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HCA Order Form
Division North Florida Division
Site/Hospital Lake City Med Ctr
Billing Delivery
Name dan.fran@hcahealthcare.com Name Donna Carpenter – Nursing Education Team
Email George.Greene1@healthtrustpg.com Email Donna.Carpenter@HCAhealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 340 NW Commerce Dr
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Lake City
State TN State FL
ZIP 37203 ZIP 32055
Items to Order
Code Description Quantity Total ($)
C99007 Brayden Adult Lung Kit Version A04 (Pack of 24) 1 $49.61
S17011 Brayden Baby/Infant Artificial Lung Air Guide 5 $8.30
C17001 Brayden Baby/Infant Replacement Lung (single) 4 $39.68
  Sub-Total $97.59