Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

www.philhealth.gov.ph

AUTO CREDIT PAYMENT NOTICE

PERIOD COVERED: 07/05/2021 to 07/09/2021
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
P14-2107-01131 2106081400168 P152025244464 ASON, XYRIE E 04/07/2021 to 04/09/2021 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
P14-2107-00308 2105171400110 P142010672553 BOCA, REAH JEAN C 02/02/2021 to 02/04/2021 99460 2,750.00 NONE 0.00 NONE 0.00 2,750.00 0.00 2,250.00 500.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2107-00285 2105191400544 P142506958554 CASERES, DALE E 03/09/2021 to 03/10/2021 99460 2,750.00 NONE 0.00 NONE 0.00 2,750.00 0.00 2,250.00 500.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2107-00895 2106081400186 P142505361880 DELA CRUZ, PRINCESS MELRUS 05/10/2021 to 05/12/2021 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
P14-2107-00155 2106011400678 P142016759960 NANAT, RONARD B 03/12/2021 to 03/14/2021 J06.9 2,800.00 NONE 0.00 NONE 0.00 2,800.00 0.00 1,960.00 840.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2107-01144 2106091400138 P141751429560 PORRAS, LUZVIMINDA M 05/21/2021 to 05/23/2021 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
P14-2107-01551 2106281400482 P141751819083 RABACA, LUCIA C 05/01/2021 to 05/03/2021 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
P14-2107-00285 2105171400112 P152031016015 SANTANDER, SIDNEY S 03/03/2021 to 03/05/2021 99460 2,750.00 NONE 0.00 NONE 0.00 2,750.00 0.00 2,250.00 500.00
Health Care Professional/s: ABBAS , NURHAINA A. Credited
P14-2107-00155 2106011400676 P142505410504 VALDEZ, JESSA MAE P 05/11/2021 to 05/13/2021 J06.9 2,800.00 NONE 0.00 NONE 0.00 2,800.00 0.00 1,960.00 840.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2107-00308 2105171400111 P142506785935 VILLAMINO, HANNAH C 02/27/2021 to 03/02/2021 99460 2,750.00 NONE 0.00 NONE 0.00 2,750.00 0.00 2,250.00 500.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited
P14-2107-01551 2106281400597 P142018408421 YBAÑEZ, EBMER T 04/10/2021 to 04/12/2021 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
P14-2107-01551 2106281400596 P142517795428 YBAÑEZ, ELLEN GYL 03/29/2021 to 03/31/2021 A09.9 4,200.00 NONE 0.00 NONE 0.00 4,200.00 0.00 2,940.00 1,260.00
Health Care Professional/s: BELLEN-RAMOS, RUZENDA C. Credited

GRAND TOTAL 52,300.00 0.00 37,910.00 14,390.00

Total no. of claims: 12

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: 12/13/2022 02:49:19 PM
 Note:
* - Deducted from IRM/IFM
** - Deducted from DCPM
*** - Deducted from Payment Recovery Breakdown :
IRM/IFM Deduction (08/11/2021) 0.00
DCPM Deduction (08/11/2021) 0.00
Payment Recovery Deduction (08/11/2021) 0.00
Auto Credit Payment (08/11/2021) 37,910.00
Grand Total 37,910.00

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: 12/13/2022 02:49:19 PM
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