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Date	Reference no.	Funding Source	Amount	Remarks

Date	E-SOA	CF4	CF5	E-Claims	Remarks

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STATEMENT OF ACCOUNT

Name: alcudia, uno raphael pigar

Address: san pedro extension lagao general santos city

Attending Physician: san pedro extension lagao general santos city

Final Diagnosis(ICD-10/RVS): ICD

Other Diagnosis(ICD-10/RVS): ICD

Patient No: i2506006 Rm P 129

Date and Time Admitted: 06/26/2025 07:28 AM

Consultation date: 06/26/2025 07:28 AM

Date and Time Discharged:

Reference No.:

SUMMARY OF FEES

Fee Particulars	Amount	Mandatory Discount	PhilHealth	Other Funding Sources	Balance

PROFESSIONAL FEES

Physician Accreditation No.	Physician Name	Amount	Mandatory Discount	PhilHealth	Other Funding Sources	Balance

ITEMIZED CHARGES

Service Date	Item Name	Unit of Measure	Price	Quantity	Amount

Billing Charges

id	Item Code	Item Name	Type	Qty	Unit	Unit Cost	Date	Total Amount	Discounted	Discount	Net Vatable Amount	PHIC	Senior	PWD	PCSO	DSWD	DOH MAP	HMO

Other Charges

id	Item Code	Item Name	Type	Qty	Unit	Unit Cost	Date	Total Amount	Discounted	Discount	Net Vatable Amount	PHIC	Senior	PWD	PCSO	DSWD	DOH MAP	HMO

Statement of Accounts

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Statement List

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