[Hospital Name]

[HospitalAddress]

IP BILL BREAKUP DETAILS
Patient Name [PatientName] Patient Number [PatientNumber]
Address [Address] Bill No [Dischargeno]
Bill Type [BillType]
Age/Gender [AgeGender] Bill Date [BillDate]
PAN No [PANCARD] IP No [ipno]
Mobile No [contactno] Doctor [doctor]
Admission Date [AdmissionDate] Department [dep]
Discharge Date [DisBillDate] Bed No [bdno]
Customer [Customer]
[Item List]
[Remarks]
Gross Total [Gross]
Discount [Discount]
Sales Return [Return]
Billed to Other Insurance [OthCredit]
Net Amount [Net]
Co-Payment Amount [Copay]
Noninsured Amount [Noninsured]
Tax Amount [taxamount]
Net Amount(Include Tax) [netamountwithtax]
Advance [advance]
Total Amount  [Ptpay]
Amount to be claimed [Claimamt]
[CashInWords]
Claimed Amount [ClaimInWords]
[SettlementCap] [Settlement]
Discount against Receipt [RecDiscount]
[table2]
Prepared By Counter

[user]

[CounterName]
* Non insured items
[Refund List]