fl'flAl-{lLA D0CTORS HOSPITAL Detailed Statement of Account

llun Datetimc 51912018 5 00 06 PM

i;(ji L.J N. Avcnut: F:rrnita, l\,4anila
T o No(s) 558-0tltlu Page No 2 o{ 2

I ranr;action No.: 114 3

lcqistry No.: L42
icr;istry [)atc: 3i26lZAIA llcqistry Iimc: 3:21 PM

)aticnt Name: FULMINAR, GIL CELDA lloom No.: 603F

)OC, DATE SLIP NO DESCRTPTION QTY PRICE AMOUNT DISCOUN NET

4l3l?-018 cH :1829 COI OS I OI\4Y I]ASEPI-N'TE 1113191,, 6OIYN{, AI.- |EIINA 2,00 453.00 906.00 0.00 906.00

COI OS fON4Y POUCI I # 1698, 6ON1N4, ALTERNA. 2.00 2/4.00 54U.00 0.00 54i1.00

MPIM (Central Service Section) Sub Total >>> 2,604.00 0.00 2,604.00

l:r.., Ir, I 0']D {Chemo}

) ).ti. l.t1 1 r ilSI Ot' IN[-. I)IJMP ( t]RAl.iN ) DAIIY 2.00 294.00 588.00 0.00 :i8u.00
" '',

Oncology OPD (Chemo) Sub Total >>> 5Uil.00 0.00 ri8[i.00

Grand Total Hospital Bill >>> 1 /3,302.U3 0.00 r /3,302.U3

looMs
1.00 3,200.00 3,200.00 0.00 3,200"00
tl1p01B 60:lr,
(r0-ll' 1.00 3,200.00 3,200.00 0.00 3,2.00.00
1l? l?0"8
1.00 3,200.00 3,200.00 0.00 3,200.00
tl'31)0'^8 603 t'

Grand Total Room And Board >>> 9,600.00 0.00 9,600.00

I otal

)ROFESSIONAL FEES
100.00 0.00 100"00
D lo / l?018 KI-IO, MARK RICHAII.D CHIONG
22.,898.00 0.00 22,898.00
)210712018 N{ACASAET, ROMEO GREGORIO NIDUAZA Iii

IIO, IlERBERT. 13,260.00 0.00 13,2_60.00

)2lo7l2ot8
'i410" (.O, CAIIlliRINE SIlvl 57,182.00 0.00 5 /, 1 il2 .00
l?otg
SILVEROSLI ANN ANI)At ES 9,260.00 0.00 9,260.00
)4lJ" l)018 tlA(-OLCOl ,
i lir, ANGT LO VAt t'N1l.il:tA 0.00 0.00 0.00
)4li):, p018 l']Olli
Grand Total Professional Fees >>> 1 02, /00.00 0.00 1 02, /00.00

:ASH R.EFIJND

"IOSPII'AL DEDUCTIONS

Guarantecd tiospital Bill 162,60) .83

413l2OrB
(iuarantced Room and Bed 9,600.00
41.]12018
Guarantr:e:d
90,100.00
41312018 PF-

l)hilt lcalth []r:ncfits 23,300.00

41.112018

TOTAL DEPARTMENTAL CHARGES.,...,. 0.00

)VlrltAt L Stil) ISSUED. "