STATEMENT OF ACCOUNT

SOA Reference No.:

MANANGO HOSPITAL
2023- 113730
National Highway, San Antonio, Alicia, Isabela, Region II Philippines
078-323-2056

Name of Patient: VIERNES, CHRISTIAN MARLOU QUIROGA Age: 21 Date & Time Admitted : 12/20/2023 10:21 AM
Address : PRK TAGUMPAY SAN FERNANDO ALICIA ISABELA 3306 Date & Time Discharged : 12/20/2023 1:51 PM

Case Number : 55394

First Case Rate : 11401
Final Diagnosis/es and ICD 10 Code/s: Second Case Rate :

1. D17.9 Benign lipomatous neoplasm, unspecified

Surgical Procedure/s and RVS Code/s, if Applicable :

1. 11401 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

SUMMARY OF FEES
Amount of Discounts Philhealth Benefits
Place _
†PCSO
Senior First Second Out of
†DSWD
Particulars Actual Charges VAT exempt Citizen/ Case Rate Case Rate Pocket
†DOH (MAP)
PWD Amount Amount of Patient
†HMO
†Others:

HCI fees
Drugs and Medicines 560.00 0.00 0.00 0.00 560.00 0.00
Laboratory & Diagnostics 1,250.00 0.00 0.00 0.00 0.00 1,250.00
Operating Room fee 0.00 0.00 0.00 0.00 0.00 0.00
Supplies 705.00 0.00 0.00 0.00 705.00 0.00
Others: pls. specify
Miscellaneous Charge 1,535.00 0.00 0.00 0.00 1,535.00 0.00
Subtotal 4,050.00 0.00 0.00 0.00 2,800.00 0.00 1,250.00
Professional fee/s
MANANGO, DANILO MARTINEZ 2,840.00 0.00 0.00 0.00 840.00 2,000.00
Subtotal 2,840.00 0.00 0.00 0.00 840.00 0.00 2,000.00
Total 6,890.00 0.00 0.00 0.00 3,640.00 0.00 3,250.00
Payments
Payments 1,250.00
Subtotal 1,250.00
BALANCE DUE 2,000.00

Prepared by: Conforme:

URSUA, JEREMY TELAN

Billing Clerk/ Accountant Member/Patient/Authorized representative
(Signature over printed name) (Signature over printed name)
Date signed.: 12/20/2023 1:51 PM Relationship to member of authorized representative:

Contact No. : (078) 323-2056 Date signed.: 12/20/2023 1:51:33 PM Contact no.: 09351337010
NOTE:
1. Fill out the form legibly.
2. The member/patient/authorized representative should not sign a blank SOA. Run Date and Time: 12/20/2023 1:51:33 PM
3. Printed copy of SOA or its equivalent should free of charge.