Medical Bill Receipt Template

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Updated June 13, 2022

A medical bill receipt is one that a doctor’s office or other medical institution will issue following the payment of an invoice. It should feature the cost of each service performed, medicine administered, and product used on the patient to provide a comprehensive breakdown of what the patient has paid for. The receipt should be kept by the patient and can be used as proof come tax season or to request compensation from a health insurance provider.

Medical Bill Invoice – When submitting a payment request to a patient with an outstanding balance.

How to Write

Download: Adobe PDF, Microsoft Word (.docx) or Open Document Text (.odt)

1 – Save The Medical Bill Receipt

Download the medical receipt using text links to obtain it as a PDF, Word, or ODT document.

2 – Produce Identifiers For The Receipt And The Practitioner

Before transcribing the information required for this invoice, you must give the invoice a unique name. This will be handled by determining then reporting the “Receipt Number” for this document on the first blank line of this paperwork.            “Date” this paperwork by entering the calendar day of its generation on the second blank line.     The first blank line in the column on the left will start the header section where defining the Medical Institution and Practitioner will be our primary focus. The “Name Of Medical Institution” line needs the legal name of the Recipient Practice or Medical Entity that has received payment.       

Below this, record the full “Practitioner Name” on the next available space down this column,            The Practitioner’s “License Number” is the next required item and should be transcribed to the third line in this column.            Finally, display the Practice’s (or Institution) current address utilizing the last two lines of this part of the receipt.         

3 – Report The Patient Information To The Header

The Patient being issued this receipt will need to have his or her “Name” documented on the first line in the “Patient Information” section.        After inputting the concerned Patient’s identity, present his or her address on the two lines “Street Address” or “City/State/ZIP”       

4 – Produce A Breakdown Of The Services, Medicine, And Supplies

In many cases, a receipt documenting the money paid for a medical bill will need to also convey the items that were being billed. A table will answer this need and has thus been produced to the center of this receipt. The columns making up this table will name the standard topics that need to be covered when documenting the medical services and items that were paid for. All such items may be listed by “Code” in the first column and presented by name in the “Description Of Services/Medicine/Products” column.            The number of items, supplies, products, or medicine that were paid for must reported in the third column. If the row you are working with concerns a service or treatment, then record the number of times that procedure was performed.            The “Rate” or unit cost charged for the care or products must be placed in the fourth column.         The final column, “Line Total ($),” is the product of “QTY” and “Rate.” Keep in mind that you must only multiply these numbers across the row you are working on.                After completing the columns in the table above, direct your attention to the bottom right area of the page. Begin supplying the “Subtotal” line in this part of the invoice with the sum of every value recorded in the above column. Notice that the “Subtotal” recorded omits any taxes. If taxes were added and paid for then, record this either as a value or a percentage in the parentheses then record the dollar value of taxes that must be added in the box immediately on the right.

Add the previous two values you entered to one sum then dispense to the “Total” line.        The “Amount Paid” for the bill you reported above must be submitted to the final line in this column.  Finally, turn your attention to the bottom left. Enter the “Payment Method” on the first available line here. This will be how the “Amount Paid” was submitted. Typically this will be with a credit card or check. If so, you must also enter the “Card/Check No.” that was used for payment.