[Hospital Name] [HospitalAddress]

Approximate In-patient Bill

Patient ID : [OPNo] IP# : [IpNo] Patient Name : [PatientName] Age/Sex : [Age] Address : [address] Admission Date : [AdmDate] [address1] Up to Date : [UptoDate] [address2] Bed : [Bed] Doctor : [Doctor] Policy/Card #[colun2] : [PlolicyNo] Policy [colun1] : [PolicyName]

[item List][cpt Code]
Discount : [Deduction] Gross [gross] Refund/Medicine Return : [refund] Less Deductions [discount] Total Deduction : [totDeduction] Net Amount [netamount] Copayment [copayment] Advance [adavnce]     Tax Amount [TaxAmount] Patient payable [Payable Amount] Amount to be Claimed [claim]
Amount in Rupees :	[rupees]
Claimed Amount :	[claimamt]
Remarks : [Remarks]
Prepared By :[user]		Cashier