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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 |
| George.Greene1@healthtrustpg.com | 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 ($) |
| [980] | Brayden Premium Urethane Adult Lung Kit (Pack of 6) | 1 | $84.00 |
| [980] | Brayden Baby/Infant Replacement Lung (single) | 3 | $27.00 |
| [980] | $0.00 | ||
| Sub-Total | $111.00 | ||
Innosonian, Inc
Innosonian, Europe