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HCA Order Form
Division Far West Division
Site/Hospital Good Samaritan
Billing Delivery
Name Elizabeth.Cabada@hcahealthcare.com Name Jessica Madison
Email George.Greene1@healthtrustpg.com Email Jessica.Madison@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 2425 Samaritan Dr
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City San Jose
State TN State CA
ZIP 37203 ZIP 95124
Items to Order
Code Description Quantity Total ($)
[980] Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug 2 $30.76
[980] Brayden Baby/Infant Replacement Lung (single) 3 $29.76
[980] Brayden Adult Airway Filter (Pack of 24) 1 $4.46
[980] Brayden Baby/Infant Double Filter (Pack of 5) 1 $29.77
[980] Brayden Premium Urethane Adult Lung Kit (Pack of 6) 1 $92.61
[980] Brayden Adult Airway Valve Assembly 1 $3.75
[980] Brayden Baby/Infant Artificial Lung Air Guide 2 $3.32
[980] Brayden Baby/Infant Replacement Airway Tube (single) 2 $6.06
  Sub-Total $200.49