Patient No : [OPNo] IP.No. : [IpNo] Patient Name : [PatientName] Age/Sex : [Age] Address : [address] Admission Dt. : [AdmDate] [address1] Up to Date : [UptoDate] [address2] Bed : [Bed] Doctor : [Doctor] Policy No. [colun2] : [PlolicyNo] Policy [colun1] : [PolicyName]

[item List]
[item List1]
Concession : [Deduction] Gross [gross] Refund/Medicine Return : [refund] Less Deductions [discount] Total Deduction : [totDeduction] Net Amount [netamount] Copayment [copayment] Advance [adavnce] Patient payable [Payable Amount] Amount to be Claimed [claim]
Amount in Rupees :	[rupees]
Claimed Amount :	[claimamt]
Remarks : [Remarks]
Prepared By :[user]	Counter :[counter]	Cashier