Medical Bill Receipt
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Patient s Contact No Name of Insurance Co: BILL SUMMARY (Detailed Break up to be provided separately as per hospital format) Particulars Gross Amount Discount Net Amount ROOM RENT SERVICES ICU CHARGES NURSING / RMO SERVICES CONSULTANT VISITS MEDICINE CONSUMABLES INVESTIGATION CHARGES SURGERY / PROCEDURE CHARGES IMPLANTS AND EQUIPMENTS MISCELLANEOUS CHARGES PACKAGE CHARGES ANY OTHER (SPECIFY) BILLED AMOUNT: Net Bill Amount after discount(A) Cashless Authorized (B) Service Tax ( C ) = (B 10.3 ) To be paid by Insurer: B + C To be Paid By Patient (A -B) PATIENT S PAYMENT RECEIPT Received Rs..
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