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  • Statement of Acoount For Animal Bite Treatment Center

    Încărcat de

    MHIEMHOI
    222 vizualizări1 pagină
    This document is a statement of account from the Tabuk II RHU Animal Bite Treatment Center. It provides information about a patient such as their name, age, diagnosis, and dates of admission and discharge. It also includes a summary of fees with columns for actual charges, discounts, PhilHealth benefits, and out of pocket costs of the patient. Signatures are required from the billing clerk and the patient or their authorized representative to confirm the details of treatment and costs.

    Descriere originală:

    SOA ABTC FORM

    Titlu original

    STATEMENT OF ACOOUNT FOR ANIMAL BITE TREATMENT CENTER

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    © © All Rights Reserved

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    This document is a statement of account from the Tabuk II RHU Animal Bite Treatment Center. It provides information about a patient such as their name, age, diagnosis, and dates of admission and discharge. It also includes a summary of fees with columns for actual charges, discounts, PhilHealth benefits, and out of pocket costs of the patient. Signatures are required from the billing clerk and the patient or their authorized representative to confirm the details of treatment and costs.

    Drepturi de autor:

    © All Rights Reserved
    Descărcați ca DOCX, PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    222 vizualizări1 pagină

    Statement of Acoount For Animal Bite Treatment Center

    Încărcat de

    MHIEMHOI
    This document is a statement of account from the Tabuk II RHU Animal Bite Treatment Center. It provides information about a patient such as their name, age, diagnosis, and dates of admission and discharge. It also includes a summary of fees with columns for actual charges, discounts, PhilHealth benefits, and out of pocket costs of the patient. Signatures are required from the billing clerk and the patient or their authorized representative to confirm the details of treatment and costs.

    Drepturi de autor:

    © All Rights Reserved
    Descărcați ca DOCX, PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    din 1

    ANNEX A

    STATEMENT OF ACCOUNT
    <HCI logo> SOA Reference No.: _______________

    TABUK II RHU ANIMAL BITE TREATMENT CENTER


    Calanan, Tabuk City, Kalinga
    09175067286

    Patient Name: _______________________ Age: ____ Date & Time Admitted: __________________
    Address: __________________________ Date & Time Discharged: __________________
    Final Diagnosis: _____________________ First Case Rate: ________________________
    Other Diagnosi: 1. ___________________________ Second Case Rate: _____________________
    2. ___________________________

    SUMMARY OF FEES
    Amount of Discounts Philhealth Benefits
    Place
    __ PCSO
    Actual Senior __ DSWD Out of Pocket
    Particulars First Case Second Case
    Charges VAT exempt Citizen/ __ DOH (MAP) of Patient
    __ HMO Rate Amount Rate Amount
    PWD
    __ Others:
    ___________
    HCI fees
    Room and Board
    Lab & Diagnostics
    Operating Room fee
    Supplies: Syringes,
    Cotton, Alcohol
    Others:
    Vaccines/Medicines
    Subtotal P P P P P P P
    Professional fee/s
    1. Dr. J. Omengan

    Subtotal P P P P P P P
    TOTAL P P P P P P P

    Prepared by: Conform:

    JANETH M. BASING-AT, RM _____________________


    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.
    3. Printed copy of SOA or its equivalent should be free of charge.

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