| Reference | [field-value] | Case Reference | [field-value] |
|---|---|---|---|
| Authorization Line Item Reference | [field-value] | Amount Paid | [Amount] |
| Number of Units | [field-value] | Unit Amount | [Amount] |
| Payee Reference | [field-value] | Payee Name | [field-value] |
| Provider Reference | [field-value] | Provider Name | [field-value] |
Client Details
| Reference | First Name | Last Name | Date Of Birth |
|---|---|---|---|
| [field-value] | [First Forename] | [Surname] | [Date] |
Payment Adjustments
| Adjustment Reason | Adjustment Amount |
|---|---|
| [field-value] | [Amount] |