Alaminos Doctors Hospital TOaAb Bolaney, Alaminos City; Pan. asinan CASE NO! 1800002824 SOA NO : ROOM/BED # 210 - BED 3 PATIENT NO 1800006650 ROOM RATE 850.00 PATIENT NAME, RIVERA, NORLYN MONZON ADMITTED 10/19/2018 01:10 PM DATE OF BIRTH 02/01/1989 OSCA/PWD ID NO: DISCHARGED 10/21/2018 o/: ar (M ATT. PHYSICIAN ELEANITA LERISSA RIVERA, MD. PHIC Self-Employed Member ‘ADDRESS HERMOSA DASOL HMO N/A COMPANY NA PERSON RESPONSIBLE FOR THE ACCOUNT: CASETYPE pC Hume wt: Pa 34/teuke Peete 7 tnetom 89 CRE onrent Type : in Patient PHILHEALTH CASE RATEL: 59514 Ar 4/7 D4 = 3789"W Ook Cama) " CORPORATE DUE FROM HOSPITAL BILL AMOUNT PanLHeaLTH CORPORATE oe $$ TOR PATIENT _ CENTRAL SUPPLIES: 400.00 : ~ 400.00 EMERGENCY ROOM 1,100.00 * me 1,100.00 MISCELLANEOUS 50.00 « in 50.00 OPERATING ROOM/DELIVERY ROOM 4,350.00 = 4,350.00 PHARMACY 17,013.85 10,400.00 : 6613.85 ROOM AND BOARD 1,200.00 1,000.00 : 200,00 HOSPITAL GROSS CHARGES 24,113.85 11,400.00 - 12,713.85 Tess: Returned Medicines/Supplies : 1,979.25 PAYMENTS/DEPOSITS DATE OR. NO. DESCRIPTION AMOUNT 10/19/2018 509804 Account Receivable Patient 10,000.00 10/20/2018 509832 Account Receivable Patient 10,000.00 Total Payments: 20,000.00 NET HOSPITAL BILL (9,265.40) PROFESSIONAL FEES AMOUNT PHIC HMO NET " ELEANITA LERISSA RIVERA, MD 27,915.40 5,850.00 - 22,065.40, GERONIMO MODESTO YU, MD. 7,750.00 1,750.00 - 6,000.00 ERLITA ROSARIO, MD. 1,500.00 : : 1,500.00 TOTAL PROFESSIONAL FEES 37,165.40 7,600.00 = 29,565.40 Totals 39,300.00 19,000.00 : NET AMOUNT DUE 20,300.00 FINAL BILL RECEIVED = er [cena no A462 919 ‘Prepared by vee Mita Billing Gerke