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HCA Order Form
Division Gulf Coast Division
Site/Hospital HCA Houston Healthcare Southeast
Billing Delivery
Name sarah.prial@hcahealthcare.com Name Minaz Dungor
Email George.Greene1@healthtrustpg.com Email minaz.dungor@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 4000 Spencer Highway
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Pasadena
State TN State TX
ZIP 37203 ZIP 77504
Items to Order
Code Description Quantity Total ($)
C99007 Brayden Adult Lung Kit Version A04 (Pack of 24) 1 $45.00
C17001 Brayden Baby/Infant Replacement Lung (single) 5 $45.00
  Sub-Total $90.00