INTERNATIONAL DRIVE CITY SOUTH SPECIAL ECONOMIC ADMINISTRATIVE ZONE,

MANTAWE AVE, TIPOLO, MANDAUE CITY, 6014 CEBU

TEL NO: (032) 233 8000
EMAIL: CUSTOMERSERVICE@CHONGHUA.COM.PH TIN 000-665-951-000 VAT EXEMPT

PARTIAL STATEMENT OF ACCOUNT

5/22/2023

PATIENT NO. 2300019564 Date Admitted: 5/19/2023

Patient name: Francis Alvin C. Pepito Time: 2:16 pm
DOB: 12/06/1989 Date Discharge:
Address: 747-5 Mt. View Kalubihan, Talamban Cebu City. Phils.
INVOICE # 568-23-0049

Attending Physician: Dr. Jose Fontanilla Arbatin Jr./

Dr. Karen Manlangit

HOSPITAL BILLS

Charges:
Admission 1,500.00
Bloodbank 360.00
Cardio Unit 868.00
Central Supply Room 8,887.00
CT SCAN 7,976.00
Emergency Room 1,906.00
Laboratory 6,523.25
Operating Room 198,460.00
Post Anesthesia Care Unit 3,16 8.00
Pharmacy 25,443.53
Ultrasound 7,400.25
Room Accommodation 22,481.00
Nurses’ Station 700.00 285,673.03

Less:
0.00
Amount Due – Hospital Bill 285,673.03

Amount Due – (Professional Fee) 0.00

Total Amount Due: 285,673.03

Claims Details________________________________________________________

Printdate: 5/22/2023 10:27 AM

Page 1 of 1
Printed by: APARINASAN

This serves as Statement of Account and not Proof of Payment.

The Hospital Reserves the right to bills you for additional charges incurred
which were not initially billed in this statement.
This likewise presents the required form for Philhealth claims as per PHIC Circular 2017 -0014.
For possible Philhealth refunds, please contact Philhealth section after Discharge Date.

Certified Copy
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