725 lines
31 KiB
XML
725 lines
31 KiB
XML
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<?xml version="1.0" encoding="UTF-8"?>
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<!-- Created with Jaspersoft Studio version 7.0.3.final using JasperReports Library version 6.1.1 -->
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<parameter name="Number" class="java.lang.Integer">
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<defaultValueExpression><![CDATA[1001]]></defaultValueExpression>
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<queryString>
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<![CDATA[Select 23451 as number,
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'' as class,
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'01/01/2022' as date,
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'1.00' as amount,
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'One Dollar and 00/100' as amountAsText,
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'Joe Q. Public' as payee,
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'100 West Test Street' as payeeAddress,
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'Joe Q Public' as patientName,
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'1' as patientNumber,
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'01/01/2022' as incurredDate,
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'600102' as planIdNumber,
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'1' as divisionNumber,
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'111' as remittanceAdviceNumber,
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'1' as vendorType]]>
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<field name="incurredDate" class="java.lang.String"/>
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<field name="planIdNumber" class="java.lang.String"/>
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<field name="divisionNumber" class="java.lang.String"/>
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<field name="remittanceAdviceNumber" class="java.lang.String"/>
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P.O. Box 400
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<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
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</textElement>
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<text><![CDATA[AMOUNT]]></text>
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<staticText>
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<reportElement x="470" y="97" width="103" height="20" uuid="355abf7b-913f-43cf-b007-f2585e309866"/>
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<font fontName="Times New Roman" size="7" isBold="true" pdfFontName="Times-Bold"/>
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</textElement>
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<text><![CDATA[Truist
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Kinston, NC 28501]]></text>
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<text><![CDATA[PAY TO
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THE
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ORDER
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OF]]></text>
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<textFieldExpression><![CDATA["C"+$F{number}+"C"]]></textFieldExpression>
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<textFieldExpression><![CDATA[$F{amount}]]></textFieldExpression>
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<textFieldExpression><![CDATA[$F{amountAsText}]]></textFieldExpression>
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<text><![CDATA[DERMATOLOGY ASSOC OF COSTAL CAROLINA]]></text>
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<text><![CDATA[66-30/531
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151]]></text>
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<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PATIENT
|
||
|
|
NAME:]]></text>
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||
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|
</staticText>
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||
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<staticText>
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||
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<reportElement x="25" y="343" width="82" height="20" uuid="76f9270b-e8b9-4800-bb5b-64c35170f5c8"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PATIENT NUMBER:]]></text>
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||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="215" y="289" width="82" height="15" uuid="711e64b2-ce10-4afe-baf4-583a5ccb1850"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[INCURRED DATE:]]></text>
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||
|
|
</staticText>
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||
|
|
<staticText>
|
||
|
|
<reportElement x="215" y="308" width="82" height="15" uuid="6e35aaef-92c8-4358-9f63-321d9f5d3449"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PLAN ID NUMBER:]]></text>
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||
|
|
</staticText>
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||
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|
<staticText>
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||
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|
