Payment Details
Payment Priority
1000
Payment Priority Note
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam nunc lorem, viverra vel nulla a, convallis sagittis felis. Sed hendrerit odio sit amet sapien rhoncus feugiat.
error_outlineLorem ipsum dolor sit amet, consectetur adipiscing elit. Nam nunc lorem, viverra vel nulla a.
error_outlineBilling Details
| Income Type | Catalog Price (฿) |
Discount / Addition (฿) |
Billable Amount (฿) |
Microsoft
1 C.C
Coverage 2000 (฿)(Payment By Company) |
Aviva
2 INS
Coverage 2000 (฿) |
Self Pay (฿) 3 SP | |||
|---|---|---|---|---|---|---|---|---|---|
| Stmt. Amt. (฿) | Actual Amt. (฿) | Stmt. Amt. (฿) | Actual Amt. (฿) | Stmt. Amt. (฿) / VAT Item Total |
Actual Amt. (฿) | ||||
| 1.1 Hospital Medical Expenses | 500.00 | - 35.00 | 465.00 | 400.00 | 00.00 |
00.00 00.00 |
|||
| 1.2 Health Professional Fees | 400.00 | - 40.00 | 360.00 | 360.00 | 00.00 |
00.00 00.00 |
|||
| 1.1.1 Drugs and Parenteral Nutrition | 3000.00 | - 300.00 | 2700.00 | 1500.00 | 00.00 |
00.00 00.00 |
|||
| 1.1.14 (1) Lorem Ipsum Medical Pack... | 1500.00 | - 150.00 | 1350.00 | Not Covered | Not Covered | 1350.00 | 150.00 | ||
| Total | 2,700.00 | - 525.00 | 2,430.00 | 2,260.00 | 2000 | 1350.00 | 1200 | 150.00 | 150 |
error_outlineOn Click of “Save” Proforma Statement will be generated.
Billing Note
Billing Note
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nam nunc lorem, viverra vel nulla a, convallis sagittis felis. Sed hendrerit odio sit amet sapien rhoncus feugiat.
error_outlineLorem ipsum dolor sit amet, consectetur adipiscing elit. Nam nunc lorem, viverra vel nulla a.
error_outline
