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Invoice

The document appears to be an invoice or statement from a medical business to a patient named Test Customer Three showing a balance of $5.00. It lists an invoice from February 5, 2013 for $5.00 and indicates the status as paid. The summary provides key details like the patient name, balance amount, invoice date and status in a concise manner.

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alex
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177 views4 pages

Invoice

The document appears to be an invoice or statement from a medical business to a patient named Test Customer Three showing a balance of $5.00. It lists an invoice from February 5, 2013 for $5.00 and indicates the status as paid. The summary provides key details like the patient name, balance amount, invoice date and status in a concise manner.

Uploaded by

alex
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Medical Business Name INVOICE

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

Bill To: Patient:

Save As New Customer View Customer Info. Same As 'Bill To'


Physician Terms Due Date

Dt of Service Description Total Fee Co-Pay Ins Reim Adj Balance (PR)

TOTAL -

Payment Type 0 Check

0 Visa 0 MasterCard 0 Amex Discover


0
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!
Medical Business Name 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
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 5 2
Medical Business Name 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!

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