Document language: Français · Nederlands · English Back
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
Bogaert Tom
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice, third-party payment

No. 2026-003 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Bogaert Tom
Date of birth
12/07/1964
National register no.
64.07.12-105.55
Health insurance fund
Mutualité de démonstration Nord
INAMI code
712611
Prescribed by
Dr Simon, neurologue
Prescription of
22/02/2026
Doctor's INAMI no.
10000007000
Medical advisor's approval
24/03/2026
Approval period
09/03/2026 to 08/03/2028

Breakdown of services

Session date INAMI code Fee Patient's share
06/09/2026 712611 77,05 € 11,00 €
13/09/2026 712611 77,05 € 11,00 €
20/09/2026 712611 77,05 € 11,00 €
27/09/2026 712611 77,05 € 11,00 €
Total fees (4 sessions)308,20 €
Amount invoiced to the health insurance fund, third-party payment264,20 €
Personal share payable by the patient44,00 €

Transfer of 44,00 € to account BE71 0961 2345 6769 in the name of Camille Renard, with the structured reference +++202/6000/00394+++.

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

BIM patient: no. 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: