Medical Invoice Template (1)

This template was designed for hospitals and health care providers who offer medical care for infants, children, and adolescents. It is used to bill the patient and contains detailed information about the type of treatment or medical service provided to the patient at the time of hospitalization.

The form contains several new fields, including the Date of service and the additional payment fields that are line itemized next to the description: "Total Fee", "CoPay", "Insurance Reim", "Ins Contract Adjust", and "Patient Responsibility". The "Patient Responsibility" field is calculated using a formula like this:

Patient Responsibility = Total Fee - CoPay - Insurance Reim - Ins Contract Adjust

Since this format is designed for those who offer medical care for infants, children, and adolescents, the "Bill To" and "Ship To" fields found on a general invoicing form are utilized a little differently. "Bill To" would represent the head of household account member, while "Ship To" would be the actual patient information. This allows you to easily deal with families with multiple children.

On the bottom of the form, there are a group of checkboxes that allow you to choose the payment type: Check, Visa, MasterCard, Amex, and Discover. The signature and the additional "date" fields are for handwriting.

The form contains the name of the medical organization, patient information such as their name, address, contact information, the name of the physician, comprehensive details on the treatment performed, and also information on medications sold to them.

This form also implements a new feature. If you fill in the "cardholder name", the invoice will be marked as paid. For this reason, if you run the Statement report, the "payment total" calculation will not work. We recommend that you remove this part from your statement report. This is because the template allows you to enter the payment information on the form; there are no separate payment records.