KCCI MEDICAL CENTER

Page No.:

Page 1 of

911 MEDSYS Bldg., Ayala Ave., Makati City

Run Date:

6/15/2026

Run Time:

2:32:22PM

120

PATIENT'S STATEMENT OF ACCOUNT

Patient

:

OLET, RAJIV RIVERA

Admission #

:

2B

Room

:

OPD

Address

:

190 SITIO 1 , 490

Hospital #

:

00000002

Rate

:

29

Admitted

:

03/29/2021

Time

:

04:39 PM

Age

:

Acct. #

:

00000002

Discharged

:

12/15/2023

Time

:

11:59 PM

Company

:

Billed Date

:

12/15/2023

Time

:

11:59 PM

Credit Limit

:

OPEN

Date

Ref #

Description

Qty

Charges

Credit

Balance

CT - CT SCAN

04/08/2026

CT

GC1000000

ABDOMINAL AORTA CTA

1

17.00

04/08/2026

CT

GC1000000

NECK / CERVICAL W/ CONTRAST

1

7,733.00

Sub Total: ==========>

7,750.00

HY - HEMO SUPPLIES

04/08/2026

HY

GC1000000

BLOODLINE AV-SET B DT INF-E

2

234.00

04/08/2026

HY

GC1000000

DIALYZER FRESENIUS ( F7 HPS

1

1.00

Sub Total: ==========>

235.00

HD - HEMODIALYSIS

04/27/2021

HD

C1K

HEMODIALYSIS

1

650.00

04/28/2021

HD

C000007O

HEMODIALYSIS

1

200.00

Sub Total: ==========>

850.00

HM - HEMODIALYSIS MEDICINE

04/08/2026

HM

GC1000000

BACTICIDE 10% 15ML. PIECE

1

57.00

04/08/2026

HM

GC1000000

D5 0.9 1 LITER EUROMED PIE

3

57.86

04/08/2026

HM

GC1000000

D5 WATER 250ML B. BRAUN PIE

3

179.40

04/08/2026

HM

GC1000000

ACID CONCENTRATE

1

3.00

06/15/2026

HM

GC1000000

CALCIUM GLUCONATE 100MG/ML 1

1

78.00

06/15/2026

HM

GC1000000

ACID CONCENTRATE

1

3,522.40

Sub Total: ==========>

3,897.66

LB - LABORATORY

04/08/2026

LB

GC1000000

2 HR POST PRANDIAL BLOOD SU

1

269.00

Sub Total: ==========>

269.00

OR - OR SERVICES

04/28/2021

OR

C000007O

OR SERVICES

1

6,562.50

Sub Total: ==========>

6,562.50

Total: ==========>

19,564.16

Total Due to Hospital: ==========>

19,564.16

Summary:

Hospital

19,564.16

Adj. / Ret.

0.00

Professional

0.00

Medicare HB

0.00

Medicare PF

0.00

Payments HB

0.00

Payments PF

0.00

Grand Total

19,564.16

Prepared by

:

MedSys, KCCI

Noted by

:

Received by

:

Date

: