FORTIS HOSPITALS LIMITED
23,80 FEET ROAD,GURUKRUPA LAYOUT 2ND
STAGE,NAGARBHAVI ,BENGALURU-560072 UPI
Tel: +91 7829997788, 08023014100 | Fax: 080- SCAN &
23014242 Pay
Emergency: 080-23014117 | Ambulance: GST
9686096860 No:29AABCF2101R1ZJ
Email:
[email protected] |
Website: www.fortishealthcare.com
OUT PATIENT BILL
Primary
: Dr. Pavankumar P Rasalkar
Name : Mrs. Gayathri . Doctor
UHID : 13458907 Ref Doctor : SELF
Contact No. : 9880656349 Payor Name : NA
Age/Sex : 65 YEAR(S)/Female Payor Site
: NA
Episode No. : 73026/24/3903 Name
Bill Date : 2024-12-07 11:34:00 Discount
: NA
Print Date : 2024-12-07 11:34:00 Scheme
: Nagarbhavi Nagarbhavi Insurance : NA
Patient TPA : NA
Bengaluru 560072 Karnataka
Address
India CIN No : U85110DL2008PLC176412
Emp.Name : NA
BILL NUMBER BILL TYPE BILL DATE BILL AMOUNT
390324OPCS068151 CASH 2024-12-07 11:34:00 4640.00
Accession HSN Service Contractual Net Gross
Sr No. Particulars Qty
No Code Amount Discount Amount
1 COMPLETE BLOOD COUNT OP.14556038 999316 1 650.00 0.00 650.00
2 UREA OP.14556039 999316 1 290.00 0.00 290.00
CREATININE EGFR- EPI
3 OP.14556040 999316 1 260.00 0.00 260.00
(1320HGFREP - SRL)
ELECTROLYTES (NA/K/CL),
4 OP.14556041 999316 1 870.00 0.00 870.00
SERUM (1568HD-SRL)
PROTHROMBIN TIME, PLASMA
5 OP.14556042 999316 1 680.00 0.00 680.00
(3892-SRL)
GLUCOSE RANDOM, PLASMA
6 OP.14556045 999316 1 210.00 0.00 210.00
(1302R-SRL)[1302R]
7 ECG OP.14556043 999316 1 510.00 0.00 510.00
COLOUR DOPPLER / ECHO
8 OP.14556044 999316 1 2330.00 0.00 2330.00
CARDIOGRAPHY[][][]
TOTAL AMOUNT 5800.00 1160.00 4640.00
BILL AMOUNT 4640.00
PAYOR SHARE 0.00
PATIENT SHARE 4640.00
TOTAL DISCR.DISCOUNT 1160.00
PAID BY PATIENT 4640.00
NET PATIENT PAYABLE 4640.00
BILL ROUND OF AMOUNT 0.00
Rupees in Words: Rupees Four Thousand Six Hundred Forty only
Payour details
Name: NA
Address: NA
GSTIN:
Prepared by Yuvarsha S Cashier Manager
Note: None
Reciept Details
Sr No. Reciept No. Reciept Date. Amount Balance Amount Payment
1 3903/DP/2412/86938 2024-12-07 11:34:00 4640.00 0.00 0.00
Regd.Office: Escorts Heart Institute and Research Centre, Okhla Road, New Delhi - 110025
(India)
Tel: Null, Fax: Null, CIN: U85110DL2008PLC176412
Note:This is computerized generated invoice doesn't required signature.
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