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BULAN MEDICARE HOSPITAL

Sitio Pawa, Bulan, Sorsogon
Telephone Nos.: 09171484187
Emergency
Room PATIENT'S STATEMENT OF ACCOUNT
SSS - Dependent102522052466 - GESTIADA, ERIKA
NAME : GUBAN, IRISH GESTIADA DATE TODAY : 02 Sep 2021 04:57:02 PM
ADDRESS : Bulan, Sorsogon HOSPITAL NO : 000000000003904
ACCOUNT NO : 2021-000002751
DATE/TIME ADMITTED : 11 Aug 2021 01:05:00 PM WARD :
DATE/TIME DISCHARGED : 11 Aug 2021 01:25:00 PM ROOM :
ATTENDING PHYSICIAN : BANDOLA, CHARLIE B. BED :
MSS CLASSIFICATION : AGE : 3 y/o
FINAL DIAGNOSIS : OPEN WOUND OF HEAD (S01.9) PHIC : SSS - Dependent
MEMBER 102522052466 - GESTIADA, ERIKA

DATE REF. NO. QTY PARTICULARS UNIT PRICE DEBIT/CHARGES DISCOUNT CREDITS BALANCE
Detailed hospital charges - Internal
08/11/2021 B21-012596 1 amp Tetanus Toxoid (Purified) 0.50 ML AMP 110.00 110.00 0.00 110.00

08/11/2021 B21-012597 1 PAT Suturing 500.00 500.00 0.00 500.00

08/11/2021 B21-012597 1 PAT WOUND CLEANING/DRESSING 50.00 50.00 0.00 50.00

Total for Detailed hospital charges - Internal 660.00 0.00 0.00 660.00
TOTAL AMOUNT DUE 660.00 0.00 0.00 660.00

SUMMARY OF CHARGES

PARTICULARS DEBIT DISCOUNT CREDIT BALANCE

Drugs and Medicine 110.00 0.00 0.00 110.00
PHIC 0.00 0.00 3,010.00 (3,010.00)
Procedure 550.00 0.00 0.00 550.00
TOTAL : 660.00 0.00 3,010.00 0.00

SUMMARY OF CHARGES - PHIC

RVS CODE: 12002

Firstcase description: Simple repair of superficial wounds of scalp, Secondcase description:
neck, axillae, external genitalia, trunk and/or
extremities (including hands and feet); 2.6
cm to 7.5 cmACTUAL SENIOR CITIZEN/ FIRST SECOND
PARTICULARS CHARGES PWD DISCOUNT CASERATE CASERATE BALANCE

Hospital Charges 660.00 0.00 3,010.00 0.00 0.00

Professional Fees 300.00 0.00 882.00 0.00 0.00

TOTAL 960.00 0.00 3,892.00 0.00 0.00

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PROFESSIONAL FEES
ACTUAL SENIOR CITIZEN/
PARTICULARS PHIC BALANCE
CHARGES PWD DISCOUNT
PF - PROFESSIONAL FEE 300.00 0
TOTAL 300.00 0.00 882.00 0.00

OR Number
AMOUNT
DATE

Signature Over Printed Name of Member or Representative

If not the member:
Relationship to Member:
Contact Number: