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    REYNALDO DONIO
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    This document is a statement of account from the Liloy Integrated Health District Hospital in Zamboanga del Norte, Philippines. It details the charges incurred by patient Estela A. Pilangan during her admission including room and board fees, medical procedures, medicines, and other miscellaneous supplies. The statement shows the actual costs, amounts covered by PHIC insurance, and any excess amounts due. It is signed by the pharmacist, collecting officer, and hospital chief to validate the services received and amounts owed.

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    Statement of Account (1)

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    This document is a statement of account from the Liloy Integrated Health District Hospital in Zamboanga del Norte, Philippines. It details the charges incurred by patient Estela A. Pilangan during her admission including room and board fees, medical procedures, medicines, and other miscellaneous supplies. The statement shows the actual costs, amounts covered by PHIC insurance, and any excess amounts due. It is signed by the pharmacist, collecting officer, and hospital chief to validate the services received and amounts owed.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    28 views3 pages

    Statement of Account

    Uploaded by

    REYNALDO DONIO
    This document is a statement of account from the Liloy Integrated Health District Hospital in Zamboanga del Norte, Philippines. It details the charges incurred by patient Estela A. Pilangan during her admission including room and board fees, medical procedures, medicines, and other miscellaneous supplies. The statement shows the actual costs, amounts covered by PHIC insurance, and any excess amounts due. It is signed by the pharmacist, collecting officer, and hospital chief to validate the services received and amounts owed.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    Republic of the Philippines

    PROVINCE OF ZAMBOANGA DEL NORTE


    LILOY INTEGRATED HEALTH DISTRICT HOSPITAL
    Liloy, Zamboanga del Norte

    STATEMENT OF ACCOUNT
    Patient: Room/Ward: ______________ Date Admitted: ______________
    Address: Category: _________________ Date Discharge: ______________
    ACTUAL PHIC EXCESS
    CHARGES:
    Room & Board ____ days ₱
    Drugs & Medicines
    Delivery Fee
    E.R Fee
    Laboratory Examination
    OTHER CHARGES:
    a. X-Ray/ECG ₱
    b. Oxygen
    c. Ambulance Fee
    d. Miscellanous
    d.1 Supplies
    d.2 Others
    SUBTOTAL ₱
    DEDUCTION ₱
    TOTAL ₱ ₱ ₱
    PROFESSIONAL FEE ₱ ₱
    PLEASE PAY THIS AMOUNT ₱

    MARITES B. CURADO WENY T. GUERRERO _________________


    Pharmacist III AA II/Collecting Officer-Designate O.R Number

    Approved by:

    NOEL C. HERRERAJR.,M.D,MPH,FPCP
    Acting Chief of Hospital
    I hereby acknowledge that the above services
    were actually received and rendered while
    admitted in this hospital

    JESSA RUMABA
    Member/Patient/Representative
    Republic of the Philippines
    PROVINCE OF ZAMBOANGA DEL NORTE
    LILOY INTEGRATED HEALTH DISTRICT HOSPITAL
    Liloy, Zamboanga del Norte

    STATEMENT OF ACCOUNT
    Patient: Room/Ward: ______________ Date Admitted: ______________
    Address: Category: _________________ Date Discharge: ______________

    ACTUAL PHIC EXCESS


    CHARGES:
    Room & Board ___ days ₱
    Drugs & Medicines
    Delivery Fee
    E.R Fee

    NBB BILLING
    Laboratory Examination

    OTHER CHARGES:
    a. X-Ray/ECG ₱ L ANCE li cy )
    BA t Po
    b. Oxygen NO ym e n
    a
    c. Ambulance Fee
    (No P
    d. Miscellanous
    d.1 Supplies
    d.2 Others
    SUBTOTAL ₱
    DEDUCTION ₱
    TOTAL ₱ ₱ ₱
    PROFESSIONAL FEE ₱ ₱
    PLEASE PAY THIS AMOUNT ₱

    MARITES B. CURADO WENY T. GUERRERO _________________


    Pharmacist III AA II/Collecting Officer-Designate O.R Number

    Approved by:

    NOEL C. HERRERA JR.,M.D,MPH,FPCP


    Acting Chief of Hospital
    I hereby acknowledge that the above services
    were actually received and rendered while
    admitted in this hospital
    ESTELA A. PILANGAN
    Member/Patient/Representative

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