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HCA Order Form
Division Mid America Division
Site/Hospital Overland Park Regional Medical Center
Billing Delivery
Name Charla.Clark@hcamidwest.com Name Ishani Akpovona
Email George.Greene1@healthtrustpg.com Email Ishani.Akpovona@hcamidwest.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 10500 Quivira Rd
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Overland Park
State TN State KS
ZIP 37203 ZIP 66215
Items to Order
Code Description Quantity Total ($)
C99008 Brayden Premium Urethane Adult Lung Kit (Pack of 6) 1 $84.00
C17001 Brayden Baby/Infant Replacement Lung (single) 3 $27.00
$0.00
  Sub-Total $111.00