DILIMAN DOCTORS HOSPITAL, INC Summary of Statement of Account
51 Commonwealth Ave, Matandang Balara, Quezon City, 1119 Metro Manila. Run Datetime: 10/23/2023 3:40:PM
Tel: 8922-2660 Inpatient
Patient Name: ASIS, MARY ANN Admission No: 11368
Hospitalization
Plan: Birth Date: 3/3/1994
Attending
Doctors: MICHAEL POL UDARBE BUENO Age: 28Y8M23D
Patient Address: 216 AMETHYS 216 PASIG CITY Admission Date: 10/19/2023 5:35PM
Discharge: 10/23/2023 2:12PM
Room No: 4012
Final Diagnosi/es and ICD 10 Code/s First Case Rate: 47562
Second Case Rate:
1. K81.0 Inflame Appendicitis
SURGICAL PROCEDURE/S and RVS Code/s , if
Applicable:
Laparoscopic
appendectomy,
surgical (any
1.47562 method)
HOSPITAL BILL PARTICULARS CHARGES PAYMENT/CN
EMERGENCY ROOM 3,194.00 0.00
XRAY 1,483.70 0.00
LABORATORY 6,197.73 0.00
CENTRAL STERILE SUPPLY 20, 681.72 0.00
INFO/ADMITTING 3,670.00 0.00
PHARMACY-PNF 10,831.78 0.00
OR COMPLEX 60,620.15 0.00
PHARMACY 3,053.34 0.00
ROOM CHARGES (4.00 Day(s) @3500.00) 10,500.00 0.00
Professional Fee 80,000.00 0.00
Pharmacy (Credit Note) 0.00 0.00
Pharmacy-PNF(Credit Note/ Down Payment) 0.00 31,000.00
Philhealth Benefits 0.00 48,400.00
Guaranteed Hospital Bill 0.00 0.00
DILIMAN DOCTORS HOSPITAL, INC Summary of Statement of Account
51 Commonwealth Ave, Matandang Balara, Quezon City, 1119 Metro Manila. Run Datetime: 10/23/2023 3:40:PM
Tel: 8922-2660 Inpatient
Guaranteed PF 0.00 0.00
200,232.42 79,400.00
BALANCE DUE 120,832.42
PROFESSIONAL FEES PARTICULARS
DOCTOR(S) CHARGES INSTRU. FEE OTHER AMT. DISCOUNT SENIOR PAYMENT HMO ADJUSTMENT PHILHEALTH BALANCE
RAMOS, PAUL JERRICO A
BUENO, MICHAEL POL UD
ESPINO, LEYA SUZETTE E
BONAGUA, DENNIS ROLA 0.00
STA. ANA, ENRICO LEGAS
PHILHEALTH DETAILS GUARANTOR DETAILS
AMOUNT
PARTICULARS COVERED GUARANTOR NAME Hospital Bill
ROOM AND BOARD
DRUGS AND MEDICINE
XRAY/LAB/OTHERS
OPERATING ROOM
FEE
TOTAL
AMOUNT BILL NO: GUARANTEED TOTAL AMOUN
NET REFUND
Received
Prepared By: By:
SHARLOTTE
MENGURIA, JOY MAE
D.
PHIC Member's Name
BILLING Pr
Verified By:
Relatio
FAJARDO, RACHELLE
PhilHealth Officer
