PHILIPPINE GENERAL HOSPITAL

The National University Hospital
University of the Philippines
Taft Avenue, Manila
PHIC Accredited Health Care Provider
ISO 9001:2008 Certified

CHARITY IN-PATIENT ACCOUNT RECORD
AS OF JULY 29, 2017 02:41 PM

Patient Name: TAÑAG, AMELITA SEÑOREZ Case No.: 4382401
Address: TULAY B MARAGONDON, CAVITE Bill No.: 239011
Discount Type: Age: 41
Date Admitted: July 26, 2017 Time Admitted: 01:56 PM
Date Discharged: July 29, 2017 Time Discharged: 02:41 PM
Room/Ward/Bed: OBAS Balance: 0.0

Summary of Charges

SERVICES DEPARTMENT FEES Gross Discount Amount Due
LABORATORIES-BLOODBANK-(40202170-00-01) 125.00 - 125.00
LABORATORIES-CLINICAL CHEMISTRY-(40202170-00-01) 370.00 - 370.00
LABORATORIES-CLINICAL MICROBIOLOGY-(40202170-00-01) 735.00 - 735.00
LABORATORIES-CLINICAL MICROSCOPY-(40202170-00-01) 240.00 - 240.00
LABORATORIES-HEMATOLOGY-(40202170-00-01) 75.00 - 75.00
PHARMACY-CONSIGNMENT 731.25 - 731.25
PHARMACY-REVOLVING FUND 429.00 - 429.00
ROOM AND BOARD CHARITY-(40202170-00-23L) 500.00 - 500.00
TOTAL CHARGES Php 3,205.25 Php 0.00 Php 3,205.25

LESS: ADJUSTMENTS
RETURN. MEDS (CM #ENC) Php 0.00
TOTAL ADJUSTMENTS Php 0.00
TOTAL CHARGES AFTER ADJUSTMENTS Php 0.00
PAYMENTS
DATE OR NUMBER AMOUNT
- - -
TOTAL PAYMENTS: Php 0.00
LESS:BENEFIT(S)
PHIC-N39.0 Php 4,620.00
OUTSTANDING HOSPITAL BILLS Php (1,414.75)

PROFESSIONAL FEE(COMPLIMENTARY):
1ST CASE RATE Php 0.00
2ND CASE RATE Php 0.00
TOTAL PROFESSIONAL FEE Php 0.00

NOTED BY: Printed by:

GOODICO M. YANZON FLORES, JEROME D.
Chief, Revenue Section Data Encoder

Note: DC 7/29/17 W/PC

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Conforme: Signature over Printed Name of Member or Representative Contact Number: If not the member: Relation to Member: Page 2 of 2 .