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| HCA Order Form | 
| Division | North Florida Division | ||
| Site/Hospital | West FL | ||
| Billing | Delivery | ||
| Name | dan.fran@hcahealthcare.com | Name | Barbara Hamilton Brian Groat | 
| George.Greene1@healthtrustpg.com | Barbara.Hamilton3@hcahealthcare.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 8383 N. Davis Hwy – 7th Fl. Nsg. Edu. Team | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | |
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Pensacola | 
| State | TN | State | FL | 
| ZIP | 37203 | ZIP | 32514 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 5 | $8.30 | 
| C17001 | Brayden Baby/Infant Replacement Lung (single) | 5 | $49.60 | 
| Sub-Total | $57.90 | ||
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