Print Receipt

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	Amount Paid	Remaining Balance Due
				{{::sub.ClaimNumber}}	{{::sub.DateOfService}}		{{::sub.BalanceAmount\|currency}}

Payment Received	Amount Paid
{{::print.receiptData.ReceiptHeaderDetails.PaymentDescription}} Authorization # {{::print.receiptData.ReceiptHeaderDetails.AuthCode}}	{{::print.receiptData.ReceiptHeaderDetails.TotalAmount\|currency:"$":2}}

Receipt

Customer:
Email:
Payment Date:

Description

Patient

Responsible Party

Account #

{{::print.receiptData.ReceiptHeaderDetails.ClaimNumberLabel}}

Amount Paid

Remaining Balance Due

{{::sub.ClientName}}

{{::sub.PatientName}}

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

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

{{::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.BalanceAmount|currency}}

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