[Hospital Name]

[HospitalAddress]

REFUND CASH INVOICE

[PatientName]	Patient No :	[Patient Id]
[Age]	Refund No :	[Refund No]
[Address]	Refund Date :	[Refund Date]
[docname]	Bill No :	[Bill No]

Amount in Rupees

[item List]

Patient
Co-payment Amount	[copayamt]
Non-Insured Amount	[noninsamt]
Return To Patient	[Total]
[rupees]

Net Amount	Gross Amount	[groamt]
[netamt]	Discount	[discamt]

Insurance/Corporate
Claimed Amount	[claimamt]

Cashier

Counter :[counter]

User :[user]