| ID | PATIENT NAME | FORM | PRIVATE SOURCE AMT | GRATUITOUS AMOUNT | PATIENT FUNDS CLERK NAME | CODE | REMARKS | BALANCE CARRIED FORWARD AMT | PVT SOURCE BAL CARRIED FWD | GRATUITOUS BAL CARRIED FWD | DEFERRAL DATE | COUNT IN RESTRICTION BALANCE | AMOUNT | TRANSACTION DATE | REFERENCE | DEPOSIT/WITHDRAWAL | CASH/CHECK/OTHER | SOURCE |
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