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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 Willems Jonas
For the attention of Parent de Jonas
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice, third-party payment

No. 2026-011 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Willems Jonas
Date of birth
30/06/2015
National register no.
15.06.30-119.46
Health insurance fund
Mutualité de démonstration Sud
INAMI code
714313
Prescribed by
Dr Martin, pédiatre
Prescription of
13/04/2025
Doctor's INAMI no.
10000007000
Medical advisor's approval
13/05/2025
Approval period
28/04/2025 to 27/04/2027

Breakdown of services

Session date INAMI code Fee Patient's share
07/09/2026 714313 38,37 € 2,00 €
Total fees (1 session)38,37 €
Amount invoiced to the health insurance fund, third-party payment36,37 €
Personal share payable by the patient2,00 €

Transfer of 2,00 € to account BE71 0961 2345 6769 in the name of Léa Exemple, with the structured reference +++202/6000/01105+++.

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).

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

Date:
Signature of the provider: