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    Provisional Bill

    Name : Mr. Sellahennadige Lalindra Deepal Fernando Bill No : BL096252


    Address : No:475, Kospalana, Polpitimukalana, Kandana Bill Date :
    Location : Gampaha,WESTERN PROVINCE MR No : MR479768
    Age/Sex : 48 Y M Visit ID : IP058548
    Company : Mobizz Elite (Pvt) Ltd Bed Type : LEVEL 04 - 413
    Consultant : DR. (MRS) DEEPA AMARASEKARA Admission Date : 26-08-2024 10:37
    Discharge Date :
    Primary Sponsor : Mobizz Elite (Pvt) Ltd

    Bed Name Bed Type No of Days In Time Out Time


    LEVEL 04 - 413 EXECUTIVE SINGLE ROOM 1.00 26-08-2024 10:37 27-08-2024 14:30
    LEVEL 04 - 413 EXECUTIVE SINGLE ROOM 1.50 26-08-2024 10:37 27-08-2024 14:30

    Charges Code/Description/Service Qty Unit Rate Discount Amount (LKR)


    Admission Charge
    26-08-2024 10:37 1.00 8,900.00 0.00 8,900.00
    Sub Total 8,900.00
    Doctor Charges
    27-08-2024 13:13 DR. (MRS) DEEPA AMARASEKARA 1.00 22,000.00 0.00 22,000.00
    (PHYSICIAN)
    27-08-2024 13:15 DR. M.B.S.N MANDAWALA 1.00 5,000.00 0.00 5,000.00
    (Radiologist)
    27-08-2024 13:13 DR. SANJEEWA RAJAPAKSHA 1.00 5,000.00 0.00 5,000.00
    (CARDIOLOGIST)
    Sub Total 32,000.00
    Ward Charges
    26-08-2024 12:11 Bed Charge (LEVEL 04 - 413) 1.50 16,500.00 0.00 24,750.00
    26-08-2024 12:11 Duty Doctor Charge (LEVEL 04 - 413) 1.50 7,000.00 0.00 10,500.00
    26-08-2024 19:22 Medical Administration Charges 1.00 4,000.00 0.00 4,000.00
    (Medical Admin Fee)
    26-08-2024 12:11 Nursing Charge (LEVEL 04 - 413) 1.50 6,150.00 0.00 9,225.00
    26-08-2024 12:11 Linen Charge (LEVEL 04 - 413) 1.50 900.00 1,350.00 0.00
    Sub Total 48,475.00
    Laboratory Charges
    27-08-2024 08:31 C REACTIVE PROTEIN 1.00 1,525.00 0.00 1,525.00
    26-08-2024 13:18 ERYTHROCYTE SEDIMENTATION 1.00 830.00 0.00 830.00
    RATE ( ESR )
    27-08-2024 08:31 FREE THYROXINE (FT4) 1.00 3,705.00 0.00 3,705.00
    26-08-2024 13:18 FULL BLOOD COUNT 1.00 400.00 0.00 400.00
    27-08-2024 08:31 GLUCOSE FASTING 1.00 795.00 0.00 795.00
    26-08-2024 13:18 GLYCO HAEMOGLOBIN (HBA 1C) 1.00 3,495.00 0.00 3,495.00
    27-08-2024 08:31 INFLUENZA H1N1 A & B 1.00 7,020.00 0.00 7,020.00
    ANTIGEN (I)
    27-08-2024 08:31 PROFILE LIPID 1.00 2,870.00 0.00 2,870.00
    26-08-2024 13:18 PROFILE LIVER 1.00 5,835.00 0.00 5,835.00
    26-08-2024 13:18 PROFILE RENAL 1.00 7,920.00 0.00 7,920.00
    26-08-2024 13:18 THYROID STIMULATING 1.00 2,925.00 0.00 2,925.00
    HORMONE (TSH)
    Radiology Charges
    27-08-2024 13:13 US SCAN ABDOMEN 1.00 3,500.00 0.00 3,500.00
    Sub Total 40,820.00
    Services & Procedures

