	[Hospital Name] [HospitalAddress] [HocTin] [HocCol] [HocTinValue]

[outlet]-[Billtype]

Patient ID	[Patient Id]	Refund #	[RefundNo]
Patient Name	[PatientName]	Refund Date	[RefundDate]
Address	[Address] [contactno]	Package	[Package]
Bill #	[Bill No]	Doctor	Dr. [doctor]
Bill Date	[Bill Date]	Mobile No	[contactno]
PAN No	[PANCARD]	[Customer]	[CustomerName]
[InsuranceDetails]

[item List]

[Remarks]

Gross Amount	[gross]
Discount	[discount]
Net Amount	[NetAmnt]
[TaxHead]	[Tax]
[CessHead]	[Cess]
[CgstHead]	[CgstMast]
[SgstHead]	[SgstMast]
[PaidAmount]	[payamt]
Total Amount	[TotalAmount]
Non insured Amount	[NonInsuredAmount]
Co-Pay/Deduct Amount	[CopDeduct]
Refundable Amount	[refund]
Claimed Amount	[ClaimedAmount]

Patient Refundable : [PtPayableInWords]

Claimed Amount : [ClaimedAmountInWords]

Outlet : [outlet],[counter]

Signature & Stamp

[UserName]

Cashier