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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 Claes Anaïa
For the attention of Parent de Anaïa
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice

No. 2026-004 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Claes Anaïa
Date of birth
28/06/2021
National register no.
21.06.28-109.48
Health insurance fund
Mutualité de démonstration Nord
INAMI code
713311
Prescribed by
Dr Lambert, ORL
Prescription of
07/02/2026
Doctor's INAMI no.
10000007000
Medical advisor's approval
09/03/2026
Approval period
22/02/2026 to 21/02/2028

Breakdown of services

Session date INAMI code Fee
07/09/2026 713311 38,37 €
14/09/2026 713311 38,37 €
21/09/2026 713311 38,37 €
28/09/2026 713311 38,37 €
Total fees (4 sessions)153,48 €
Amount to be paid by the patient153,48 €

Transfer of 153,48 € to account BE71 0961 2345 6769 in the name of Camille Renard, with the structured reference +++202/6000/00495+++.

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

BIM patient: no. 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: