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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 Simon Nathan
For the attention of Parent de Nathan
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice, third-party payment

No. TE-2026-003 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Simon Nathan
Date of birth
29/06/2017
National register no.
17.06.29-147.90
Health insurance fund
Mutualité de démonstration Sud
INAMI code
733316
Prescribed by
Dr Simon, neuropédiatre
Prescription of
28/05/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
27/06/2025
Approval period
12/06/2025 to 11/06/2027

Breakdown of services

Session date INAMI code Fee Patient's share
04/09/2026 733316 38,37 € 2,00 €
18/09/2026 733316 38,37 € 2,00 €
25/09/2026 733316 38,37 € 2,00 €
Total fees (3 sessions)115,11 €
Amount invoiced to the health insurance fund, third-party payment109,11 €
Personal share payable by the patient6,00 €

Transfer of 6,00 € to account BE68 5390 0754 7034 in the name of Tom Exemple, with the structured reference +++202/6020/00315+++.

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. 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: