	[Hospital Name] [HospitalAddress]

[Title]

[Cancel]

Patient ID	[PatientNo]			Refund No	[Refund No]
Name	[PatientName]			Payment Type	[Payment Type]
Age/Gender	[Age/Sex]			Refund Date	[Refund Date]
Address	[Address]			Invoice #	[Invoiceno]
				Doctor	[Doctor]
Insurance	[Insurance]			Policy/Card No	[InsuranceNo]

[item List]

Gross Amount

[GrossAmt]

Discount

[Discount]

[Billother]

[BillOtherAmt]

Net Amount

[NetAmt]

Deduct Amount

[DeductAmt]

Co-Payment Amount

[CopaymentAmt]

Noninsured Amount

[NoninsuredAmt]

Tax Amount

[Taxtotal]

Return to Patient

[PatientPayable]

Amount to be Claimed

[AmtClaimed]

Return to Patient : [PatientPaywords]

Claimed Amount : [ClaimedAmtWords]

Prepared By : [Username]	Counter Name : [Counter]	Cashier
Invoice Date : [InvioceDatetime]	Remarks : [Remarks]