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    Sabal Hospital Inc.: Summary of Fees

    Uploaded by

    Quinio Rey
    This document is a statement of account from Sabal Hospital for patient Emelia Damalan. It details charges of $95,314.98 for room and board, drugs, lab tests, supplies, and other hospital fees. It also lists professional fees of $52,980 for services by doctors Irnie Dave E. Gomez and Mellanie T. After applying a $10,000 discount to Dr. E's fees, the total charges were $148,294.98. The patient's PhilHealth benefits covered $143,267, leaving a balance due of $0.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Sabal Hospital Inc.: Summary of Fees

    Uploaded by

    Quinio Rey
    177 views2 pages
    This document is a statement of account from Sabal Hospital for patient Emelia Damalan. It details charges of $95,314.98 for room and board, drugs, lab tests, supplies, and other hospital fees. It also lists professional fees of $52,980 for services by doctors Irnie Dave E. Gomez and Mellanie T. After applying a $10,000 discount to Dr. E's fees, the total charges were $148,294.98. The patient's PhilHealth benefits covered $143,267, leaving a balance due of $0.

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    n/a

    Original Title

    HIS_ADHOC_BillStatement_Std_Rev1 (2)

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    This document is a statement of account from Sabal Hospital for patient Emelia Damalan. It details charges of $95,314.98 for room and board, drugs, lab tests, supplies, and other hospital fees. It also lists professional fees of $52,980 for services by doctors Irnie Dave E. Gomez and Mellanie T. After applying a $10,000 discount to Dr. E's fees, the total charges were $148,294.98. The patient's PhilHealth benefits covered $143,267, leaving a balance due of $0.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    177 views2 pages

    Sabal Hospital Inc.: Summary of Fees

    Uploaded by

    Quinio Rey
    This document is a statement of account from Sabal Hospital for patient Emelia Damalan. It details charges of $95,314.98 for room and board, drugs, lab tests, supplies, and other hospital fees. It also lists professional fees of $52,980 for services by doctors Irnie Dave E. Gomez and Mellanie T. After applying a $10,000 discount to Dr. E's fees, the total charges were $148,294.98. The patient's PhilHealth benefits covered $143,267, leaving a balance due of $0.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    IMPERIO, EMELIA DAMALAN

    STATEMENT OF ACCOUNT
    SOA Reference No.: 2021- 434700
    Sabal Hospital Inc.
    292 Don A. Velez St. Cagayan de Oro City Barangay 20 Cagayan De Oro City (Capital)
    Misamis Oriental Philippines 9000
    856-2206 / 856-2619 / 72-7247 / 72-4041

    Name of Patient: IMPERIO,


    PADINIT, EMELIA
    PORFERIO PABILLARAN JR
    DAMALAN Age: 64
    50 Date & Time Admitted : 5/18/2021
    5/19/20213:34PM
    3:34 PM
    Address : MORNING STREET, MACASANDIG,
    ZONE 4 BIASONG, CABALLERO COMP., BALULANG,
    CAGAYAN DE OROCDO
    9000 Date & Time Discharged : 6/7/2021
    5/31/20218:30PM
    8:30 PM

    First Case Rate : C19IP2


    Final Diagnosis/es and ICD 10 Code/s: Second Case Rate :

    1. U07.1 COVID-19 COFIRMED POSTIVE Room No. 301


    2. J18.92 PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA MODERATE RISK
    3. E11.9 DIABETES MELLITUS TYPE II CONTROLLED
    Surgical Procedure/s and RVS Code/s, if Applicable :

    1. C19IP2 MODERATE PNEUMONIA (COVID-19)

    SUMMARY OF FEES
    Amount of Discounts Philhealth Benefits
    Place _
    †PCSO
    Senior First Second Out of
    †DSWD
    Particulars Actual Charges VAT exempt Citizen/ Case Rate Case Rate Pocket
    †DOH (MAP)
    PWD Amount Amount of Patient
    †HMO
    †Others:

    HCI fees
    Room and Board 5.00 Day(s) @
    1500.00, 1.00 Day(s) @ 2200.00, 25,300.00 0.00 0.00 0.00 0.00
    6.00 Day(s) @ 2600.00
    Drugs and Medicines 14,601.60 0.00 0.00 0.00 0.00
    Laboratory & Diagnostics 750.00 0.00 0.00 0.00 0.00
    Operating Room fee 0.00 0.00 0.00 0.00 0.00
    Supplies 20,613.38 0.00 0.00 0.00 0.00
    Others: pls. specify
    ER Occupancy Charge 500.00 0.00 0.00 0.00 0.00
    Hospital Services 11,050.00 0.00 0.00 0.00 0.00
    Medical Instrument Usage 2,600.00 0.00 0.00 0.00 0.00
    Medical Oxygen 10,900.00 0.00 0.00 0.00 0.00
    Nursing Services 8,050.00 0.00 0.00 0.00 0.00
    Procedure 500.00 0.00 0.00 0.00 0.00
    ROD Services 450.00 0.00 0.00 0.00 0.00
    Subtotal 95,314.98 0.00 0.00 0.00 100,287.00 0.00 0.00
    STATEMENT OF ACCOUNT
    SOA Reference No.: 2021- 434700
    Sabal Hospital Inc.
    292 Don A. Velez St. Cagayan de Oro City Barangay 20 Cagayan De Oro City (Capital)
    Misamis Oriental Philippines 9000
    856-2206 / 856-2619 / 72-7247 / 72-4041

    Name of Patient: PADINIT,


    IMPERIO, PORFERIO PABILLARAN JR
    EMELIA DAMALAN Age: 64
    50 Date & Time Admitted : 5/18/2021
    5/19/2021 3:34PM
    3:34 PM
    Address : MORNING
    ZONE STREET,MACASANDIG,
    4 BIASONG, CABALLERO COMP., BALULANG,
    CAGAYAN DE OROCDO
    9000 Date & Time Discharged 6/7/2021 8:30PM
    : 5/31/2021 8:30 PM

    Professional fee/s
    OBIAS, IRNIE DAVE E 52,680.00 0.00 0.00 0.00 10,000.00
    GOMEZ, MELLANIE T 300.00 0.00 0.00 0.00 0.00
    Subtotal 52,980.00 0.00 0.00 0.00 42,980.00 0.00 10,000.00
    Total 148,294.98 0.00 0.00 0.00 143,267.00 0.00 10,000.00
    Payments
    Payments 10,000.00
    Subtotal 10,000.00
    BALANCE DUE 0.00

    Prepared by: Conforme:

    Administrative Account

    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. Run Date and Time: 7/13/2021 10:46:35 AM
    3. Printed copy of SOA or its equivalent should free of charge.

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