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| HCA Order Form | 
| Division | Continental Division | ||
| Site/Hospital | HCA Healthcare Center for Clinical Advancement | ||
| Billing | Delivery | ||
| Name | Scott.Bartholomew@HealthONEcares.com | Name | Scott Bartholomew | 
| George.Greene1@healthtrustpg.com | Scott.Bartholomew@HealthONEcares.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 333 W. Hampden Ave | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | Suite 200 | 
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Englewood | 
| State | CO | State | CO | 
| ZIP | 37203 | ZIP | 80110 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| C17006 | Brayden Baby/Infant Double Filter (Pack of 5) | 1 | $28.35 | 
| C17004 | Brayden Baby/Infant Back Skin | 1 | $42.00 | 
| C17003 | Brayden Baby/Infant Body Skin | 1 | $57.75 | 
| $0.00 | |||
| Sub-Total | $128.10 | ||
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