<reportElement x="215" y="327" width="82" height="15" uuid="0ede1930-56c0-43c0-a503-863a4c8e05d9"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[DIVISION NUMBER:]]></text>
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||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="215" y="346" width="82" height="15" uuid="d9b3a38f-8358-41b6-90a0-b331b73a2839"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[REMITTANCE ADVICE:]]></text>
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||
|
|
</staticText>
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||
|
|
<staticText>
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||
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<reportElement x="404" y="288" width="82" height="15" uuid="a5eb7155-cb31-4cc9-8835-bba037d53182"/>
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||
|
|
<textElement>
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||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
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||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CHECK DATE:]]></text>
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||
|
|
</staticText>
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||
|
|
<staticText>
|
||
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|
<reportElement x="404" y="326" width="82" height="15" uuid="283c1d69-2dc4-4dc1-b597-3ed16b887f7b"/>
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||
|
|
<textElement>
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||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[AMOUNT:]]></text>
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||
|
|
</staticText>
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||
|
|
<staticText>
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||
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<reportElement x="404" y="307" width="82" height="15" uuid="ebdd239d-be89-4ec2-b3b5-5c3dc207842d"/>
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||
|
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<textElement>
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||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CHECK NUMBER:]]></text>
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||
|
|
</staticText>
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||
|
|
<textField>
|
||
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|
<reportElement x="300" y="346" width="72" height="15" uuid="47e8fd78-853c-4db2-9eb9-3a26fd7ccb63"/>
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||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{remittanceAdviceNumber}]]></textFieldExpression>
|
||
|
|
</textField>
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||
|
|
<textField pattern="">
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||
|
|
<reportElement x="487" y="288" width="82" height="15" uuid="cfdac42c-160a-4c48-8ba4-3e02a0e41031"/>
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||
|
|
<textElement textAlignment="Right">
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||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{date}]]></textFieldExpression>
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||
|
|
</textField>
|
||
|
|
<textField pattern="¤ #,##0.00">
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||
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<reportElement x="488" y="326" width="82" height="15" uuid="6b25dfa6-d44f-486f-a41c-1f5114053b12"/>
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||
|
|
<textElement textAlignment="Right">
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||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
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||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{amount}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="488" y="308" width="82" height="15" uuid="3c01b947-2de9-42c0-ae28-a1ca0df8d27f"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{number}]]></textFieldExpression>
|
||
|
|
</textField>
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||
|
|
<staticText>
|
||
|
|
<reportElement x="400" y="665" width="82" height="15" uuid="d5f3c0a1-bff7-4641-be61-52c27ff5ec0d"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CHECK DATE:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="208" y="723" width="82" height="15" uuid="26e19805-7165-4c9a-bb3a-528121606718"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[REMITTANCE ADVICE:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="208" y="666" width="82" height="15" uuid="cf729b5e-b577-4c64-afee-070c111f4006"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[INCURRED DATE:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="400" y="703" width="82" height="15" uuid="1d4a63b5-33c4-4bcd-a689-2cf125dd3eb1"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[AMOUNT:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="16" y="720" width="82" height="20" uuid="703b9f76-654a-463a-a49a-bf0942aa31c5"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PATIENT NUMBER:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="489" y="685" width="82" height="15" uuid="e7270913-b4fd-4639-a7c0-7b811a243288"/>
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||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{number}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField pattern="¤ #,##0.00">
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||
|
|
<reportElement x="489" y="703" width="82" height="15" uuid="02e49fb0-8386-4f12-b57f-ef375259dd21"/>
