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GKZ Eio 3: S Tatement of Account
GKZ Eio 3: S Tatement of Account
GKZ Eio 3: S Tatement of Account
S tatement of Account
R eference No.
PANTALE ON G. GOTLADE R A ME MOR IAL HOS PITAL
PAWA, BULAN, S OR S OGON
pggmhbulan@gmaiL com
( +63) 0917448- 4187
Patient's Name: l.WbQ91 L&i'// A ge: V 117i4'0/ Date & Time A dmitted: If br,~J
Mailing A ddress: ft%.1if 'J 'f V I /øi//'
lO7s-i') Date & Time Discharged: -)/- 14
Final Diagnosis: 1. VY AI/2/. /t7 O iY 1It i 1t-1/) AV
2. C IclNt-P fY b / ,•,f1'Ufrlc , First Case Rate:
3. Lan lrn. 'i- / !.u'lF /L ,lo /4 Second Case Rate:
SUMMA RY OF PROFESSIONA L FE E S
AMOUNT OF DIS C OUNTS PHILHE ATH BE NE FITS
PC S O
S E NIOR PATIE NT'S
VAT DS WD
AC TUAL C ITIZE N/PWD (MAP) F IR S T C AS E S E C OND C AS E OUT OF
PAR TIC ULAR S BILLING
E X E MPTION
DIS C OUNT
DOH
R ATE AMOUNT R ATE AMOUNT THE
(12%) HMO
(20%) POCKET
Ot her
MD.,MSPa
w
CHAR W B. BA NDOL A .
3 gkz eiO
4
5
SUB-T OT A L (HCI) `' £ 0 14)
NOTE:
1. Fill out the form legibly
2. The Member/Patient/Authorized Representative should not sign a blank SOA
3. Printed copy of SOA or its equivalent should be free of charge.
MA. S HE E NA M. HIZOLA
Acting Administrative Officer