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 03:52 PM

Patient Name: LUZA, MARIA ALTHEA PAHAYAHAY Case No.: 4440640
Address: 13111 BRGY. 13, CALUMPANG, LANTIC, CARMONA, CAVITE Bill No.: 239220
Discount Type: Age:
Date Admitted: July 27, 2017 Time Admitted: 02:52 AM
Date Discharged: July 29, 2017 Time Discharged: 03:52 PM
Room/Ward/Bed: 16-19 Balance: 0.0

Summary of Charges

SERVICES DEPARTMENT FEES Gross Discount Amount Due
NURSING EDUCATION AND TRAINING(DNET)-(40202990-00-13-2B) 550.00 - 550.00
ORL-(40202170-00-439-161) 200.00 - 200.00
PHARMACY-REVOLVING FUND 490.25 - 490.25
TOTAL CHARGES Php 1,240.25 Php 0.00 Php 1,240.25

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-99432 Php 1,250.00
OUTSTANDING HOSPITAL BILLS Php (9.75)

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 .