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