Format spec

Medical payment receipt template

A patient payment record with an insurance adjustment ladder in place of a tax line.

This is a generic industry format — the printing convention, not any company’s trade dress. You supply your own business identity; Get Receipt supplies the grid it prints on.

Open this format in the maker Every format

Physical spec

Paper: A5 page
Roll or sheet width: 148 mm
Printable width: 128 mm

Ordered field list

Top of the document to the bottom. This is the order a reader expects and the order a scanner, a bookkeeper or a returns desk looks for.

1.Practice name, address and phone
2.Provider name and national provider identifier
3.Patient name, account number and date of birth
4.Date of service
5.Procedure codes with descriptions and charges
6.Diagnosis codes
7.Total charges
8.Insurance adjustment or allowed amount
9.Insurance paid
10.Patient responsibility
11.Amount paid today and the method
12.Balance
13.Reimbursement-eligibility note
14.Privacy footer

Alignment

A charge table with a right-aligned money column, followed by the adjustment ladder.

Tax convention

None at all. Medical services are essentially universally exempt, and the adjustment ladder occupies the space a tax line would.

Tender

Copay or patient payment collected, with the method.

Machine-readable code

None.

How to recognise it

Procedure and diagnosis codes
National provider identifier
The adjustment, insurance-paid and patient-responsibility waterfall
No tax line

Get Receipt renders this as Medical co-pay receipt

A5 clinic receipt: patient and visit block, the co-pay amount collected at the desk, and a note that the balance is billed to the insurer. Every total is recomputed by the engine from the line items, so the printed lines always sum to the printed total — the one thing generated receipts most often get wrong.