STATEMENT OF ACCOUNT

SAMAR PROVINCIAL HOSPITAL

CAPITOL GROUNDS, BRGY 7, CATBALOGAN CITY

ACCOUNT INFORMATION BILLING INFORMATION

Account Number : 0000631 Statement Date : December 16, 2018

HCI Code : H08013394 Due Date : Payable 15 calendar day(s) from receipt of billing
SOA Number : 20180014564 Term/Billing Cycle : Semi-monthly
TIN : 000-000-000-000 Service Fee per Claim : ₱ 10.00
Business Style :

STATEMENT SUMMARY
Period Covered : Dec 01, 2018 - Dec 15, 2018

Total Claims 453 ₱ 4,530.00

453 ₱ 4,530.00

Vatable Sales ₱ 4,044.64

Value Added Tax (12%) ₱ 485.36
Total Amount ₱ 4,530.00

PAYMENT SUMMARY

Payment Date Billing Period Payment Amount Amount

Dec 10, 2018 Jul 16, 2018 - Jul 31, 2018 ₱ 920.00 ₱ 920.00
Dec 10, 2018 Aug 01, 2018 - Aug 15, 2018 ₱ 1,010.00 ₱ 1,010.00
Dec 10, 2018 Aug 16, 2018 - Aug 31, 2018 ₱ 2,250.00 ₱ 2,250.00
Dec 10, 2018 Sep 01, 2018 - Sep 15, 2018 ₱ 1,130.00 ₱ 1,130.00
Total Amount : ₱ 5,310.00

Overdue/Balance from previous billing/s ₱ 24,290.00

Current Amount Due ₱ 4,530.00

Total Amount Paid (₱ 5,310.00)

Total Amount Due (Inclusive of VAT) : ₱ 23,510.00

Please make all cheque payments payable to EUROLINK NETWORK INTERNATIONAL CORP. and kindly deposit any mode of
payment (cash or cheque) to the following bank accounts:

* Union Bank Account No. 000590016428

* Banco De Oro Account No. 003430017615
* Bank of the Philippines Islands Savings Account No. 004013030524

Note: To properly account your payment, please notify us by sending a scanned copy of the validated deposit slip and
indicate your Facility Name with corresponding Philhealth Accreditation Number (PAN) at eurolink@euroempire.com.

Telephone: (+632) 687 9999

Unit 2101 Tektite East Tower, Philippine Stock Exchange Center, Exchange Road, Ortigas, Pasig City, Philippines, Philippines 1605 Telephone: (+632) 661 4797
Website:
Fax: (+632) 687 5020
Unit 1605 Tektite West Tower, Philippine Stock Exchange Center, Exchange Road, Ortigas, Pasig City, Philippines, Philippines 1605 www.easyclaimsph.com