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HCA Order Form
Division North Texas Division
Site/Hospital NTXD HHCCA
Billing Delivery
Name marlo.cooper@medicalcityhealth.com Name Tracy Clement
Email George.Greene1@healthtrustpg.com Email tracy.clement@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 211 4th St, Alexandria, LA 71301
Address Line 2 Clinical Education Financial Reporting Address Line 2 Education Department
Address Line 3 Suite 1100 Address Line 3
City Nashville City 211 4th St, Alexandria
State TN State LA
ZIP 37203 ZIP 71301
Items to Order
Code Description Quantity Total ($)
C17001 Brayden Baby/Infant Replacement Lung (single) 10 $94.50
  Sub-Total $94.50