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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 Janssens Sarah
For the attention of Parent de Sarah
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
Janssens Sarah
Date of birth
30/06/2013
National register no.
13.06.30-127.93
Health insurance fund
Mutualité de démonstration Sud
INAMI code
714313
Prescribed by
Dr Martin, pédiatre
Prescription of
10/10/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
09/11/2025
Approval period
25/10/2025 to 24/10/2027

Breakdown of services

Session date INAMI code Fee
04/09/2026 714313 38,37 €
11/09/2026 714313 38,37 €
18/09/2026 714313 38,37 €
Total fees (3 sessions)115,11 €
Amount to be paid by the patient115,11 €

BIM patient: no. 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: