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Medical Expense Receipt Template

This medical expense receipt summarizes charges for a patient's hospital visit from a certain date range. It lists various diagnostic and treatment procedures, medications, and other services or charges. The receipt shows the insurance points covered and the patient's liability for each item and service, as well as subtotals and totals owed.

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akhil kottedi
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987 views1 page

Medical Expense Receipt Template

This medical expense receipt summarizes charges for a patient's hospital visit from a certain date range. It lists various diagnostic and treatment procedures, medications, and other services or charges. The receipt shows the insurance points covered and the patient's liability for each item and service, as well as subtotals and totals owed.

Uploaded by

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

English/英語

患者氏名 ：
患者 ID ：

Medical Expense Receipt


Date issued (YYYY/MM/DD) : / /
Hospital name: □Outpatient □Inpatient □Second opinion
Department： Insurance type: (Percentage of patient liability: %)
Billing period: From / / to / /
Hospital ID No.: Patient name:

Diagnostic procedure
First/subsequent visit fees Admission charges, etc. Medical supervision charges, etc. Home medical care
combination (DPC)
Insurance points
Patient liability ¥ ¥ ¥ ¥ ¥
Examinations Diagnostic imaging Medication Injections Rehabilitation
Insurance points
Patient liability ¥ ¥ ¥ ¥ ¥
Specialized psychiatric treatment Medical treatment Surgery Blood transfusion Anesthesia
Insurance points
Patient liability ¥ ¥ ¥ ¥ ¥
Dental crown restoration /
Radiotherapy Pathological diagnosis Prescriptions SUBTOTAL
Prosthodontics
Insurance points
Patient liability ¥ ¥ ¥ ¥ ¥

Dietary therapy Documentation Delivery charges Extra room charges Special or specified medical care

Patient liability ¥ ¥ ¥ ¥ ¥
Others SUBTOTAL
Patient liability ¥ ¥

Comments： Sales tax


TOTAL RECEIVED
Subtotal to be taxed Tax

¥ ¥ ¥

医療費領収書 ： 2014 年３月初版

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