________
    _________ Laboratory (Diagnostics)………………………………….... _________
    Laboratory (Diagnostics)………………………………….... _________ ECG……………………………………………………….... _________
    ECG……………………………………………………….... _________ X-Ray……………………………………………………….. _________
    X-Ray……………………………………………………….. _________ OR/DR fee………………………………………………….. _________
    OR/DR fee………………………………………………….. _________ Birth/Death Certificate…………………………………………… _________
    Birth/Death Certificate…………………………………………… _________ Room and board…………………………………………….. _________
    Room and board…………………………………………….. _________ Doctor’s fee…………………………………………………… _________
    Doctor’s fee…………………………………………………… _________ Miscellaneous………………………………………………. _________
    Miscellaneous………………………………………………. _________ Donation……………………………………………………… __________
    Donation……………………………………………………… __________ Others………………………………………………………… __________
    Others………………………………………………………… __________
    TOTAL
    TOTAL Noted by
    Noted by
    JENNYLYN Q. ERANDIO
    JENNYLYN Q. ERANDIO Billing Clerk
    Billing Clerk
    Prepared by
    Prepared by
    RELMA S. VILLABROZA/ YSABELLA S. VILLABROZA
    RELMA S. VILLABROZA/ YSABELLA S. VILLABROZA Pharmacist
    Pharmacist
    Republic of the Philippines

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