Prompt | Response | Req | Len |
---|---|---|---|
Social Security No. | 12 | ||
Date of Birth | 10 | ||
Balance Due $ | 10 | ||
Date of Last Visit | 10 | ||
Last Payment Date | 10 | ||
Last Payment Amt $ | 10 | ||
Internal Comment | 45 | ||
Accounting Date | 10 | ||
Refund Date | 10 | ||
Refund Amount $ | Enter the Amount of the Credit or 'Q' to Quit | 10 | |
Refund Code | Enter a Refund Code from the Adjustment Code Table or HELP for a List | 10 | |
Remarks | Enter An Optional Comment | 40 |