SOA Reference No.

STO. ROSARIO HOSPITAL

C130 V. Escano cor G. Recto Sts., Rosario, Batangas
(043) 3213988

Patient Name: DE CASTRO, JAMESON EZEKIEL Age: 4MOS Date & Time Admitted : 6/14/2019
Address: QUILO QUILO, PADRE GARCIA BATANGAS RM: 410 Date & Time Discharged: 6/17/2019
Final Diagnosis: First Case Rate:
Other Diagnosis: 1. ______________________________________ Second Case Rate: _______________________(if applicable)
2. ______________________________________ ICD Code:
3. ______________________________________ RUV: ____________________________________________

SUMMARY OF FEES

Actual Amount of Discounts PhilHealth Benefits

Charges Senior ______PCSO First Second
Particulars
Citizen/ ________DOH(MAP) Case Rate Case Rate
PWD HMO amount amount

VAT Others
exempt
HCI Fees 2,225.00
Room and Board 3,825.00
Drugs and Medicines 1,688.00
Laboratory & Diagnostics 245.00
Operating Room Fee -
Supplies 1,205.00
Others: pls. specify 850.00
Subtotal 10,038.00
Professional fee/s

Subtotal 0.00 0.00

Total 10,038.00 0.00 0.00

Prepared by: Conforme:

___________________________
MICHELLE S. ANOG Member/Patient/Authorized Representative
Billing Clerk (Signatureover printed name)
(signature over printed name) Relationship to member of authorized rep:___________
Date signed: __________________ Date signed:_________ Contact no._______________
Contact no.: 043-321-3988

STO. ROSARIO HOSPITAL

C130 V. Escano cor G. Recto Sts., Rosario, Batangas
(043) 321 -3988

Patient Name: DE CASTRO, JAMESON EZEKIEL Age: 4MOS Date & Time Admitted : 6/14/2019
Address: QUILO QUILO, PADRE GARCIA BATANGAS RM: 410 Date & Time Discharged: 6/17/2019

Billing Department
IV Tray and Syringes 1 350.00 350.00
Resident Fee 1 300.00 300.00
Miscellaneous Fee 1 395.00 395.00
Disinfection Fee 1 275.00 275.00
Admitting Kit 1 360.00 360.00
Splint 1 120.00 120.00
Specimen Bottle 1 25.00 25.00
Pillow 1 200.00 200.00
Other Fees 1 200.00 200.00
Total --Billing Department 2,225.00

Details of Pharmacy Quantity Unit Price Amount

06/14/19 Collector 1 20.00 20.00
Metronidazole vial 1 300.00 300.00
Ercelora 4 52.00 208.00
Restime drops 1 130.00 130.00
E-zinc drops 1 120.00 120.00
Soluset 1 410.00 410.00
06/15/19 Collector 1 20.00 20.00
Metronidazole vial 1 300.00 300.00
ranitidine ampule 1 180.00 180.00
Total 1,688.00

Laboratory & Diagnostic

Urinalysis 1 125.00 125.00
Fecalysis 1 120.00 120.00
Total 245.00
Supplies
D5NP 1 740.00 740.00
IV Catheter 2 140.00 280.00
Venoset 1 185.00 185.00
1,205.00

Admission Fee 1 500.00 500.00

ER Use 1 350.00 350.00

850.00
 2:15PM

_______________(if applicable)

_________________________

Out of
Pocket of
Patients

10,038.00

-
0.00
-
-
0.00

10,038.00
2:15PM