Receipt

Receipt Number : {{::print.receiptData.ReceiptHeaderDetails.ReceiptNumber}}
Customer:
Email:
Payment Date(Central Time):
Transaction Type:
Status:
Original Tx No.:
Source:
Description Patient Responsible Party Account # {{::print.receiptData.ReceiptHeaderDetails.ClaimNumberLabel}} Date Of Service Original Amount Discount Amount Amount Paid Remaining Balance Due
{{::sub.ClientName}} {{::sub.PatientName}} {{::sub.GuarantorName}} {{::sub.ChargerHeaderAccountNumber}} {{::sub.ClaimNumber}} {{::sub.DateOfService}} {{::sub.RowAmount|currency}} {{::sub.DiscountAmount|currency}} {{::(sub.RowAmount - sub.DiscountAmount)|currency}} {{::sub.BalanceAmount|currency}}

Reversal Reason :

{{print.reversalReason}}

Payment Received Amount Paid
{{::print.receiptData.ReceiptHeaderDetails.PaymentDescription}} Authorization # {{::print.receiptData.ReceiptHeaderDetails.AuthCode}} {{(print.receiptData.ReceiptHeaderDetails.TotalAmount - print.receiptData.ReceiptHeaderDetails.TotalDiscountAmount)|currency}}