» » Medical Invoice Template

Medical Invoice Template

The Medical Invoice Template is a document that is used by physicians and/or medical office personnel to provide an itemized invoice for services to individual patients. The form will provide information such as the physician’s information, patient’s information, invoice information and titled columns in which medical personnel may provide itemization and totals for the patient to make payment to the Doctor or medical facility.

How to Write

Step 1 – Download the form – Submit the following:

Bill From –

  • Physician’s name
  • Name of medical facility (if any)
  • Street address
  • City, State, Zip Code
  • Physician’s telephone number

Bill To – Enter:

  • Patient’s name
  • Company name (if applicable)
  • Street address
  • City, State, Zip Code
  • Patient’s telephone number

Invoice Information – Enter the individual services into the following columns:

  • Medical Services Performed
  • Medication
  • Patient
  • Rate(s)
  • Totals
  • AND
  • Once the rows of information have been completed, enter the amount per service, into the “Total” field at the end of each row
  • Calculate all of the totals
  • Enter the calculated sum of the totals into the “Subtotal” field
  • Enter the amount of sales taxes due
  • Enter any “other” charges
  • Calculate the totals from “subtotal,” “Sales Tax,” and “Other,” enter that amount into the “Total” box at the end of the “Total” column

Step 2 – Terms and Conditions –

  • Enter the amount of days that payment must be received within
  • Submit the percentage per service or invoice, as late payment fees, should payment be presented late

Step 3 – Choose a Payment Type –

  • Check the selected Credit or Debit Card type
  • Cardholder name
  • Account/Credit Card or Debit Card number
  • Expiration date (located on the front of the card)
  • CVV (three digit code on the back of the card)

Step 4 – Agreement and Signature –

  • The patient must read the statement
  • If in agreement, provide the patient’s signature in the line provided
  • Date the signature in mm/dd/yyyy format

Bank Wire –

  • Should the patient prefer to pay by bank wire and the medical office is in agreement enter:
  • The name on the bank account
  • Street address
  • Bank name
  • Account number
  • Routing number
  • Account type

PayPal –

  • If the patient would like to pay via PayPal account, they must simply provide the email address that is connected with their PayPal account

Related pages

nys power of attorneysample resignation form30 day eviction notice pdfprintable rental agreementsri certificate of good standingadvance directives texaslandlord tenant hawaiisample room lease agreementsample letter to give notice to landlordllc membership certificate examplewyoming landlord tenant law60 day notice to vacate formrent receipt format dochow to write letter to landlord moving outfull form of todca assoc realtorslandlords 30 day notice to vacate for tenantwills formatsample letter to tenant from landlordretail lease agreement templateontario rental lease agreement formbbt deposit check onlinetypes of deeds in texasnd estates agents in jerseyinvoice blank formnew york residential lease agreement pdflast wills and testament forms3 day notice to vacate ohiochase routing number wisconsincommercial tenant application formarkansas dmv bill of salehillsborough county registry of deeds nhalaska recorderhow to dissolve an llc in arizonanavy federal check depositconnecticut lease agreementtexas realtors lease agreementpower of attorney for health care illinoissample letter of lease termination from tenantsmall estate affidavit virginiamissouri llc filingillinois quit claim deed formwarranty deed form floridarent increase notice templatewrit of possession hawaiisocial security administration direct deposit formsllc operating agreement massachusettssublet njmassachusetts eviction lawsresignation notice templatenyc residential leaseblank contractor invoicewills in njeviction north carolinamaine probate court formssub lease contractloan agreement sample between friendsintuit direct depositwhere to send form 2848texas department of motor vehicles bill of salerental termination letter from landlordmv 13stny state willssample of short notice resignation lettercure or quit notice californianotice to pay rent or quit california formtexas durable power of attorneyinvoice template for cleaning servicesdmv form mv 82rent increase letter to tenantshouse rental agreements templateseviction forms californiafree sublease agreementbill of sale for a vehicle templategeorgia evictionnew york guardianship forms