DIVINE MERCY FOUNDATION OF URDANETA, INC.

# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan

Tel #075 -656-2103/ Cp# 09175002025 Email Add:dmhospurd@gmail.com

NAME: MIRAR, ALEXIS VALENTIN ROOM:(REGULAR ROOM)

ADDRESS: Pedro T. Orata, Urdaneta City, Pangasinan DATE: NOVEMBER 27, 2022
Philhealth Type: Lifetime Member Patient Type: In patient
Date of Admission: November 22, 2022
DIAGNOSIS:
 Periappendiceal Abscess, with autolyzed necrotic appendicitis, sub cecal; with phlegm, friable
necrotic surrounding soft tissues
 Electrolyte Imbalance
 Urinary Tract Infection
 Hypothermia t/c sepsis
STATEMENT OF ACCOUNT
TOTAL SENIOR PHILHEALTH OTHER TOTAL
CHARGES DISCOUNT DISCOUNT DISCOUNT AMOUNT

ROOM (206) 12,500.00 3,000.00 9,500.00

ER FEE 500.00 500.00
OPERATING ROOM FEE 8,000.00 3,000.00 5,000.00
RECOVERY FEE 2,000.00 2,000.00
DRUGS & MEDS 23,870.00 3,000.00 20,870.00
MEDICAL SUPPLIES 14,975.00 3,000.00 11,975.00
ANESTHETIC DRUGS 25,000.00 2,000.00 23,000.00
LABORATORY FEES 8,675.00 8,675.00
XRAY 750.00 750.00
ECG 250.00 250.00
PULSE OXIMETER 2,500.00 2,500.00
OXYGEN 2,500.00 2,500.00
SUCTIONING 2,500.00 2,500.00
CARDIAC MONITOR 2,500.00 2,500.00
ANESTH. MACHINE 2,500.00 2,500.00
INSTRUMENT 6,000.00 400.00 5,600.00
PROTECTIVE EQUIP. 500.00 500.00
ELEC. COMM. 500.00 500.00
DEVICE CHARGING 200.00 200.00
MISCELLANEOUS FEE 1,500.00 1,500.00
ADMISSION FEE 500.00 500.00
SUBTOTAL 118,220.00 14,400.00 103,820.00
DR. ANITA C. TARECTECAN 46,400.00 6,400.00 40,000.00
DAILY ROUNDS SURGEON 12,500.00 12,500.00
DR. ANNE MOYA 25,200.00 3,200.00 22,000.00
TOTALTOTAL AMOUNT 202,320.00 24,000.00 178, 320.00

PREPARED BY: CONFORMED:

RUTH VINLUAN GANDIA _______________________________________

Signature Over Printed Name Signature Over Printed
Date Signed: November 27, 2022 Date Signed: November 27, 2022
Contact No: 0917-500-2025
 DIVINE MERCY FOUNDATION OF URDANETA, INC.
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel #075 -656-2103/ Cp# 09175002025 Email Add:dmhospurd@gmail.com

NAME: MIRAR, ALEXIS VALENTIN ROOM:(REGULAR ROOM)

ADDRESS: Pedro T. Orata, Urdaneta City, Pangasinan DATE: NOVEMBER 27, 2022

MEDICINES/ DRUGS
Drugs/Medicines Unit Price Quantity Gross
Amount
PNSS 1L 150.00 5 750
AMINO ACID 350.00 8 2800
B-COMPLEX IV 150.00 8 1200
D5LRS 1L 150.00 3 450
CEFTRIAXONE IV 350.00 18 6300
DIPHENHYDRAMINE CAP 30.00 10 300
METRONIDAZOLE IV 300.00 18 5400
TRAMADOL IV 350.00 5 1750
KETOROLAC IV 350.00 4 1400
PANTOPRAZOLE TABLET 50.00 10 500
OMEPRAZOLE IV 350.00 5 1750
DEXAMETHASONE IV 200.00 1 200
METOCLOPRAMIDE IV 120.00 1 120
PARACETAMOL IV 120.00 5 600
TRAMADOL + PARACETAMOL 35.00 10
TAB 350
TOTAL ₱23,870.00

ANESTHESIA DRUGS ONLY

Medical Supplies Unit Price Quantity Gross
Amount
NALBUPHINE 1,000.00 1 1,000.00
BUPIVACAINE 2,200.00 1 2,200.00
PROPOFOL 2,200.00 8 17,600.00
MIDAZOLAM 2,200.00 1 2,200.00
FENTANYL 2,000.00 1 2,000.00
TOTAL ₱25,000.00
 DIVINE MERCY FOUNDATION OF URDANETA, INC.
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel #075 -656-2103/ Cp# 09175002025 Email Add:dmhospurd@gmail.com

NAME: MIRAR, ALEXIS VALENTIN ROOM:(REGULAR ROOM)

ADDRESS: Pedro T. Orata, Urdaneta City, Pangasinan DATE: NOVEMBER 27, 2022

Medical Supplies Unit Price Quantity Gross

Amount
5 CC 20.00 10 200
1 CC 20.00 10 200
3 CC 20.00 5 100
BT SET 500.00 2 1000
MACROSET 150 1 150
ABBOCATH G.18 150.00 3 450
IFC F.16 250.00 1 250
URINE BAG 100.00 1 100
10 CC 30.00 3 90
K Y JELLY 20.00 3 60
CLEAN GLOVES 25.00 100 2500
STERILE GLOVES 7.5 75.00 5 375
OS 25.00 5 125
3 WAY 350.00 1 350
SPLINT 150.00 1 150
VICRYL 0 950.00 3 2850
CHROMIC 2.0 450.00 2 900
SUCTION TIP 250.00 1 250
IRRIGATING SOLUTION 150.00 2 300
CLEAN GLOVES 50.00 5 250
STERILE WATER 6.5 75.00 1 75
HEAD CAP 50.00 5 250
PPE 1,500.00 2 3000
VS 100.00 10 1000
TOTAL ₱14,975.00