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This document goes out with reservations: 2 sessions outside the medical advisor's approval (01/09/2026, 08/09/2026): the health insurance fund will not reimburse them, check the approval or remove them from the invoice.
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 Dubois Malik
For the attention of Parent de Malik
Rue de l'Exemple 1
1000 Bruxelles

Speech therapy invoice, third-party payment

No. 2026-005 · Issued on 25/10/2026

Sessions of September 2026

Patient and prescription

Patient
Dubois Malik
Date of birth
29/06/2019
National register no.
19.06.29-111.71
Health insurance fund
Mutualité de démonstration Sud
INAMI code
733316
Prescribed by
Dr Simon, neuropédiatre
Prescription of
31/08/2026
Doctor's INAMI no.
10000007000
Medical advisor's approval
Approval period
10/09/2026 to 09/09/2028

Breakdown of services

Session date INAMI code Fee Patient's share
01/09/2026 733316 38,37 € 2,00 €
08/09/2026 733316 38,37 € 2,00 €
14/09/2026 733316 38,37 € 2,00 €
15/09/2026 733316 38,37 € 2,00 €
21/09/2026 733316 38,37 € 2,00 €
22/09/2026 733316 38,37 € 2,00 €
28/09/2026 733316 38,37 € 2,00 €
Total fees (7 sessions)268,59 €
Amount invoiced to the health insurance fund, third-party payment254,59 €
Personal share payable by the patient14,00 €

Transfer of 14,00 € to account BE71 0961 2345 6769 in the name of Léa Exemple, with the structured reference +++202/6000/00596+++.

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: