HTML Preview Medical Bill Receipt page number 1.
IFFCO TOKIO BILL CUM RECEIPT FORMAT
HOSPITALIZATION DETAILS
1 Hospital Name ………………………………………… Hospital NSP Code: ……………………………
2 Address Hospital PIN Code:
3 Bill no. Bill Date and Time
4 PAN Number Service Tax No
5 IP No Bed Number
6 Date and time:Admission Date and time: Discharge
7 Patient Name Member ID / Card No.
8 Patient's address Patient's Contact No
9 Cashless Issued Amount Name of Insurance Co:
BILL SUMMARY (Detailed Break up to be provided separately as per hospital format)
Particulars Gross Amount Discount Net Amount
1
ROOM RENT SERVICES
2
ICU CHARGES
3
NURSING / RMO SERVICES
4
CONSULTANT VISITS
5
MEDICINE & CONSUMABLES
6
INVESTIGATION CHARGES
7
SURGERY / PROCEDURE CHARGES
8
IMPLANTS AND EQUIPMENTS
9
MISCELLANEOUS CHARGES
10
PACKAGE CHARGES
11
ANY OTHER (SPECIFY)
12
BILLED AMOUNT:
1 Net Bill Amount after discount(A)
2 Cashless Authorized (B)
3 Service Tax ( C ) = (B*10.3%)
4 To be paid by Insurer: B + C
5 To be Paid By Patient (A -B)
PATIENT'S PAYMENT RECEIPT
Patients Signature Authorized Signatory- hospital with seal
Sl No
Received Rs. ………………….. (Rupees …………………………… …………………………………………………………………....only)
by cash / cheque No………………………...on date …………………… ……...towards settlement of the above bill.