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Léa Exemple
Speech therapist, INAMI no. 6-00011-31-111
Rue de la Démonstration 1, 1000 Bruxelles
Tel. 0400 00 00 00 · lea@example.org
Enterprise no. 0123.456.749
To the parents of Adam Ilyas
For the attention of Parent de Ilyas
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice, third-party payment

No. 2026-001 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Adam Ilyas
Date of birth
30/06/2012
National register no.
12.06.30-143.56
Health insurance fund
Mutualité de démonstration Sud
INAMI code
723310
Prescribed by
Dr Lambert, ORL
Prescription of
24/03/2026
Doctor's INAMI no.
10000007000
Medical advisor's approval
23/04/2026
Approval period
08/04/2026 to 07/04/2028

Breakdown of services

Session date INAMI code Fee Patient's share
09/09/2026 723310 38,37 € 5,50 €
16/09/2026 723310 38,37 € 5,50 €
23/09/2026 723310 38,37 € 5,50 €
30/09/2026 723310 38,37 € 5,50 €
Total fees (4 sessions)153,48 €
Amount invoiced to the health insurance fund, third-party payment131,48 €
Personal share payable by the patient22,00 €

Transfer of 22,00 € to account BE71 0961 2345 6769 in the name of Léa Exemple, with the structured reference +++202/6000/00192+++.

Or scan this code with your banking app: everything fills in by itself.

BIM patient: no. Third-party payment applied: the health insurance fund's share is paid directly to the speech therapist. Enterprise no. 0123.456.749.

Healthcare services exempt from VAT (article 44, § 1, paragraph 1, 1°, of the VAT Code).

Léa Exemple, speech therapist, INAMI no. 6-00011-31-111, certifies having provided the services listed above.

Date:
Signature of the provider: