MEDICAL BILL RECEIPT

Receipt Number: SBH6098

Date: 02/10/2022
Name of Medical Institution: St Barnabas Hospital
City/State/Zip: Bronx

Patient Information:
Name: Angel
City/State/Zip: Bronx

Code Description of Qty Rate Line Total

Services/Medicine/Products ($)
013 Abdomen scan 100

121 Stomach X-ray 50

048 Blood sample 50

017 Urine sample 50

028 Ulcer test 50

073 Treatment 100

192 Extra day with food 100

Subtotal: $ 500
Tax Rate ( ):
Total: $ 500
Amount Paid: $ 500

Payment Method:
Card/Check No: