| TRANSACTION ID | PATIENT NAME | FORM | PRIVATE SOURCE AMT | GRATUITOUS AMOUNT | PATIENT FUNDS CLERK | VALIDATION CODE | VALIDATION VERSION | ELECTRONIC SIGNATURE | REMARKS | BALANCE CARRIED FORWARD AMT | PVT SOURCE BAL CARRIED FWD | GRATUITOUS BAL CARRIED FWD | DEFERRAL DATE | PATIENT TRANSACTION # | SIG CONVERSION COMPLETED | SIGNATURE CODE DATE/TIME | AMOUNT | TRANSACTION DATE | DATE TRANSACTION ENTERED | DAYS BETWEEN DATES | REFERENCE | DEPOSIT/WITHDRAWAL | CASH/CHECK/OTHER | SOURCE |
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