Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

www.philhealth.gov.ph

AUTO CREDIT PAYMENT NOTICE

PERIOD COVERED: 06/14/2021 to 06/18/2021
HCI NAME: MAHAYAG MUNICIPAL HOSPITAL
ADDRESS: SAN VICENTE, MAHAYAG, ZAMBOANGA DEL SUR
ACCREDITATION NO: H09014295

Bank Account Name: MAHAYAG MUNICIPAL GOVERNMENT - MUNICIPAL HOSPITAL PHILHEALTH - HCI
Bank Account No.: 2842107884
Caserate 1 Caserate 2 Others Total
PABN No. Series No. Member PIN Patient Name Confinement Period
Code Gross Code Gross Code Gross Gross WTax HCI PF
P14-2106-04264 2105071400605 P142016090386 CALDEA, MERALUNA P 04/15/2021 to 04/16/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-03800 2105241400665 P142506908379 CAMPOS, ARGE P 03/19/2021 to 03/20/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-04223 2105121400465 P142506785935 CANILLO, JOANN A 02/27/2021 to 03/02/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2106-03425 2106081400224 P150253532310 CARABALLO, KYL DEXZIL JON M 05/19/2021 to 05/21/2021 N39.0 5,250.00 NONE 0.00 NONE 0.00 5,250.00 0.00 3,675.00 1,575.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2106-04109 2104301400732 P142006186598 CATUBIS, CAMAEKHYL 02/25/2021 to 02/27/2021 K27.3 4,270.00 NONE 0.00 NONE 0.00 4,270.00 0.00 2,989.00 1,281.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2106-03425 2106081400171 P142506900653 DEPIO, METHALIA GRACE G 04/05/2021 to 04/08/2021 J18.92 10,500.00 NONE 0.00 NONE 0.00 10,500.00 0.00 7,350.00 3,150.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-04223 2105121400463 P142506958554 ELORDE, CLAIRE MAE P 03/09/2021 to 03/10/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-03848 2106081400838 P142002199326 EMBALSADO, PRINCESS DIANNE 05/16/2021 to 05/20/2021 N39.0 5,250.00 NONE 0.00 NONE 0.00 5,250.00 0.00 3,675.00 1,575.00
C
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2106-02765 2106081400149 P142005444666 NAGAO, DEDIE A 04/04/2021 to 04/07/2021 N39.0 5,250.00 NONE 0.00 NONE 0.00 5,250.00 0.00 3,675.00 1,575.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-03565 2106081400777 P120507565854 SALADO, RHIANNE LEIGH C 05/20/2021 to 05/22/2021 N39.0 5,250.00 NONE 0.00 NONE 0.00 5,250.00 0.00 3,675.00 1,575.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2106-04223 2105121400464 P152031016015 SOLATORIO, RUTCHEL M 03/03/2021 to 03/05/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-03880 2106011400260 P150503963037 YAÑEZ, CRISTOLEN V 03/05/2021 to 03/06/2021 NSD01 6,500.00 NONE 0.00 NONE 0.00 6,500.00 0.00 3,900.00 2,600.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2106-04091 2105101400150 P140250937500 ZABALLERO, BABY JANE C 02/18/2021 to 02/20/2021 T78.4 4,340.00 NONE 0.00 NONE 0.00 4,340.00 0.00 3,038.00 1,302.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited

GRAND TOTAL 79,110.00 0.00 51,477.00 27,633.00

Total no. of claims: 13
IN COMPLIANCE TO THE NATIONAL INTERNAL REVENUE CODE CHAPTER 11 SECTION 237, OFFICIAL RECEIPT (O.R.) OF THIS REIMBURSEMENT SHOULD BE ISSUED NOTE: THIS IS A SYSTEM GENERATED REPORT, SIGNATURE IS NO LONGER REQUIRED
Page 1 of 1 / Date Generated: 12/01/2022 09:22:13 AM
 Note:
* - Deducted from IRM/IFM
** - Deducted from DCPM
*** - Deducted from Payment Recovery Breakdown :
IRM/IFM Deduction (06/23/2021) 0.00
DCPM Deduction (06/23/2021) 0.00
Payment Recovery Deduction (06/23/2021) 0.00
Auto Credit Payment (06/23/2021) 51,477.00
Grand Total 51,477.00

IN COMPLIANCE TO THE NATIONAL INTERNAL REVENUE CODE CHAPTER 11 SECTION 237, OFFICIAL RECEIPT (O.R.) OF THIS REIMBURSEMENT SHOULD BE ISSUED NOTE: THIS IS A SYSTEM GENERATED REPORT, SIGNATURE IS NO LONGER REQUIRED
Page 1 of 1 / Date Generated: 12/01/2022 09:22:13 AM
Powered by TCPDF (www.tcpdf.org)