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Medical Receipt Template

A medical receipt is proof a patient paid for care. It shows the provider and their tax ID, the patient, the date of service, what was done with the procedure code, the amount charged and the amount paid. Patients need it to claim from an out-of-network insurer or to substantiate an HSA or FSA withdrawal. You can make one free below.

Patients ask for this more than practices expect, because a card statement showing a clinic name proves nothing to an insurer or a benefits administrator. They want to see what the money bought.

What goes on a medical receipt

  • Practice or provider name, address and phone
  • Rendering provider name, credentials and NPI number
  • Practice tax identification number
  • Patient name and date of birth
  • Date of service, and place of service
  • Each service on its own line with a CPT or HCPCS procedure code and a plain description
  • Diagnosis code linked to each service, usually ICD-10
  • Charge per line, and the total charged
  • Amount paid by the patient, the method, and the date received
  • Insurance payment or adjustment if any, and the remaining balance

One visit, coded

Office visit, established patient, 25 minutes. CPT 99214, diagnosis M54.5, charged $215. Therapeutic exercise, CPT 97110, one unit, $58. Total charged $273. Patient paid $273 in full by card on the day. Provider NPI 1548392017, practice EIN 45-6677881, date of service 8 April, place of service 11.

Superbill or receipt

These overlap and get confused. A superbill is prepared so a patient can submit it to their insurer for reimbursement, and it must carry the diagnosis and procedure codes the insurer needs. A receipt is narrower: it proves payment. In practice most patients paying out of pocket want a document that does both, which is why the codes belong on it. If you need the full insurer facing version, use the medical invoice and superbill template instead.

For an HSA or FSA claim, the administrator is looking for the date of service, the patient, a description of the care and the amount paid. A receipt without a date of service is the most common reason those claims are rejected.

Give a patient a receipt

Add the codes and the amount paid in the receipt generator, then print or email the PDF. Nothing you enter reaches our servers.

Related templates

Frequently asked questions

What does an insurer need on a medical receipt?

The provider name and NPI, the practice tax ID, the patient details, the date of service, and each service listed with a CPT procedure code and an ICD diagnosis code. Without the codes an out-of-network claim usually cannot be processed.

Is a medical receipt enough for an HSA or FSA claim?

Usually, provided it shows the date of service, who was treated, what the care was and the amount paid. A card slip or a balance forward statement is normally rejected because it lacks the date of service.

What is the difference between a superbill and a receipt?

A superbill is built for the patient to submit to an insurer and carries full diagnosis and procedure coding. A receipt proves payment was made. Many practices issue one document that serves both purposes.