Free Medical Bill Template
Medical Bill
Date: October 15, 2050
Bill Number: MB2050-0156
Patient: Jerrell Lowe
Account Number: #123456789
|
Bill Summary |
Quantity |
Unit Price |
Total |
|---|---|---|---|
|
Consultation Fee |
1 |
$200.00 |
$200.00 |
|
Blood Test |
1 |
$150.00 |
$150.00 |
|
X-Ray Imaging |
2 |
$100.00 |
$200.00 |
|
Medication (Antibiotics) |
1 |
$50.00 |
$50.00 |
|
Total Amount Due |
$600.00 |
Insurance Information:
-
Insurance Provider: MindStove Insurance
-
Coverage: 80% of total bill
-
Amount Covered: $480.00
-
Amount Due from Patient: $120.00
Payment Instructions:
-
Account Name: Notable20 Bank
-
Account Number: 1234567890
-
Routing Number: 987654321
For any questions or payment inquiries, contact us at [YOUR COMPANY EMAIL] or call [YOUR COMPANY NUMBER].
