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Prescription Receipt
A prescription receipt documents payment for a prescribed medication. It is commonly used for insurance claims, HSA/FSA reimbursement, and medical record keeping.
Prescription receipts usually include prescription number, medication name, and patient copay.
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Item
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Value
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PRESCRIPTION RECEIPT
Walgreens Pharmacy
Store #7721
Denver, CO
Prescription No: RX-884193
Patient: Daniel Moore
Medication:
Amoxicillin 500 mg
Qty: 30 capsules
02/14/2026, 17:29:29
Insurance Copay
18.00€
Total Paid
18.00€
Card number
**** **** **** 1234
Card type
Debit
Status
APPROVED
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