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 03:11 PM

Patient Name: BOLIVAR, ESTELA ABORQUE Case No.: 4019110
Address: 321 G. MARQUEZ ST. SINEGUELASAN BACOOR CITY CAVITE Bill No.: 238712
Discount Type: Age: 33
Date Admitted: July 25, 2017 Time Admitted: 07:39 PM
Date Discharged: July 29, 2017 Time Discharged: 03:11 PM
Room/Ward/Bed: 15-20 Balance: 0.0

Summary of Charges

SERVICES DEPARTMENT FEES Gross Discount Amount Due
LABORATORIES-BLOODBANK-(40202170-00-01) 125.00 - 125.00
LABORATORIES-CLINICAL MICROSCOPY-(40202170-00-01) 310.00 - 310.00
LABORATORIES-HEMATOLOGY-(40202170-00-01) 75.00 - 75.00
PHARMACY-CONSIGNMENT 261.00 - 261.00
PHARMACY-REVOLVING FUND 1,223.00 - 1,223.00
ROOM AND BOARD CHARITY-(40202170-00-23L) 500.00 - 500.00
TOTAL CHARGES Php 2,494.00 Php 0.00 Php 2,494.00

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-NSD01 Php 3,000.00
OUTSTANDING HOSPITAL BILLS Php (506.00)

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

Page 1 of 2

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