S TATE ME NT OF AC C OUNT

S tatement of Account
R eference No.
PANTALE ON G. GOTLADE R A ME MOR IAL HOS PITAL
PAWA, BULAN, S OR S OGON
pggmhbulan@gmaiL com
( +63) 0917448- 4187

Patient's Name: l.WbQ91 L&i'// A ge: V 117i4'0/ Date & Time A dmitted: If br,~J
Mailing A ddress: ft%.1if 'J 'f V I /øi//'
lO7s-i') Date & Time Discharged: -)/- 14
Final Diagnosis: 1. VY AI/2/. /t7 O iY 1It i 1t-1/) AV
2. C IclNt-P fY b / ,•,f1'Ufrlc , First Case Rate:
3. Lan lrn. 'i- / !.u'lF /L ,lo /4 Second Case Rate:

SUMMA RY OF T HE HOSPIT A L CHA RGE S

AMOUNT OF DIS C OUNTS PHILHE ATH BE NE FITS
PCSO T
S E NIOR PATIE NT'S
VAT - DS WD
AC TUAL C ITIZE N/PWD F IR S T C AS E S E C OND C AS E OUT OF
PAR TIC ULAR S BILLING
E X E MPTION
DIS C OUNT
DOH (MAP)
R ATE AMOUNT R ATE AMOUNT THE
(12%) (20%) HMO
POCKET
Ot her
Room & Board
Drugs & Medicines !fo f'i()
L aboratory& Diagnostics
Operating Room Fee ~v~d
Supplies
Other /L fee rlD '"
SUB-T OT A L (HCI) IV
/A /. /1 D/d 1G~

SUMMA RY OF PROFESSIONA L FE E S
AMOUNT OF DIS C OUNTS PHILHE ATH BE NE FITS
PC S O
S E NIOR PATIE NT'S
VAT DS WD
AC TUAL C ITIZE N/PWD (MAP) F IR S T C AS E S E C OND C AS E OUT OF
PAR TIC ULAR S BILLING
E X E MPTION
DIS C OUNT
DOH
R ATE AMOUNT R ATE AMOUNT THE
(12%) HMO
(20%) POCKET
Ot her

MD.,MSPa
w
CHAR W B. BA NDOL A .
3 gkz eiO
4
5
SUB-T OT A L (HCI) `' £ 0 14)

UMMA RY OF CIIA RGE S

AMOUNT OF DIS C OUNTS PHILHE ATH BE NE FITS
PCSO
S E NIOR PATIE NT'S
VAT DS WD
ACTUAL C ITIZE N/PWD F IR S T C AS E S E C OND C AS E OUT OF
PAR TIC ULAR S BILLING
E X E MPTION
DIS C OUNT
DOH (MA P)
R ATE AMOUNT R ATE AMOUNT THE
(12%) _ HMO
(2a%) POC KE T
Ot her
Total HCI Fees (.P
Total PF
GRA ND TOTA L
Excess Payment Php: Official Receipt No.:
cc ~l d
Prepared By: Conformed:
CHE AR f2-i1Cp9— c cc77 Z7?
NA ME OF BIL L ING CL ERK MEMBER/PA TIENT/A UTHORIZED REPRESENTA TIV E
(SIGNA TURE OV ER PRjNT ,D NA ME) (SIGNA TURE OOI~~E I~NA ME )
Date signed: Relation to Member:
Contact No.: A ddress & Contact No.:

NOTE:
1. Fill out the form legibly
2. The Member/Patient/Authorized Representative should not sign a blank SOA
3. Printed copy of SOA or its equivalent should be free of charge.
MA. S HE E NA M. HIZOLA
Acting Administrative Officer