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||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{amount}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="208" y="685" width="82" height="15" uuid="23e49582-b9c4-4dca-a571-a0fd104a8644"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PLAN ID NUMBER:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="208" y="704" width="82" height="15" uuid="43009c11-35cc-4105-9133-7ec0623eafe0"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[DIVISION NUMBER:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="293" y="723" width="72" height="15" uuid="40909d92-42bd-4f81-88de-fb391dd07bfe"/>
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||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{remittanceAdviceNumber}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="16" y="682" width="40" height="20" uuid="68059abe-b3fe-44be-9df1-30a40f8eda42"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PATIENT
|
||
|
|
NAME:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField pattern="">
|
||
|
|
<reportElement x="488" y="665" width="82" height="15" uuid="dcffdf50-108f-4264-a5f5-bdd1881f76f7"/>
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||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{date}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<rectangle>
|
||
|
|
<reportElement x="13" y="660" width="173" height="20" backcolor="#E5E5E5" uuid="c6ec5fb8-6d36-48bc-a95e-f0f4a4738c5b"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</rectangle>
|
||
|
|
<rectangle>
|
||
|
|
<reportElement x="393" y="640" width="183" height="20" backcolor="#E5E5E5" uuid="f488537a-8fca-4765-bde5-326e0af7e5b5"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</rectangle>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="400" y="684" width="82" height="15" uuid="24e5999f-b63b-4352-8a97-3cc823a7bfcc"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CHECK NUMBER:]]></text>
|
||
|
|
</staticText>
|
||
|
|
<rectangle>
|
||
|
|
<reportElement x="203" y="640" width="173" height="20" backcolor="#E5E5E5" uuid="1d4bdd38-37ff-44fd-8f2a-e823d68f20c1"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</rectangle>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="14" y="660" width="172" height="20" uuid="645b4bb7-c74d-4d99-9663-1bc3257adf6e"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CLAIMANT INFORMATION]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement mode="Transparent" x="393" y="640" width="184" height="20" uuid="9ffbb2d9-6eaa-45bd-9d34-b027a1e01b55"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CHECK INFORMATION]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="203" y="640" width="172" height="20" uuid="f8febf1a-1f52-4162-96a8-cfba41a902fc"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[CLAIM INFORMATION]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="22" y="480" width="456" height="20" uuid="31465df8-8177-4adc-b917-747a1ec9843b"/>
|
||
|
|
<textElement verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" size="10" isBold="true" isItalic="true" pdfFontName="Times-BoldItalic"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{amountAsText}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="104" y="518" width="286" height="43" uuid="731b5b63-1fd0-48a2-8a1b-5ad552c754f6"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="8" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{payeeAddress}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<rectangle>
|
||
|
|
<reportElement x="381" y="434" width="193" height="12" backcolor="#E5E5E5" uuid="cb6865ef-017f-487a-a74a-7145a9c5fa93"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</rectangle>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="0" y="401" width="576" height="37" uuid="ebe1a483-ae33-49a8-b595-bcc69ab7a63c"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="8" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[
|
||
|
|
P.O. Box 400
|
||
|
|
Kinston, NC 28502-0400]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="472" y="480" width="103" height="20" uuid="1e2d4c7f-ae4a-4a7c-bd0a-e2a9535a72a6"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="7" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[First Citizens Bank]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="381" y="434" width="96" height="12" uuid="0fc29cb1-b709-4c60-ba66-7d350790386d"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[DATE]]></text>
|
||
|
|
</staticText>
|
||
|
|
<line>
|
||
|
|
<reportElement x="537" y="393" width="33" height="1" uuid="50837cf2-e1d8-4b4b-8d3a-002331b20b25"/>
|
||
|
|
</line>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="478" y="434" width="96" height="12" uuid="57fd7b75-fc9e-4c11-aaeb-d7870c295665"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[AMOUNT]]></text>
|
||
|
|
</staticText>
|
||
|
|
<line>
|
||
|
|
<reportElement x="382" y="565" width="193" height="1" uuid="4caf501a-e208-4986-8fd0-54d592d60bd7"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</line>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="104" y="508" width="286" height="10" uuid="0f9032df-8ccc-4d46-836f-2b6cd181d32e"/>
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||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="8" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{payee}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="537" y="384" width="35" height="25" uuid="66142c9d-9af9-4427-8c64-583ef0ab60d9"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="8" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[66-30/531
