| Label | Type | Description | Mandatory |
| Updated On | CURAM_DATETIME | The date on which the last update was made to the evidence. | No |
| Effective Date of Change | CURAM_DATE | Date which the evidence becomes effective | No |
| Approval Requested | CURAM_INDICATOR | Approval Requested | No |
| Payment Receipt Number | RECEIPT_NUMBER | Receipt number on the receipt received by the household member from the medical service provider for the payment made in respect of the medical expense. | No |
| Payment Method | METHOD_OF_RECEIPT_CODE | Method of payment for the medical expense from the drop-down list of payment methods, e.g., "cash" or "check". Your system administrator can add a new payment method via the Code Tables page (see "Code Tables" in the Cúram Administration Guide). | No |
| Date Paid | CURAM_DATE | Date that the payment was made by the household member to the medical service provider in respect of the medical expense. | No |
| Amount Paid | CURAM_AMOUNT | The monetary value of the payment made in respect of the medical expense. | No |
|
| Updated By |
| Label | Type | Description | Mandatory |
| Updated By | USER_NAME | | No |
|
|
|
| Medical Expense Payment |
| Label | Type | Description | Mandatory |
| Household Member | FULL_NAME | Household member and social security number of the participant to whom the medical expense payment evidence applies from the drop-down list of household members. | No |
|
| Comments |
| Label | Type | Description | Mandatory |
| Comments | COMMENTS | | No |
|
