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 26/10/2026

Sessions of September 2026

Patient and prescription

Patient: Willems Jonas
Date of birth: 01/07/2015
National register no.: 15.07.01-119.50
Health insurance fund: Mutualité de démonstration Sud
INAMI code: 714313

Prescribed by: Dr Martin, pédiatre
Prescription of: 14/04/2025
Doctor's INAMI no.: 10000007000
Medical advisor's approval: 14/05/2025
Approval period: 29/04/2025 to 28/04/2027

Breakdown of services

Session date	INAMI code	Fee	Patient's share
02/09/2026	714313	38,37 €	2,00 €
30/09/2026	714313	38,37 €	2,00 €

Total fees (2 sessions)	76,74 €
Amount invoiced to the health insurance fund, third-party payment	72,74 €
Personal share payable by the patient	4,00 €

Transfer of 4,00 € 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: