[Hospital Name]

[HospitalAddress]

[Title]

[Cancel]

Patient No.

:

[Patientno]

Refund No

:

[Refund No]

Name

:

[PatientName]

Payment Type

:

[Payment Type]

Age/Sex

:

[Age/Sex]

DOB

:

[DOB]

Refund Date

:

[Refund Date]

Address

:

[Address]

Invoice No

:

[Invoiceno]

Doctor

:

[Doctor]

Insurance

[Insurance]

Policy

:

[InsuranceNo]

[item List]

Gross Amount	:	[GrossAmt]
Discount :	:	[Discount]
Net Amount	:	[NetAmt]
Deduct Amount	:	[DeductAmt]
Co-Payment Amount	:	[CopaymentAmt]
Noninsured Amount	:	[NoninsuredAmt]
Patient Refundable	:	[PatientPayable]
Amount to be Claimed	:	[AmtClaimed]

Return to Patient : [PatientPaywords]

Claimed Amount : [ClaimedAmtWords]

Prepared By	:	[Username]	Counter Name	:	[Counter]	Cashier
Invoice Date	:	[InvioceDatetime]
* Non insured items