Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

www.philhealth.gov.ph

AUTO CREDIT PAYMENT NOTICE

PERIOD COVERED: 06/21/2021 to 06/25/2021
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
P14-2106-04776 2105071400602 P142022854789 BULAWIN, JOHN MARK L 04/10/2021 to 04/13/2021 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

GRAND TOTAL 10,500.00 0.00 7,350.00 3,150.00

Total no. of claims: 1

Note:
* - Deducted from IRM/IFM
** - Deducted from DCPM
*** - Deducted from Payment Recovery Breakdown :
IRM/IFM Deduction (06/30/2021) 0.00
DCPM Deduction (06/30/2021) 0.00
Payment Recovery Deduction (06/30/2021) 0.00
Auto Credit Payment (06/30/2021) 7,350.00
Grand Total 7,350.00

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 02:47:58 PM
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