Medical invoice form is prepared and executed for the medical services availed by the patients. These forms are prepared by the medical billing department by mentioning the details of the patient and total cost of the treatment including medicines.
Sample Medical invoice form:
- Invoice Number: ___________________
- Date: ____/____/_____
- Medical organization details (clinic, hospital, nursing home):
Name of the medical organization: _____________________
Location: _________________________________________
Phone Number: ___________________________________
URL address: ____________________________________
- Patient Details:
Name: __________________________________________
Street Address: _____________, City: _____________, State: _______________
Phone Number: ______________________
Alternate Mobile Number: ________________________
E-mail Id: ______________________________________
- Medical details & Amount:
Service Yes/ No Amount
Charges of syringe and thermometer: ________ __________
Medicines and injection charges: _________ __________
Emergency/ Ward Charges: ________ __________
Any surgical kit/ Oxygen Kit installed: ________ ___________
Any supporting machines & equipment used: ________ __________
Total doctor fees: ___________
Nursing Assistant Service Charges: ___________
Total Amount to be paid by the patient ______________
- Billing Department Details:
Prepared By: _______________________
Checked By: _______________________
Signature of the Patient/ parent/ guardian: ________________
