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| HCA Order Form | 
| Division | North Florida Division | ||
| Site/Hospital | Capital Regional Medical Ctr | ||
| Billing | Delivery | ||
| Name | dan.fran@hcahealthcare.com | Name | Angie Webb | 
| George.Greene1@healthtrustpg.com | Angelia.Webb@hcahealthcare.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 2626 Capital Medical Blvd. – Education Office (1st Floor) | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | |
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Tallahassee | 
| State | TN | State | FL | 
| ZIP | 37203 | ZIP | 32308 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| A99003 | Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug | 4 | $58.60 | 
| Sub-Total | $58.60 | ||
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