ABC Healthcare INVOICE

Address
City, State ZIP DATE: May 12, 2019
Phone#, web address INVOICE #:

Bill To: # Patient:

Name Name
Address Address
City, ST ZIP City, ST ZIP
Country Country
Phone Contact
Save As New Customer View Customer Info. Same As 'Bill To'
Physician Terms Due Date
Sales1 Net 60

Dt of Service Description Total Fee Co-Pay Ins Reim Adj Balance (PR)
Jan 2, 19 Bariatric Surgery
Jan 3, 19 Center for Human Nutrition
Jan 4, 19 Weight Management Prog.
May 1, 19
May 2, 19
May 3, 19

12.00
TOTAL -

0
Payment Type Check
0

VISA
0 0 MasterCard
0 Amex 0
Discover
Cardholder Name
Account Number
Exp Date
CVV2 (3 digit number on the back of Visa/MC, 4 digits on front of AMEX)

_________________________________________ Date ___/___/____

Notes:

Thank you!
ABC Healthcare Encounter
Address
City, State ZIP
Report
Phone#, web address

Date:
From 2/6/2012
To 2/5/2013

Month Date Cost Invoice # Physician Total Paid Fee

2/2013 2/5/2013 0.00 INV1052 Sales1 5.00 5.00 18.00
2/2013 Total 0.00 5.00 5.00
Grand Total 0.00 5.00 5.00
Encounter
Report

Co Pay Ins Rem Adj

6.00 5.00 2.00
ABC Healthcare Patient Statement
Address
City, State ZIP
Phone#, web address

Bill To:
ID: C1004 Balance forward -
Name: Test Customer Three Current balance 5.00
Address: 123 Big Forest Valley
City,ST ZIP: Ottawa, On Z12345 Invoice total 5.00
Country: Canada Payment total -
Phone:

Statement Period:
From:
To: 2/5/2013

Date Description Document# Due Date Status Amount Balance

2/5/2013 Invoice INV1052 3/7/2013 Paid 5.00 5.00

Thank you for your business!

Medical Invoice Template (1) - c7009

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