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STATEMENT OF ACCOUNT
Patient No.: 110022635105 SA Number: OPDC11277218
Patient Name: IMPERIAL, JEFFREY MIRAL Telephone No.: 92046482288
DOB: 04/08/1985 Date Admitted: 09/27/2021
Address: BUNLAN Adlaon Cebu City, Cebu 6000 Date Discharged: 09/27/2021
Charged To:
Attending Physician: DR. MAIA CELESTE ALIX ARBATIN

HOSPITAL BILLS
Charges:
Bloodbank 6,235.00 6,235.00

Less:
Partial Payments 4,988.00
4,988.00

Adjustments:
DISCOUNT - PWD (1,247.00) (1,247.00)

Amount Due - Hospital Bill 0.00

PROFESSIONAL FEES

Amount Due - ( PROFESSIONAL FEE ) 0.00

Total Amount Due 0.00

CLAIM DETAILS

Rundate: 2021-10-23 05:44:28
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This serves as statement of account and not as proof of payment.
The hospital reserves the right to bill and collect from you:
1. additional charges actually incurred which were not initially billed
2. Philhealth claims deducted in this statement of account but underpaid or denied by
Philhealth such as but not limited to - benefit already exhausted, violation of
Single Period Policy, double filing.
For possible Philhealth refund, please coordinate with our Refund/Billing Section (30) days
after receipt of payment confirmation from Philhealth.