Medical Receipt Template

woman-in-lab-coat-holding-medical-receipt

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A medical receipt is a written record of a payment transaction from a patient to a medical institution or organization. The issuing party generally sends this to the patient following the patient’s payment of a medical bill invoice. Patients need to save medical receipts for their tax returns and insurance reimbursements, if applicable.

What to Include

  • Description of each service performed;
  • Medical institution’s information (name, address, phone, email);
  • Medical practitioner’s name, address, phone number, and license number;
  • Name, description, and dosage of each medication administered;
  • Patient’s information (name, address, phone, email);
  • Payment method (cash, check, credit card, other);
  • Receipt number;
  • Signatures of both parties;
  • Summary of charges:
    • Billing codes;
    • Cost of each service performed and medication administered,
    • Cost of add-ons (if applicable),
    • Quantities of items and add-ons,
    • Subtotal,
    • Tax rate,
    • Total taxes due,
    • Total amount due,
    • Amount paid, and
    • Outstanding balance (if applicable); and
  • Transaction date.