|
||
|
|
151]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="14" y="383" width="108" height="24" uuid="918894d0-3548-4687-a4c3-1b0050d30bf3"/>
|
||
|
|
<textElement textAlignment="Left">
|
||
|
|
<font fontName="Times New Roman" size="18" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{number}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<rectangle>
|
||
|
|
<reportElement x="381" y="446" width="193" height="16" uuid="686d6f89-6c3b-4fa0-abd2-6d06cdbd9782"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</rectangle>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="0" y="384" width="576" height="25" uuid="ddb3d6ca-ed61-457c-80c9-dcc202ba7241"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="16" isBold="true" pdfFontName="Times-Bold" isPdfEmbedded="false"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[DERMATOLOGY ASSOC OF COSTAL CAROLINA]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="22" y="508" width="42" height="53" uuid="98ee63c6-75e3-4259-90f4-b0642224aff0"/>
|
||
|
|
<textElement textAlignment="Left">
|
||
|
|
<font fontName="Times New Roman" size="8" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[PAY TO
|
||
|
|
THE
|
||
|
|
ORDER
|
||
|
|
OF]]></text>
|
||
|
|
</staticText>
|
||
|
|
<line>
|
||
|
|
<reportElement x="477" y="434" width="1" height="28" uuid="0abe9e45-9a8c-424f-a31b-da015e3f6f44"/>
|
||
|
|
<graphicElement>
|
||
|
|
<pen lineWidth="0.75"/>
|
||
|
|
</graphicElement>
|
||
|
|
</line>
|
||
|
|
<textField pattern="">
|
||
|
|
<reportElement x="381" y="446" width="96" height="16" uuid="1fa51fb0-7075-47ac-a1d1-6c8bc11c0476"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" size="9" isBold="true" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{date}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField pattern="¤ #,##0.00">
|
||
|
|
<reportElement x="478" y="446" width="95" height="16" uuid="9333c126-24a4-4d56-b6f8-c9b751eee083"/>
|
||
|
|
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
|
|
<font fontName="Times New Roman" size="9" isBold="true" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{amount}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="0" y="585" width="575" height="42" uuid="9435ce0c-5ff1-4a2e-beea-21ea495a2bc6"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="36" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[FILE COPY]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="383" y="554" width="192" height="20" uuid="000cbe09-7c36-4b99-9d34-2cbb17796edc"/>
|
||
|
|
<textElement textAlignment="Center">
|
||
|
|
<font fontName="Times New Roman" size="9" isBold="true" pdfFontName="Times-Bold"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[***NON-NEGOTIABLE***]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="300" y="308" width="72" height="15" uuid="af54f112-1883-4923-81bc-7ab33352deb7"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[600123]]></text>
|
||
|
|
</staticText>
|
||
|
|
<staticText>
|
||
|
|
<reportElement x="293" y="685" width="72" height="15" uuid="01543073-e47d-49cf-b988-1275b2f94cc5"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7" pdfFontName="Times-Roman"/>
|
||
|
|
</textElement>
|
||
|
|
<text><![CDATA[600123]]></text>
|
||
|
|
</staticText>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="63" y="304" width="123" height="20" uuid="900e1990-5681-4e81-9759-e2f43da6c29f"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{patientName}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField isBlankWhenNull="true">
|
||
|
|
<reportElement x="307" y="289" width="65" height="14" uuid="26a252de-d513-43ea-9975-1d37a5a7eb64"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{incurredDate}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="63" y="682" width="123" height="20" uuid="8a792e8a-330d-4ca8-9eb9-9eb4eb42b25d"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{patientName}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="292" y="704" width="72" height="15" uuid="abbf2e40-d282-4920-8198-5aa973e2dfb7"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{divisionNumber}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField isBlankWhenNull="true">
|
||
|
|
<reportElement x="299" y="666" width="65" height="14" uuid="59cb9fac-5709-467c-9972-3951ba59c383"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{incurredDate}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="300" y="327" width="72" height="15" uuid="c668585e-24a3-4576-a145-d0f0026d387c"/>
|
||
|
|
<textElement textAlignment="Right">
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{divisionNumber}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="98" y="343" width="88" height="20" uuid="4d9b7f7f-8d76-4f7e-a466-d13eef79cf38"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{patientNumber}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
<textField>
|
||
|
|
<reportElement x="98" y="720" width="88" height="20" uuid="07a43a68-a11b-4c69-883e-1f22a2dd6e64"/>
|
||
|
|
<textElement>
|
||
|
|
<font fontName="Times New Roman" size="7"/>
|
||
|
|
</textElement>
|
||
|
|
<textFieldExpression><![CDATA[$F{patientNumber}]]></textFieldExpression>
|
||
|
|
</textField>
|
||
|
|
</band>
|
||
|
|
</detail>
|
||
|
|
<columnFooter>
|
||
|
|
<band splitType="Stretch"/>
|
||
|
|
</columnFooter>
|
||
|
|
<pageFooter>
|
||
|
|
<band splitType="Stretch"/>
|
||
|
|
</pageFooter>
|
||
|
|
<summary>
|
||
|
|
<band splitType="Stretch"/>
|
||
|
|
</summary>
|
||
|
|
</jasperReport>
|