Jack Doe
(1234567890)
Male - 64 year - B +ve
+66 2 123 4567
jackdoe@email.com
Apt. ID -
372439
Admit ID -
405588
Patient Billing Code
GEN
Payment Priority
1
C.C
2
Ins
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One
Two
Three
Claim Form
Invoice
Doctor Form
Medical Certificate
Invoices
Admission Date
25-03-2020
Discharge Date
30-03-2020
#
Invoice No.
Ins. Company
Claim Submission Date
Claim Note
Claimed Amt.(฿)
01
NSB7881
Aviva
26-03-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
562.10
attach_file
02
BC65243
TATA AIA
27-03-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
747.29
attach_file
PID_154367-V1468_Aviva.pdf
PID_154367-V1468_214_Av...
03
IN32456
Aviva
31-03-2020
9000.00
attach_file
PID_154367-V1468_Aviva.pdf
PID_154367-V1468_214_Av...
Income Type
Catalog
Price (฿)
Billable
Amount (฿)
Claimed
Amount (฿)
1.1 Hospital Medical Expenses
3000.00
2700.00
2000.00
1.2 Health Professional Fees
2000.00
1800.00
1500.00
1.1.1 Drugs and Parenteral Nutrition
5000.00
4500.00
3000.00
1.1.3 Blood Transfusion Services and Blood Com...
1500.00
1350.00
500.00
1.1.5 Drugs and Parenteral Nutrition
2500.00
2250.00
2000.00
Total
14,000.00
12,600.00
9,000.00
04
BC32456
TATA AIA
31-03-2020
766.71
attach_file
PID_154367-V1468_Aviva.pdf
PID_154367-V1468_214_Av...
05
BC32456
TATA AIA
04-04-2020
Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text
544.83
attach_file
PID_154367-V1468_Aviva.pdf
PID_154367-V1468_214_Av...
Doctor Form
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