Medical Billing Invoice Submission
Invoice Number
Patient Name
Patient ID
Date of Service
Date of Invoice
Provider Name
Provider NPI
Facility Name
Facility Address
Billing Contact Email
Diagnosis Code(s)
Procedures / Services Rendered
CPT/HCPCS Code
Description
Units
Charge ($)
Total Charges ($)
Amount Paid ($)
Patient Responsibility ($)
Insurance Billed
Notes / Comments