    Page 1 of 3
    27-08-2024 16:13 ECG 1.00 1,000.00 0.00 1,000.00
    27-08-2024 13:13 ECHOCARDIOGRAM - DR. 1.00 4,000.00 0.00 4,000.00
    SANJEEWA RAJAPAKSHA
    Sub Total 5,000.00
    Other Charges
    27-08-2024 16:13 SLEEP STUDY TEST 1.00 20,000.00 0.00 20,000.00
    27-08-2024 13:13 WATER BOTTLE 1 L 1.00 150.00 0.00 150.00
    Sub Total 20,150.00
    Taxes
    26-08-2024 12:11 LEVEL 04 - 413 (26-08-2024 10:37 to 1.00 4,455.00 0.00 4,455.00
    27-08-2024 14:30)
    Sub Total 4,455.00
    Returns
    27-08-2024 12:16 ALCOHOL PADS (SOFTA) -3.00 6.59 0.00 -19.77
    27-08-2024 12:16 ATORVA 10MG -1.00 22.14 0.00 -22.14
    27-08-2024 12:16 CLAVAMOX 500MG -5.00 98.70 0.00 -493.50
    27-08-2024 12:16 DERIPHYLLIN-R 300MG -1.00 14.08 0.00 -14.08
    26-08-2024 13:05 FLUTICONE N/SPRAY -1.00 1,780.80 0.00 -1,780.80
    27-08-2024 12:16 PANTODAC 40MG -1.00 55.59 0.00 -55.59
    27-08-2024 12:16 PREDNISILON 5MG -5.00 2.62 0.00 -13.10
    27-08-2024 12:16 SYRINGE 5CC terumo -2.00 63.45 0.00 -126.90
    27-08-2024 12:16 Zypent 10mg -3.00 22.90 0.00 -68.70
    Sub Total -2,594.58
    Items
    26-08-2024 12:34 ALCOHOL PADS (SOFTA) (No. 4.00 6.59 0.00 26.36
    577930)
    26-08-2024 12:34 ATORVA 10MG (No. 577930) 2.00 22.14 0.00 44.28
    27-08-2024 16:06 ATORVA 10MG (No. 578153) 5.00 22.14 0.00 110.70
    27-08-2024 16:06 ATORVA 10MG (No. 578153) 25.00 22.14 0.00 553.50
    27-08-2024 10:02 CLAVAMOX 500MG (No. 578100) 6.00 98.70 0.00 592.20
    27-08-2024 16:06 CLAVAMOX 500MG (No. 578153) 10.00 98.70 0.00 987.00
    26-08-2024 19:00 DERIPHYLLIN-R 300MG (No. 577993) 2.00 14.08 0.00 28.16
    27-08-2024 16:06 DERIPHYLLIN-R 300MG (No. 578153) 5.00 14.08 0.00 70.40
    26-08-2024 12:34 EXAMINATION GLOVES (S) (No. 10.00 14.74 0.00 147.40
    577930)
    26-08-2024 12:34 FLUTICONE N/SPRAY (No. 577930) 1.00 1,780.80 0.00 1,780.80
    27-08-2024 16:19 INFECTION CONTROL and 1.00 3,000.00 0.00 3,000.00
    PREVENTION CONSUMABLES (No.
    578156)
    26-08-2024 14:32 PANTODAC 40MG (No. 577950) 4.00 55.59 0.00 222.36
    27-08-2024 16:06 PANTODAC 40MG (No. 578153) 10.00 55.59 0.00 555.90
    26-08-2024 19:00 PREDNISILON 5MG (No. 577993) 12.00 2.62 0.00 31.44
    27-08-2024 16:06 PREDNISILON 5MG (No. 578153) 24.00 2.59 0.00 62.16
    26-08-2024 12:34 SYRINGE 5CC terumo (No. 577930) 4.00 63.45 0.00 253.80
    27-08-2024 10:02 TAMIFLU 75MG (OSELTAMIVIRE) 10.00 2,798.96 0.00 27,989.60
    (No. 578100)
    26-08-2024 12:34 TERUMO 3CC SYRINGE (No. 577930) 3.00 52.65 0.00 157.95
    26-08-2024 19:00 Zypent 10mg (No. 577993) 4.00 22.90 0.00 91.60
    27-08-2024 16:06 Zypent 10mg (No. 578153) 5.00 22.90 0.00 114.50
    Sub Total 36,820.11
    Bill Amount 194,025.53

    Bill Transaction Details Amount (LKR)

    Page 2 of 3
    Bill Amount 195,375.53
    Total Discount 1,350.00

    Patient Due 0.00


    Total Claim 194,025.53
    Less Sponsor Pay 0.00
    Sponsor Due 194,025.53

    BILLING INCHARGE PREPARED BY CASHIER PATIENT ATTENDENT


    PRINT DATE:27-08-2024 16:35 (Umesha Jayasinghe)

    Page 3 of 3

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