Lejeune Rayan
Certificate of care provided, October 2026, 4 services.
Fees 153,48 €. Third-party payment: the health insurance fund pays 98,64 €, the patient pays 54,84 € as personal share. This is the amount shown in the box “A.R. 15.07.2002” and on the receipt, as INAMI requires.
The sheet
paper size, 127 × 304.8 mmThe sheet is not printed from this page: the real paper already carries everything drawn on it. The certificate is printed from the third-party payment page, on screen, on the MOD 111 form.
The paper as it is pre-printed, and on top of it what the software will write. The proportions and positions are those of the paper; the size shown depends on the screen setting. Two things are not shown here, but do exist on the paper: the form's serial number, and the top of the sheet, above the title. The patient's identity box is printed normally.
Commit a form
Note the number printed on the form you are about to commit. It is saved for the accounts and can no longer be used.
This computer's printer: Practice printer.
On the MOD 111 formThe form is printed on the official pre-printed sheet, at the position measured for each box.
PDF in the form's formatA 127 x 304.8 mm page, at the same positions, to print at 100%, without scaling. How to print it
Check the alignment on A4Two ordinary A4 pages, at scale 1: the form's marks and the values in their place. Put a real MOD 111 sheet on top, against a window, and see whether everything lines up. To do once, before committing the first form.
Without a print window, in one click: LeLogo program for this computer.
Form scrapped
MOD 111 forms are numbered in advance, in a continuous series. A torn or badly printed sheet leaves a gap in the numbers, which the health insurance fund may notice. Declaring it here explains the gap. A number committed for another patient cannot be scrapped from here.
Values shown on the sheet
each value can be corrected before printingA correction applies to this certificate only. The patient's record and the attendance do not change.
Patient's identity
| Patient's surname and first name | Lejeune Rayan |
|
|---|---|---|
| 37 characters at most | ||
| Health insurance fund | Mutualité de démonstration Sud |
|
| 40 characters at most | ||
| NISS | 22.06.29-115.33 |
|
| 50 characters at most | ||
| Patient's address | Rue de l'Exemple 1, 1000 Bruxelles |
|
| 46 characters at most | ||
Provider's part
| Patient's surname and first name, provider's part | Lejeune Rayan |
|
|---|---|---|
| 34 characters at most | ||
Services
| No. | Date | Nomenclature | Amount | Actions |
|---|---|---|---|---|
| 1 | 02/10/2026 | 713311 | 38,37 € |
|
| 2 | 09/10/2026 | 713311 | 38,37 € |
|
| 3 | 16/10/2026 | 713311 | 38,37 € |
|
| 4 | 23/10/2026 | 713311 | 38,37 € |
|
| Total recorded sessions | 153,48 € | |||
Prescription
| Prescribed by | Dr Martin, pédiatre |
|
|---|---|---|
| 47 characters at most | ||
| Prescription dated | 11/09/2025 |
|
| Prescriber's INAMI number | 10000007000 |
|
| 20 characters at most | ||
| Medical advisor's approval dated | 11/10/2025 |
|
| Approval period, from | 26/09/2025 |
|
| Approval period, to | 25/09/2027 |
|
Stay
| The patient is | ambulant |
|
|---|---|---|
| Institution number | empty |
|
| 20 characters at most | ||
| Department | empty |
|
| 20 characters at most | ||
Amount and provider
| Fees charged, box A.R. 15.07.2002 | 54,84 € |
|
|---|---|---|
| Provider identification | Tom Exemple, INAMI 6-00022-20-222, Rue de la Démonstration 1, 1000 Bruxelles |
|
| 4 lines of 66 characters at most, cut at the commas | ||
| Signature date | 26/10/2026 |
|
Receipt
| Received on behalf of enterprise number | 0234.567.873 |
|
|---|---|---|
| 28 characters at most | ||
| Receipt date | empty |
|
| Received the sum of | empty |
|