Receipt

Customer:
Email:
Payment Date (Central Time):

Description

Patient

Responsible Party

Account #

{{::receipt.receiptData.ReceiptHeaderDetails.ClaimNumberLabel}}

Original Amount

Discount Amount

Amount Paid

Remaining Balance Due

{{::sub.ClientName}}

{{::sub.PatientName}}

Receipt No : {{::sub.ReceiptNo}}

Transaction Type :{{::sub.TransactionType}}

Date of Service :{{::sub.DateOfService}}

{{::sub.GuarantorName}}

Payment Method :{{::sub.PaymentDescription}}

Status :{{::sub.TxnStatus}}

{{::sub.ChargerHeaderAccountNumber}}

Auth Code :{{::sub.AuthCode}}

Original Tx No :{{::sub.OrginalTxnNo}}

{{::sub.ClaimNumber}}

{{::sub.RowAmount|currency}}

{{::sub.DiscountAmount|currency}}

{{::(sub.RowAmount - sub.DiscountAmount)|currency}}

{{::sub.BalanceAmount|currency}}

Payment Received	Amount Paid
Dishonored Reason : {{receipt.reversalReason}}
{{::receipt.receiptData.ReceiptHeaderDetails.PaymentDescription}} Authorization # {{::receipt.receiptData.ReceiptHeaderDetails.AuthCode}}	{{(receipt.receiptData.ReceiptHeaderDetails.TotalAmount - receipt.receiptData.ReceiptHeaderDetails.TotalDiscountAmount)\|currency}}

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