Date of Payment: Payment Code: Line Description: Transaction Description: Amount 5/1/20XX MED ADJ Medicare Write-off Adjustment ($10.00) 5/1/20XX MED ADJ Medicare Write-off Adjustment ($10.00) 5/1/20XX MED ADJ Medicare Write-off Adjustment ($8.00) 5/1/20XX MED ADJ Medicare Write-off Adjustment ($7.00) 5/1/20XX MED ADJ Medicare Write-off Adjustment ($8.00) Total: ($ Patient Payments Date of Payment: Payment Code: Payment Description: Transaction Description: Amount 2/1/20XX COCHECK Copay Check Payment ($20.00) 3/1/20XX CCARDCOP Credit Card Copay ($20.00) 4/1/20XX COPAYCASH Cash Copayment ($20.00) 5/1/20XX COPAY20 $20 Co-Payment ($20.00) Procedure Form 16-1