STATEMENT OF ACCOUNT

SQA Reference No.

MEDICAL MISSION GROUP HOSPITAL & HEALTH SERVICES

COOPERATIVE

Binayran Road Dampas District Tagbilaran City(Capital) Bohol Philippines

***-**** ** ***-****

Name of Patient: Perocho, Cherry Ann Age: 25 Date Of Checkup: May 23, 2019

Address : Cadapdapan, Candijay, Bohol

Final Diagnosis and ICD code: First Case Rate :

Second Case Rate :

Surgical Procedure and RVS Code, as if Applicable:

SUMMARRY OF FEES

Particulars

Actual Charges

VAT Exempt

Amount of Discounts

Philhealth Benefits

Out of pocket of Patient

Senior

Citizen/

PWD/

Courtesy

Place

PCSO

DSWD

DOH

OTHERS

First Case Rate Amount

Second Case Rate Amount

HCI Fees

Drugs and Medicine

15,232.00

0.00

0.00

0.00

0.00

0.00

15,232.00

Laboratory & DIAGNOSTICS

10,685.00

0.00

0.00

0.00

0.00

0.00

10,865.00

Supplies

1,757.00

0.00

0.00

0.00

0.00

0.00

1,757.00

Miscellanies Fee

3,810.00

0.00

0.00

0.00

0.00

0.00

3,810.00

Subtotal

31,484.00

0.00

0.00

0.00

0.00

0.00

31,384.00

Professional fee/s

CARD NO. MARBERT JOHN T

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Subtotal

0.00

0.00

0.00

0.00

0.00

0.00

0.00

Total

31,484.00

0.00

0.00

0.00

0.00

0.00

31,484.00

Payments

BALANCE DUE: 31,484.00

Contact this candidate