< Chippenham Hospital ACAMPUS OF CJW MEDICAL CENTER 7101 Jahnke Ra, Rctenond, VA 23225, United States MEDICAL SERVICE BILL PATIENT INFORMATIONS Name : Georgia 0 Elle IP/No. :97101 ID No. : 0000246611 Dob : 06/08/1950 Admission Dt./Time : 30-Jun-2022 7:22 AM Bill No. : ICR33504 Discahrge Dt./Time : 25-Jun-2022 10:06 AM SUMMARY OF SERVICE FOR Service Price ($) ROOM & NURSING SERVICE 2,850.00 PHARMACY 2,210.00 SUPPLIES 4,047.00 LABORATORY 1,341.00 RADIOLOGY 1,506.00 EMERGENCY ROOM 3,211.00 RECOVERY ROOM SERVICE 1,918.00 EKG/ECG 306.00 Total Charges $ 17,389.00 In Words Seventeen Thousand Three Hundred And Eighty Nine Dollars This is a computer generated statement and requires no signature. This Receipt is valid for an employer or insurer, who is contractually obligated to reimburse the medical expenses covered by Medisave. © Chippenham Hospital, Richmond, All Rights reserved