IMPERIO, EMELIA DAMALAN

STATEMENT OF ACCOUNT
SOA Reference No.: 2021- 434700
Sabal Hospital Inc.
292 Don A. Velez St. Cagayan de Oro City Barangay 20 Cagayan De Oro City (Capital)
Misamis Oriental Philippines 9000
856-2206 / 856-2619 / 72-7247 / 72-4041

Name of Patient: IMPERIO,

PADINIT, EMELIA
PORFERIO PABILLARAN JR
DAMALAN Age: 64
50 Date & Time Admitted : 5/19/2021 3:34 PM
Address : MORNING STREET, MACASANDIG,
ZONE 4 BIASONG, CABALLERO COMP., BALULANG,
CAGAYAN DE OROCDO
9000 Date & Time Discharged : 5/31/2021 8:30 PM

First Case Rate : C19IP2

Final Diagnosis/es and ICD 10 Code/s: Second Case Rate :

1. U07.1 COVID-19 COFIRMED POSTIVE Room No. 301

2. J18.92 PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK
3. E11.9 DIABETES MELLITUS TYPE II CONTROLLED
Surgical Procedure/s and RVS Code/s, if Applicable :

1. C19IP2 MODERATE PNEUMONIA (COVID-19)

SUMMARY OF FEES
Amount of Discounts Philhealth Benefits
Place _
†PCSO
Senior First Second Out of
†DSWD
Particulars Actual Charges VAT exempt Citizen/ Case Rate Case Rate Pocket
†DOH (MAP)
PWD Amount Amount of Patient
†HMO
†Others:

HCI fees
Room and Board 5.00 Day(s) @
1500.00, 1.00 Day(s) @ 2200.00, 25,300.00 0.00 0.00 0.00 0.00
6.00 Day(s) @ 2600.00
Drugs and Medicines 14,601.60 0.00 0.00 0.00 0.00
Laboratory & Diagnostics 750.00 0.00 0.00 0.00 0.00
Operating Room fee 0.00 0.00 0.00 0.00 0.00
Supplies 20,613.38 0.00 0.00 0.00 0.00
Others: pls. specify
ER Occupancy Charge 500.00 0.00 0.00 0.00 0.00
Hospital Services 11,050.00 0.00 0.00 0.00 0.00
Medical Instrument Usage 2,600.00 0.00 0.00 0.00 0.00
Medical Oxygen 10,900.00 0.00 0.00 0.00 0.00
Nursing Services 8,050.00 0.00 0.00 0.00 0.00
Procedure 500.00 0.00 0.00 0.00 0.00
ROD Services 450.00 0.00 0.00 0.00 0.00
Subtotal 95,314.98 0.00 0.00 0.00 100,287.00 0.00 0.00
 STATEMENT OF ACCOUNT
SOA Reference No.: 2021- 434700
Sabal Hospital Inc.
292 Don A. Velez St. Cagayan de Oro City Barangay 20 Cagayan De Oro City (Capital)
Misamis Oriental Philippines 9000
856-2206 / 856-2619 / 72-7247 / 72-4041

Name of Patient: PADINIT,

IMPERIO, PORFERIO PABILLARAN JR
EMELIA DAMALAN Age: 64
50 Date & Time Admitted : 5/19/2021 3:34 PM
Address : MORNING
ZONE STREET,MACASANDIG,
4 BIASONG, CABALLERO COMP., BALULANG,
CAGAYAN DE OROCDO
9000 Date & Time Discharged : 5/31/2021 8:30 PM

Professional fee/s
OBIAS, IRNIE DAVE E 52,680.00 0.00 0.00 0.00 10,000.00
GOMEZ, MELLANIE T 300.00 0.00 0.00 0.00 0.00
Subtotal 52,980.00 0.00 0.00 0.00 42,980.00 0.00 10,000.00
Total 148,294.98 0.00 0.00 0.00 143,267.00 0.00 10,000.00
Payments
Payments 10,000.00
Subtotal 10,000.00
BALANCE DUE 0.00

Prepared by: Conforme:

Administrative Account

Billing Clerk/ Accountant Member/Patient/Authorized representative

(Signature over printed name) (Signature over printed name)
Date signed.: Relationship to member of authorized representative:

Contact No. : Date signed.: Contact no.:

NOTE:
1. Fill out the form legibly.
2. The member/patient/authorized representative should not sign a blank SOA. Run Date and Time: 7/13/2021 10:46:35 AM
3. Printed copy of SOA or its equivalent should free of charge.