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HCA Order Form
Division San Antonio Division
Site/Hospital Methodist Childrens Hospital
Billing Delivery
Name Abram.Bustamante@MHShealth.com Name Abram Bustamante
Email George.Greene1@healthtrustpg.com Email abram.bustamante@mhshealth.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 8109 Fredericksburg Rd
Address Line 2 Clinical Education Financial Reporting Address Line 2 2nd floor CAPE center
Address Line 3 Suite 1100 Address Line 3
City Nashville City San Antonio
State TN State TX
ZIP 37203 ZIP 78229
Items to Order
Code Description Quantity Total ($)
C17001 Brayden Baby/Infant Replacement Lung (single) 3 $28.35
C99008 Brayden Premium Urethane Adult Lung Kit (Pack of 6) 1 $88.20
  Sub-Total $116.55