Patient Information Form Page 3
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4Schedule-IV
{LOGO}
. Schedules:
{NAME & ADDRESS OF THE HOSPITAL}
Schedule-IV A
SUMMARY BILL FORMAT
Bill Number
Provider Name
Provider
registration No.
Bill Date
Address
PAN Number
Service Tax
IP No
Regn No
Date of
Patient Name
admission
Date of
XXXX Insurance
Payer Name
Company Ltd
Discharge
Member Address
Bed Number
Billing Summary
Amount
SI No
Primary Code
Particulars
1
100000
Room & Nursing Charges
2
200000
ICU Charges
3
300000
OT Charges
4
400000
Medicine & Consumables
5
500000
Professional Fees'
6
600000
Investigation Charges
Ambulance Charges
7
700000
8
800000
Miscellaneous Charges
9
900000
Package Charges
Total Bill Amount
0
Amount paid by
member
0
.............
Amount charged to
0
Payer
Discount Amount
0
Service Tax
0
A
m
u o
t n
P
y a
b a
e l
0
Rupees Zero Only
Amount in Words
Patients Signature
Authorized Signatory
Page 3
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Parent category: Medical