Document language: Français · Nederlands · English Back
Tom Exemple
Speech therapist, INAMI no. 6-00022-20-222
Rue de la Démonstration 1, 1000 Bruxelles
Tel. 0400 00 00 00 · demonstration@exemple.be
Enterprise no. 0234.567.873
To the parents of Hendrickx Mila
For the attention of Parent de Mila
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice

Issued on 25/10/2026

Sessions of September 2026 · DRAFT, do not send

Patient and prescription

Patient
Hendrickx Mila
Date of birth
28/06/2021
National register no.
21.06.28-123.34
Health insurance fund
Mutualité de démonstration Sud
INAMI code
713311
Prescribed by
Dr Martin, pédiatre
Prescription of
25/10/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
24/11/2025
Approval period
09/11/2025 to 08/11/2027

Breakdown of services

Session date INAMI code Fee
02/09/2026 713311 38,37 €
09/09/2026 713311 38,37 €
16/09/2026 713311 38,37 €
23/09/2026 713311 38,37 €
Total fees (4 sessions)153,48 €
Amount to be paid by the patient153,48 €

BIM patient: no. Enterprise no. 0234.567.873.

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

Tom Exemple, speech therapist, INAMI no. 6-00022-20-222, certifies having provided the services listed above.

Date:
Signature of the provider: