Scribd
Upload
665 views1 page

Statement of Account For Tuberculosis

This document is a statement of account from a hospital stay that provides a summary of fees and charges. It lists the patient's name, age, diagnosis, admission and discharge dates, applicable rates, and an itemized breakdown of fees including room and board, lab tests, supplies, vaccines, professional fees, and totals. It also notes any discounts, philhealth benefits applied, and the remaining out of pocket amount due from the patient. The document requires signatures from both the billing clerk and patient or authorized representative to confirm the accuracy of the charges.

Uploaded by

MHIEMHOI
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
665 views1 page

Statement of Account For Tuberculosis

This document is a statement of account from a hospital stay that provides a summary of fees and charges. It lists the patient's name, age, diagnosis, admission and discharge dates, applicable rates, and an itemized breakdown of fees including room and board, lab tests, supplies, vaccines, professional fees, and totals. It also notes any discounts, philhealth benefits applied, and the remaining out of pocket amount due from the patient. The document requires signatures from both the billing clerk and patient or authorized representative to confirm the accuracy of the charges.

Uploaded by

MHIEMHOI
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

ANNEX A

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

TABUK II RHU TB DOTS


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.

You might also like