Camille Renard

Speech therapist, INAMI no. 6-00000-05-111

Rue de la Démonstration 1, 1000 Bruxelles

Tel. 0400 00 00 00 · demonstration@exemple.be

Enterprise no. 0123.456.749

To the parents of Peeters Noah

For the attention of Parent de Noah

Rue de l'Exemple 1

1000 Bruxelles

Speech therapy invoice, third-party payment

No. 2026-009 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient: Peeters Noah
Date of birth: 29/06/2018
National register no.: 18.06.29-107.54
Health insurance fund: Mutualité de démonstration Sud
INAMI code: 723310

Prescribed by: Dr Lambert, ORL
Prescription of: 27/06/2025
Doctor's INAMI no.: 10000007000
Medical advisor's approval: 27/07/2025
Approval period: 12/07/2025 to 11/07/2027

Breakdown of services

Session date	INAMI code	Fee	Patient's share
06/09/2026	723310	38,37 €	2,00 €
13/09/2026	723310	38,37 €	2,00 €
20/09/2026	723310	38,37 €	2,00 €

Total fees (3 sessions)	115,11 €
Amount invoiced to the health insurance fund, third-party payment	109,11 €
Personal share payable by the patient	6,00 €

Transfer of 6,00 € to account BE71 0961 2345 6769 in the name of Camille Renard, with the structured reference +++202/6000/00903+++.

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

BIM patient: yes. 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).

Camille Renard, speech therapist, INAMI no. 6-00000-05-111, certifies having provided the services listed above.

Date:

Signature of the provider: