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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 / Kristin Black – Education Team
Email George.Greene1@healthtrustpg.com Email Angelia.Webb@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 2626 Capital Medical Blvd
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 ($)
C17001 Brayden Baby/Infant Replacement Lung (single) 5 $47.25
  Sub-Total $47.25