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Soa Philhealth

This document is a statement of account from Mapandan Community Hospital detailing medical services provided to a patient. It lists the patient's name, age, diagnosis, admission and discharge dates and fees including room and board, drugs, laboratory tests, surgery and professional fees. Discounts, insurance benefits and amounts owed by the patient are also specified. The billing clerk and patient or representative signatures confirm the accuracy of the statement.

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Danica
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3K views1 page

Soa Philhealth

This document is a statement of account from Mapandan Community Hospital detailing medical services provided to a patient. It lists the patient's name, age, diagnosis, admission and discharge dates and fees including room and board, drugs, laboratory tests, surgery and professional fees. Discounts, insurance benefits and amounts owed by the patient are also specified. The billing clerk and patient or representative signatures confirm the accuracy of the statement.

Uploaded by

Danica
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SOA Reference No:______________

Republic of the Philippines


Province of Pangasinan
MAPANDAN COMMUNITY HOSPITAL
Fire Tree St. Poblacion, Mapandan, Pangasinan 2429
Tel./Fax No. (075) 632-0491

STATEMENT OF ACCOUNT

Patient Name : _____________________________ Age : ________ Date & Time Admitted : ____________________
Address : _______________________________________________ Date & Time Discharged : __________________
Final Diagnosis: _________________________________________ First Case Rate : __________________________
Other Diagnosis: 1. _______________________________________ Second Case Rate : ________________________
2. _______________________________________
3. _______________________________________

SUMMARY OF FEES
Amount of Discounts Philhealth Benefits
Place /
____ PCSO Out of the
Senior ____ DSWD First Second
Particular Actual Charges Vat ____ DOH(MAP)
Pocket of
Citizen/ Case Rate Case Rate
Exempt _____ HMO Patient
PWD Amount Amount
____ Others:

HCI Fees
Room and Board
Drugs and Medicines
Laboratory &
Diagnostics
O.R / D.R. Fees
Newborn Screening
Ambulance Fee
Supplies
Others : Pls Specify
Subtotal
Professional fee/s
1.
2.
3.
4.
5.
Subtotal
Total

Prepared by: Conforme:

LARRY JANE PADILLA ______________________________________


Billing Clerk Member/ Patient / Authorized Representative

Date signed : _________________ Relationship of member of authorized representative: _____


Contact No. : (075) 632-0491 Date Signed : ___________ Contact No. _______________

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