Annex A

STATEMENT OF ACCOUNT
SOA Reference No.:

SUGPON MUNICIPAL HEALTH OFFICE

Poblacion, Sugpon, Ilocos Sur
09509783177; sugpon_rhu@yahoo.com

Patient Name: Age: Date & Time Admitted:

Address: Date & Time Discharged:
Final Diagnosis: First Case Rate:
Other Diagnoses:1. Second Case Rate: (If applicable)
2.
3.

SUMMARY OF FEES

Amount of Discounts PhilHealth Benefits

Place ⁄
PCSO
Out of
Actual Senior DSWD First Case Second Case
Particulars VAT Pocket of
Charges Citizen/ DOH (MAP) Rate Rate
exempt Patient
PWD HMO Amount Amount
Others:

HCI Fees
Room & Board
Drugs & Medicines
Laboratory &
Diagnostics
Operating Room Fee
Supplies
Others: Pls Specify
Subtotal P P P P P P P
Professional Fee/s
1.
2.
3.
4.
5.
Subtotal P P P P P P P

Total P P P P P P P

Prepared by: Conforme:

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.
3. Printed copy of SOA or its equivalent should be free of charge.