TAX OUTPATIENT INVOICE (Credit-GMA MEDICAL TREATMENT FACILITATION SERVICES LLC)

Patient No. : GH00094427 Invoice No : 218727

Name : Mr Khojiakbar Karimberdiev Invoice Type : Credit
Age/Sex : 23Y/M DOB :23/07/1999 Invoice Date : 30/10/2022
Address : ,Abu Dhabi Visit Date : 30/10/2022
Tax Reg. No. : Doctor : M. TAREK MOUALEM
     Department : ORTHOPAEDICS
: GMA MEDICAL TREATMENT FACILITATION SERVICES :
Insurance Policy No
LLC
: GMA MEDICAL TREATMENT FACILITATION SERVICES Member ID/Card :
Policy Name 123
LLC #
Customer Reg. :
No
Insurance
Approval Code :
Net Tax Patient
Description Unit Gross Discount Discount% Tax% Credit
Amount Amount Pay
CONSULTATION
7041 Consultation Specialist Initial 1 690.00 0.00 0.00 690.00 0.00 0.00 0.00 690.00
(10)
RADIOLOGY
8527 Radiologic Examination, 1 437.00 0.00 0.00 437.00 0.00 0.00 0.00 437.00
Pelvis; Complete, Minimum
Of 3 Views
(72190)
8644 X-Ray Exam Of Knee 3 1 388.00 0.00 0.00 388.00 0.00 0.00 0.00 388.00
(73562)

Gross Amount : 1,515.00

Net Amount : 1,515.00
Amount to be Claimed : 1,515.00

Claimed Amount : DIRHAMS One Thousand Five Hundred and Fifteen

Prepared By : 7000268 Counter Name : Opd Counter Cashier

Printed Date : 03/11/2022 16:03:21

* Non insured items