Print Receipt

Receipt

Customer:
Email:
Payment Date(Central Time):

Description

Patient

Responsible Party

Account #

{{::print.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}}

Reversal Reason :

{{print.reversalReason}}

Payment Received	Amount Paid
{{::print.receiptData.ReceiptHeaderDetails.PaymentDescription}} Authorization # {{::print.receiptData.ReceiptHeaderDetails.AuthCode}}	{{::print.receiptData.ReceiptHeaderDetails.TotalAmount\|currency}}